OT Manager

The
Occupational
Therapy
Manager
6th EDITION
Lead Editors: Karen Jacobs, EdD, OT, OTR, CPE, FAOTA, and
Guy L. McCormack, PhD, OTR/L, FAOTA
Associate Editors: Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA; Albert E. Copolillo, PhD,
OTR/L, FAOTA; Roger I. Ideishi, JD, OT/L, FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA;
Sarah McKinnon, OT, OTR, OTD, BCPR, MPA; Donna Costa, DHS, OTR/L, FAOTA; Nathan B.
Herz, OTD, MBA, OTR/L; Lea Brandt, OTD, MA, OTR/L; and Karen Duddy, OTD, MHA, OTR/L
Purchased from AOTA for the exclusive use of Alyssa Myers (u0871036@utah.edu 000004564714)
© 2020 AOTA. Please report unauthorized use to aotapress@aota.org
AOTA Vision 2025
Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective
solutions that facilitate participation in everyday living.
Mission Statement
The American Occupational Therapy Association advances occupational therapy practice, education, and research through standard-setting
and advocacy on behalf of its members, the profession, and the public.
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It is the objective of the American Occupational Therapy Association to be a forum for free expression and interchange of ideas. The opinions
expressed by the contributors to this work are their own and not necessarily those of the American Occupational Therapy Association.
ISBN: 978-1-56900-390-9
Ebook ISBN: 978-1-56900-592-7
Library of Congress Control Number: 2019937715
Cover design by Debra Naylor, Naylor Design, Inc., Washington, DC

Composition by Maryland Composition, White Plains, MD
Printed by Automated Graphics, White Plains, MD
Dedication
To all current and future occupational therapy practitioners:

May you be agents of change.
—K. J.
To the students, practitioners, managers, and
leaders in occupational therapy.
—G. M.
iii
Contents
About the Editorsix Chapter 6. Leading and Managing

About the Associate Editors and Within Health Care Systems 59
Contributorsxi Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA
List of Figures, Tables, Exhibits, Chapter 7. Creating a Business in an
Case Examples, and Appendixes xvii Emerging Practice Area 69
Note From the Publisher xxi Ingrid M. Kanics, OTR/L, FAOTA
Christina A. Davis
Chapter 8. Management for
Occupation-Centered Practice 77
Introductionxxiii Debbie Amini, EdD, OTR/L, FAOTA, and
Karen Jacobs, EdD, OT, OTR, CPE, FAOTA; Guy L. McCormack, Melissa Tilton, OTA, BS, COTA, ROH
PhD, OTR/L, FAOTA; Judith A. Parker Kent, OTD, EdS, OTR/L,
FAOTA; Albert E. Copolillo, PhD, OTR/L, FAOTA; Roger I. Ideishi,
JD, OT/L, FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA; Sarah Section II. Organizational Planning
McKinnon, OT, OTR, OTD, BCPR, MPA; Donna Costa, DHS, and Culture 89
OTR/L, FAOTA; Nathan B. Herz, OTD, MBA, OTR/L; Lea Brandt, Edited by Judith A. Parker Kent, OTD, EdS,
OTD, MA, OTR/L; and Karen Duddy, OTD, MHA, OTR/L OTR/L, FAOTA
Section I. F
oundations of Occupational Chapter 9. Strategic Planning 91
Therapy Leadership and L. Randy Strickland, EdD, OTR/L, FAOTA
Management1
Chapter 10. Using Data to Guide
Edited by Karen Jacobs, EdD, OT, OTR, CPE, FAOTA
Business Decisions 99
Chapter 1. Theories of Leadership 3 Carolyn Giordano, PhD, FASAHP
Virginia “Ginny” Stoffel, PhD, OT, FAOTA
Chapter 11. Risk Management and
Chapter 2. Perspectives on Management 19 Contingency Planning 107
Brent Braveman, PhD, OTR/L, FAOTA Sarah Corcoran, OTD, OTR/L
Chapter 3. Leadership vs. Management: Chapter 12. Marketing Strategies

Differences and Skill Sets 27 and Analysis 121
Debi Hinerfeld, PhD, OTR/L, FAOTA Jessica McMurdie, OTR/L
Chapter 4. Evolution and Future of Chapter 13. Building Capacity 133

Occupational Therapy Service Delivery 35 Susan Touchinsky, OTR/L, SCDCM, CDRS
Anne M. Haskins, PhD, OTR/L, and
Chapter 14. Starting New Programs 141
Debra J. Hanson, PhD, OTR/L, FAOTA
Ann Burkhardt, OTD, OTR/L, FAOTA
Chapter 5. Global Perspectives on
Occupational Therapy Practice 49
Elizabeth W. Stevens-Nafai, MSOT, CLT, and
Said Nafai, OTD, OTR, CLT
vi The Occupational Therapy Manager
Chapter 15. Cultivating a Positive and Section IV. Outcomes and

Collaborative Workplace 153 Documentation233
Winnie Dunn, PhD, OTR, FAOTA; Edited by Shawn Phipps, PhD, OTR/L, FAOTA
Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA;
Evan Dean, PhD, OTR/L; and Lindsey Jarrett, PhD Chapter 24. Managing Quality and
Promoting Evidence-Based Practice 235
Chapter 16. Promoting and Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ,
Managing Diversity 159 FNAP, FACRM; Maria Cecilia Alpasan, MA, OTR/L, CPHQ;
Roxie M. Black, PhD, OTR, FAOTA and Ashley Uyeshiro Simon, OTD, OTR/L, MSCS
Chapter 17. Volunteering: Staff Chapter 25. Understanding

Participation Outreach and Client-Centered Practice 243
Contributing to the Community 167 Shawn Phipps, PhD, OTR/L, FAOTA, and
Mary J. Hager, MA, OTR/L, FAOTA Kathleen T. Foley, PhD, OTR/L, FAOTA
Chapter 26. Evaluating Occupational

Section III. Navigating Change Therapy Services and Client Satisfaction 251
and Uncertainty 173 Shawn Phipps, PhD, OTR/L, FAOTA
Edited by Roger I. Ideishi, JD, OT/L, FAOTA, and
Albert E. Copolillo, PhD, OTR/L, FAOTA Chapter 27. Measuring Outcomes 257
Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH®
Chapter 18. Managing Organizational Certified Instructor, and Jess Anthony Holguin, OTD, OT/L
Change 175
Patricia Laverdure, OTD, OTR/L, BCP Chapter 28. Guidelines for Effective
Documentation and Quality Reporting 269
Chapter 19. Planning During Karen M. Sames, OTD, MBA, OTR/L, FAOTA
Uncertainty 185
Jaime L. Smiley, MS, OTR/L, and Chapter 29. Federal Health Care
Thomas Smith, MBA, OTR/L Programs and Outcomes 277
Jeremy R. Furniss, OTD, OTR/L, BCG
Chapter 20. Handling Resistance
During Change 193 Chapter 30. Private Health Insurance 285
Albert E. Copolillo, PhD, OTR/L, FAOTA, and Katie Jordan, OTD, OTR/L, and Sharmila Sandhu, JD
Dianne F. Simons, PhD, OTR/L, FAOTA
Chapter 31. Workers’ Compensation 297
Chapter 21. Communicating During Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA
Change or Uncertainty 201
Sheila Moyle, OTD, OTR/L, and Chapter 32. Delivering Services Through
Bridget Trivinia, OTD, MS, OTR/L Telehealth 311
Jana Cason, DHSc, OTR/L, FAOTA, and
Chapter 22. Adding Value During Tammy Richmond, MS, OTR/L, FAOTA
Change 213
Roger I. Ideishi, JD, OT/L, FAOTA Section V. Interprofessional Practice
Chapter 23. Becoming a Change Agent 225 and Teams 319
Sarah Bream, OTD, OTR/L Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA
Chapter 33. Advocating Occupational

Therapy’s Distinct Value Within
Interprofessional Teams 321
Craig E. Slater, PhD, MPH, BOccThy, and
Anne Cusick, PhD, OTR(Australia)
Contents vii
Chapter 34. Supervising Other Chapter 46. Grant Proposal Writing 427
Disciplines 329 Jessica J. Bolduc, DrOT, OTR/L, and
Debra Margolis, MS, OTR/L Regula Robnett, PhD, OTR/L, FAOTA
Chapter 35. Building Effective Teams 337 Chapter 47. Practitioner–Client

Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP Communication 437
Tamera Keiter Humbert, DEd, OTR/L
Section VI. Supervision 343

Edited by Donna Costa, DHS, OTR/L, FAOTA Section VIII. Finance and Budgeting 449
Edited by Nathan B. Herz, OTD, MBA, OTR/L
Chapter 36. Recruiting, Hiring, and
Retaining Personnel 345 Chapter 48. Understanding Economic
Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA and Political Trends 451
Sabrena McCarley, MBA–SL, OTR/L, CLIPP,
Chapter 37. Conflict Resolution 351 RAC–CT, QCP
Shawn Phipps, PhD, OTR/L, FAOTA
Chapter 49. Designing a Payment
Chapter 38. Mentoring and Structure 457
Motivating Others 357 Ellen Hudgins, OTD, OTR/L, ITOT
Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, C/NDT, PAM
Chapter 50. Developing a Budget 465
Chapter 39. Promoting Professionalism 369 Nathan B. Herz, OTD, MBA, OTR/L
Sean M. Getty, MS, OTR/L
Chapter 51. Determining Costs for
Chapter 40. Providing Constructive New Programs 471
Feedback 377 Nathan B. Herz, OTD, MBA, OTR/L
Jeanette Koski, OTD, OTR/L
Chapter 52. Monitoring Cash Flow 477
Chapter 41. Working With Occupational Chuck Partridge, CPA
Therapy Assistants 385
Heather Thomas, PhD, OTR/L Chapter 53. Professional Liability
Insurance 505
Chapter 42. Occupational Therapy Christopher M. Bluhm, CAE, CMA, CPA
Assistants as Managers 393
Melissa Tilton, OTA, BS, COTA, ROH, and Section IX. Professional Standards 511
Donna Costa, DHS, OTR/L, FAOTA
Edited by Guy L. McCormack, PhD, OTR/L, FAOTA
Chapter 43. Management of
Chapter 54. Continuing Competence 513
Fieldwork Education 401
Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA
Donna Costa, DHS, OTR/L, FAOTA
Chapter 55. Major Accrediting
Organizations 521
Section VII. Communication 407 Shawn Phipps, PhD, OTR/L, FAOTA
Chapter 56. Accreditation Related to
Chapter 44. Communicating Across Education 529
Generations and Cultures 409 Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA
Melissa A. Plourde, OTR/L
Chapter 45. Using Social Media

Appropriately 419
Amanda Nardone, OTS
viii The Occupational Therapy Manager
Section X. Ethical and Legal Chapter 68. Returning to the

Considerations537 Occupational Therapy Workforce 633
Edited by Lea Brandt, OTD, MA, OTR/L Catherine C. Haines, OTR/L, and
Stephanie Johnston, OTD, OTR, FAOTA
Chapter 57. Organizational Ethics 539
Deborah Yarett Slater, MS, OT, FAOTA Chapter 69. Transitioning to
New Practice Areas 643
Chapter 58. Ethics in Fieldwork 547 Tracy L. Witty, OTD, OTR/L, Reg.(OT), CLCP
Joanne Phillips Estes, PhD, OTR/L, and
Leslie E. Bennett, OTD, OTR/L Chapter 70. Becoming a Successful
Contractor 651
Chapter 59. Ethics for OTA Managers 555 Shelley Margow, OTD, OTR/L
Callie Schwartzkopf, OTD, OT/L, and
Melissa Tilton, OTA, BS, COTA, ROH Chapter 71. Professional Development 659
Shain Davis, OTD, OTR/L
Chapter 60. Understanding the Law 565
Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, Chapter 72. Entrepreneurship 667
CDMS, CPE Jayne Knowlton, OTD, OTR/L
Chapter 61. Malpractice 571
Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, Section XII. Public Policy 675
CDMS, CPE Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA
Chapter 62. Intellectual Property and Chapter 73. Why Is Policy Important? 677
Social Media 581 Diane L. Smith, PhD, OTR/L, FAOTA, and
Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, Melanie Concordia, OTD, OTR/L
CDMS, CPE
Chapter 74. Regulatory and
Chapter 63. Billing for Occupational Payment Issues 687
Therapy 589 Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA
Richard Y. Cheng, JD, MBA, OT/L, CHC, and
Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, Chapter 75. State Regulation of
CCM, CDMS, CPE Occupational Therapy 695
Kristen Neville, MA, and Chuck Willmarth, CAE
Chapter 64. Understanding
Employment Laws 597 Chapter 76. Becoming an Advocate 707
Veda Collmer, JD, OTR/L Elizabeth C. Hart, MS, OTR/L
Chapter 65. Addressing Health

Disparities 609 Appendix A. Answers to
M. Beth Merryman, PhD, OTR/L, FAOTA Review Questions 715
Chapter 66. Moral Distress 617
Kimberly S. Erler, PhD, OTR/L Subject Index 771
Citation Index 781
Section XI. Managing Your Career 623
Edited by Karen Duddy, OTD, MHA, OTR/L
Chapter 67. Succeeding as a

New Leader or Manager 625
Mandyleigh Smoot, MOT, OTR/L
About the Editors
Karen Jacobs, EdD, OT, OTR, CPE, FAOTA, earned a doc- rehabilitation to help students find accommodations that can
toral degree at the University of Massachusetts in educational help them be successful. This interdisciplinary initiative op-
leadership in schooling, a master of science in occupational erated at Kent State University, Boston University, and West
therapy at Boston University, and a bachelor of arts in psy- Virginia University, with its evaluation provided by JBS
chology at Washington University in St. Louis. International.
Karen is a past president and vice president of the Amer- In addition to being an occupational therapist with 40 years
ican Occupational Therapy Association (AOTA). She has re- of experience, Karen is a certified professional ergonomist; a
ceived 41 awards and honors, including Fulbright Scholarship fellow of the Human Factors ad Ergonomics Society (HFES);
to the University of Akureyri in Akuryeri, Iceland, in 2005; and is a consultant in ergonomics, marketing, and entrepre-
the Award of Merit from the Canadian Association of Occu- neurship. She is the chairperson of the Outreach Division and
pational Therapists in 2009; the Award of Merit from AOTA in chairperson of the Environmental Design Technical Group of
2003; and the 2011 Eleanor Clarke Slagle Lectureship Award. the HFES.
Since completing her doctorate in 1993, Karen has au-
thored, co-authored, edited, or co-edited more than 81 peer Guy L. McCormack, PhD, OTR/L, FAOTA, has practiced
reviewed journal articles; 24 book chapters; and 24 books, as an occupational therapist for over 46 years. He started his
such as Occupational Therapy Essentials for Clinical Com- college education by completing an associate degree in liberal
petency (3 editions); The Occupational Therapy Manager; arts with a focus on art and science. He enlisted in the U.S.
Ergonomics for Therapists (2 editions); Health Professional Navy as a non-commissioned petty officer in the Seabees,
as Educator (2 editions); and Work Practice: International where he served in military missions in Vietnam in support
Perspectives. She is the co-author of 16 children’s books and of the Marines and in civic action programs teaching con-
hosts the podcast Lifestyle by Design. Karen is the founding struction skills to Vietnamese civilians. After receiving an
editor-in-chief of the international, interprofessional journal, honorable discharge, he worked as an occupational therapy
WORK: A Journal of Prevention, Assessment, and Rehabilita- assistant in a sheltered workshop in a psychiatric hospital in
tion (IOS Press, The Netherlands). She is the moderator of the Upstate New York, where he developed a passion for discov-
complementary webinar series, Learn at WORK. ering the value of occupation.
Karen is a clinical professor of occupational therapy and He earned a bachelor of science degree in occupational
the program director of the online postprofessional doctorate therapy at the University of Puget Sound in Tacoma, WA, fol-
(OTD) in occupational therapy program at Boston University. lowed by his master of science degree from The Ohio State
She has worked at Boston University for 36 years and has ex- University in 1975. He received his doctorate in human sci-
pertise in the development and instruction of online gradu- ence from Saybrook University in San Francisco in 1999.
ate courses, use of technology to enable social participation Guy started his teaching career at the University of Florida
among various populations of persons with disabilities, erin Gainesville. He was recruited to teach at San Jose State Uni-
gonomics, and health care marketing. She is a faculty-in- versity (SJSU), where he served for 16 years and became a ten-
residence at Boston University, where she holds the weekly ured full professor. He was the founding program director for
Sargent Choice Test Kitchen. the occupational therapy program at Samuel Merritt Univer-
Karen’s research examines the interface between the envi- sity (SMU) in Oakland, CA. He practiced as an occupational
ronment and human capabilities. In particular, she examines therapist in home health in the San Francisco Bay area. He
the individual factors and environmental demands associated also served as the program director of the Occupational Ther-
with increased risk of functional limitations among various apy Program at the University of Missouri–Columbia. Guy
populations. Karen was the co-principal investigator for Proj- returned to SMU as a teaching professor and contributed to
ect Career, a National Institute on Disability, Independent the development of the occupational therapy doctoral degree
Living, and Rehabilitation Research 5-year interprofessional program.
demonstration grant. To improve academic and employment Throughout his career, Guy has been active in state and
outcomes for 2- and 4-year college students, including veter- national occupational therapy associations. He was Chair of
ans with cognitive disabilities due to traumatic brain injury, Government Affairs when occupational therapists and occu-
Project Career integrates assistive technology and vocational pational assistants became licensed in California. He served
ix
x The Occupational Therapy Manager
twice as vice president for the Occupational Therapy Associa- for occupational therapy education. Guy has presented over
tion of California (OTAC). He has served on the Board for the 70 papers at state, national, and international conferences.
American Occupational Political Action Committee. He also Guy has received the rank of Professor Emeritus at SMU,
serves on multiple editorial boards. the Lifetime Achievement Award by OTAC, congressio-
Guy has an active research agenda, ranging from studies in nal recognition for service to the community, the Award of
alternative and complementary interventions to integration of Recognition for achieving occupational therapy licensure
neuroscience evidence into occupational therapy practice. He in California, appointment to the Roster of Fellows for the
has conducted grant-funded research on the use of computer- American Occupational Therapy Association, the OTAC
assisted neurofeedback training to ameliorate postcancer cog- Outstanding Service Award, the Joseph Picchi Memorial
nitive impairment in women with breast cancer, the effects of Lecture, the Strommen–Dillashaw Award at SMU, a gradu-
neurofeedback training on children with autism spectrum dis- ate scholarship grant from California Foundation of Occu-
orders, and cognitive functions in older adults. pational Therapy, the Award of Merit from the Santa Clara
Guy’s scholarly publications have included book author- Chapter of Occupational Therapy, and the Meritorious Per-
ships on The Therapeutic Use of Touch for Health Profession- formance Award at SJSU.
als and Pain Management. He was the editor and co-editor Guy is currently an associate professor and the interim
for the 4th and 5th editions of The Occupational Therapy program director for the developing entry-level occupational
Manager, respectively. He has written 31 journal articles and therapy doctoral program at the University of the Pacific in
chapters in peer-reviewed publications and has developed 10 Sacramento, CA. He resides in Seaside, California, in Monterey
audio–visual productions for teaching and learning modules County, where he enjoys walks on the beach in Carmel by the Sea.
About the Associate Editors and Contributors
Maria Cecilia Alpasan, MA, OTR/L, CPHQ Lea Brandt, OTD, MA, OTR/L
Quality and Education Coordinator Director
Cedars–Sinai MU Center for Health Ethics
Los Angeles Executive Director
Missouri Health Professions Consortium
Debbie Amini, EdD, OTR/L, FAOTA Associate Professional Practice Professor
Director of Professional Development School of Medicine
American Occupational Therapy Association University of Missouri–Columbia
Bethesda, MD
Brent Braveman, PhD, OTR/L, FAOTA
Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, Director
C/NDT, PAM Department of Rehabilitation Services
Assistant Professor MD Anderson Cancer Center
Department of Occupational Therapy Houston
College of Health and Human Sciences
San Jose State University Sarah Bream, OTD, OTR/L
San Jose, CA Associate Chair of Academic and Community Program
Support and Development
Leslie E. Bennett, OTD, OTR/L Associate Professor of Clinical Occupational Therapy
Assistant Professor Director of the Doctorate of Occupational Therapy Program
School of Health Sciences: Occupational Therapy Program Chan Division of Occupational Science and Occupational
The Sage Colleges Therapy
Troy, NY University of Southern California
Los Angeles
Roxie M. Black, PhD, OTR, FAOTA
Professor Emerita Ann Burkhardt, OTD, OTR/L, FAOTA
Occupational Therapy Program Professor and Program Director
University of Southern Maine Johnson and Wales University
Lewiston College of Health and Wellness
Providence, RI
Christopher M. Bluhm, CAE, CMA, CPA
Chief Operating Officer Jana Cason, DHSc, OTR/L, FAOTA
American Occupational Therapy Association Professor
Bethesda, MD Auerbach School of Occupational Therapy
Spalding University
Jessica J. Bolduc, DrOT, OTR/L Louisville, KY
Adjunct Professor and Occupational Therapist
University of New England Richard Y. Cheng, JD, MBA, OT/L, CHC
Portland, ME Partner
DLA Piper, LLP
Dallas
xi
xii The Occupational Therapy Manager
Veda Collmer, JD, OTR/L Winnie Dunn, PhD, OTR, FAOTA

In-house Counsel, Chief Compliance Officer Distinguished Professor
WebPT University of Missouri
Phoenix Columbia
Melanie Concordia, OTD, OTR/L Kimberly S. Erler, PhD, OTR/L

Occupational Therapist Assistant Professor
University of Colorado Health at Memorial Hospital Central MGH Institute of Health Professions
Colorado Springs Boston
Albert E. Copolillo, PhD, OTR/L, FAOTA Joanne Phillips Estes, PhD, OTR/L
Associate Professor and Chair Assistant Professor
Department of Occupational Therapy Department of Occupational Therapy
College of Health Professions Xavier University
Virginia Commonwealth University Cincinnati, OH
Richmond
Kathleen T. Foley, PhD, OTR/L, FAOTA
Sarah Corcoran, OTD, OTR/L Associate Professor and Director, School of Occupational
Assistant Professor Therapy
Occupational Therapy Department Ivester College of Health Sciences
University of the Sciences Brenau University
Philadelphia Gainesville, GA
Donna Costa, DHS, OTR/L, FAOTA Jeremy R. Furniss, OTD, OTR/L, BCG
Program Director and Associate Professor Director of Quality
University of Nevada, Las Vegas American Occupational Therapy Association
Bethesda, MD
Anne Cusick, PhD, OTR(Australia)
Professor and Chair of Occupational Therapy Sean M. Getty, MS, OTR/L
University of Sydney Clinical Assistant Professor and Site Coordinator
Professor Emeritus Stony Brook Southampton
Wester Sydney University Southampton, NY
Australia
Carolyn Giordano, PhD, FASAHP
Shain Davis, OTD, OTR/L Associate Provost, Institutional Effectiveness
Clinical Director of Related Services University of the Sciences
Achieve Beyond Pediatric Services Philadelphia
Whittier, CA
Mary J. Hager, MA, OTR/L, FAOTA
Evan Dean, PhD, OTR/L Occupational Therapist (Retired)
Assistant Professor Charleston, WV
Department of Occupational Therapy Education
University of Kansas Catherine C. Haines, OTR/L
Kansas City Occupational Therapist
Cambridge Health Alliance
Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP Cambridge, MA
Associate Professor and Program Director
Department of Occupational Therapy Debra J. Hanson, PhD, OTR/L, FAOTA
School of Health and Rehabilitation Sciences Professor
MGH Institute of Health Professions Academic Fieldwork Coordinator
Boston Occupational Therapy Department
University of North Dakota
Karen Duddy, OTD, MHA, OTR/L Grand Forks
Occupational Therapy Supervisor
Tibor Rubin VA Medical Center
Long Beach, CA
About the Associate Editors and Contributors xiii
Elizabeth C. Hart, MS, OTR/L Lindsey Jarrett, PhD

Occupational Therapist Senior Solution Strategist
Carol Woods Retirement Community Intelligence Organization
Chapel Hill, NC Cerner Corporation
Kansas City, MO
Anne M. Haskins, PhD, OTR/L
Associate Professor Stephanie Johnston, OTD, OTR, FAOTA
Occupational Therapy Department Fieldwork Coordinator and Professor
School of Medicine and Health Sciences Occupational Therapy Assistant Program
University of North Dakota Occupational Therapy Practitioner Reentry Program
Grand Forks Lone Star College–Tomball
Tomball, TX
Nathan B. Herz, OTD, MBA, OTR/L
Founding Director, OTD Program Katie Jordan, OTD, OTR/L
Presbyterian University Professor of Clinical Occupational Therapy
Clinton, SC Associate Chair of Clinical Occupational Therapy Services
Director of Occupational and Speech Therapy Hospital
Debi Hinerfeld, PhD, OTR/L, FAOTA Practice
Clinical Assistant Professor Keck Hospital of USC; Norris Comprehensive Cancer Center
Occupational Therapy Chan Division of Occupational Science and Occupational
Byrdine F. Lewis College of Nursing and Health Professions Therapy
Georgia State University University of Southern California
Atlanta Los Angeles
Jess Anthony Holguin, OTD, OT/L Ingrid M. Kanics, OTR/L, FAOTA

Assistant Professor of Clinical Occupational Therapy President
Keck Medical Center of USC Kanics Inclusive Design Services, LLC
University of Southern California New Castle, PA
Los Angeles
Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA
Ellen Hudgins, OTD, OTR/L, ITOT Associate Professor
President Occupational Therapy Department
Progressive Therapy University of the Sciences
Farmville, VA Philadelphia
Leadership Elective Track Director
Rocky Mountain University of Health Professions Jayne Knowlton, OTD, OTR/L
Provo, UT Interim Director of Occupational Therapy
Roberts Wesleyan College
Tamera Keiter Humbert, DEd, OTR/L Rochester, NY
Associate Professor
Chair and Program Director of Occupational Therapy Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE,
Elizabethtown College CCM, CDMS, CPE
Elizabethtown, PA Law Office of Barbara Kornblau
Miami, FL
Roger I. Ideishi, JD, OT/L, FAOTA Adjunct Occupational Therapy Faculty
Program Director and Professor Florida A&M University
Program in Occupational Therapy Tallahassee
Temple University Rocky Mountain University of the Health Professions
College of Public Health Provo, UT
Philadelphia Executive Director
Coalition for Disability Health Equity
Karen Jacobs, EdD, OT, OTR, CPE, FAOTA Alexandria, VA
Clinical Professor and Program Director
Online Postprofessional Doctorate in Occupational Therapy Jeanette Koski, OTD, OTR/L
Program Assistant Professor and Academic Fieldwork Coordinator
Boston University University of Utah
Salt Lake City
xiv The Occupational Therapy Manager
Patricia Laverdure, OTD, OTR/L, BCP Said Nafai, OTD, OTR, CLT
Assistant Professor President
Department of Occupational Therapy Occupational Therapy Association of Morocco
Virginia Commonwealth University Assistant Professor
Richmond School of Health Sciences, Division of Occupational Therapy
American International College
Debra Margolis, MS, OTR/L Springfield, MA
Director
Volunteer Services Amanda Nardone, OTS
Spaulding Rehabilitation Hospital and Spaulding Hospital Occupational Therapy Student
Cambridge Boston University
Charlestown and Cambridge, MA
Kristen Neville, MA
Shelley Margow, OTD, OTR/L Manager, State Affairs
Clinical Director American Occupational Therapy Association
Georgia Developmental Services Bethesda, MD
Roswell
Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH ®
Sabrena McCarley, MBA–SL, OTR/L, CLIPP, RAC–CT, Certified Instructor
QCP Assistant Director of Clinical Occupational Therapy
Director of Quality Associate Professor of Clinical Occupational Therapy
RehabCare Keck Medical Center of USC
Napa, CA, and Louisville, KY USC Norris Comprehensive Cancer Center
University of Southern California
Guy L. McCormack, PhD, OTR/L, FAOTA Los Angeles
Professor Emeritus
Samuel Merritt University Chuck Partridge, CPA
Oakland, CA Chief Financial Officer
American Occupational Therapy Association
Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA Bethesda, MD
Director of Home and Community-Based Occupational
Therapy Shawn Phipps, PhD, OTR/L, FAOTA
Rehab Educators, LLC Chief Quality Officer
Akron, OH Associate Hospital Administrator
Rancho Los Amigos National Rehabilitation Center
Sarah McKinnon, OT, OTR, OTD, BCPR, MPA Downey, CA
Lecturer Adjunct Faculty and Board of Councilors
Boston University Chan Division of Occupational Science and Occupational
Therapy
Jessica McMurdie, OTR/L University of Southern California
Owner and Clinical Director Los Angeles
Stepping Stones Therapy Network
Bellevue, WA Melissa A. Plourde, OTR/L
Integrated Developmental Center Department Supervisor of Occupational Therapy
Bothell, WA Regional School Unit 73
Towns of Jay, Livermore Falls, and Livermore, ME
M. Beth Merryman, PhD, OTR/L, FAOTA
Professor and Chairperson Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA
Department of Occupational Therapy and Occupational Science Associate Dean
Towson University College of Health and Human Services
Towson, MD Touro University Nevada
Henderson
Sheila Moyle, OTD, OTR/L
Assistant Professor and Academic Fieldwork Coordinator
Occupational Therapy Program
Temple University
Philadelphia
About the Associate Editors and Contributors xv
Tammy Richmond, MS, OTR/L, FAOTA Ashley Uyeshiro Simon, OTD, OTR/L, MSCS
President and Chief Executive Officer Associate Professor of Clinical Occupational Therapy
Go 2 Care, Inc. Chan Division of Occupational Science and Occupational
Los Angeles Therapy
University of Southern California
Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, Los Angeles
FNAP, FACRM
Executive Director and Professor, Physical Medicine and Dianne F. Simons, PhD, OTR/L, FAOTA
Rehabilitation Assistant Professor
Executive Director, Academic and Physician Informatics Department of Occupational Therapy
Cedars–Sinai College of Health Professions
Los Angeles Virginia Commonwealth University
Richmond
Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA
Assistant Director Inpatient Therapy Services Craig E. Slater, PhD, MPH, BOccThy
University of Chicago Medicine Director, Interprofessional Education and Practice
Chicago College of Health and Rehabilitation Sciences:
Sargent College
Regula Robnett, PhD, OTR/L, FAOTA Boston University
Professor
University of New England Deborah Yarett Slater, MS, OT, FAOTA
Portland, ME Consulting Practice Manager, Ethics
Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA Bethesda, MD
Associate Professor
Director of the PhD in Occupational Science Jaime L. Smiley, MS, OTR/L
Chan Division of Occupational Science and Occupational Clinical Education Coordinator
Therapy Medical Facilities of America
University of Southern California Roanoke, VA
Los Angeles Adjunct Faculty
Department of Occupational Therapy
Karen M. Sames, OTD, MBA, OTR/L, FAOTA Virginia Commonwealth University
Professor of Occupational Therapy Richmond
St. Catherine University
St. Paul, MN Diane L. Smith, PhD, OTR/L, FAOTA
Professor and Doctoral Capstone Coordinator
Sharmila Sandhu, JD MGH Institute of Health Professions
Counsel and Director of Regulatory Affairs Boston
Bethesda, MD Thomas Smith, MBA, OTR/L
Chief Operating Officer
Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA MossRehab/Einstein Elkins Park
Professor and Chairperson Elkins Park, PA
Occupational Therapy Department
San Jose State University Mandyleigh Smoot, MOT, OTR/L
San Jose, CA Assistant Chief of Physical Medicine and Rehabilitation
Veterans Affairs Medical Center
Callie Schwartzkopf, OTD, OT/L Minneapolis
Occupational Therapy Assistant Program Director
Central Community College Elizabeth W. Stevens-Nafai, MSOT, CLT
Grand Island, NE Occupational Therapist
Worcester Public Schools
Worcester, MA
xvi The Occupational Therapy Manager
Virginia “Ginny” Stoffel, PhD, OT, FAOTA Bridget Trivinia, OTD, MS, OTR/L
Associate Professor and Associate Program Director Academic Fieldwork Coordinator and Clinical Assistant
Department of Occupational Science and Technology Professor
University of Wisconsin–Milwaukee Occupational Therapy Program
Widener University
L. Randy Strickland, EdD, OTR/L, FAOTA Chester, PA
Professor of Occupational Therapy
Auerbach School of Occupational Therapy Chuck Willmarth, CAE
Spalding University Associate Chief Officer, Health Policy and State Affairs
Louisville, KY American Occupational Therapy Association
Bethesda, MD
Heather Thomas, PhD, OTR/L
Professor Tracy L. Witty, OTD, OTR/L Reg.(OT), CLCP
West Coast University Director of Occupational Therapy and Life Planner
Los Angeles Turning Point Rehabilitation Consulting, Inc.
Vancouver, BC, and Palm Desert, CA
Melissa Tilton, OTA, BS, COTA, ROH
Clinical Operations Area Director Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA
Genesis Rehab Services Associate Professor and Chair
Saugus, MA Department of Occupational Therapy
Adjunct Faculty University of Missouri
North Shore Community College Columbia
Danvers, MA
Susan Touchinsky, OTR/L, SCDCM, CDRS

Occupational Therapy Certified Driver Rehabilitation
Specialist and Owner
Adaptive Mobility Services, LLC
Orwigsburg, PA
List of Figures, Tables, Exhibits, Case Examples,
and Appendixes
Figures Figure 54.1. K nowledge translation: What it is

Figure 2.1. A sample and abbreviated organizational and what it isn’t��514
chart�� 20 Figure 59.1. Tip box�� 556
Figure 2.2. F ishbone diagram on causes for extended Figure 71.1. Standards for continuing competence............. 660
time to receive and schedule initial Figure 73.1. Steps of the policy process.................................. 678
evaluations............................................................... 24 Figure 74.1. The service-payment cycle: Provision of
Figure 4.1. Occupational therapy employment OT services to reimbursement.......................... 688
by setting�� 40
Figure 8.1. Occupational therapy domain and process......... 79 Tables
Figure 8.2. C ircumplex of change recipients’ responses Table 2.1. Commonly Used Tools and Techniques in
to change and underlying core affect................... 82 Continuous Quality Improvement......................... 23
Figure 8.3. Model of responses to change............................... 83 Table 3.1. Complementary Process Differences
Figure 9.1. Strategic planning cycle.......................................... 94 Between Leaders and Managers.............................. 29
Figure 10.1. Dashboard example............................................. 103 Table 4.1. Types of Health Care Organizations ..................... 36
Figure 11.1. H ealth care risk management events in the Table 4.2. Medicare, Medicaid, and CHIP Overview............ 37
United States, 1980–2015.................................... 109 Table 4.3. Legislative Influence on Service Provision............ 38
Figure 11.2. Sample risk matrix...............................................111 Table 4.4. Emerging Niche Practice Areas.............................. 41
Figure 11.3. Example of root cause analysis for a Table 6.1. C riteria for Trustworthy Clinical
witnessed fall.........................................................114 Practice Guidelines................................................... 64
Figure 12.1. The 7 Ps of marketing......................................... 123 Table 11.1. R isk Management Strategies and
Figure 18.1. Kotter’s 8 steps of change................................... 178 Guiding Questions.................................................110
Figure 21.1. Sample organizational structure....................... 202 Table 11.2. O ccupational Therapy Skills and Risk
Figure 21.2. Stakeholder map.................................................. 205 Management Strategies........................................ 115
Figure 22.1. Eleanor Clarke Slagle.......................................... 219 Table 13.1. Steps for Developing Capacity............................. 137
Figure 23.1. C ore Centennial Float Committee Table 16.1. Racial Demographic Trends in the
Members, 2011–2017, and change agents United States, 1975–2065 by Percentage of
in the early stages of the float’s building Population............................................................... 160
process�� 228 Table 16.2. Cultural Functions of Managers......................... 162
Figure 23.2. The float Celebrating a Century of Table 18.1. Key Theories, Frameworks, and Models
Occupational Therapy during the Annual That May Have Utility in Implementing
Tournament of Roses Parade on Change in Occupational Therapy
January 1, 2017.................................................... 229 Organizations, Programs, and Staff................... 177
Figure 24.1. The IHI Triple Aim............................................. 236 Table 18.2. Steps Taken to Support Change in Practice ..... 182
Figure 24.2. The Donabedian model of patient safety......... 237 Table 21.1. Characteristics of 3 Leadership Styles ............... 208
Figure 25.1. C ore components of client-centered and Table 22.1. Client-Centered Strategies Framework...............214
patient-centered care...........................................244 Table 22.2. Sample Person-, Population-, Organization-
Figure 27.1. C ategories of quality measures listed in Level Occupational Therapy Needs.................... 217
the National Quality Measures Table 22.3. Sample Person, Population, and
Clearinghouse...................................................... 259 Organizational Intervention Plan...................... 218
Figure 27.2. ICHOM standard set for dementia................... 260 Table 27.1. Measurement Properties ...................................... 262
Figure 29.1. The National Quality Strategy........................... 279 Table 27.2. Assessing Existing Tools...................................... 265
Figure 30.1. Percentage of people by type of health Table 27.3. Measurement Resources....................................... 265
insurance coverage and change from Table 29.1. R esources for Current Federal Programs
2013 to 2016.......................................................... 286 and Outcomes........................................................ 280
Figure 30.2. H ealth insurance coverage of Table 30.1. Several Common Managed Care Plans ............ 287
children, 2015...................................................... 294
xvii
xviii The Occupational Therapy Manager
Table 33.1. Key Characteristics of Multidisciplinary Exhibit 24.2. Sustainment Plan Example.............................. 239
and Interprofessional Teams................................ 323 Exhibit 30.1. C hecklist of Key Questions to
Table 34.1 E thical and Core Values of Allied Health Ask About Insurance Plan Coverage ............. 293
Professions............................................................... 331 Exhibit 32.1. Key Telehealth Resources................................. 315
Table 35.1. Responsibilities of Effective Team Leaders........ 340 Exhibit 33.1. Occupational Therapy Code of Ethics
Table 39.1. Stage-Specific Strategies for Promoting References to Interprofessional
Professionalism...................................................... 372 Collaborative Practice....................................... 324
Table 44.1. Generational Differences..................................... 413 Exhibit 34.1. E xamples of Behavioral
Table 45.1. Social Media Platforms......................................... 420 Interviewing Questions.................................... 332
Table 47.1. F
ocus of Practitioner–Client Exhibit 35.1. Key Elements of Effective Teams..................... 339
Communication as Represented in AJOT, Exhibit 38.1. Common Mentor and Mentee Benefits.......... 358
1950–Present.......................................................... 439 Exhibit 44.1. R eflective Activity: Cultural Awareness........ 411
Table 47.2. Ethical Considerations Related to Exhibit 45.1. Social Media Tips............................................... 421
Practitioner–Client Communication................. 441 Exhibit 46.1. Steps of Grant Proposal Writing..................... 428
Table 47.3. Difficult or Challenging Conversations Exhibit 46.2. Timeline Template............................................ 431
and Suggested Strategies......................................443 Exhibit 46.3. Budget Template................................................ 432
Table 65.1. O ccupational Therapy Provider Exhibit 46.4. 11 Key Steps in Grant Writing......................... 433
Demographics........................................................ 613 Exhibit 48.1. Great Recession Effects .................................... 452
Table 67.1. Turning Leadership Challenges Into Exhibit 50.1. O ccupational Therapy Clinic
Treatment Plans..................................................... 627 Cost Breakdown.................................................466
Table 73.1. AOTA Policy Resources....................................... 679 Exhibit 51.1. P
roforma Neurology Start-Up
Table 73.2. T ypes of Policies and Overlap With Areas (First Year)........................................................... 472
of Occupation........................................................ 680 Exhibit 51.2. Revenue Calculation......................................... 473
Exhibit 51.3. Short-Form Calculation.................................... 473
Exhibits Exhibit 51.4. Long-Form Calculation.................................... 473
Exhibit 4.1. Policy Learning Activity....................................... 39 Exhibit 51.5. Neurology Start-up Budget.............................. 474
Exhibit 4.2. H ow the Judicial Branch Can Affect Exhibit 57.1. Framework for Ethical Decision Making....... 541
Health Care ........................................................... 39 Exhibit 57.2. AOTA Ethics Publications................................ 541
Exhibit 5.1. Terms Related to Cultural Relevance.................. 50 Exhibit 68.1. The Value of Returning Practitioners............. 634
Exhibit 7.1. AOTA-Defined Emerging Practice Areas.......... 70 Exhibit 68.2. Survey: Reentry Into the
Exhibit 9.1. SWOT Analysis for Proposed Hand Occupational Therapy Workforce.................. 634
Rehabilitation Program......................................... 93 Exhibit 68.3. A OTA’s Guidelines for Reentry Into the
Exhibit 10.1. Research Plan ..................................................... 101 Field of Occupational Therapy......................... 637
Exhibit 10.2. Questions to Ask a Data Scientist................... 104 Exhibit 68.4. Reentry and Refresher Courses....................... 638
Exhibit 11.1. Description of Enterprise Exhibit 68.5. Self-Care and Stress Management.................. 638
Risk Domains..................................................... 108 Exhibit 69.1. Internal and External Factors Leading to
Exhibit 11.2. Dos and Don’ts for Incident Reporting ..........111 Overall Retention...............................................644
Exhibit 11.3. Sample Risk Report........................................... 113 Exhibit 70.1. Reflective Questions to Ask When
Exhibit 12.1. Marketing Examples......................................... 124 Considering Working as a Contractor........... 652
Exhibit 12.2. Target Market Areas......................................... 124 Exhibit 70.2. I RS Multifactor Test: Employee or
Exhibit 12.3. Environmental Assessment Factors............... 125 Independent Contractor?................................. 653
Exhibit 12.4. Marketing Plan Key Components................... 125 Exhibit 74.1. C ritical CMS Excerpts Related to
Exhibit 12.5. Internet and Social Media Channels for What Constitutes Reasonable and
Marketing........................................................... 128 Necessary Skilled Therapy ............................... 689
Exhibit 14.1. T ypical Sections of a Policy and Exhibit 75.1. AOTA’s Model Practice Act’s Definition
Procedures Manual............................................ 145 of Occupational Therapy................................... 699
Exhibit 14.2. Practical Considerations for Starting Exhibit 75.2. State Regulation Online Resources................. 700
New Programs.................................................... 150 Exhibit 76.1. E xamples of Advocacy at the
Exhibit 16.1. N ational CLAS Standards in Health and Daily Practice Level........................................... 708
Health Care......................................................... 161 Exhibit 76.2. Examples of Advocacy at the
Exhibit 16.2. E xample of an Organization’s Value Professional Level.............................................. 708
Statement............................................................ 163 Exhibit 76.3. E xamples of Advocacy at the
Exhibit 22.1. Sample Stakeholder Mapping: Systems Level...................................................... 709
Prioritizing Value, Needs, and Actions Exhibit 76.4. Writing to Elected Representatives................. 710
Through Stakeholder Mapping........................ 216 Exhibit 76.5. S ample Phone Call to a
Exhibit 23.1. Qualities of an Effective Change Agent.......... 226 Member of Congress......................................... 710
Exhibit 24.1. QAPI Plan Project Template............................ 237
List of Figures, Tables, Exhibits, Case Examples, and Appendixes xix
Exhibit 76.6. Dos and Don’ts When Meeting With Case Example 18.1. B uilding a Culture of Knowledge
Elected Officials................................................. 711 Translation in a School Setting ........... 181
Exhibit 76.7. T
ips for Building Relationships With Case Example 19.1. Payment Methodology Adaptation..... 190
Elected Officials.................................................. 711 Case Example 20.1. C reating a New
Evaluation Process................................. 197
Case Examples Case Example 21.1. Communicating During Change........ 209
Case Example 1.1. Ginny Stoffel’s Leadership Journey........... 7 Case Example 22.1. Person, Population,
Case Example 2.1. R obin: Starting as a New and Organizational Perspectives ........ 220
Occupational Therapy Manager.............. 24 Case Example 23.1. C elebrating a Century of
Case Example 3.1. B
alancing the Roles of Occupational Therapy........................... 228
Leader and Manager ................................. 32 Case Example 24.1. Process Improvement Model............... 240
Case Example 4.1. E xploring Stakeholders Case Example 24.2. Outcome Measurement Model............ 241
and Partnerships for Case Example 25.1. Lynn: Client-Centered Practice........... 247
New Programming.................................... 45 Case Example 26.1. Client-Centered Evaluation.................. 254
Case Example 5.1. International Opportunities: Case Example 27.1. D emonstrating Value in an Evolving
Morocco....................................................... 54 Reimbursement Landscape .................. 266
Case Example 5.2. D omestic Cultural Experience................ 55 Case Example 28.1. Hannah’s Documentation
Case Example 5.3. S upporting Refugees at Home................. 55 Challenge................................................ 274
Case Example 6.1. Acute Care Readmissions......................... 65 Case Example 29.1. Quality Improvement in a Skilled
Case Example 7.1. A
llison: An Occupational Therapy Nursing Facility Under Medicare........ 283
Twist on a Travel Business........................ 74 Case Example 30.1. Navigating the Maze of Private
Case Example 7.2. Megan: Creating an Inclusive Swimming Health Insurance................................... 292
Program for Children With ASD Case Example 31.1. Best Practices for Managing a
and SPD....................................................... 74 Workers’ Compensation Claim............ 306
Case Example 8.1. New Manager and a Paradigm Shift....... 85 Case Example 32.1. Telehealth Program Development....... 315
Case Example 9.1. M
ount View Hospital Case Example 33.1. E stablishing a New Occupational
Transformation........................................... 95 Therapy Service...................................... 326
Case Example 10.1. J anelle: A School District Manager Case Example 34.1. Supervising Interdisciplinary
Needs to Review..................................... 104 Teamwork............................................... 334
Case Example 11.1. H ome Health Agency Case Example 35.1. Patrice: Intra- and Interprofessional
Risk Management ................................. 112 Communication..................................... 341
Case Example 11.2. Julia: New Private Case Example 36.1. Kids Therapy Seeks New Therapist..... 349
Outpatient Practice ................................117 Case Example 37.1. Conflict Resolution................................ 354
Case Example 11.3. Managing Risk in School Settings.......117 Case Example 38.1. Mary: New Occupational
Case Example 12.1. C onducting an Organizational Therapy Manager................................... 364
Assessment.............................................. 130 Case Example 39.1. D eveloping Staff Professionalism in
Case Example 13.1. B uilding Capacity to Improve a Rehabilitation Setting......................... 374
Driving and Community Case Example 40.1. Application of the Reflective
Mobility Services.................................... 138 Model of Feedback................................. 382
Case Example 14.1. Starting Programs in Case Example 41.1. Joe: Evaluation Process Challenge....... 386
Clinical Settings..................................... 143 Case Example 41.2. Consuela: Levels of Supervision.......... 388
Case Example 14.2. S tarting Educational Programs........... 146 Case Example 42.1. S haron: First Steps as an
Case Example 15.1. Strengths-Based Leadership OTA Manager......................................... 399
in Fieldwork Supervision...................... 157 Case Example 43.1. S usan: Beginning Fieldwork
Case Example 15.2 S trengths-Based Leadership Education................................................ 405
in a Research Team................................. 157 Case Example 44.1. Thomas: Generation Z.......................... 416
Case Example 15.3. S trengths-Based Leadership Case Example 45.1. Project Career and Social Media......... 425
in an Academic Department................ 157 Case Example 46.1. Zoey: Prevention and Wellness........... 433
Case Example 16.1. S arah: Managing Diversity................... 165 Case Example 46.2. Acquired Brain Injury
Case Example 17.1. Braille Trail.............................................. 168 Community Program........................... 434
Case Example 17.2. C hallenger Baseball............................... 168 Case Example 47.1. Stephanie, Jenny, and Mrs. White:
Case Example 17.3. W orking With Veterans and Communication and Empathy.............444
Young Adults With Disabilities........... 169 Case Example 48.1. Maria: Chronic Pain.............................. 456
Case Example 17.4. Love of Nature........................................ 169 Case Example 49.1. Ms. Jones: Bundled Care....................... 463
Case Example 17.5. National Volunteer Opportunity......... 170 Case Example 50.1. Developing a Budget..............................466
Case Example 17.6. Learning New Skills............................... 170 Case Example 51.1. Calculating Staffing and
Case Example 17.7. Day at the Legislature............................ 171 Space for a Hospital Clinic.................... 475
xx The Occupational Therapy Manager
Case Example 53.1. W orking Outside the Case Example 69.2. R obert: Public Health to
Accepted Scope of Practice .................. 506 Private Practice......................................646
Case Example 53.2. Unattended Child Falls Case Example 69.3. Kate: Seeking Direct Treatment
Off a Swing.............................................. 507 Opportunities.........................................648
Case Example 53.3. Injury During Electrotherapy.............. 507 Case Example 70.1. Jane: Working as a Contractor............. 654
Case Example 53.4. S tudent Intern Injured by Case Example 70.2. J enny: Calculating
Equipment............................................... 508 Take-Home Pay...................................... 656
Case Example 54.1. C raig: Continuing Case Example 70.3. Tom: Changing W-2 Status�� 657
Competence ........................................... 518 Case Example 71.1. Luke: New Practitioner
Case Example 55.1. K aren: Preparing for an Professional Development.................... 665
Onsite Survey Visit................................ 528 Case Example 72.1. AquaEve.................................................. 672
Case Example 56.1. I nternal Institutional Case Example 73.1. Alice: Home Health Advocacy............. 683
Review Process....................................... 534 Case Example 74.1. Preauthorization.................................... 693
Case Example 57.1. P
ower Differentials Within the Case Example 75.1. How Do I Obtain a License?................. 704
Health Care Team..................................542 Case Example 76.1. Camille: Advocating for
Case Example 57.2. Competing Goals................................... 543 Occupational Therapy........................... 712
Case Example 57.3. Uphold the Code or Comply
With the Directive?................................544 Appendixes
Case Example 58.1. Sally: Level II Fieldwork........................ 552 Appendix 1.1. Values Card Sort Activity................................... 9
Case Example 59.1. Becky and Roshni: Daily Life of Appendix 5.A. WFOT Disaster Preparedness and
an OTA Manager................................... 558 Response Position Statement......................... .58
Case Example 59.2. L indee: Articulating the Role Appendix 11.A. Risk Management Resources...................... 120
of an OTA Manager............................... 559 Appendix 23.A. Change Analysis........................................... 232
Case Example 59.3. G oing Through the Appendix 25.A. AOTA’s Occupational Profile Template.......249
Decision-Making Process..................... 560 Appendix 46.A. Sample Cover Letter.................................... 435
Case Example 62.1. Lela: Social Media and Appendix 52.A. AOTA’s Financial Statements..................... 485
Intellectual Property�� 586 Appendix 54.A. A OTA Standards for
Case Example 64.1. Understanding Employment Laws......606 Continuing Competence............................ 520
Case Example 65.1. Addressing Health Disparities..............614 Appendix 58.A. SWOT Analysis to Examine an
Case Example 66.1. Moral Distress in Organization’s Ability to Participate
Inpatient Acute Care............................. 620 in Fieldwork Education............................... 554
Case Example 67.1. Adele’s Leadership Journey................... 630 Appendix 58.B. Role-Play Activity......................................... 554
Case Example 68.1. Returning to the Occupational Appendix 59.A. Ethics Resources for OTA Managers........... 563
Therapy Workforce................................ 639 Appendix 68.A. Reentry Into the Occupational
Case Example 69.1. Diane: Exploring Mental Health.........646 Therapy Workforce��642
Note From the Publisher
When I first arrived at the American Occupational Therapy We also have several non–occupational therapy pro-
Association (AOTA) nearly 2 decades ago, one of the first fessionals who have applied their unique wisdom and skill
texts that greeted me on my desk was the 4th Edition of The sets in service of teaching on a wide range of management
Occupational Therapy Manager (McCormack et al., 2003). topics. This edition reflects the work of not only the editors
I had page proofs to review, and that close read provided a and authors, who are listed in the front matter and whose
crash course on the occupational therapy profession, infor- stellar work has eclipsed our expectations, but also of AOTA
mation that I then used with our publishing team to restart staff from across the association who have either written or
an idling book program. Since then, each revision has be- performed peer review on this work—or both—under the
come even more robust, like occupational therapy itself, and guise of “other duties as assigned” or by taking vacation
as the publisher I am pleased to say that over its history, this days (now that is dedication!) to help. They are acknowl-
book has consistently captured a large share of the market- edged here, in alphabetical order: Debbie Amini, Christopher
place. But most importantly, since the inaugural edition’s Bluhm, Chris Davis, Barb Dickson, Jeremy Furniss, Frank
publication in the mid-1980s (Bair & Gray, 1985; see also Gainer, Neil Harvison, Ashley Hofmann, Christina Metzler,
Bair & Gray, 1992; Bair, 1996; Jacobs & McCormack, 2011), Kristen Neville, Heather Parsons, Chuck Partridge, Maureen
this book has reflected expanding opportunities for OTs Peterson, Sabrina Salvant, Sharmila Sandhu, Deborah Slater,
and OTAs to lead not only members of their own profession Chuck Willmarth, and Monica Wright.
but also within health care and education in general. We As change in continues to advance exponentially through-
have seen how management, administration, and leader- out the world, we are confident that there will be as-yet-
ship have become more complicated over the years, and it is unimagined topics to discuss in a future 7th edition. Perhaps
important for occupational therapy students, practitioners, some of you reading this book will step up to contribute!
managers, and leaders to be fluent in the topics discussed in
this book. —Christina A. Davis
For this 6th edition, AOTA Press sought to combine time- Associate Chief Officer, AOTA Press & Content Strategy
tested thought leaders with new authors, allowing for more American Occupational Therapy Association
diverse perspectives on the issues while creating an upward Bethesda, MD
ladder for future editorial leadership. We hope that read-
ers will agree that this seems to have worked well and has
generated a more comprehensive collection of chapters. As I REFERENCES
(along with my Communications colleagues) have said over Bair, J., & Gray, M. (Eds.). (1985). The occupational therapy manager.
the years to countless students and new practitioners in our Rockville, MD: American Occupational Therapy Association.
AOTA Annual Conference presentation and as I have coun- Bair, J., & Gray, M. (Eds.). (1992). The occupational therapy man-
seled long-time leaders over many publishing projects, “you’ve ager (rev. ed.). Rockville, MD: American Occupational Therapy
got this,” and occupational therapy professionals at all career Association.
levels should feel confident telling their story (see Whitney Bair, J. (Ed.). (1996). The occupational therapy manager (rev. ed.).
& Davis, 2013). We are pleased to have representation from Bethesda, MD: American Occupational Therapy Association.
McCormack, G. L., Jaffe, E. G., & Goodman-Lavey, M. (Eds.). (2003). The
a wide range of generational cohorts in this book to match
occupational therapy manager (4th ed.). Bethesda, MD: AOTA Press.
those in the occupational therapy workforce. In addition, we Jacobs, K., & McCormack, G. L. (Eds.). (2011). The occupational
have broken down the 76 chapters—the largest edition ever— therapy manager (5th ed.). Bethesda, MD: AOTA Press.
to focus more closely on essential considerations and prac- Whitney, R. V., & Davis, C. A. (Eds.). (2013). A writer’s toolkit for
tical applications, recognizing that today everyone is chal- occupational therapy and health care professionals: An insider’s
lenged for time in consuming and understanding an overload guide to writing, communicating, and getting published. Bethesda,
of information. MD: AOTA Press.
xxi
Introduction
Karen Jacobs, EdD, OT, OTR, CPE, FAOTA; Guy L. McCormack, PhD, OTR/L, FAOTA; Judith A. Parker
Kent, OTD, EdS, OTR/L, FAOTA; Albert E. Copolillo, PhD, OTR/L, FAOTA; Roger I. Ideishi, JD, OT/L,
FAOTA; Shawn Phipps, PhD, OTR/L, FAOTA; Sarah McKinnon, OT, OTR, OTD, BCPR, MPA; Donna
Costa, DHS, OTR/L, FAOTA; Nathan B. Herz, OTD, MBA, OTR/L; Lea Brandt, OTD, MA, OTR/L; and
Karen Duddy, OTD, MHA, OTR/L
OVERVIEW OF THE OCCUPATIONAL SECTION I. FOUNDATIONS OF

THERAPY MANAGER, 6TH EDITION OCCUPATIONAL THERAPY
In today’s health care environment, occupational therapy man- LEADERSHIP AND MANAGEMENT
agers and leaders must be prepared to ensure that high-quality There is not one way to be a leader, and readers will find
care is delivered; staff morale and efficiency remain high; busi- themselves leading in different ways, depending on where
nesses and organizations are profitable; and the profession is they are, who they are around, and what role they are filling.
recognized by other health care professionals, reimbursers, Leadership is not simply an innate characteristic; it is a skill
and clients as a valuable service steeped in evidence. This new that requires self-awareness and practice.
edition of The Occupational Therapy Manager takes this charge Section I, “Foundations of Occupational Therapy Lead-
seriously, greatly expanding the areas and topics covered. This ership and Management,” contains 8 chapters that examine
new edition has 76 chapters and is organized by 12 sections: broad ideas of leadership, the skills of management, and the
■ Section I. Foundations of Occupational Therapy Leader- role of occupational therapy practitioners as leaders in es-
ship and Management tablished health care systems, in emerging areas of practice,
■ Section II. Organizational Planning and Culture and across the globe. It introduces relevant theories of lead-
■ Section III. Navigating Change and Uncertainty ership and uses a comparison of servant, transactional, and
■ Section IV. Outcomes and Documentation transformational leadership to challenge readers in thinking
■ Section V. Interprofessional Practice and Teams about their own leadership approach. This section sets you up
■ Section VI. Supervision to begin thinking about and developing your personal lead-
■ Section VII. Communication ership trajectory and action plan. Opportunities to develop
■ Section VIII. Finance and Budgeting leadership skills are introduced, and details are presented
■ Section IX. Professional Standards about AOTA’s Emerging Leadership Development Program
■ Section X. Ethical and Legal Considerations and Middle Manager and Executive Leadership Institute
■ Section XI. Managing Your Career Programs. You are called to action!
■ Section XII. Public Policy Perspectives on management are introduced to identify
and explain the commonly identified key functions of a man-
These sections are designed to address the importance of ager. Examples of how occupational therapy managers are in-
good leadership through economic, political, and cultural volved in management development and assessment of com-
changes as well as the practical aspects of day-to-day man- petency, marketing, program development, and continuous
agement. Chapters include learning objectives, key terms and quality improvement are described in this section. Readers
concepts, essential considerations and practical applications are challenged to explore the relationship among leaders,
in occupational therapy, a case example, and relevant ACOTE management, and supervision.
Standards. Learning activities and review questions challenge
the reader’s understanding and application of the concepts.
Throughout the text, authors across practice areas and settings SECTION II. ORGANIZATIONAL
provide strategies on the how-to aspects of business adminis-
tration and program development while emphasizing occupa-
PLANNING AND CULTURE
tional therapy’s distinct role and value. Promoting the profession The term organization gives the sense of a single entity that exists
through capable and effective leadership results in high-quality in its own right and is more than the people and parts that make
service delivery, better client outcomes, successful reimburse- it up. However, each organization has a culture or sense of iden-
ment, and wider recognition of the value occupational therapy. tity that is created and actualized by each of the organization’s
xxiii
xxiv The Occupational Therapy Manager
members, internal groups, and departments (Doorewaard & measuring outcomes, and documentation. As the health care
Benschop, 2002). How do these individuals, groups, and depart- systems in the United States shift from fee-for-service care,
ments form and continue the organization’s existence? documentation of quality care will be essential to receiving
Section II, “Organizational Planning and Culture,” con- compensation. Section IV examines the current third-party
tains 9 chapters that examine how culture is formed and, payer systems and looks at an emerging area of health care
with this sense of identity, how an organization plans for and delivery: telehealth.
actualizes its future. It explores how a strategic plan evolves
as a guide and data are used for decision-making. The many
challenges that affect evolving organizations are examined SECTION V. INTERPROFESSIONAL
through the lens of risk management. Improving outcomes PRACTICE AND TEAMS
through capacity building and program development, and Occupational therapy practitioners have a distinct value in
how to market them, are explored. Chapters devoted to fos- the care of populations across the lifespan. The occupational
tering collaboration, diversity, and volunteering remind therapy practitioner’s role may vary based on the needs of
readers that organizations are ultimately made of up people. the client population, the type of setting, or the access to re-
Organizational culture matters. Multiple approaches and sources; however, a common denominator in effective care is
ways of thinking can support an organization’s flexibility in the collaboration of members of the interprofessional team to
continually changing internal and external environments. achieve quality care and desirable client outcomes. The ability
to contribute to the effective care of a client is best supported
SECTION III. NAVIGATING CHANGE when working with other disciplines to collectively achieve
the goals that are in the client’s best interest. Collaboration
AND UNCERTAINTY with team members who together work closely with the client
Change occurs on a daily basis. Change and uncertainty have and family can not only lead to effective outcomes but also
garnered substantial attention in the health care industry improve the quality of the relationships between the various
in recent years. During organizational change, stakeholders disciplines on the team (World Health Organization, 2012).
need to know that change is coming, why the changes are Section V, “Interprofessional Practice and Teams,” con-
being made, what the implementation plan is, and that lead- tains 3 chapters that examine the distinct role of occupational
ership is supportive of staff. therapy practitioners in interprofessional teams and also
Section III, “Navigating Change and Uncertainty,” con- optimal action steps and behaviors to be an effective team
tains 6 chapters that examine how to manage organizational member while working with various disciplines.
change, which is influenced by regulatory, policy, and pay- An occupational therapy practitioner can be a part of
ment reforms that value high-quality, client-centered care many dynamic relationships while working as a member of
and reproducible cost-efficient results. Occupational therapy an interprofessional team. In fact, the practitioner must learn
managers are challenged to lead change and innovation in to juggle many roles: working as a practitioner, working as
health, education, and social systems without compromising a team member, and for some, working as a supervisor of
care and service delivery. these dynamic teams. Active interprofessional collaboration
Planning during uncertainty is challenging. This section among all health disciplines on the same team is vital for the
is intended to help occupational therapy managers create new coordination and delivery of client-centered health care.
word associations when faced with uncertainty and explore
approaches for dealing with uncertainty where team members
can recognize and analyze their perceptions. Managers can SECTION VI. SUPERVISION
then objectively explore alternative perspectives for approach- Today’s students are tomorrow’s leaders; being a leader and
ing and planning during uncertainty. Change always brings manager today means having the privilege and responsibil-
resistance, so minimizing the degree of resistance and ensur- ity to train and mentor junior practitioners and students.
ing successful transitions and positive outcomes are discussed. Section VI, “Supervision,” contains 8 chapters that examine
Communication is essential during organizational change, the cycle of recruiting, hiring, mentoring, and managing ju-
and an entire chapter is devoted to this topic. nior practitioners. It looks at mentoring as more than a pos-
itive role model relationship; instead, it views mentoring as
a relationship that promotes professionalism, motivates, and
SECTION IV. OUTCOMES AND provides constructive feedback for both practitioners. This
DOCUMENTATION section also looks at the supervisory roles between occupa-
Documentation is a powerful tool to advocate for your clients’ tional therapy practitioners and students in fieldwork.
needs and for your skilled services. Well-written documenta-
tion can show that you deliver prompt, quality, client-centered
care with measurable outcomes using evidence-based practice.
SECTION VII. COMMUNICATION
Section IV, “Outcomes and Documentation,” contains Although it has been said that “words connote reality”
9 chapters that examine best practices for care delivery, (Coster, 2008, p. 744), one must learn to use them skillfully
Introduction xxv
because, in words often attributed to George Bernard Shaw, SECTION IX. PROFESSIONAL
“The greatest problem in communication is the illusion that STANDARDS
it has been accomplished.” This means two things: One, we
cannot assume that our beliefs are known by an audience, Professional standards are the backbone of a health profes-
and two, we cannot assume that our beliefs are shared by the sion and have elevated the discipline of occupational therapy
audience. Occupational therapy practitioners and students to what it is today. Professional standards provide a frame-
become accomplished communicators only when they can work for consistency of practice, safety for the consumer, and
effectively communicate that occupation is essential to indi- ethical practices. Today, licensing boards enforce the practice
viduals’ and society’s health and well-being (Jacobs, 2012). act and the laws; they also litigate against those refusing to
Section VII, “Communication,” contains 4 chapters that participate within their scope of practice or those who con-
examine common communication challenges and different ceal any unethical, false, fraudulent, or deceptive activity.
mediums for communication. As a manager you will have to Section IX, “Professional Standards,” contains 3 chapters
communicate with people from different cultures and gener- that examine the historical scene surrounding occupational
ations, and each situation may bring its own issues and sur- therapy standards and the continued reasons for them. The
prises; this section addresses many of those. section addresses some major accrediting organizations and
Communication goes beyond sharing information in related educational requirements.
traditional ways. With today’s social media platforms, the Occupational therapy is not a job; it is a profession. The
virtual environment is open for information sharing, and cost of education is increasing, and the cost to be a member
as practitioners, we have an opportunity to share powerful of a professional organization, as well as the cost of creden-
stories and vital information. Effective communication is tialing and licensure, can be expensive. Continuing com-
also essential for proposing grants and writing successful petency, accrediting agencies, and even the development of
proposals. We are health communicators, and the words we professional standards add to the cost of being a professional.
use are important as we “share health-related information Students often ask: Why are professional regulations so im-
with the goal of influencing, engaging and supporting indi- portant? Why is it so important to belong to a professional or-
viduals, communities, health professionals, special groups, ganization? Why is it so time-consuming to be a professional?
policy makers and the public to champion, introduce, adopt, The answer is, we as occupational therapy practitioners are
or sustain a behavior, practice or policy that will ultimately the only profession that enables a person to carry out the ac-
improve health outcomes” (Schiavo, 2007, p. 7). tivities and roles they need, want, or are expected to do in
their daily life. We enable people to carry on with their occu-
pational performance.
SECTION VIII. FINANCE AND
BUDGETING
SECTION X. ETHICAL AND LEGAL
Financial considerations are an important aspect of any
endeavor. It is necessary to know where your business is in
CONSIDERATIONS
relation to expenses and profitability. Although many occu- Section X, “Ethical and Legal Considerations,” contains
pational therapy managers see themselves as occupational 10 chapters. Managing occupational therapy services and
therapy practitioners, not business people, understanding personnel is a complex enterprise marked by market pres-
business practices is crucial to the success or failure of occu- sures to “do more with less” in a pluralistic society. Because of
pational therapy practice itself. the complexity of the health care system, occupational ther-
Section VIII, “Finance and Budgeting,” contains 6 chapter apy managers and practitioners alike may find it difficult to
that examine how general business practices and strategies adhere to the ethics standards that traditionally have defined
are applied to occupational therapy practice and manage- and molded clinical practice. Merely being aware of AOTA’s
ment. The chapters in this section are interrelated and im- Occupational Therapy Code of Ethics (2015) (2015; hereinafter,
portant to the financial health of a clinic or program. Readers the “Code”) will not result in the resolution of many ethical
are not asked to be accountants, but managers must fully un- conflicts encountered in practice. Using the Code in conjunc-
derstand the business fundamentals presented. tion with licensure board regulations, standards of practice,
As health care costs continue to rise, medical care is be- and related laws may optimize the chances of adopting and
coming increasingly difficult to pay for. With the Patient Pro- promoting ethical behaviors, but managers must cultivate
tection and Affordable Care Act of 2010 (P. L. 111–148) and professional behaviors that support ethical decision-making.
its requirements, some individuals and families are paying Most health care professionals practice ethics every day
higher deductibles and are concerned about how to pay for and may not even realize they are applying the concepts of
care. Insurance policies with lower deductibles have higher right and wrong to choices in their daily lives. However, read-
premium costs, making coverage out of reach for some. How- ers should recognize that the study of ethics is systematic in
ever, increasing the focus on quality, patient satisfaction, and nature and is grounded in philosophical principles and the-
cost effectiveness creates opportunities to demonstrate the ory. To apply ethical reasoning in management, practitioners
value of occupational therapy. must be able to differentiate among ethics, morality, and the
xxvi The Occupational Therapy Manager
law. Given the complexity and diversity of the environments considered to be active players or main agents in managing
in which occupational therapy services are provided, ethical and shaping their career trajectories.
reasoning must be applied appropriately, and practitioners Emerging practices and opportunities created by changes in
must refrain from making decisions solely based on value- health care and reimbursement models provide practitioners
laden judgments. Acting legally is a minimum standard of with a greater scope to construct their career paths. These newly
behavior, and while managers must be familiar with and constructed career paths are mainly derived from individual
abide by the law, professional ethics holds one to a higher choices and preferences. “People are becoming the masters
standard. Understanding the language of ethics as well as the of their own destiny, and thus the managers of their careers”
foundational philosophy undergirding ethical reasoning is (Baruch, 2006, p. 127). The transformation of the occupational
an antecedent to acting ethically. therapy profession during the past 100 years and the increase
in practitioner autonomy lead us toward becoming more re-
SECTION XI. MANAGING YOUR sponsible for the destiny of our careers and the profession.
Change also brings opportunities for adding value. As
CAREER change brings about new values for collaborative work envi-
Section XI, “Managing Your Career,”contains 6 chapters that ronments, it requires team members to adopt newer and better
examine concepts and information relevant to managing evidence-based practices. Change depends on change agents.
a service or organization, leading people, driving perfor- Developing the confidence to bring about positive change
mance improvement, and promoting the occupational ther- affects occupational therapy practice and client outcomes.
apy profession. A properly managed department can achieve We hope you find that the 6th edition of The Occupational
high-value outcomes and satisfaction among staff and clients. Therapy Manager provides you with tools to confidently and
Similarly, a properly managed career can achieve high-value competently be an agent of change.
outcomes for the individual practitioner on both a personal
and professional level. Managing one’s own career often
means having the responsibility and freedom to direct your REFERENCES
own professional path across a continuously evolving busi- American Occupational Therapy Association. (2015). Occupational
ness and health care landscape. therapy code of ethics (2015). American Journal of Occupational
Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot.2015
.696S03
SECTION XII. PUBLIC POLICY Baruch, Y. (2006). Career development in organizations and be-
Public policy affects you in everyday life in more ways than yond: Balancing traditional and contemporary viewpoints.
you are aware of. It touches the systems and institutions that Human Resource Management Review, 16(2), 125–138. https://
you rely on in your personal life, and it overtly influences and doi.org/10.1016/j.hrmr.2006.03.002
shapes the health care, education, or other service system you Coster, W. J. (2008). Embracing ambiguity: Facing the challenge of
measurement (Eleanor Clarke Slagle Lecture). American Jour-
work in or around.
nal of Occupational Therapy, 62, 743–752. http://doi.org/10.5014
The text concludes with Section XII, “Public Policy,” /ajot.62.6.743
which contains 4 chapters that examine public policy af- Doorewaard, H. & Benschop, Y. (2002). HRM and organizational
fecting health care systems and payment issues from the change: An emotional endeavor. Journal of Organizational
federal and state levels. This section goes beyond explaining Change Management, 16(3), 272–286. http://doi.org/10.1108
why an interest in public policy is important and articulates /09534810310475523
how you can be an advocate and agent of change. It is your Jacobs, K. (2012). PromOTing occupational therapy: Words, im-
responsibility as occupational therapy practitioners and stu- ages, and actions [Eleanor Clarke Slagle Lecture]. American Jour-
dents to help create the future we envision for our beloved nal of Occupational Therapy, 66, 652–671. http://doi.org/10.5014
profession. /ajot.2012.666001
Patient Protection and Affordable Care Act of 2010, Pub. L. 111–148,
§3502, 124 Stat. 1999, 124 (2010).
FUTURE DIRECTIONS Schiavo, R. (2007). Health communication: From theory to practice.
San Francisco: Jossey-Bass.
According to U.S. News and World Report (2019), occupa- U.S. News and World Report. (2019). The 100 best jobs of 2018.
tional therapy ranks number 13 in the 100 Best Jobs report. Retrieved from https://money.usnews.com/careers/best-jobs
A job can be considered an activity through which an indi- /rankings/the-100-best-jobs
vidual can earn money. A career is the pursuit of a lifelong World Health Organization. (2012). Being an effective team player.
ambition or the general course of progression toward lifelong Geneva: WHO. Retrieved from http://www.who.int/patientsafety
goals. When managing one’s own career, individuals are /education/curriculum/who_mc_topic-4.pdf
SECTION I.
Foundations of Occupational
Therapy Leadership and
Management
1
CHAPTER
Theories of Leadership
Virginia “Ginny” Stoffel, PhD, OT, FAOTA 1
LEARNING OBJECTIVES
After completing this chapter, readers should be able to
■ Define leadership,
■ List Spears’s (2000) 10 characteristics associated with effective servant leaders,
■ Describe transformational leadership,
■ Compare transactional leadership to transformational leadership, and
■ Discuss features of AOTA’s Emerging Leadership Development Program and Middle Manager and Executive
Leadership Institute Programs.
KEY TERMS AND CONCEPTS

• Call to serve • Leadership sustainability • Transformational leadership
• Core values • Servant leadership • Vision 2025
• Leadership coherence • Transactional leadership
OVERVIEW behavioral health workforce staffing certified community be

havioral health clinics), understanding theories about lead
T
his chapter addresses readers as current and future lead ers, leadership development, and leading effectively can help
ers in the profession of occupational therapy. Rooted in leaders mindfully engage in leadership as a process of influ
a contemporary perspective that to be an effective occu ence toward a goal that produces the greatest common good
pational therapy practitioner one must be aware of and engage (Dickmann & Stanford-Blair, 2009).
in leadership opportunities that pave the journey toward the
American Occupational Therapy Association’s (AOTA; 2017b)
Vision 2025, this chapter encourages readers to personally ex
plore values that underlie leadership activation across their
ESSENTIAL CONSIDERATIONS
professional careers. What does it mean to be a leader? What calls people into tak
Leadership theories, conceptual models, and important ing on and assuming leadership roles? What are the character
constructs are illuminated so that as occupational therapy istics of an effective leader? How does a leader act to influence
practitioners develop their leadership capacities, they can others? What role does reflection play in leadership develop
appreciate the complexity of what it means to lead and how ment? How do leaders build on their core values to defining
to explore and expand their leadership capacity, the capac their purpose or mission and outcomes? How can a leader cre
ity of those they lead, and the organizations they influence ate a path of sustainability? This section explores these ques
and to which they are accountable. Whether the efforts are tions while examining several leadership theories and models,
to shape the environment (e.g., by leading student activists and readers are encouraged to apply these questions in a per
toward making beaches accessible to persons with mobility sonal manner (e.g., What does it mean for me to be a leader?
disabilities) or to shape policies (e.g., by calling for inclu What calls me toward taking on and assuming a leadership
sion of occupational therapy practitioners as members of the role?) as they move through this chapter.
Copyright © 2019 by the American Occupational Therapy Association. For permission to reuse, contact www.copyright.com.
https://doi.org/10.7139/2019.978-1-56900-592-7.001
4 SECTION I. Foundations of Occupational Therapy Leadership and Management
Servant Leadership picture of how these characteristics shape how servant lead
ers work with others, build their own capacity as well as that
Servant leadership, a term first coined by AT&T executive and
of others, and facilitate a shared vision toward which to focus
management consultant Robert K. Greenleaf (1977/2002), is a
their collective efforts. Reflection is a disciplined habit for
theory of leadership that focuses on the leader and offers a per
servant leaders because it enhances self-awareness as well as
spective of the motivation and character of the leader.
awareness of others and creates an optimum environment for
careful decision-making and goal-setting in a manner that
The servant–leader is servant first. It begins with the natural
integrates these 10 characteristics.
feeling that one wants to serve. Then conscious choice brings
Servant leaders work with others in a collaborative style
one to aspire to lead. The best test is this: Do those served
that downplays hierarchical structures and emphasizes that
grow as persons? Do they, while being served, become
the leaders listen carefully, get to know the strengths and tal
healthier, wiser, freer, more autonomous, more likely
ents of others, and build their capacity so that they can be
themselves to become servants? And, what is the effect on
come autonomous. Philosophically, servant leaders embrace
the least privileged in society? Will they benefit or at least
the values of altruism and humanism, creating a culture of
not be further deprived? (Greenleaf, 1977/2002, p. 27)
mutual respect and shared power. Servant leaders share in
The leader’s inclination to serve is the mark of the servant fluence and focus on capacity-building (self, others, organiza
leader. Readers might pay attention to what they perceive as tion). Liden et al.’s (2008) 28-item Servant Leadership Ques
a call to serve, especially when that call is matched with any tionnaire consists of 7 distinct dimensions, similar to Spears’s
of the distinct values of occupational therapy (AOTA, 2015). (2000) characteristics:
The call to serve may happen without conscious deliberate
1. Conceptualizing
thought but manifests as an inner drive to intervene consis
2. Emotional healing
tent with one’s values and ethics as an occupational therapy
3. Putting followers first
practitioner. Once the lived experience of serving and leading
4. Helping followers grow and succeed
occurs, a more conscious decision might follow (e.g., “I did
5. Behaving ethically
that. It made a difference. I wonder if there is more I can do
6. Empowering
to contribute”).
7. Creating value for community.
Stoffel’s (2013) AOTA Inaugural Presidential Address,
“From Heartfelt Leadership to Compassionate Care,” high Linden et al.’s research noted that servant leadership has the
lights envisioning every AOTA member as a leader, which, in greatest impact when the followers want to be involved in
turn, expands the commitment of the organization to con growth and are open to this style of leadership.
tinually building leadership capacity for all members and ac
tively building the organization’s capacity to use and depend
on its members for effective leadership. When servant lead Leadership Coherence
ership is implemented in this manner, sustainable leadership On the basis of stories collected from 36 exemplary global
becomes a reality. leaders, Stanford-Blair and Dickmann (2005a, 2005b) devel
Spears (2000) emphasized 10 characteristics associated oped a model of leadership coherence. They asked 3 main
with effective servant leaders: questions when eliciting their leadership development stories:
1. Listening (for deep understanding combined with reflection) 1. How were you formed as a leader?
2. Empathy 2. How do you perform as a leader?
3. Healing 3. How do you sustain your leadership over time and
4. Awareness (general and heightened self-awareness) adversity?
5. Persuasion (effective at building consensus)
Stanford-Blair and Dickmann discovered that each leader
6. Conceptualization (keeping in mind the big picture)
was guided by unshakeable core values that influenced how
7. Foresight (combines an understanding of the past, reali
they led. Their inner values were coherent with their leader
ties of the present, and potential future consequences)
ship disposition and how they connected with and influenced
8. Stewardship (full commitment to serving others)
others. The core values themselves were not necessarily the
9. Commitment to the growth of people (being sure that
same across the leader participants; rather, when each re
resources are expended as investments in those being
flected on the questions, the stories reflected each leader’s per
served, who then join in serving)
sonally held core values. What also emerged was the notion
10. Building community (within the organization being
that their leadership influence and behaviors tended to reflect
served).
those core values, hence the “leadership coherence” perspec
Readers are encouraged to reflect on these characteristics tive: that leaders enacted their values, and did so across time,
and examine their own experiences for evidence of these, as with a pattern of self-care habits.
well as finding exemplars in leaders with whom they observe This pattern of self-care habits was also “observed as
and work. Moreover, readers are encouraged to build a clear a reciprocal relationship in that what the leaders did to
CHAPTER 1. Theories of Leadership 5
sustain their leadership reinforced their performance, and well beyond what might be expected. Bass stated that a trans
performance, in turn, reinforced core values nested at the formational leader
heart of the leaders’ formative experience” (Stanford-Blair
& Dickmann, 2005a, p. 65). Therefore, readers will find a ■ Is perceived by followers as a strong role model whom
values exercise in the “In-Class Assignments and Reflec others want to emulate, a leader who is deeply respected
tive Exercises” section to discern 3 to 4 (no more!) core and trusted and who provides followers with vision and a
values that will be reflected in their leadership experiences sense of mission;
across time. ■ Inspires a team spirit in which people are motivated to be
part of the shared vision and to achieve high expectations;
■ Offers intellectual stimulation by encouraging creativity,
Leadership Sustainability innovation, and an openness to challenging one’s own be
Leadership sustainability themes were extracted from liefs and values; and
Stanford-Blair and Dickmann’s (2005b) study. Sustainabil ■ Provides followers with individualized consideration
ity was considered an element of leadership coherence as a through listening carefully and providing supportive feed
means of continually building capacity at the organizational back, helping followers grow through the process.
level as well as expanding leadership influence to achieve
Transformational leaders share many of the characteris
organizational goals and building a legacy. The practices
tics of servant leaders and are offered here as another source
they found endorsed by the 36 exemplary global leaders are
of information that readers can use to examine their own
■ Staying physically fit; leadership development process. Whereas transformational
■ Managing emotions to one’s mental and physical advantage; leaders might not always be servant leaders, servant leaders
■ Valuing counsel from family, friends, and colleagues; are likely to be transformational leaders, given how they
■ Creating space for maintaining clarity and perspective; work. Taken together, they offer rich information to emerg
■ Gaining satisfaction on the challenges and results associ ing leaders in occupational therapy.
ated with one’s commitments;
■ Seeking intellectual stimulation; and
Review Questions
■ Welcoming inspiration through connection to a higher
purpose. 1. What role do values play in the development of leaders,
and how does leadership coherence shape the ways that
As you read through this list, reflect on your own habits and
leaders behave?
how they contribute to your fitness as a leader. Think about
2. How does the servant leader contrast with leaders who
strategies you could use to incorporate more of these self-sus
emphasize power and control?
taining behaviors into your routines. Observe and ask role
3. What are the kinds of habits that lead to leadership
models of leadership excellence around you to determine how
sustainability?
and what their self-care strategies are and how they affect
leadership effectiveness across time and adversity.
PRACTICAL APPLICATIONS IN
Other Theories OCCUPATIONAL THERAPY
Several other leadership theories commonly referenced in Beginning with AOTA’s concerted efforts as it planned for
the health care leadership and management literature will 2017 and its 100th anniversary, AOTA’s (2007) Centennial
be briefly explored, including transactional and transfor Vision called for occupational therapy practitioners to be
mational leadership (Ledlow & Coppola, 2014; Northouse, “powerful.” In 2008, the AOTA Representative Assembly
2016). Transactional leadership is often described as a prag (RA) voted to approve a proposal that supported the devel
matic give-and-take process, such as the exchange that oc opment of leadership development programs, consistent with
curs when a high-performing employee is rewarded with a then–AOTA President Penny Moyers’s (2007) call for creat
promotion, when the organization is set up to reward those ing a legacy of leadership.
who are viewed as high performers. In general, transactional Between 2009 and 2017, nearly 200 occupational therapy
leaders are viewed as able to deliver expected outcomes based practitioners and occupational therapy assistants partici
on their brokering skills. In contrast, transformational lead- pated in the AOTA Emerging Leadership Development Pro
ership is a process of having the leader connect with follow gram or the AOTA Middle Manager and Executive Leader
ers in a manner that heightens motivation by attending to ship Institute Programs, in addition to targeted leadership
their needs and engaging them as team members. Transac development programs for academic leaders, scientists, state
tional leadership was explained by Burns (1978) as a contrast association presidents, and RA members. Graduates of the
to transformational leadership. first 2 named programs have gone on to fill significant lead
Bass (1985) built on Burns’s (1978) work to describe how ership roles within AOTA, state associations, and other inter
transformational leaders engage others to achieve outcomes professional organizations.
In addition, consistent with the development of the clinical implement quality improvement strategies to boost outcomes
doctorate (Accreditation Council for Occupational Therapy by emphasizing health and wellness alongside traditional
Education, 2012; 2018; Case-Smith et al., 2014), leadership ex approaches used in rehabilitation settings. In addition, oc
pectations of occupational therapists trained at the doctoral cupational therapy entrepreneurs will look for opportunities
level were expanded to include advocacy, care coordination, to establish community-based programs directed to specific
and leadership of interprofessional teams and systems to pro populations and the well-being of the community overall.
vide high-quality, evidence-informed, and cost-effective pro A recent example of this is the work of Susan Bazyk, pro
grams with high satisfaction from those they serve. Hence, the fessor of occupational therapy at Cleveland State University.
emphasis on leadership development begins in professional She engaged in efforts to train school-based occupational
entry programs for occupational therapists and occupational therapy practitioners across Ohio to work as change agents
therapy assistants and continues throughout one’s profes in their school districts to influence mental health promo
sional career as new theories and science about leadership are tion strategies in a public health manner, not only meeting
discovered and applied to occupational therapy, health care, the needs of students identified as requiring individualized
education, and community health. education plans but also addressing students at risk for men
Given the increased emphasis on exploring oneself as a tal health issues, as well as promoting mental health for all
leader who will influence others (those one serves, those one students (Bazyk et al., 2015).
works with, the public, and one’s communities), the AOTA
Vision 2025 can be used as a focus for leadership efforts and Review Questions
to examine the possibilities for future leadership initiatives
led by occupational therapy practitioners: “Occupational 1. Reflect on Vision 2025 and identify 3 areas that you could
therapy maximizes health, well-being, and quality of life focus your attention on that would help achieve what is
for all people, populations, and communities through effec envisioned in this statement.
tive solutions that facilitate participation in everyday living” 2. How do the Vision 2025 guideposts provide important
(AOTA, 2017a, p. 1). clarification on aspects that need to be addressed so
In addition to this statement, AOTA developed several the profession meets goals for diversity, inclusion, and
guideposts to ensure that the core tenets of Vision 2025 were collaboration?
clearly communicated: 3. Talk with your peers, occupational therapy practitioners,
and others in your community to identify several strate
■ Accessible: Occupational therapy provides culturally gies for engaging leadership at the state level to increase
responsive and customized services. membership engagement and leadership that will facili
■ Collaborative: Occupational therapy excels in working tate leadership development at the local level. What would
with clients and within systems to produce effective activate you to be a leader at the local or state levels?
outcomes.
■ Effective: Occupational therapy is evidence based, client
centered, and cost-effective. SUMMARY
■ Leaders: Occupational therapy is influential in changing This chapter was intended to provide readers with information
policies, environments, and complex systems. (AOTA,
about leadership and leadership development, theories, and
2017b, p. 1)
vision, all designed to build their leadership capacity. The re
When the AOTA Centennial Vision was articulated, dis view questions were meant to highlight important content as
seminated, and used as the focus of national, state, and local well as encourage readers to connect the concepts with their
occupational therapy leadership efforts, the key words and own development and observations of leaders around them.
concepts embedded in the vision were carefully scrutinized, Leadership in contemporary occupational therapy prac
shared, developed, and expanded over time to meet the tice is not only important for those who pursue formal orga
changing priorities. To align efforts to meet the Centennial nizational leadership roles, as was seen in the case example
Vision, AOTA created the Centennial Commission, chaired but also to synthesize leadership within practice settings,
by the AOTA vice president. The chairs of all the organiza promote collaborative interprofessional practice, influence
tional commissions or official bodies were represented at a policies at the population and community levels, and ulti
quarterly meeting during which leaders shared their current mately influence the state of health, well-being, and quality of
and planned activities and framed their focus on one or more life for all persons, populations, and communities, resonant
parts of the Centennial Vision. For example, the development with AOTA’s Vision 2025. ❖
of practice tools that were evidence informed was a priority of
the Special Interest Section Council (SISC), aligned with the
emphasis on “science-driven” and “evidence-based” terms in
LEARNING ACTIVITIES
the Centennial Vision. 1. Using Appendix 1.A., “Values Card Sort Activity,” copy
Given the changing environment for occupational therapy or print the list of values, and cut them into “cards.”
services in health care, social services, public health, educa Carefully read through the entire list of values, includ
tion, and community programs, innovative leaders will likely ing the definitions. Read them a 2nd time, and identify
CASE EXAMPLE 1.1. Ginny Stoffel’s Leadership Journey
As a lifelong learner and an active leader across my entire career from the time I was an occupational therapy student more than 40 years ago, I
offer my own leadership development reflections as the “case” to ponder in this chapter. It is fitting that one of my earliest occupational therapy
mentors was Sister Genevieve Cummings, a faculty member and department chair at the College of St. Catherine, who was serving in the AOTA
RA and the AOTA Executive Board around the time I was a student. Sister’s leadership style was examined by Dillon (2001) as an exemplar of an
authentic and effective leader who embodied servant leadership in her demeanor and actions, and I must admit the servant leader practices were a
good fit for me as well.
In addition, I must also give sincere thanks for Sally Ryan, another faculty member at St. Catherine’s, who was honored in 2016 as one of
“occupational therapy’s 100 influential people” (www.otcentennial.org; AOTA, 2017a) for her role in education, authoring a primary text for
occupational therapy assistant students, and for her leadership, serving as the first occupational therapy assistant on the AOTA Executive Board and
the first occupational therapy assistant to receive the Roster of Honor award to high-achieving occupational therapy assistants.
These women served not only as my mentors but also as role models and champions for helping me connect with occupational therapy
leaders across the United States during my 2 years as a student and actively for my first decade as a practitioner. With their encouragement, I first
pursued opportunities to participate in the Commission on Education (as a student, then a fieldwork practitioner), which allowed me to participate
in shaping educational standards and practices. Later I served on the Commission on Practice, during which the first version of the Occupational
Therapy Practice Framework was developed (AOTA, 2002); the SISC as the Mental Health chair and later the SISC chair; the RA, where I helped
shape professional policies; the Commission on Continuing Competence and Professional Development, helping to develop board certifications in
gerontology and mental health; and the Board of Directors twice, serving a dual role as AOTA’s first alternate representative to the World Federation
of Occupational Therapists, and on the AOTA RA, representing members who reside outside of the United States.
At a more local level, beginning in the early 1980s, I served on the Wiscouncil Steering Committee (Wisconsin Occupational Therapy Education
Council) and the Wisconsin Occupational Therapy Association Board. I sought out active board or leadership positions in Transitional Living Services,
a community-based organization providing housing, recovery programs, and employment for adults with psychiatric disabilities, and served on
committees and chaired the board for Mental Health America of Wisconsin (2001–2012).
When I pursued a doctorate, I was drawn to Cardinal Stritch University’s PhD in Leadership for the Advancement of Learning and Service, being
able to add new knowledge, lots of reflection, and carried out my dissertation research in a mental health clubhouse community where shared
leadership of members and staff provided a rich foundation to explore its impact on mental health recovery.
While writing this chapter, I especially enjoyed rereading Dillon’s (2001) historical work on Sister Genevieve Cummings and was amazed at how
much I could relate to her ways of leading and developing habits of the mind and spirit as a leader. I find myself drawn toward continually expanding
my learning from others, while at the same time focusing on the needs of others in an authentic, holistic, and inclusive manner, like Sister did.
I get feedback from others about my open and accessible style, and Sister was seen to openly share her lived experiences and wisdom; during
troubling times, we both find a calm demeanor helps to facilitate reasoned action. One of Dillon’s final quotes illustrates Sister Genevieve’s inclusive
style: “In addition, when collaboratively developing a vision for an organization or group and leading in a manner that is caring and inclusive, the
leader indicates that each constituent plays an important role in achieving group success” (pp. 447–448). I am hopeful that should a retrospective
analysis of my years as AOTA vice president and president occur, we will see how the organization successfully activated leadership and leadership
development (remember my early mantra, “Every member a leader,” which by 2016 was “Every member a leader, a member for life”) as priorities
that served society, the profession, and AOTA.
In Fall 2017, as cofacilitator of the AOTA Emerging Leaders Development Institute, I joined the participants in building a personal mission
statement after a deep period of reflection, values clarification, and sharing. Here is what I developed as that personal mission statement: “My
mission is to lead through engagement (doing with) by offering mindfulness, reflection, and cultivation of trust to support the growth of others”
(dated September 26, 2017). At this point in my career, there is nothing I would love more than to continue to cultivate genuine and authentic leaders
in occupational therapy, in the United States and globally.
Review Questions
1. What influences did Sister Genevieve Cummings and Sally Ryan have on Ginny’s early leadership experiences in AOTA and occupational
therapy?
2. What characteristics of a servant leader do you see in Ginny’s case reflections and in her 2013 Inaugural Presidential Address, “From Heartfelt
Leadership to Compassionate Care”?
3. How do you view the various leadership roles within AOTA, occupational therapy state associations, and other organizations as they influenced
Ginny’s leadership development over time?
how you would code each value for you (always valued, with a partner, and tell a story about how these came
often valued, sometimes valued, seldom valued, least to be your core values and how they have been tested
valued). Mark the sheet or place into card piles until you over time.
have coded all values, with only 3 cards in the “always 3. Reflect on how these core values might influence the kind
valued” pile. of leader you hope to be and how they will guide your
2. Ref lect on your core values and identify how you came leadership development and the skills and capacities you
to understand these as your core values. Share them are working on.
4. Based on an understanding of your core values, try to develop American Occupational Therapy Association. (2017b). Vision 2025.
a purpose or mission statement reflecting the goals you hope American Journal of Occupational Therapy, 71, 7103420010.
to achieve as a leader. See the examples shared in the chapter. https://doi.org/10.5014/ajot.2017.713002
Read how participants in AOTA’s Emerging Leader Develop Bass, B. M. (1985). Leadership performance beyond expectations.
New York: Free Press.
ment Program experienced this process (Amanat et al., 2016).
Bazyk, S., Demirjian, L., LaGuardia, T., Thompson-Repas, K., Con
5. Spend time reflecting on AOTA’s Vision 2025. Identify
way, C., & Michaud, P. (2015). Building capacity of occupational
the possibilities for leadership influence where you live, therapy practitioners to address the mental health needs of chil
study, and practice occupational therapy to enact this vi dren and youth: A mixed-methods study of knowledge transla
sion. Create a leadership mission statement for the por tion. American Journal of Occupational Therapy, 69, 6906180060.
tion of Vision 2025 that you hope to achieve in the next https://doi.org/10.5014/ajot.2015.019182
year. Share your mission with another occupational ther Burns, J. M. (1978). Leadership: Transformative leadership, transac-
apy student or practitioner. Ask for this person’s support tional leadership. New York: Harper & Row.
and engagement in helping you develop your leadership Case-Smith, J., Page, S. J., Darragh, A., Rybski, M., & Cleary, D.
capacity to actualize your goal. (2014). The Issue Is—The professional occupational therapy doc
toral degree: Why do it? American Journal of Occupational Ther-
apy, 68, e55–e60. https://doi.org/10.5014/ajot.2014.008805
ACOTE STANDARDS Dickmann, M. H., & Stanford-Blair, N. (2009). Mindful leadership:
A brain-based framework (2nd ed.). Thousand Oaks, CA: Corwin
This chapter addresses the following ACOTE Standards: Press.
Dillon, T. H. (2001). Authenticity in occupational therapy lead
■ B.7.1. Ethical Decision Making
ership: A case study of a servant leader. American Journal of
■ B.7.2. Professional Engagement. Occupational Therapy, 55, 441–448. https://doi.org/10.5014
/ajot.55.4.441
Greenleaf, R. K. (2002). Servant–leadership: A journey into the na-
REFERENCES ture of legitimate power and greatness. Mahwah, NJ: Paulist Press.
Accreditation Council for Occupational Therapy Education. (2012). (Original work published 1977)
2011 Accreditation Council for Occupational Therapy Education Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health pro-
(ACOTE) standards. American Journal of Occupational Therapy, fessionals: Theory, skills and applications. Burlington, MA: Jones
66, S6–S74. https://doi.org/10.5014/ajot.2012.66S6 & Bartlett Learning.
Accreditation Council for Occupational Therapy Education. (2018). Liden, R. C., Wayne, S. J., Zhao, H., & Henderson, D. (2008). Ser
2018 Accreditation Council for Occupational Therapy Education vant leadership: Development of a multidimensional measure
(ACOTE) standards and interpretive guide. American Journal of and multi-level assessment. Leadership Quarterly, 19, 161–177.
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org https://doi.org/10.1016/j.leaqua.2008.01.006
/10.5014/ajot.2018.72S217 Moyers, P. A. (2007). A legacy of leadership: Achieving our Cen-
Amanat, Y., Lingelbach, S., & Schoen, T. (2016, July 25). OT Per tennial Vision. American Journal of Occupational Therapy, 61,
spectives—Core values: A leader’s guiding principles. OT Prac- 622–628. https://doi.org/10.5014/ajot.61.6.622
tice, 24–25. Northouse, P. G. (2016). Leadership theory and practice (7th ed.).
American Occupational Therapy Association. (2002). Occupational Thousand Oaks, CA: Sage.
therapy practice framework: Domain and process. American Spears, L. C. (2000). Character and servant leadership: Ten charac
Journal of Occupational Therapy, 56, 609–639. https://doi teristics of effective, caring leaders. Concepts and Connections:
.org/10.5014/ajot.56.6.609 Newsletter of the National Clearinghouse for Leadership Pro-
American Occupational Therapy Association. (2007). AOTA’s grams, 8(3).
Centennial Vision and executive summary. American Journal Stanford-Blair, N., & Dickmann, M. H. (2005a). Leadership coher
of Occupational Therapy, 61, 613–614. https://doi.org/10.5014 ence: An emerging model from interviews with leaders around
/ajot.61.6.613 the globe. In N. S. Huber & M. C. Walder (Eds.), Emergent models
American Occupational Therapy Association. (2015, May 22). of global leadership (pp. 50–66). College Park, MD: International
Articulating the distinct value of occupational therapy. Retrieved Leadership Association.
from https://www.aota.org/Publications-News/AOTANews/2015 Stanford-Blair, N., & Dickmann, M. H. (2005b). Leading coherently: Re-
/distinct-value-of-occupational-therapy.aspx flections from leaders around the world. Thousand Oaks, CA: Sage.
American Occupational Therapy Association. (2017a, December 18). Stoffel, V. C. (2013). From heartfelt leadership to compassionate care.
The AOTA centennial year that was—and those who made it all American Journal of Occupational Therapy, 67, 633–640. https://
possible. OT Practice, 22–25. doi.org/10.5014/ajot.2013.676001
APPENDIX 1.1. VALUES CARD SORT ACTIVITY
Always
Always
Always
Always
Values
Values
Values Cards
Cards
ValuesCards
Cards Valued
Valued
Valued
Valued
Sometimes
Sometimes
Sometimes
Sometimes
Often
Often
Often Valued
Valued
OftenValued
Valued Valued
Valued
Valued
Valued
Seldom
Seldom
Seldom
Seldom Least
Least
Least Valued
Valued
LeastValued
Valued
Valued
Valued
Valued
Valued
(Continued)
Source. Adapted from “Personal Values Card Sort,” 2001, by W. R. Miller, J. C’de Baca, D. B. Matthews, & P. L. Wilbourne. In the public
domain.
APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)
Challenge Rationality
Emotionally detached, clear
Testing your limits physically
logical thinking
Tradition Power
Consideration for the way
things have customarily The ability to influence the
been done behavior of myself and others
Competence Self-Control
Being good at what I do, Restraint, able to
capable, effective discipline self
(Continued)
Stability Perseverance
Dependability, able to Staying with tasks through
predict experience completion
Respectful Honesty
Regarding others with honor
Expressing only the truth
and consideration
Personal
Communication
Growth
Committed to a process of Open exchange of views
ever developing self-
awareness and skills
(Continued)
Helping Forgiveness
Reaching out
Reaching out to
to meet
meet Capable of
Capable of pardoning
pardoning and
and
other’s needs
other’s needs moving on
moving on
Family Inner
Harmony
Attending to
Attending to and
and enjoying
enjoying
time with
time with loved
loved ones
ones Seeking inner
inner peace
peace and
and
Seeking
integration
integration
Peace Diplomacy
End of
End of war,
war, nonviolent
nonviolent Searching for
Searching for common
common ground
ground
conflict resolution
conflict resolution to resolve
to resolve conflict
conflict
(Continued)
Play Courageous
Doing just for fun, Standing up for what you
spontaneity believe in, even when risky
Community Appearance
Close involvement Taking care of looks, dressing
with neighbors well, keeping in shape
Consensus Adventure
Forming decisions everyone Taking risks, challenging
can support yourself
(Continued)
Competition Aesthetic
“Beating” others,
“Beating” others, Respect for
Respect for beauty
beauty and
and
coming in
coming in first
first artistry
artistry
Intellectual
Safety
Status
Security, free
Security, free from
from
risk and
risk and worry
worry
Being seen
Being seen as
as aa
knowledgeable expert
knowledgeable expert
Prosperity Advancement
Able to
Able to afford
afford things
things you
you Wanting to
Wanting to move
move up,
up,
want, well
want, well off
off get ahead
get ahead
(Continued)
Integrity
Integrity Spiritual
Growth
Your actionsmatch
Youractions match
your Connection
Connection to a higher
higher
yourbeliefs
beliefs
purpose,
purpose, divine presence
presence
Intimacy
Intimacy Neatness
Solidand
Solid anddeep
deepemotional
emotional Having things
Having things clean
clean
relationship
relationship and in
and in order
order
Friendship
Friendship Self-Esteem
Self-Esteem
Accepting and
Ongoing close relationships Accepting and
Ongoing close relationships respecting yourself
respecting yourself
(Continued)
Creativity Pleasure
Open
Open to
to discovery
discovery of
of new
new Seeking
Seeking enjoyment
enjoyment
ways,
ways, innovative
innovative and
and delight
delight
Teamwork Health
Collaborating with
Collaborating with others
others to
to Tending to
Tending to physical
physical and
and
reach goals
reach goals mental well-being
mental well-being
Tolerance Achievement
Visible
Visible evidence
evidence
Respecting
Respecting those
those different
different
of
of successfully
successfully
from
from you
you
completed
completed endeavors
endeavors
(Continued)
Fairness Authority
Treating everyone
Treating everyone equally,
equally, Steering the
Steering the process,
process, having
having
with respect
with respect power to
power to direct
direct events
events
Knowledge Belonging
Continuous learning, looking Being accepted
Being accepted and
and
for intellectual
for intellectual stimulation
stimulation liked by
liked by others
others
Ecology Recognition
Having others
Having others notice
notice
Taking care
Taking care of
of the
the Earth
Earth good work
work
good
(Continued)
WILD CARD WILD CARD W
CHAPTER
Perspectives on Management
Brent Braveman, PhD, OTR/L, FAOTA 2
LEARNING OBJECTIVES
■ Identify and explain the commonly identified key functions of managers;
■ Provide examples of how occupational therapy managers would be involved in financial management, the develop-
ment and assessment of competency, marketing, program development, and continuous quality improvement; and
■ Identify questions for further exploration on the relationship among leadership, management, and supervision.

• Competency • Market analysis • Planning
• Competency statements • Marketing • Program development
• Continuous quality improvement • Marketing communications • Program evaluation
• Controlling • Middle managers • Program implementation
• Control mechanism • Needs assessment • Program planning
• Directing • Organizing • Staffing
• Environmental assessment • Organizational assessment • Strategic planning
• Management • Plan–Do–Study–Act Cycle • Value-based leadership
OVERVIEW activities important. This chapter provides an overview of the

roles and functions of occupational therapy managers.
M
anagers play a critical role in organizations, including
hospitals, schools, community-based organizations,
skilled nursing facilities, private practices, businesses, ESSENTIAL CONSIDERATIONS
and other organizational settings in which occupational ther-
Background and History
apy practitioners provide services. While some occupational
therapy managers rise to top positions in organizations, many Before the Industrial Revolution, there was not much “man-
may be considered middle managers, meaning that they agement.” Typically, the only person involved in management
oversee a department or group of services, coordinate subor- functions in business was the owner (McGrath, 2014). However,
dinates or employees, and report up the chain of command this changed with the rise of the Industrial Revolution as or-
to a superior who may be a top leader in the organization. ganizations grew larger and adopted new means of producing
These managers are in the middle of the organization and are goods. McGrath (2014, para. 4) noted that “to coordinate these
accountable to those above and below them in the organiza- larger organizations, owners needed to depend on others, which
tional chart (see Figure 2.1). economists call ‘agents’ and the rest of us call ‘managers.’”
Managers are key to translating the mission and vision Early pioneers in occupational therapy played the role of
of the organization to employees at all levels by connect- manager in many ways, and management further gained a
ing their everyday tasks to the larger scope and mission. stronghold in 1984 when the American Occupational Ther-
Managers help employees in making simple, everyday work apy Association’s (AOTA’s) Administration & Management
https://doi.org/10.7139/2019.978-1-56900-592-7.002
19
CHAPTER
Perspectives on Management
Brent Braveman, PhD, OTR/L, FAOTA 2
LEARNING OBJECTIVES
■ Identify and explain the commonly identified key functions of managers;
■ Provide examples of how occupational therapy managers would be involved in financial management, the develop-
ment and assessment of competency, marketing, program development, and continuous quality improvement; and
■ Identify questions for further exploration on the relationship among leadership, management, and supervision.

• Competency • Market analysis • Planning
• Competency statements • Marketing • Program development
• Continuous quality improvement • Marketing communications • Program evaluation
• Controlling • Middle managers • Program implementation
• Control mechanism • Needs assessment • Program planning
• Directing • Organizing • Staffing
• Environmental assessment • Organizational assessment • Strategic planning
• Management • Plan–Do–Study–Act Cycle • Value-based leadership
OVERVIEW activities important. This chapter provides an overview of the

roles and functions of occupational therapy managers.
M
anagers play a critical role in organizations, including
hospitals, schools, community-based organizations,
skilled nursing facilities, private practices, businesses, ESSENTIAL CONSIDERATIONS
and other organizational settings in which occupational ther-
Background and History
apy practitioners provide services. While some occupational
therapy managers rise to top positions in organizations, many Before the Industrial Revolution, there was not much “man-
may be considered middle managers, meaning that they agement.” Typically, the only person involved in management
oversee a department or group of services, coordinate subor- functions in business was the owner (McGrath, 2014). However,
dinates or employees, and report up the chain of command this changed with the rise of the Industrial Revolution as or-
to a superior who may be a top leader in the organization. ganizations grew larger and adopted new means of producing
These managers are in the middle of the organization and are goods. McGrath (2014, para. 4) noted that “to coordinate these
accountable to those above and below them in the organiza- larger organizations, owners needed to depend on others, which
tional chart (see Figure 2.1). economists call ‘agents’ and the rest of us call ‘managers.’”
Managers are key to translating the mission and vision Early pioneers in occupational therapy played the role of
of the organization to employees at all levels by connect- manager in many ways, and management further gained a
ing their everyday tasks to the larger scope and mission. stronghold in 1984 when the American Occupational Ther-
Managers help employees in making simple, everyday work apy Association’s (AOTA’s) Administration & Management
https://doi.org/10.7139/2019.978-1-56900-592-7.002
19
FIGURE 2.1. A sample and abbreviated organizational chart.
Board of
Trustees
Chief Executive Chief Medical

Officer Officer
Vice-President Vice-President Chief of Chief of

Clinical Support Nursing Cardiology PM&R
Services
Director of Director of Nursing Staff Staff

Rehabilitation Social Work Directors Physicians Physicians
OT/PT/SLP Nursing
SW Staff
Staff Staff
Source. Adapted from Braveman (2016, p. 113) with permission.

Note. Due to space limitations only a few departments are shown. A real hospital organizational chart might be more complex and include many more departments.
OT = occupational therapist; PM&R = physical medicine and rehabilitation; PT = physical therapist; SLP = speech–language pathologist; SW = social work.
Special Interest Section (AMSIS) was officially created and the

For Additional Learning
first AMSIS Quarterly was published in 1985. In 2017, AOTA
changed the Special Interest Sections’ structure and AMSIS no For additional learning, see Chapter 1, “Theories of Leadership.”
longer exists as a separate SIS. Instead, each of the 9 SIS groups
includes a position dedicated to administration and manage-
ment titled the “Leadership and Management Coordinator.”
Today, it is common for occupational therapy practitioners An important consideration in the manager–leader con-
to assume the role of managers, and the accreditation standards nection is that of value-based leadership, which Durante
for entry-level education for occupational therapy practitioners (2016) described as “a model where the values of all stake-
include multiple standards related to management (Accredita- holders create an organizational code of standards and
tion Council for Occupational Therapy Education, 2018). ethics that enables individuals to make independent deci-
sions aligned to the organization’s values” (p. 662; see also
Management vs. Leadership and Supervision Mendonca & Kanungo, 2007). Peregrym and Wollf (2013)
defined values-based leadership as “consistently leading out
Management is defined as “the process of guiding an orga- of personal values that are both desirable and beneficial for
nization by planning for future work obligations, organizing ourselves, those in our communities, and/or the organiza-
employees into functional units, directing employees in the tions we serve” (p. 5). Value-based leaders concentrate on the
process of completing daily work tasks, and controlling work core values of the organizations in which they work and view
processes and systems to assure adequate quality of work out- these values as directing principles that shape the behavior
put” (Braveman, 2016, p. 6). It is difficult to have a discussion and action of the members of the organization (van Niekerk
of management without addressing the topics of leadership & Botha, 2017). Value-based leaders use their values to tran-
and supervision. Leadership is “a process of creating structural scend the everyday and create environments in which em-
change wherein the values, vision, and ethics of individuals ployees can concentrate on what is most important to the
are integrated into the culture of a community as a means of core work of the organization.
achieving sustainable change” (Braveman, 2016, p. 6). Super-
vision is “the control and direction of the work of one or more
Traditional Management Functions
employees in a manner that promotes improved performance
and a higher-quality outcome” (Braveman, 2016, p. 187). These Braveman (2016) observed that most introductory texts on
2 topics are addressed in more depth in other chapters in this management identify 4 traditional management functions:
textbook. Effective managers who also function as leaders use (1) planning, (2) organizing (and sometimes staffing), (3) di-
behaviors associated with these theories in their everyday work. recting, and (4) controlling.
CHAPTER 2. Perspectives on Management 21
Planning and that these persons have the necessary skills to do the job.
Staffing ensures that the organization will have sufficient
Planning is the process of establishing short- and long-term
quantity and quality of personnel to achieve its mission and
goals, measurable objectives, and action plans related to the
goals. This ongoing process accounts for recruiting, hiring,
organization’s mission. Goals are usually distinguished from
training, firing, and replacing personnel as necessary.
objectives in terms of the scope of the accomplishment. Man-
agers can be involved in different types of planning, including
day-to-day operational planning, financial planning, long-term Directing
strategic planning, and planning for space and facilities, among Directing is the “process of providing guidance and oversight
others. Planning relates closely to the other management func- so that the work performed is goal oriented and focused on
tions and includes determining the needs for the human re- achieving desired departmental and organizational outcomes”
sources, materials, supplies, facilities, and equipment. Develop- (Braveman, 2016, p. 175). The manager must lead employees
ing the procedures to support the identified goals and objectives and motivate them to work toward achieving organizational
and documenting these procedures along with policies can help goals and objectives. Mentoring and coaching are directing
guide the use of materials, supplies, facilities, and equipment. activities, as is correcting difficult employee behavior through
Managers are responsible for planning the operational or discipline or even separation if an employee cannot alter work
day-to-day activities within a department and organization, performance and behavior to meet expectations.
but they are also responsible for longer term planning. This
longer term planning, commonly referred to as strategic plan-
ning, is the process of determining the long-term goals of an Controlling
organization, developing concrete measures of success and Controlling is the process of measuring actual performance
achievement, and formulating the strategies and general action against expectations and guiding staff to overcome obstacles
plans to accomplish these goals. One of the most important to achieve desired outcomes. The use of control mechanisms or
planning responsibilities of many managers is the development control indicators is one way to perform the controlling func-
and oversight of a department budget (i.e., financial planning). tion. A control mechanism or control indicator is a “check”
or measure that is in place to constantly monitor the output
For Additional Learning or product of a system. When the check reveals that perfor-
mance falls below a previously established limit, it indicates
For additional learning, see Chapter 9, “Strategic Planning.” that unacceptable variation has entered the work processes.
The check is the cue to take action by correcting or adjust-
ing relevant work processes. In addition to checking work-
Another type of complicated planning that managers may flows or processes, control mechanisms can assess expected
encounter is planning the spaces and facilities in which oc- outcomes or work products. The tools that managers use to
cupational therapy practitioners work. Space planning has implement and manage control mechanisms include policies,
important implications for the flow of occupational therapy procedures, and documentation systems.
clients and the everyday work of occupational therapy prac-
titioners. Space planning is typically completed as part of a
team with consultation from professional space planners or Review Questions
engineers because of its complexity. 1. What does it mean to be a middle manager?
2. What are key outcomes of leading from a values-based
Organizing perspective?
Organizing (which sometimes includes staffing) is the process 3. What are the 4 commonly identified functions of managers?
of designing workable units, determining lines of authority
and communication, and developing and managing patterns of PRACTICAL APPLICATIONS IN
coordination. Organizing involves creating the most effective
grouping of activities together with the necessary guidelines
OCCUPATIONAL THERAPY
and coordinating systems so that the organization’s goals can Occupational therapy managers carry out the traditionally
be achieved as efficiently as possible. The management func- identified management functions in different combinations
tion of organizing typically serves to answer these questions: to complete the varied responsibilities they face in their daily
work. A few of these responsibilities are described in the fol-
■ Who is responsible for work tasks and outputs of critical
lowing sections of this chapter.
work processes?
■ Who has the authority to make decisions?
■ How will work activities be functionally separated? Developing and Assessing Staff and
■ What are the expected levels of performance for individu- Managerial Competencies
als and groups?
An important role of managers is to assess and ensure the com-
Staffing is the process of ensuring that the right person is petency of staff. Competency is “an individual’s actual per-
completing the right tasks within predetermined work units formance in a particular situation” (Braveman, 2016, p. 298).
Managers are typically responsible for identifying the essen- clinical technologies include physical agent modalities, ul-
tial work functions included in the job descriptions for each trasound machines, driving simulators, and technologies to
position they oversee and determining whether employees assess vision. Managers often must become adept at learning
can meet the competency standards required to work in a how to evaluate the cost and benefit of technologies that they
particular setting. Managers do so by identifying compe- have not personally used in clinical practice.
tency statements or checks, which are “explicit measures,
indicators, or statements that define specific areas of knowl- Marketing
edge, skills and abilities related to essential functions and as-
signed duties” (Braveman, 2016, p. 298). A helpful resource Marketing is “the management process through which goods
from AOTA is its Standards for Continuing Competence and services move from concept to the customer. It includes
(AOTA, 2015). the coordination of four elements called the 4 P’s of mar-
After staff is trained, managers assess competencies by keting” (Businessdictionary.com, 2017), which include the
using several methods, including observation, written tests, (1) development and definition of products produced by the
return demonstration, or critical reasoning exercises. Com- organization, (2) price, (3) place or where the product is deliv-
petencies can range widely depending on the practice setting. ered, and (4) development of a promotional strategy.
Examples of competencies include making a resting hand When thinking of marketing, it may be tempting to im-
splint that meets set criteria, safely applying a therapeutic mediately think about promoting a product. After all, one
modality, or demonstrating cultural sensitivity during an is confronted almost every day with constant promotional
occupational therapy evaluation. messages in all forms of advertising. However, much of the
Competencies also can be identified related to managerial marketing process happens before one ever sees a print, tele-
roles. Areas often cited as necessary for a manager to practice vision, radio, or online promotion. There are 4 components of
competently include professionalism, leadership, knowledge the marketing process:
of health care systems, business knowledge and skills, prob- 1. Organizational assessment involves examining what
lem solving, gathering and synthesizing information, inter- will influence the development and promotion of a new
personal communication, team management and coaching, product or service. This includes identifying strengths
and continuous quality improvement. and weaknesses through a SWOT (strengths, weaknesses,
opportunities, threats) analysis.
Financial Management 2. Environmental assessment involves examining the
needs of target populations that guide the development
Financial management, financial planning, and the devel- and promotion of a new product or service.
opment and oversight of a department budget are important 3. Market analysis involves validation of the perceptions of
functions of many occupational therapy managers. Budget- the wants and needs of the target populations that will
ing is both a planning and a controlling function. It involves receive a new product or service.
planning because managers must project the financial impact 4. Marketing communications involves packaging and
of meeting clients’ needs, and it involves controlling because promoting a product so the target populations and other
managers must set limits on the everyday activity of staff and key stakeholders have a clear understanding of what the
their salary, as well as other forms of compensation and re- product or service is and how it may be accessed.
wards to staff for doing their jobs. Developing and manag-
ing a budget can be a complex process; occupational therapy
practitioners who have the goal of becoming a departmental Program Development
manager or director are encouraged to obtain knowledge and Program development is the process of formulating orga
develop skills far beyond what they will learn in an entry-level nized elements of service to meet a set of predetermined
occupational therapy program. and desired clinical goals and outcomes. It is common for
occupational therapy managers to develop, plan, implement,
and evaluate occupational therapy programming. The level
Technology and Management
of complexity of program development can vary greatly. An
Managers must become familiar with the use and application example of a relatively simple program development might
of a wide range of technologies. These technologies include be adding a new element of service delivery to an existing
business, information, and communication technologies that program and a known population, such as adding a pread
are used to run the business of the organization and, in many mission or prehabilitation visit for a client who will undergo
settings, clinical technologies that are used in interventions a stem cell transplant when one is already providing inpa
with clients. Examples of business, information, and commu- tient and postdischarge outpatient services to these clients.
nication technologies include analytical software, data stor- However, program development can also be compli-
age and analysis technologies, and technologies to run virtual cated and challenging. An example would be designing a
meetings or collaborate with others in real time. An electronic population health initiative for a community to address
health record is another example of an information technol- the occupational needs of new immigrants displaced by
ogy that is common in many settings today. Examples of war and military struggles. Managers who are developing
TABLE 2.1. Commonly Used Tools and Techniques in Continuous Quality Improvement
TOOL OR TECHNIQUE USE OR APPLICATION

Brainstorming Technique to generate a large number of ideas in a short period of time
Cause-and-effect (fishbone) diagram Diagram that relates identified causes to the problem (effect) being studied
Check sheet Standardized tool developed for manual data collection
Histogram Bar graph that shows the distribution of a set of data; each bar on the horizontal axis represents
a subset of data, whereas the vertical axis indicates number or frequency
Nominal group technique/multivoting Team voting method
Pareto chart Bar graph that includes a second vertical axis to demonstrate cumulative percentage; the chart
is used to identify the vital few causes of a problem
PDSA (Plan–Do–Study–Act) Cycle Systematic, repeatable, and teamwork-based process for solving problems or realizing
opportunities for enhanced performance at the organizational, system, process, and
employee levels in order to achieve desired results
Process flowchart Graphical representation of the steps and decisions in a process
Run chart Graph that shows measurement (on the vertical axis) against time (on the horizontal axis)
occupational therapy or interprofessional programs rely on improvement opportunities and managing CQI teams tasked
and use paradigmatic knowledge, including theories, frames with analyzing problems so that solutions can be identified
of reference, and conceptual practice models, as well as re- and implemented; in this way, desired results are achieved.
lated knowledge developed in other disciplines and fields. CQI approaches such as the Plan–Do–Study–Act (PDSA)
Various program development models or frameworks Cycle are commonly used in health care (W. Edwards Dem-
exist in the literature of the occupational therapy profession ing Institute, 2014). The PDSA Cycle includes these 4 steps:
and related fields, but what follows is a simple 4-step model
1. Plan: The change to be tested or implemented
for understanding the program development process.
2. Do: Carry out the test or change
1. Needs assessment: The process of describing the target 3. Study: Examine the data before and after the change and
population, naming perceived and felt needs, and ana- reflect on what was learned
lyzing available resources and constraints both internal 4. Act: Plan the next change cycle or full implementation.
and external to the organization or context in which the
A short list of commonly used CQI tools and techniques is
program is being planned.
included in Table 2.1.
2. Program planning: The process of identifying the steps
and sequence of actions to be taken to plan for initiation
of the program. Review Questions
3. Program implementation: The process of initiating in-
tervention first in trial format and then in a more formal 1. What is the purpose of a competency statement or check,
and sustained manner. and how is it used by occupational therapy managers?
4. Program evaluation: The ongoing process of assessing 2. What traditional management function would include
the impact and quality of program processes and out- financial management? Why?
comes and making continuous improvements in effi- 3. Name the 4 components of the marketing process and
ciency and effectiveness. explain their purpose.
4. Briefly describe the 4 steps of the program development
process.
Continuous Quality Improvement 5. Is continuous quality improvement a management phi-
losophy, a management method, or both? Explain your
Continuous quality improvement (CQI) is both a manage-
answer.
ment philosophy and a management method. As a manage-
ment philosophy, CQI takes an organizational perspective:
setting direction and promoting strategically aligned im-
provement initiatives through leadership support, organiza
SUMMARY
tional learning, and resource allocation. As a management The role of occupational therapy managers can be complex
method, CQI provides a framework for identifying and includes a wide range of activities and functions. Most of
CASE EXAMPLE 2.1. Robin: Starting as a New Occupational Therapy Manager
Robin is a new occupational therapy manager in a small occupational therapy department in a community-based acute care hospital. She has
recently completed her orientation and has taken stock of priorities for the department and the team she will lead. She is anxious to apply all
she has learned about being an occupational therapy manager. Robin begins by thinking through her primary responsibilities and uses the
4 traditional management functions of planning, organizing, controlling, and directing as a framework to be sure she is not overlooking anything
important. She also begins an assessment of her skills and areas for improvement as a leader, manager, and supervisor.
Robin completes the important step of thinking about both the personal values that she holds and wants to exemplify as a leader and the values
of the organization that she has just joined. She begins to think about ways she can demonstrate her values of transparency, respect for others,
constant learning and discovery, and serving others as a leader. She also considers how she can demonstrate the organizational values of caring,
innovation, and person-centered care in her leader behaviors.
Robin decides to involve her staff in some visioning activities to include them in planning the future of the department and uses the results, along
with the results of a SWOT analysis, to begin a strategic plan. The plan will guide her focus and the focus of her staff for the next 3 years. She also
reaches out to others, such as physicians, nurses, physical therapists, case managers, and social workers, as key stakeholders in the products her
department provides for the organization.
Robin knows she has much to learn, including how to plan and manage the department finances, a responsibility that will be new for her.
During the interview process, she learned that demand for occupational therapy services was growing and that with the development of new
medical services lines (i.e., cancer rehabilitation in an inpatient rehabilitation unit), she would need to develop new occupational therapy
programming. She begins this process by assessing the current competencies of her staff and their needs for learning in new areas. She introduces
her staff to the principles of CQI and begins to guide them through the PDSA process to examine how they receive and schedule initial evaluations
in the hopes of making this process more efficient. During this process, she begins to use CQI tools such as a fishbone diagram (see Figure 2.2).
It’s just a start. As Robin continues to learn, she is confident that if she lets her values guide her, she will succeed.
Review Questions
1. What is the PDSA process, and how is it related to CQI and improving efficiency in scheduling initial evaluations?
2. What is values-based leadership, and how can it help to guide Robin’s decisions and actions?
3. What are competencies, and how can Robin use them to plan and deliver occupational therapy services in her organization?
FIGURE 2.2. Fishbone diagram on causes for extended time to receive and schedule initial evaluations.
CAUSES OF EXTENDED TIME TO RECEIVE

AND SCHEDULE INITIAL EVALUATIONS
Technology People
Use of paper logs

instead of electronic Too busy to
attend to referrals
No downtime procedure
Forget to log
new referrals
Incompetent employees
Too long to receive
and schedule
initial evaluations
Duplication in steps
No standardization
Assignment process
is confusing
Processes
these activities can be grouped under the commonly identi- ■ B.5.4. Systems and Structures That Create Legislation
fied functions of managers that include planning, organizing ■ B.5.5. Requirements for Credentialing and Licensure
(and sometimes staffing), controlling, and directing. Effective ■ B.5.6. Market the Delivery of Services
managers also function as leaders, and 1 model of leadership ■ B.5.7. Quality Management and Improvement
to consider is that of values-based leadership. Leaders who ■ B.5.8. Supervision of Personnel.
lead from a values-based perspective can help employees to
connect their everyday work to the core functions and mis-
sion of the organization. The topics addressed in this chapter For Additional Learning
and a range of other topics related to the occupational therapy
manager are explored in the remaining chapters of this text- For additional information about concepts discussed in this chapter,
book. Case Example 2.1 describes a new occupational therapy please refer to
manager learning to lead from a values-based perspective. ❖ ■ Chapter 1, “Theories of Leadership,”
■ Chapter 9, “Strategic Planning,”
■ Section VI, “Supervision,” and
LEARNING ACTIVITIES ■ Chapter 50, “Developing a Budget.”
1. At the start of the chapter, the difference between
management and leadership was introduced, as was the
concept of values-based leadership. Reflect on (a) your REFERENCES
personal values, (b) the values of the occupational ther- Accreditation Council for Occupational Therapy Education. (2018).
apy profession, and (c) the values you hope organizations 2018 Accreditation Council for Occupational Therapy Education
that you work for will hold. What would be possible (ACOTE) standards and interpretive guide. American Journal of
strategies for coming to terms with any conflicts you en- Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org
counter between your personal values and the values of /10.5014/ajot.2018.72S217
the occupational therapy profession or an organization? American Occupational Therapy Association. (2015). Standards
Where would you begin if you perceived a conflict in val- for continuing competence. American Journal of Occupational
Therapy, 69, 6913410055. https://doi.org/10.5014/ajot.2015.696S16
ues? How might you use resources provided by AOTA?
Braveman, B. (2016). Leading and managing occupational therapy
2. Working as an occupational therapy manager and com- services: An evidence-based approach. Philadelphia: F. A. Davis.
pleting the wide variety of tasks and responsibilities that Businessdictionary.com. (2017). Marketing. Retrieved from http://
fall to most managers is complex. Reflect on your cur- www.businessdictionary.com/definition/marketing.html
rent skills and experiences, and consider what learning or Durante, R. (2016). Value-based leadership and personality type: The
growth activities you could pursue if you were interested influence on organizational culture. In V. C. X. Wang (Ed.), En-
in a job as an occupational therapy manager or found cyclopedia of strategic leadership and management (pp. 662–685).
yourself in a position where you had to manage occupa- Hershey, PA: IGI Global.
tional therapy services for a time. What strengths do you McGrath, R. G. (2014). Management’s three eras: A brief history.
have that you could leverage, and what areas would you Retrieved from https://hbr.org/2014/07/managements-three-eras
need to focus on most to begin a path toward being an -a-brief-history
Mendonca, M., & Kanungo, R. N. (2007). Ethical leadership.
effective occupational therapy manager?
New York: Open University Press.
Peregrym, D., & Wollf, R. (2013). Values-based leadership: The foun-
ACOTE STANDARDS dation of transformational servant leadership. Journal of Value-
Based Leadership, 6(2), Art. 7. Retrieved from https://scholar.valpo
This chapter addresses the following ACOTE Standards: .edu/cgi/viewcontent.cgi?article=1084&context=jvb
van Niekerk, M., & Botha, J. (2017). Value-based leadership approach:
■ B.4.25. Principles of Interprofessional Team Dynamics A way for principals to revive the value of values in schools.
■ B.4.27. Community and Primary Care Programs Educational Research and Reviews, 12, 133–142. https://doi.org
■ B.4.29. Reimbursement Systems and Documentation .10.5897/ERR2016.3075
■ B.5.1. Factors, Policy Issues, and Social Systems W. Edwards Deming Institute. (2014). PDSA Cycle. Retrieved from
■ B.5.3. Business Aspects of Practice. https://deming.org/explore/p-d-s-a
Leadership vs. Management: CHAPTER
Differences and Skill Sets
Debi Hinerfeld, PhD, OTR/L, FAOTA 3
LEARNING OBJECTIVES
■ Differentiate between leadership and management intentions or behaviors,
■ Discuss how a blended approach of leadership and management promotes effective team work and continuity of lead-
ership in the future, and
■ Recognize themselves as leaders and begin to develop a personal leadership trajectory and action plan.

• Interprofessional health • Management • Transformational
care teams • Managers • Values
• Leaders • Paradigm shift • Vision
• Leadership • Power
OVERVIEW improved outcomes” (Lamb, 2016, p. 3). In response, health
L
care organizations seek professionals who can be instrumen-
eadership and management are 2 different but integrally tal in the administrative processes of planning, communicat-
related skill sets that are critical to organizational suc-
ing, implementing, and sustaining an organization as well
cess in a rapidly changing health care environment. To
as assist in strengthening and moving their organizations
understand and appreciate leadership requires a paradigm
forward while managing change (Phipps, 2015). At the same
shift, which is a change in beliefs from those previously held
time, strong leaders are needed to advocate effectively for the
about managerial approaches used in the past. Current con-
distinct value of occupational therapy in new service deliv-
cepts of leadership are focused on a distribution of power
from an individual to a team that works collaboratively to ery models, not only in their organizations but also in policy
develop proactive and innovative solutions to organizational decision-making circles, to ensure that occupational therapy
challenges. Management has always been based on the ad- becomes a highly valuable and viable solution during health
ministrative authority of someone who plans, organizes, care reform (Lamb, 2016).
directs, and controls employees in their daily tasks and main- This chapter seeks to differentiate leadership and man-
tains stability and consistency of individuals’ work. Today’s agement on the basis of intentions and behaviors, guiding
challenges create a strong demand for both leadership and readers toward an understanding of how a combination of
management for organizations to prosper in uncertain times. approaches helps move organizations and advocacy efforts
The Triple Aim of health care reform, which was designed forward in meaningful and effective ways. This chapter also
to reduce costs while improving quality and efficiency of ser- discusses the importance of the concept that “every member
vices, has a significant impact on health care; it focuses on [be] a leader” (Stoffel, 2014, p. 634) and practical ways that
“interprofessional primary health care, new models for pay- occupational therapy practitioners can further develop their
ment, and an emphasis on value as demonstrated through leadership capacities.
https://doi.org/10.7139/2019.978-1-56900-592-7.003
27
Leadership vs. Management: CHAPTER
Differences and Skill Sets
Debi Hinerfeld, PhD, OTR/L, FAOTA 3
LEARNING OBJECTIVES
■ Differentiate between leadership and management intentions or behaviors,
■ Discuss how a blended approach of leadership and management promotes effective team work and continuity of lead-
ership in the future, and
■ Recognize themselves as leaders and begin to develop a personal leadership trajectory and action plan.

• Interprofessional health • Management • Transformational
care teams • Managers • Values
• Leaders • Paradigm shift • Vision
• Leadership • Power
OVERVIEW improved outcomes” (Lamb, 2016, p. 3). In response, health
L
care organizations seek professionals who can be instrumen-
eadership and management are 2 different but integrally tal in the administrative processes of planning, communicat-
related skill sets that are critical to organizational suc-
ing, implementing, and sustaining an organization as well
cess in a rapidly changing health care environment. To
as assist in strengthening and moving their organizations
understand and appreciate leadership requires a paradigm
forward while managing change (Phipps, 2015). At the same
shift, which is a change in beliefs from those previously held
time, strong leaders are needed to advocate effectively for the
about managerial approaches used in the past. Current con-
distinct value of occupational therapy in new service deliv-
cepts of leadership are focused on a distribution of power
from an individual to a team that works collaboratively to ery models, not only in their organizations but also in policy
develop proactive and innovative solutions to organizational decision-making circles, to ensure that occupational therapy
challenges. Management has always been based on the ad- becomes a highly valuable and viable solution during health
ministrative authority of someone who plans, organizes, care reform (Lamb, 2016).
directs, and controls employees in their daily tasks and main- This chapter seeks to differentiate leadership and man-
tains stability and consistency of individuals’ work. Today’s agement on the basis of intentions and behaviors, guiding
challenges create a strong demand for both leadership and readers toward an understanding of how a combination of
management for organizations to prosper in uncertain times. approaches helps move organizations and advocacy efforts
The Triple Aim of health care reform, which was designed forward in meaningful and effective ways. This chapter also
to reduce costs while improving quality and efficiency of ser- discusses the importance of the concept that “every member
vices, has a significant impact on health care; it focuses on [be] a leader” (Stoffel, 2014, p. 634) and practical ways that
“interprofessional primary health care, new models for pay- occupational therapy practitioners can further develop their
ment, and an emphasis on value as demonstrated through leadership capacities.
https://doi.org/10.7139/2019.978-1-56900-592-7.003
27
ESSENTIAL CONSIDERATIONS little regard to external forces that can have a tremendous
impact on the viability of the organization in changing times.
Current health care challenges in the United States require an
understanding and a strong belief in systemic, postindustrial
managerial approaches that are visionary, collaborative, and Leaders focus on relationships, managers focus
interprofessional, rather than reactive, hierarchical, and au- on operational procedures.
thoritative (Komives, 2013). Beliefs around management and Leaders focus on people, whereas managers focus on the
leadership can be construed and misconstrued through dif- completion of established procedures. By developing strong
ferent assumptions based on power, defined as influence, con- relationships with others, leaders know who their teams and
trol, or authority over others (Edwards et al., 2015; “Power,” stakeholders are and how best to serve them. They establish di-
n.d.). Although there are notable differences between a pure rection by setting the bar high, aligning resources, inspiring,
managerial approach and a pure leadership approach, the dif- and motivating people to move the organization forward de-
ferences between management and leadership are primarily spite challenges. Leaders trust that their teams are equally pas-
based on intention and behaviors. sionate about the vision and empower teams to be innovative.
Leaders create a culture of community and do not microman-
Differences Between Management age to ensure that people are engaged in meaningful work that
and Leadership motivates them to work at higher levels. They publicly recog-
nize and celebrate individual and team contributions, provide
Theorists on management and leadership believe that despite social outlets to support collaboration, and demonstrate that
similarities between leadership and management approaches, they care by being personally involved (Kouzes & Posner, 2017).
very distinct differences exist between them. Functions and Management focuses on getting work done through people
behaviors of management do not automatically translate into and processes, relying on authority and control to keep peo-
leadership. Rather, leadership is determined by a person’s be- ple and projects moving forward. Managers assign and closely
havior and overall effectiveness while guiding others toward supervise tasks, often with little input from the individuals
the achievement of organizational goals. In hierarchical orga- carrying out the job. They set standards, establish consistency
nizational structures, managers often manage through an au- and predictability, and create order (Arruda, 2016).
thoritative approach to the achievement of short-term orga-
nizational goals, directing others through a specific chain of
command (Carpenter et al., n.d.; Cox, 2016). Leadership is a
Leaders inspire and empower, managers direct
highly relational and ethical process that inspires individuals and control.
to work together to create necessary changes that effectively It is no longer believed that leaders must have special attri-
move an organization toward an ideal model of the future butes or titles to influence and motivate others to join them
despite challenges. in leadership efforts (Kruse, 2013). Leaders inspire others by
Leaders serve others and develop future leaders. Both being authentic, which comes from an acute self-awareness
leaders and managers establish direction, align resources, and the ability to be honest about personal beliefs, values, at-
and motivate teams toward organizational goals. Although titudes, and emotions. Behaving in ways that are congruent
management is focused on planning, organizing, directing, with their beliefs and values, personal expressions of what is
and controlling day-to-day employee tasks, leadership is a important to them, leaders model the way, setting examples
strategic approach focused on inspiring and empowering for others to do the same (Kouzes & Posner, 2017). Leaders
teams to pave alternative paths in organizational processes empower teams by providing all necessary resources and
that make it possible to achieve the collective vision. clearing the path of obstacles so that they can strategically
focus on necessary changes and desired outcomes.
Managers are responsible for delegating responsibilities
Leaders create vision, managers set goals. and evaluating performance. Although directing and con-
A vision represents an ideal model of the future that implies trolling employees ensures that they are responsibly doing
change and challenges organizations to transcend the status the job that they were hired to do, it is also important that
quo (Phipps, 2015). Leaders inspire others by enthusiastically employees are engaged in meaningful, satisfying work to en-
communicating a clear and compelling vision that influ- courage high performance (Carpenter et al., n.d.; Cox, 2016).
ences actions toward the achievement of organizational goals
(Kouzes & Posner, 2017; Kruse, 2013; Surbhi, 2015). The vi-
Leaders challenge the process, managers
sion brings individuals together for common purposes. It fo-
maintain the status quo.
cuses team efforts on the horizon while navigating challenges
presented by a constantly changing external environment. Leaders support good ideas and encourage risk taking in sup-
Managers dutifully oversee employees’ work toward the port of innovative best practices (Phipps, 2015). They are flexible,
achievement of predictable and short-term objectives. They forward thinking, enthusiastic, and confident, and they are will-
are mainly concerned with individual performance and mea- ing to try something new that could support the team’s mission
surement of outcomes that are focused on operations with and vision. They fully realize that change is often a byproduct
CHAPTER 3. Leadership vs. Management: Differences and Skill Sets 29
TABLE 3.1. Complementary Process Differences Between Leaders and Managers
PROCESS LEADER MANAGER

Developing a plan ■ Establishes direction ■ Plans and budgets
■ Envisions the future ■ Assigns action and sets schedules
■ Is Passionate about the vision and facilitates change ■ Allocates resources
Developing people ■ Aligns people with goals ■ Organizes staffing

■ Communicates vision and strategy ■ Develops policies and procedures
■ Establishes teams ■ Monitors progression of work
Operations ■ Motivates and inspires ■ Controls

■ Removes obstacles and barriers to success ■ Short-term problem solver
■ Focused on order, predictability, and consistency
Outcomes ■ Focused on change ■ Monitors results against plan and takes corrective action
Source. Adapted from Kotterman (2006).
of innovation, and they empower their teams to think creatively outcomes. At the highest level of guidance toward envisioned
about alternative paths moving forward. Although innovation outcomes, leaders and managers must have complementary
may result in failure, leaders understand that failure is often a skill sets and adopt a blended approach (Delmatoff & Lazarus,
critical step toward success and that much can be learned from 2014). See Table 3.1 to understand how leadership and man-
what did not work the first time (Arruda, 2016). agement processes complement each other.
Managers are more likely to take a low-risk approach to Taken together, management and leadership are consid-
problem solving because their focus is on short-term de- ered transformational because they prompt both leaders and
cision making, bringing stability to processes that have al- followers to adhere to higher levels of ethical aspirations and
ways worked in the past rather than thinking about how to conduct when pursuing a shared purpose toward organiza-
do things differently in the future. They avoid risk of failure tional change (Komives, 2013). Effective transformational
by reactively controlling problems, developing process steps, leadership is critical to sustaining long-term efforts toward
and setting timelines for accomplishment when something the vision, particularly during health care reform when
gets out of sequence or control (Bârgău, 2015; Ross, 2014). change is inevitable (Phipps, 2015). Transformational leaders
must be able to create an inspirational vision and build orga-
Leaders believe in lifelong leadership nizational capacities to manage change that leads to better
development, managers maintain existing skills. health care solutions. Rapid changes in the health care en-
vironment, however, require effective management to ensure
Leaders believe that learning is a lifelong process and that organizational sustainability (Trastek et al., 2014).
their development is never complete. They are seekers of infor- During challenging times, transformational leaders inspire
mation and higher-level leadership experiences that expand employees toward an optimistic future by meaningfully en-
and diversify their skills. Leaders strengthen the leadership gaging them in decision-making processes, problem solving,
capacities of others by engaging them in meaningful expe- and creating solutions that support systems improvement and
riences, whereby the cycle of leadership grows exponentially project management (Gousy & Green, 2015; Phipps, 2015). As
as those leaders continue the process (Solomon et al., 2016). organizations implement strategic change in response to new
Because management is based on completing predictable policy mandates and diverse payer models, a transformational
tasks, managers typically rely on existing skill sets that have approach is necessary to maintain high engagement and for-
enabled employees to perform successfully. Managers who ward momentum at all employee levels. Transformational
take a management approach may perfect the execution of leaders create a culture of leadership by which employees lead
tasks with practice, but they are not necessarily focused on one another in efforts toward the vision while the leader effec-
developing higher level skills for themselves or others. tively manages resources that support their work.
Leadership and Management as Review Questions

Complementary Approaches
1. The difference between leadership and management is
With the many changes affecting the health care industry, now based on
is certainly not the time to take a 1-size-fits-all approach to a. Values and power
business operations. Management with insufficient leadership b. Intentions and behavior
can be overbearing and bureaucratic, and leadership without c. Control and budgeting
management can lead to inefficient efforts toward purposeless d. Directing and planning
2. In hierarchical organizational structures, managers often Seeking Organizational Opportunities

take an approach to the achievement of short-
Employees have many opportunities to practice and develop
term organizational goals.
leadership skills; they can serve on committees, participate
a. Organized
in the development of new policies or procedures, conduct
b. Repetitive
research, or organize professional development with col-
c. Authoritative
leagues. Occupational therapy practitioners have oppor-
d. Friendly
tunities to develop their leadership skills while serving on
3. A vision represents an ideal model of the future that
interprofessional health care teams.
implies
Interprofessional health care teams comprise individu-
a. Progress
als from multiple health care disciplines who agree to share
b. Change
their point of view and expertise and are open to learning
c. Status quo
and sharing in a trusting environment to help solve organi-
d. Acuity
zational problems. These teams instill a sense of leadership
in everyone regardless of hierarchical role, title, or position.
PRACTICAL APPLICATIONS IN It is through leadership actions, passion, and dedication that
OCCUPATIONAL THERAPY leaders continue to develop their own leadership skills and
prepare to take on higher level leadership challenges.
Occupational therapy leaders have been successful in ex-
panding practices in alternative practice settings and have
Identifying Values
improved public awareness of occupational therapy over
the past 100 years. The American Occupational Therapy Leadership can be developed in any context of life and often
Association (AOTA) has positioned the profession well to- occurs when one has very little awareness that it is happen-
ward Vision 2025, which is designed to “maximize health, ing. Mentoring a recent occupational therapy graduate who
well-being, and quality of life for all people, populations, is new to practice, volunteering to organize social activities
and communities through effective solutions that facili- within the department, and describing occupational ther-
tate participation in everyday living” (AOTA, 2017b, p. 1). apy to someone who has never heard about it before are all
However, as current occupational therapy leaders begin to examples of leadership that builds on leadership capacities.
retire and significant changes continue to happen in the Engagement in leadership often starts when one’s personal
world, there is a critical need for every occupational ther- core values align with those of others who are also motivated
apy practitioner to practice leadership to continue moving to make a positive difference toward a greater good. People’s
the profession forward, particularly during challenging values inform their leadership practices and drive them to
times. focus on what they believe, setting an example for others.
(Readers can identify their core values by doing the values
Developing Occupational Therapy Leaders card sort activity in Appendix 1.A in Chapter 1, “Theories
of Leadership.”) Authentically demonstrating core values
Regardless of title or position, leadership is everyone’s busi- through actions and words is the most powerful way that
ness (Stoffel, 2014). It is crucial that the profession of oc- leaders influence others and have a broad impact.
cupational therapy develop leaders in all areas of practice,
research, and education to sit confidently at policy and
Becoming Lifelong Learners
payment decision-making tables (Stoffel, 2014). Developing
occupational therapy leaders will generate a collective power It is important that professionals become lifelong learners
that is necessary to clearly articulate the distinct value of the and understand how to find leadership development oppor-
profession as a client-centered and occupation-based profes- tunities in different contexts of practice. Practitioners should
sion, to develop strong evidence behind occupational ther- always have a long-range plan and consider where they want
apy practices, to provide quality and cost-effective services, to be in 5 or 10 years to establish time frames for advanc-
and to ensure inclusion in new health care and payment ing career goals. Occupational therapy students and practi-
models. tioners must envision themselves as future administrators,
Knowing that leaders are developed, and believing that department heads, team leaders, board or specialty certified
everyone has the capacity to become a leader, occupational practitioners, clinical education coordinators, professors,
therapy practitioners have always been encouraged to take postgraduate fellows, CEOs of a health care company, or
the leadership challenge and say “yes” to opportunities. college or university presidents.
Within organizational structures, occupational therapy prac- Reflection on past leadership participation is important to
titioners are uniquely positioned to develop and demonstrate realize leadership capacities that have been developed and to
leadership capacities that easily translate into administrative have the confidence to seek out higher level leadership op
positions in traditional as well as nontraditional areas, such portunities when they present themselves in the future. Oc-
as primary care, private practice, practice in underserved cupational therapy practitioners who serve in leadership roles
areas, and research (Rogers et al., 2016). grow professionally through their leadership experiences,
gaining skills in other critical professional areas such as stra- Review Questions
tegic planning, management, interpersonal communication,
1. Leaders and managers must have a complementary skill
and collaborative problem solving.
set and adopt what type of approach?
a. Forced
Participating in Professional Organizations b. Visionary
c. Blended
Occupational therapy practitioners have opportunities to
d. Controlled
develop their leadership skills not only in their jobs but also
2. Transformational leadership can be described as every-
through their involvement in professional organizations.
thing listed except
Practitioners who become lifelong members of their state oc-
a. Inspiring
cupational therapy association and AOTA are acknowledging
b. Engaging
that they are mindful of their professional responsibility and
c. Visionary
willing to support the profession as it moves into the next
d. Preventing change
100 years. These associations rely deeply on members’ financial
3. Who should assume leadership of the profession of occu-
support of valuable practice, legislative, and educational bene-
pational therapy?
fits and members’ volunteer efforts to help guide and shape the
a. AOTA Board members
profession while it navigates a challenging future. Members
b. Only members of professional associations such as
have opportunities through state and national occupational
state occupational therapy associations and AOTA
therapy organizations to participate in legislative days at the
c. AOTA employees
state or national capital and meet their legislators and educate
d. Everyone
them on occupational therapy and its distinct value as an es-
sential health service. Members may also practice advocacy
by getting involved in grassroots letter or email writing cam-
paigns to legislators on hot political topics that affect practice
SUMMARY
and patient access to occupational therapy services. Leadership and management represent different but com-
Occupational therapy practitioners have opportunities to plementary administrative approaches. Having visionary,
share their leadership and expertise by running for an elected collaborative, and innovative teams is important; similarly,
position or applying for an appointment to an ad hoc or stand- management processes such as planning, directing, budget-
ing committee. Online continuing education on leadership de- ing, and organizing are also necessary to keep teams focused
velopment is available at a discount for all members of AOTA. on goals and action plans that move organizations forward.
Early career practitioners, middle managers, and educators This chapter describes leadership and management as sep-
have opportunities to apply for the AOTA mentored leader- arate skill sets and emphasizes that differences are based on
ship development institutes offered annually. The profession of interpersonal relationships, style, approach, behaviors, and
occupational therapy also benefits when occupational therapy perception of power. Health care administrators who use
leaders actively serve in their communities on organizational a blended leadership and management approach are more
boards and committees; at organized events; and as political likely to benefit from the collective effort of engaged employ-
leaders to educate the public about the benefits of occupational ees in efforts that move the organization forward, particu-
therapy to individuals, communities, and populations. larly in a challenging environment that is difficult to navigate.
It is essential that occupational therapy practitioners
consider the development of leadership skills as part of their
Modeling Self-Care
professional development (see AOTA, 2015, for standards
Leaders who take care of themselves are better equipped to for continuing competence and AOTA, 2017a, for informa-
take care and serve others. It is important to evaluate work– tion on continuing professional development in occupational
life balance and time considerations when deciding to commit therapy). Occupational therapy leaders are needed at all lev-
to a leadership opportunity. Leaders know that they must be els of practice, education, and research to communicate the
present, available, accountable, and at their best to model and distinct value of the profession and to develop future lead-
promote leadership for others. They are kind to themselves ers. Administrative leaders who are also occupational ther-
when they stretch themselves to grow, set short timelines, apy practitioners are uniquely positioned to communicate
work hard but within their limitations, forgive themselves for how inclusion of occupational therapy in client services can
responsible failure, and believe that success may come from support organizational efforts aimed at the challenge of pro-
second chances (Rockwell, 2017; see Case Example 3.1). viding quality care with fewer resources that also decreases
Taking care to practice what we preach and engage in overall health care costs.
meaningful occupations such as eating and sleeping well, get- Authentic leaders inspire and motivate others by sharing
ting adequate exercise, taking time to play, and spending time values and establishing common purposes, developing strong
with family and friends are all very important to remaining relationships with team members, and allowing teams to be
physically and mentally healthy and to continue functioning innovative; they challenge current processes that may be bar-
effectively in a leadership role. riers to achieving the vision. Leaders are not afraid of failure
CASE EXAMPLE 3.1. Balancing the Roles of Leader and Manager
Sue is the director of occupational therapy at a community-based outpatient wellness and rehabilitation center known for its positive,
interprofessional, and highly supportive work environment and excellent patient care. She supervises 15 occupational therapy practitioners and
directs operations of the department to ensure that her department is engaged in efforts to achieve the center’s vision to be the premier wellness
and rehabilitation center in the city.
As the director, Sue must balance her role as a manager with leading her staff toward excellent patient care and professional development. She
values the diverse number of years of experience and specialty practice areas that each person brings to the department. Knowing that meaningful
and challenging work as well as a friendly and collaborative work environment translates into more satisfied employees, Sue strives to ensure that
each one of her employees has opportunities to grow professionally and have fun together.
Everyone in the department appreciates knowing that Sue welcomes feedback on how the department is operating and that she values staff
ideas and involvement in centerwide strategic initiatives. As a team, Sue and her staff recently discussed the increased productivity standards
and determined that they were too high for the department. As a manager, Sue understands that it is necessary to balance staff concerns and
professional ethics while maintaining the fiscal strength of the department. She took time to explain the fiscal goals of the department and
appointed a team to develop innovative ideas that members of her department could implement to increase revenue, while maintaining ethical
productivity standards.
At staff meetings, Sue shares updates on centerwide initiatives and seeks ideas from her staff on how best to implement new processes with
success. When an interdepartmental quality assurance initiative was being introduced, Sue asked Amy to attend interprofessional centerwide
meetings and organize and lead efforts within the department. Amy is a new therapist but always has good ideas on how to manage risk in the clinic
(e.g., by posting signs to clean up water spills or making sure that the oven is turned off after sessions). Amy was thrilled that Sue recognized her in
this way and was excited to learn something new and be instrumental in leading her colleagues toward higher quality outcomes.
While supervising a student, Matt had an idea to organize a journal club within the department that could help him and his colleagues become
better evidence-based practitioners. Sue thought this was a wonderful idea. She not only gave Matt and his student time to organize and plan for a
monthly journal club but also went to the center administrator to request a subscription to an online journal repository so that all practitioners could
have access to current research for their discussions and for future reference.
As an occupational therapy practitioner, Sue feels strongly that it is a professional responsibility to be a member of both the state and national
occupational therapy associations; she regards it as professionally beneficial as well. She believes that when people come together collectively,
they are more powerful in influencing policy decisions, and she highly valued the resources available for continuing competence, practice guidance,
and advocacy. Sue often mentions her use of the AOTA website to download consumer tip sheets for her clients and her use of the evidence-based
practice resources when discussing the value of occupational therapy with external audiences, such as other program managers in the center and
external stakeholders. As an incentive to join, Sue includes professional association memberships and participation in leadership as criteria for
moving forward in career ladders. Sue is happy to learn that everyone on her staff joined both the state association as well as the AOTA. In return,
Sue frequently points out opportunities for leadership that would fit well with individuals in her department and encourages them to apply. Believing
that each member of her staff is a potential leader, Sue is not surprised to learn that four individuals have been elected or appointed to positions at
the state and national association levels.
Sue appreciates her team and how hard they work to support her and the department as a valued therapy service within the center. She gets
to know her staff and pays attention so that she can personally recognize individuals for their contributions. She promotes supportive relationships
at work so that others feel a sense of connection with coworkers, fostering accountability, engagement, and commitment to the team and to the
center (Kouzes & Posner, 2017). Birthdays are celebrated once a month and recognition celebrations are frequent.
As a busy manager and mother of 2 children, Sue knows that it is important to take care of herself so that she can continue to help others. She
makes sure that she is eating healthy foods, exercising, getting enough sleep, and making time to have fun with family and friends. She takes
time to regularly reflect on where she has been in her career and her professional goals for the future and thinks about how to develop others into
leaders who can join her on her journey.
Review Questions
1. When Sue involved her staff in problem solving and decision making around productivity standards, she was
a. Directing
b. Managing
c. Controlling
d. Leading
2. Educating and engaging her department on the vision is
a. Condescending
b. Directing
c. Inspiring
d. Evaluating
3. By encouraging her employees to join their state and national occupational therapy associations, Sue was influencing all the following except
a. Professional responsibility
b. Leadership
c. Professional development
d. Control
and are willing to take risks to generate small wins. Manag- ACOTE STANDARDS
ers without a complementary leadership approach may be
focused on the accomplishment of meaningless day-to-day This chapter addresses the following ACOTE Standards:
tasks and do little to motivate employees to tackle difficult ■ B.5.2. Advocacy
organizational challenges from external forces. ■ B.5.8. Supervision of Personnel
The ability to lead is not based on position or title and can ■ B.7.2. Professional Engagement
be developed by anyone at any time. It is important that em- ■ B.7.3. Promote Occupational Therapy
ployees think of themselves as leaders and set leadership de- ■ B.7.5. Personal and Professional Responsibilities.
velopment goals as part of their career trajectory. As current
leaders retire in areas of administration, practice, academia,
and research, the need is acute for emerging and established For Additional Learning
leaders to step into those positions to continue communicat-
ing occupational therapy’s strength as a viable and valuable For additional information about concepts discussed in this chapter,
health care discipline. Administrative and volunteer leaders see Chapter 1, “Theories of Leadership.”
have opportunities to develop leadership in themselves and in
others through the leadership process. Identifying leadership
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Evolution and Future of Occupational Therapy CHAPTER
Service Delivery
Anne M. Haskins, PhD, OTR/L, and Debra J. Hanson, PhD, OTR/L, FAOTA 4
LEARNING OBJECTIVES
■ Understand the evolution and funding sources of existing health care systems;
■ Understand the influence of population needs, legislation, and scientific discovery on health care services development;
■ Explore current trends in occupational therapy service delivery;
■ Identify current population needs and implications for occupational therapy services;
■ Explore future occupational therapy service delivery models; and
■ Consider steps for influencing future public policy.

• Baby Boomers • Millennials • Reimbursement
• Interprofessional collaborative • Primary care • Telehealth
practice • Private health insurance • Triple Aim
• Managed care
OVERVIEW care organizations. At the end of the 19th century, all health
care was provided in the home. However, public health facili-
H
ealth care delivery in the United States is influenced by ties were developed for the indigent population, in the form of
the dynamic interplay among societal needs, public local and state-run sanatoriums for individuals with chronic
health care policy, legislative and judicial decisions, sci-
medical and mental health concerns (Wall, 2015).
entific discovery, and the reimbursement structures underly-
Over the course of the first 2 decades of the provision of
ing each context. In this chapter, we first consider the evolution
occupational therapy services, a great deal of momentum was
of health care systems within the United States, the associated
achieved in these settings; providers offered diversional, recu-
reimbursement structures, and changes to these systems and
perative, and vocation-focused therapy appropriate for graded
structures over time. We explore current trends in occupa-
activity during a lengthy convalescence (Friedland & Silva,
tional therapy service delivery and reflect on their develop-
2008). However, by 1919, approximately 123,000 soldiers with
ment. Consideration of population needs sets the stage for
examining future opportunities for occupational therapy and disabilities had returned to the United States after World War I,
associated service delivery models. The chapter concludes with and the country was compelled to provide federally funded
some thoughts about steps for influencing future public policy. medical and rehabilitative services for these veterans (Gritzer
& Arluke, 1985). A renewed sense of social responsibility devel-
oped as people became more aware of social problems. In par-
ESSENTIAL CONSIDERATIONS ticular, a growing number of individuals were injured in work
accidents resulting from industrialization (Quiroga, 1995).
Evolving U.S. Health Care Systems: History of
By the 1920s, new scientific discoveries, as well as physician
Health Care Organizations and Settings credentialing and regulation by the American Medical Asso-
The history of the occupational therapy profession in the ciation (AMA), were changing the hospital from a warehouse
United States is closely aligned with the development of health of care for the indigent to a place where modern and antiseptic
https://doi.org/10.7139/2019.978-1-56900-592-7.004
35
Evolution and Future of Occupational Therapy CHAPTER
Service Delivery
Anne M. Haskins, PhD, OTR/L, and Debra J. Hanson, PhD, OTR/L, FAOTA 4
LEARNING OBJECTIVES
■ Understand the evolution and funding sources of existing health care systems;
■ Understand the influence of population needs, legislation, and scientific discovery on health care services development;
■ Explore current trends in occupational therapy service delivery;
■ Identify current population needs and implications for occupational therapy services;
■ Explore future occupational therapy service delivery models; and
■ Consider steps for influencing future public policy.

• Baby Boomers • Millennials • Reimbursement
• Interprofessional collaborative • Primary care • Telehealth
practice • Private health insurance • Triple Aim
• Managed care
OVERVIEW care organizations. At the end of the 19th century, all health
care was provided in the home. However, public health facili-
H
ealth care delivery in the United States is influenced by ties were developed for the indigent population, in the form of
the dynamic interplay among societal needs, public local and state-run sanatoriums for individuals with chronic
health care policy, legislative and judicial decisions, sci-
medical and mental health concerns (Wall, 2015).
entific discovery, and the reimbursement structures underly-
Over the course of the first 2 decades of the provision of
ing each context. In this chapter, we first consider the evolution
occupational therapy services, a great deal of momentum was
of health care systems within the United States, the associated
achieved in these settings; providers offered diversional, recu-
reimbursement structures, and changes to these systems and
perative, and vocation-focused therapy appropriate for graded
structures over time. We explore current trends in occupa-
activity during a lengthy convalescence (Friedland & Silva,
tional therapy service delivery and reflect on their develop-
2008). However, by 1919, approximately 123,000 soldiers with
ment. Consideration of population needs sets the stage for
examining future opportunities for occupational therapy and disabilities had returned to the United States after World War I,
associated service delivery models. The chapter concludes with and the country was compelled to provide federally funded
some thoughts about steps for influencing future public policy. medical and rehabilitative services for these veterans (Gritzer
& Arluke, 1985). A renewed sense of social responsibility devel-
oped as people became more aware of social problems. In par-
ESSENTIAL CONSIDERATIONS ticular, a growing number of individuals were injured in work
accidents resulting from industrialization (Quiroga, 1995).
Evolving U.S. Health Care Systems: History of
By the 1920s, new scientific discoveries, as well as physician
Health Care Organizations and Settings credentialing and regulation by the American Medical Asso-
The history of the occupational therapy profession in the ciation (AMA), were changing the hospital from a warehouse
United States is closely aligned with the development of health of care for the indigent to a place where modern and antiseptic
https://doi.org/10.7139/2019.978-1-56900-592-7.004
35
surgical and medical procedures were available and recovery

and cure could be achieved (Wall, 2015). Although hospitals TABLE 4.1. Types of Health Care Organizations
were clearly the way of the future, by 1938 only 13% of hospi-
TYPE OF
tals approved by the AMA had qualified occupational therapy
ORGANIZATION GENERAL DESCRIPTION
practitioners on their staffs; the majority of practitioners were
still employed in mental institutions, tuberculosis sanatori- Federal government ■ Hospitals serving disabled veterans
ums, and penal institutions (Andersen & Reed, 2017). ■ Hospitals serving Armed Forces and Coast
World War II ushered in the rehabilitation movement, Guard
■ Indian Health Service
and as a result, rehabilitation departments were developed,
■ Public Health Service hospitals and clinics
first within the veterans’ hospitals and then as nonprofit and (including leprosarium)
for-profit entities. Medical advances made during the war, ■ Medical facilities associated with prisons
such as the invention of antibiotics, allowed more soldiers
to survive, but their physical handicaps hampered their re- State government ■ Infirmaries associated with prisons and
turn to independent living. Therefore, occupational therapy reformatories
shifted attention from providing diversional, recuperative, ■ Hospitals for people with mental illness
■ State medical school hospitals and clinics
and vocational-focused therapy to ADLs and other areas that
promote client independence (Andersen & Reed, 2017). At the Local government ■ City hospitals and clinics
same time, diseases common in the United States before the ■ County hospitals and public health clinics
war, such as tuberculosis and polio, were eliminated through
Nonprofit ■ Charity hospitals
scientific discoveries; subsequently, many sanatoriums that had
organization ■ Community hospitals
been built for individuals with those conditions were closed.
■ HMOs
As doors closed for occupational therapy involvement in ■ Home health facilities
sanatoriums, legislation opened the door for occupational ■ Hospices
therapy involvement in hospital settings. The Vocational ■ Industrial hospitals and clinics
Rehabilitation Act Amendments of 1943 (P. L. 78–113; for- ■ PPOs
mally, the Barden–LaFollette Act) provided funds for physical ■ Private teaching hospitals
restoration services as part of vocational rehabilitation pro- ■ Specialty hospitals
grams (Gritzer & Arluke, 1985), and the Hospital Survey and ■ Surgical centers
Construction Act of 1946 authorized federal grants to states ■ Wellness centers
for construction and modernization of hospitals throughout For-profit ■ Facilities owned by individuals or groups for
the United States (Wall, 2015). organization the care of their own patients or clients
These initiatives coincided with Franklin D. Roosevelt’s in- ■ Investor-owned facilities (e.g., hospitals,
troduction of the Economic Bill of Rights in 1944; he affirmed laboratories, nursing homes, surgical
in his State of the Union address (Roosevelt, 1944) the right of centers, rehabilitation facilities, home health
every American to achieve and enjoy good health, thereby set- facilities, HMOs, PPOs, hospices), including
ting the stage for the growth of nonprofit and for-profit health corporations and management corporations
care organizations (Andersen & Reed, 2017). Charity and com- ■ Walk-in medical clinics
munity hospitals were formed first, but others were established Note. HMOs = health maintenance organizations; PPOs = preferred provider
as population needs expanded. Coinciding with advances in organizations.
medicine, demographic shifts, and changing family structures, Source. From K. Jacobs, 2011, “Evolution of occupational therapy delivery
geriatric care was introduced in the 1950s, and it was expanded systems,” in K. Jacobs & G. L. McCormack (Eds.), The Occupational Therapy
Manager (5th ed., p. 41), Bethesda, MD: AOTA Press. Copyright © 2011 by
with support from legislation related to Medicare. AOTA Press. Used with permission.
Care in the United States is currently delivered through
federal, state, and private institutions. Examples are pre-
sented in Table 4.1. U.S. Department of Health and Human Services [DHHS],
n.d.). The viability of occupational therapy as a health care
Reimbursement for Health Care service is dependent on availability of reimbursement sources
and reimbursement eligibility.
Reimbursement is payment for medical or health care ser-
vices (Vennes, 2009) and an essential component of the con-
Private health insurance
tinued existence of any health care organization. The U.S.
reimbursement system comprises private health insurance Private health insurance, also referred to as commercial
and federally funded health insurance programs, including plans, is purchased by employers or by individuals (Barnett
Medicare (Medicare Law of 1965), Medicaid (established & Berchick, 2017) and, although it is identified as “private,”
with Medicare), the Children’s Health Insurance Program it is affected by federal subsidies (to offset costs and make in-
(CHIP; established by the Balanced Budget Act of 1997), and surance more affordable to people with lower incomes) and
coverage for military personnel (Barnett & Berchick, 2017; policy (Congressional Budget Office [CBO], n.d.). The cost of
CHAPTER 4. Evolution and Future of Occupational Therapy Service Delivery 37
private health insurance continues to rise. Though the rise members’ families account for an additional 1.8 million
of premiums has slowed in recent years, recent orders by the people (DoD, 2015). Insurance coverage is also available for
U.S. administration may affect the cost of private health in- military personnel, veterans, and their families. TRICARE
surance (CBO, n.d.). coverage is available for active-duty personnel, retiree (CMS,
In October 2017, President Donald Trump signed an ex- n.d.-b); and personnel of the Civilian Health and Medical
ecutive order to remove the payment of federal subsidies to Program of the Department of Veterans Affairs and the vet-
private insurance companies (White House, 2017); the actual erans health program (CMS, n.d.-b). Varying coverage plans
influence of this order on cost and care remains unknown. are available within each of these insurance options.
Coverage offered by employers or purchased by individuals is
highly variable in regard to premiums paid. In general, higher Insurance Coverage Overall
premiums result in broader coverage, whereas lower premi-
ums result in less coverage and more out-of-pocket expenses. In 2016, private health care insurance covered 67.5% of the
population, whereas federally funded coverage insured 37.3%
of the population (Barnett & Berchick, 2017). Employer-paid
Federally funded health insurance insurance provided coverage for 55.7% of the population,
Federally supported health insurance programs are prom- whereas Medicaid and Medicare provided coverage for
inent in the United States. Supported programs include 19.4% and 16.7%, respectively (Barnett & Berchick, 2017).
Medicare, Medicaid, CHIP, and coverage for active duty and Direct-purchase coverage was assumed by 16.2% of the
veteran military members and their families. population, and military personnel represented 4.6% of the
population (Barnett & Berchick, 2017). In 2016, as many as
Medicare, Medicaid, and CHIP. Medicare, Medicaid, 28.1 million Americans (8.8% of the population) remained
and CHIP coverage is for specific populations. Medicare uninsured (Barnett & Berchick, 2017), although the number
is designed to provide insurance coverage for people ages of insured Americans has grown substantially as a result of
65 years or older and, in some cases, those younger than 65 health care reform legislation.
with specified diagnoses (Centers for Medicare and Medicaid
Services [CMS], 2014, 2017a). Medicaid is a federally and state Managed Care
funded program for people with low incomes, women who are
Managed care represents health care delivery systems that
pregnant, and populations with long-term health care needs
began with implementation of the Health Maintenance
(CMS, 2017a). CHIP originated from the Balanced Budget
Organization Act of 1973 (P. L. 93–222) and was intended
Act of 1997 and is a federally and state-funded program de-
to improve quality and accessibility as well as streamline
signed to supplement families who do not meet the criteria for
care, thereby controlling costs (Social Security Administra-
Medicaid but require health care reimbursement assistance
tion, n.d.). Four types of managed care insurance plans are
(CMS, n.d.-b, 2017a). Table 4.2 gives an overview of each of
available:
the aforementioned programs and the populations served.
1. Exclusive provider organizations,
Military coverage. Globally, there are 19 million U.S. 2. Health maintenance organizations (HMOs),
military veterans (Holder, 2016) and 1.3 million active duty 3. Preferred provider organizations (PPOs), and
servicemen and servicewomen in the U.S. military (U.S. 4. Point of service (POS) plans (CMS, n.d.-c, n.d.-d; U.S.
Department of Defense [DoD], 2015). Active-duty service National Library of Medicine [NLM], n.d.).
TABLE 4.2. Medicare, Medicaid, and CHIP Overview
INSURANCE TYPE POPULATIONS

Medicare Individuals age 65 years or older, younger than 65 with
■ Part A: Inpatient hospital short-term skilled nursing facility coverage; funded specific diagnoses, and/or in end-stage renal disease
by payroll taxes. (CMS, 2014, 2017a) (CMS, 2014, 2017a)
■ Part B: Supplemental insurance that covers doctor’s visits, occupational
therapy, other rehabilitation services, home health, and necessary medical
equipment; individual pays a monthly premium (CMS, 2014, 2017a)
Medicaid Individuals with low incomes, pregnant women, people with

■ Federal- and state-funded program disabilities, those who need long-term care (CMS, 2017a).
CHIP Children whose families do not qualify for Medicaid services

■ Federal- and state-funded program (CMS, n.d.-b, 2017a)
Note. CHIP = Children’s Health Insurance Program; CMS = Centers for Medicare and Medicaid Services.
Each type of plan is intended to reduce health care costs including military veterans, people with disabilities, elderly
(CMS, n.d.-d) through the use of networks. people, children, and others. In some instances, legislation ad-
Exclusive provider organizations require that individ- dressed occupational therapy services and provided support
uals see only specific health care professionals in a speci- for specific occupational needs, including supported employ-
fied network to receive coverage (CMS, n.d.-c). In HMOs, ment, education, and assistive device coverage (Andersen &
the individual is assigned to a primary care physician who Reed, 2017). However, legislation also curtailed occupational
is responsible for care coordination (i.e., the client needs a therapy involvement in some practice areas. For example, the
referral to access other services; CMS, n.d.-d; NLM, n.d.). Social Security Amendments of 1965 initially included occu-
Individuals covered through PPOs have lower copays, pational therapy as a covered service, but later it was inter-
and health care services are reimbursed at a higher rate if preted to require a physician order for occupational therapy
they remain inside the predetermined network as opposed services. A sample of the legislative influence on occupational
to seeking care outside of the network (NLM, n.d.). In POS therapy services is provided in Table 4.3. The table shows that
plans, the individual selects either an HMO or PPO for each legislation has had (and continues to have) a strong role in
episode of care (NLM, n.d.). In 2016, managed care plans determining which populations are served by occupational
accounted for 30.6% of Medicare plans, 62.7% of Medicaid therapy, where the services are provided, and how those ser-
plans, 100% of military plans, and 99.1% of private plans vices are reimbursed (Exhibit 4.1).
(MCOL, n.d.).
Continued Influence of Legislation on Health
Legislative Influence on Health Care Care Policy
Services Evolution
In 2010, President Barack Obama signed into law the Patient
Several legislative measures have been instituted since the Protection and Affordable Care Act (ACA), which took ef-
1940s that influenced the availability of reimbursement for fect in 2014. The intent of the ACA was to provide health
health care services to population groups in the United States, care coverage to those who were uninsured (Braveman &
TABLE 4.3. Legislation Influence on Service Provision
LEGISLATION AND JUDICIAL YEAR

DECISIONS ENACTED INFLUENCE ON HEALTH CARE, POPULATIONS, AND OCCUPATIONAL THERAPY
Social Security Act—Additional of 1965 Provision of care for those age 65 years or older. Initially included occupational therapy
Title 18: Medicare as covered as part of usual services; later interpreted occupational therapy to require a
physician order (Andersen & Reed, 2017).
Health Maintenance Organization Act 1973 Established HMOs to manage care and control costs (Andersen & Reed, 2017).
Education for All Handicapped 1975 ■ Enhanced occupational therapy provision in schools
Children ■ Established IEPs (Jackson, 2007).
Omnibus Reconciliation Act of 1980 1980 Occupational therapy coverage in rehabilitation and as stand-alone service in home health
(AOTA, n.d.).
Omnibus Reconciliation Act of 1981 1981 Occupational therapy was no longer considered a stand-alone service for home health (AOTA, n.d.).
Children’s Health Insurance Program 1997 Provided coverage for children whose families were eligible for Medicaid services (Andersen &
(Balanced Budget Act of 1997) Reed, 2017).
Balanced Budget Act 1997 ■ Emphasized controlling health care costs through prospective payment systems
■ Capped Medicare payments to occupational therapy in rehabilitation, outpatient, and skilled
nursing facilities (Andersen & Reed, 2017).
Children’s Health Insurance Program 2009, 2015 ■ Reauthorized the Children’s Health Insurance Program (Centers for Medicare and Medicaid
Reauthorization Act Services, n.d.-a)
■ 6-year extension in 2017 (Kaiser Family Foundation, 2018).
Tax Reconciliation Act 2017 ■ Repealed the individual mandate for individual health insurance.
■ Medicare Part B occupational therapy $2,010.00 reimbursement cap that first accompanied
the Balanced Budget Act of 1997 was reinstituted as Congress did not extend the exception
policy (Parsons, 2018).
Note. AOTA = American Occupational Therapy Association; HMOs = health maintenance organizations; IEPs = individualized education programs.
EXHIBIT 4.1. Policy Learning Activity
Using available textbooks, databases, search engines, and the American Occupational Therapy Association (AOTA) website section “Advocacy and
Policy” (http://www.aota.org/Advocacy-Policy.aspx), search for and review the legislative and judicial outcomes in the table below and identify their
influence on health care, populations, and occupational therapy service provision.
INFLUENCE ON HEALTH CARE, POPULATIONS,
LEGISLATION AND JUDICIAL DECISIONS YEAR ENACTED AND OCCUPATIONAL THERAPY
Comprehensive Outpatient Rehabilitation Facilities Regulations (CMS, 2013) 1982
Tax Equity and Fiscal Responsibility Act of 1982 1982
Social Security Amendments of 1983 1983
Developmental Disabilities Act of 1984 1984
Education of the Handicapped Act Amendments of 1986 1986
Americans with Disabilities Act 1990
Individuals with Disabilities Education Act (IDEA) of 1990 1990
Human Services Amendments of 1994 (Head Start was reauthorized) 1994
Health Insurance Portability and Accountability Act of 1996 1996
Individuals with Disabilities Education Act Amendments of 1997 1997
Olmstead v. L.C. 1999
Individuals with Disabilities Education Improvement Act of 2004 2004
Patient Protection and Affordable Care Act 2010

Go to the “Advocacy and Policy” Section of the AOTA website and select “Congressional Affairs”. What legislation issues are currently influencing occupational therapy practice?
Metzler, 2012), including individuals with preexisting con- ranging from states’ rights to its original mandate of con-
ditions; expand coverage for those with limited coverage; traceptive coverage (Hall, 2016). “We have not seen federal
improve overall health care system delivery; enhance com- law fought so fiercely since the Civil Rights era” (Hall, 2016,
munication and collaboration between providers; fund p. 576), and the ACA’s opposition in the judicial arena has
public health and other prevention programs; and ease the already influenced health care (see Exhibit 4.2).
financial burden on existing private and federal insuring Ultimately, the outcomes of the ACA on health care, in-
bodies (Braveman & Metzler, 2012; Fisher & Friesema, 2013; cluding occupational therapy, are still relatively unknown
Moyers & Metzler, 2014). given the newness of the act and passage of a recent tax
Despite the increase in coverage for approximately reform bill. The Tax Reconciliation Act of 2017 (P. L. 115–97)
23 million Americans (Dickman et al., 2017), the ACA has included a provision to eliminate the mandate for individuals
been met with substantial opposition from varying political to buy health insurance. It is expected that this provision will
and religious bodies, which have challenged the law on issues result in approximately 4 million fewer people purchasing
EXHIBIT 4.2. How the Judicial Branch Can Affect Health Care
Although numerous lawsuits have been filed in opposition to the ACA, one has substantial influence over the original intent of the ACA. National
Federation of Independent Businesses (NFIB) v. Sebelius (2012) was a Supreme Court case in which 24 states and additional private businesses
challenged the constitutionality of the ACA to require states’ Medicaid expansion (Hall, 2016). The Supreme Court ruled that states could opt out of
expanding Medicaid coverage. This ruling likely dealt a substantial blow to the potential success of the ACA; in 2016, only 31 states had expanded
Medicaid programming (Hall, 2016).
Research regarding the outcomes of the ACA has shown that coverage gains for the uninsured were greater in states with Medicaid expansion
than in those without expansion (Buchmueller et al., 2016). In NFIB v. Sebelius, the Supreme Court also ruled that individuals would not be mandated
by law to secure insurance but would be penalized for being uninsured in the form of a federal tax (Hall, 2016). Ultimately, the outcome of NFIB v.
Sebelius was lesser coverage options through Medicaid in 29 states and individuals opting out of coverage (Hall, 2016).
health insurance in 2019 and 13 million fewer people by 2027, evidence-based profession with a globally connected and di-
which in turn will influence the federal subsidies to private verse workforce meeting society’s occupational needs” (p. 613).
insurers and Medicaid (CBO, 2017). Despite the provisions in the ACA to build preventive public
health programming and address the needs of underinsured or
Review Questions uninsured populations as well as societal needs, occupational
therapy continues to serve in traditional medical settings in a
1. What relationships do you notice between population reactive, rather than revolutionary, type of service delivery in
needs and legislative actions in past history? emerging settings.
2. Which type of insurance (private or federally funded) The primary settings in which practitioners are em-
represents the majority of the insurance coverage used ployed are long-term care/skilled nursing facilities (55.9%
by the U.S. population? What influence might insurance OTAs/19.2% OTs) and hospitals (11.4% OTAs/26.6% OTs),
coverage have on client access to occupational therapy followed by pediatric settings (AOTA, 2015). The smallest
services? areas of practice are community settings, which account for
3. What are the primary differences in the 4 types of man- 1.7% of OTAs and 2% of OTs, followed by mental health set-
aged care plans, and how might the differences in plans tings, in which 1.4% of OTAs and 2.4% of OTs are employed
affect patient access to health care services? (AOTA, 2015). Figure 4.1 shows practitioner employment
by setting.
As reported in the 2015 Salary and Workforce Survey
PRACTICAL APPLICATIONS IN (AOTA, 2015), 3 work settings accounted for the majority
OCCUPATIONAL THERAPY (68.7%) of occupational therapy practice: hospital (non–
mental health), schools, and long-term care (LTC)/skilled
Current Trends in Occupational Therapy
nursing facility (SNF). Those working in the hospital (non–
Service Delivery
mental health) were identified as least likely to have changed
The American Occupational Therapy Association’s (AOTA’s; jobs within the last 2 years (83.6%), closely followed by a low
2007) Centennial Vision reads “[w]e envision that occupational turnover rate for individuals working in schools (83.1%), and
therapy is a powerful, widely recognized, science-driven, and LTC/SNF settings (73.9%; AOTA, 2015).
FIGURE 4.1. Occupational therapy employment by setting.
1.5% OTAs
Academia
6.1%
OTs
1.7%
Community
2%
2.8%
Early Intervention
4.6%
5.39%
Free-Standing Outpatient
10.7%
4.3%
Home Health 6.8%
11.4%
Hospital
26.6%
55.9%
LTC/SNFs
19.2%
1.4%
Mental Health
2.4%
.9%
Other
1.5%
15%
Schools
19.9%
0 10% 20% 30% 40% 50% 60%
Source. From 2015 AOTA Salary & Workforce Survey by the American Occupational Therapy Association, 2015, p. 4, Bethesda MD: AOTA Press. Copyright © 2015 by the
American Occupational Therapy Association. Reprinted with permission.
Note. LTC = long-term care; OTA = occupational therapy assistant; OT = occupational therapists; SNF = skilled nursing facility.
These findings suggest that there is a low likelihood that (6) mental health; (7) nutrition, physical activity, and obesity;
occupational therapy practitioners with the requisite skills (8) oral health; (9) reproductive and sexual health; (10) social
would be drawn to explore work in emerging practice areas. determinants; (11) substance abuse; and (12) tobacco use.
However, for those practitioners who did change jobs in 2014,
the opportunity to work in a more desirable or more flexi-
Population needs
ble employment setting was most commonly identified as
the reason for change (41.8%); it was cited more often than With a population of more than 327 million people, the United
salary and benefits (26.8%), and family or personal reasons States was the 3rd most populated country in the world in
(25.6%). Moreover, for the 9.2% of respondents who indicated 2018 (U.S. Census Bureau, 2018b), with an ever-growing di-
that they were considering or planning to leave the profes- versity in race, ethnicity, and age (U.S. Census Bureau, 2017).
sion, 19.2% indicated that they desired to work in a different In 2017, non-Hispanic White people continued to comprise
field, and 22% expressed dissatisfaction with the profession the majority of the population in the United States, and cu-
(AOTA, 2015). These data suggest that a small but growing mulatively, minority populations represented slightly more
percentage of the profession is poised to explore alternative than one-third of the population (U.S. Census Bureau, 2012).
practice areas. Population growth is expected to slow nationally and reach
More than a decade ago, the AOTA Board of Directors approximately 400 million by 2051 (U.S. Census Bureau,
identified a misalignment between the profession and the ex- 2015b). Population projections indicate that by 2060, mi-
ternal environment as forming a barrier to the profession’s nority populations will represent 56% of the total population
Centennial Vision (AOTA, 2007). Simply, the profession’s (U.S. Census Bureau, 2015b). For occupational therapy, pop-
priorities were not congruent with the needs of society. Al- ulation diversity represents a need for practitioners who are
though there is a need for occupational therapy practitioners culturally sensitive and prepared to serve people with varying
to serve individuals in traditional settings, practitioners must “customs, beliefs, activity patterns, behavioral standards, and
grow in their knowledge of other paths to serving the nation’s expectations” (AOTA, 2014b, p. S9).
needs (AOTA, 2007). Two generations are particularly important when con-
In 2011, AOTA identified emerging niche areas for oc- sidering occupational therapy service delivery: (1) Baby
cupational therapy within the areas of children and youth, Boomers and (2) Millennials. The population of the United
health and wellness, mental health, productive aging, States is significantly older than it was at the turn of the last
rehabilitation, disability and participation, work and in- century (U.S. Census Bureau, 2017). Baby Boomers, people
dustry, and education (Yamkovenko, n.d.) and comprise born between 1946 and 1964, account for 75.4 million peo-
subtopics that reflect present and anticipated societal needs ple (U.S. Census Bureau, 2015a) of the U.S. population, and
(see Table 4.4). those ages 65 years or older are expected to account for 19% of
The Healthy People Initiative (DHHS, 2017) provides fur- the population by 2030 (Vincent & Velkoff, 2010). The aging
ther guidance for areas of focus for occupational therapy. of this population accounted for an increase of 14.2 million
Initiatives essential to support health outlined in the Healthy people ages 65 years or older between 2000 and 2016 (U.S.
People 2020 report include (1) access to health services; Census Bureau, 2017). When all Baby Boomers reach the age
(2) clinical preventive services; (3) environmental quality; of 65 years in 2030, they will account for 1 in 7 people in the
(4) injury and violence; (5) maternal, infant, and child health; United States (U.S. Census Bureau, 2015b). The growth of the
TABLE 4.4. Emerging Niche Practice Areas
BROAD PRACTICE AREA AREA OF NEED

Children and youth Broader scope in schools, bullying, childhood obesity, driving for teens, transitions for older youth
Education Distance learning, reentry to the profession
Health and wellness Chronic disease management, obesity, prevention
Mental health Depression, recovery, peer support model, sensory approaches to mental health, veterans’ and
wounded warriors’ mental health
Productive aging Aging in place and home modifications, low vision, community mobility, and older drivers
Rehabilitation, disability, and participation Autism in adults, cancer care and oncology, hand transplants and bionic limbs, new technology for
rehabilitation, telehealth, veteran and wounded warrior care
Work and industry Aging workforce, new technology at work

Source. Data are from Yamkovenko, n.d.
population ages 65 or older has significant ramifications for access to health care services, a result of lack of insurance
the U.S. health care system, because the incidence of disease and the high cost of care.
and disability increases with age.
Millennials, those born between 1982 and 2000, now Mental health and substance abuse. Perceived psy-
represent more than 25% of the U.S. population; 44.2% of chological stress is now recognized nationally as a determi-
the 83.1 million millennials are part of an ethnic or racial nant of overall health and wellness. The results of a recent
minority population (U.S. Census Bureau, 2015a). The mil- survey series conducted by the American Psychological
lennial generation is larger and more complex in terms of Association (APA; n.d.) revealed “the serious physical and
other demographic characteristics than the Baby Boomer emotional implications of stress and the inextricable link
generation, and occupational therapy as a profession must between the mind and body” (para 1).
consider Millennials’ present and future influence on society, Occupational therapy practitioners must build program-
the workforce, and the health care system. ming to address this epidemic across existing practice settings
Among the plethora of variables that influence health and and in the public health arena. Special emphasis should be
health care delivery in the United States, arguably the most placed on addressing the mental health needs of Millennials
influential is socioeconomic status. In 2016, the median in- who have been found not only to have significantly higher
come per household in the United States was $59,039 (Semega rates of anxiety than the Baby Boomer population but also
et al., 2017). In 2016, women earned $41,554 on average com- exercise fewer active coping strategies (Brown et al., 2017).
pared to earnings of $51,640 for men (Semega et al., 2017). Individuals who are uninsured have been reported to ex-
Although median income per household has grown in recent perience higher psychological stress than do those with in-
years, approximately 12.7% (40.6 million people) of the U.S. surance (APA, 2018), and occupational therapy practitioners
population falls below the national poverty level (Semega should identify avenues addressing the health needs of this
et al., 2017). The poverty threshold in the United States was population.
$24,858 for a household of 2 adults and 2 children (U.S. Cen- Occupational therapy has deep roots in working with
sus Bureau, 2018a). About 14.0% of those living in poverty veterans and must continue service in traditional capacities
are women ages 18–64 years, and 32.6% are children (Semega of working with veterans who have experienced physical or
et al., 2017). psychological trauma and are seeking to gain independence
in occupations and reintegrate into their families and com-
Population implications for occupational munities. Occupational therapy practitioners must also con-
therapy services tinue to build services to address the mental health needs of
veterans, with an emphasis on posttraumatic stress disorder
Of the priorities identified within the AOTA emerging niches
and suicide. It has been estimated that 20 veterans die each
and the Healthy People’s 2020 initiative, several are reflected
day from suicide (U.S. Department of Veterans Affairs, 2016).
as needs in occupational therapy literature:
Occupational therapy practitioners must begin to explore
■ Access to care (AOTA, 2017b), their role in suicide prevention, advocacy, and intervention
■ Mental health and substance abuse disorder services (Kashiwa et al., 2017).
(Braveman & Metzler, 2012), and The occupational therapy profession must also address
■ Prevention and wellness (Braveman & Metzler, 2012; the mental health needs of forcibly displaced refugees and
Hildenbrand & Lamb, 2013). human trafficking survivors. At the conclusion of 2015, an
estimated 65.3 million people had been displaced forcibly
Access to care. Vision 2025 (AOTA, 2017b) outlined worldwide; 51% of those displaced were children (United
5 guidelines for care. One is that services must be accessible, Nations High Commissioner for Refugees, 2015). Refugees
that is, individualized and culturally sensitive. Culturally experience a plethora of traumatic events ranging from
sensitive care requires moving beyond basic notions of race lack of basic necessities and emotional security to violence
and ethnicity to seeking understanding of each individu- and, subsequently, experience high frequency of mental
al’s socioeconomic status, values, family, beliefs, and needs health issues (Abou-Saleh & Christodoulou, 2016). When
(AOTA, 2014a) and accepting that those characteristics are people become refugees, every aspect of their life is com-
fundamental to designing appropriate care (see Wells et al., pletely upended.
2016, for more on culturally sensitive care). Similarly, the World Health Organization (WHO; 2012;
Accessibility is particularly important to addressing WHO, Regional Office for Europe, 2014) has recognized
the significant health disparities in the United States that human trafficking as a public health crisis and has called
are largely attributed to economic inequality. Buchmueller for a multidisciplinary approach to provide interventions
et al. (2016) reported improved coverage for Hispanic, Black, for survivors and to identify the victims. Occupational ther-
and White populations as a result of the ACA, but they apy practitioners can work with refugees and survivors to
noted that significant disparities continue with regard to develop healthy active coping skills, build new habits and
race, ethnicity, and health care. Dickman et al. (2017) found routines in novel environments, and cultivate skills that
that wealthy Americans now outlive poor Americans by contribute to individuals’ abilities to engage in satisfying
10–15 years, largely because poor Americans have limited occupations.
In 2017, a total of 16 natural disasters in the United States managing diabetes might be obese, with associated high
resulted in an estimated cost of $306 billion, 362 deaths, and blood pressure and chronic heart failure.
the displacement of residents in the areas affected (National Primary care is defined as “[t]he provision of integrated,
Oceanic and Atmospheric Administration, 2018). Nursing accessible health care services by clinicians who are account-
literature demonstrates that the nursing professions’ involve- able for addressing a large majority of personal health care
ment in environmental disaster response stretches back for needs, developing a sustained partnership with patients, and
decades (Polivka & Chaudry, 2018). AOTA (2017a) has as- practicing in the context of family and community” (Metzler
serted that “occupational therapy, too, has a role in disaster et al., 2012, p. 266). There is tremendous opportunity for occu-
response and risk reduction” (para. 1). AOTA identified oc- pational therapy practitioners working in primary care to ad-
cupational therapy practitioners’ skill at evaluation and in- dress health promotion and lifestyle modification, including
tervention of and for mental health needs during “disruption mental and behavioral health management (AOTA, 2014b;
in life routines” (para. 4) and ability to address other long- Posmontier & Breiter, 2012). For example, practitioners might
term needs that influence individuals’ ability to engage in assist the client to create routines to support health, including
occupations. medication management, blood sugar checks, healthy eating,
Opioid abuse has reached epidemic proportions in the and physical and social activity.
United States and has been declared a public health emer- To achieve integration into the primary care setting, re-
gency (Salama, 2017). Opioids include both prescription and imbursement challenges must be navigated successfully
illegal drugs such as oxycodone, fentanyl, hydrocodone, mor- (Hildenbrand & Lamb, 2013; Mackenzie et al., 2013; Metzler
phine, and heroin (National Institute on Drug Abuse, 2017). et al., 2012; Muir, 2012). Currently, public funds, such as the
Opioid overdose deaths increased 200% in the past 17 years, Prevention and Public Health Trust Fund, and Community
with significant increases in men and women, people of all Transformation Grants, have opened doors for occupational
races, and those between the ages of 25 and 44 years and therapy services (Hildenbrand & Lamb, 2013), and options
ages 55 years or older, especially in the Midwest, South, and for occupational therapy reimbursement have been explored
Northeast regions of the United States (Rudd et al., 2016). The within the chronic care model, Medicaid health homes,
occupational therapy profession must begin to prepare prac- CMS comprehensive primary care, and Federally Qualified
titioners to address the needs of individuals with substance Health Centers, and other health care service delivery models
abuse and addiction issues, with a focus on development of (AOTA, 2013; Goldberg & Dugan, 2013). However, consis-
life skills. tent funding will be dependent on legislative developments
related to the ACA and other health care measures (AOTA,
Prevention and wellness. A key need in this area for 2014c; Hildebrand & Lamb, 2013).
the Baby Boomer population is safety and fall prevention
(AOTA, 2014c; Mackenzie et al., 2013). Falls are the leading
Models for cost containment
cause of accidental injury or death among the older popula-
tion (Mackenzie et al., 2013). Fall hospitalization rates are in- The United States spends more on health care than any other
creasing, and fiscal projections allot more than $100 million industrialized country in the world (Schneider et al., 2017).
for fall-related accidents (Mackenzie et al., 2013). Instead of National health expenditures reached $3.2 trillion (17.8% of
waiting for elderly patients to fall and sustain hip fractures, the GDP) in 2015 (Dieleman et al., 2017) and are projected to
occupational therapy practitioners could complete a physi- represent 19.9% of the GDP by 2025 (CMS, 2017b). Despite
cal assessment and a home evaluation to eliminate hazards the amount of money spent on health care, the United States
contributing to falls (AOTA, 2014c; Metzler et al., 2012; ranked last in health care access, equity, and outcomes when
Muir, 2012). compared with 10 other high-income countries (Schneider
et al., 2017). The poor ranking of the U.S. health care system
internationally is a result of numerous factors, including lim-
Future Occupational Therapy Service Models ited access to care, inequality in the health care system, and
Occupational therapy in primary care: prevalence of chronic conditions.
Cost containment in occupational therapy will include
Prevention, wellness, and chronic disease
increased use of OTAs to extend the services provided by
management
occupational therapy (Johnson, 2013). Successful collabora-
The Triple Aim of the ACA (2010) is to increase efficiency in tion between OTs and OTAs can maximize use of labor op-
health care delivery, increase effectiveness to the population, tions (AOTA, 2014a). The consumer is able to obtain services
and improve the patient experience. The goal is to reduce re- at a reduced cost without reduction in quality, assuming ap-
admission rates, increase patient satisfaction, and lower over- propriate therapist supervision. In addition, therapists’ time
all health care costs. Initiatives are specifically aimed at the is released to pursue such areas as program development, re-
133 million Americans with 1 or more chronic conditions search, and administration.
that account for more than 75% of health care costs (AOTA, Incorporation of a data-driven management process is es-
2014c). In many of these situations, management of 2 or more sential to reduce costs, improve outcomes, and highlight the
chronic conditions is required. For example, the individual unique value of occupational therapy services (Hitchon, 2014).
This requires integration of quality measures into the occupa- management. Academic and continuing education programs
tional therapy practice process, with consideration to proac- must build opportunities for students and practitioners to build
tive measures such as fall prevention (Leland et al., 2012). these skills to allow them to navigate the complexities of occu-
pational therapy practice in the 21st century.
Interprofessional collaborative practice and
community partnership service models Public Policy’s Ongoing Influence
The complexities of the health care system and the people it Public policy has shaped delivery of health care in the United
serves mandates interprofessional collaboration in service de- States and will continue to influence service delivery. Occu-
livery. Interprofessional collaborative practice happens“[w]hen pational therapy practitioners must take the initiative to both
multiple health workers from different professional backgrounds understand and advocate for legislation that is beneficial to
work together with patients, families, [careers], and communi- population needs and to the profession. The legislation, in-
ties to deliver the highest quality of care” (WHO, 2010, p. 7). In- cluding the ACA (Yuen et al., 2017), is so complex that it can
terprofessional health care has been emphasized as a need by the be difficult to follow and understand, but doing so is central
WHO since 1977, because lack of interprofessional care is a lead- to developing reimbursable programs.
ing cause of patient deaths in the United States (Sternberg, 2016). In addition to building and maintaining an awareness of
In addition to collaboration within medical settings, oc- current societal trends, occupational therapy practitioners
cupational therapy practitioners must seek to build collabo- can benefit from national resources and organizational
rative relationships with other professionals and community groups such as the American Occupational Therapy Political
members to meet the dynamic and complex needs of the Action Committee, which advances occupational therapy
public. As an example, AARP (2015) describes the descrip- services through federal legislative measures and informs
tion of the role of occupational therapy in enhancing home practitioners of measures influencing practice. However it is
fit is described by AARP (2015). Other examples of partner accomplished, it is essential that practitioners play an active
organizations to enhance driving and community mobility role in shaping public policy that affects the profession.
are described in the “Practice” section of the AOTA website
under the heading “Productive Aging” (http://www.aota.org Review Questions
/Practice/Productive-Aging.aspx).
1. When considering the Emerging Niches Practice Areas
and Health People 2020 initiatives, what opportunities
Scientific Discovery, Information Management, for occupational therapy do you note that cannot be re-
and Technology alized within current occupational therapy practitioner
Throughout history, scientific discovery and technology have employment patterns?
played a major role in health care delivery. Occupational 2. What effect do occupational therapy practitioners who
therapy practitioners are inundated with new options for work in primary care settings have on health promotion
practice, ranging from provision of client care following ever- and lifestyle modification?
changing and improving medical procedures, smartphone 3. How do you expect the health care needs of the Baby
technologies for intervention, and virtual reality rehabilita- Boomers and Millennials to affect occupational therapy
tion to expansion in state-of-the-art prosthetics. services in the future?
Telehealth, an emerging service model associated with
technology development, includes “the application of eval-
uative, consultative, preventive, and therapeutic services
SUMMARY
delivered through telecommunication and information Health care systems and occupational therapy services have
technologies” (AOTA, 2013, p. S69). Through telehealth, occu- evolved since the inception of the profession, influenced by
pational therapy practitioners are able to direct occupational population needs, scientific discovery, legislative actions, and
therapy services, provide consultation, and coordinate home available reimbursement structures. To ensure a strong role
transitions for clients (Cason & Jacobs, 2014). Reimbursement for occupational therapy in the future, these same factors
for occupational therapy telehealth services has been approved must be considered and available resources used to maximize
in numerous states (Center for Connected Health Policy, 2018). occupational therapy potential. Hinojosa (2007) suggested in
Technology also makes possible immediate access to cli- his Eleanor Clarke Slagle Lecture that “[w]e live in a time of
ents’ electronic health care records, more than 24 million ar- hyperchange—rapid, dramatic, complex, and unpredictable
ticles on PubMed, and countless resources through the AOTA change occurring in today’s society, which creates unprece-
website. For occupational therapy practitioners, vigilance in dented challenges” (p. 629). Challenges also present oppor-
evaluating the worth of new intervention technologies and tunities for extraordinary growth, change, and innovation in
competence in prescribing those interventions are imperative. occupational therapy practice.
Equally essential is the practitioner’s ability to simply manage Ultimately, it will be the responsibility of each occupa-
the flow of information that informs practice. Ultimately, occu- tional therapy practitioner to take advantage of opportuni-
pational therapy practitioners must become adept at information ties through awareness of population health care trends and
CASE EXAMPLE 4.1. Exploring Stakeholders and Partnerships for New Programming
You have been hired by a facility in a rural area that serves individuals in a 100-mile radius. Recently your community has become concerned with
an influx of refugees into the rural area. A long-standing concern with alcohol addiction in your rural state is magnified by an increase in opioid
abuse. You have been tasked to expand an already existing occupational therapy department that has historically provided inpatient and outpatient
hospital-based services for individuals with physical conditions. Recently your department has established contracts with a local SNF, elementary
school, and high school. The facility administrator has encouraged you to be innovative and expand community programming but cautioned you to
maintain awareness of cost containment and reimbursement.
Review Questions
1. What do you need to know about the populations and culture within the area?
2. What will you consider regarding legislation that influences those populations?
3. What community partnerships might you pursue?
4. How might reimbursement influence program development?
emerging occupational therapy service models coupled with American Occupational Therapy Association. (2013). Telehealth.
support of political action advocacy. Use Case Example 4.1. to American Journal of Occupational Therapy, 67(Suppl. 6),
explore the variables that practitioners should consider when S69–S90. https://doi.org/10.5014/ajot.2013.67S69
building new programs. ❖ American Occupational Therapy Association. (2014a). Guidelines
for supervision, roles, and responsibilities during the delivery
of occupational therapy services. American Journal of Occupa-
ACOTE STANDARDS tional Therapy, 68(Suppl. 3), S16–S22. https://doi.org/10.5014
/ajot.2014.686S03
This chapter addresses the following ACOTE Standards: American Occupational Therapy Association. (2014b). Occu-
pational therapy framework: Domain and process (3rd ed.).
■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
and Lifestyle Choices https://doi.org/10.5014/ajot.2014.682006
■ B.1.3. Social Determinants of Health American Occupational Therapy Association. (2014c). Primary care.
■ B.3.1. OT History, Philosophical Base, Theory, and Socio- Retrieved from https://www.aota.org/Practice/Manage/primary
political Climate -care.aspx
■ B.4.19. Consultative Process American Occupational Therapy Association. (2015). Execu-
■ B.4.20. Care Coordination, Case Management, and Tran- tive summary. In 2015 salary and workforce survey (pp. 1–14).
sition Services Bethesda, MD: AOTA Press. Retrieved from https://www.aota
■ B.4.27. Community and Primary Care Programs .org/Education-Careers/Advance-Career/Salary-Workforce
■ B.4.29. Reimbursement Systems and Documentation -Survey.aspx
■ B.5.1. Factors, Policy Issues, and Social Systems American Occupational Therapy Association. (2017a). AOTA’s soci-
etal statement on disaster response and risk reduction. American
■ B.5.2. Advocacy
Journal of Occupational Therapy, 71(Suppl. 2), 7112410060.
■ B.5.4. Systems and Structures That Create Legislation. https://doi.org/10.5014/ajot.2017.716S11
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Global Perspectives on Occupational CHAPTER
Therapy Practice
Elizabeth W. Stevens-Nafai, MSOT, CLT, and Said Nafai, OTD, OTR, CLT 5
LEARNING OBJECTIVES
■ Self-reflect on cultural humility skills;
■ Describe the history of global occupational therapy organizations, such as the World Federation of Occupational
Therapists (WFOT), and global activities such as the Occupational Therapy Global Day of Service;
■ Discuss domestic global perspectives for managers;
■ List 3 current global opportunities for occupational therapy practitioners, managers, and students;
■ Understand an international opportunity in Morocco; and
■ List global resources for domestic and international interests.

• Critical reflection • Human rights • Professional power
• Cultural effectiveness model • Occupational justice • Refugees
• Cultural humility • Occupational Therapy Global • United Nations
• Cultural relevance Day of Service • World Federation of
• Cultural safety • Occupational Therapy Occupational Therapists
• Cultural sensitivity International Online Network
• Global initiatives
OVERVIEW manager has a staff needing support in this area? Where do

global initiatives fit in with this standard from ACOTE and
G
lobal initiatives identify a topic or area of need and with daily practice for managers and their staff?
create outreach and collaboration to support this This chapter draws on current evidence-based practices
topic or need across national boundaries. How are using the cultural effectiveness model to educate occupa-
U.S. occupational therapy practitioners involved in global tional therapy managers on how to support their staff, as well
initiatives? Many opportunities are available to become in- as a list of 6 marginalized groups who commonly make up the
volved with occupational therapy in a global way, even in caseloads for the typical occupational therapy practitioner.
daily practice without physically leaving one’s geographical The chapter then outlines U.S. and international occupa-
location. tional therapy community structures and how occupational
The Accreditation Council for Occupational Therapy Edu- therapy practitioners can access these communities to sup-
cation (ACOTE®; 2018) Standards charge occupational therapy port their daily practice and find relevant global initiatives in
practitioners to provide “culturally relevant” (p. 43) screening, which to participate. Current global trends, such as refugee
evaluation, referrals, and intervention planning and service migrations and natural disasters, and an example of an inter-
delivery. Occupational therapy practitioners are expected to national occupational therapy experience in Morocco, illus-
acquire skills to provide culturally relevant services in their trate ways in which an occupational therapy manager can use
training, but what happens when an occupational therapy the skills discussed in this chapter.
https://doi.org/10.7139/2019.978-1-56900-592-7.005
49
Global Perspectives on Occupational CHAPTER
Therapy Practice
Elizabeth W. Stevens-Nafai, MSOT, CLT, and Said Nafai, OTD, OTR, CLT 5
LEARNING OBJECTIVES
■ Self-reflect on cultural humility skills;
■ Describe the history of global occupational therapy organizations, such as the World Federation of Occupational
Therapists (WFOT), and global activities such as the Occupational Therapy Global Day of Service;
■ Discuss domestic global perspectives for managers;
■ List 3 current global opportunities for occupational therapy practitioners, managers, and students;
■ Understand an international opportunity in Morocco; and
■ List global resources for domestic and international interests.

• Critical reflection • Human rights • Professional power
• Cultural effectiveness model • Occupational justice • Refugees
• Cultural humility • Occupational Therapy Global • United Nations
• Cultural relevance Day of Service • World Federation of
• Cultural safety • Occupational Therapy Occupational Therapists
• Cultural sensitivity International Online Network
• Global initiatives
OVERVIEW manager has a staff needing support in this area? Where do

global initiatives fit in with this standard from ACOTE and
G
lobal initiatives identify a topic or area of need and with daily practice for managers and their staff?
create outreach and collaboration to support this This chapter draws on current evidence-based practices
topic or need across national boundaries. How are using the cultural effectiveness model to educate occupa-
U.S. occupational therapy practitioners involved in global tional therapy managers on how to support their staff, as well
initiatives? Many opportunities are available to become in- as a list of 6 marginalized groups who commonly make up the
volved with occupational therapy in a global way, even in caseloads for the typical occupational therapy practitioner.
daily practice without physically leaving one’s geographical The chapter then outlines U.S. and international occupa-
location. tional therapy community structures and how occupational
The Accreditation Council for Occupational Therapy Edu- therapy practitioners can access these communities to sup-
cation (ACOTE®; 2018) Standards charge occupational therapy port their daily practice and find relevant global initiatives in
practitioners to provide “culturally relevant” (p. 43) screening, which to participate. Current global trends, such as refugee
evaluation, referrals, and intervention planning and service migrations and natural disasters, and an example of an inter-
delivery. Occupational therapy practitioners are expected to national occupational therapy experience in Morocco, illus-
acquire skills to provide culturally relevant services in their trate ways in which an occupational therapy manager can use
training, but what happens when an occupational therapy the skills discussed in this chapter.
https://doi.org/10.7139/2019.978-1-56900-592-7.005
49
ESSENTIAL CONSIDERATIONS Culturally Effective Management

Cultural relevance refers to the teaching of cultural aware- Wells et al. (2016) introduced the theory and evidence to sup-
ness skills in relevant and effective ways and is often asso- port use of the cultural effectiveness model in occupational
ciated with the terms cultural humility, cultural sensitivity, therapy, through which “culturally effective services are re-
cultural safety, human rights, and occupational justice (see spectful of and responsive to the beliefs and practices and
Exhibit 5.1; Aronson & Laughter, 2016). These terms are not cultural and linguistic needs of diverse populations” (p. 66).
exclusive to global or international aspects of occupational On the basis of the cultural effectiveness model, managers
therapy but are a part of daily practice as well. Hammell with cultural sensitivity skills would have explored their
(2014) asserted that “Cultures are fluid—not static” and are own cultural knowledge and used cultural skills for commu-
influenced by factors more diverse than just race and ethnic- nication and critical reflection (Wells et al., 2016). Beyond
ity, “such as age and generation, gender identity, social posi- self-
reflection and self-criticism, 3 additional elements to
tion, education, religious affiliation, and exposure to cultural developing cultural humility are (1) learning from clients,
diversity” (p. 42). (2) building partnerships, (3) and maintaining lifelong
Crawford et al. (2017) identified 6 groups of clients who growth in the area of cultural humility (Black, 2016a, p. 55).
often have marginalized human rights and yet comprise the Understanding the inherent power dynamics in health
majority of caseloads in the United States for occupational care, especially the role of the manager regarding professional
therapy practitioners: power with clients who are in a state of disability, is vital.
Because “power is an inherent characteristic in this relation-
1. People with disabilities, ship, with the therapist seen as the expert and the client seek-
2. Refugees and asylum seekers, ing his or her assistance” (Black, 2016b, p. 98), self-awareness
3. Children, is needed to become a culturally humble and sensitive occu-
4. People with mental illness, pational therapy practitioner.
5. Indigenous peoples, and
6. Older adults.
Cultural Humility: Self-Reflection
Crawford et al. argued that “occupational therapists require
All occupational therapy practitioners come with a personal
knowledge and confidence regarding human rights if they
story of who they are and how they got here, just as their cli-
are to work effectively with these client groups” (p. 130). It is
ents do. Sometimes their story or background is similar to
crucial for occupational therapy practitioners working with
that of their clients’, but often their backgrounds differ. To
these groups of clients to nurture their cultural humility, the
fully support clients and colleagues, occupational therapy
ongoing process of building relationships and trust through
practitioners must pause and self-reflect on who they are,
honest self-reflection of one’s own culture to increase one’s
what biases they may have, or in which areas of cultural hu-
knowledge of other cultures and gain the skills to meet these
mility they have deficits.
clients’ needs. Global initiatives can bring cultural differ-
Deficits or biases often come from lack of knowledge about
ences into sharper contrast, but differences also exist in daily
other cultures. To develop cultural humility skills, occupa-
practice as the above list exemplifies.
tional therapy practitioners must research and engage the
area of deficit to increase their knowledge of their clients
and cultural groups with which they have little experience.
EXHIBIT 5.1. Terms Related to Cultural Relevance For example, Level I fieldwork requires students (who, in the
United States, are traditionally young adults) to spend time in
■ Cultural humility: The ongoing process of building relationships different settings across the age span, such as visiting assisted
and trust through honest self-reflection of one’s own culture to living centers to meet older clients, in order to grow cultural
increase one’s knowledge of other cultures.
sensitivity toward people of other age groups.
■ Cultural sensitivity: The ability to recognize but not judge the
Cultural effectiveness grows from critical reflection, or
differences and similarities between people.
■ Cultural safety: A collaborative health care experience for clients the metacognition process of examining knowledge, chal-
in which they feel the health care provider communicates in lenging beliefs, and exploring alternatives. Three stages of the
respectful, inclusive, and empowering ways that recognize that critical reflective process are
not all people have the same beliefs or act in the same way
1. Awareness,
(Canadian Association of Occupational Therapy, 2011).
2. Critical analysis, and
■ Human rights: A right that is universally believed to belong
to every person, regardless of race, sex, nationality, ethnicity, 3. New perspectives (Atkins & Murphy, 1993).
language, religion, or any other status. Raising awareness in the critical reflection process can
■ Occupational justice: “The right of every individual to be able to occur through formal and informal discussions in the class-
meet basic needs and to have equal opportunities and life chances
room and workplace, independent journaling, social media,
to reach toward her or his potential but specific to the individual’s
and local volunteering experiences. Critical analysis is the
engagement in diverse and meaningful occupation” (Wilcock &
Townsend, 2009, p. 193). process of turning inward and truly examining beliefs, be-
haviors, and unconscious or conscious bias toward the
CHAPTER 5. Global Perspectives on Occupational Therapy Practice 51
cultural groups being explored. Critical analysis can start the 2017 WHO Global Research, Innovation, and Education
with provocative journal or discussion prompts such as, in Assistive Technology summit held at WHO headquarters
“I think all older people are ” or “People on disabil- in Geneva, Switzerland. At least 10 occupational therapy
ity benefits are .” Examining sweeping generalizations practitioners were invited by WHO among the 150 top re-
can be a jumping-off point to push forward bias and examine searchers, innovators, and educators in the field of assistive
deeper beliefs. New perspectives grow from examining this technology (WHO, 2017).
awareness and critical analysis, giving voice to the analysis,
expressing these new perspectives, and personal journaling. Domestic Global Perspectives
Participating in a facilitated work or school group is a way to
The American Occupational Therapy Association (AOTA)
incorporate the new perspectives into personal beliefs.
recently published Vision 2025 as its vision statement. Vision
2025 grew out of stakeholder research and built upon the pre-
Global Organizations vious Centennial Vision (AOTA, 2007), which used specific
WFOT language of a “globally connected and diverse workforce” (p. 1).
Vision 2025 omits this direct phrase and uses broader lan-
Globally, the World Federation of Occupational Therapists guage with additional “pillars” to elaborate on the intended au-
(WFOT) is the official representative of the occupational dience, specifically the pillar stating that occupational therapy
therapy profession. WFOT was established in 1952 with will be “Accessible: Occupational therapy provides culturally
7 countries; now 101 countries are member organizations. responsive and customized services” (AOTA, 2007, 2017c, p. 71).
WFOT officially began collaborating with the World Health The Vision 2025 sentiment is intentionally inclusive and im-
Organization (WHO) in 1959. In 1963, the United Nations plies that occupational therapy providers need to develop their
(UN) recognized WFOT as a non-governmental organization cultural humility skills to provide such customized services.
(NGO; WFOT, 2012). AOTA has multiple resources, both in print and digitally,
WFOT currently represents 550,000 occupational thera- about developing a global perspective for occupational ther-
pists worldwide (WFOT, 2018). Registered occupational therapy managers, practitioners, and students. For example, OT
apy practitioners and student members participate through Practice is a monthly magazine with a section that addresses
trainings, certifications, online tools, and attendance at areas of global interest. In addition, the AOTA Press has
WFOT congresses, which occur every 4 years. published Culture and Occupation: Effectiveness for Occupa-
Occupational therapy practitioners and students have tional Therapy, Practice, Education, and Research, 3rd Edition
many structured and unstructured opportunities in which (Wells et al., 2016), to foster culturally effective, globally
to incorporate global perspectives of occupational therapy minded practice.
practice. Occupational therapy managers can support global To support diversity, AOTA has translated important doc-
activities, on a local level at the facility they manage, in sev- uments and videos into Spanish and Chinese with the help of
eral ways. For example, Occupational Therapy Global Day of its members and other national occupational therapy associ-
Service is a yearly event to celebrate World Occupational Ther- ations. For example, a popular video, “The Distinct Value of
apy Day. Occupational therapy practitioners and students are OT,” translated into Chinese and Spanish, connects occupa-
able to participate globally in local events with activities such tional therapy practitioners and students globally to the value
as blood drives and playground repairs (Jacobs, 2017). of the occupational therapy profession (AOTA, 2014).
CommunOT (https://communot.aota.org) is AOTA’s web-
OTVx based clearinghouse of information available to its members,
through which a member can subscribe to groups and re-
Another global event is the Occupational Therapy Virtual Ex- ceive email updates. Topics such as “international,” “disaster
change (OTVx). Since 2010, occupational therapy practitioners relief,” “multicultural/diversity,” and “international fieldwork
and students from around the world participate in a free on- opportunities” can be found there. Group members can pose
line conference, typically for 24 hours. The OTVx was started questions in this digital community. CommunOT addresses
as a collaboration among 6 occupational therapy practitioners such topics as how students can participate in international
from Australia, Canada, New Zealand, the United Kingdom, fieldwork on the members’ portion of the website.
and the United States. Speakers from around the world give
presentations on topics such as “Conflict and Emergencies” by Review Questions
Handicap International or “Global Cooperation for Assistive
Technology” by WHO (Hook, 2017). 1. Are you a member of a unique community, perhaps an
ethnic, racial, or linguistic group that can serve as a guide
for others? If so, how might you go about offering insight
WHO
into your community? If not, where might you find re-
The WFOT executive management team attends several sources or people to provide information on this group?
WHO meetings each year to nurture this collaboration and 2. You are the occupational therapy clinical fieldwork su-
advance the occupational therapy profession. For example, pervisor for a small outpatient hand clinic. A local oc-
occupational therapy practitioners were among attendees at cupational therapy graduate program placed a Level II
fieldwork student who has not shown up to scheduled from their homes, according to United Nations High Com-
Saturday hours. After discussion with the student, he re- missioner for Refugees (UNHCR; 2016). Refugees are people
vealed that his Jewish faith prohibits work on Saturdays, who have had to leave their nation of birth to seek safety from
but he was unsure about telling you ahead of time. What violence, war, or persecution. By 2016, as a result of world-
is the next step you should take? wide humanitarian crises, there are more than 17 million
refugees, about 3 million asylum seekers, more than 36 mil-
a. Tell him that the clinic is open 6 days a week, and he
lion internally displaced people, 7 million returned refugees,
must follow your caseload schedule closely to com-
and more than 3 million stateless persons (UNHCR, 2016).
plete his fieldwork successfully.
These disasters result in the disruption of daily occupations.
b. Tell the school not to send you any more students who
AOTA’s official document on disaster response and risk re-
cannot follow your schedule, and interview students
duction outlines the distinct value and ethical considerations
before placement in the future to be sure they can
for intervening in disasters: “Occupational therapy is an evi-
meet your needs.
dence-based profession that can be an integral component of
c. Get in touch with a local synagogue and ask about
comprehensive and sustainable disaster response and risk-re-
typical work schedules of congregation members.
duction efforts at the local, state, national, and international
d. Make a plan with the student that fits his religious
levels” (AOTA, 2017a, p. 2).
needs, and attend a poster presentation at the next
WFOT’s (2014) position statement on disaster prepared-
AOTA Annual Conference & Expo on how to support
ness and response (see Appendix 5.A) includes the organi-
fieldwork students with diverse cultural needs.
zation’s statement on how to prepare for and respond to
3. As the occupational therapy manager at a Florida inpa- disasters. In it, WFOT also argues why disaster response is
tient mental health facility, you notice a recent increase important for society and occupational therapy, and brings
in patients who speak Spanish and are of Puerto Rican awareness to the challenges and strategies necessary to pro-
descent or nationality, many of whom present with divide an effective response to disasters.
agnoses related to posttraumatic stress disorder. Con- WFOT (2014) resources include position statements about
sidering the recent natural disasters in Puerto Rico and diversity and culture, human displacement, and occupa-
the many residents who have been displaced or who have tional therapy in disaster preparedness and response. Occu-
been without power or resources, you decide that the best pational therapy practitioners and students need to be aware
professional development to serve this population in the of resources for helping people who experience disruption in
coming months is for you to participate in their daily occupations. WFOT (2016b) has compiled a guide,
endorsed by 5 global associations with experience in interna-
a. Attending a semester of night classes in Spanish at the
tional emergencies, on the do’s and don’ts for rehabilitation pro-
local vocational school.
fessionals responding internationally to disasters. The 23-item
b. Interviewing local members of the Puerto Rican com-
list gives examples of everything from equipment donations to
munity on the status of the island after the disaster.
documentation to self-care upon return home (WFOT, 2016b).
c. Monitoring the National Oceanic and Atmospheric
Occupational therapy managers can encourage these do’s and
Administration’s website for hurricane watches and
don’ts for practitioner self-care and reflection for their staff,
warnings to reassure patients more hurricanes are not
whether responding to a disaster abroad or at home.
happening soon.
d. Enrolling in a 5- to 10-week certification course in di-
saster management from WFOT. Natural Disasters
On January 12, 2010, Haiti experienced a massive earthquake
that killed more than 200,000 Haitians (WHO, 2011a). The
PRACTICAL APPLICATIONS IN earthquake also destroyed the fragile health care system in
OCCUPATIONAL THERAPY Haiti. The earthquake injured 300,000 Haitians and initially
Globalization and access to the Internet and social media displaced 1.5 million people; 37,867 people remain displaced as
make it possible to learn about, connect to, and even join of September 2017 (CNN, 2017). This disaster ultimately brought
people from other countries in events related to occupational an aid response from the global community spearheaded by the
therapy. WHO, United Nations, Red Cross, and other NGOs.
The volunteer therapists of Healing Hands for Haiti (HHH)
were among the first to reach Haiti, bringing needed rehabil-
Humanitarian Crises
itation equipment and providing free occupational therapy
The UN (2017), which is charged with protecting human services to Haitians affected by the earthquake. This was de-
rights globally, reached out to all its member countries, tailed in the interview-based qualitative research case study
NGOs, and other stakeholders to collaborate and strengthen by Riggers (2011) that comprised a series of interviews with
the response to humanitarian crises. Hope (name changed for privacy), an occupational therapy
During the past 2 decades, the world has seen many hu- volunteer who arrived in Port-au-Prince on February 15, 2010,
manitarian crises as a result of wars, conflicts, and natural a month after the earthquake. Clients and stakeholders wel-
disasters, that led to the displacement of millions of people comed an occupational therapy education program in Haiti.
Among the occupational therapy personnel was Janet therapy practitioners to look for the marginalized segments
O’Flynn, an occupational therapy practitioner from the of a population, the people who are being occupationally de-
United States. O’Flynn worked tirelessly to create a team of prived and socially excluded, as a key population with which
occupational therapy practitioners and faculty to help Haiti’s to intervene. Occupational deprivation is “a state in which
earthquake victims. Furthermore, O’Flynn attended AOTA’s people are precluded from opportunities to engage in oc-
Annual Conference & Expo to connect with more occupa- cupations of meaning due to factors outside their control”
tional therapy practitioners to help her create a new occupa- (Whiteford, 2000, p. 200).
tional therapy education program in 2015 in Leogane. The
first occupational therapy cohort will be graduating in 2019 Review Questions
(J. O’Flynn, personal communication, April 30, 2017).
1. Review the WFOT Disaster Preparedness and Response
Position Statement (Appendix 5.A). Do you feel you pos-
Virtual Platforms sess the skills to address the 8 bulleted “specific roles
In 2016, WFOT launched the Occupational Therapy Interna- post-disaster”? If so, which ones? If not, how can you
tional Online Network (OTION), a virtual platform to give oc- grow your skills to incorporate these demands?
cupational therapy practitioners and students from across the 2. A newly arrived El Salvadoran refugee family visited your
world a place to network, share ideas, and communicate about clinic to receive skilled occupational therapy services for
topics concerning occupational therapy. OTION is a free re- their son with autism spectrum disorder. With the help
source with the following sections: education, practice, research, of interpretation services, you discovered that the family
students, working in another country, studying in another coun- lacks health literacy and the financial means to purchase
try, and congress (WFOT, 2016a). When occupational therapy the recommended compression garment from which the
students and practitioners prioritize membership in WFOT, son would benefit. After obtaining consent from the fam-
they benefit from the opportunity to be connected to more than ily, what should you do next?
101 WFOT member countries and more than 550,000 occupa- a. Nothing; it is a concern for the social worker.
tional therapy practitioners around the world (WFOT, 2017). b. Inform the school committee where the child attends
that he needs a compression garment.
Research c. Create an online crowd-funding account to fund the
garment.
In response to the World Report on Disability (WHO, 2011b), d. Refer the family to a local church with support ser-
WFOT identified international research priorities through a vices in the community for children with disabilities.
2017 Delphi study to determine common themes of research
to address health care through the lens of occupational 3. Name a recent (within past 12 months) international
therapy (WFOT et al., 2017). The rationales and scopes of disaster. Identify where occupational therapy has been
8 research priorities were culled from the responses of occu- involved in the relief work (or could have been if infor-
pational therapy practitioners from 46 countries, including mation is unavailable). Has this disaster influenced occu-
the United States, and are applicable to most settings of U.S. pational therapy practitioners in the United States? If you
occupational therapy practice: were an occupational therapy manager, what role might
you play in this scenario?
1. Effectiveness of occupational therapy interventions,
2. Evidence-based practice and knowledge translation,
3. Participation in everyday life, SUMMARY
4. Healthy aging,
Occupational therapy practitioners have many opportunities
5. Occupational therapy and chronic conditions,
to affect the global community both domestically and inter-
6. Sustainable community development and population-based
nationally, and good managers address these growth oppor-
occupational therapy interventions,
tunities. Duncan (2016) notes that “occupational therapists as
7. Technology and occupational therapy, and
change agents must therefore be informed about and, where
8. Occupational therapy professional issues (WFOT et al.,
possible, actively participate in a wide range of public dia-
2017).
logue spaces” (p. 223); being agents of change for global ini-
Occupational therapy managers, practitioners, and stu- tiatives starts at home and with self-recognition.
dents can choose to conduct research in these priority areas The cultural effectiveness model can help grow occupa-
to further the international research priorities, or they may tional therapy practitioners’ self-reflection, communication,
simply choose to take a few minutes to participate in the and efficacy to provide culturally relevant care. Participation
next survey or similar study that comes their way via social in local global initiatives, such as the OT Global Day of Ser-
media, email, or other research stream to support fellow oc- vice or the OT Virtual Exchange, can be invigorating and
cupational therapy researchers and global initiatives. Case informative to local practices by fostering feelings of global
Example 5.1 illustrates finding international opportunities. connectedness, engaging in public dialogue, and enriching
Gail Whiteford (2011), an occupational therapist, intercultural humility skills. Virtual participation in forums like
national researcher, and professor, challenges occupational the OT4OT Facebook group is a highly accessible way for
CASE EXAMPLE 5.1. International Opportunities: Morocco
As U.S.-trained occupational therapy practitioners, the authors of this chapter have spent more than 10 years volunteering in Morocco during
vacation time, breaks in between jobs, teaching courses, and on grants. One of the chapter authors (Dr. Said Nafai) is a native Moroccan and speaks
Arabic fluently. Inspired by a sibling with a foot deformity, he pursued first an associate’s degree and then a master’s in occupational therapy. Using
their occupational therapy skills, the Nafais started off with summer family vacations visiting elderly family members, then slowly broadened to local
community centers for children with disabilities and various outpatient clinics to consult with staff on tough cases. They quickly felt overwhelmed by
the level of need they found in Morocco.
Once they realized the extensive demand for occupational therapy in Morocco, Said Nafai pursued a doctorate in occupational therapy with the
goal of developing an entry-level occupational therapy education program curriculum for Moroccan students. More than just a handful of informal
volunteers, mostly from United States, France, and Spain, are required to meet the needs of the nation.
When summer vacations no longer sufficed, the Nafais arranged longer trips between job changes, taught an undergraduate course for a
semester at a U.S. institution with a campus in Morocco, and finally participated as part of a vocational training team for a Rotary International
grant to teach physical therapists how to think like occupational therapy practitioners. This entailed training the physical therapists to ask questions
about what the client wished to be able to do more independently that they could not currently do; to look at the layout of the therapy space, to
add functional activities to interventions; and most successfully to add play for children’s interventions, rather than relying on more traditional rote
exercises for strengthening movements and range of motion.
The Nafais began to document their experiences with a series of presentations about the need for occupational therapy in Morocco at national
AOTA conferences and in OT Practice. Additionally, they gathered a circle of non–occupational therapy professionals in Morocco to support their
endeavors, to show these doctors, physiatrists, dentists, and neurologists the value and role of occupational therapy. In fact, there is not just a dearth
of occupational therapy practitioners but of doctors as well; the physician-to-population ratio in Morocco in 2014 was 0.618 to 1,000 (WHO, 2016).
Although both physical and speech therapists are trained and work in Morocco, no domestically trained occupational therapy practitioners existed
in the Moroccan health care system or education program until September 2017. At this time, after years of collaboration with national stakeholders
and WFOT approval, a public health institute, Instituts Supérieurs des Professions Infirmières et Techniques de Santé in the capital city of Rabat,
opened the first occupational therapy education program in the country. The school accepted 20 students in the first cohort.
In December 2017, the WFOT recognized Morocco as a full member. Currently, there are opportunities to volunteer throughout Morocco as either
a student or a practitioner to supervise occupational therapy students, because there is still a lack of occupational therapy practitioners in Morocco
until the first cohort of students graduates from the Rabat occupational therapy education program. The Nafais organize service learning trips for
occupational therapy students and practitioners and those of other related health and social science fields who wish to volunteer in Morocco while
experiencing a cultural exchange. AOTA’s (2017b) “General Guide for Planning International Fieldwork” can help students confirm that their fieldwork
abroad meets ACOTE Standards.
Review Questions
1. Go to the www.wfot.org website. On the “Membership” icon, click on “Country and Organisation Profile.” Select a country, check its national
occupational therapy association’s website, and answer these questions:
■ When was the association of the selected country founded?
■ Does the definition of occupational therapy differ from that of your own national occupational therapy association?
■ What is the word for occupational therapy in the language of the selected country? Does this word translate directly to mean “occupational
therapy,” or does it have a slightly different meaning or context than in the United States (e.g., in Chinese occupational therapy was initially
translated as “assignments therapy”).
■ How many occupational therapy practitioners are members of the chosen organization?
■ Does this organization provide any professional development and training to its members? What are the professional development require-
ments for that country?
occupational therapy practitioners around the world to sup- Disaster preparedness training through WFOT can help oc-
port global initiatives and foster discussions for growth. cupational therapy managers prepare for large magnitude
Using the free and paid membership resources available emergencies in their areas and to support people in affected
through AOTA and WFOT can bolster occupational therapy areas domestically and abroad.
managers in daily practice. For example, AOTA’s tip sheets are Finding opportunities to affect people’s lives internation-
available in English and Spanish, and the public and members’ ally is much easier than before. Opportunities such as interna-
forums in CommunOT on AOTA’s website can help uncover tional service learning and International Level I and Level II
additional resources. The “Cultural Competency Tool Kits” are fieldwork will allow one to have a closer look at the host coun-
part of the umbrella of multicultural, diversity, and inclusion net- try’s culture, health care system, and education. Even after re-
works; 7 networks that provide information on cultural norms turn from an international experience, one can still connect
for a variety of groups found in the United States (AOTA, 2018). with staff and clients from the host country via telehealth.
The Delphi research study mentioned earlier in this Lastly, the unique initiatives from Morocco described in
chapter identified 8 priority areas to support occupational this chapter exemplify the spirit of global perspectives in
therapy practice at home and abroad (WFOT et al., 2017). occupational therapy. Case Examples 5.2 and 5.3 are real
CASE EXAMPLE 5.2. Domestic Cultural Experience
A school-based occupational therapy practitioner in a large urban school district was assigned initial evaluation of incoming 3- and 5-year-old
siblings with suspected disabilities to determine possible eligibility for special education via an individualized education plan. The early intervention
background referral information for the children revealed that their native language was Nepali and that the family had relocated from Nepal
4 years earlier.
Because she had never worked with a family from Nepal before and did not want to do something that could inadvertently be considered rude
or disrespectful, the occupational therapy practitioner performed a brief Google search for “culture and etiquette norms of Nepal.” She learned
from multiple sources that certain hand gestures and phrases were considered impolite. Although the information was not from an evidence-based
journal review or personal testimony from a member of that cultural group, the occupational therapy practitioner felt more comfortable interviewing
the family (via a Nepali interpreter) after her quick research. Upon meeting the family and the 3-year-old boy, she noticed he had pierced ears
with large, heavy gold earrings, something she had never seen in a toddler before. After quick internal reflection, she remembered her research
revealed that heavy eye makeup on infant girls was part of cultural decoration of young children in some Nepali families; the occupational therapy
practitioner extrapolated that pierced ears and ornate jewelry for boys might be a similar type of decoration.
Doing a few minutes of background research allowed the occupational therapy practitioner to let go of her own cultural expectations of what little
boys “typically look like” and move into the assessment with no judgments about appearances.
Review Questions
1. This case example illustrates cultural humility because the occupational therapy practitioner
a. Learned about another culture.
b. Reflected on her own knowledge base and cultural assumptions.
c. Did her job without judgment.
d. Made interpretations of Nepalese culture because of her research.
2. The best next step after the family had left the evaluation is to
a. Ask the interpreter, a member of the Nepali community, a few questions regarding the cultural norms, including confirmation that the gold
earrings held a cultural significance.
b. Do an Internet search on the significance of gold earrings on boys from Nepal.
c. Let the school administration know that the toddler had on earrings that could be considered a safety risk to himself and peers if they got
caught on them.
d. Add into her evaluation report that parents should not allow their son to wear large heavy gold earrings to preschool for his personal safety
both from injury and fear of gold theft in the urban school district.
CASE EXAMPLE 5.3. Supporting Refugees at Home
At a local children’s hospital, an occupational therapy practitioner, Sally, was working with a 10-year-old boy, Nabil, who had bilateral transhumeral
amputations after a bomb explosion in his Syrian hometown. Nabil had spent time in Jordanian refugee camps with initial medical care. A nonprofit
humanitarian aid group obtained a medical visa and sponsorship for Nabil and his father to travel to the United States for medical treatment.
Through a lengthy medical process of intervention, Nabil was finally ready to begin using his conventional body-powered hook prosthetics. Nabil
made great progress in the clinic, and he was able to manipulate many objects successfully from occupational therapy training with the medical
interpreter and Sally’s demonstrations.
As Sally began to address more complex ADLs with Nabil, his father asked that the training stop, stating, “I will do it for him.” Sally tried to
explain that Nabil’s father would not be with Nabil at school and that eventually Nabil would have to manage toilet hygiene and similar issues
independently. Realizing that there was a barrier to progress for Nabil based on much bigger cultural issues, including cultural discomfort expressed
by Nabil’s father, Sally was granted a privacy release and was then able to reach out to the sponsoring humanitarian aid organization director to get
help. The aid organization director located a male, Arabic-speaking, Muslim occupational therapy practitioner to work with Nabil and his father on
toilet training and other personal ADLs with prosthetics. In a few volunteer sessions at the boy’s home, the male occupational therapy practitioner
was able to coach Nabil and his father through the toilet hygiene process in a way that respected all concerned. Although this was very atypical to
the process for Sally, she used her community resources and put her own ego aside to get Nabil the help he needed in the best manner she could.
Review Questions
1. What reasons did Nabil’s father have for stopping ADL training? Do you consider them valid?
2. Did Sally do the right thing by involving people from the community? Explain your answer.
3. Put yourself in Sally’s place and self-reflect on the situation. Name 3 points from Nabil’s case that would have challenged you. What other
solutions could you think of to remedy this situation?
scenarios that occupational therapy practitioners have expe- Black, R. M. (2016b). Prejudice, privilege, and power. In S. A. Wells,
rienced. Let the cases serve as models of how occupational R. M. Black, & J. Gupta (Eds.), Culture and occupation: Effective-
therapy practitioners have embraced global initiatives do- ness for occupational therapy practice, education, and research
mestically and be a guide for developing new initiatives. ❖ (3rd ed., pp. 91–102). Bethesda, MD: AOTA Press.
Canadian Association of Occupational Therapy. (2011). CAOT position
statement: Occupational therapy and aboriginal health. Retrieved
from https://www.caot.ca/site/pt/caot_posn_stmt?nav=sidebar
ACOTE STANDARDS CNN. (2017). Haiti earthquake fast facts. Retrieved from https://
This chapter addresses the following ACOTE Standards: edition.cnn.com/2013/12/12/world/haiti-earthquake-fast-facts
/index.html
■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, Crawford, E., Aplin, T., & Rodger, S. (2017). Human rights in occu-
and Lifestyle Choices pational therapy education: A step towards a more occupation-
■ B.4.0. Referral, Screening, Evaluation, and Intervention ally just global society. Australian Occupational Therapy Journal,
Plan 64, 129–136. https://doi.org/10.1111/1440-1630.12321
■ B.5.0. Context of Service Delivery, Leadership, and Man- Duncan, E. M. (2016). Development reasoning in community prac-
agement of Occupational Therapy Services tice. In M. B. Cole & J. Creek (Eds.), Global perspectives in profes-
■ B.5.1. Factors, Policy Issues, and Social Systems sional reasoning (pp. 203–238). Thorofare, NJ: Slack.
Hammell, K. W. (2014). Belonging, occupation and human well-
■ B.5.2. Advocacy being: An exploration. Canadian Journal of Occupational Ther-
■ B.7. Professional Ethics, Values, and Responsibilities apy, 81, 39–50. https://doi.org/10.1177/0008417413520489
■ B.7.2. Professional Engagement Hook, A. (2017). OT24Vx: Occupational therapy, 24 hours, virtual
■ C.1.16. Fieldwork Supervision Outside the U.S. exchange. Retrieved from http://ot4ot.com/ot24vx.html
Jacobs, K. (2017, October). Global day of service—how can I help?
Retrieved from http://promotingot.org/global-day-of-service
-how-can-i-help
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Accreditation Council for Occupational Therapy Education. (2018). therapist in disaster response. Unpublished master’s thesis,
2018 Accreditation Council for Occupational Therapy Education University of Puget Sound, Tacoma, WA.
(ACOTE) standards and interpretive guide. American Journal United Nations. (2017). Refugees and migrants: 2016 Global response.
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi Retrieved from http://refugeesmigrants.un.org/global-response
.org/10.5014/ajot.2018.72S217 United Nations High Commissioner for Refugees. (2016). The world
American Occupational Therapy Association. (2007). AOTA’s in numbers. Retrieved from http://popstats.unhcr.org/en/overview
Centennial Vision and executive summary. American Journal Wells, S. A., Black, R. M., & Gupta, J. (2016). Model for culture ef-
of Occupational Therapy, 61(6), 613–614. https://doi.org/10.5014 fectiveness. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture
/ajot.61.6.613 and occupation: Effectiveness for occupational therapy practice,
American Occupational Therapy Association. (2014). Spanish and education, and research (3rd ed., pp. 65–79). Bethesda, MD:
Chinese translations: Making OT globally connected. Retrieved AOTA Press.
from https://www.aota.org/Publications-News/AOTANews/2014 Whiteford, G. (2000). Occupational deprivation: Global challenge
/Translations.aspx in the new millennium. British Journal of Occupational Therapy,
American Occupational Therapy Association. (2017a). AOTA’s soci- 63, 200–204. https://doi.org/10.1177/030802260006300503
etal statement on disaster response and risk reduction. American Whiteford, G. (2011). From occupational deprivation to social inclu-
Journal of Occupational Therapy, 71(Suppl. 2), 7112410060. sion: Retrospective insights. British Journal of Occupational Ther-
https://doi.org/10.5014/ajot.2017.716S11 apy, 74, 545. https://doi.org/10.4276/030802211X13232584581290
American Occupational Therapy Association. (2017b). Interna- Wilcock, A. A., & Townsend, E. A. (2009). Occupational justice. In
tional fieldwork. Retrieved from https://www.aota.org/Practice E. B. Crepeau, E. S. Cohn, & B. A. Boyt Schell (Eds.), Willard
/Manage/Intl/InternationalFW.aspx and Spackman’s occupational therapy (11th ed., pp. 192–199).
American Occupational Therapy Association. (2017c). Vision 2025. Baltimore: Lippincott Williams & Wilkins.
American Journal of Occupational Therapy, 71, 7103420010. World Federation of Occupational Therapists. (2012). History.
https://doi.org/10.5014/ajot.2017.713002 Retrieved from http://www.wfot.org/AboutUs/History.aspx
American Occupation Therapy Association. (2018). Cultural com- World Federation of Occupational Therapists. (2014). Occupational
petency tool kits. Retrieved from https://www.aota.org/Practice Therapy in Disaster Preparedness and Response (DP&R) CM2014.
/Manage/Multicultural/Cultural-Competency-Tool-Kit.aspx Retrieved from http://www.wfot.org/ResourceCentre.aspx
Aronson, B., & Laughter, J. (2016). The theory and practice of cul- World Federation of Occupational Therapists. (2016a). OT inter-
turally relevant education: A synthesis of research across content national online network (OTION). Retrieved from http://www
areas. Review of Educational Research, 86, 163–206. https://doi .wfot.org/Groups/OTInternationalOnlineNetworkOTION.aspx
.org/10.3102/0034654315582066 World Federation of Occupational Therapists. (2016b). Responding
Atkins, S., & Murphy, K. (1993). Reflection: A review of the lit- internationally to disasters: A do’s and don’ts guide for rehabili-
erature. Journal of Advance Nursing, 18, 118–119. https://doi tation professionals. Retrieved from http://www.wfot.org/Portals
.org/10.1046/j.1365-2648.1993.18081188.x /0/PDF/2016/Dos%20and%20Donts%20in%20Disasters%20
Black, R. M. (2016a). The changing language of cross-cultural prac- April%202016.pdf
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year later. Retrieved from http://www.who.int/hac/crises/hti report. Retrieved from http://www.who.int/iris/handle/10665
/earthquake/en/ /259746
APPENDIX 5.A. WFOT DISASTER particularly those with psycho-social trauma and physical
PREPAREDNESS AND RESPONSE injuries who will benefit from occupational and community
based rehabilitation and support programs; stronger referral
POSITION STATEMENT and follow-up systems between community care, hospital and
rehab centre programs; and more disability and age friendly
INTRODUCTION accessibility in private and public buildings/spaces.
Occupational Therapy is a profession concerned with promot-

ing health and well-being through occupation. The primary Significance to Occupational Therapy
goal of occupational therapy is to enable people to participate Specific roles post-disaster may include but are not limited to:
successfully in activities of everyday life in a range of environ-
ments and participate in community. Occupational therapists ■ ensuring accessible environments post disaster at all
(OTs) achieve this outcome by enabling people to do things stages of recovery (e.g. in displaced persons camps) and
that will enhance their ability to live meaningful lives. reconstruction (in rebuilding homes and community fa-
Disasters, both natural and man-made, are occurring cilities) to better support participation.
more regularly world-wide. The World Federation of Occupa- ■ organization of daily routines in displaced persons camps
tional Therapists (WFOT) acknowledges that they can cause and surviving communities to include persons with dis-
loss of life, property damage, and economic loss. They can abilities and existing illnesses, women, elderly and children
affect a person’s health, well-being and ability to engage in ■ facilitating access to mainstream health care services
meaningful activities of life. Community resilience and pos- ■ liaison with and encouragement of community leaders and
itive well-being are key themes in disaster response and are others to reorganize community supports and routines
supported by meaningful occupation. ■ use of everyday occupations to facilitate recovery
■ facilitating the reestablishment of livelihoods
■ assessment of mental health status of survivors for anxi-
The World Federation of Occupational ety, depression and suicidal tendencies, with subsequent
Therapists position is that: counselling and occupation-based activities
Occupational therapists facilitate the engagement in meaningful ■ training of volunteers to carry out ‘quick mental health
routines and occupations which may be disrupted by disaster. assessment’ and counselling, and to facilitate activities
Occupational therapists should be involved in all stages and social connectivity, thus providing more immediate
of disaster management at both local and national level. This services for greater numbers.
involvement ranges from immediately post disaster to long
term rehabilitation and reconstruction. It also includes plan- Challenges
ning and preparation.
Occupational therapists are challenged to raise awareness of the
The WFOT notes that effective disaster preparedness and
benefits of occupational therapy and occupation-based com-
response management also requires long term strategies in
munity involvement to both government and community lead-
collaboration with key stakeholders.
ers. Capacity building is necessary to ensure that occupational
therapy volunteers are prepared to undertake disaster response.
SIGNIFICANCE TO SOCIETY
Through an occupational focus, disaster-affected communi- Strategies
ties and people are better served in their ongoing efforts to For individual occupational therapists, key recommenda-
rebuild their lives and livelihoods, contributing to outcomes tions include involvement with local community disaster
that can be sustained by local service providers and systems. preparedness and planning to include vulnerable groups.
Improved occupational engagement promotes positive well- For national associations: Through national workshops
being and mental health, enabling greater productivity and and capacity building, national associations can support oc-
community resilience. cupational therapists to more effectively be involved in disas-
Occupational therapists engaging with disaster and re- ter response. For occupational therapists affected by disaster
construction policy, planning and coordination mechanisms, and engaged directly in disaster response, national associa-
contribute pertinent expertise to response efforts while laying tions can provide support.
the foundation for more cohesive involvement and response For WFOT: Provision of timely responses, distribution of
efforts in the event of future disasters. support materials and information package, ongoing support
Stronger networking and coordination between local and networking.
health professionals, government services and projects, and
national and international NGO programs, potentially pro-
vide for a more integrated, holistic and yet rationalised and Source. Reprinted from “Position Statement: Occupational Ther-
apy in Disaster Preparedness & Response (DP&R)” by the World
self-reliant service framework. Federation of Occupational Therapists, 2014. Copyright © 2014
At a more practical level, benefits include: better quality, by The World Federation of Occupational Therapists (WFOT).
ongoing care and support for individuals and their families, ALL RIGHTS RESERVED. Reproduced with permission.
Leading and Managing Within CHAPTER
Health Care Systems
Marla R. Robinson, MSc, OTR/L, BCPR, BT–C, FAOTA 6
LEARNING OBJECTIVES
■ Describe the importance of value-based care,
■ Describe 2 initiatives that are used to improve care delivery and reduce the burden of health care costs,
■ Describe 2 metrics used to measure efficiency in health care delivery, and
■ Discuss 2 strategies for occupational therapy’s role in the delivery of care in health care systems.

• Acute care • External benchmarking • Outcomes
• Acute inpatient rehabilitation • Health care system • Outpatient rehabilitation
• Benchmarking • Home health services • Patient/client satisfaction
• Bundled Payment for Care • Hospital Readmissions Reduction • Primary care
Improvement Program • Productivity
• Case management • Internal benchmarking • Quality
• Centers for Medicare and • Lean methodologies • Skilled nursing or subacute
Medicaid Services • Length of stay rehabilitation
• Day rehabilitation • Long-term acute care • Throughput
OVERVIEW size from single entities to a conglomeration of entities with a

common purpose and oversight. They can include 1 or more
A
ssuming a leadership role within health care sys- levels of care.
tems is more of a challenge now than it has ever
been. How health care is delivered, received, and re-
imbursed can change on a daily basis. Leaders need to be Value-Driven Care
prepared to be flexible, innovative, and authentic in their Health care systems strive to provide care in the most efficient
approach and delivery in order to guide their teams through and effective manner; the goal is to achieve the best clinical
these challenges. This chapter provides an overview of the outcomes for patients while providing the best customer ser-
levels of care, care transitions, challenges in reimbursement vice. Providing quality care delivered in an efficient manner
that affect care delivery, and important considerations when is essential to payers, health care providers, and consumers.
making decisions. Many agencies monitor and guide health care systems in
providing quality care in an efficient manner; examples in-
clude the Centers for Medicare and Medicaid Services (CMS),
ESSENTIAL CONSIDERATIONS National Quality Forum, and The Joint Commission.
A health care system is the organization of resources, institu- CMS is a federal agency that provides health care coverage for
tions, and people that delivers health care services to meet the beneficiaries, works with state governments to administer Med-
health needs of populations. Health care systems can vary in icaid and other health care coverage, and provides standards
https://doi.org/10.7139/2019.978-1-56900-592-7.006
59
Leading and Managing Within CHAPTER
Health Care Systems
LEARNING OBJECTIVES
■ Describe the importance of value-based care,
■ Describe 2 initiatives that are used to improve care delivery and reduce the burden of health care costs,
■ Describe 2 metrics used to measure efficiency in health care delivery, and
■ Discuss 2 strategies for occupational therapy’s role in the delivery of care in health care systems.

• Acute care • External benchmarking • Outcomes
• Acute inpatient rehabilitation • Health care system • Outpatient rehabilitation
• Benchmarking • Home health services • Patient/client satisfaction
• Bundled Payment for Care • Hospital Readmissions Reduction • Primary care
Improvement Program • Productivity
• Case management • Internal benchmarking • Quality
• Centers for Medicare and • Lean methodologies • Skilled nursing or subacute
Medicaid Services • Length of stay rehabilitation
• Day rehabilitation • Long-term acute care • Throughput
OVERVIEW size from single entities to a conglomeration of entities with a

common purpose and oversight. They can include 1 or more
A
ssuming a leadership role within health care sys- levels of care.
tems is more of a challenge now than it has ever
been. How health care is delivered, received, and re-
imbursed can change on a daily basis. Leaders need to be Value-Driven Care
prepared to be flexible, innovative, and authentic in their Health care systems strive to provide care in the most efficient
approach and delivery in order to guide their teams through and effective manner; the goal is to achieve the best clinical
these challenges. This chapter provides an overview of the outcomes for patients while providing the best customer ser-
levels of care, care transitions, challenges in reimbursement vice. Providing quality care delivered in an efficient manner
that affect care delivery, and important considerations when is essential to payers, health care providers, and consumers.
making decisions. Many agencies monitor and guide health care systems in
providing quality care in an efficient manner; examples in-
clude the Centers for Medicare and Medicaid Services (CMS),
ESSENTIAL CONSIDERATIONS National Quality Forum, and The Joint Commission.
A health care system is the organization of resources, institu- CMS is a federal agency that provides health care coverage for
tions, and people that delivers health care services to meet the beneficiaries, works with state governments to administer Med-
health needs of populations. Health care systems can vary in icaid and other health care coverage, and provides standards
https://doi.org/10.7139/2019.978-1-56900-592-7.006
59
for quality improvement initiatives. Many agencies report acute myocardial infarction. In 2015, elective total knee
on quality and safety data for consumers to use as they make replacements, total hip replacements, and acute exacerbation
decisions about health care providers. These ratings identify of chronic obstructive pulmonary disease were added. In
high-performing hospitals, educate consumers on the safety of 2017, coronary artery bypass grafts were also included in the
hospitals, and provide data to support value-based purchasing. program. According to Desai et al. (2016), hospitals subject to
Health care costs in the United States are among the high- penalties under the HRRP demonstrated greater reductions
est in the world, accounting for 17.9% of the GDP in 2016 in readmission rates when compared with hospitals not in the
and resulting in $3.3 trillion in spending (CMS, 2016). CMS program. The changes in these rates were more significant for
has led efforts to reduce health care costs through many the diagnoses identified in the HRRP.
value-based projects, including bundled payments, readmis- Providing efficient care in all phases of care, from acute to
sion penalties, and quality payment programs. postacute, is an important component for maximizing cost
Bundled Payment for Care Improvement (BPCI) is a containment. In addition, providing quality care is imperative
CMS initiative addressing performance and accountability for promoting clinical outcomes that support healthier popu-
for an episode of care, with the aim to improve coordination lations. This concept of Value = (Quality + Outcomes)/Cost is
of care across providers and care environments. This ini- at the center of CMS initiatives. In this new approach to pro-
tiative includes 4 models of care that address performance viding health care, all providers are held accountable for their
and financial accountability for an episode of care for Medi- contributions to providing high-quality, evidence-based,
care beneficiaries (Press et al., 2016). The BPCI model was patient-/client-centered care.
developed to promote coordinated care across providers and
through the continuum of care. Levels of Care and Care Transitions
Forty-eight clinical episodes currently are being evaluated
At the center of many efforts to improve care delivery is the
through this payment model. Episodes could include an acute
aim of enhancing care coordination with a focus on commu-
care stay, an inpatient hospital stay through postacute care
nication among providers, patients/clients, and caregivers.
services for 90 days, the postacute care stay, or a single pro-
This includes enhanced use of electronic medical records and
spective payment for all services provided. Health care insti-
developing agreements between facilities for improved tran-
tutions receive a fixed amount for reimbursement to provide
sitions of care from one level of care to another. A coordi-
the necessary care for an individual for the entire episode of
nated discharge plan includes a focus on patient/client and
care. Many institutions and health care systems have cre-
caregiver education to facilitate carryover of skills and
ated clinical pathways to streamline care, reducing variation
knowledge to the next level of care. All health care providers,
in practice and associated costs and, when needed, creating
including occupational therapy practitioners, have an essen-
collaborative agreements with postacute care institutions
tial role in promoting patient-/client-centered, coordinated,
for continuity of care. These collaborative agreements often
and evidence-based care in an efficient manner.
include the extension of clinical pathways and cost sharing
Several levels of care are available:
in the care of the patient/client and reimbursement received.
Studies show that this bundled payment initiative has ■ Acute care is care provided in a hospital setting where
resulted in a decreased length of stay (LOS; a metric used by the treatment of the medical condition is the focus for
health care organizations and systems that reflects the dura- intervention.
tion of an individual’s hospitalization), increased discharge to ■ Skilled nursing or subacute rehabilitation involves care
home, and stable readmission rates (Iorio et al., 2016). All of provided in a facility supporting ongoing medical recovery
these factors contribute to cost savings for the organization. where the individual may receive skilled rehabilitation care.
This study found that implementation of clinical care path- ■ Acute inpatient rehabilitation is where clients receive
ways, evidence-based protocols, and improved care coordina- skilled rehabilitation services for 3 hours a day requiring
tion were instrumental in improving the quality outcomes for at least 2 therapeutic disciplines (occupational, physical,
cost containment within this CMS initiative (Iorio et al., 2016). and speech therapy) in addition to nursing care. Clients
Another initiative by CMS addresses the issue of hospital may receive additional skilled services such as psycholog-
readmissions through the Hospital Readmissions Reduction ical services and recreation therapy.
Program (HRRP). The 30-day all-cause readmission measure ■ Long-term acute care provides specialized care (e.g., com-
is a risk-standardized readmission rate for Medicare benefi- plex wound care, respiratory care services) to its residents
ciaries who were hospitalized in an acute care hospital and in a hospital setting.
experienced an unplanned readmission for any cause to an ■ Day rehabilitation is designed to provide intensive indi-
acute care hospital within 30 days of discharge. The rationale vidualized rehabilitation care in an outpatient facility.
for the program is that many readmissions are a result of poor ■ Home health services involve nursing care and other ther-
coordination of care, including inadequate planning for tran- apy provided in the individual’s home environment.
sitions from the acute care environment and poor quality of ■ Primary care is the setting in which an individual receives
care (Gerhardt et al., 2013). basic medical care in an outpatient setting.
Initial programs included financial penalties for the ■ Outpatient rehabilitation involves therapy services pro-
30-day all-cause readmission measure for patients with ini- vided in an outpatient setting either as part of a hospital
tial admitting diagnoses of heart failure, pneumonia, and or in a stand-alone facility.
CHAPTER 6. Leading and Managing Within Health Care Systems 61
Some health care systems provide several levels of care, using historical data. For therapy services, productivity is
allowing for efficient transitions and communication between often measured through both billable time for financial pur-
each level. When facilities are independent of one another, poses and patient visits as a measure of throughput. While
communication for care transitions can become fractured, many organizations use productivity as a primary metric for
leading to inefficiencies and discoordination in care provi- performance, achieving positive clinical outcomes is equally
sion. Coordinated communication of discharge plans across important. This brings us back to the discussion of the con-
the levels of care is imperative to ensure that all needs are cept of Value = (Quality + Outcomes)/Cost.
addressed and carried over, especially with important rou-
tines such as medication management and health prevention
Benchmarking
or promotion tasks.
Care coordination is a key tenet of effectively navigating Benchmarking is “a standard by which others may be mea-
health care systems. All stakeholders, including clients, care- sured or judged” (Benchmark, 2011) and can be used for
givers, payers, and clinicians, need to be flexible, collabora- comparison. In health care systems, benchmarking is used
tive, and receptive to new approaches (Robinson et al., 2016) to support decision making with respect to performance
to facilitate effective management of disease processes and in various measures, including productivity, financial tar-
transitions from one level of care to another. Care coordina- gets, clinical processes, and outcomes as comparisons are
tion should be interprofessional and client centered; it should made to identified standards. Benchmarking is also used as
engage caregivers and family members, while advocating for a tool to engage stakeholders to understand how their per-
the health care needs of clients. formance compares to others and provides opportunities to
The key interventions that have proven to add value to identify areas for improvement.
the effectiveness of care transitions include making appoint- Aparicio et al. (2014) discuss 2 forms of benchmarking:
ments for follow-up care, organizing postdischarge services, (1) internal and (2) external. Internal benchmarking com-
educating patients about their medications, providing indi- pares best practices within an organization as well as eval-
vidualized education to the client and caregivers, assessing uating performance of the organization over time. External
client understanding of discharge education and instruc- benchmarking assesses performance in comparison to other
tions, and calling patients after discharge to reinforce the dis- organizations whose strategies have proven effectiveness.
charge plan (Mitchell et al., 2016). Research has shown that
when compared with routine discharge care, an individual-
Quality Initiatives
ized discharge plan can reduce hospital LOS and readmis-
sions (Gonçalves-Bradley et al., 2016). The other important components of value are quality and
outcomes. Quality care is provided through the consistent
use of evidence-based practice that can be measured. The use
LOS and Productivity
of outcome measurements to assess and evaluate change over
To provide efficient care and respond to financially driven time from admission to discharge provides data that can
programs, many health care systems focus on LOS and pro- demonstrate the impact of the care provided. Patient/client
vider productivity. Service-driven protocols or clinical path- satisfaction is a type of outcome consistently measured by
ways are developed to structure the care provided to facili- health care systems that measures an individual’s perception
tate discharge in a specified LOS within the hospital. These and attitudes of the care provided and received. Outcome
evidence-based clinical pathways are designed to guide the data can be used to determine gaps in care provision leading
care for each discipline to ensure a coordinated plan for each to quality improvement initiatives or research opportunities
day and consistent care delivery. Many health care organiza- that can inform evidence-based practice.
tions monitor the LOS on a daily basis and have created com- Many organizations have implemented lean methodologies
munication pathways to facilitate the discharge process such to facilitate process improvement throughout the health care
as multidisciplinary rounds and care conferences. system. Lean methodology is used to improve the quality and
Throughput, or moving the client through the episode of safety of care for clients, improve work flows for clinicians and
care while achieving all of the clinical milestones, is an im- staff, and increase financial performance through eliminating
portant metric that has financial implications. The shorter inefficiencies and waste (D’Andreamatteo et al., 2015; DiGioia
the LOS for the entire episode of care, the greater the effi- et al., 2015). The principles used to guide lean implementation
ciency and financial return for the health care system. This is are applied to all aspects of care delivery in the health care sys-
especially true for BPCI, managed care products, and negoti- tems through the creation of standard work, a workflow that is
ated care contracts with payers. able to be replicated by all through standardization.
Productivity is a metric used in many health care systems The use of evidence-based practice guidelines provides clini-
to determine efficiency in the delivery of care against an es- cians with a standard approach to care, leading to fewer medical
tablished standard. Along with finance reports, this measure errors and more efficient care delivery. As part of these prac-
is used to determine whether revenue projections are being tice guidelines, health care systems are implementing the use of
met and where opportunities exist in enhancing efficiencies. order sets within their electronic medical record systems and
Many organizations have established productivity metrics standardized approaches to all aspects of care delivery. Con-
through benchmarking with other health care systems or sistent use of medical tests, consultation requests with various
clinical disciplines, and timing and dosing of medications and PRACTICAL APPLICATIONS IN
interventions are examples of standardized approaches. This OCCUPATIONAL THERAPY
approach also includes implementing systems for supply moni-
toring and restocking to ensure that care providers have the sup- Occupational therapy leaders, managers, practitioners, and
plies and tools readily available to provide optimal care. students have an important role in identifying the distinct value
Patient/client satisfaction is a quality metric used by many of occupational therapy to health care systems. As mentioned
regulatory bodies and payers to assess the care provided by a earlier in this chapter, health care delivery is now value driven.
health care system. Patient/client satisfaction is a reflection Occupational therapy practitioners and students provide care
of an individual’s perception and attitudes toward their care to clients in all contributing environments of health care sys-
(Jenkinson et al., 2002). As consumers have choices in health tems, from acute care through the continuum to postacute
care plans and providers, patient/client engagement and the care and primary care settings. In each setting, occupational
voice of the customer are important metrics used by health therapy providers are challenged to provide evidence-based
care systems to gauge opportunities for improvement in care care that contributes to positive clinical outcomes for clients
delivery (Custer et al., 2015). in an efficient and effective manner. This care must be pro-
Areas of assessment related to patient satisfaction include vided in a manner reflecting “the core belief that occupational
the cleanliness of the facility, friendliness and responsive- therapy practice is anchored in the meaningful, necessary and
ness of the care providers, collaboration and coordination familiar activities of everyday life,” demonstrating the distinct
of care, perceived quality of the care provided, pain manage- value of occupational therapy (Lamb, 2017, p. 3).
ment, cultural competence, and health literacy. Providing In her American Occupational Therapy Association
patient-/client-centered care and partnering with patients in (AOTA) Presidential Address, Ginny Stoffel (2013) stated
decision making are important components of client satisfac- that “leadership is a process of influence. Organizations
tion (Al-Abri & Al-Balushi, 2014). Marley et al. (2004) stated are healthier when leaders influence others to take action”
that measuring satisfaction should include aspects of process (p. 634). Each occupational therapy practitioner has the
components of “how” the service was provided as well as the opportunity to be a leader. Leadership can occur at all levels
interpersonal aspects of the care provided. if goals and objectives are understood. Occupational therapy
Regulatory bodies and payers are assessing the care pro- managers and leaders in health care systems are uniquely
vided according to the clinical outcomes, quality indicators, positioned to influence the actions of others to improve how
and patient satisfaction outcomes. These metrics are used to health care is delivered. Leaders are also required to connect
determine readiness for various designations, including spe- the purpose of initiatives to the outcomes achieved to engage
cialty certifications through different certifying bodies. stakeholders in the process.
Review Questions Occupational Therapy Contributions to

Value-Driven Care
1. Value-based programs were implemented to
a. Improve coordination of care. Occupational therapy practitioners work with client popula-
b. Improve quality of care. tions identified in the BPCI and HRRP initiatives. Occupa-
c. Reduce health care costs. tional therapy managers and leaders need to be recognized as
d. All of the above. stakeholders in these initiatives and clearly define the critical
2. Strategies to improve care transitions include all except role occupational therapy plays to facilitate efficiencies in care
a. A coordinated individualized discharge plan, includ- and reduce readmission rates.
ing the client and caregivers. Many health care systems have developed clinical path-
b. Follow-up telephone call to reinforce discharge edu- ways to support efficiencies and create standard approaches
cation and respond to concerns. to clinical care delivery, identifying the role of each disci-
c. Medication reconciliation and education. pline. These pathways are designed to reduce redundancies
d. Discharge planning assigned to a single provider. while promoting positive clinical outcomes, from prehos-
e. Providing clients with follow-up appointments at the pital admission through postacute care environments.
time of discharge. Occupational therapy practitioners should be involved in the
3. Benchmarking in health care systems: development and evaluation of the effectiveness of the clin-
a. Benchmarking allows comparison in performance ical pathways to ensure that functional needs are addressed
with other similar organizations for improvements in to facilitate optimal engagement and participation of clients
different areas of measurement. as they transition through the various levels of care. Occupa-
b. External benchmarking allows comparisons of best tional therapy practitioners can assist in identifying barriers
practices within an organization. for discharge early in the process that contribute to inefficien-
c. Internal benchmarking assesses performance with cies in discharge planning.
other organizations. According to Gerhardt et al. (2013), from 2007–2011 the
d. Benchmarking sets up competition between organi- national 30-day all-cause readmission rate was an average
zations for financial gain. of 19%. During the calendar year 2012, this rate dropped
to 18.4% and is presumed to be a result of initiatives imple- The Commission for Case Manager Certification (2017)
mented to address inefficiencies in care delivery. Gage et al. defines case management as “a collaborative process that
(2012) reported readmission rates of 17.4% for inpatient reha- assesses, plans, implements, coordinates, monitors, and
bilitation, 19.8% for skilled nursing facilities, 21.1% for long- evaluates the options and services required to meet the cli-
term acute care, and 20.2% for home health agencies. As these ent’s health and human service needs. It is characterized by
statistics underscore, readmissions occur in all levels of care, advocacy, communication, and resource management and
and opportunities to improve care processes can be found at promotes quality and cost-effective interventions and out-
all levels in a health care system. comes” (para. 1). Occupational therapy practitioners acquire
An individual’s functional level has been shown to affect these skills through their formal education. As stated by
hospital readmissions. DePalma et al. (2013) found that Robinson et al. (2016), occupational therapy practitioners
individuals with unmet ADL needs were more likely to be have a unique lens to assess the intersection of occupation,
readmitted to a hospital within a year; they reported that occupational performance, and individual factors to support
1 in 4 Medicare beneficiaries were discharged with unmet successful care transitions. Facilitating roles for occupational
ADL needs. Naylor et al. (2011) reported that most transi- therapy practitioners in case management is an opportunity
tional care focuses on medical management for discharge, for occupational therapy leaders to positively affect care tran-
with few addressing the functional needs of the individual. sitions in health care systems.
Occupational therapy practitioners are trained to address the Many of the initiatives addressing bundled payments
functional needs of individuals, including ADLs, medication and hospital readmissions focus on the LOS in the hospital.
management, and health routines to support the highest level Directly related to this is the ability of occupational therapy
of independence, in all settings. personnel to evaluate clients in a timely manner, identify
Opportunities to collaborate with other disciplines to appropriate discharge dispositions to initiate transition to
reduce the risk of hospital readmissions through proactive the next level of care, and develop an individualized plan of
interventions such as early mobility programs have demon- care. Occupational therapy practitioners then provide inter-
strated improvements in cognitive function, with fewer days of ventions that are consistent with the frequency and duration
delirium and better functional outcomes at hospital discharge identified in the individualized plan of care.
(Schweickert et al., 2009; Nydahl et al., 2017). Another exam- Occupational therapy managers develop procedures for
ple includes the role of occupational therapy practitioners in timely completion of these tasks that support clinical path-
optimizing medication management and subsequent medical ways and established standards of care. Many health care
adherence through the unique lens of time management, cli- systems have developed procedures to prioritize client popu-
ent participation in healthy habits and routines, and the use of lations and diagnoses to facilitate these processes.
assistive technology (Schwartz & Smith, 2017). One way to identify the ability of the team to meet client
Focusing on self-management skills is an important care needs within a health care system is through tracking
factor in health maintenance. Occupation therapy practi- individual and aggregated team productivity to report bill-
tioners are experts in identifying opportunities for improve- able time and client visits. These data points are often used to
ments in task performance through task analysis and then justify current staffing needs or staffing requirements as vol-
actively engaging clients and caregivers in developing the umes change over time. These data may be used for internal
skills for self-management (Lamb & Metzler, 2014; Roberts & and external benchmarking to identify gaps in service deliv-
Robinson, 2014). Occupational therapy managers and leaders ery and opportunities for enhanced efficiency. Occupational
are expected to identify and support the role of occupational therapy managers and leaders are often required to report
therapy in assessing functional abilities, providing interven- these metrics as part of a health care system to inform the
tions, and recommendations to facilitate appropriate dis- organization’s financial performance. These data can be used
charge planning and follow up for individuals as they move to support decisions for new program development or the
from one level of care to another. Managers need to ensure need to streamline current programming.
that occupational therapy is an identified stakeholder and key
participant for discharge planning and decisions. Occupational Therapy’s Role in
Quality Initiatives
Occupational Therapy’s Role in
Occupational therapy practitioners are ethically responsible
Care Transitions
for the value of the service they provide to facilitate opti-
Occupational therapy practitioners are undertaking roles in mal clinical outcomes for clients (Leland et al., 2015). This
care coordination and primary care environments with skills is accomplished through consistent use of evidence-based
suited to lead care transitions (Lamb & Metzler, 2014). In assessments and interventions. These best practice initia-
these roles, therapists are completing assessments and iden- tives can assist in identifying the practice gaps in the pro-
tifying opportunities for enhanced support and intervention fession of occupational therapy to inform research initiatives
for individuals to integrate daily health habits and routines (Braveman, 2016; Lamb & Metzler, 2014; Leland et al., 2015).
that improve function and participation in ADLs and IADLs Occupational therapy managers and leaders need to cham-
while promoting self-sufficiency and independence. pion these efforts and provide opportunities for clinicians to
engage in quality initiatives to improve care delivery. This can Within health care systems, occupational therapy practi-
occur through performance improvement, implementation tioners can provide leadership on committees addressing hospital
of lean methodologies for process improvements, or more readmissions, clinical pathway development, care coordination,
formally through the development of research projects. quality improvement, client satisfaction, clinical innovation, and
The implementation of occupational therapy practice client education to address concerns of health literacy. Having a
guidelines to reduce variation in clinical practice and enhance presence and ability to contribute as a stakeholder in these initia-
efficiencies in outcomes is an effective way to achieve the tives allows occupational therapy to promote healthy transitions
above-mentioned goals. These practice guidelines are based on through health care systems in an efficient and effective manner.
systematic reviews of the literature and provide practitioners
with assessments and interventions that demonstrate effective
Review Questions
outcomes. AOTA (n.d.) provides practice guidelines for spe-
cific topics “to support decision making that promotes a high 1. Occupational therapy leaders can facilitate the role of oc-
quality health care system” (para. 1). Components of clinical cupational therapy providers in reducing hospital read-
practice guidelines (see Table 6.1) involve a comprehensive missions by
review of the research evidence, proposed evaluation tools, a. Assisting in optimizing client participation in medi-
outcome measures, and interventions to implement. These cation management.
guidelines often provide an algorithm for decision making to b. Collaborating for the implementation of coordinated
assist the clinician in efficiency in care provided. mobility and early intervention programs.
As discussed previously, client satisfaction is an important c. Facilitating self-management in establishing health
quality initiative in health care systems. Every health care pro- routines that promote healthy lifestyles.
fessional has a role in client satisfaction and can influence cli- d. Participating in the development and evaluation of
ent and family perceptions of the care delivered. Occupational clinical pathways.
therapy managers provide education and training to staff on e. All of the above.
expectations related to customer service, communication 2. Opportunities for occupational therapy providers to
standards, and care delivery models for the health care system. demonstrate leadership roles in care transitions include
Many organizations require leaders to perform rounds with all except
clients in the hospital or postacute facility to solicit feedback a. Advocating for client needs when resources may be
on the quality of the facilities, amenities, and communication limited.
with and among care providers as well as on the perceived b. Assessing and evaluating functional abilities and
quality of the care received and to provide the opportunity to identifying barriers for discharge.
respond to concerns in a timely manner. In doing so, the facil- c. Completing medication reconciliation to ensure no
ity is provided with the opportunity to intervene immediately potential concerns for discharge.
with service recovery if needed or to acknowledge the work of d. Communicating recommendations for appropriate
individuals or teams that facilitate positive client experiences. level of care with the interprofessional team.
TABLE 6.1. Criteria for Trustworthy Clinical Practice Guidelines
STANDARD DESCRIPTION
1. Transparency Clear description of the funding sources should be readily available.
2. Management of conflict of interest Conflicts of interest for the individuals and groups involved in developing the guidelines
should be disclosed and managed as appropriate.
3. Composition of guideline development group The group should be composed of multidisciplinary members (stakeholders, experts, clinicians).
4. Review of the literature The guideline should be based on systematic reviews of the research evidence and literature.
5. Rating strength of evidence and Each recommendation should include the potential risks and benefits, a summary and quality
recommendations of the evidence, underlying rationale, rating of the level of confidence in the evidence and
the strength of the recommendation, and differences of opinion regarding recommendations.
6. Presentation of recommendations The guideline should include recommended actions, when they should be performed, and how
they could be measured.
7. External review The guidelines should be reviewed by relevant stakeholders.
8. Updating Guidelines should include date of development, date of evidence, and date of proposed
review; should be updated when new evidence is available.
Source. Adapted from Clinical Practice Guidelines We Can Trust by the Institute of Medicine of the National Academies (2011). Available at https://bit.ly/2HhabhJ. In the
public domain.
CASE EXAMPLE 6.1. Acute Care Readmissions
Samantha is an occupational therapy practitioner working in an acute care hospital with patients being treated for congestive heart failure (CHF).
She is concerned that she continues to see the same clients being readmitted to the hospital with exacerbation of their symptoms. Samantha is
aware that her hospital is working on trying to reduce hospital readmissions as part of cost-saving initiatives. She approaches her manager, Nancy,
with her concerns.
Nancy asks Samantha how the occupational therapy team might contribute to reducing readmissions for clients with CHF. Samantha identifies
several opportunities, such as an occupational therapy assessment for patients upon admission to the hospital to assess their habits and routines,
including self-management for daily weights, medications, and activities. In addition, she believes that a cognitive assessment may be helpful for
clients who live alone and have comorbidities.
Nancy suggests that Samantha complete a review of the literature to support occupational therapy interventions with this population. Once she
has completed the evidence review, Samantha is asked to develop a standardized clinical pathway for occupational therapy assessments, outcome
measurements, and appropriate interventions, including recommended frequency and duration of these interventions. Nancy has recently asked to
be included in the organization’s readmissions committee and plans to share the occupational therapy plan for this population.
As the manager, Nancy will also need to develop a plan to evaluate the impact of this new pathway and to determine whether these interventions
have affected hospital readmissions. She will also need to work collaboratively with the care coordination team and occupational therapy personnel
in the other postacute environments to ensure that clients have the resources at home to sustain the healthy habits and routines such as weight
scales and home health support when needed.
Review Questions
1. Samantha identifies a concern for a high readmission rate for the clients she sees with CHF. What recommendations does her manager
recommend to address this concern?
a. Complete a literature review for best practices in occupational therapy in working with clients with CHF.
b. Develop standardized clinical best practice guidelines for occupational therapy practitioners in working with clients with CHF.
c. Identify appropriate outcome measurements to use with clients with CHF.
d. All of the above.
2. The value-driven initiatives used in the case example to work toward a positive impact for the health care system include
a. Assessment of patient/client satisfaction.
b. Clinical pathway development.
c. Provision of daily occupational therapy interventions.
d. None of the above.
3. Leadership qualities displayed by Nancy include all except
a. Coaching.
b. Competition.
c. Engagement.
d. Influencing.
3. Tools used by occupational therapy managers to measure Leadership is a collaborative process in all levels of care in
efficiencies in health care systems include a health care system, and the goal for occupational therapy
a. LOS. leaders is to engage and influence their teams to take action to
b. Productivity. provide care in the most efficient and effective manner. Case
c. Clinical outcome measurements. Example 6.1 illustrates leadership in the health care system. ❖
ACOTE STANDARDS
SUMMARY This chapter addresses the following ACOTE Standards:
This chapter provides an overview of the levels of care, care ■ B.1.2. Sociocultural, Socioecomonic, Diversity Factors,
transitions, challenges in reimbursement that affect care de- and Lifestyle Choices
livery, and important considerations for leaders to consider ■ B.1.3. Social Determinants of Health
in making decisions in health care systems. Occupational ■ B.1.4. Quantitative Statistics and Qualitative Analysis
therapy offers distinct value in promoting efficiencies in ■ B.2.1. Scientific Evidence, Theories, Models of Practice,
care delivery in health care systems to reduce LOS, promote and Frames of Reference
throughput, and optimize functional abilities of individuals. ■ B.3.1. OT History, Philosophical Base, Theory, and Socio-
Occupational therapy practitioners have opportunities to political Climate
serve in leadership roles to promote quality improvements, ■ B.3.3. Distinct Nature of Occupation
implement lean methodologies, and engage in process ■ B.3.4. Balancing Areas of Occupation, Role in Promotion
improvement to efficiently deliver care. of Health, and Prevention
■ B.4.6. Reporting Data conditions. JAMA, 316, 2647–2656. https://doi.org/10.1001/jama

■ B.4.19. Consultative Process .2016.18533
■ B.4.20. Care Coordination, Case Management, and Tran- DiGioia, A. M., Greenhouse, P. K., Chermak, T., & Hayden, M. A.
(2015, December). A case for integrating the patient and family
sition Services
centered care methodology and practice in lean healthcare or-
■ B.4.24. Effective Intraprofessional Collaboration ganizations. Healthcare, 3, 225–230. https://doi.org/10.1016/j
■ B.4.25. Principles of Interprofessional Team Dynamics .hjdsi.2015.03.001
■ B.4.27. Community and Primary Care Programs Gage, B., Ingber, M., Smith, L., Deutsch, A., Kline, T., Dever, J., . . .
■ B.4.29. Reimbursement Systems and Documentation Garfinkel, D. (2012). Post-acute care payment reform demonstra-
■ B.5.0. Context of Service Delivery, Leadership, and Man- tion: Final report. Retrieved from https://www.cms.gov/Research
agement of Occupational Therapy Services. -Statistics-Data-and-Systems/Statistics-Trends-and-Reports
■ B.7.0. Professional Ethics, Values, and Responsibilities. /Reports/Research-Reports-Items/PAC _Payment_Reform
_Demo_Final.html
Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E.,
& Brennan, N. (2013). Data shows reduction in Medicare hospital
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CHAPTER
Creating a Business in an Emerging Practice Area
Ingrid M. Kanics, OTR/L, FAOTA 7
LEARNING OBJECTIVES
■ Define emerging practice area in the field of occupational therapy,
■ Describe current emerging practice areas in occupational therapy,
■ Describe the process of creating an emerging practice business,
■ Identify mentors for an emerging practice, and
■ Create a plan to sustain an emerging practice.

• Business goals • Formal evaluation • Needs assessment
• Business model canvas • Informal evaluation • Potential partner
• Business plan • Lean startup plan • SMART method
• Emerging areas of practice • Mentors • Traditional business plan
• Evidence review
OVERVIEW Some examples of societal trends that are creating new areas
for occupational therapy practice include the following:
T
hroughout its history, the occupational therapy pro-
fession has always responded to the emerging needs of ■ The worldwide population of individuals ages 60 years or
society. From treating the vast number of returning ser- older currently is 901 million, with the number projected
vicemen of World War I to supporting the growing number of to reach nearly 2.1 billion by 2050 (Barratt, 2017).
children in neonatal intensive care units today, occupational ■ More than 50% of youth with autism who had left high
therapy practitioners have been there to address these ever- school in the past 2 years had no participation in employ-
changing needs. Occupational therapy practitioners have the ment or education (Shattuck et al., 2012).
opportunity to work with people where they live, from their ■ Nearly 1 in 4 active-duty military members have showed
houses to museums, airplanes, and community centers, and signs of a mental health condition, with the rate of post-
are continually adapting their practice areas to meet the con- traumatic stress disorder being 15 times higher than in
tinuously growing needs of society. civilian populations (Kessler et al., 2014).
Emerging areas of practice, sometimes referred to as non- ■ The national childhood obesity rate among 2- to 19-year-
traditional practice areas, are areas in which the occupational olds is 18.5% (The State of Childhood Obesity, 2017).
therapy role has not been established (Overton et al., 2009). In ■ In a recent American Well (a telemedicine technology
2011, as part of the American Occupational Therapy Associ- provider) poll of 4,000 respondents, 65% said they were
ation’s (AOTA) Centennial Vision process, emerging practice interested in seeing their primary care physician (PCP)
areas in occupational therapy were identified (see Exhibit 7.1). over video. Parents of children younger than 18 had a 74%
Many areas of opportunity are available to occupational interest in seeing their PCP through telehealth technology
therapy practitioners to practice with various populations. (Landi, 2017).
https://doi.org/10.7139/2019.978-1-56900-592-7.007
69
CHAPTER
Creating a Business in an Emerging Practice Area
Ingrid M. Kanics, OTR/L, FAOTA 7
LEARNING OBJECTIVES
■ Define emerging practice area in the field of occupational therapy,
■ Describe current emerging practice areas in occupational therapy,
■ Describe the process of creating an emerging practice business,
■ Identify mentors for an emerging practice, and
■ Create a plan to sustain an emerging practice.

• Business goals • Formal evaluation • Needs assessment
• Business model canvas • Informal evaluation • Potential partner
• Business plan • Lean startup plan • SMART method
• Emerging areas of practice • Mentors • Traditional business plan
• Evidence review
OVERVIEW Some examples of societal trends that are creating new areas
for occupational therapy practice include the following:
T
hroughout its history, the occupational therapy pro-
fession has always responded to the emerging needs of ■ The worldwide population of individuals ages 60 years or
society. From treating the vast number of returning ser- older currently is 901 million, with the number projected
vicemen of World War I to supporting the growing number of to reach nearly 2.1 billion by 2050 (Barratt, 2017).
children in neonatal intensive care units today, occupational ■ More than 50% of youth with autism who had left high
therapy practitioners have been there to address these ever- school in the past 2 years had no participation in employ-
changing needs. Occupational therapy practitioners have the ment or education (Shattuck et al., 2012).
opportunity to work with people where they live, from their ■ Nearly 1 in 4 active-duty military members have showed
houses to museums, airplanes, and community centers, and signs of a mental health condition, with the rate of post-
are continually adapting their practice areas to meet the con- traumatic stress disorder being 15 times higher than in
tinuously growing needs of society. civilian populations (Kessler et al., 2014).
Emerging areas of practice, sometimes referred to as non- ■ The national childhood obesity rate among 2- to 19-year-
traditional practice areas, are areas in which the occupational olds is 18.5% (The State of Childhood Obesity, 2017).
therapy role has not been established (Overton et al., 2009). In ■ In a recent American Well (a telemedicine technology
2011, as part of the American Occupational Therapy Associ- provider) poll of 4,000 respondents, 65% said they were
ation’s (AOTA) Centennial Vision process, emerging practice interested in seeing their primary care physician (PCP)
areas in occupational therapy were identified (see Exhibit 7.1). over video. Parents of children younger than 18 had a 74%
Many areas of opportunity are available to occupational interest in seeing their PCP through telehealth technology
therapy practitioners to practice with various populations. (Landi, 2017).
https://doi.org/10.7139/2019.978-1-56900-592-7.007
69
EXHIBIT 7.1. AOTA-Defined Emerging Practice Areas
Start With an Idea
■ Children and Youth Although AOTA has defined some emerging practice areas
■ Broader scope in schools
(see Exhibit 7.1), it is important to realize that these areas
■ Bullying
will continue to evolve as society’s needs change. An occu-
■ Childhood obesity
■ Driving for teens
pational therapy practitioner who is involved in a commu-
■ Transitions for older youths nity activity that they enjoy might also see an opportunity
■ Health and Wellness to bring their occupational therapy skills to this activity to
■ Chronic disease management enable others to fully engage and participate. For example,
■ Obesity a clinician who does pottery as a hobby may have noticed
■ Prevention several seniors, who love doing this activity, now need addi-
■ Mental Health tional supports after a lengthy illness. Combining occupa-
■ Depression tional therapy skills with the knowledge of making pottery
■ Recovery and peer support model can help to create adaptations that allow these seniors to
■ Sensory approaches to mental health
fully engage in this experience.
■ Veterans and wounded warriors’ mental health
The opportunities for creating a business around an emerg-
■ Productive Aging
■ Aging in place and home modification
ing practice can come from many areas of the community as
■ Low vision well as the occupational therapy practitioner’s own skills and
■ Community mobility and older drivers interests. The key is to match the practitioners’ knowledge,
■ Rehabilitation, Disability, and Participation talents, and interests with an unmet community need. This
■ Autism in adults process can include nonwork interests, such as those tied to
■ Cancer care and oncology hobbies, health and wellness, or family activities.
■ Hand transplants and bionic limbs Community needs can come in many forms. They can be
■ New technology for rehabilitation designing a better way for people to get around town, creating
■ Telehealth care opportunities for young children and seniors, or develop-
■ Veteran and wounded warrior care
ing after-school programs that foster community service for
■ Work and Industry
teens. What is important is to be open to possibilities of how oc-
■ Aging workforce
■ New technology at work
cupational therapy can meet a need in nontraditional settings.
■ Education
■ Distance learning
Learning Activity
■ Reentry to the profession
Source. Adapted from Yamkovenko (2011). Copyright © 2011 by the American On a flipchart, writing board, or piece of paper, brainstorm ideas
Occupational Therapy Association. Used with permission. of activities that you enjoy and with which you could utilize your
occupational therapy skills. These could be connected to hobbies,
new ideas related to your current work, or areas that you would like
All of these are areas where occupational therapy prac- to try for yourself. Next, create a list of unmet community needs.
titioners can provide services because occupational therapy You may want to do this in a group or with a mentor. This is the
has something to offer in every aspect of daily life. Although brainstorming stage, so there should be no judgments put on the
list that you create. Once both of these lists have been generated,
many positions are available within traditional medical set-
look for common threads or themes that might help to identify an
tings, the future of occupational therapy lies in its continued emerging area of practice.
response to helping people engage in their daily needs. This
chapter provides tools to identify community-based areas of
need that occupational therapy practitioners can address and Needs Assessment
a template for creating a plan to develop a business to address
this need, allowing others to see how occupational therapy It is important to do a full needs assessment of the emerging
can touch many areas of community. practice area, which is a systematic process of exploring and
addressing an area of need in the community. This assessment
should be progressively completed on several levels, starting
with an informal evaluation followed by a formal evaluation
Learning Activity
and an evidence review.
Explore the emerging practice areas defined by AOTA in greater
detail by visiting https://www.aota.org/Practice/Manage/Niche.aspx Informal evaluation
and identifying which of these niche practice areas are of interest
to you. Informal evaluation, or casual discussions with community
members to get a feel for whether a trend one has noticed is
CHAPTER 7. Creating a Business in an Emerging Practice Area 71
being noticed or expressed by others who might work in this

Learning Activity
area, determines a gap in an individual, group, or community
need. This can be a physical, emotional, or psychosocial need. Use the SBA marketing and trends resources (https://bit.ly/2yHKRK7)
to explore one of the populations of needs that you identified on
Formal evaluation your brainstorming list. Are there any trends that appear around that
population? For example, data on the employment of young adults
If the informal evaluation indicates that a need might be
with autism can be explored using the employment statistics found
unmet, then a formal evaluation should be done to determine on the SBA site.
if the gap really exists and to identify any individual, group,
or organization that is working to meet this need. Unlike an
informal evaluation, which involves casual conversations, a
formal evaluation is a formalized process of setting up focus Find Mentors
groups, surveys, and interviews with specifically defined
While conducting a needs assessment of the community,
questions to address the gap that is has been identified. In
occupational therapy practitioners will find it helpful to con-
some cases, a community partner that the occupational ther-
nect with 1 or 2 mentors. These mentors should be people
apy practitioner can work with is identified to address this
who know the occupational therapy practitioner well and can
unmet community need. In this way, practitioners do not
help them both sift through the data collected and assess their
have to “reinvent the wheel” but can bring their skills and
own skills and talents and how these can be used to meet the
distinct value to an organization that is already working to
identified community need.
address the identified community resource.
The occupational therapy practitioner may also look for a
mentor in the emerging practice area. For example, a practi-
Evidence review
tioner who is looking to create a business that involves envi-
An evidence review can provide a larger picture of occupa- ronmental modification in museums might want to identify a
tional therapy practitioners and organizations that might be designer or architect who can help them navigate the world of
trying to address the identified community need in another design in museums. Such a mentor can help the practitioner
region of the country or the world. This information can pro- understand the terminology and processes involved to be
vide occupational therapy practitioners with the resources on successful in an emerging practice of environmental modi-
models that have been tried to meet the need and any outcomes fication in museums. Mentors can provide much more than
that have been achieved. This type of assessment may result in just a listening ear.
acknowledging the need and showing that there are few pro- Occupational therapy practitioners going into an emerg-
grams addressing it. This can be an effective way to identify ing practice area should consider a mentor for these reasons
the need for a program to address the community need. (Eugenio, 2016):
Data can be gathered in various ways during a formal
needs assessment (University of Minnesota, n.d.), such as
■ To gain experience not found in books or on the Inter-
net. A mentor can share knowledge based on real-life
■ Attending or holding community meetings with those experiences.
who are in need; ■ To increase the chances of success. A mentor provides
■ Creating focus groups to get more detailed information ongoing direction and timely advice on real-life business
from specific groups within the community; issues.
■ Interviewing key community members to get firsthand ■ To develop relationships. A mentor provides networking
definitions of issues and needs; opportunities and has connections that can help address
■ Creating a survey that can be used in an online, mailed, or business needs.
in-person format; and ■ To have an ally. A mentor provides reassurance and
■ Using the free marketing data and trends resources that are encouragement at all stages of business development,
available on the U.S. Small Business Administration (SBA) especially during difficult times.
website (www.sba.gov) to better understand other orga- ■ To grow. A mentor can help strengthen one’s emotional
nizations that might be working to address the identified intelligence, allowing one to better weather the ups and
community need. This information will help identify other downs of running a business.
organizations that could become resources or are competi-
Occupational therapy practitioners can have different types
tors. If no businesses are addressing this need, this fact may
of mentors. Some can be more occupational therapy–based,
provide further confirmation that the emerging practice
whereas others can provide financial and business structure
business would meet an unmet need in the community.
guidance. Still others can provide specific knowledge and
All the information gathered during the needs assessment skills to help practitioners meet the needs of the community
should be finalized and organized before looking for potential members the emerging practice business is trying to address.
funding sources and considering creating a business around Regardless, one should never try to enter into any business
the identified emerging practice area (Cameron & Luvisi, 2012). venture without at least 1 mentor to help in the process.
3. Which of the following are reasons why an occupational

Learning Activity
therapy should consider having a mentor?
Write down the names of potential mentors for your emerging a. Success is more likely with a mentor.
practice business and how they could help you. Include a list of b. Mentors will help you develop a stronger emotional
occupational therapy practitioners and others, as well as a list of intelligence to ensure you can handle the ups and
skills you might need but do not have a current mentor to provide. downs of running a business.
Brainstorm a list of where you might find people with these skills. c. Mentors can share knowledge based on real-life
experience.
d. All of the above
Identify Potential Partners
During the needs assessment process, the occupational PRACTICAL APPLICATIONS IN
therapy practitioner may discover 1 or more community OCCUPATIONAL THERAPY
organizations either working with the community in need in
a different capacity or running a program similar to what the Develop Business Goals
practitioner wants to create. In either case, this organization An important part of creating an emerging practice is to
could become a potential partner for the emerging practice clearly define goals for the business and the programs pro-
business. The organization could be a resource for referrals vided to the community in need. Business goals describe
to the program or may be open to hiring the practitioner to what one expects to accomplish with in a company over
design and run the program as part of its services. specific periods of time, often defined as 1 year, 5 years, or
A key consideration when looking for potential partners 10 years. The SMART method promotes specific, measurable,
is to be sure that the emerging practice business’s vision, achievable, relevant, and time-bound program and business
mission, and philosophy and the partner’s vision, mission, goals. Any program and business in an emerging practice
and philosophy are aligned in a way that will benefit all area should be contributing to best practices for the broader
involved—the community in need, the organization, and occupational therapy profession, which is facilitated by hav-
the occupational therapy practitioner. It takes time to get to ing clear, measurable goals.
know an organization, so consider running a trial version of
the program with the organization to see if a longer term re-
lationship will work for everyone involved.
Learning Activity
Learning Activity Use the SMART method to write a goal for a program that your
emerging practice business will provide for your community group
Based on the brainstorming from your previous activity, identify in need:
community organizations that might provide programs or work with S - Specific
the community in need. This may involve conducting an Internet M - Measurable
search to see if such organizations exist and what services they A - Achievable
provide to your target population. For example, what organizations R - Relevant
run programs to help young adults with autism transition into the T - Time bound
workplace? Hypothetical example:
This business will operate an 8-week, occupation-based community
employment skills group for young adults with autism that will
Review Questions increase employment rates by 30% (based on local demographic
employment data for young adults with autism).
1. Which topics are possible emerging practice areas? Write at least 1 long-term goal and 2 short-term goals/objectives
a. Home health for your new emerging practice business.
b. School mental health program
Source. Adapted from Smart Goals Guide (2016).
c. Telehealth
d. Outpatient hand therapy
e. Evaluation of business offices for universal access
Create a Business Plan
f. Neonatal intensive care unit
2. Which process is not part of the formal evaluation An emerging practice business involves creating a business
process? plan to guide the occupational therapy practitioner in build-
a. Reviewing evidence literature ing and running the business. This plan includes goals as well
b. Engaging in casual conversations as the steps the business will take to achieve these goals. It
c. Setting up formal focus groups with clearly defined will include programs offered, how they will be marketed,
questions and how the success of these programs will be evaluated. It
d. Identifying community partners who work to meet also should include specifics on financials and daily opera-
the unmet community need tional processes. A vast array of tools and organizations can
be used to create a business plan. SBA recommends 2 differ- Lean startup plan: Business model canvas
ent formats to create such a plan: (1) the traditional business
Before creating a full traditional business plan, it can be
plan and (2) the lean startup plan.
helpful to create a lean startup plan. This plan is highly
focused, usually fast to write, and contains only key ele-
Traditional business plan ments. Some lenders and investors will not find this type
A traditional business plan is detailed and comprehensive, of plan to be enough information, but it can be a good
requiring a good deal of time to write. This is the plan the way to conceptualize an emerging practice business (SBA,
lenders and investors will often request when an occupational n.d.).
therapy practitioner is seeking financing. A lean startup plan involves creating a more visual
The traditional business plan includes the elements dis- representation of what the emerging practice business
cussed in this section. Not all elements need to be included, will look like. The business model canvas created by Alex
but be sure to include the ones that make sense for the busi- Osterwalder is one of the oldest and most well-known
ness being design (SBA, n.d.): examples. Its visual format is easy to work with, and its free
template allows this tool to be replicated and modified, so it
1. Executive summary—The “what” and “why” of the com- is included in this chapter for readers’ use. Many additional
pany, which includes a mission statement, services pro- tools are available online for free from Strategyzer (https://
vided, leadership, location, financial information, and bit.ly/2erkmON).
projected growth. The business model canvas also includes 9 components,
2. Company description—Detailed information about the many of which align with occupational concepts (SBA,
company, including the need it is designed to address, the n.d.):
population to be served, and its competitive advantage.
3. Market analysis—Describes the size of the market, cus- 1. Key partners—Include community partners, suppliers,
tomer segments and buying patterns, competition, and and strategic partners who will work with the emerging
barriers to entry. All the needs assessment data collected practice.
earlier in the process fit in this area. 2. Key activities—Include the ways the business will gain a
4. Organizational structure and management of the competitive advantage through the services the emerging
business—How the company is structured and who will practice will provide.
run it. The legal structure of the business can include a 3. Key resources—Consist of all the resources that the
corporation, general partnership, limited partnership, emerging practice has to deliver the services, including
sole proprietorship, or limited liability corporation. staff, capital, and intellectual property.
5. Services provided/product line—Includes a descrip- 4. Value propositions—Clear and compelling statements
tion of the services or products that the business will about the unique value that the emerging practice brings
provide and the benefits to the community in need. This to the community.
should include intellectual property, copyright and pat- 5. Customer relationships—Describe how the emerging
ents, and research and development on the services and practice will interact with the community in need and
products. include in-person and online interactions from start to
6. Marketing and sales—Includes the plan to reach the finish of services.
community in need, such as various strategies and how 6. Customer segments—Identify the community in need
the services will be delivered. that the emerging practice is trying to address.
7. Funding requests or grants—Contains information about 7. Channels—List different ways through which the emerg-
the business goals and the next 5-year financial plan. All ing practice will communicate with the community
debt and equity are shared in this part of the business plan. members in need.
8. Financial projections—Builds on the funding request 8. Cost structure—List the types and proportions of fixed
and details income projections, cash flow, and expenses and variable costs for the emerging practice business
for the next 5 years. and how the business will maximize value and reduce
9. Appendix—Includes all supporting documents, such costs.
as credit histories, licenses, permits, and other legal 9. Revenue streams—Explain how the company will actu-
documents. ally make money and include all the revenue streams for
the emerging practice business.
Learning Activity
Learning Activity
Explore the tools and examples of traditional business plans provided
on SBA’s website at https://bit.ly/2wtW93k. Consider how you Print the business model canvas free template (https://bit.ly/2erkmON).
would use this website to create your emerging practice traditional Pick an emerging practice area from the ideas that were generated as
business plan. part of your earlier brainstorming, and complete the business model.
CASE EXAMPLE 7.1. Allison: An Occupational Therapy Twist on a Travel Business
Allison is an occupational therapy practitioner who has been in practice for 5 years. She has spent her entire occupational therapy career working in a local
orthopedic hospital seeing many patients who have had hip, knee, and ankle surgery. On the side, she continues to help her parents run their travel business.
Recently, Allison’s parents have begun to talk about retiring and have hinted that it would be great to keep the travel business in the family. This
got Allison thinking about how she could combine her occupational therapy skills and her family travel business. Allison loves to travel and taking
over the business is attractive to her, but she loves being an occupational therapy practitioner as well.
Allison thought about her current occupational therapy clients and realized that many of them were fairly healthy seniors who also enjoyed
traveling but might need a few supports when they travel because of medical issues. She did some research on travel programs for seniors and
what types of adaptations and supports these programs provided. She found that this was an emerging area of tourism that she was perfectly
aligned to jump into, because she understood the travel industry quite well and knew that she could use her occupational therapy skills to help
design travel supports to ensure a quality travel experience for those with medical conditions that might limit their chances to travel.
Allison talked with 1 of her occupational therapy mentors to share her ideas and create an overall plan for inclusive travel. She also discussed
with her parents about how she could continue the family business with a new twist of making it more inclusive for potential clients of varying
abilities, thus creating a marketing advantage for the business as it went forward.
With her parents’ help, Allison was able to identify a particular travel experience partner that would be open to adapt its current travel packages
to make it more accessible to people of varying abilities. Allison helped with onsite environmental modifications and provided the staff with some
disability awareness training. They ran the 1-week-long adaptive travel experience once a month for 3 months, and Allison made slight modifications
to the experience each time to ensure the program met the needs of travelers. The travel partner was so happy with the results that it asked Allison
to help modify their other travel experiences to make them more inclusive as well. Allison’s parents were also happy with where they saw their
business going and continue to work with Allison to make the business grow in inclusive travel opportunities.
Review Questions
1. List the key activities that Allison is bringing to the family business that will give her an advantage over other travel agencies.
2. Who is Allison’s customer segment?
3. Describe ways that Allison can reach her customer segment.
CASE EXAMPLE 7.2. Megan: Creating an Inclusive Swimming Program for Children With ASD and SPD
Megan has been an avid swimmer for as long as she can remember. Currently, she swims on her university swim team and is studying to become
an occupational therapist.
Recently, the university and Megan’s swim team hosted several community swim events for children with autism spectrum disorder
(ASD) and sensory processing disorder (SPD). Megan noticed that many children seemed to respond positively to these swimming
experiences, and some even expressed interest in swimming regularly. This insight made Megan wonder whether there was a way to
combine her passion for swimming with her developing occupational therapy skills. She shared this insight with her mentors, her swim
team coach, and one of her occupational therapy professors, and she expressed an interest in creating a regular swim program for
children with ASD and SPD. She approached the community organization to see whether the families would be interested in a regular
swimming program.
Working with these mentors, Megan researches physical activity for these populations and created an inclusive swim program that she felt
would meet the needs of those who had attended the community swimming events. She made sure that the program easily fit with the community
organization’s mission. The community organization ran a trial version of Megan’s swimming program, starting with a small group of swimmers to
ensure that each swimmer received the support needed. The community organization made sure to interview parents and children as part of the
program to measure its impact.
The trial program was a huge success, and several children joined their local swim teams while continuing to participate in Megan’s swim
program. Several children with SPD talked about how swimming made them feel more focused after they had been in the swimming program for
several weeks. The local community group was so happy with program’s outcome that it worked with Megan to write a grant to hire her part-time
and make the program a permanent part of the programming. Upon graduating, Megan joined the community organization in a full-time position as
an inclusion expert, expanding her work beyond the swimming program to bring inclusive practices to all the community programs hosted by the
organization.
Review Questions
1. Who is Megan’s customer segment?
2. What is the value that Megan brings as an occupational therapist?
3. Who are other community partners that Megan could consider for her swimming program?
Review Questions ACOTE STANDARDS

1. What acronym describes how to create business goals? This chapter addresses the following ACOTE Standards:
a. SMART method
b. MAKER method ■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors,
c. Goal Attainment Scale and Lifestyle Choices
d. SOAP note ■ B.1.3. Social Determinants of Health
2. A business plan that is very detailed, takes a good deal ■ B.3.6. Activity Analysis
of time to write, and is very comprehensive. This is ■ B.4.14. Community Mobility
the plan the lenders and investors will often request ■ B.4.23. Effective Communication
when looking for financing. What is this business plan ■ B.4.24. Effective Intraprofessional Communication
called? ■ B.4.25. Principles of Interprofessional Team Dynamics
a. Budget ■ B.4.26. Referral to Specialists
b. Lean startup plan ■ B.4.27. Community and Primary Care Programs
c. Executive summary ■ B.5.1. Factors, Policy Issues, and Social Systems
d. Traditional business plan ■ B.5.2. Advocacy
3. In the business model canvas, what term best describes ■ B.5.3. Business Aspects of Practice
the clear and compelling value that the occupational ■ B.5.6. Market the Delivery of Services
therapist feels they bring to an emerging practice? ■ B.5.7. Quality Management and Improvement
a. Channels ■ B.6.2. Quantitative and Qualitative Methods
b. Key activities ■ B.6.3. Scholarly Reports
c. Value proposition ■ B.6.4. Locating and Securing Grants
d. Key partners ■ B.7.1. Ethical Decision Making
4. One type of business plan is detailed and comprehensive ■ B.7.2. Professional Engagement
and can take a good deal of time to write; this is the plan ■ B.7.3. Promoting Occupational Therapy
lenders and investors will often request when looking for ■ B.7.4. Ongoing Professional Development
financing. What is this plan called? ■ B.7.5. Personal and Professional Responsibilities.
a. Budget
b. Lean startup plan
c. Executive summary
REFERENCES
d. Traditional business plan
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SUMMARY of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
Occupational therapy practitioners have the ability to assess .org/10.5014/ajot.2018.72S217
community needs and step in to provide solutions for the Barratt, J. (2017). We are living longer than ever. But are we liv-
ever-changing challenges found in the world today. While ing better? Stat. Retrieved from https://www.statnews.com
being an innovator in occupational therapy practice can be /2017/02/14/living-longer-living-better-aging/
Cameron, K. A. V., & Luvisi, J. (2012). Grants: Fulfilling dreams and
exciting, it is important to take time to research and develop a
needs for occupational therapy. Administration and Manage-
business plan for the emerging practice that will reduce anx- ment Special Interest Section Quarterly, 28(1), 1–3.
iety of “stepping out of the box” and ensure that the business Eugenio, S. (2016). 7 reasons you need a mentor for entrepreneurial
will be successful. success. Entrepreneur. Retrieved from https://www.entrepreneur
It is also important to clearly identify the needs and the .com/article/280134
community partners who can be part of the solution. Em- Kessler, R., Heeringa, S., Stein, M., Colpe, L. J., Fullerton, C. S.,
bracing mentors in occupational therapy and other fields that Hwang, I., . . . Ursano R. J. (2014). Thirty-day prevalence of
connect with the business concept is important to the devel- DSM–IV mental disorders among nondeployed soldiers in the
opment and ongoing growth and evaluation of the business. US Army: Results from the Army Study to Assess Risk and Resil-
Clearly defined goals help with the creation of a business ience in Servicemembers (Army STARRS). JAMA Psychiatry, 71,
plan, and occupational therapy practitioners should take 504–513. https://doi.org/10.1001/jamapsychiatry.2014.28
Landi, H. (2017). Top ten tech trends 2017: Telehealth reaches
advantage of the many resources available to create a solid
the tipping point. Healthcare Informatics. Retrieved from
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tional therapy practice that will meet community needs and Overton, A., Clark, M., & Thomas, Y. (2009). A review of non-traditional
expand the reach of occupational therapy around the world. occupational therapy practice placement education: A focus on role-
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Shattuck, P., Carter Narendorf, S., Cooper, B., Sterzing, P., Wagner, University of Minnesota. (n.d.). Conducting a needs assessment.
M., & Lounds Taylor, J. (2012). Postsecondary education and Retrieved from https://cyfar.org/ilm_1_9
employment among youth with an autism spectrum disorder. U.S. Small Business Administration. (n.d.). 10 steps to start
Pediatrics, 129(6), 1–8. https://doi.org/10.1542/peds.2011-2864 your business. Retrieved from https://www.sba.gov/business
Smart Goals Guide. (2016). Smart goal setting. Retrieved from -guide/10-steps-start-your-business/
http://www.smart-goals-guide.com/smart-goal-setting.html Yamkovenko, S. (2011). The emerging niche: What’s next in your
The State of Childhood Obesity. (2017). Childhood obesity trends. Re- practice area? Retrieved from https://www.aota.org/Practice
trieved from https://stateofobesity.org/childhood-obesity-trends/ /Manage/Niche.aspx
CHAPTER
Management for Occupation-Centered Practice
Debbie Amini, EdD, OTR/L, FAOTA, and Melissa Tilton, OTA, BS, COTA, ROH 8
LEARNING OBJECTIVES
After completing this chapter, readers will be able to
■ Define and differentiate occupation-centered, occupation-based, and occupation-focused occupational therapy;
■ Describe the importance of occupation-centered practice to all stakeholders in a changing health care environment;
■ Identify organizational leadership, management, and educational strategies to assist with a paradigm shift to
occupation-centered practice;
■ Identify characteristics of successful transformational leaders; and
■ Identify barriers to change from preparatory-focused interventions to an occupation-centered paradigm in medical settings.

• Change proactivity • Occupation-centered practice • Primary appraisal
• Change recipients • Occupation-focused practice • Secondary appraisal
• Choosing Wisely ® • Organizational change • Triple Aim
• Leadership vision • Patient-Driven Payment Model • Valence
• Occupation-based practice
OVERVIEW have started to recognize that involvement in meaningful ac-
T
tivities, in natural contexts and with other people, is indeed
he power of occupation is often masked by its simplicity. the recipe for quality of life, health, and wellness that tran-
It is intuitive and natural for humans to create, explore,
scends the physical body. Occupational therapy now stands
build, rest, enjoy, and learn. By completing important
ready to take on the challenge of being the go-to profession
and meaningful activities, people find a sense of fulfillment,
when illness, disability, context changes, work difficulties,
pride, and purpose as they progress along Abraham Maslow’s
and social and economic crises affect a person’s ability to par-
hierarchy to reach self-actualization (Maslow, 1943). In other
ticipate in daily life activities. Occupational therapists have
words, humans are occupational beings (Meyer, 1922).
After World War II and the decline of the Industrial Age known for more than 100 years that occupation, otherwise
in the late 1950s, the occupational therapy profession was thought of as “the things that you do with your time,” is not
challenged both internally and externally to identify as a lin- only the means to productive end results; its execution is a
ear natural science and a medical model profession in which highly important end unto itself (Trombly, 1995).
our tools are highly manufactured and our methods proven Unfortunately, although change is occurring, the accep-
effective through the empirical scientific method. Those ad- tance of the paradigm shift from a preparatory and reduc-
vocating for this change disregarded how the proposed shift tionist focus to an occupation-centered practice has not been
would move us away from the original philosophies of our fully realized by occupational therapy practitioners (Lamb,
founders whose tools were everyday engagements and whose 2017). This chapter discusses the role of occupational therapy
positive results were participation in life (West, 1984). managers in ensuring that practitioners are not only provid-
As a profession seeking a secure identity, we are fortunate ing beneficial interventions but are doing so in an evidence-
that since the early 2000s, society and the medical community supported and efficient way to provide the client with the best
https://doi.org/10.7139/2019.978-1-56900-592-7.008
77
CHAPTER
Management for Occupation-Centered Practice
Debbie Amini, EdD, OTR/L, FAOTA, and Melissa Tilton, OTA, BS, COTA, ROH 8
LEARNING OBJECTIVES
After completing this chapter, readers will be able to
■ Define and differentiate occupation-centered, occupation-based, and occupation-focused occupational therapy;
■ Describe the importance of occupation-centered practice to all stakeholders in a changing health care environment;
■ Identify organizational leadership, management, and educational strategies to assist with a paradigm shift to
occupation-centered practice;
■ Identify characteristics of successful transformational leaders; and
■ Identify barriers to change from preparatory-focused interventions to an occupation-centered paradigm in medical settings.

• Change proactivity • Occupation-centered practice • Primary appraisal
• Change recipients • Occupation-focused practice • Secondary appraisal
• Choosing Wisely ® • Organizational change • Triple Aim
• Leadership vision • Patient-Driven Payment Model • Valence
• Occupation-based practice
OVERVIEW have started to recognize that involvement in meaningful ac-
T
tivities, in natural contexts and with other people, is indeed
he power of occupation is often masked by its simplicity. the recipe for quality of life, health, and wellness that tran-
It is intuitive and natural for humans to create, explore,
scends the physical body. Occupational therapy now stands
build, rest, enjoy, and learn. By completing important
ready to take on the challenge of being the go-to profession
and meaningful activities, people find a sense of fulfillment,
when illness, disability, context changes, work difficulties,
pride, and purpose as they progress along Abraham Maslow’s
and social and economic crises affect a person’s ability to par-
hierarchy to reach self-actualization (Maslow, 1943). In other
ticipate in daily life activities. Occupational therapists have
words, humans are occupational beings (Meyer, 1922).
After World War II and the decline of the Industrial Age known for more than 100 years that occupation, otherwise
in the late 1950s, the occupational therapy profession was thought of as “the things that you do with your time,” is not
challenged both internally and externally to identify as a lin- only the means to productive end results; its execution is a
ear natural science and a medical model profession in which highly important end unto itself (Trombly, 1995).
our tools are highly manufactured and our methods proven Unfortunately, although change is occurring, the accep-
effective through the empirical scientific method. Those ad- tance of the paradigm shift from a preparatory and reduc-
vocating for this change disregarded how the proposed shift tionist focus to an occupation-centered practice has not been
would move us away from the original philosophies of our fully realized by occupational therapy practitioners (Lamb,
founders whose tools were everyday engagements and whose 2017). This chapter discusses the role of occupational therapy
positive results were participation in life (West, 1984). managers in ensuring that practitioners are not only provid-
As a profession seeking a secure identity, we are fortunate ing beneficial interventions but are doing so in an evidence-
that since the early 2000s, society and the medical community supported and efficient way to provide the client with the best
https://doi.org/10.7139/2019.978-1-56900-592-7.008
77
that occupational therapy has to offer. In addition, this chap- connection of factor-focused interventions on occupational
ter provides assistance in creating an occupational therapy participation and ensure that such a connection actually exists
department, clinic, or program where practitioners hold the and correlates with the outcome sought.
focus of occupational participation as their distinct guiding In addition to preparatory methods and tasks, occupation-
professional tenet and harness the power of occupation as the focused practice also allows using approaches to intervention
solution to improving the lives of the clients they serve. identified in the Occupational Therapy Practice Framework:
Domain and Process (OTPF–3; AOTA, 2014). These approaches
ESSENTIAL CONSIDERATIONS are not occupations per se (i.e., education, adaptation, pre-
vention) but are occupation centered. Although a somewhat
Anne Fisher (2013) offers 3 conceptual terms to help us think different way of organizing practice than the OTPF–3, the
about and integrate occupation as the core of practice. The first occupation-focused concept overlies interventions and ap-
term, occupation centered, is the tenet of occupational therapy proaches in the OTPF–3 and helps solidify the notion that in-
for which this chapter is written. In occupation-centered prac- terventions that do not have occupational participation as their
tice, practitioners or settings share the perspective that occupa- goal are not part of the occupation-centered paradigm.
tion is the central organizing lens or framework that grounds An example of an appropriate occupation-centered and
practice, education, and research (Nielson, 1998; Yerxa, 1998). occupation-focused (but not occupation based) interven-
To ensure that practice maintains an occupation-centered tion is an orthotic device such as a CMC (carpometacarpal)
focus within the practice setting, managers or leaders must immobilization orthosis that reduces thumb pain to allow
center their personal practice paradigm on occupation and electronic device use at work. The same would hold true for
hold it as the distinct difference between occupational therapy the use of a physical agent modality that could improve oc-
and other professions in the health care arena. In addition, cupational performance such as a dynamic splint containing
all facility occupational therapy staff should become famil- electrodes to stimulate muscle contractions worn during a
iar with occupation-centered thinking and share a common functional activity such as dressing.
understanding that occupation is at the core of the profes-
sion. A shared paradigm helps ensure fidelity of departmental AOTA Official Documents
or program client outcomes.
Fisher (2013) also identifies occupation-based and occupation- AOTA publishes several official documents that explicitly
focused as additional terms that further describe how occupa- support the paradigm of occupation-centered practice from
tion-centered occupational therapy practitioners organize their both a theoretical and a practical perspective. As mentioned
thinking and interventions around the notion of occupation. previously, the OTPF–3, adopted by AOTA’s Representative
In simplest terms, occupation-based practice refers to evalu- Assembly, describes occupation as the core of the profession
ating and providing treatment interventions that are the exact, and offers the overarching outcome statement, “Achieving
or parts of the exact, occupations targeted as the outcomes of health, well-being, and participation in life through engage-
intervention (Fisher, 2013). For example, observing a client as ment in occupation” (AOTA, 2014, p. S4). The document sup-
she makes breakfast is an occupation-based way to evaluate ports and articulates that occupations are the means and the
cognitive and motor function. Having that client, whose goal is ends to intervention; it also identifies the domain, or areas
to return to making meals for her husband, cook a light meal is of concern for the profession, and articulates their transac-
an occupation-based intervention to work on meal preparation tional relationship with the established process, or applica-
and to improve problem-solving skills and physical endurance. tion, of occupational therapy as a client-centered intervention
Occupation-focused is similar to occupation-based prac- focused on occupational participation. Figure 8.1 provides a
tice insofar as occupation is the targeted outcome. However, visual of the relationship of occupational therapy’s domain
occupation-focused practice also leaves room for the use of and its process and the overarching statement.
interventions that are not considered occupations but are Another AOTA document that provides the groundwork
more preparatory in nature (American Occupational Therapy for the use of an occupation-centered lens for practice is the
Association [AOTA], 2014). In the case of occupation-focused Standards of Practice for Occupational Therapy (AOTA, 2015),
interventions, the focus refers to the relative distance of actual which defines the minimum expectations for occupational
participation from the intervention. In other words, does the therapy practitioners and articulates to all stakeholders that
intervention, whether an occupation, activity, or preparatory the practice of occupational therapy means
method or task, closely resemble or directly lead to the actual
goal of intervention? If so, the intervention is proximally fo- the therapeutic use of occupations (everyday life activities)
cused on occupation. However, if the intervention—which with persons, groups, and populations for the purpose of
could conceivably be an unrelated occupation, activity, or task, participation in roles and situations in the home, school,
such as playing a game of horseshoes to increase the client fac- workplace, community, or other settings. (p. 1).
tor of shoulder range of motion for the goal of yard care—does The Philosophical Base of Occupational Therapy (AOTA,
not immediately or directly impact the target occupation, it 2017b) states that the profession is
is not considered proximal, and therefore the intervention is
not occupation focused (Fisher, 2013). Therefore, practitioners based on the belief that occupations are fundamental to
must always have an occupation-centered lens to articulate the health promotion and wellness, remediation or restoration,
CHAPTER 8. Management for Occupation-Centered Practice 79
FIGURE 8.1. Occupational therapy domain and process.
Education
Social
Participation Play
Work
Client Performance
Factors Patterns
Performance
Rest/ Skills ADLs
Sleep
IADLs
Leisure
Source. From “Occupational Therapy Practice Framework: Domain and Process,” by the American Occupational Therapy Association. American Journal of Occupational
Therapy, 2018, Vol. 68, Suppl. 1, p. S18. Copyright © 2014 by the American Occupational Therapy Association. Used with permission.
health maintenance, disease and injury prevention, and research articles appearing in AJOT that report positive out-
compensation and adaptation. The use of occupation to comes through the use of high-quality studies targeting oc-
promote individual, family, community, and population cupational therapy interventions and approaches.
health is the core of occupational therapy practice,
■ A Model for Client-Centered, Occupation-Based Palliative
education, research, and advocacy. (p. 1).
Care: A Scoping Review: This scoping review, which looked
These documents and others that support the occupation- at more than 75 articles dedicated to the use of client-
centered paradigm are published in the American Journal of centered and occupation-based palliative care, found over-
Occupational Therapy (AJOT), which is available to all AOTA whelming support for the value and unique contribution
members or by subscription at https://ajot.aota.org. of occupational therapy in this setting. It found that the
most important role of occupational therapy is to provide
interventions that focus on valued occupations with the
Evidence Supporting an Occupation-Centered
understanding of the importance of time (from diagnosis
Approach to Care
to death) as a condition of occupation (Yeh et al., 2018).
Being a leader in providing occupation-centered care means ■ Promoting Health Through Engagement in Occupations
being familiar with the evidence, seminal and recent, that That Maximize Food Resources: This participatory action
supports the efficacy and efficiency of occupation-centered research (PAR) project explored the potential benefit of a
occupational therapy for our clients and the health care sys- participant-driven, occupation-based approach to improv-
tem in general. The following annotated list is a sampling of ing food security among people living in poverty. The study
yielded statistically significant improvements in the ability used with clients. Choosing Wisely is an initiative of the ABIM
of participants to make meals using identified food items Foundation (American Board of Internal Medicine) that has
as well as in their satisfaction and performance scores in recognized the importance of patients and health care profes-
self-identified activities related to food resource manage- sionals working together to ensure that health care offers ev-
ment (Schmelzer & Leto, 2018). idence-based, safe, and effective options. Understanding the
■ Impact of an Activity-Based Program on Health, Quality of importance of this initiative, AOTA joined Choosing Wisely
Life, and Occupational Performance of Women Diagnosed to help improve the quality and safety of occupational therapy
With Cancer: This 1-group, pretest–posttest, repeated- services (AOTA, 2018b).
measures design used a functional health measure, a Through a 3-step process that included outreach to AOTA
quality-of-life measure, and an occupational performance stakeholders and practice experts, the association identi-
and satisfaction measure to determine the efficacy of a fied 5 interventions as not being good options for inclusion
6-week activity-based program. The results of the study within an occupational therapy plan of care; none of the
indicate improved occupational performance, satisfaction, interventions selected are classified as occupation centered
and social relationships of community-living women di- or inherently occupation based or occupation focused. The
agnosed with cancer after the occupation-based program 5 recommendations are
(Maher & Mendonca, 2018b).
■ Effectiveness of Occupational Therapy Interventions to 1. Don’t provide intervention activities that are nonpur-
Enhance Occupational Performance for Adults With poseful (e.g., cones, pegs, shoulder arc, arm bike). Using
Alzheimer’s Disease and Related Major Neurocognitive valued activities is at the core of occupational therapy.
Disorders: A Systematic Review: This systematic review Meaningful activities motivate, build endurance, and
yielded strong evidence for the benefits of occupation- increase attention.
based interventions in addition to error-reduction learn- 2. Don’t provide sensory-based interventions to individual
ing and physical exercise. The researchers concluded that children or youth without documented assessment results
daily occupations should be integrated into the daily of difficulties processing or integrating sensory informa-
routine of adults with Alzheimer’s disease to delay function. Sensory issues are complex, and an intervention that
tional decline and enhance occupational performance does not address the correct problem can be ineffective or
(Smallfield & Heckenlaible, 2017). even harmful.
■ Impact of a 1-Week Occupation-Based Program on Pain, 3. Don’t use physical agent modalities (PAMs) without pro-
Fatigue, Participation, and Satisfaction in Women With viding purposeful and occupation-based intervention
Cancer Living in the Community: This prospective 1-group activities. Using heat, cold, mechanical devices, electro-
pretest–posttest design study recruited women living with therapeutic, and other agents without incorporating a
cancer in underserved communities in urban, rural, and purposeful activity is not occupational therapy.
suburban areas. This study investigated the impact of an 4. Don’t use pulleys for individuals with a hemiplegic shoul-
occupation-based program that lasted for 1 week and tar- der. Overhead pulleys often lead to shoulder pain among
geted pain, fatigue, occupational performance, and satisfac- stroke survivors and other individuals with hemiple-
tion with the participant group. Results demonstrate that gia and should be avoided. Gentler controlled range of
this program was effective in decreasing pain and fatigue; motion exercises and activities are preferred.
it also improved participants’ occupational performance 5. Don’t provide cognitive-based interventions (e.g., paper-
and satisfaction, which translated into overall improved and-pencil tasks, table-top tasks, cognitive training
participation in occupations (Maher & Mendonca, 2018a). software) without direct application to occupational per-
formance. Occupational therapy interventions related to
Managers and leaders should remember that integrating cognition should be part of an activity that is important
research into occupational therapy practice is essential if the to the person (AOTA, 2018b).
profession is to continue to grow and be recognized (Garber,
2016). We need to maintain the vitality of what occupational Although sometimes faulted for presenting the negative
therapy is and the scope of interventions, and we must also side of the project findings (what not to do) instead of helping
lead the team along these same lines. Leaders and manag- practitioners know what interventions are better to use (what
ers should not implement treatments that do not promote to do), the Choosing Wisely document can be a useful tool
occupation-based practices, and we must proactively support to start a conversation with staff regarding their views of oc-
those on the team who may need a refresher or change their cupation and occupational therapy and the existent evidence
personal paradigm to occupation-centered. and association philosophy on occupation-centered care.
Choosing Wisely® Reimbursement, Quality Outcomes, and

Occupational Therapy
In 2017, AOTA embarked on a project called Choosing Wisely ®

with the goal of identifying interventions that, despite being Another area that supports the paradigm shift to occupation-
popular in practice, do not necessarily have supportive evi- centered and occupation-based practice concerns changes to
dence and should therefore be strongly considered before being health care reimbursement that began as part of the Patient
Protection and Affordable Care Act (ACA; P. L. 111–148) in success or failure. To guarantee that change is seen in a posi-
2010. In part, the ACA is meant to reform health care delivery tive light and is sustained, managers must understand
to achieve the Triple Aim that includes better care, affordable
■ The impact of change on practitioners,
care, and healthier people and communities (AOTA, 2013).
■ How their reactions can make or break that change,
One target of the Triple Aim has been the reduction of
■ What needs to be done to facilitate long-term positive
hospital readmissions. The high rate of people returning
acceptance of the change (Oreg et al., 2018).
to hospitals after only a short time at home is the result of
many factors such as poor medication compliance, falls,
and other areas that an occupation-centered approach can
address. A recent study found that increased spending on For Additional Learning
occupational therapy services in an acute care setting cor-
related with reduced readmissions for all conditions studied For additional learning, see
(Rogers et al., 2016). ■ Chapter 18, “Managing Organizational Change,” and
Another change planned for October 2019 concerns phas- ■ Chapter 20, “Handling Resistance During Change.”
ing out the Resource Utilization Group (RUG) reimbursement
system and replacing it with the Patient-Driven Payment
Model (PDPM). Under PDPM, skilled nursing facilities will
receive payment based on the client’s characteristics regard- Practitioner response to change
less of the services provided, which is different from RUGs The experience of the recipients of change has taken center
where more services meant a higher reimbursement rate stage in the world of scholarly research on the topic (Oreg et al.,
(AOTA, 2018a). To allay concerns that occupational ther- 2018; Ouedraogo & Ouakouak, 2018). For transformational
apy will not be fully used because of lower reimbursement leaders, this is good news because we can now understand
rates, managers need to guide practitioners to approach cli- the factors responsible for acceptance and nonacceptance and
ents using the profession’s distinct focus on occupational and work to address them.
functional outcomes. Functional outcomes matter to facili- The concepts that managers or leaders must understand
ties and payers because they save money for the system by when thinking about how practitioners are going to respond
ensuring that clients are safe and functional in their home to change include
environment and can receive less expensive services out of
the hospital. ■ The notion of valence—in other words, how positively or
In addition, occupational therapy practitioners must strive negatively recipients respond to change;
to achieve critical client outcomes and articulate the distinct ■ The degree of activation, which describes passivity vs.
value of occupational therapy services by carefully docu- activity when dealing with the change (Oreg et al., 2018);
menting occupation-based interventions and outcomes in the and
medical record (Sandhu, 2015). To this end, practitioners will ■ Affect vs. behavior and the cognitive appraisal process
see the benefit of completing an occupational profile—a part that precedes affective and behavioral responses.
of the OTPF–3 that is required for occupational therapy eval- Oreg et al. (2018) developed a model that illustrates which
uation coding according to the Current Procedural Terminol- combination of change concepts will lead to more positive
ogy (American Medical Association, 2019) coding system—to and lasting change outcomes and which may lead to unsuc-
assist them in identifying and documenting what areas of cessful change. Figure 8.2 shows the 4 quadrants of change
improvement are meaningful and motivating to the client as recipient response options. The lower right quadrant indi-
both outcomes and interventions (AOTA, 2018a). cates an acceptance of change yet shows that such accep-
tance is done with little activation despite being relatively
positive. Although a group arriving at change acceptance in
Organizational Change
this manner may seem like a win for leadership, the associ-
The switch to an occupation-centered care paradigm is equiv- ated passivity may cause change to lose endurance because
alent to an organizational change where a mandate, outside there is no real champion for keeping the change. Conversely,
the control of the everyday worker, leads to emotional, cog- the upper right quadrant reflects positive valence and high
nitive, and behavioral responses (Oreg et al., 2018). Although activation—a proactive change recipient. Although some-
one may consider changing a practice paradigm to be a per- times overly optimistic and perhaps questioning of new ideas,
sonal practitioner decision, the fact that reimbursement and practitioners in this group will likely ensure that change hap-
the profession’s future are potentially at stake shifts the view pens and endures. Those with high yet negative activation as
from change as an option to change that must occur. When noted in the upper left quadrant are resistant and will likely
a change event such as this is on the horizon, the impact on work to ensure that change does not occur, whereas those
the change recipients, the individuals or group of individ- who fall to the bottom left quadrant will become disengaged.
uals that are affected by this change (in this case the practi- Disengaged and accepting recipients are sometimes difficult
tioners), cannot be overstated. This impact ultimately imbues to discern because both groups will do little to ensure either
the recipient with a great deal of power to make the change a success or failure of a change (Oreg et al., 2018).
FIGURE 8.2. Circumplex of change recipients’ responses to change and underlying core affect.
Circumplex of Change Recipients’ Responses to Change Underlying Core Affect
High
activation
Change resistance Change proactivity

(stressed, angry, (excited, elated,
upset) enthusiastic)
Negative Positive
valence valence
Change disengagement Change acceptance

(despaired, sad, helpless) (calm, relaxed, content)
Low
activation
Source. From “An Affect-Based Model of Recipients’ Responses to Organizational Change Events,” by S. Oreg, J. M. Bartunek, G. Lee, & B. Do. Academy of Management
Review, 2018, Vol. 43, p. 69. Copyright © 2018 by the Academy of Management. Used with permission.
When managers are working as change leaders with a group In the case of activation, a combination of positive coping
of change recipients, creating a culture of change proactivity is potential and high goal relevance leads to a recipient who is
the desired outcome. To accomplish this goal, managers must highly activated—the activation can be positive or negative
understand the leadership skills needed to create the positive depending on the perceived impact on them personally or
valence and high activation that defines change proactivity. on their organization. In other words, high coping poten-
According to Folkman et al. (as cited in Oreg et al., 2018), the tial, high relevance, and high congruence lead to a proactive
cognitive appraisal process is the key. Cognitive appraisal is recipient, whereas low coping, low relevance, and low con-
undertaken by change recipients as the means of evaluating gruence lead to disengagement. Acceptance in this model is a
the potential impact of change events on themselves and their product of high congruence but low coping potential and low
self-interests; resources for coping with the change event are relevance, with resistance being brought on by high coping
also taken into consideration. According to Oreg et al., the out- and high relevance but low congruence.
come of the cognitive appraisal process leads to the affective and
behavioral responses the recipient experiences; these outcomes
Leadership for Change
are identified as accepting, disengaged, proactive, or resistant.
As seen in Figure 8.3, primary appraisal is where a A transformational leader will be interested in gaining buy-in
recipient determines the change relevance and significance from the staff to accept the switch to occupation-centered
to themselves and the degree to which the change is relevant practice and a commitment to work at it to get the expected
to their goals—both personal and organizational. Secondary client outcomes. According to Figure 8.2, the predictor cri-
appraisal, according to Moors et al. (as cited in Oreg et al., teria for adoption of the new practice are changeable factors
2018), refers to the recipient’s control or power—their belief that are potentially under the leader’s control. Attention to
in their ability to cope with the change (i.e., coping poten- these factors and a concerted effort to ensure that they posi-
tial). The outcomes of primary and secondary appraisal influ- tively support staff coping potential, goal relevance, and goal
ence both activation and valence, hence yielding the recipient congruence can facilitate a proactive attitude toward change
response to change. in the change recipients.
FIGURE 8.3. Model of responses to change.
Predictor criteria
Factors that
impact perceived Secondary
Coping potential
support and appraisal
control
Response
activation
Factors that (+)
decrease
Goal relevance
psychological
distance Change Change
Primary
Goal congruence resistance proactivity
appraisal
Factors that Response
impact recipients’ Personal valence (–)
Change Change (+)
perceptions that
their interests are disengage- acceptance
Organizational ment
considered
(–)
Source. From “An Affect-Based Model of Recipients’ Responses to Organizational Change Events,” by S. Oreg, J. M. Bartunek, G. Lee, & B. Do. Academy of Management
Review, 2018, Vol. 43, p. 79. Copyright © 2018 by the Academy of Management. Used with permission.
For example, if a leader creates a work environment where In 2018, Seijts and Gandz published a leader character
staff feels empowered and in control of elements of their framework based on research with more than 2,500 leaders
workplace; where the psychological distance of the change from across the world. This framework identifies 11 dimen-
is not seen as too far from them personally; and where the sions of leadership that affect the outcome of organizational
“what’s in it for me?” question is acknowledged and answered change efforts (Seijts & Gandz, 2018):
in the positive, it is reasonable to assume that the recipients of
change will become champions of that change. 1. Judgment,
2. Transcendence,
3. Drive,
Leadership Characteristics and 4. Collaboration,
Skills Supporting Change 5. Humanity,
Understanding the recipient’s needs is necessary to identify 6. Humility,
which leadership characteristics and skills can address these 7. Temperance,
needs. According to a model created by John Kotter in 1996, 8. Integrity,
there are 8 steps to leading successful organizational change. 9. Justice,
In order of occurrence, these steps are 10. Accountability, and
11. Courage.
1. Establish a sense of urgency,
2. Create a guiding coalition of people who share a similar These character dimensions can be linked to the 8 stages of
belief in the change, Kotter’s model to further operationalize and pinpoint leader
3. Develop a vision and strategy to help break through the skills and attributes that must be present for each stage of
status quo, Kotter’s model to be effective. According to Seijts and Gandz,
4. Communicate the change vision, not all dimensions are necessarily incorporated into each
5. Empower recipients for broad-based action, step of Kotter’s change process, but all are needed to reach
6. Generate short-term wins to build credibility needed for the last step of anchoring of new approaches in the culture
sustained change efforts, (Kotter, 1996).
7. Consolidate gains and produce more change to prevent To better understand the relationship of leader skills and
premature victory declarations, and character dimensions to proactivity in change recipients, we
8. Anchor new approaches in the culture so new practices can look to the predictors of change elements in Figure 8.2
can grow deep roots. that identify the aspects of the environment that affect the
outcomes of the appraisal process (Oreg et al., 2018). Although Communication allows for the deconstruction of old hab-
the figure is not organized as a step continuum and does not its and routines and the creation of new ones as organiza-
explicitly list the leader characteristics described by Seijts and tional change leads to differentiation from the past. To assist
Gandz, the end result of anchoring the new approach into the practitioners in changing their practice paradigm, the leader
culture for a sustained period of time is the implicit goal; it must provide ample opportunities for communication within
requires all of the character dimensions to be present within the department; this can be in the form of team meetings and
the leader during the appraisal of the change event. 1:1 discussions. Differentiation of the past from the future can
For example, to address the predictor of change that speaks be accomplished through discussions and by sharing current
to the practitioners’ needed sense of support and control lead- practice beliefs and those of occupation-centered thinking.
ing to positive activation, the leader must possess transcen- As described earlier, many tools are available to the leader,
dence, courage, justice, integrity, humility, humanity, and including the OTPF–3, other official AOTA documents,
collaboration. Each of these provides a sense of security, con- research articles, Choosing Wisely materials, and informa-
sistency, fairness, and trust that are cornerstones for the per- tion about changes to documentation and reimbursement; all
ception that coping will be possible during the time of change. of these set a vision of the future post-change.
The leader’s ability to minimize the sense of psychological Discussions of cases and the creation of future-focused sce-
distance of the change will also require accountability, temper- narios are ways to communicate the possible impact of change.
ance, transcendence, collaboration, integrity, and judgment. Communication also allows the leader to hear feedback, accept
The recipients must trust that the goal of the change is relevant assistance, and gather ideas from practitioners as they become
and in their best interest before they will willingly support it. an active part of the change process. Skilled leaders, using their
Finally, the leader must possess the character dimensions personal characteristics of collaboration, humanity, humility,
of drive, temperance, humanity, and collaboration to create transcendence, and integrity, will facilitate this open and honest
trust in the fact that the change will positively impact the dialogue (Seijts & Gandz, 2018). Allowing organizational silence,
recipients, their organization, and ultimately their clients. driven by the leader’s fear of letting people share dissenting opin-
When a transformational leader asks recipients of change ions or potentially creating disagreements within a department,
to make real and lasting change efforts, they must draw on is one of the most detrimental things leaders and managers can
soft skills, including communication, attitudes, and trust do when attempting to build trust (Park & Kim, 2018).
(Ouedraogo & Ouakouak, 2018). A hard approach to orga- The messaging and discussions surrounding change to a new
nizational change that includes economic incentives or dis- intervention paradigm must be honest and consistent over time.
incentives, restructuring, or downsizing often fails to create Such consistency not only builds a common vision for the future
effective or lasting change, and instead leads to resistance or of the department, but it also builds trust between the leader and
passive acceptance that sets the change on a course to failure the practitioners and among the practitioners themselves. Role
(Ouedraogo & Ouakouak, 2018). modeling and being a champion for occupation-centered prac-
tice will also go a long way to build trust. To be successful with
this tactic, managers must know their own sentiments about
Review Questions
change and make them known to staff. Additionally, change
1. What is occupation-centered practice? recipients need to know when, how, and by whom the change
2. What is an example of occupation-focused practice? will be implemented; they also want details about what is ex-
What makes it occupation-focused? pected of them, including the potential risks and benefits for
3. What is the overarching outcome of occupational therapy themselves, the department, and the profession. Communica-
as described in the OTPF–3? What does it say regarding tion and trust lead to a sense of shared purpose and camaraderie
occupation-centered practice? that increase trust and communication (Park & Kim, 2018).
To facilitate knowledge sharing and a culture of learning in
an occupational therapy department, managers must demon-
PRACTICAL APPLICATIONS IN strate good judgment, drive, and courage to ensure that prac-
OCCUPATIONAL THERAPY titioners learn how occupation-centered therapy works, what
challenges and rewards are likely, and how to document to sup-
Strategies for Change to the
port our distinct value. Managers must also provide resources
Occupation-Centered Paradigm
that practitioners can use in their own learning and share with
Beyond a manager gaining the 11 personality dimensions of a each other. For example, a leader should work with upper man-
successful transformational leader, strategies that directly affect agement to provide AOTA membership for those who are not
the appraisal process for paradigm change to an occupation- members. Attendance at conferences and workshops and par-
centered practice include building a culture of communication, ticipation in continuing education programs that support the
knowledge sharing, and organizational learning that leads to new paradigm should be funded or strongly encouraged.
interpersonal trust (Ouedraogo & Ouakouak, 2018; Park & It should be noted that change and transition can take
Kim, 2018). Managers and leaders must help practitioners overtime; managers and leaders must not be discouraged by the
come resistance and motivate them to devote the efforts needed fact that developing habits through the diffusion of new
for the success of the change (Ouedraogo & Ouakouak, 2018). knowledge is a slow and tedious process (Garber, 2016).
Developing a Personal Leadership Vision A leader will first identify what kind of leader they want
to be and then identify a vision statement, which will help
As an occupational therapy practitioner, a transforma-
guide the chosen leadership style. Sharing the vision with the
tional leader needs to have a personal leadership vision
team will begin a dialogue about the change in which the staff
and plan. Why is it necessary to have a personal leadership
learns from the leader and the leader learns from the staff.
vision? A leadership vision represents an ideal future state
The team may be encouraged to develop a department leader-
and guides the organization toward a higher standard of
ship statement and tie it back to the vision and mission of the
excellence. Our profession has resources, workshops, and
organization and the profession.
conferences to help us, but we must put it into practice.
Identifying that we need to lead with occupation-based
practice is the first step, and it should be followed by iden-
Review Questions
tifying a vision where we can see ourselves doing just that. 1. Beyond the 11 important character dimensions of a trans-
Putting occupation-based practice on paper as a goal, or formational leader, what other leader qualities are im-
a vision, will help identify areas in which one might need portant in an environment of organizational change?
more training or support and areas in which one can share 2. A forward-facing vision in which the past is in the past is
successes with others. essential for success of organizational change. How can
a leader assist staff in separating from past methods of
occupational therapy intervention?
3. What types of resources should a transformational leader
For additional learning, see Chapter 1, “Theories of Leadership.” provide or suggest to staff that are going through a change
in practice paradigm?
CASE EXAMPLE 8.1. New Manager and a Paradigm Shift
Raphael, a new rehabilitation manager at a long-term care facility, walks into the occupational therapy clinic and sees occupational therapy
practitioners using arm bikes, cones, and pencil-and-paper tasks while clients passively participate in their treatment sessions. Family members
are observing treatment, and Raphael overhears a woman ask whether these tasks might be done at home instead of taking time off from work to
drive her family member to the clinic. Raphael spends some time watching and listening to the practitioners interact with the clients. He notices
a lack of enthusiasm in the practitioners’ voices when speaking with clients, and he hears comments that indicate the need for clients to complete
tasks as soon as possible so the practitioner can move on to the next person.
Raphael then completes a chart review and finds that several clients have recently been readmitted to the facility from the hospital after having
been discharged to home due to falls. Several who had been discharged with modified independence in self-care ADLs now require moderate
to maximum assist. Some charts did not have an occupational profile or any type of standard assessment to validate the selection of client
factor–focused goals.
This is not how Raphael was trained, and these practices do not align with his understanding of best practice occupational therapy. Raphael
decides that as the department manager, he must do something to address his concerns.
Raphael recognizes that change is required within this clinical setting and takes the following steps:
1. He prints out several official documents from AOTA describing occupation-centered practice and reviews them so he can share information
with his staff.
2. He sets up a time for all practitioners in the department to have lunch together so they can get to know each other.
3. When treating his own caseload, he evaluates clients using the AOTA Occupational Profile Template (AOTA, 2017a) available from AOTA,
other tools that assess client factors, and performance skills using activities. He creates a plan of care documenting client-centered and
occupation-based goals.
4. He establishes a weekly meeting with the entire staff to discuss the history and philosophy of occupational therapy and how health care
changes are identifying traditional occupational therapy interventions as important for saving money.
5. He arranges to show an AOTA regulatory webinar explaining the coming changes to reimbursement.
6. He works with practitioners to create their personal practice philosophy.
7. He seeks feedback and suggestions from the staff to determine the next steps to changing the paradigm of the department.
8. He creates a vision for the department with the staff.
9. He asks each staff member to research an aspect of occupation-based practice that should be integrated into the department and then share
their findings with the rest of the staff.
Review Questions
1. How will the steps identified encourage practitioner buy-in to change vs. resistance to change?
2. How does realigning treatment with occupation-based practice improve quality of care?
3. What could occur during the change to an occupation-centered paradigm if acceptance without proactivity is the manner in which the staff
approaches the change?
SUMMARY American Occupational Therapy Association. (2015). Standards of

practice for occupational therapy. American Journal of Occupa-
This chapter reviewed the value and importance of occupational Therapy, 69(Suppl. 3), 6913610057. https://doi.org/10.5014
tion-centered practice as well as the supportive literature. /ajot.2015.696S06
As the profession distinctly focused on ensuring that clients American Occupational Therapy Association. (2017a). AOTA
can engage in purposeful and meaningful activities, manag- occupational profile template. American Journal of Occupational
ers must transition from current client factor–focused inter- Therapy, 71, 7112420030. https://doi.org/10.5014/ajot.2017.716S12
vention to an occupation-centered paradigm; they must also American Occupational Therapy Association. (2017b). Philosophical
base of occupational therapy. American Journal of Occupational
encourage practitioners to adopt this new paradigm. Case
Example 8.1 describes realigning to occupation-based practice.
American Occupational Therapy Association. (2018a). CMS adopts
To gain acceptance and lasting change of the new para- new SNF PPS patient-driven payment model (PDPM): Important
digm, transformational leaders must use their leadership highlights from the SNF PPS 2019 final rule. Retrieved from https://
skills and communication abilities to establish trust and www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2018
develop a work culture that has a shared vision and shared /CMS-SNF-PPS-Patient-Driven-Payment-Model.aspx
appreciation of learning. Practitioners who demonstrate American Occupational Therapy Association. (2018b). Five things
change proactivity—who are affectively interested in the patients and providers should question [Brochure]. Retrieved from
change and behaviorally motivated by the change—will en- http://www.choosingwisely.org/wp-content/uploads/2018/05
sure a positive outcome. ❖ /AOTA-Choosing-Wisely-List.pdf
American Medical Association. (2019). CPT 2019 professional edition.
Chicago: Author.
LEARNING ACTIVITIES Fisher, A. (2013). Occupation-centred, occupation-based, occupation-
focused: Same, same or different? Scandinavian Journal of Occupa-
1. Develop a personal philosophy of occupational therapy tional Therapy, 20, 162–173. https://doi.org/10.3109/11038128.2012
and a leadership vision. .754492
Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., DeLongis, A., &
2. Identify the skills and attributes that define the leadership
Gruen, R. J. (1986). Dynamics of a stressful encounter: Cognitive
dimensions as described by Seijts and Gandz (2018).
appraisal, coping, and encounter outcomes. Journal of Person-
3. Review the documents identified in this chapter that sup- ality and Social Psychology, 50, 992–1003. https://doi.org/10.1037
port occupation-centered practice. /0022-3514.50.5.992
4. Create a list of opportunities and challenges to adopt- Garber, S. L. (2016). The prepared mind. American Journal of
ing an occupation-centered paradigm that are specific to Occupational Therapy, 70, 7006150010. https://doi.org/10.5014
your setting; share this list and elicit feedback from the /ajot.2016.706001
occupational therapy staff. Kotter, J. P. (1996). Leading change. Boston: Harvard Business
5. Work with the staff to create an educational experience Review Press.
for your facility to highlight the distinct value of occupa- Lamb, A. J. (2017). Unlocking the potential of everyday opportuni-
tional therapy. ties. American Journal of Occupational Therapy, 71, 7106140010.
https://doi.org/10.5014/ajot.2017.716001
Maher, C., & Mendonca, R. (2018a). Impact of a one-week
ACOTE STANDARDS occupation-based program on pain, fatigue, participation, and
satisfaction in women with cancer living in the community.
This chapter addresses the following ACOTE Standards: American Journal of Occupational Therapy, 72, 7211515234.
https://doi.org/10.5014/ajot.2018.72s1-po3025
■ B.5.2. Advocacy
Maher, C., & Mendonca, R. J. (2018b). Impact of an activity-based pro-
■ B.5.7. Quality Management and Improvement gram on health, quality of life, and occupational performance of
■ B.7.3. Promote Occupational Therapy. women diagnosed with cancer. American Journal of Occupational
Therapy, 72, 7202205040. https://doi.org/10.5014/ajot.2018.023663
Maslow, A. H. (1943). A theory of human motivation. Psychological
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leadership and knowledge sharing. Journal of Knowledge Manage- tional therapy interventions to enhance occupational perfor-
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lower readmission rates. Medical Care Research and Review, 74, fulness as therapeutic mechanisms. American Journal of Occupa-
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/j.bushor.2017.11.005 Therapy, 52, 365–372. https://doi.org/10.5014/ajot.52.5.365
SECTION II.
Organizational Planning and Culture
Edited by Judith A. Parker Kent, OTD, EdS, OTR/L, FAOTA
89
CHAPTER
Strategic Planning
L. Randy Strickland, EdD, OTR/L, FAOTA 9
LEARNING OBJECTIVES
■ Understand the steps in strategic planning for an organization and its stakeholders,
■ Identify current and future use of strategic planning in both work or professional settings and in personal application,
■ Use the SWOT analysis and scenario development processes as a base for an organization or program’s planning, and
■ Describe varied leadership roles for the occupational therapy practitioner in strategic planning in varied settings.

• Mission • Strategic plan • SWOT analysis
• Opportunities • Strategic planning • Threats
• Scenarios • Strategy • Vision
• Stakeholder input • Strengths • Weaknesses
OVERVIEW health, educational, or human services agencies are greatly

influenced by social, economic, political, geographic, cultural,
S
trategic planning is a process used by organizations to and technological factors. Occupational therapy practitioners,
chart or map future plans and goals. An organization’s as essential service providers, researchers, educators, consul-
planning process results in the creation of a strategic tants, and community/organizational leaders, are key par-
plan, which sets the pathway for an organization’s development ticipants in the strategic planning processes in their specific
and success. Strategic planning considers an organization’s roles and settings. Their perspective in strategic planning is
purpose and future aims or aspirations. The resulting strategic a valued addition to the interdisciplinary process, which ul-
plan includes specific goals focused on attaining the organiza- timately strengthens the overall results for an organization
tion’s vision. These goals are linked to objectives and strategies or program. Involving occupational therapy staff in strategic
that provide ongoing support of its mission (Rhine, 2015). planning at an individual, unit, or organizational level pro-
Merely setting goals is often a useless exercise unless an motes and ensures that valued occupational therapy services
organization’s leaders and members commit to identify- are recognized and available for patients and clients.
ing and using strategy, or methods or activities that enable
achievement of the plan’s goals. A viable and dynamic stra-
tegic plan includes the buy-in and active participation of its ESSENTIAL CONSIDERATIONS
stakeholders and leaders. Strategic planning includes staff at
Mission and Vision
all levels of an organization regardless of size and can pro-
mote personal growth for its individual members. The first step in strategic planning is identifying why the or-
This chapter describes the strategic planning process and ganization exists. The stated purpose of an organization is re-
its application for occupational therapy settings and practi- ferred to as its mission. The organization’s mission provides
tioners. Organizations and programs serving individuals in the foundation for its very existence and plans.
https://doi.org/10.7139/2019.978-1-56900-592-7.009
91
92 SECTION II. Organizational Planning and Culture
An organization’s or program’s purpose typically does not consumers or individuals the organization serves. The rich-
change substantially over time. For example, a pediatric outpa- ness of input and active participation in both the design and
tient clinic’s purpose might be providing community-based de- implementation of a strategic plan are maximized through
velopmental services, and this purpose remains a foundation of diverse stakeholder involvement in the process.
the program across time. However, the clinic’s goals and strat- Different opinions and perspectives enrich the strategic
egies may shift based on internal and external environmental planning process and produce better plans more likely to suc-
changes and influences. Such shifts still affirm the mission’s ceed. Participation levels may range broadly from total immer-
necessity but also result from aspiration for a new or expanded sion in the planning process to simply seeking a group’s or an
level of achievement or contribution by the organization. This individual’s review or feedback about parts of the plan. Seeking
vision or aspiration states an ideal of what the organization input from the bottom-up of an organization’s members rather
perceives as its desired and prized benchmark of achievement. than from a top-down management approach provides mean-
For example, the American Occupational Therapy Association ingful data. This broad participation ensures the likelihood of
(AOTA) is a professional membership organization grounded planning success and relevance to the real needs and potential
by its mission linked to its vision. AOTA’s mission is of the unit or organization (Roth, 2015). Organizational com-
munication to stakeholders about what information is used
To advance occupational therapy practice, education, and and why a strategy or goal is selected better influences the ulti-
research through standard setting and advocacy on behalf mate success of the strategic plan (Cervone, 2014).
of its members, the profession, and the public. (AOTA, 2018,
para. 6)
SWOT Analysis
AOTA also has a vision, Vision 2025:
A strategic plan involves a systematic approach for determin-
Occupational therapy maximizes health, well-being, and ing needed resources to address strategic goals and help the
quality of life for all people, populations, and communities organization achieve its vision and support the mission. Stra-
through effective solutions that facilitate participation in tegic planning includes thoughtful analysis of the organiza-
everyday living. (AOTA, 2017, p. 1) tion’s internal and external environment. This environmental
review sets the stage for better understanding the quantitative
The mission and vision of an organization are the founda-
and qualitative factors influencing the organization’s day-to-
tional cornerstones of the strategic planning process. These
day operations and future aspirations and goals.
statements define an organization’s purpose through setting
One widely used approach in strategic planning is a SWOT
the stage; identifying the organization’s core values; and pro-
analysis. The organization often conducts the SWOT analy-
viding guideposts for planning, goal setting, and decision
sis over a period of time, including both internal and external
making (Eber & Smith, 2015).
stakeholders. This SWOT assessment includes identifying
Broad Stakeholder Participation ■ S: Strengths—Internal assets or characteristics within the
organization or unit that enhance the organization’s ca-
An organization involved in the strategic planning process
pacity for growth or change;
needs to ensure that any new or revised plans are based on
■ W: Weaknesses—Internal conditions or characteristics
a sound process. Typically, a strategic plan encompasses a
within the organization or unit that hinder or restrict the
relatively short time span of 3–5 years (Eber & Smith, 2015).
organization’s growth potential;
Considerable time and staff resources are often allocated
■ O: Opportunities—External events or possible or current
to designing a strategic plan. Most important, the strategic
changes in the environment that may affect the organiza-
planning process should advance the organization. The plan
tion in a potential positive capacity; and
should not merely become a document in a file but a viable
■ T: Threats—External actions or events—current or
plan to help an organization remain true to its mission and
potential—that may cause harm to the organization’s
attain goals through strategies that promote its vision. A key
strategic growth, well-being, and possible competitiveness.
ingredient in a successful strategic plan is broad participation
of its stakeholders. Strengths and weaknesses are those factors that character-
Stakeholder input is key information or data collected ize the organization from an internal view; opportunities and
from individuals, agencies, organizational units, and consum- threats represent those factors that may affect the organiza-
ers who are invested in the success of the organization and its tion from outside the organization or unit (Harrison, 2016).
mission. Stakeholder input is important for identifying, un- Exhibit 9.1 provides an abbreviated SWOT analysis for
derstanding, and appreciating the multidimensional aspects adding a proposed hand rehabilitation facility at an existing
of the organization’s reputation and its influence within the branch location of an established hospital system.
environmental context (Gatzert & Schmit, 2016). Stakeholder The SWOT analysis in Exhibit 9.1 was completed by indi-
input can be categorized into varied groups, depending on viduals familiar with the organization or unit. Internal op-
the type of organization, and may include both internal and erations reports such as financial data, sources of physician
external groups. Stakeholder examples include the organiza- referrals, and staffing are important data sources. External
tion’s own staff and leadership, community advisory groups, information such as competitor analysis, regulatory factors,
payers and other financial groups, and, most important, the and other external reports helps create an environmental
CHAPTER 9. Strategic Planning 93
EXHIBIT 9.1. SWOT Analysis for Proposed Hand The strategic plan should be focused by a comprehensive
Rehabilitation Program strategy that explicitly details the plans for achievement in
easily understood language. The criteria for goal success must
■ Strength: The hospital system has an existing branch for also be delineated. As the plan proceeds, the goals may be
outpatient service with unused space and 2 occupational therapy met or deemed inappropriate and requiring review or change;
staff (both certified hand therapists) in the hospital with interest in continuous assessment of successful strategies and goals met
outpatient services. promotes a strategic planning model that integrates planning
■ Weakness: The rehabilitation director recently retired, and the
and outcomes measurement in a transparent manner to all
position is currently unfilled.
stakeholders (Cervone, 2014). Successful strategic planning is
■ Opportunities: Several referring physician orthopedic practices are
in the same area as the branch location. not static but is a dynamic, evolving process and is closely
■ Threats: A competing regional hand practice is reported to be akin to the patient evaluation process (see Figure 9.1).
considering adding a location in the same area.
Review Questions
1. Select a nonprofit health or human services organization
analysis for the organization. This analysis leads to the and review its website or other print materials. What are
formulation of the SWOT, which provides a benchmark de- its stated mission and vison? How do they support each
tailing the organization’s current status and the feasibility of other? What similarities or differences exist between your
either beginning or refining its operations to achieve its goals selected organization’s vision and mission statements and
and vision (Kash & Deshmukh, 2013). those of AOTA?
2. What are key differences among the strengths (S), weak-
Scenario Identification nesses (W), opportunities (O), and threats (T) in an orga-
nization’s SWOT analysis?
Examining the organization’s SWOT can empower its lead-
3. What are the key steps in the strategic planning process?
ers and stakeholders to begin future planning. Knowing the
4. What are some examples of both internal and external re-
organization’s history and related strengths and weaknesses
sources that can be useful in obtaining a better environmen-
provides the basis for evaluating possible future actions. If
tal picture or view of an organization today and in the future?
the mission of an organization provides its purpose or anchor
5. Why is stakeholder participation important in the stra-
and the vision provides a future aim or aspiration, the SWOT
tegic planning process, and how can different groups or
sets the stage for considering future action and strategy.
perspectives be facilitated and included?
Selecting goals and strategy (the means or activity to
achieve the goal) is premature without asking a series of
“what-if” questions. Such questions lead to identifying PRACTICAL APPLICATIONS IN
scenarios that may occur given the results of the organiza- OCCUPATIONAL THERAPY
tion’s SWOT. Scenarios represent potential alternative views
of the future. Strategic planning and the SWOT analysis Occupational therapy practitioners may perceive that strate-
process provide an organization with the tools to thought- gic planning processes do not directly affect their daily prac-
fully visualize potential desired or potentially undesirable tice environments, but all occupational therapy programs are
futures. Identification of actions that may lead to more de- a part of some organization or system, whether the setting is
sirable future outcomes is vital for effective decision making a solo practitioner with a contracting practice, school-based
and strategic planning (Ungerer et al., 2016). therapy services, a therapist-owned outpatient clinic, an occu-
Debating the merits of multiple scenarios allows the orga- pational therapy department in a freestanding facility, reha-
nization to weigh varied options and select the scenario (or bilitation services in a skilled nursing facility (SNF), or various
combination) that provides the best direction for the strategic other settings. Occupational therapy practitioners are part of
plan. Selection may be directed toward program growth or organizations that must engage in strategic planning and stra-
development or toward risk reduction. tegic decision making in order to remain viable, competitive,
The scenario leads to the development of strategies and and relevant in an ever-changing service delivery system.
goals, which must be measurable. Input from all levels of the Occupational therapy staff may be afforded the oppor-
organization should be used as appropriate. tunity to participate in an organization’s strategic planning
process. Participation may include a staff member serving
as a committee member or as part of a focus group. The oc-
Strategic Goal Prioritization, Selection, and
cupational therapy unit and its staff may be asked to review
Evaluation
possible plans or data about the organization and the clients
Once the unit or organization determines its direction, de- served (past, present, and future) and provide feedback. Most
veloping strategic goals begins. Keep in mind that the plan’s important, the occupational therapy perspective and voice
goals are typically measurable over a 3- to 5-year period and can help shape an organization’s strategic plan, including its
are prioritized based on the organization’s SWOT, mission, goals, strategies, and future approaches, and the allocation of
and vision. The number of goals in a plan varies but is often financial resources. Occupational therapy’s contributions to
5 goals or fewer. the organization’s strategic plan can foster greater financial
FIGURE 9.1. Strategic planning cycle.
1. Mission Review
& Vision
Development
2. SWOT
8. Plan
Development and
Review/Revision
Validation
3. Possible
7. Plan Evaluation Strategic Scenarios
Review
6. Strategies 4. Scenario(s)
Identification Selection
5. Strategic Goals
Formulation and
Review
Source. Adapted from “Strategic planning,” by R. Strickland, 2011, in K. Jacobs & G. L. McCormack (Eds.), The Occupational Therapy Manager (5th ed., p. 106),
Bethesda, MD: AOTA Press. Copyright © 2011 by the American Occupational Therapy Association. Adapted with permission.
stability or growth, the development of new or enhanced ser- plan, including new or revised program plans, as a part of or
vice delivery products, and support of its vision and mission. in support of the organization’s larger plan.
Selected key applications for occupational therapy practi- Whether the idea of a new or revised program or service
tioners include originates in the organizational strategic plan or as a strategy in
the occupational therapy unit, any new initiative must be vet-
■ Advocacy, ted. Considering the development of a new service means revis-
■ Advancement, and iting and reviewing the SWOT process to determine the unit’s
■ Personal development and professional growth. capacity to undertake a new initiative. Looking at costs and the
return on investment certainly examines the program’s value
Advocacy for Patients and Profession for the targeted patient/client population. The financial and
Occupational therapy practitioners provide identification of clinical evidence base of the program must be carefully docu-
and voice to the needs of patients/clients and, by participat- mented. Timely and current evidence-based practice research
ing in an organization’s planning activities, can advocate for is an essential part of any strategic approval of a new initiative.
needed services, including occupational therapy. Participating The vetting also needs to consider whether the new approach
in member and advocacy organizations also provides an im- or protocol supports the organization’s mission or vision, and
portant voice for the occupational therapy view and profession. whether the organization has the resources, including qualified
staffing (current or future hires), for program success.
Advancing New or Improved Services

Personal Development and
Beginning a new clinical program is often an activity oc-
Professional Growth
cupational therapy practitioners undertake. For example, a
practitioner may be asked to develop and lead a new program Occupational therapy practitioners usually work as part of
that supports the organization’s strategic goals. Or the occu- teams in myriad organizations. The organization may be non-
pational therapy unit may have developed its own strategic profit, for profit, or even a therapist-owned proprietorship.
Regardless of the work setting, the individual practitioner others also promote personal and professional development.
is part of a larger system. In turn, the organization has both Applying the concepts of personal strategic plan development
an ethical and a fiduciary responsibility to ensure that all its to their lives helps practitioners to competitively prepare for
members or employees are competently fulfilling their duties ever-evolving service delivery models. Developing one’s own
pertinent to their assigned roles. strategic plan and focus recognizes both the accountability
Each occupational therapy practitioner manages the delivery and professional autonomy of each practitioner.
of occupational therapy services regardless of position title. Like-
wise, the practitioner’s assumption of leadership roles in profes-
Review Questions
sional membership or other community organization creates
the stage for participation in the strategic planning and direc- 1. As a member of your state occupational therapy associa-
tion of those groups. The assumption of varied leadership roles tion, what outreach steps can you undertake to influence
is greatly expanded when occupational therapy practitioners the strategic planning of state or community agencies?
become strategically creative in their thinking (Drenkard, 2012). How would you prioritize your actions?
Successful fulfillment of both paid (e.g., practitioner, ed- 2. Consider that you, as the occupational therapy supervisor,
ucator, consultant, manager or administrator) and volunteer are presenting a new program idea to the administrative
roles by occupational therapy practitioners depends on each council of the rehabilitation hospital. What steps regard-
individual’s personal and professional development. Hino- ing the strategic plan of the hospital should you review
josa (2012) described the daily challenges for occupational prior to your presentation? Why?
therapy practitioners in ever-changing work settings and 3. Can you describe your own personal vision statement as
recommended that practitioners develop individual strate- an occupational therapy practitioner for the next 5 years?
gic plans for their own growth and development. Employers, What specific goals and strategies are you considering to
professional membership organizations such as AOTA, and achieve your vision?
CASE EXAMPLE 9.1. Mount View Hospital Transformation
Mount View Hospital (MVH) is situated in a rural vacation community with a year-round population of 18,000, which more than doubles during
its 3 peak tourist seasons. For more than 60 years, this locally directed nonprofit hospital has served the community and offered an emergency
department, 50 acute care beds, and outpatient services, including physical therapy and labs. Twenty-five years ago, MVH issued a bond for the
construction of a 60-bed SNF wing, including inpatient rehabilitation services (occupational therapy, physical therapy, and speech–language pathol-
ogy); this diversification was planned to offer a new revenue stream and meet a community need for SNF services since the nearest facility was in
another county.
Over the past 5 years, MVH has experienced financial challenges and an annual growing budget deficit. Acute-care bed occupancy averages less
than 50%; SNF occupancy has remained around 92%, but reimbursement levels, along with relatively few subacute admissions, have not supported
expenditures. Outpatient services have shown a very profitable gain but are hampered by limited space. Hospital debt (both operating costs and
bond debt) has been managed with a $250,000 withdrawal each of the past 3 years from the MVH endowment; this endowment will be exhausted
within 5 years if no sustainable action plan occurs.
MVH’s current mission statement (established at its formation 62 years ago) is
MVH will provide needed hospital and medical services to the residents and visiting tourists to this community. MVH strives to offer the best
possible emergency and inpatient care for the community.
MVH has used multiyear operational plans for most of its existence but has not undergone a comprehensive strategic planning process with the
creation of a new or renewed vision in at least 10 years. The organization has existed primarily through its endowment and generous community
support. Recently, the MVH Board of Trustees and the newly appointed chief executive officer (CEO) began a strategic discussion and analysis of
the organization’s long-term sustainability. As with many rural hospitals, MVH faces significant financial peril in the advent of increasing costs,
decreased revenues, and shifting program needs.
With support and participation of the Board of Directors, the CEO launched an organization-wide strategic planning initiative. Community advisory
groups were polled regarding MVH and its services. A hospital services consulting firm conducted an analysis of MVH’s operations, collected patient
satisfaction survey data, and completed a competitor analysis. Mini-SWOT meetings were conducted with all units throughout the hospital. As a
result of this initiative, a draft strategic plan was prepared, and varied stakeholder groups were assigned areas for review. A summary of the draft
is provided.
Strategic Plan: Initial Draft for Stakeholder Input
MVH Mission
We will serve the Mount View residents and visitors by providing compassionate, quality health services that promote their health and well-being.
(Continued)
CASE EXAMPLE 9.1. Mount View Hospital Transformation (Cont.)
MVH Vision
MVH will be the health provider of choice through inpatient, outpatient, and community services and will be recognized for its cost-effective, quality
patient outcomes.
SWOT Analysis
■ Strengths: Community support, endowment for growth, excellent physical plant with possible expansion space, excellent physician support,
excellent nursing and rehabilitation staff, and highly regarded outpatient services, including physical therapy.
■ Weaknesses: Low acute care occupancy, SNF revenues shortfall, failure to meet budget for past 3 years, continued rising wage costs, no recent
viable strategic plan, loss of 2 CEOs in last 4 years (health issue, family death).
■ Opportunities: New orthopedic group adding branch location; new local for-profit long-term care facility offering to purchase the SNF 60 license;
and regional health education center establishing cooperative to provide rural-based preservice education internships for physicians, nurses,
and allied health providers.
■ Threats: Adjacent county hospital joining national hospital chain, possible federal and state funding reductions, and increasing supply costs.
Scenario Identification and Selection

Possible scenario options (select items) if MVH
1. Continues to use endowment and faces possible closure within 5 years or less,
2. Reduces its operations to only outpatient services,
3. Eliminates losing units such as SNF,
4. Identifies new partnerships to decrease costs, and
5. Creates new programs.
MVH has determined that Option 1 is not a responsible action. Option 2 limits the organization’s financial exposure but loses an important niche
with inpatient services and the later flow into outpatient programs that are profitable. MVH is proposing that a combination of Options 3–5 may
provide a better and more community-oriented approach.
By further focusing its resources and programs, MVH can become financially solvent and a more valuable community asset. Selling the SNF
license and the 60 beds provides SNF beds in the community by another organization whose primary business is long-term care. The existing
SNF rehabilitation services staff (3 PTs and 1 PTA, 3 OTs and 1 OTA, and 2 SLPs) and outpatient physical therapy staff can develop new outpatient
programs. Likewise, other hospital units can propose new or revised services. The acute care unit will be reduced to 25 inpatient beds, with 5
observation beds. Finally, MVH is developing a joint management proposal with the regional health education center and a university with its medical
school’s affiliated teaching hospital system.
Strategic Goals
MVH has formulated 4 broad strategic goals and has requested specific units to provide comments, possible strategy statements or plans, and
evaluation criteria. The 4 draft strategic goals include
1. Reduce operating deficits and achieve a balanced budget within 24 months;
2. Develop centers of excellence in select outpatient services;
3. Implement a joint management contract with the medical school’s affiliated hospital system; and
4. Streamline the acute care services, including developing its role as part of a regional referral system.
Next Steps
This MVH draft plan is incomplete and requires considerable input by stakeholders both within and outside the organization. One major proposal in
the plan is the further development of outpatient rehabilitation services. With the closing of the SNF unit, currently employed occupational therapy
and other rehabilitation staff have been asked to consider remaining with MVH and further developing the existing rehabilitation outpatient services,
which currently include only physical therapy. The hospital recognizes that while the therapy services represent financial costs, an opportunity exists
for developing a new center of excellence with current staff. The rehabilitation staff needs to consider several strategy items as they prepare their
response to the draft document.
• Now is the time for the rehabilitation staff to collectively prepare their input as a unit. Seeking input from others for ideas and suggestions about
new programming in the outpatient arena will broaden their perspectives.
• On the basis of the MVH proposed scenario, the unit can complete its own internal SWOT analysis. Focusing on the range, community need, and
cost–benefit analysis for varied programs will assist MVH in developing strategy and measurable, detailed goal selection. Strategy choices for
Goals 2 and 3 are areas of possible high impact as brought forward through the planning efforts of the rehabilitation services team.
• It is often stated that the most valued and costly resource to replace for any organization is its people or staff. It is prudent for the staff’s feed-
back to address any needed retraining or skill acquisitions that may be desired for program success and staff investment and competency.
Ultimately, MVH has both tremendous challenges and opportunities. Occupational therapy practitioners and the other rehabilitation staff can help
create new sources of revenue and, most important, promote the achievement of MVH’s vision and mission.
(Continued)
CASE EXAMPLE 9.1. Mount View Hospital Transformation (Cont.)
Review Questions
1. The MVH case is similar to many other situations in the health and human service delivery systems. Often, an individual unit such as the
Occupational Therapy Department does not stand alone, but collaborates with others in service delivery. What are some key factors to consider
in the rehabilitation services internal SWOT analysis for the draft MVH strategic plan?
2. How can broad participation with other disciplines support the establishment and attainment of Strategic Goals 1–4? What are the
recommended new or revised rehabilitation program–specific goals and strategy steps required to support the overall MVH plan?
3. What are the key challenges and opportunities in personal and professional development plans for the rehabilitation staff who may transition
into newly designed outpatient programs?
4. What strategies or approaches can you, as an occupational therapy practitioner, use to become an active contributor in the strategic planning
process in your work position or volunteer role?
SUMMARY American Occupational Therapy Association. (2017). Vision 2025.

Strategic planning creates the means for an organization to https://doi.org/10.5014/ajot.2017.713002
both examine its current position and chart a future course. American Occupational Therapy Association. (2018). About
The strategic plan is anchored by its mission and designs its AOTA: Mission statement. Retrieved from https://www.aota.org
future plan based on a vision or aspiration. Developing a stra- /AboutAOTA.aspx
tegic plan benefits from broad stakeholder participation, in- Cervone, H. F. (2014). Improving strategic planning by adapting
cluding members of the organization and interested related or agile methods to the planning process. Journal of Library Ad-
ministration, 54, 155–168. https://doi.org/10.1080/01930826.2014
community-based groups, as illustrated by Case Example 9.1.
.903371
A strategic plan is based on an internal and external en-
Drenkard, K. (2012). Strategy as solution: Developing a nursing
vironmental assessment. A SWOT analysis provides the strategic plan. Journal of Nursing Administration, 42, 242–243.
framework for gauging an organization’s current status and https://doi.org/10.1097/NNA.0b013e318252efef
future potential. The SWOT analysis leads to the generation Eber, D. R., & Smith, F. L. (2015). Strategic planning: An interactive
of possible scenarios that may occur in the future. Scenario process for leaders. New York: Paulist Press
selection, including the elimination of less likely ones and Gatzert, N., & Schmit, J. (2016). Supporting strategic success through
possible combinations of others, helps the organization in enterprise-wide reputation risk management. Journal of Risk Fi-
selecting and formulating goals and strategy. An ongoing nance, 17(1), 26–45. https://doi.org/10.1108/JRF-09-2015-0083
cycle of evaluation and reassessment continues this process. Harrison, J. P. (2016). Essentials of strategic planning in healthcare.
The thoughtfully prepared strategic plan promotes strate- Chicago: Health Administration Press.
Hinojosa, J. (2012). Personal strategic plan development: Getting
gic dialogue and thinking by an organization’s leaders and
ready for changes in our professional and personal lives. Amer-
members and provides a pathway for successful growth and
ican Journal of Occupational Therapy, 66, e34–e38. https://doi
development. ❖ .org/10.5014/ajot.2012.002360
Kash, B. A., & Deshmukh, A. A. (2013). Developing a strategic mar-
keting plan for physical and occupational therapy services: A col-
ACOTE STANDARDS laborative project between a critical access hospital and a graduate
This chapter addresses the following ACOTE Standards: program in health care management. Health Marketing Quar-
terly, 30, 263–280. https://doi.org/10.1080/07359683.2013.814507
• B.5.1. Factors, Policy Issues, and Social Systems Rhine, A. S. (2015). An examination of the perceptions of stakehold-
• B.5.2. Advocacy ers on authentic leadership in strategic planning in nonprofit arts
• B.5.3. Business Aspects of Practice organizations. Journal of Arts Management, Law, and Society, 45,
• B.5.6. Market the Delivery of Services. 3–21. https://doi.org/10.1080/10632921.2015.1013169
Roth, W. F. (2015). Strategic planning as an organizational design
exercise. Performance Improvement, 54, 6–12. https://doi.org
/10.1002/pfi.21487
REFERENCES Strickland, R. (2011). Strategic planning. In K. Jacobs & G. L.
Accreditation Council for Occupational Therapy Education. (2018). McCormack (Eds.), The occupational therapy manager (5th ed.,
2018 Accreditation Council for Occupational Therapy Education pp.103–112). Bethesda, MD: AOTA Press.
(ACOTE) standards and interpretive guide. American Journal of Ungerer, M., Ungerer, G., & Herholdt, J. (2016). Navigating strategic
Occupational Therapy, 72(Suppl. 2), 7214210005. https://10.5014 possibilities: Strategy formulation and execution practices to flour-
/ajot.2018.72S217 ish. Randburg, South Africa: KR Publishing.
CHAPTER
Using Data to Guide Business Decisions
Carolyn Giordano, PhD, FASAHP 10
LEARNING OBJECTIVES
■ Understand the essentials of collecting and analyzing data,
■ Identify the pros and cons of quantitative and qualitative data,
■ Identify security and ethical considerations of collecting and using data,
■ Implement action plans based on the collection and analysis of data, and
■ Apply data collection and analysis principles to the Accreditation Council for Occupational Therapy Education®
(ACOTE; 2018) standards related to the analysis and planned action of collection of data.

• Dashboard report • Figures • Quantitative methods
• Data • Graphs • Outliers
• Data visualization • Mixed methods • Tables
• Descriptive statistics • Qualitative methods
“It is a capital mistake to theorize before one has data. and more. Increasingly, technology allows for tracking every
Insensibly one begins to twist facts to suit theories, interaction, leaving users with huge quantities of data.
instead of theories to suit facts.” It is not enough to simply have large amounts of data.
Having a solid plan, asking the right research questions, and
—Sir Arthur Conan Doyle, A Scandal in Bohemia
knowing how to analyze and use the data are critical to run-
(1891, para. 24)
ning a practice. This chapter guides occupational therapy
managers and administrators in using data in practical ways,
including asking the right questions, identifying sources of
OVERVIEW data, understanding whether data can be trusted, and com-
M
aking thoughtful decisions based on a thorough municating findings.
analysis of existing literature and data can be chal-
lenging, and the success of occupational therapy
managers and administrators relies on navigating many ESSENTIAL CONSIDERATIONS
sources of data to make sound business decisions. Just as oc-
The research process has 8 steps:
cupational therapy practitioners use evidence to drive treat-
ment plans, data-driven managers and administrators keep 1. Identify the problem or research question.
data at the forefront of any process. 2. Scan the literature.
Because data are of no use unless someone takes action on 3. Make a plan, including timeline, budget, and communi-
them, data should be collected purposefully and be actionable. cation of results. Be very detailed in this stage, and make
Data should drive budgeting, long- and short-term planning, sure that the plan is realistic and ties back into the re-
process implementation, staff retention and development, search question.
https://doi.org/10.7139/2019.978-1-56900-592-7.010
99
CHAPTER
Using Data to Guide Business Decisions
Carolyn Giordano, PhD, FASAHP 10
LEARNING OBJECTIVES
■ Understand the essentials of collecting and analyzing data,
■ Identify the pros and cons of quantitative and qualitative data,
■ Identify security and ethical considerations of collecting and using data,
■ Implement action plans based on the collection and analysis of data, and
■ Apply data collection and analysis principles to the Accreditation Council for Occupational Therapy Education®
(ACOTE; 2018) standards related to the analysis and planned action of collection of data.

• Dashboard report • Figures • Quantitative methods
• Data • Graphs • Outliers
• Data visualization • Mixed methods • Tables
• Descriptive statistics • Qualitative methods
“It is a capital mistake to theorize before one has data. and more. Increasingly, technology allows for tracking every
Insensibly one begins to twist facts to suit theories, interaction, leaving users with huge quantities of data.
instead of theories to suit facts.” It is not enough to simply have large amounts of data.
Having a solid plan, asking the right research questions, and
—Sir Arthur Conan Doyle, A Scandal in Bohemia
knowing how to analyze and use the data are critical to run-
(1891, para. 24)
ning a practice. This chapter guides occupational therapy
managers and administrators in using data in practical ways,
including asking the right questions, identifying sources of
OVERVIEW data, understanding whether data can be trusted, and com-
M
aking thoughtful decisions based on a thorough municating findings.
analysis of existing literature and data can be chal-
lenging, and the success of occupational therapy
managers and administrators relies on navigating many ESSENTIAL CONSIDERATIONS
sources of data to make sound business decisions. Just as oc-
The research process has 8 steps:
cupational therapy practitioners use evidence to drive treat-
ment plans, data-driven managers and administrators keep 1. Identify the problem or research question.
data at the forefront of any process. 2. Scan the literature.
Because data are of no use unless someone takes action on 3. Make a plan, including timeline, budget, and communi-
them, data should be collected purposefully and be actionable. cation of results. Be very detailed in this stage, and make
Data should drive budgeting, long- and short-term planning, sure that the plan is realistic and ties back into the re-
process implementation, staff retention and development, search question.
https://doi.org/10.7139/2019.978-1-56900-592-7.010
99
4. Collect data. Gather data from existing or new data observations but also on a thorough review of the literature.
sources, and be prepared for surprises. A plan to run a As stated in Step 2, reviewing what data have been collected
focus group with 10 individuals might end up with only 5 at other institutions or centers will help guide the research
showing up. study. Project planning should always start with a research
5. Prepare data. Examine data for errors, duplicate records, question and include steps for analyzing and communicating
and outliers. the research.
6. Analyze data. Compute frequencies and descriptive sta- Many who do planning and assessment rely on the SMART
tistics first, then determine the appropriate inferential goal process (Doran, 1981). SMART stands for Specific, Mea-
analysis. Create themes from qualitative data and begin surable, Attainable, Realistic, and Tangible (or Time-Bound).
synthesizing with the quantitative data. Compare trends The SMART model sets planners up for success, because a
and determine whether any predictions can be made. specific goal keeps the outcomes focused and limits wasted
7. Report findings. The data analysis should be the basis time and financial resources. A measurable goal drives the
from which a decision is made. Is the research question planning process by ensuring information is based on avail-
answered? How confident are you in the results? able data. It separates the dreams (e.g., “Wouldn’t it be nice
8. Assess the process. Are more data points needed after to know this if we had all the access, money, and time in the
reviewing the data and implementing the plan? Debrief world?”) from the realities of (e.g., “We can gauge this with
with a team. What could be done differently next time? our available resources”).
What was a surprise? Did questions come up? Similarly, attainable goals ground researchers in reality
and limit wasting time and effort. The program goal may be
to use gold and diamond bricks as building materials in a
Step 1. Identify the Problem or new office space, but that is not attainable. This also leads to a
Research Question realistic goal. “Shooting for the moon” will waste a lot of time
Proper planning is critical to any research process. Time is if managers or administrators do not recognize their limits.
wasted if data are collected that do not answer the research Finally, goals should be tangible or time bound. Include time
question. Start by writing down the problem statement or re- parameters in setting a goal. When should data collected by?
search question to help frame project and limit the resources When should data be reviewed? When do decisions need to
and scope. be made and results shared? Exhibit 10.1 shows a template for
Before making any decisions, identify your needs. Begin by a research plan.
documenting questions and goals, and decide whether the re-
sources are available to collect and analyze the data. Asking Step 4. Collect Data
relevant, answerable questions is the key to good planning and
is the first step toward being able to know what data are needed. Without a clear focus when assessing goals, managers and
administrators can be overwhelmed with data and unable
to make decisions. Collecting, organizing, analyzing, and
Step 2. Scan the Literature presenting data are essential skills required for any decision
The next step is to research the academic and business envi- making. Professionals now can gather data in many more
ronment to see what has been published about the research ways than ever before and do not have to rely solely on indi-
question or topic. Learn from others’ successes and failures, rect observations, such as interviews, focus groups, surveys,
and document what can be translated into the project. or questionnaires. Direct encounters can be measured, an-
Reading key pieces of literature and studying studies and alyzed, and turned into action plans. Technology is used in
reports can guide planning. For example, if the goal is to in- the workplace to find and recruit employees, to monitor and
crease client satisfaction in client-centered approaches, read improve performance, to measure client interactions, and to
the literature to see what questionnaires have been used to track budget and marketing.
assess this topic, in which type of setting, and on what type
of population. Reviewing the literature may provide existing Data sources
points of data, personal contacts in the field, and ideas with
which to move forward. This review will drive the project and Data are pieces of information used as a source of thoughtful
protect its budget, it will reduce replicating what is already discourse, planning, and decision making and can include
known and can uncover the pitfalls of others. This step will direct observations of opinions, attitudes, and perceptions
help determine the right questions to ask. Understanding the that are given in both quantitative and qualitative forms.
environment will help managers and administrators identify These data sources can be gathered in the forms of a cus-
needs and measure resources. tomer, client, or patient satisfaction survey; focus groups; or
interviews. These data provide a great deal of information but
can be prone to bias and external factors.
Step 3. Make a Plan
Quantitative methods of data collection provide numer-
A focused research plan will help guide the study and limit ical responses to closed-ended questions (Babbie, 2010) and
resources. The plan should be based not only on anecdotes or include objective measurements of data points and their
CHAPTER 10. Using Data to Guide Business Decisions 101
EXHIBIT 10.1. Research Plan
What is your research question?
What is your sample?
How are you going to collect your data?
Are you going to analyze the data or

will you hire someone?
What is your timeline?
What is your budget?
Who is your audience, and how will you

communicate your findings to them?
analysis with mathematics or statistics. They provide finite Office tracking data connected with electronic health records
insight on the measurement of relationships. Questions can can unveil issues and increase productivity.
be asked in a binary (e.g., yes/no, like/dislike) or on a Likert Such data connectivity can help improve care while con-
scale (e.g., “Please rate your level of satisfaction from 1 = very trolling costs. More precisely, tailored health plans can be
satisfied to 5 = very dissatisfied” or “Please rate your level of created by using the health data from smart devices that
pain on a scale from 1 to 10”). Quantitative analysis can be clients wear. By extracting enough direct data, predictive
effective, quick, and relatively inexpensive to administer to analytical models can help guide decisions on care and ser-
large samples. vices offered. Additionally, with sound data analysis, big data
Qualitative methods of data collection include open- can help management answer questions that were impossible
ended questions on surveys, questions in focus groups, or several years ago (George et al., 2016).
interviews, and gather data by generalizing information from Using different sources of data can help gain better un-
individuals or groups of people to explain an event. Often, in- derstanding of a particular issue. If 1 data point is a specific
dividuals are asked to comment on how they feel or describe client outcome, another data point can help explain why or
why they think a certain way. Interviews and focus groups how clients felt about the process. For example, although
can adopt structured or unstructured methods and can lead understanding that clients have a better range of motion after
to a rich variety of data. Qualitative methods can surface is- 6 weeks of therapy is important, coupling the data with satis-
sues previously unknown or provide deeper perspectives on faction and attitudes about the therapy process is just as im-
populations. However, they can be time intensive and costly portant. This process would help managers or administrators
to run, analyze, and interpret. understand the likelihood that clients would recommend the
Combining quantitative and qualitative research results in therapy to someone else, which might increase business.
mixed methods data collection. This approach is best when Similarly, advertising campaigns have data in “click-through”
incorporated in the research planning phase to help meet a numbers and can often tally the number of advertising views.
timeline and budget, but it also can be done after 1 stage of the However, without another source of data investigating opinions
research has been analyzed. Quantitative analysis often pro- and perceptions, it may not be clear whether those advertise-
vides a data point that can help guide decision making. For ex- ments resulted specifically in increased number of clients and
ample, knowing that 90% of clients are satisfied with a certain how prospective clients perceived those advertisements. Es-
occupational therapy practitioner in the office is very helpful. sentially, knowing that the clients saw an advertisement is not
However, adding a qualitative question can help explain why enough; follow up is required to learn if they liked the advertise-
and provide support to what the team is doing or to inform ment and if it, in turn, led them to the business.
making adjustments and improvements in other areas.
In addition to data collection in a planned research study,
Storing data
data also are collected on everyday devices that are not al-
ways intended for research purposes. Smartphones, wearable Once data have been collected, planning how to safely store
devices, and smart home and office technology are making that data is important. The storage system should be acces-
automatic quantitative data collection more commonplace. sible by password, with only the appropriate individuals
having access to the data. When possible, data should be kept Review outliers by running a frequency distribution on the
anonymous, or at least confidential. A good reference guide data set to review each case. This process will help identify
on data safety and security standards can be found in the Pa- missing cases or extreme deviations in scores. An example
tient-Centered Outcomes Research Institute’s (PCORI; 2018) of an outlier would be if the research on the geriatric com-
Methodology Standards. munity contains an age of 38 in the descriptive analysis,
which indicates a problem with the data. Or, if 1 person
Step 5. Prepare Data scored 100 on a test but the rest of the group maxed out at
60, think about what to do with that outlier score of 100.
Before data can be analyzed, they need to be prepared. Data One outlier, even if it is accurate, can affect the mean scores
preparation entails examining the collected data for errors, and alter decisions.
bias, missing data, and outliers. Options for handling missing data and outliers include
keeping the data as they are, deleting the entire entry, or en-
Errors tering a mean or aggregate data point. A similar process can
be done with outliers. Once a choice is made, document the
Research can be prone to errors. Even research that has gone decision and report it when the results are communicated.
through extensive planning can be subject to flaws along the
way. Sources of errors can stem from sampling the wrong Step 6. Analyze Data
population. If researchers sample only a small number of in-
dividuals, they may not be able to generalize their findings to After reviewing the data and finding all records to be accu-
a larger population. Similarly, if researchers sample a popula- rate, analyze the data. Microsoft Excel (Redmond, WA) has
tion that does not represent the group they are interested in, statistical functionality, but other programs such as IBM SPSS
their results may not be accurate. (Armonk, NY), SAS (Cary, NC), and R (Vienna, Austria) pro-
Sampling can also be biased. It is easy to ask friends, neigh- vide a more enhanced level of analysis. Begin with simple de-
bors, family, or colleagues how they feel about a certain issue, scriptive statistics, such as the count, percentage, and range of
but that type of convenience sample may not provide trusted the data by certain groupings. Presenting measures of central
results. At the core of good research is objective, randomly tendency (e.g., mean, median, mode) will help in understand-
assigned participants who provide data. ing the data as a whole and by different groupings. For exam-
Errors can also be made in collecting and storing data. ple, a manager or administrator might answer the question of
Although many researchers no longer rely on paper data col- what is the mean satisfaction score by male or female clients,
lection, that modality still exists. Translating data from paper and did it differ between them?
to computer systems can lead to data-entry errors. Quality Return to the research question, and identify the correct
control processes should be in place to ensure data are en- statistic to answer it. These statistics depend on the sample
tered correctly. Electronic systems contain less error in data size and research methodology, but an example would be
entry, but data should still be reviewed. When analyzing data asking whether to predict something via regression equa-
in a spreadsheet, take time to assess whether the data look tions or see if there are mean differences between groups and
correct. knowing if the sample is large enough and of the right type of
data to answer these questions.
Missing data and outliers
Step 7. Report Findings
PCORI (2018) suggests that you plan for monitoring the re-
Sharing data with others is key to convincing stakeholders
search process to avoid missing data. This means not wait-
of a manager’s or administrator’s plans as a decision maker;
ing until the end of the collection period to review data but
however, be wary of modern infographics and pie charts.
checking in on the research process at regular intervals. Next,
The goal is to present findings in a clear manner and create
create a plan for how to handle missing data.
an action plan. A communication plan should be created
Several tasks should be done before beginning a data anal-
from the beginning of the research process. Decide to whom
ysis. First, scan the data by running simple descriptive statis-
to communicate—internal and external stakeholders—and
tics on each variable. Descriptive statistics describe the data
communicate with them.
through a frequency distribution or measures of central ten-
According to Knaflic (2015), “being able to visualize data
dency or variability, such as mean scores, ranges, and stan-
and tell stories with it is key to turning it into information that
dard deviations (Creswell, 2014). Descriptive statistics do not
can be used to drive better decision making” (p. 2). Knaflic
infer anything about a larger population but simply describe
suggested 6 guidelines for data communication:
the data. By running a frequency distribution, it is possible
to see whether any data are missing and whether the missing 1. Understand context.
data are clustered in a particular area. 2. Choose an appropriate display.
The data distribution and range of scores can help de- 3. Eliminate clutter.
termine whether there are any extreme cases that should 4. Focus attention where you want it.
not be included. These extreme cases are called outli- 5. Think like a designer.
ers (Salkind, 2010) and can affect the mean significantly. 6. Tell a story. (p. 12)
Although it is beyond the scope of this chapter to detail error, these tools are worthless. There is also a tendency for
data visualization strategies, which include methods of these tools to be more distracting than informative, and in
sharing information in charts, tables, or figures, occupational the end, simpler may be better when reporting results.
therapy managers and administrators should remember that
anyone can use a Microsoft Office tool to create a chart or
Step 8. Assess the Process
graph. However, making that information meaningful de-
pends on deliberately presenting relevant data that the audi- After analyzing and presenting the data, review the process.
ence needs to know. Were the timeline and budget met? Was the research question
A common reporting tool is a dashboard report, which is answered? What feedback was received from stakeholders
a summary that contains data points to measure performance who were presented with the data? Many times the research
success in various areas (Figure 10.1). This report is meant process not only leads to data that can help managers or ad-
to be a quick reference tool. Although many commercial ministrators make decisions but also uncovers new questions
interactive dashboard tools are available, visualization can and ideas, leading perhaps to a new project!
be as simple as up-and-down arrows, or red–yellow–green
circles, next to a variable of interest. A dashboard provides
Review Questions
a quick guide and is based on data elements. A sample of
outcomes in a typical occupational therapy practice might 1. What is the first step in the research process, and why is this
include client performance, cost of service, success of treat- step important? Who would you consult in this first step?
ment, quality-of-life indicators, and or client satisfaction 2. What does the M in SMART goals stand for, and why is it
(Pitonyak, 2014). important?
When presenting data, remember to return to the research 3. What is a dashboard report, and what types of data can
question and answer it as simply as possible. In addition to you display on it? What are some limitations of dash-
the narrative text, answer it with a table, a figure, or a graph. board reports?
Tables are rows and columns of data and show exact data
points. Graphs are a type of figure that illustrates quantita-
tive data points and are best when data are too complex to be PRACTICAL APPLICATIONS IN
reported as a table and the decision maker or audience would OCCUPATIONAL THERAPY
not be able to swiftly understand the data presented in the
Consider Outcomes
table. A simple graph can easily show outliers in data and can
educate about the differences in groups. Figures are images, What is the desired outcome in collecting and analyzing
maps, or diagrams and should be used to present complicated data? Is it client satisfaction? Client outcome improvement?
results. Each reporting method should be concise but include Staffing issues? Whatever the problem to be solved, it should
explanations and legends where appropriate, be clearly la- be practical and also reflect client or organizational needs.
beled, and be legible. Identifying outcome, client satisfaction, and practitioner
Every day more and more data visualization tools and productivity can be done in several ways depending on the
techniques are available for purchase. Common ones are organization. Managers or administrators may choose to
Microsoft BI (Redmond, WA), Tableau (Seattle, WA), and identify the outcome alone or to work with a team. If choos-
Infogram (San Francisco, CA). These are usually easy to ma- ing to work alone, know that there will be bias and a limited
nipulate but require a good understanding of data manage- perspective. If working with a team, keep the team small,
ment to be able to load in the raw data tables for the visualiza- and appoint a leader or chair to make any final decisions
tions to work. Without the underlying data being free from and to move the project forward. This team should also be
FIGURE 10.1. Dashboard example.
Goal Performance
Third quarter revenue up 10% after marketing Revenue up 12% in

plan implemented in Quarter 1. the third quarter.
Staffing level 100%,

Increase staffing by filling open positions by
onboarding training
September 1.
underway.
data be used data to support this request? Case Example 10.1

EXHIBIT 10.2. Questions to Ask a Data Scientist provides a case example of a new school district manager of
occupational therapy using and analyzing data.
■ How did you obtain the data?
■ Are there other methods you could use to obtain the data?
■ What was your sampling plan? Does the respondent
Ethics
characteristics match the larger population? An additional consideration is the ethical dilemma of using
■ What is the sample size? data for marketing and research purposes without employee
■ Describe the data for me. Where there any outliers, and how did or client consent. If using technology to track encounters
they affect results?
and monitor other information, use flyers or signage to in-
■ How did you analyze the data? Why? Are there other methods you
form individuals, such as clients and employees. Store that
could have used?
information safely and securely, and review cyber technology
standards. This would include, but go beyond, reviewing
tasked with reviewing results and ensuring all stakeholders and implementing the Health Insurance Portability and
are communicated with properly. Accountability Act of 1996 (HIPAA; P. L. 104–191) privacy
and security rules regularly (U.S. Department of Health and
Human Services [HHS], 2013). HHS (2018) also has a website
Working With a Data Scientist
(https://bit.ly/2uJAcjr) that lists HIPAA-covered entities that
If the idea of working with spreadsheets and doing statistical are subject to following cybersecurity rules.
analysis on data is not in the skill set of a manager or adminis-
trator, it is possible to outsource some of this work to someone Review Questions
who is knowledgeable about data and statistics. If the organi-
zation chooses to hire a data scientist, understanding the scope 1. How do you think clients may react when they learn that
of work is key. Does the organization need someone to run the you may be using technology to track encounters and
entire project, or just to pull data and run the numbers. See interactions?
Exhibit 10.2 for a list of questions to ask a data scientist. 2. Where can you find information about emerging cyber
technology standards?
3. As documented in the AOTA (2015) Occupational Ther-
A Practical Example
apy Code of Ethics (2015), the standard for Nonmalefi-
An occupational therapy department has been in operation for cence states that “Occupational therapy personnel shall
more than 5 years and serves a variety of clients. The depart- refrain from actions that cause harm” (p. 3). Describe
ment has collected data on the clients served, and the supervisor what harm may come from collecting data from clients
is asking for longitudinal productivity numbers. How would using technology without their consent.
CASE EXAMPLE 10.1. Janelle: A School District Manager Needs to Review
Janelle, a new school district manager of occupational therapy services in Pennsylvania, was asked to review child services and outcomes from
the last 3 years in 2 high schools so she can properly allocate resources. She requested data from the school district. The data file came in a
Microsoft Excel format and contained variable names for each column, and 1 row of data for each student encounter. She opened the data file and
ran descriptive statistics on each variable of interest. In the frequency distribution, she saw several cases (i.e., missing rows) of missing data and
3 outliers, or extreme scores in her data.
Janelle discussed with her team the possible causes for this and decided to keep missing data but to remove the 3 outliers from the data set.
She then looked for differences between the 2 high schools on services provided and outcomes over the past 3 years. She compared demographic
information, such as gender, age, race, or ethnicity. She also compared student socioeconomic status by comparing students who are receiving
free-lunch vouchers. She presented her findings in a table and included a few graphs that illustrated the mean differences in her demographic
breakdowns and showed trends by year.
Janelle’s research and data allowed her to make the case that more resources are needed. She reported her findings to the school district and
at a monthly school board meeting to the public, in which it was decided that more advanced statistics are needed to build a predictive model. She
partnered with a data analyst to see which variables are likely to predict successful outcomes.
Review Questions
1. Review Janelle’s approach to keeping the instances of missing data. She decided not to replace the missing data with mean scores or to delete
the entire row of data, removing all information for that particular case or student, but instead left the missing data as is and continued with her
analysis. Do you agree with this approach? Why or why not?
2. Janelle reported her findings in both tabular and graphical form. Why is presenting this way important?
3. Imagine you were a member of the audience during this school board meeting. What questions might you have for Janelle and her team as they
move forward with building a predictive model?
SUMMARY REFERENCES
When starting a new program, business, or practice, occupa- Accreditation Council for Occupational Therapy Education. (2018).
tional therapy managers and administrators must understand 2018 Accreditation Council for Occupational Therapy Education
the data that drive all aspects of decision making. Knowing (ACOTE®) standards and interpretive guide. American Journal of
how to implement action plans based on data collection and Occupational Therapy, 72(Suppl. 2). https://doi.org/10.5014/[TK]
American Occupational Therapy Association. (2015). Occupa-
analysis is key.
tional therapy code of ethics (2015). American Journal of Oc-
Action plans may be client based, dealing with safety and cupational Therapy, 69, 6913410030. https://doi.org/10.5014
the success and timeliness of services, or internal business /ajot.2015.696S03
based, such as employee performance or finances. Either type Babbie, E. R. (2010). The practice of social research (12th ed.).
requires a clear vision, organized SMART goals, sound data Belmont, CA: Wadsworth Cengage.
collection that is free from bias, and strong interpretation of Creswell, J. W. (2014). Research design: Qualitative, quantitative, and
the data. ❖ mixed methods approaches (4th ed.). Thousand Oaks, CA: Sage.
Doran, G. T. (1981, November). There’s a SMART way to write man-
agement’s goals and objectives. Management Review, 70, 35–36.
LEARNING ACTIVITIES Doyle, A. C. (1891). A scandal in Bohemia. Retrieved from https://
www.gutenberg.org/files/1661/1661-h/1661-h.htm
1. Use Exhibit 10.1 to create a hypothetical research plan.
George, G., Osinga, E., Lavie, D., & Scott, B. (2016). From the edi-
2. You have received a data set containing more than 1,000 tors: Big data and data science methods for management research.
records of client satisfaction ratings for the 5 occupa- Academy of Management Journal, 59, 1493–1507. https://doi
tional therapy practitioners on your staff. Your first step .org/10.5465/amj.2016.4005
is to run descriptive statistics to determine whether any Health Insurance Portability and Accountability Act of 1996
data are missing or outliers exist. You find 15 records with (HIPAA), Pub. L. 104–191.
missing data for satisfaction scores, which is your main Knaflic, C. N. (2015). Storytelling with data: A data visualization
research objective. You also review and notice there are guide for business professionals. Hoboken, NJ: Wiley.
4 scores outside your expected range. Describe your plan Patient-Centered Outcomes Research Institute. (2018). PCORI
for handling missing data and your rationale. Next, de- methodology standards. Retrieved from https://www.pcori.org
scribe your plan for handling your outliers and why you /sites/default/files/PCORI-Methodology-Standards.pdf
Pitonyak, J. S. (2014). Occupational therapy evaluation and
chose that method.
evidence-based practice. In J. Hinojosa & P. Kramer (Eds.), Eval-
uation in occupational therapy: Obtaining and interpreting data
ACOTE STANDARDS (4th ed., pp. 267–280). Bethesda, MD: AOTA Press.
Salkind, N. (2010). Encyclopedia of research design. Thousand Oaks,
This chapter addresses the following ACOTE Standards: CA: Sage.
U.S. Department of Health and Human Services. (2013). Summary
■ B.1.4. Qualitative Statistics and Qualitative Analysis of the HIPAA security rule. Retrieved from https://www.hhs.gov
■ B.4.6. Reporting Data /hipaa/for-professionals/security/laws-regulations/index.html
■ B.4.7. Interpret Standardized Test Scores U.S. Department of Health and Human Services. (2018). Cyber se-
■ B.4.8. Interpret Evaluation Data curity guidance material. Retrieved from https://www.hhs.gov
■ B.6.2. Qualitative and Quantitative Methods /hipaa/for-professionals/security/guidance/cybersecurity/index
■ B.6.3. Scholarly Reports. .html
CHAPTER
Risk Management and Contingency Planning
Sarah Corcoran, OTD, OTR/L 11
LEARNING OBJECTIVES
■ Define risk, risk management, and contingency planning;
■ Identify examples of types of risk within an organization;
■ Analyze the contextual factors that have shaped the history of risk management in health care;
■ Describe the 5 risk management strategies;
■ Discuss the relationship between risk management and quality improvement within an organization; and
■ Recognize responsibilities of occupational therapy practitioners in risk management and contingency planning.

• Adverse event • Plan–Do–Study–Act Cycle • Risk matrix
• Clinical risk • Quality improvement • Risk report
• Contingency plan • Risk • Root cause analysis
• Incident report • Risk management • Sentinel events
• Near miss • Risk management plan
OVERVIEW controlling, reporting, and monitoring the likelihood and

potential impact of events that threaten an organization’s re-
R
isk is everywhere. Because people need and want to sources (CDC, 2006; Clarke, 2000; Dickson, 1995). The greatest
do things, they find ways to manage risk. Think about resources of an organization include its mission or purpose,
the risks that people notice, avoid, or create every day. its employees, and its consumers. This chapter covers infor-
People set alarm clocks to avoid oversleeping. Students study mation that occupational therapy leaders need to know about
for exams to avoid the risk of failing a course. Homeowners risk management in the context of organizational planning
install gutters so that water does not damage their home. Oc- and culture.
cupational therapy practitioners recommend grab bars and
adaptive equipment to prevent the risk of a client falling.
How would each day be different if risks were not managed? ESSENTIAL CONSIDERATIONS
A world without risk is appealing but not possible. There-
Risk Management in Health Care
fore, people assess risks and analyze strategies to effectively
respond to potential hazards. Like any business, health care organizations face exposures
A business, regardless of its size and structure, must iden- to many risks. In addition to clinical risk, or risk associated
tify and manage risks in order to succeed. Risk is defined as with patient safety and the delivery of care, it is also essential
a possible, uncertain event usually measured by how likely it for the organization to consider operational, strategic, finan-
is to occur and the severity of the potential impact (Centers cial, workforce, legal, technology, and hazard risks (American
for Disease Control and Prevention [CDC], 2006; Ross, 2012). Society for Healthcare Risk Management [ASHRM], 2016).
Risk management is the practice of identifying, analyzing, These types of risk and examples are shown in Exhibit 11.1.
https://doi.org/10.7139/2019.978-1-56900-592-7.011
107
CHAPTER
Risk Management and Contingency Planning
Sarah Corcoran, OTD, OTR/L 11
LEARNING OBJECTIVES
■ Define risk, risk management, and contingency planning;
■ Identify examples of types of risk within an organization;
■ Analyze the contextual factors that have shaped the history of risk management in health care;
■ Describe the 5 risk management strategies;
■ Discuss the relationship between risk management and quality improvement within an organization; and
■ Recognize responsibilities of occupational therapy practitioners in risk management and contingency planning.

• Adverse event • Plan–Do–Study–Act Cycle • Risk matrix
• Clinical risk • Quality improvement • Risk report
• Contingency plan • Risk • Root cause analysis
• Incident report • Risk management • Sentinel events
• Near miss • Risk management plan
OVERVIEW controlling, reporting, and monitoring the likelihood and

potential impact of events that threaten an organization’s re-
R
isk is everywhere. Because people need and want to sources (CDC, 2006; Clarke, 2000; Dickson, 1995). The greatest
do things, they find ways to manage risk. Think about resources of an organization include its mission or purpose,
the risks that people notice, avoid, or create every day. its employees, and its consumers. This chapter covers infor-
People set alarm clocks to avoid oversleeping. Students study mation that occupational therapy leaders need to know about
for exams to avoid the risk of failing a course. Homeowners risk management in the context of organizational planning
install gutters so that water does not damage their home. Oc- and culture.
cupational therapy practitioners recommend grab bars and
adaptive equipment to prevent the risk of a client falling.
How would each day be different if risks were not managed? ESSENTIAL CONSIDERATIONS
A world without risk is appealing but not possible. There-
Risk Management in Health Care
fore, people assess risks and analyze strategies to effectively
respond to potential hazards. Like any business, health care organizations face exposures
A business, regardless of its size and structure, must iden- to many risks. In addition to clinical risk, or risk associated
tify and manage risks in order to succeed. Risk is defined as with patient safety and the delivery of care, it is also essential
a possible, uncertain event usually measured by how likely it for the organization to consider operational, strategic, finan-
is to occur and the severity of the potential impact (Centers cial, workforce, legal, technology, and hazard risks (American
for Disease Control and Prevention [CDC], 2006; Ross, 2012). Society for Healthcare Risk Management [ASHRM], 2016).
Risk management is the practice of identifying, analyzing, These types of risk and examples are shown in Exhibit 11.1.
https://doi.org/10.7139/2019.978-1-56900-592-7.011
107
EXHIBIT 11.1. Description of Enterprise Risk Domains
ERM Risk Domains
Domain Description/Example
Operational The business of health care is the delivery of care that is safe, timely, effective, efficient,
and patient-centered within diverse populations. Operational risks relate to those risks
resulting from inadequate or failed internal processes, people, or systems that affect
business operations. Included are risks related to: adverse event management,
credentialing and staffing, documentation, chain of command, and deviation from practice.
Clinical/Patient Safety Risks associated with the delivery of care to residents, patients and other health care
customers. Clinical risks include: failure to follow evidence based practice, medication
errors, hospital acquired conditions (HAC), serious safety events (SSE), and others.
Strategic Risks associated with the focus and direction of the organization. Because the rapid pace
of change can create unpredictability, risks included within the strategic domain are
associated with brand, reputation, competition, failure to adapt to changing times, health
reform or customer priorities. Managed care relationships/partnerships, conflict of interest,
marketing and sales, media relations, mergers, acquisitions, divestitures, joint ventures,
affiliations and other business arrangements, contract administration, and advertising are
other areas generally considered as potential strategic risks.
Financial Decisions that affect the financial sustainability of the organization, access to capital or
external financial ratings through business relationships or the timing and recognition of
revenue and expenses make up this domain. Risks might include: costs associated with
malpractice, litigation, and insurance, capital structure, credit and interest rate fluctuations,
foreign exchange, growth in programs and facilities, capital equipment, corporate
compliance (fraud and abuse), accounts receivable, days of cash on hand, capitation
contracts, billing and collection.
Human Capital This domain refers to the organization’s workforce. This is an important issue in today’s
tight labor and economic markets. Included are risks associated with employee selection,
retention, turnover, staffing, absenteeism, on-the-job work-related injuries (workers’
compensation), work schedules and fatigue, productivity and compensation. Human
capital associated risks may cover recruitment, retention, and termination of members of
the medical and allied health staff.
Legal/Regulatory Risk within this domain incorporates the failure to identify, manage and monitor legal,
regulatory, and statutory mandates on a local, state and federal level. Such risks are
generally associated with fraud and abuse, licensure, accreditation, product liability,
management liability, Centers for Medicare and Medicaid Services (CMS) Conditions of
Participation (CoPs) and Conditions for Coverage (CfC), as well as issues related to
intellectual property.
Technology This domain covers machines, hardware, equipment, devices and tools, but can also
include techniques, systems and methods of organization. Healthcare has seen an
explosion in the use of technology for clinical diagnosis and treatment, training and
education, information storage and retrieval, and asset preservation. Examples also
include Risk Management Information Systems (RMIS), Electronic Health Records (EHR)
and Meaningful Use, social networking and cyber liability.
Hazard This ERM domain covers assets and their value. Traditionally, insurable hazard risk has
related to natural exposure and business interruption. Specific risks can also include risk
related to: facility management, plant age, parking (lighting, location, and security),
valuables, construction/renovation, earthquakes, windstorms, tornadoes, floods, fires.
Note. ERM = enterprise risk management. Copyright © 2016 by the American Society for Healthcare Risk Management. Reprinted with permission.
CHAPTER 11. Risk Management and Contingency Planning 109
Historical Perspective
perspective, the National Patient Safety Foundation’s 2015
Risk management in health care has evolved as health care report Free From Harm included the agency’s assessment that
has changed in the United States (see Figure 11.1). Hospitals medical errors and related consequences were still rampant.
began to focus on risk management as malpractice claims in- A paper published in 2016 by physicians Makary and Daniel
creased in the 1970s (ECRI Institute, 2014). The aim of risk at Johns Hopkins University suggested that medical error is
management in the 1970s was to defend organizations from the 3rd leading cause of death in the United States.
legal and financial types of risks. Over the next couple of The occupational therapy profession has also recognized
decades, the health care industry began to connect clinical the presence of clinical risk in occupational therapy practice.
risk management with quality improvement, which is the In 2006, Mu et al. published results from a national survey
continual process of monitoring outcomes to ensure opti- of occupational therapy practitioners that indicated that
mal care delivery within an organization (American Society practice errors were frequent, even among the most experi-
for Healthcare Risk Management of the American Hospital enced clinicians. The occupational therapy practitioners in
Association, 2007). this study also reported improvement in their own practice
National quality improvement and risk management or- and client outcomes when the practitioners reported errors.
ganizations formed, and regulatory agencies set standards A follow-up study identified strategies for occupational ther-
for health care organizations’ risk management programs. apy practitioners, students, and managers to reduce practice
For example, in 1996, the Joint Commission began to require errors and build a culture of safety within organizations (Mu
organizations to investigate and report sentinel events, or et al., 2011). The occurrence of practice errors may also be
adverse events resulting in death or serious harm to a patient evident in review of malpractice claims. Between 2006 and
(The Joint Commission, 2017b). An adverse event is an in- 2015, the professional liability companies CNA and Health-
cident that causes an undesired outcome, such as harm to care Providers Service Organization reported that malprac-
a patient, not expected during the normal delivery of care tice claims for occupational therapy practitioners insured
(Levinson, 2012). through these companies totaled $2,717,629 (CNA, 2017).
In 1999, the Institute of Medicine released a report entit led Health care leaders, including occupational therapy prac
To Err is Human: Building a Safer Health System, which re- titioners and managers, must meet the complex task of man-
vealed a high rate of death from medical errors in the United aging all areas of risk that are present within their work
States. This report prompted the health care industry to con- settings. With the expansion of technology, health care sys-
sider the larger, systemic causes of adverse events and near tems rely on electronic systems to secure large amounts of
misses. A near miss is an unplanned event, or close call, that private information. Regulatory agencies (e.g., CMS) expect
could have caused harm to a person but did not because of health care organizations to take responsibility for the elec-
chance or intervention (National Safety Council, 2013; U.S. tronic systems that they use. As companies merge to develop
Department of Veterans Affairs, 2015). expansive health care systems, leaders must stay aware of the
The Joint Commission and Centers for Medicare and strategic and financial risk exposures. Organizations need
Medicaid Services (CMS) began requiring health care or- to adhere to specific regulations and know the legal risks in
ganizations to report adverse events and near misses and their ventures. Risk management in health care is complex,
provided tools to guide patient safety programs. Even with and those responsible for risk management must understand
a heightened focus on managing clinical risk from a system all types of risk and use essential risk management strategies.
FIGURE 11.1. Health care risk management events in the United States, 1980–2015.
1980 1990 2000 2010
• American Society for • National Committee for • The Joint Commission • World Health
Healthcare Risk Quality Assurance announced National Organization developed
Management formed (1990) Patient Safety Goals Multiprofessional
established (1980) • The Joint Commission (2002) Patient Safety
• Agency for Health Care issued Sentinel Event • National Quality Forum Curriculum (2011)
Policy and Research Policy (1996) issued list of Serious • National Patient Safety
created (1989) • Institute of Medicine Reportable Events Foundation (2015)
released To Err is (2002) released Free From
Human: Building a Harm
Safer Health System
(1999)
Risk Management Team may specify that patient safety is the responsibility of all
employees. It may state that the members of the organization
Depending on an organization’s size and structure, the organi-
must create and uphold a just culture in which the focus is on
zation may appoint a person or a team of people to conduct risk
learning, communicating, and improving quality of care. The
management, or it may outsource to a risk management com-
organization identifies key terms and definitions that are im-
pany (ASHRM, 2006b, 2006c; American Society for Health-
portant to how it understands risk and conducts risk manage-
care Risk Management of the American Hospital Association,
ment activities. The plan also names the person(s) responsible
2007). The resources and needs of each organization will de-
for risk management within the structure of the organization
termine who is responsible for risk management activities.
(CNA, 2014; ECRI Institute, 2014).
People who hold risk management positions can have dif-
The processes for day-to-day risk management, such as how
ferent professional backgrounds, but the focus of risk man-
patient complaints are handled or how policies are revised, are
agement is the same. Key risk management responsibilities
outlined here. Timelines to guide risk management are plotted,
include identifying the organization’s critical risks, learn-
including how often risk priorities are assessed. For example,
ing industry standards and regulations, creating policies
a business may indicate that the plan itself will be evaluated
to increase safety, educating staff about potential risks and
and modified as needed but at least annually. Overall, this plan
plans, investigating complaints, working with legal matters
conveys the need to know information about risk management
(e.g., malpractice, workers’ compensation), tracking data to
within the organization to all employees and external stake-
locate root causes and action plans, and reporting risk-related
holders, including consumers, accrediting bodies, and po-
information to stakeholders.
tential business partners. For this reason, the plan should be
readily available and shared with employees upon orientation
Risk Management Strategies and on a routine basis, especially when revisions are made.
There are 5 key risk management steps, or strategies:
1. Plan, Risk assessment
2. Assessment, Next, the organization must determine the risks to which it is
3. Analysis, exposed. The aim of risk assessment is to find areas of vulnera-
4. Response, and bility within the organization, potential threats, and the impact
5. Report and monitoring. if the risk occurs (Ross, 2012). Health care leaders can identify
Guiding questions for each step are suggested in Table 11.1. the most likely and serious risk exposures by learning current
industry trends. They want to know what risks have threatened
other similar businesses so that they can proactively manage
Risk management plan
these risks and avoid negative outcomes for their own organi-
Creating a risk management plan is the first step to develop- zation. They also study current laws, regulations, and profes-
ing a risk management program. This plan defines the busi- sional standards that point to critical industry risks related to
ness’s philosophy on risk. For example, a business’s risk plan the provision of care. For example, The Joint Commission sets
Table 11.1. Risk Management Strategies and Guiding Questions
RISK MANAGEMENT STRATEGY GUIDING QUESTIONS

Plan ■ What is the organization’s philosophy on risk?
■ Who is responsible for risk management?
■ What are the risk program’s goals?
■ How will the organization conduct daily risk management activities?
■ How often will the organization formally review the risk plan and related policies?
Assessment ■ Which risks are most likely to impact this organization?
■ What unexpected events have occurred within this organization?
■ What trends are observed through incident reports?
■ What trends are observed through employee and patient satisfaction surveys?
Analysis ■ What is the impact if the risk occurs?
■ What caused an unexpected event?
■ What are possible ways to deal with the risk?
Response ■ How will the organization act on the risk? Will it mitigate, eliminate, accept, or transfer the risk?
Reporting and monitoring ■ How will the organization monitor ongoing and new risks?
■ What information is important to communicate to internal and external stakeholders?
■ How will this communication occur?
FIGURE 11.2. Sample risk matrix.
Risk Ranking Matrix
Risk Map
Critical
4
Impact
Moderate
2
Insignificant
Unlikely Potential Likely

Likelihood
1 2 3 4 5
Source. Copyright © 2014 by American Society for Healthcare Risk Management. Reprinted with permission.
minimum requirements that hospitals and home health orga- collected as soon as possible after an adverse event or near
nizations must meet to assess risks such as infection, oxygen miss for the purpose of tracking data, ensuring appropriate
and medication management, and patient falls. follow up, and learning how to reduce or eliminate risk of
During risk assessment, organizations prioritize risks to reoccurrence (Levinson, 2012). Near misses are included in
most effectively use their resources, including time, money, incident reporting because they tell an important story, with-
and staff training. A risk matrix is a mapping tool used to rate out harm to the client or worker, to prevent harm in the future.
the likelihood and severity of the impact of risks in order to A staff member who is involved in an adverse event or near
identify the most critical risks to be addressed (see Figure 11.2; miss or who is the first to become aware of the event usually
ASHRM, 2006a; CMS, 2007). Organizations’ risk managers or completes the incident report together with his or her super-
risk management teams create a matrix to guide the identifi- visor (see Exhibit 11.2). The risk manager or risk team reviews
cation of the most likely and serious risks. Risk matrixes are the details of the incident report. They monitor these reports
revised at intervals specified in the risk plan in order to accu- for trends. It is vital that health care leaders create a culture
rately reflect threats and weaknesses, which change over time. in which employees feel comfortable communicating when
Businesses also use feedback from employees and clients to things do not happen as planned. An organization’s policies
assess risk. This information may be supplied by satisfaction should guide how and when incident reports are completed.
surveys and complaints, as well as observation of work envi-
ronments (CNA, 2014). Employees and clients who are closest
to the work being done within the organization often have
EXHIBIT 11.2. Dos and Don’ts for Incident Reporting
the best view of unexpected events, causes, and possible ways
to reduce risk. Documentation and communication of unex- GUIDELINES FOR INCIDENT REPORTING
pected events are essential to effective assessment of the orga-
nization’s risks. Formally tracking the details of unexpected Do Do Not
events helps the organization to identify weaknesses in prac- ■ Report to supervisor ■ Wait
■ Complete as soon as possible ■ Blame
tices and policies to avoid future risks and improve quality.
■ Provide facts and statements ■ Document opinions
A common way to track an unexpected event is to use an ■ Assist with client concerns
incident report, which is a document of objective information
Risk analysis to be monitored as part of risk management. When an unavoid-

able risk cannot be tolerated, the organization transfers the risk.
After the organization has determined its most critical risks,
This is often done through the purchase of insurance (Dickson,
the risk manager or risk team guides the identification of
1995). For example, because the possibility of clinical errors and
possible causes, effects, and solutions through risk analysis.
litigation may not be eliminated entirely, an organization will
During this step, the risk manager or team seeks to under-
often carry malpractice insurance for the business and its pro-
stand the underlying systemic root causes of the problem.
fessional employees like occupational therapy practitioners. The
Health care teams often use a root cause analysis, which is
risk of liability is shared through the insurance to minimize the
a tool used by a team to determine all system factors directly
negative impact on the function of the organization.
associated with an adverse event or near miss with the aim of
developing an action plan to reduce risk (Occupational Safety
and Health Administration, 2016; U.S. Department of Veterans Risk reporting and monitoring
Affairs, 2015). A cause-and-effect (“fishbone”) diagram pro- How does an organization know if its risk management efforts
vides a visual tool for the root cause analysis (CMS, n.d.; see also are working? Organizations continue to monitor identified
Figure 11.3). Essentially the team continues to ask “why” until risks and communicate about risk with internal stakeholders
all core reasons for a problem are recognized. When the root (e.g., employees) and external stakeholders (e.g., health care
causes are known, the organization can plan ways to respond to consumers). Information shared with stakeholders should
the risk. The Joint Commission (2017a) provides a framework include the risk management activities that have been under-
for root cause analysis to guide health care organizations. Risk taken for identified risk and data that have been tracked to as-
analysis is vital to effective risk management and should include sess success of these activities. The risk report will include data
input from those directly connected to the risk or problem. such as unexpected events, reportable outcomes (e.g., quality
key indicators, claims), policy changes, credentialing proce-
dures, staff training, and patient safety activities. It is also es-
Risk response
sential for the organization to continue to monitor and report
Organizations respond to risk in 4 ways: (1) mitigating or new risks as contextual factors influencing the delivery of care.
reducing, (2) eliminating or avoiding, (3) accepting, or (4) trans- This step in risk management includes quality improve-
ferring the risk (ASHRM, 2006a; CDC, 2006). Careful assessment. Just as risk managers use techniques to assess, analyze,
ment and analysis determine the best response. Ideally, the and control risk, quality improvement specialists use special
organization will eliminate risks completely. When this is not tools to monitor quality, track and report data, and test possi-
possible, it will reduce the risk as much as possible. Strategies ble solutions. When a plan of action is established by the root
to eliminate and mitigate risk include adopting policies and cause analysis, a model called the Plan–Do–Study–Act Cycle
procedures, documentation and reporting processes, environ- (PDSA), is commonly used to test solutions (Morelli, 2016; W.
mental adaptations, staff training and competencies, commu- Edwards Deming Institute, 2017). Health care leaders use this
nication, and planning (Clarke, 2000). team approach to test a solution for a problem in a similar way
When a risk cannot be avoided or reduced, the organization to the scientific method of testing a hypothesis (Gorenflo &
either accepts or transfers the risk. When risk is accepted, the Moran, 2010). To learn more about PDSA, visit the Minnesota
organization decides that it can tolerate this amount of risk Department of Health website (https://bit.ly/2MeZOuq).
within its daily operations. The risk is known and will continue Case Example 11.1 illustrates risk management.
CASE EXAMPLE 11.1. Home Health Agency Risk Management
In home health, a risk often addressed is the clinical risk of client injury related to falls. In this case example, consider the risk management process
used by a home health agency attempting to decrease the risk of client falls.
Risk plan
The agency has a written risk plan, which includes its philosophy that patient safety is the responsibility of every employee. Risk management goals
include minimizing client risk of injury and hospitalization in order for the client to remain at home, in keeping with the agency’s mission. The risk
plan identifies the risk officer as the primary responsible person for risk management activities. The risk officer reports to the chief financial officer
and communicates with clinical managers and the quality improvement department during risk management activities.
Risk assessment
The risk officer at the agency routinely tracks the rate of home health clients who receive emergency care for an injury from a fall while on service with
the agency. The agency has reported a higher rate of client injury from falls than the national average over the past 2 years. This is a negative outcome for
the organization. Because of frequent client falls and the potentially severe negative impact on the agency’s ability to fulfill its mission, the administration has
rated this risk as a high priority when completing an annual risk matrix. The agency had planned several opportunities for staff education on fall prevention.
The risk officer reviews all incident reports completed by agency employees. Recently, an incident report was completed by a clinical manager
when a client fell during a visit from the home health aide (see Exhibit 11.3).
(Continued)
CASE EXAMPLE 11.1. Home Health Agency Risk Management (Cont.)
EXHIBIT 11.3. Sample Risk Report
HOME HEALTH AGENCY INCIDENT REPORT

Date and Time of Event: 6/20/2019 Type of event: Witnessed fall
10:05 a.m.
Client Name: Mr. M Client ID: 000000000
Location of event: Client’s home, 123 ABC Street
Employees involved: Anna, home health aide
Other witnesses: Client’s wife, Mrs. M
DESCRIPTION OF EVENT
Home health aide arrived at patient’s home to assist him with showering. Client accessed his shower and participated in bathing while seated
on his shower chair. When client finished shower, aide turned the water off and helped client to dry his body as much as possible while seated
on shower chair. Client turned his body on shower chair to prepare to exit shower using the method that he had been using in previous sessions
with occupational therapy practitioner. Client stood with assistance from aide and placed his hands on his walker while aide reached for the
client’s robe. Client let go of the walker with both hands to fix his hair while looking in the mirror and lost his balance. Home health aide was
able to place hands on client’s shoulder and torso to help ease his descent to the floor.
Condition of client before event: Client, seated in a chair in his bedroom, presented with intact mental status. He reported feeling fatigued
after visiting the doctor this morning for a routine medical exam but asked to shower today as planned.
Condition of client after event: Client reported pain in his right hip while lying on the floor in the bathroom. He began to sit up from
the floor but then reclined again, reporting right hip pain was severe. Client did not hit his head or lose
consciousness.
Was injury sustained? Yes—right hip pain
Did client require emergency care? Yes
IMMEDIATE FOLLOW-UP TO THE EVENT
Aide stayed with client while client’s wife called 911. Paramedics arrived and transported client to emergency room for assessment of right
hip pain. Aide notified supervisor, the nurse, and the occupational therapy practitioner on Mr. M’s case about this fall. Dr. S was notified of fall,
hip pain, and transport to emergency room.
PLAN OF ACTION
Case manager will attempt to contact client’s wife this evening (6/20/19) and the hospital as needed, to determine the status of Mr. M. Case
manager, occupational therapist, home health aide, and clinical manager will review Mr. M’s home health aide care plan and revise as needed
depending on his ability when he returns home. Occupational therapist plans to reassess fall risk and educate client and caregiver on fall
prevention during ADLs. Team plans to continue interdisciplinary communication related to client safety.
Additional Comments: On 6/20/19, supervisor received confirmation from hospital that client was admitted to hospital with a right hip fracture.
Completed by: B. Supervisor Date: 6/20/19
Reviewed by: Risk Manager Date: 6/21/19
Note. ADLs = activities of daily living.
Risk analysis
A small group, including the risk officer, clinical manager, occupational therapy practitioner, physical therapist, nurse, and home health aide,
met to analyze the details of this client’s fall, which caused a hip fracture. A root cause analysis was performed (see Figure 11.3). The risk officer
facilitated the meeting, ensuring that everyone involved understood that the focus of the meeting was to identify possible system causes, not
to assign blame. The home health aide reported feeling rushed during her day because she had a high caseload. She had been asked to cover
for another aide who was sick.
The aide reported that she was running behind schedule when she arrived at the client’s home. Despite rushing, she had checked that the
bathroom floor was dry and that a towel and robe were within reach before the client exited the shower. The occupational therapy practitioner
reported that this client’s ability to transfer to and from the shower chair had declined in the past week.
The practitioner left a message for the assigned home health aide but did not realize that this aide was out sick. The nurse mentioned that the
client had a loss of balance as he stepped onto the scale during her visit, but he did not fall. She did not report this to the team because the client
was not injured. The physical therapist reported that she was attempting to schedule an evaluation of this client, but had not been able to reach him.
She did not notify the team members. She reported that she did not have time because many clients were waiting to be evaluated. The root cause
analysis determined that staffing issues, communication issues, and lack of training on reporting near misses were system causes (Figure 11.3).
(Continued)
CASE EXAMPLE 11.1. Home Health Agency Risk Management (Cont.)
FIGURE 11.3. Example of root cause analysis for a witnessed fall.
Di Processes Environment
d
to not k
rep no
or w
t
Near fall not reported Limited space in
client’s bathroom
Delay in therapy evaluations
s Client
ue sustained
ss
ngi hip fracture
affi
St No gait belt available Lack of team during
communication witnessed fall
Lack of employee planning time No additional coverage

for sick staff member
Equipment/Resources Staff/People
Risk response and monitoring

Based on the analysis, the risk officer and administration created an action plan to mitigate staffing issues and eliminate breakdowns in team
communication and reporting processes. The action plans included revision of procedures and staff education on when and why to report near
misses in addition to adverse events.
The risk officer shared information about client fall outcomes and trends in staff reporting at monthly team meetings and worked closely with
clinical managers to assure staffing needs were met. The quality improvement department audited charts to assess the implementation of best
practices in fall prevention and team communication.
Staff and client surveys included questions about the success or need to improve in these targeted areas. The agency’s rate of client injury
from falls decreased over the course of 1 year, but the agency again included this area of risk in the next annual risk matrix because of the crucial
impact of client falls on the agency’s ability to fulfill its mission.
Review Questions
1. How did the home health agency determine that the risk of client injury from falls should be a priority?
2. How did the root cause analysis help the group (which included a risk manager) to determine the agency’s risk response for client injury from falls?
3. What did the agency do to continue monitoring this risk?
Contingency Planning
Plans should be clear, simple to follow, and realistic (World
When risks become reality, businesses follow a contingency Health Organization [WHO], 2012). The plan must be estab-
plan, or a predetermined course of action to guide an orga lished, written, shared, and tested well in advance of the pos-
nization’s response to and recovery from a negative or un- sible trigger for it to be effectively implemented.
expected event in order to resume normal operation (CDC, Testing the plan includes practice. First, a small group of
2008). A contingency plan is similar to the idea of a “Plan B” administrators, usually including a risk manager, implements
that we may use in our everyday lives. It is not the first or best tabletop exercises to discuss the execution of a contingency
plan, but it is necessary when “Plan A” will not work. Con- plan for a hypothetical emergency. The goal of a tabletop ex-
tingency plans plot the course of action for an organization ercise is to find out how the contingency plan will be imple-
to respond to and recover from an unexpected negative event mented and discuss what worked and did not work within an
in order to resume normal operation (CDC, 2008). These de- informal environment (U.S. Department of Homeland Secu-
liberate plans are developed collaboratively through careful rity [DHS], 2013). The group can then make corrections before
assessment of risk and resources. the plan is shared with all staff.
Contingency plans are documented at a policy level so Once the plan is approved and staff is trained in the emer-
that everyone in the organization is aware of the details. gency preparedness procedures, an organization prudently
Policymakers often include a decision tree to guide staff when assesses staff members’ knowledge and confidence regard-
carrying out the plan (Turoff et al., 2013). ing the plan (Turoff et al., 2013). At this time, larger scale
operations-based exercises are completed. During operations- PRACTICAL APPLICATIONS IN

based exercises, including drills, employees respond to a hypo- OCCUPATIONAL THERAPY
thetical emergency by enacting their roles and responsibilities
listed within the contingency plan (DHS, 2013). Outside enti- Occupational therapy practitioner Aideen Gallagher (2013)
ties (e.g., first responders) may or may not be included in the proposed that successful participation in occupations “de-
exercise. Operations-based exercises are intended to assess mands an engagement with risk” (p. 338). Occupational
the ability for the members of the organization to collaborate scientists have studied the connection between risk and
and execute the contingency plan. The drills or exercises can occupations (Dennhardt & Rudman, 2012). The American
pinpoint areas that require change or additional training that Occupational Therapy Association (AOTA; 2014) supports
is needed to facilitate best practices during a real emergency. organization- or systems-level practice in occupational ther-
The contingency plan must be monitored and updated on apy in the Occupational Therapy Practice Framework: Domain
an ongoing basis to ensure that it works as risks and resources and Process (OTPF–3). Businesses, like occupational therapy
change. Routine staff training and practice must accompany clients, must encounter risk in order to grow.
contingency planning (Turoff et al., 2013). Organizations As experts in the transactional relationships among per-
make contingency planning part of the organizational rou- son, environment, and occupations, occupational therapy
tine by including staff members in planning, making poli- practitioners can adeptly understand and respond to risk in
cies and procedures accessible, training staff regularly, and both their practice and leadership roles (Gallagher, 2013).
practicing drills and simulations. Professional organizations Several occupational therapy skills place occupational ther-
(e.g., Joint Commission, CMS, Commission on Accreditation apy practitioners in a prime position to successfully manage
of Rehabilitation Facilities, WHO) offer specific resources to risks (see Table 11.2). Practitioners aim to maximize perfor-
guide health care organizations as they develop contingency mance and participation whether leading clients, staff, or a
plans for emergencies. business.
Review Questions Managing Risks in Practice

1. What are the 5 strategies of risk management? In clinical practice, occupational therapy practitioners con-
2. Which tools are used in risk management and quality tinuously monitor for client safety risks. Still, near misses
improvement? Briefly describe how they work. and adverse events occur in occupational therapy practice,
3. How do contingency plans fit within an organization’s risk most often during interventions (Mu et al., 2006). Clinical
management program? risks for occupational therapy clients include falls, injuries,
TABLE 11.2. Occupational Therapy Skills and Risk Management Strategies
OCCUPATIONAL THERAPY SKILL RISK MANAGEMENT STRATEGY RELATIONSHIP

Systems-oriented approach Risk assessment Occupational therapy practitioners understand how client factors, skills,
patterns, and contexts connect and how the mission, needs, resources,
threats, and opportunities of an organization connect to effectively
plan interventions and monitor outcomes.
Activity analysis Risk analysis Occupational therapy practitioners analyze the specific skills required for
an activity and the root causes of a problem to plan for improvement.
Knowledge of performance Risk response Occupational therapy practitioners understand that routines can support
patterns or limit performance for a client or an organization. By learning the
routines of members of the organization, they can help to determine
and embed best practices in the organizational routine.
Clinical reasoning and Risk reporting Occupational therapy practitioners use theory and strong interpersonal
therapeutic use of self skills to facilitate collaborative therapeutic relationships with clients
and to enable a culture of safety within an organization.
Adaptation Contingency planning Occupational therapy practitioners naturally adapt process, tools, and
environment to promote client engagement in occupation and to
create and implement contingency plans in response to conditions that
threaten an organization’s operations. WFOT (2016) and AOTA (2015)
have formally affirmed the role of occupational therapy in disaster
risk reduction.
Note. AOTA = American Occupational Therapy Association; WFOT = World Federation of Occupational Therapists.
and adverse reactions to modalities and other treatments. Occupational therapy practitioners who own their own
Strategies to reduce clinical risk include attending to clients’ practice or manage a department must consider additional
needs and conditions; assessing the environment of care; financial, strategic, operational, and human capital risks.
and adherence to professional standards, state practice acts, Occupational therapy managers and practice owners have
and organizational policies and procedures (CNA, 2017; additional layers of responsibility regarding risk manage-
Ranke & Moriarty, 1997). Evidence supports a connection ment. As leaders, they are likely to be directly involved with
between communication and risk management in occupa- managing adverse events, strategic partnerships, billing for
tional therapy practice (Atwal et al., 2011; Mu et al., 2011). services, and ensuring compliance with regulatory stan-
Occupational therapy practitioners’ communication skills dards. These individuals are also involved in, and sometimes
are critical to minimizing risks and promoting best practice solely responsible for, hiring and terminating staff. They must
strategies. abide by regulations such as those set by the Americans With
Practitioners must also consider other types of risk in prac- Disabilities Act (P. L. 101–336). Occupational therapy leaders
tice, including legal risks. Adherence to standards of care and support a culture of safety within their settings when they
accurate documentation can help clinicians to reduce legal facilitate communication, standardized processes, compe-
risk. Clinicians may decide to share the risk of litigation by tency checks, and a dedicated reporting system with their
purchasing liability insurance. Two professional liability com- teams (Mandel, 2017; Mu et al., 2011).
panies, CNA and Healthcare Providers Service Organization, Occupational therapy managers and leaders also use con-
reported that malpractice claims against occupational ther- tingency planning when addressing the potential of events
apy practitioners from 2006 through 2015 most frequently not going as planned. For example, a manager may tem-
occurred in outpatient clinics (52%), followed by patient porarily partner with a contract staffing agency to keep a
homes (18%) and aging services facilities (14%; CNA, 2017). department operating smoothly despite a staffing shortage,
Some occupational therapy practitioners may be insured or a private practice owner could develop an alternative
through their employer and should know the details about plan to continue serving clients during a local community
the coverage provided. Independent contractors must be disaster.
aware of the details of agreements with organizations and
regulatory standards that apply specifically to contractors. Review Questions
Working in a world of advancing technology, practitioners
must also consider technology risks related to patients’ pro- 1. How do the skills of the occupational therapy practi-
tected health information and use of social media. tioner transfer to successful use of risk management
strategies?
2. Which types of risk are present in occupational therapy
For Additional Learning practice and management?
3. What are some examples of risks that an occupa-
For additional learning, see Chapter 53, “Professional Liability tional therapy manager or organizational leader might
Insurance.” encounter?
Occupational therapy practitioners also use contingency SUMMARY

planning in their practice. A simple contingency plan may be Health care organizations implement risk management
to modify a treatment plan because space is not available or a strategies to ensure the ability to carry out their mission.
client is having too much difficulty with the planned interven- These strategies include planning, assessing, analyzing, re-
tion. When employed within an organization, occupational sponding, monitoring, and reporting. The organization de-
therapy practitioners may be part of contingency plans that velops contingency plans for instances when risk cannot be
are built into the agency’s policies. These plans can include avoided or controlled in order to minimize interruption to
emergency situations within the work setting or community, its operations.
weather situations, and a shortage of resources. Occupational therapy practitioners manage risks, regard-
less of their roles within an organization. The skill set of
occupational therapy professionals, including holistic assess-
Managing Risks in Supervision, Management,
ment, activity analysis, knowledge of performance patterns,
and Organizational Leadership
ability to adapt, and clear communication, naturally facili-
Occupational therapy practitioners who provide supervision tates risk management, contingency planning, and quality
to students, occupational therapy assistants, and aides must improvement at an organizational level.
consider risks in the practice of these individuals, as well as See Case Examples 11.2 and 11.3 for examples of managing
their own. Failure to supervise according to the profession’s risk. Appendix 11.A, “Risk Management Resources,” provides
standards and licensure requirements creates risks for both additional resources for risk management and contingency
occupational therapy clients and practitioners. planning. ❖
CASE EXAMPLE 11.2. Julia: New Private Outpatient Practice
Julia is an occupational therapist who has recently opened a private outpatient occupational therapy practice. The business is located in a unit
of an office building in a small suburban town. There is another outpatient therapy practice in town that provides physical therapy and speech–
language pathology services, in addition to occupational therapy. Julia’s specialty, driver rehabilitation, has been well-marketed with referral
sources and within the community. Julia employs 1 additional occupational therapist and 1 part-time receptionist.
Julia had worked as an occupational therapist in several outpatient centers prior to opening her own business. She was familiar with strategies
to ensure best practice and avoid clinical patient safety risks, but her entrepreneurial pursuit invited new, additional risks. When preparing to
open the practice, Julia needed to decide on a strategic plan to focus the direction of the business. This included branding, determining competition
in the area, and marketing. She also needed to ensure that she had the financial resources and assistance for the business to get started
and continue its mission. She consulted a financial manager regarding billing processes. Her ongoing attention to financial risk is required for
successful operations.
As Julia planned to hire staff, it was necessary to consider how she would conduct credentialing and fair employee practices. It is necessary for
Julia to address liability risk through adherence to best practices and the purchase of insurance.
Review Questions
1. Which types of risk are evident in this case example? Can you think of other risks that would likely be present for a new private occupational
therapy practice?
2. How is Julia responding to the risks that she has identified in starting a new practice? What other resources could she use in her risk response?
3. Julia has done her best to plan for the business to operate smoothly. Can you think of any unforeseen circumstances that could threaten the
practice? How might Julia use contingency planning to ensure normal operations if these circumstances occur?
CASE EXAMPLE 11.3. Managing Risk in School Settings
Occupational therapy practitioners who work across practice settings are exposed to risks. In the school setting, aggressive student behaviors,
including hitting, kicking, and pinching, are potential risks that should be addressed. In this example, a team of professionals attempts to reduce
the aggressive behaviors of a child to minimize the risk of student and staff injury.
The risk plan of the school specifies that all employees are responsible for promoting a safe and effective learning environment. Teachers
communicate with the educational team, including the occupational therapy practitioner, physical therapist, speech language pathologist,
school counselor, and a board-certified behavioral analyst (BCBA), and they report directly to the principal. Teachers track aggressive behaviors in
the classroom.
Since the beginning of the school year, there has been a high frequency of aggressive behaviors reported. The educational team has participated
in professional development activities to decrease aggressive behaviors in the classroom as well as various preventive classroom management
strategies. Recently, Student A hit Student B while traveling between classrooms. Student B had a bruise on his arm after the incident. He went to
the nurse and his parents were called. An incident report was completed.
The teacher and all members of the educational team met to analyze details of this adverse event. The teacher reported that the routine
class schedule was disrupted due to a morning assembly. The occupational therapy practitioner reported that a sensory assessment of student A
was in progress and that sensory concerns might be raised. The BCBA also noted that the behavioral plan was not implemented during transition by
the classroom aide. The group performed a root cause analysis to determine the underlying system factors, including limited planning for change in
daily schedule, decreased communication among staff regarding the behavioral plan, and limited time to complete full assessments.
The group created an action plan to reduce the risk of injury from aggressive behaviors in the future. The action plan included completion
of sensory assessment to assess tactile defensive or body awareness concerns and a review and further education about the behavior plan by
the BCBA for the entire team; a new policy was instituted whereby the administration would email all staff members about schoolwide events at
least 2 days in advance. In addition, the entire team attended a professional development series.
To report and continue monitoring the risk of injury from aggressive behaviors, team members met weekly to review all instances of aggressive
behaviors in the classroom. The BCBA and occupational therapy practitioners completed classroom management assessments to provide
information about behavioral and sensory strategies in the classroom. These assessments are monitored and shared, with the staff members
involved, at least monthly.
Review Questions
1. The steps of risk management (i.e., risk plan, assessment, analysis, response, reporting or monitoring) can be observed through this case study.
List the events in the case study that correspond with each step in the risk management process.
2. What commonalities and differences do you notice between this case example in a school setting and examples of risk management in a
health care setting?
LEARNING ACTIVITIES American Society for Healthcare Risk Management. (2006b).

Enterprise risk management. Part two: Getting an ERM program
1. Consider risks in your own routine. How do you recog- started. Retrieved from http://www.ashrm.org/pubs/files/white
nize and respond to them? Complete a root cause analysis _papers/ERMmonograph.pdf
of a problem that you may be experiencing in your rou- American Society for Healthcare Risk Management. (2006c). Enter-
tine. Use a fishbone diagram. prise risk management. Part three: The role of the chief risk officer
2. Search the OTPF–3 for aspects of the profession’s domain (CRO). Retrieved from http://www.ashrm.org/pubs/files/white
and process that relate to risk management. Read the Oc- _papers/ERMmonograph.pdf
American Society for Healthcare Risk Management. (2014). Enter-
cupational Therapy Code of Ethics (2015) (AOTA, 2015).
prise risk management: A framework for success. Retrieved from
How do occupational therapy leaders uphold each princi-
http://www.ashrm.org/pubs/files/white_papers/ERM-White
ple through the process of risk management? -Paper-8-29-14-FINAL.pdf
3. Consider various occupational therapy practice settings. American Society for Healthcare Risk Management. (2016). Enter-
What types of unique risk would you expect to find in prise risk management. Retrieved from http://www.ashrm.org
certain practice settings? Are there risks that may be /resources/pdf/ERM-Tool_final.pdf
present across all practice settings? American Society for Healthcare Risk Management of the American
4. Invite a panel of clinicians and administrators from local Hospital Association. (2007). Different roles, same goal: Risk
practice settings to the classroom. Engage students in a dis- and quality management partnering for patient safety. Journal of
cussion with this panel about the panel members’ experi- Healthcare Risk Management, 27, 17–23, 25. https://doi.org/10.1002
ences of risk management, safety, and quality improvement. /jhrm.5600270205
Americans With Disabilities Act, Pub. L. 101–336, 42 U. S. C. § 12101
5. During a fieldwork experience, request to meet with
(1990).
someone who holds a dedicated risk management posi-
Atwal, A., Wiggett, C., & McIntyre, A. (2011). Risks with older adults
tion within the organization or attend a risk management in acute care settings: Occupational therapists’ and physiothera-
meeting. pists’ perceptions. British Journal of Occupational Therapy, 74,
6. Conduct a mock risk management committee meeting 412–418. https://doi.org/10.4276/030802211X13153015305510
for a hospital. Consider which professions would be repre- Centers for Disease Control and Prevention. (2006). CDC unified
sented, including occupational therapy. Draft a risk man- process practices guide: Risk management. Retrieved from https://
agement statement, including a brief description with a list www2a.cdc.gov/cdcup/library/practices_guides/CDC_UP_Risk
of the people responsible for managing risk. _Management_Practices_Guide.pdf
Centers for Disease Control and Prevention. (2008). CDC unified pro-
cess practices guide: Contingency planning. Retrieved from https://
ACOTE STANDARDS w w w2.cdc.gov/cdcup/librar y/practices_guides/CDC _UP
_Contingency_Planning_Practices_Guide.pdf
This chapter addresses the following ACOTE Standards: Centers for Medicare and Medicaid Services. (n.d.). How to use the
■ B.3.7. Safety of Self and Others fishbone tool for root cause analysis. Retrieved from https://www
■ B.5.1. Factors, Policy Issues, and Social Systems .cms.gov/medicare/provider-enrollment-and-certification/qapi
/downloads/fishbonerevised.pdf
■ B.5.3. Business Aspects of Practice
Centers for Medicare and Medicaid Services. (2007). Basics of
■ B.5.7. Quality Management and Improvement
risk analysis and risk management. HIPAA Security Series 2(6).
■ B.7.1. Ethical Decision Making. Retrieved from https://www.hhs.gov/sites/default/files/ocr/privacy
/hipaa/administrative/securityrule/riskassessment.pdf
Clarke, C. (2000). Risk management: A user guide. British Journal
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/bmj.i2139 .fema.gov/media-library-data/20130726-1914-25045-8890
Mandel, C. (2017). Patient safety is everyone’s business. Journal of /hseep_apr13_.pdf
Medical Radiation Sciences 64, 161–162. https://doi.org/10.1002 U.S. Department of Veterans Affairs. (2015). Glossary of patient
/jmrs.241 safety terms. Retrieved from https://www.patientsafety.va.gov
Morelli, M. S. (2016). Using the Plan, Do, Study, Act model to /professionals/publications/glossary.asp
implement a quality improvement program in your practice. W. Edwards Deming Institute. (2017). PDSA cycle. Retrieved from
American Journal of Gastroenterology, 111, 1220–1222. https:// https://deming.org/explore/p-d-s-a
doi.org/10.1038/ajg.2016.321 World Federation of Occupational Therapists. (2016). Position state-
Mu, K., Lohman, H., & Scheirton, L. (2006). Occupational ther- ment: Disaster risk reduction. Retrieved from http://www.wfot
apy practice errors in physical rehabilitation and geriatrics set- .org/ResourceCentre.aspx
tings: A national survey study. American Journal of Occupational World Health Organization. (2011). Topic 6: Understanding and
Therapy, 60, 288–297. https://doi.org/10.5014/ajot.60.3.288 managing clinical risk. In The multi-professional patient safety
Mu, K., Lohman, H., Scheirton, L. S., Cochran, T. M., Coppard, curriculum guide. Retrieved from http://www.who.int/patient
B. M., & Kokesh, S. R. (2011). Improving client safety: Strategies safety/education/curriculum/who_mc_topic-6.pdf
to prevent and reduce practice errors in occupational ther- World Health Organization. (2012). Guidance for contingency plan-
apy. American Journal of Occupational Therapy, 65, e69–e76. ning rom (DRAFT). Retrieved from http://www.searo.who.int
https://doi.org/10.5014/ajot.2011.000562 /entity/emergencies/cpforwebsite.pdf?ua=1
APPENDIX 11.A. RISK MANAGEMENT Videos

RESOURCES ■ Risk Management: Chris Davenport at TEDxMileHigh
Online (https://youtu.be/zyet9fPS24k)
In this TED Talk, skier Chris Davenport relates risk and
■ The Joint Commission on Root Cause Analysis (https:// risk management involved in skiing to risk and risk man-
bit.ly/2AWbtLx) agement within an organization.
The Joint Commission provides a template to guide or- ■ Cause and Effect Diagram (https://youtu.be/mLvizyDFLQ4)
ganizations when analyzing an event and developing an Brief video highlights how health care organizations use
action plan. cause-and-effect diagrams. A sample diagram is created
■ The Minnesota Department of Health: Plan–Do–Study– to address improvement in handwashing.
Act (PDSA; https://bit.ly/2MeZOuq) ■ Root Cause Analysis Training for Health Care: Root Cause
The Minnesota Department of Health explains the PDSA Analysis (https://youtu.be/4bldoFN5a1g)
cycle that is often used when an organization wishes to This 54-minute video training by Rosemary Emmons
improve performance. aims at making root cause analyses in health care systems
effective.
■ Quality Improvement in Health Care: https://youtu.be
/jq52ZjMzqyI
This brief video depicts historical overview of quality
improvement in health care.
CHAPTER
Marketing Strategies and Analysis
Jessica McMurdie, OTR/L 12
LEARNING OBJECTIVES
■ Understand the basic concepts of marketing strategies and the tactics used to market occupational therapy services or
products,
■ Understand how market research helps to identify and locate the potential needs for services,
■ Describe the 3 primary target markets for occupational therapy practitioners,
■ Learn why market analysis is important for assessing the success of a marketing plan,
■ Define a unique selling proposition and understand the importance of differentiating from competitors when market-
ing a product or service,
■ Understand the basic structure of a marketing plan and the purpose of incorporating business strategies to track and
measure the effectiveness of the marketing plan,
■ Describe how marketing trends and technologies can increase awareness of services and brand promotion through
digital communication and connectivity, and
■ Describe the use of social media in marketing and the various channels in which occupational therapy can be promoted.

• Conversion strategy • Market position • Outcome marketing
• Customer experience • Marketing • Positioning strategy
• Description of services • Marketing mix • Referral strategy
• Environmental assessment • Marketing research • Social media
• Evangelism • Marketing plan • Target market
• Implementation • Mission statement • Target marketing
• Key performance indicators • Online marketing strategy • Unique selling proposition
• Market analysis • Organizational assessment • Vision statement
OVERVIEW occupational therapy managers adopt a marketing mindset
T
he successful promotion of occupational therapy is to stay competitive and promote the value of occupational
directly related to the practice and the art of market- therapy in the greater health care marketplace.
ing. Occupational therapy practitioners have many The job outlook for occupational therapy practitioners is
opportunities to implement marketing techniques to achieve projected to grow at a rate of 27% between 2014 and 2024. The
their organization’s business success while concurrently de- average growth rate for all occupations is 7% (Bureau of Labor
livering expected clinical outcomes and providing a remark- Statistics, 2017). Given the anticipated growth of the profession,
ably positive patient experience. In the current health care a vast array of potential practice areas and marketing oppor-
environment of declining reimbursements and the myriad tunities await occupational therapy practitioners across set-
choices that consumers are presented with, it is crucial that tings and patient populations. This chapter focuses on general
https://doi.org/10.7139/2019.978-1-56900-592-7.012
121
CHAPTER
Marketing Strategies and Analysis
Jessica McMurdie, OTR/L 12
LEARNING OBJECTIVES
■ Understand the basic concepts of marketing strategies and the tactics used to market occupational therapy services or
products,
■ Understand how market research helps to identify and locate the potential needs for services,
■ Describe the 3 primary target markets for occupational therapy practitioners,
■ Learn why market analysis is important for assessing the success of a marketing plan,
■ Define a unique selling proposition and understand the importance of differentiating from competitors when market-
ing a product or service,
■ Understand the basic structure of a marketing plan and the purpose of incorporating business strategies to track and
measure the effectiveness of the marketing plan,
■ Describe how marketing trends and technologies can increase awareness of services and brand promotion through
digital communication and connectivity, and
■ Describe the use of social media in marketing and the various channels in which occupational therapy can be promoted.

• Conversion strategy • Market position • Outcome marketing
• Customer experience • Marketing • Positioning strategy
• Description of services • Marketing mix • Referral strategy
• Environmental assessment • Marketing research • Social media
• Evangelism • Marketing plan • Target market
• Implementation • Mission statement • Target marketing
• Key performance indicators • Online marketing strategy • Unique selling proposition
• Market analysis • Organizational assessment • Vision statement
OVERVIEW occupational therapy managers adopt a marketing mindset
T
he successful promotion of occupational therapy is to stay competitive and promote the value of occupational
directly related to the practice and the art of market- therapy in the greater health care marketplace.
ing. Occupational therapy practitioners have many The job outlook for occupational therapy practitioners is
opportunities to implement marketing techniques to achieve projected to grow at a rate of 27% between 2014 and 2024. The
their organization’s business success while concurrently de- average growth rate for all occupations is 7% (Bureau of Labor
livering expected clinical outcomes and providing a remark- Statistics, 2017). Given the anticipated growth of the profession,
ably positive patient experience. In the current health care a vast array of potential practice areas and marketing oppor-
environment of declining reimbursements and the myriad tunities await occupational therapy practitioners across set-
choices that consumers are presented with, it is crucial that tings and patient populations. This chapter focuses on general
https://doi.org/10.7139/2019.978-1-56900-592-7.012
121
marketing concepts, the evolution of marketing frameworks for and Industry). These payers reimburse facilities and prac-
the 21st century, practical applications for promoting occupa- titioners for billable occupational therapy services, most
tional therapy services, the key components of a marketing plan, commonly paid based on units of time, allowed amounts,
trends in technology, and considerations for implementing best level of complexity, and perceived value. Reimbursement for
practices when marketing occupational therapy services. occupational therapy services may be reviewed for medical
necessity, and it is essential for the practitioners’ documen-
ESSENTIAL CONSIDERATIONS tation to prove that therapy is directly related to functional
outcomes.
The American Marketing Association (2013) defined market-
ing as “the activity, set of institutions, and processes for creating,
communicating, delivering, and exchanging offerings that have Referral sources
value for customers, clients, partners, and society at large” (para. The third type of target market is referral sources or, in the
1). Philip Kotler, a leading marketing expert, defined marketing as context of social media, “influencers.” Referral sources are
considered one of occupational therapy’s target markets
[T]he science and art of exploring, creating, and delivering because they are individuals or organizations that refer and
value to satisfy the needs of a target market at a profit. recommend occupational therapy services as a solution for a
Marketing identifies unfulfilled needs and desires. It client’s need or problem. According to Hootsuite.com,
defines, measures and quantifies the size of the identified
market and the profit potential. It pinpoints which A social media influencer [italics added] is someone who
segments the company is capable of serving best and wields that influence through social media. . . . The right
it designs and promotes the appropriate products and influencer is someone who can reach your target audience,
services. (Kotler Marketing Group, n.d., para. 1) build trust, and drive engagement. They will create
Traditional marketing concepts have shifted from primar- original, engaging content that is in line with their own
ily focusing on product, price, placement, and promotion to a brand. (Newberry, 2018, para. 6–7)
new framework based on providing value, meaning, and the For example, a pediatrician identifies a child with delayed
careful analysis of what comprises an amazing customer expe- visual motor skills during an annual checkup. As the pri-
rience. Occupational therapy managers must answer to this val- mary care provider, the doctor refers this child to the occupa-
ue-based mindset through a systematic marketing approach to tional therapy clinic with whom he or she is familiar and has
meet the expectations, desires, and needs of clients in a consum- developed a referral relationship when coordinating the care
er-driven market (Jantsch, 2011). Today’s consumers of health of mutual patients.
care have access to incredible amounts of information online,
making them better educated and savvier than ever before.
Marketing Mix
Market Marketing mix, also called a promotional mix, refers to the
tactical, controllable, and operational components of a mar-
A target market is a specific group of consumers or clients at
keting plan that may be combined to produce the desired
whom a company aims its products and services (Entrepre-
response from the target market. The original marketing
neur Small Business Encyclopedia, n.d.). Marketing research
mix is most commonly known as the 4 Ps: product, price,
is the first step in identifying the specific target audience with
place, and promotion. An extended marketing mix includes
whom to share expertise, provide services, or build a success-
the addition of 3 Ps: people, process, and physical evidence/
ful payer or referral relationship. In occupational therapy,
environment (Bitner & Brooms, 1981, as cited in Hanlon,
there are 3 primary target markets: (1) clients and potential
2018; see Figure 12.1). The 7 Ps of the marketing mix are par-
clients, (2) payers, and (3) referral sources or influencers.
ticularly relevant to service industries such as occupational
therapy. The service offerings made to a client can be altered
Clients and potential clients
by varying the mix elements, which are explained below
The first target market is composed of clients and potential cli- (Marketing Teacher, n.d.).
ents who directly benefit from occupational therapy services.
Some examples include adult patients recovering from an
■ Product is defined as the “goods-and-services combina-
tion the company offers to the target market” (Kotler &
acute injury or neurological event, elderly patients in a skilled
Armstrong, 2010, para. 11). A product is commonly con-
nursing facility (SNF) setting, or children with developmental
sidered a tangible, physical item that one buys or sells,
delays who receive services at school or a community clinic.
whereas a service, such as occupational therapy, is consid-
ered an intangible product.
Payers
■ Price refers to the amount of money charged for a prod-
The second target market consists of the payers, specifically uct or service that consumers exchange for the bene-
commercial health insurance companies and government fit of having or consuming that product (Kotler, 2000).
programs (e.g., Medicare, Medicaid, Departments of Labor Factors that influence the price of a service or product
CHAPTER 12. Marketing Strategies and Analysis 123
FIGURE 12.1. The 7 Ps of marketing.
Product
Physical
Price
Evidence
7 Ps
Marketing Mix
Process Place
People Promotion
are overhead costs, such as rent and equipment, cost of services through a form of personal selling via videos.
materials, labor wages, the fair market value, and the Video promotion serves as a powerful tool to increase
market demand for the product or service. In the health awareness and promote the value of occupational therapy.
care landscape, pricing of medical services is frequently Effective video storytelling is authentic, compelling, and
predetermined by governing bodies or third-party pay- planned, yet not fully scripted and contains a defining
ers. For example, occupational therapy practitioners moment with a combination of familiar and surprising
in a contract arrangement with a payer abiding by the elements (American Occupational Therapy Association
current allowed amounts, coding rules, and regula- [AOTA], 2017).
tions ultimately drive the reimbursement structure and ■ People are the essential element to occupational ther-
pricing. apy services because clients make judgments about the
■ Place is the physical or virtual location where the goods organization’s services based on the people representing
and services are provided. For example, a hand clinic the organization. It is essential for occupational therapy
opens a new office in the same building as the town’s managers to recruit the right staff and hire those whose
orthopedic surgery practice. The location is conveniently attitudes and behaviors align with the mission, vision, and
located for patients as well as strategically located to culture of the company.
maintain an alliance and referral relationship between the ■ Process refers to how the service is delivered. Processes are
2 practices. essential to delivering a consistent quality of care, espe-
■ Promotion details how to reach new clients and referral cially when the care is provided by different people within
sources. Promotional strategies such as special offers are the organization. A well-organized process with systems
often used to grow the company’s client base by secur- in place and clear communication fosters client loyalty
ing new clients and encouraging former clients to help and confidence in the company.
generate new referrals. Promotional techniques are used ■ Physical evidence or environment refers to the physical
to provide information, explain a problem and offer a elements that convey an organization’s brand and affects
solution, and persuade and influence the target market how clients experience its services. Examples of physical
to convert prospects into future clients. Examples of pro- evidence that affect clients’ impressions may start when
motional strategies include advertising, sales promotions, they are viewing the organization’s website and continue
public relations, and personal selling. Modern market- as they enter the door and experience the organization’s
ing tactics are trending toward promoting products and atmosphere when participating in therapy.
includes studying the characteristics, spending habits, loca-

EXHIBIT 12.1. Marketing Examples tion, and needs of the business’s target market, the indus-
try as a whole, and the particular competitors within the
Advertising industry (Entrepreneur Encyclopedia, n.d.). The ultimate
■ Direct mail
objective of marketing research is to determine which seg-
■ Print brochure ment of the market one is going to own or participate in and
■ Flyer/handout how to properly position one’s product within that segment
■ Magazine or journal advertisement (Marshall, 2014).
■ Digital marketing A key component of marketing research is target mar-
■ Website keting, which “allows you to reach, create awareness in,
■ Social media and ultimately influence the group of people most likely to
select your products and services as a solution to their needs,
Sales Promotions
while using fewer resources and generating greater returns”
■ Coupons (Gandolf, 2017b; “The Target Market Profile”). Marketing
■ Discounts research involves discovering commonalities found in the
■ Loyalty programs following 4 categories: (1) geographics, (2) demographics,
■ Gift certificates (3) psychographics, and (4) behavior (see Exhibit 12.2).
■ Referral incentives
■ Subscriptions
■ Company-branded items (e.g., pens, clothing, mugs) Market Position
■ Gifts or treats
Establishing a solid market position involves defining an or-
■ Free screenings
■ Giveaways
ganization’s unique selling proposition or how its service is
different, special, or unique as compared with competitors
Public Relations to influence the consumers’ perception of brand. To estab-
lish a strong position in the market, it is often advantageous
■ Testimonials
■ Guest speakers
■ Published research
■ Authoring an article
■ Case study
EXHIBIT 12.2. Target Market Areas
■ Community events
■ Health fairs
■ Open house Geographics
■ Networking meeting
■ Location
■ Interview/podcast
■ Size of the area
■ Charitable events
■ Population density
■ TV appearance
■ Climate zone
Personal Selling Demographics
■ Personalized cards or gifts ■ Age
■ Attending seminars ■ Gender
■ Networking events ■ Education
■ Forming business alliances ■ Income
■ Collaborating with other professionals ■ Family composition and size
■ Interacting with influencers through social media ■ Language spoken
■ Writing a blog
■ Hosting a YouTube channel Psychographics
■ Video storytelling
■ General personality
■ Lifestyle
■ Beliefs
■ Rate of use
Exhibit 12.1 provides examples of ways to promote occu- ■ Repetition of need
pational therapy to reach new clients and referral sources. ■ Benefits sought
Marketing Research Behaviors

■ General attitude
Marketing research is the process of gathering, analyzing,
■ Needs and wants the customer seeks to fulfill
and interpreting information about a market; about a prod- ■ Level of knowledge, information sources, and technology used
uct or service to be offered for sale in that market; and about
past, present, and potential customers. Marketing research Source. Adapted from Gandolf (2017b).
to create new markets, focus on a specific niche segment, or

improve on a unique or superior service in an already estab- EXHIBIT 12.3. Environmental Assessment Factors
lished industry. Occupational therapy practitioners are at an
advantage because they offer a unique skill set and can read- Sociocultural Trends
ily draw from their knowledge and experience base as experts ■ Language
within their field. ■ Education
■ Values
Market Management ■ Beliefs
■ Attitudes
The 4 steps in market management are (1) market analysis,
(2) planning, (3) implementation, and (4) monitoring. Demographic Information
■ Population statistics
Market analysis ■ Age
■ Ethnicity
The first step in market management is market analysis, ■ Sex
which is the use of assessment techniques to understand ■ Education
customers, markets, and marketing effectiveness (Kotler, ■ Income
2003). The information gathered from market analysis ■ Labor force projections
research determines the details of the marketing plan. A
competitive market analysis identifies the organization’s Economic Changes
competitors and evaluates their strengths and weaknesses ■ Overall economy
relative to those of the organization’s own services or prod- ■ Cost of living
uct. A competitive market analysis equips the business to ■ Financial markets
proactively anticipate competitive influences and potential ■ Government spending
issues, serving as a foundational strategy to stay ahead of ■ Rising costs of health care
■ Patient ability to pay for therapy services
the competition.
The 2 approaches to conduct market analysis are (1) Political Issues
organizational assessment and (2) environmental assessment.
An organizational assessment is a self-assessment of the or- ■ Commercial payer regulations
■ Federal regulations—awareness of the Health Insurance
ganization’s strengths, weakness, available opportunities,
Portability and Accountability Act of 1996 (P.L. 104–191) and
and potential threats (see Case Example 12.1, “Conducting
the Health Information Technology for Economic and Clinical
an Organizational Assessment”). An environmental assess- Health Act (enacted as part of the American Recovery and
ment identifies the greater forces, changes, and trends in the Reinvestment Act of 2009)
environment (local, national, and international) that may ■ Government regulations and initiatives
affect occupational therapy practitioners’ business relation- ■ Health care reform
ships with the target market and overall marketing strategy.
An environmental assessment also examines sociocultural
trends, economic issues, political issues, legal issues, and Description of products and services. The descrip-
trends in technology. By anticipating these changes, one can tion of services can be described as elevator speech, a term
take a proactive approach to position a product or service in that refers to the short amount of time when one must cap-
response to the trends in the greater environment. ture the listener’s attention to provide informative, yet suc-
An example of useful demographic information is when a cinct information about a product, services, and brand.
hospital is determining the potential location of a new home
health satellite clinic for older adults. On the basis of an en-
vironmental assessment, the hospital decides to locate the EXHIBIT 12.4. Marketing Plan Key Components
home health clinic within a community with highest concen-
tration of people ages 65 years or older. A second example is ■ Description of products or services
how the economy and political climate can dramatically af- ■ Company mission statement
fect how health care services are accessed by patients and the ■ Vision statement
level of reimbursement to providers (see Exhibit 12.3). ■ Description of the target market
■ Positioning strategy
■ Online marketing strategy
Planning ■ Advertising and promotional strategy
■ Sales and conversion strategy
An effective marketing plan provides the framework for cre-
■ Referral and retention strategy
ating goals and developing the specific marketing activities
■ Key performance indicators
and strategies to support the growth and success of the busi- ■ Goals
ness within a set time period. Key components of a marketing
plan are listed in Exhibit 12.4 (Lavinsky, 2013). Source. Adapted from Lavinsky (2013).
Mission statement. A company mission statement is a Advertising and promotional strategies and tac-
clear and concise statement that communicates the organi- tics. Consider which types of advertising, promotions, and
zation’s overall goals and aspirations while functioning as public relations and personal selling activities are best suited
the basis for strategic decision making. In other words, “Why for the product or services offered (see Exhibit 12.1).
does the company or organization exist?” For example, the The advertising strategy should utilize the results of tar-
mission statement for AOTA is “To advance occupational get market research to effectively communicate the brand
therapy practice, education, and research through standard or image and clearly inform customers of the benefits of the
setting and advocacy on behalf of its members, the profes- product or services being offered. Traditional advertising
sion, and the public” (AOTA, n.d.; “Mission Statement”). tactics include promoting a product or service through mass
media such as radio, television, and direct mail and print for-
Vision statement. The vision statement is future mats such as newspapers, magazines, or other publications.
based and relates to the company’s overall strategic plan. A Examples of online advertising campaigns include using ban-
well-crafted vision statement should be compelling, reflect ners on a website, performing keyword research to achieve
the organization’s core values, inspire employees, and help set higher Google search rankings, or using social media ads
priorities for the future of the organization. For example, the to promote the product or services. Common social media
AOTA Vision 2025 statement reads, “Occupational therapy platforms for advertising are Facebook, LinkedIn, Pinterest,
maximizes health, well-being, and quality of life for all peo- Twitter, and Instagram.
ple, populations, and communities through effective solu- Social media advertising is focused primarily on educating
tions that facilitate participation in everyday living” (AOTA, clients and providing articles of high value content that are
2017, p. 1). intended to direct visitors back to the company’s website or
blog. This style of social media advertising may be considered
Description of the target market. Marketing efforts a less direct method of promotion compared to advertising.
that focus on meeting the specific need of a target market are The goal of personal selling activities is developing mean-
the most efficient way to allocate the marketing budget, time, ingful and ongoing relationships with clients and being able
and resources. Knowing one’s target market is being able to to identify clients’ problems and offer the business’s prod-
describe the “ideal” clients’ behavior and their motivations ucts or services as a solution. Examples of public relations
for seeking out therapy services. activities include maintaining a positive image of the com-
pany through mass media publicity, such as highlighting
Positioning strategy. A positioning strategy is essential company achievements in press releases or being a corporate
for differentiating one’s products or services from the compe- sponsor for a local charity or event.
tition. The purpose of a positioning strategy is to help estab-
lish company identity and highlight how its product or ser- Sales and conversion strategy. A conversion strategy
vices can surpass the competition. The positioning strategy is the method for turning prospects into customers and mak-
should include a competitive market analysis and outline the ing the sale. Conversion marketing is producing high-quality,
unique selling proposition. A unique selling proposition is engaging content that compels visitors to take action because
the real or perceived benefit that differentiates a product or the expertise shared fulfills their need or provides a direct
service within the market of similar, competing brands. Mar- solution to their problem (Lavinsky, 2013). With digital mar-
keting campaigns with a unique selling proposition make the keting, great content drives sales by attracting visitors, con-
product or service stand out in a market filled with similar verting visitors into leads, converting leads into clients, and
items, thereby securing a strong position to sell to the target converting clients into loyal customers and evangelists for a
market. company’s services (Marketing Matters Inbound, 2017).
Online marketing strategy. An online marketing strat- Referral and retention strategy. A referral strategy is
egy is essential for a company to establish its brand, build a a formalized set of marketing activities to gain new referrals
reputation, and to be discovered by potential customers on- from current clients or referral sources. Occupational ther-
line. Through the use of various online tools and by paying apy practitioners who provide the expected outcomes and
attention to key website or social media analytics, a company exceptional patient experience inspire positive ratings, refer-
can increase its visibility through search engine optimization rals, and repeat visits. A retention strategy focuses market-
and other Internet tactics. It is imperative to gain a competi- ing efforts on investing in current clients or customers to buy
tive advantage in today’s technological and consumer-driven more frequently over time. Examples of retention strategy
environment where clients go online to find, review, and are patient recognition for consistent attendance, a monthly
purchase. The primary components to a successful online newsletter, or referral incentive program.
marketing strategy include search engine optimization, key-
word strategies, online advertising, social media marketing, Key performance indicators. Key performance indica-
reputation management, and a website conversion strategy tors (KPIs) are specific, numerical metrics that organizations
(i.e., website content that attracts clients and leads to a sale; track to measure their progress toward a defined goal in a
Martin, 2017). specific timeline. Some examples of marketing KPIs include
financial projections of sales revenue, the cost per lead, in- Exchange. Exchange refers to the benefits clients receive
come, budget, timeline, customer lifetime value, return on in exchange for buying a product or service. The focus is
investment, website traffic, conversion rates for social media, on the benefits that clients receive in exchange for services,
website landing page metrics, and mobile devices (Edge- such as pain relief, productivity, greater independence, new
comb, 2016). For example, a designated marketing budget skills, confidence, personal relationships, and peace of mind
may range anywhere from 0.5% to 10% of the gross income (Gandolf, 2017b).
(Marshall, 2014). A marketing budget may go toward hir-
ing experts skilled in website strategy, graphic design, social Evangelism. Evangelism is commonly known as word-
media, and marketing analytics. of-mouth marketing, when a current client spreads the
“good news” about the company’s product or service. Evan-
Goals. Creating goals using the SMART acronym is essen- gelism marketing has a high return on investment because
tial in goal-setting discussions. SMART goals as related to clients who refer family and friends through positive refer-
health care marketing are rals are essentially free. The occupational therapy manager
■ S = specific, significant, systematic, and synergistic can promote evangelism marketing by offering referral
■ M = measurable, meaningful, and motivational incentives. In addition, positive reviews and recommenda-
■ A = achievable, agreed-upon, action-based, and accountable tions from current clients are powerful methods for pro-
■ R = relevant, realistic, responsible, results-oriented and moting the brand and attracting future clients. Evangelism
rewarding or testimonials among one’s peers, related professionals,
■ T = tangible, time-based, thoughtful (Gandolf, 2017a). and online influencers will also drive business toward the
product and services.
Implementation
Implementation is the phase of executing the marketing plan Monitoring
by putting the marketing tactics into action, including deter- Marketing plans must undergo periodic reevaluation
mining who is responsible for the specific actions in the mar- for modifications depending on the business goals and
keting plan to achieve the plan’s objectives to ultimately meet organizational and environmental circumstances. The
the company’s goals. Today’s most effective marketing plans occupational therapy manager can use marketing ques-
include both online and offline tactics to build relationships tionnaires such as The Executive Guide to Marketing Ef-
and engage clients (Jantsch, 2011). A 21st century update to fectiveness (Kotler, 2016) to assess marketing effectiveness
the original 4 Ps marketing mix framework is known as the within the organization. For online and digital market-
4 Es of marketing. The updated terms of the marketing mix ing, tracking website metrics and social media analytics
have shifted from product to experience, from place to every- is essential for monitoring which types of advertising are
place, from price to exchange, and from promotion to evan- the most effective for bringing in new clients. Every touch
gelism (Harnish, 2011). This evolution in terminology can be point of the client’s marketing journey should follow a
attributed in large part to the impact of the Internet, digital process and be analyzed for effectiveness from ease of
interactivity, and social media, which have all created a shift website navigation to customer service and interpersonal
in the overall marketing landscape and how customers access interactions with employees.
information and make purchases.
Experience. The customer experience is the product, Marketing Success and Outcome Marketing
which begins with the early stages of researching, navigating Writing SMART goals with expected marketing outcomes
the company’s website, and scheduling an appointment to en- is essential to accurately tracking and measuring the effec-
tering the office and receiving treatment. All of these touch tiveness of the marketing plan. Outcome marketing goes
points, from online to offline, are part of the client experience. beyond measuring metrics alone because it focuses on re-
And it is this client experience, whether positive or negative, sults. For example, when evaluating the marketing effec-
that will result in gaining the clients’ business or potentially tiveness of Facebook advertising, one’s focus should not
losing them to a competitor. Occupational therapy practi- be on metrics alone but rather what types of advertising,
tioners and managers must strive to provide an exceptional promotions, or content creation are the best lead generators
client experience, which includes excellent customer service and the most profitable.
at every interaction. A clinical example of outcome marketing is when a hospi-
tal pilots a specialized evidence-based program that results in
Everyplace. In today’s digital age, place becomes every- expected patient outcomes and a highly satisfying patient ex-
place, as advertising techniques have evolved and a company’s perience. The hospital can promote the value of this program
branding can be found potentially everywhere (e.g., website, to the target market by sharing the metrics of patient success
social media, ads, community events). With advances in tech- and positive patient outcomes with a goal of attracting more
nology and the web, potential customers can also be found patients, gaining future funding, or justifying reimburse-
everywhere rather than limited to 1 specific place or location. ment by payers.
EXHIBIT 12.5. Internet and Social Media Channels for Marketing
■ Blogs: Regularly updated websites or webpages written in a conversational style.

■ Facebook Live: A live broadcast of video presented on Facebook.
■ Facebook Messenger: A mobile messaging app that can be used to communicate with the user’s friends on Facebook.
■ Google Hangouts: A communication platform that includes text, voice, or video chat.
■ Instagram: A social networking app for photo and video sharing from a smartphone.
■ LinkedIn: A social network designed for career and business professionals to connect and build strategic relationships.
■ Meetup: Real-life gatherings where members and organizers get together to connect, discuss, and practice activities related to shared interests.
■ Online forums: Internet forums or message boards for online discussions where users can hold conversations in the forum for posted messages
that may be archived.
■ Periscope: A live video streaming platform that allows users to share video directly from their phones.
■ Pinterest: A website that allows users to discover and save ideas in the form of images and manage them by posting them onto boards (also
known as “pinning”).
■ Reddit: A social news aggregation, web content rating, and discussion website where users submit content to the site (links, texts, posts, and
images) that are voted up or down by other members.
■ Snapchat: A mobile messaging application used to share photos, videos, texts, and drawings that will disappear from the recipient’s phone after a
few seconds.
■ Tumblr: A social blogging platform enabling users to share their own blog, interact, and follow other blogs that interest them.
■ Twitter: An online news and social networking site that allows users to communicate in short messages called tweets to anyone who follows the user.
■ YouTube: A video sharing website for users to watch, like, share, and comment on videos and upload their own videos.
Source. Adapted from Managing the Social Media Slice of Your Marketing Plan, by S. Gandolf, 2017a. Retrieved from http://www.healthcaresuccess.com/blog/healthcare
-marketing/social-media-marketing-plan.html
Ideally, marketing efforts should be integrated into all as- traditional avenues of marketing. Recent surveys reveal that
pects of the organization, from the front desk receptionist to three-quarters of patients use search engines before making
the board of directors. Occupational therapy managers have an appointment (Do, 2017). Therefore, an integrated mar-
an important role in training staff on how to provide a pos- keting plan with a strong Internet presence will include a
itive client experience as well as involving them in various conversion-focused website, online advertising, reputation
marketing tasks to support the success of the company. Of management, search engine optimization, and social media
equal importance is designing a systematic marketing pro- marketing. It is important to align the business’s goals with
cess for interactions that will engage new prospects and build key business objectives. A strategic social media strategy will
relationships with current clients who have the potential to help the organization achieve the key performance indica-
become the company’s evangelists. Inspired by the positive tors in the marketing plan (Gandolf, 2017a). To stay on top of
outcome of their treatment and the exceptional service, these the market, occupational therapy marketers need to expand
ideal clients may proactively share, refer, and recommend an the strategies for building connection and engagement as
organization’s services to others. technology changes and evolves (Exhibit 12.5).
Marketing Technologies and Trends

Occupational therapy managers can capitalize on new tech-
nologies for marketing with the increased use of digital com- For additional learning, see Chapter 45, “Using Social Media
munication and connectivity with one another through so- Appropriately.”
cial media and communication applications. Social media
are interactive applications and tools used to share informa-
tion among people via the Internet or phone. In addition,
Review Questions
the technology for telemedicine allows occupational therapy
practitioners to expand their marketing reach for potential 1. List and define the 7 Ps of marketing.
target markets through virtual communication and telether- 2. Define and describe the importance of an organiza-
apy services. tional assessment and an environmental assessment.
It is imperative for occupational therapy practitioners to Before launching a new product or service, why should
create an awareness of their services, promote their brand, an occupational therapy practitioner conduct a market
create engaging content, and establish their credibility analysis?
through shared expertise in both offline and online plat- 3. What are the primary components of a marketing plan?
forms. Digital marketing methods are projected to lead What is the purpose of a marketing plan?
PRACTICAL APPLICATIONS IN plan to reach and engage the ideal clients or target market?
OCCUPATIONAL THERAPY It is important to represent the company’s brand image pro-
fessionally and positively. Think about topics occupational
Marketing Promotions therapy practitioners could write about that offer high value
content or information for their clients.
Visit AOTA’s website (www.aota.org) and find 2 to 3 different
It is also important to determine the best way to reach the
marketing promotions that convey the value of occupational
ideal client. Avenues for reaching out to potential clients in-
therapy. Determine the target market for these promotions
clude newsletters, websites, blogs, and social media.
or events and think about a description of the “ideal” client,
including specific information to describe the client as related
to demographics, geographics, psychographics, and behav- Review Questions
iors. You can go further and give your ideal client a name and 1. Why is it important to identify your target market before
age and detailed description of who this person is and how he you promote or implement a marketing campaign?
or she could benefit from the event or promotion. 2. What are 1 or 2 web-based platforms or social media
channels that AOTA could use to promote the profession?
Unique Selling Proposition 3. After comparing 2 companies or websites that offer the
same type of occupational therapy services, why is a
Consider how your business, therapy service, or product is
unique selling proposition important? What traits do the
different from that of your competitors. Keep in mind the
companies have in common? What are the qualities or
definition of a unique selling proposition, which is the real
services that differentiate them from their competition?
or perceived benefit that differentiates a product or service
Which would you choose and why?
within the market of similar, competing brands. What are
ways to secure a strong position to sell to your target market?
For example, if there are multiple outpatient occupational SUMMARY
therapy clinics in your city, what are the top 3–5 reasons a po-
tential client should choose your clinic over a different clinic? The health care environment is constantly changing. There-
Think about ways to make your business stand out from the fore, it is imperative that occupational therapy providers, as
pediatric therapy clinics parents may be researching to pro- individuals and as part of the greater profession, serve as ad-
vide services for their children. vocates in promoting the distinct value of occupational ther-
The first strategy is making your clinic easy to find on- apy through marketing and advocacy efforts.
line by maintaining your website, maximizing search engine It is important for occupational therapy practitioners,
optimization, and writing about your services in a way that managers, and leaders to understand how an effective mar-
offers a potential solution to a potential client’s problem. keting plan influences the overall success and financial sta-
Examples of qualities that could be considered unique sell- bility of the organization. Equipped with an understanding
ing propositions that differentiate between 2 clinics offering of marketing fundamentals, marketing research, and a struc-
the same types of services include customer service, ease of tured marketing plan, occupational therapy practitioners and
scheduling, therapist level of expertise, the general ambiance managers will be better equipped to anticipate their clients’
or vibe, and company culture from the first moment the pa- needs and offer solutions.
tient walks through the door. The original marketing mix concepts of the 4 Ps (product,
Keep in mind that a marketing mindset should permeate all price, place, and promotion) are merging with the modern-day
levels of the organization, from the initial phone call, through- framework of the 4 Es (experience, everyplace, exchange, and
out the course of treatment, to discharge and asking for refer- evangelism; Edgecomb, 2013). This evolution in marketing
rals from satisfied clients (e.g., refer-a-friend program). approach is directly related to the rise in technology because
an exponentially increasing number of consumers are rely-
ing heavily on the Internet, mobile devices, and social media
Networking to research their health care options. The best way to reach
Visit AOTA’s CommunOT and Special Interest Sections to these target markets is through an online and digital market-
follow the latest discussions, recent blogs, and industry an- ing tactic that focuses on engaging consumers with valuable
nouncements. Consider ways you can network with other information, offering a unique solution to a problem, and ul-
occupational therapy practitioners online (e.g., LinkedIn, timately providing an exceptional client experience (online
Twitter). and offline) that is enough to warrant the client evangelizing
to others about a company’s services.
The future marketing success of occupational therapy
Social Media Promotion
practice must keep pace with technology to meet the needs of
Research ways to promote a company’s brand or image on today’s empowered and informed health care consumer. Oc-
social media. What social media platform do you think a cupational therapy practitioners have the ability to positively
company’s clients or patients use the most? How could this affect and influence society while leaving a digital and soci-
knowledge be leveraged to aid in the company’s marketing etal footprint. Today’s occupational therapy practitioners,
CASE EXAMPLE 12.1. Conducting an Organizational Assessment
Emily works in the rehabilitation hospital’s inpatient unit treating patients with neurological deficits, such as traumatic brain injury and stroke. She
completes an organizational assessment with a SWOT (strengths, weaknesses, opportunities, threats) analysis to determine whether the unit has the
resources, budget, staffing, and potential opportunities to support a new patient program. This IADL training program will be located on the unit floor
and focuses on teaching independent living skills and home management tasks prior to discharge home (e.g., simple meal preparation, managing
household chores, money management).
Emily also conducts a market analysis for the current patients who would be appropriate for this group program. Her goal is to determine the
best day of the week, time, frequency, and level of interest. The information will be gathered from this target market using a survey and talking
to patients and their families about which specific daily tasks and roles are the most difficult to perform. She collects her survey results and
determines the dates, times, description of the group program, and potential outcomes for its participants. She uses this information to create a flyer
to promote the new IADL group to prospective patients and referring physicians.
Review Questions
1. What is the acronym used to summarize the components of an organizational assessment? What are these components?
2. Give some examples of how Emily analyzed her market and conducted an environmental assessment to address the needs of the patients in an
IADL group. What are the methods she uses to obtain this information?
3. As her manager, what are some examples of how you could promote this group program? Which types of social media do you think would be
the most appropriate for Emily’s target market and potential referral sources?
managers, and leaders must understand how marketing’s American Occupational Therapy Association. (n.d.). Mission state-
ever-increasing potential is essential to propel the profession ment. Retrieved from https://www.aota.org/AboutAOTA.aspx
forward to fulfill occupational therapy’s brand promise of American Occupational Therapy Association. (2017). Vision 2025.
“Living Life to Its Fullest” for as many people as possible. ❖ American Journal of Occupational Therapy, 71, 7103420010.
Bitner, M. J., & Brooms, H. (1981). Marketing strategies and orga-
LEARNING ACTIVITIES nization: Structure for service firms. In J. H. Donnelly & W. R.
George (Eds.), Marketing of services (pp. 47–52). Chicago: Amer-
1. Visit AOTA’s website and identify 3 social media channels ican Marketing Association.
that are being used to promote valuable content, news, or Bureau of Labor Statistics. (2017). Occupational outlook hand-
upcoming events. Write examples of how you would pro- book occupational therapists. Retrieved from https://www.bls
mote the content using a specific channel of social media. .gov/ooh/healthcare/occupational-therapists.htm
Do, P. (2017, September 15). 5 ways to clobber the competition with
2. Find 2 websites that offer the same type of occupational
healthcare marketing. Retrieved from http://www.healthcare
therapy services (e.g., hospital, outpatient pediatric clinic,
success.com/blog/healthcare-marketing/clobber-competition
hand therapy, mental health, geriatrics SNF, industrial -healthcare-marketing.html
rehabilitation). Perform a competitive market analysis by Edgecomb, C. (2013, August 28). The 4 E’s of inbound marketing.
identifying the unique selling proposition of each. Retrieved from https://www.impactbnd.com/blog/the-4-es-of
-inbound-marketing
Edgecomb, C. (2016, February 16). The 10 marketing KPIs you
ACOTE STANDARDS should be tracking. Retrieved from https://www.impactbnd.com
/the-10-marketing-kpis-you-should-be-tracking
This chapter addresses the following ACOTE Standards:
Entrepreneur Encyclopedia. (n.d.). Target market. Retrieved from
• B.4.29. Reimbursement Systems and Documentation https://www.entrepreneur.com/encyclopedia/target-market
• B.5.3. Business Aspects of Practice Gandolf, S. (2017a, September 18). Managing the social media slice of
• B.5.6. Market the Delivery of Services your marketing plan. Retrieved from http://www.healthcaresuccess
• B.5.7. Quality Management and Improvement. .com/blog/healthcare-marketing/social-media-marketing-plan
.html
Gandolf, S. (2017b, April 20). What is a healthcare marketing plan?
Retrieved from http://www.healthcaresuccess.com/blog/health-
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2018 Accreditation Council for Occupational Therapy Education trieved from https://www.smartinsights.com/marketing-planning
(ACOTE) standards and interpretive guide. American Journal /marketing-models/how-to-use-the-7ps-marketing-mix/
of Occupational Therapy, 72(Suppl. 2), 7912410005. https://doi Harnish, V. (2011, September 21). Improving marketing: Five tech-
.org/10.5014/ajot.2018.72S17 niques. Retrieved from https://gazelles.com/article/improving
American Marketing Association. (2013, July). Definition of mar- -marketing-five-techniques
keting. Retrieved from https://www.ama.org/AboutAMA/Pages Health Information Technology for Economic and Clinical Health
/Definition-of-Marketing.aspx (HITECH) Act of 2009, 42 USC sec 139w-4(0)(2)
Health Insurance Portability and Accountability Act of 1996 Lavinsky, D. (2013, September 30). Marketing plan template: Exactly
(HIPAA), Pub. L. 104–191 what to include. Forbes. Retrieved from https://www.forbes.com
Jantsch, J. (2011). Duct tape marketing. Nashville, TN: Thomas /sites/davelavinsky/2013/09/30/marketing-plan-template-exactly
Nelson. -what-to-include/#315a57ed3503
Kotler, P. (2000). Marketing management: Millennium edition Marketing Matters Inbound. (2017). The 4E’s of inbound conversion
(10th ed.). Upper Saddle River, NJ: Pearson. marketing content that converts. Retrieved from https://marketing
Kotler, P. (2003). Marketing insights from A to Z: 80 concepts every mattersinbound.com/inbound-conversion-marketing/
manager needs to know. Hoboken, NJ: Wiley. Marketing Teacher. (n.d.). Marketing essentials. Retrieved from
Kotler, P. (2016). The executive guide to marketing effectiveness. Mar- http://www.marketingteacher.com/lesson-store/#essentials
keting Journal. Retrieved from http://www.marketingjournal.org Marshall, M. (2014). Putting together the entrepreneurial puzzle: The
/the-executive-guide-to-marketing-effectiveness-philip-kotler/ ten pieces every business needs to succeed. Charleston, SC: Veritas
Kotler, P., & Armstrong, G. (2010) Principles of marketing Vincit Press.
(13th [Global] ed.). Boston: Pearson Education. Martin, G. (2017). The essential social media marketing handbook.
Kotler Marketing Group. (n.d.). What is marketing? Retrieved Wayne, NJ: Career Press.
from http://www.kotlermarketing.com/phil_questions.shtml Newberry, C. (2018, July 10). What is a social media influencer? Retrieved
#answer3 from https://blog.hootsuite.com/influencer-marketing/#whatis
CHAPTER
Building Capacity
Susan Touchinsky, OTR/L, SCDCM, CDRS 13
LEARNING OBJECTIVES
■ Discuss the application of capacity building in the current health care system,
■ Recognize and learn steps to developing capacity, and
■ Apply concepts of capacity building to develop specific clinical programs within occupational therapy departments.

• Bottom-up approach • Community approach • Reciprocal relationships
• Capacities • Infrastructure • Stakeholders
• Capacity building • Needs assessment • Top-down approach
• Capacity development • Partnership approach
OVERVIEW methodology are used to expand services and meet a greater

need of the community. It is most commonly used in devel-
T
he current health care environment continues to de- oping communities; however, it is appropriately applied to
mand that occupational therapy practitioners and the ongoing development of systems for health care and, spe-
managers do more with less, increase efficiency, and cifically, occupational therapy (United Nations Development
ensure positive revenue. These pressures can be a great Programme [UNDP], 2009).
demand on a manager and department and may result in The term capacity building lends itself well to the idea of
management that leads to restraint to reduce cost and ineffi- program development for occupational therapy as it reflects
ciencies, minimalism, and staff dissatisfaction. the idea of establishing and implementing sustainable sys-
Capacity building involves a range of methods and pro- tems with built-in strategies for continuous quality improve-
cesses to develop, improve, and maintain skills needed to do ment and revisions. Not unlike the process of occupational
a job. It often includes a systematic approach and reflects a therapy, the process of capacity involves
long-term, continual process. By applying capacity building,
managers can ensure a thorough process for program devel- ■ Identifying stakeholders (i.e., caregivers),
opment that focuses on efficiency and sustainable outcomes. ■ Assessing needs (i.e., evaluation),
It also reflects important elements of capacities and reciprocal ■ Developing reciprocal relationships (i.e., building rapport),
relationships (Lorenzo & Joubert, 2011). These elements will ■ Developing an infrastructure (i.e., plan of care), and
be vital for job satisfaction and commitment to the process. ■ Continually reassessing and revising (i.e., altering in-
terventions and revising new goals) to help achieve im-
proved quality systems (i.e., reach goals of operating at full
ESSENTIAL CONSIDERATIONS capacity).
Capacity building is the development of systems, processes, Because the process of capacity building mimics occupa-
and strategies aimed at developing sustainable outcomes tional therapy, it is a process that many occupational ther-
for improving health practices. Education, research, and apy managers have already naturally developed. These steps
https://doi.org/10.7139/2019.978-1-56900-592-7.013
133
CHAPTER
Building Capacity
Susan Touchinsky, OTR/L, SCDCM, CDRS 13
LEARNING OBJECTIVES
■ Discuss the application of capacity building in the current health care system,
■ Recognize and learn steps to developing capacity, and
■ Apply concepts of capacity building to develop specific clinical programs within occupational therapy departments.

• Bottom-up approach • Community approach • Reciprocal relationships
• Capacities • Infrastructure • Stakeholders
• Capacity building • Needs assessment • Top-down approach
• Capacity development • Partnership approach
OVERVIEW methodology are used to expand services and meet a greater

need of the community. It is most commonly used in devel-
T
he current health care environment continues to de- oping communities; however, it is appropriately applied to
mand that occupational therapy practitioners and the ongoing development of systems for health care and, spe-
managers do more with less, increase efficiency, and cifically, occupational therapy (United Nations Development
ensure positive revenue. These pressures can be a great Programme [UNDP], 2009).
demand on a manager and department and may result in The term capacity building lends itself well to the idea of
management that leads to restraint to reduce cost and ineffi- program development for occupational therapy as it reflects
ciencies, minimalism, and staff dissatisfaction. the idea of establishing and implementing sustainable sys-
Capacity building involves a range of methods and pro- tems with built-in strategies for continuous quality improve-
cesses to develop, improve, and maintain skills needed to do ment and revisions. Not unlike the process of occupational
a job. It often includes a systematic approach and reflects a therapy, the process of capacity involves
long-term, continual process. By applying capacity building,
managers can ensure a thorough process for program devel- ■ Identifying stakeholders (i.e., caregivers),
opment that focuses on efficiency and sustainable outcomes. ■ Assessing needs (i.e., evaluation),
It also reflects important elements of capacities and reciprocal ■ Developing reciprocal relationships (i.e., building rapport),
relationships (Lorenzo & Joubert, 2011). These elements will ■ Developing an infrastructure (i.e., plan of care), and
be vital for job satisfaction and commitment to the process. ■ Continually reassessing and revising (i.e., altering in-
terventions and revising new goals) to help achieve im-
proved quality systems (i.e., reach goals of operating at full
ESSENTIAL CONSIDERATIONS capacity).
Capacity building is the development of systems, processes, Because the process of capacity building mimics occupa-
and strategies aimed at developing sustainable outcomes tional therapy, it is a process that many occupational ther-
for improving health practices. Education, research, and apy managers have already naturally developed. These steps
https://doi.org/10.7139/2019.978-1-56900-592-7.013
133
are discussed further in the section “Steps for Developing either require reworking a plan to restart the program or pro-
Capacity.” gram termination. Such situations can be avoided if the time
Capacity building goes beyond basic quality improvement. is taken to build relationships and capacity among several
In a health care system with constant flux, building capacity occupational therapy practitioners. In the previous exam-
helps ensure continued growth and change to meet the evolv- ple, developing a second practitioner’s skills in hand therapy
ing needs of the health care environment by ensuring that the would ensure a sustainable capacity. Then, the second prac-
organization and its systems remain relevant. titioner would also be developing reciprocal relationships
that would allow them to continue easily with the program,
Capacity and Capacity Development should the first practitioner leave (Lorenzo & Joubert, 2011).
In another example, consider a rehabilitation hospital that
Capacities include both tangible items such as equipment, revis starting an outpatient driving rehabilitation program. A sin-
enue, and products, as well as personal skills such as the skill gle occupational therapy practitioner is identified and trained
set of the individual occupational therapy practitioner, lead- to become a specialist. Limited resources are allocated to sup-
ership skills of the department head, and support skills of the port reciprocal relationships with the other practitioners and
large personnel structure. Board and specialty certifications are referral sources, resulting in limited interest. Program devel-
examples of personal skill capacities. During capacity building, opment is limited to the specialist, and capacity development
the development of personal capacities remains front and cen- is limited. When the specialist is gone on medical leave and
ter to ensure that skills are effective and relevant (Eade, 1997). no other occupational therapy practitioners are available in
The implementation of the capacity-building process, this area of practice (and no sustainable referral relationships
known as capacity development, focuses on development of have been developed), the program is discontinued. Situa-
resources, reciprocal relationships with key groups and indi- tions like this may be avoided if the time is taken to develop
viduals, infrastructure to support growth, and ongoing as- interest in the program, build numerous relationships, and
sessment. Capacity development engages review and revision continue with capacity building among several practitioners.
that ensures quality, growth, development, efficiency, and
ultimately success. This is a continual process rather than a
Infrastructure
project with a start and a finish. This process results in im-
proved quality and helps foster a more integrated, sustainable Infrastructure is the network and systems used to support
system (Corbei-Smith et al., 2015). capacity development. Development of infrastructure is
needed to support growth and may include structures such
Reciprocal Relationships as a policy and procedures manual, mission or vision state-
ments, care delivery models, best practices, documentation
Reciprocal relationships are relationships in which both and communication systems, and program guidelines. In-
participants benefit from the relationship. The development frastructure is valuable in supporting the process for devel-
of reciprocal relationships may be with key groups or indi- opment of capacities and reciprocal relationships. In general
viduals. Groups may include other departments within the terms, the infrastructure supports daily operations as well as
same system or key supporting groups external to the system; global goals. Infrastructure allows the program to function
individuals may include internal occupational therapy practi- on a day-to-day basis without constant oversight because
tioners. Developing reciprocal relationships is key during ca- there are systems in place and the staff simply follow the rules
pacity building for developing a sustainable process, culture, and procedures (Corbei-Smith et al., 2015).
and supportive infrastructure (Lorenzo & Joubert, 2011). The value of a strong infrastructure, especially a mission
Consider the reciprocal relationships between a rehabili- or vision statement, should not be minimized. It is a critical
tation facility manager and an occupational therapy practi- step for capacity development and is needed to foster inde-
tioner working to start a hand clinic. A reciprocal relationship pendence, support integration of systems, strengthen pro-
might include an agreement that the company pay for ad- gram outcomes, and enhance the development of human
vanced training and board certification in hand therapy for potential (UNDP, 2009).
the practitioner, who in return will agree to specific time
commitments, productivity measures, and patient outcomes.
Steps for Developing Capacity
The reciprocal relationship reinforces capacity development
of the hand clinic and motivates each party (Lorenzo & According to the UNDP (2009), capacity building includes
Joubert, 2011). 5 steps:
Reciprocity between 2 or more individuals or groups is
1. Identification and engagement of stakeholders,
key for continued growth and sustainable development. For
2. Identification of assets and needs (needs assessment),
example, a program that has levels of personnel engaged,
3. Identification of approach,
with small overlaps of roles, will continue to do well even if
4. Implementation of plan, and
a practitioner goes out on family medical leave or leaves the
5. Ongoing evaluation of the program.
program. Programs built by a single practitioner, without
reciprocal relationships to ensure continuity, fail when that This section discusses each step as it relates to occupational
person (or capacity) leaves, which results in a gap that will therapy practice.
CHAPTER 13. Building Capacity 135
Identification and engagement of stakeholders Qualitative information is gathered through focus groups,
interviews with key informants, surveys, and department
Capacity building begins with identification and then en-
meetings. Use the needs assessment process as an opportunity
gagement of key stakeholders. Stakeholders are the individu-
to identify strengths as well as opportunities for improvement.
als or groups that have a financial or personal investment in
After information is gathered, the needs are analyzed to
the program or process and may be used to leverage support
identify priorities, gaps, and next steps. To move forward, there
or develop infrastructure, capacities skills, and reciprocal re-
must be a clear understanding of past history and culture: iden-
lationships. Stakeholders for occupational therapy program
tify what works, what has not worked (and why), and the chal-
development may include the hospital chief financial officer,
lenges encountered. Understanding this history is necessary to
outpatient manager, director of social services, marketing
build a foundation and move forward. It is also essential to en-
director, risk management and maintenance personnel, and
sure that efforts are not spent on repeating or recreating failed
other therapy team members.
approaches. This process is about efficiency and sustainability.
It is important to start by identifying those individuals and
Use the needs assessment to identify both what is needed and
groups who will affect capacity development. Stakeholders
what is already established that may be used (Organisation for
may be supportive, indifferent, or opposed. These relation-
Economic Co-operation and Development, 2006).
ships should be considered carefully, and stakeholders should
be engaged in reciprocal relationships (a win–win situation).
This is key for developing a sustainable relationship and en- Identification of approach
suring investment in the project/process.
For example, consider a program’s mission and values To build capacity in health care, Crisp et al. (2000) described
and how stakeholders embrace these values and the extent to 4 approaches: (1) bottom-up, (2) top-down, (3) partnership,
which they align with the goal of capacity building. Deepen and (4) community. Typically, more than 1 approach is used
the commitment and involvement of the stakeholder by en- when developing capacity, and in many situations all 4 are
gaging them in the decision-making and implementation integrated to develop a sustainable approach.
processes. This will foster a sense of responsibility in the
process and ownership. An invested stakeholder will work Bottom-up approach. A bottom-up approach to build-
to support the goals of capacity building, rather than being ing organizational capacity focuses on developing capacities in
an obstacle. Think of capacity building as a stream of water people by working on the development of performance skills
with momentum. An engaged stakeholder becomes the leaf of the employee or expert. This approach looks specifically at
floating on the stream, while a disengaged or unengaged the clinical skills of the occupational therapy practitioner, iden-
stakeholder may be a rock or even a dam. Even stakeholders tifies potential areas for growth and expansion of skills, and
who are simply opposed and uninvolved can still interrupt or then provides opportunities to expand the skills or capacities
interfere with program efforts. of practitioners. The idea is that by focusing on personnel de-
velopment, less reliance is needed on external consultants and
Identification of assets and needs resources. Individuals can gain technical expertise and then
train one another (i.e., train-the-trainer model; Eade, 1997).
(needs assessment)
For example, an employer might send an occupational therapy
A needs assessment is performed to identify and assess needs practitioner to a specialized training course, and then this prac-
and assets, including knowledge, interests, abilities, and skills titioner could, in turn, educate other clinicians in the program.
of capacities; state of current infrastructure; current culture; A bottom-up approach can work well if many clinicians
reciprocal relationships; and opportunities for changes to im- need to be trained and it is a skill that can be taught easily by
prove process. During the needs assessment process, the cur- trainers. A bottom-up approach is also beneficial when ca-
rent state of a program is reviewed thoroughly and objectively pacity development focuses on change at the individual level.
to gather information about the following areas: This approach reinforces the reliance on the individual skill
■ Infrastructure. Is there an existing structure to support sus- set to integrate and then sustain change.
tainable and efficient program growth, such as policies and
procedures or a mission? A stable infrastructure will provide Top-down approach. A top-down approach focuses on de-
the rules needed to guide the program in daily operations veloping infrastructure to support program development. At-
and establishes safeguards to ensure success and quality. tention is paid to policies, procedures, and program guidelines
■ Culture. How will the culture affect acceptance of the pro- that support the goal of growth and development. The infra-
cess or program? Understanding the prior history of the structure outlines the rules that guide the program in daily op-
culture and current state of moods, attitudes, and will- eration and establishes safeguards to ensure success and quality.
ingness to change will be imperative for knowing how to A top-down organization of a community-based, outpatient oc-
move forward with program development. cupational therapy program may include policy and procedures
■ Needs and resources. What needs exist and what capaci- for providing mobile treatment, emergency preparedness, or
ties or resources are already in place? Understanding what storage of medical records. This method is used more commonly
is needed will help identify current gaps in occupational to change at the facility level versus the individual level. This
therapy practice. change is helpful for development of infrastructure.
Partnership. A partnership approach reinforces the value Ongoing evaluation of the program
of reciprocal relationships and focuses on establishing mu-
The evaluation and ongoing review are applied to the capacity
tually beneficial partnerships among groups of people and
development process to determine effectiveness and efficiency
organizations that may not normally interact. This ap-
for developing capacity and program sustainability against
proach emphasizes building capacity by building relation-
established measures. This part of the process promotes ac-
ships and communications among different groups to help
countability and commitment. Evaluation should include
reach a goal. Such relationship building could mean foster-
all parts of the system—from infrastructure, to stakeholders
ing relationships between departments within an institu-
and reciprocal relationships, to capacities and opportunities
tion that do not normally connect, such as risk management
for growth.
and maintenance and therapy to establish an occupational
The evaluation process should include a review of the fol-
therapy driving rehabilitation program. More broadly, such
lowing areas:
relationship building could include developing relation-
ships with other organizations, such as the state licensing ■ Infrastructure. Ensure that guidelines and policies are
administration or state medical advisory board (Lorenzo & present to support sustainability, review processes for effi-
Joubert, 2011). ciency of flow, and evaluate the infrastructure’s ability to
This capacity development approach has proven valu- engage capacities and promote sustainability.
able for establishing and maintaining connections between ■ Stakeholders. Evaluate buy-in, engagement, the benefits
groups and stakeholders. Without use of this approach, ca- of the relationship, and opportunities for improvement or
pacity development tends to “fizzle out” and be less effective. need for dissolution.
Relationships with invested stakeholders are needed to build ■ Capacities. Evaluate the scope of skills, availability of re-
sustainability. sources, and method for continuing development and
integration.
Community approach. A community approach is used ■ Opportunities for growth. Identify successes and areas
more commonly for community-based capacity development. that need further development; identify opportunities
It tends to focus on the most disenfranchised communities for change and develop approaches to continue capacity
and works to engage community members by moving them building.
from a state of disengagement to engagement. This approach
focuses on the capacities of individual community members Review Questions
to develop reciprocity and an integrated culture. The com-
munity approach is needed when developing capacity in a 1. How are the steps for developing capacity similar to
culture where change is needed to improve the situation. It the therapeutic process used by occupational therapy
integrates elements of the partnership and the bottom-up practitioners?
approach to identify key community members who have an 2. What are the disadvantages of developing capacity
interest in effecting change (Crisp et al., 2000). without identifying stakeholders or completing a needs
A risk to this approach is the trend for community mem- assessment?
bers with newly acquired or strengthened skills to leave the 3. Thinking about your own practice or vision of how you
community for alternate employment opportunities. For ex- would like your practice to look like in the future, iden-
ample, a community approach may be engaged to help rebuild tify examples of when each of the 4 approaches may be
the culture of an occupational therapy program after sustain- used for your own capacity building.
ing significant loss from company layoffs or other events that
have left a negative culture, such as negative program reviews
or numerous customer service complaints. PRACTICAL APPLICATIONS IN
Implementation of the plan Table 13.1 lists the steps for capacity building and highlights
focus areas and guiding questions. This table may be helpful
After stakeholders have been identified and engaged, needs
when considering capacity development and during the pro-
have been assessed and prioritized, and a plan of approach
cess to ensure that all steps are being implemented.
has been developed, the plan can be implemented. Imple-
The following list provides a summary of general tips and
mentation should occur at the individual, institutional, and
practical experience for capacity building.
global levels. Strategies and the pace for implementation will
vary according to stakeholders, development of reciprocal ■ The needs assessment process is a great opportunity to
relationships, and capacities. The implementation will also ensure a complete understanding of infrastructure, cul-
be affected by the current culture’s readiness to change. Ap- ture, resources, and opportunities for change. It is also a
proach implementation as an ongoing and continual process great opportunity to incorporate discovery of information
that needs regular evaluation. As such, it is important to have to identify the program’s vision. Development of a vision
measurable achievements, positive reinforcements, and goals or mission statement is essential for successful program
to use for progress evaluation. development.
TABLE 13.1. Steps for Developing Capacity
STEPS FOR QUESTIONS TO GUIDE STEPS FOR DEVELOPING CAPACITY

DEVELOPING CAPACITY AREAS OF FOCUS WITHIN AN OCCUPATIONAL THERAPY DEPARTMENT
Identify stakeholders ■ Identification of key individuals ■ Who are the key individuals or groups?
■ Determination of thoughts, beliefs, and ■ What are the thoughts, beliefs, and motivations of these stakeholders?
motivations ■ What relationships exist and how can these be strengthened? What
■ Review of current need to develop relationships need development?
reciprocal relationships ■ How can stakeholders be leveraged to support program development and
■ Method for engagement in decision- promote investment in development? What are the primary and secondary
making process gains?
■ Method for invested for support, growth, ■ How can the strengths of the stakeholder be leveraged to make decisions
outcome, and program sustainability and improve the process?
■ Foster partnership and ownership
Identify assets and Identification and review of: ■ What are the current medical and occupational therapy needs of the health
needs (complete a ■ Needs care environment?
needs assessment) ■ Gaps in practice ■ What needs are being met and what resources exist?
■ Capacities ■ What needs are not being addressed? What are the gaps in practice?
■ Infrastructure ■ What are the current capacities of the department and individual
■ Culture trends practitioners? Does a needed skill exist or who presents with potential for
■ Reciprocal relationships development?
■ Assess readiness to change ■ What training will be needed?
■ Level of buy-in or engagement ■ What reciprocal relationships, guidelines, and/or policy and procedures
■ Prioritize needs and actions exist to support program development?
■ What is the current culture of the team? What is the readiness to change?
■ What areas should be prioritized?
■ What is the primary type of change needed: individual capacities,
infrastructure, relationship development, or community level?
Identify plan of approach ■ Bottom-up Bottom-up approach
■ Top-down ■ What occupational therapy training will be needed to reach the goal?
■ Partnership ■ What will be the method for initial and continued training?
■ Community organizational ■ What are the considerations for investment of training time and resources?
Is formal employee commitment needed?
■ What opportunities exist for mentorship of newly developed skills?
Top-down approach
■ What policies, specialty job descriptions, practice acts, and regulatory
guidelines exist or need to be developed?
■ What equipment will be needed?
Partnerships
■ What internal or external relationships exist and could be strengthened?
What new relationships could be developed?
■ What are the key organizations that support your program development?
■ What are opportunities for building reciprocal relationships?
Community development
■ How can lead capacities be identified and developed to lead change?
■ How can these capacities be motivated to remain in the community?
Implementation ■ Individual, institution, global levels ■ Who are the key people?
■ Varying pace and timing ■ What are the goals and key indicators to measure success?
Evaluation and ongoing ■ Promotes accountability ■ What do the key indicators show?
evaluation of program ■ Measures performance-based measures ■ How do the following categories support the goal: infrastructure,
stakeholders, reciprocal relationships, and current capacities?
■ What are the opportunities for growth?
■ Revise and continue
■ The use of more than 1 approach may be needed to achieve Review Questions
goals, but it is important to identify and define which ap-
1. Is the process of developing capacity linear or ongoing?
proach or delivery model will be used to guide actions and
Why or why not?
practice. This is needed to ensure that all participants have
2. Can capacity building be effective and sustainable if
a clear understanding of the approach, which will result
stakeholders, capacities, and infrastructure are developed
in better alignment of key participants and more cohesive
only within the occupational therapy department?
efforts.
3. What step of capacity development might be most
■ Do not underestimate the value of the stakeholders and challenging?
building of reciprocal relationships. These relationships
often determine the sustainability or long-term success of
capacity building. Focus on both internal and external rela- SUMMARY
tionships to ensure engagement of stakeholders on all levels.
The process of capacity building lends itself well to the needs
■ With occupational therapy, most capacity building occurs of an occupational therapy manager looking to develop
with clinical treatment programs. This means that capac-
and implement sustainable programs. The process itself (of
ity may be dependent on individual occupational therapy
needs assessment, reciprocal relationships, development of
practitioners. It will be important to layer the development
infrastructure, implementation, and evaluation) reflects our
of skills or capacities to ensure that the program does not
foundational practices within occupational therapy, making
stall or fail if a practitioner leaves the program.
capacity building a natural fit with the profession. Many oc-
■ Taking the time up front to identify and engage stakehold- cupational therapy managers have already naturally devel-
ers and complete a needs assessment will ensure efficiency
oped the process and can learn to apply our capacity more
sustainability.
thoroughly. Each step is integral for developing a sustainable
Case Example 13.1 describes capacity building in the con- approach and to achieve positive quality outcome and pro-
text of driving and community mobility. gram development. ❖
CASE EXAMPLE 13.1. Building Capacity to Improve Driving and Community Mobility Services
An occupational therapy department at an inpatient rehabilitation hospital has identified the need to improve services that address driving and
community mobility. Recently a patient was discharged from the hospital after recovering from a stroke. The patient walked out to his car in the
parking and attempted to drive home, only to cause a 4-vehicle crash at the exit light of the hospital. The crash has resulted in increased concerns
from the physicians, hospital, and community at large.
Identify Stakeholders
Through targeted interviews and discussions, the following individuals and groups have been identified as stakeholders with the following assets
(Dickerson et al., 2011):
■ Occupational therapy department
■ Therapy providers who will evaluate, assess, and intervene to assess performance skills needed for driving and community mobility; identify
areas of concern; communicate to other team members; and then refer for additional services as needed.
■ Invested to improve quality of care provided to patients and assist patients with meeting goals for driving and community mobility.
■ Director of Physical Medicine and Rehabilitation Department (PM&R)
■ Direct organizational support to practitioners.
■ Assist with development of program guidelines and policy and procedures to support needed infrastructure.
■ Provide direct oversight, assistance for interventions and billing, and support for development of clinicians’ capacities; develop reciprocal
relationships with other stakeholders; support communication from occupational therapy practitioners to the referring physician.
■ Motivated to support clinical team, physician groups, and hospital.
■ PM&R physicians
■ Lead member of the medical team who will receive objective information from the therapy team to make recommendations related to client
driving.
■ Position reinforced by state licensing agency that requests reports concerning medication conditions by physician.
■ Physician buy-in related to well-being of patient, practice, and hospital, as well as ethical obligations as outlined by the state licensing agency.
■ Social services department
■ Representative to support patient goals and discharge disposition.
■ Motivated to provide patient support and transportation options that align with recommendations from a physician and occupational therapy
practitioners.
■ Hospital administration
■ Provide overview operation structure and support.
■ Motivated to reduce risk management, to generate revenue, and to improve facility reputation.
(Continued)
CASE EXAMPLE 13.1. Building Capacity to Improve Driving and Community Mobility Services (Cont.)
■ Hospital risk management department

■ Provide support for the development of policies and procedures that reflect risk management as well as meet the requirements of the state
licensing agency.
■ Motivated to reduce risk and liability of hospital and to ensure that physicians and clinicians are operating within role as providers.
■ State licensing agency
■ External stakeholder may have little investment in program development but will be key for developing a positive relationship with physi-
cians who report concerns.
■ Motivated to provide driver’s license to drivers who demonstrate skills for operating a motor vehicle and to protect state residents by
ensuring that motorists have the skill set need to operate a motor vehicle.
■ Hospital community, local state police, and emergency responders
■ Concerns from the surrounding community for the safety of the residents in the immediate vicinity of the hospital.
■ Motivated to reduce crash risk and increase awareness of safety for all drivers.
■ Many are motivated to work for an employer who addresses community concerns for safety and represents values that reflect community goals.
Identify/Assess Needs and Assets

Once the stakeholders have been identified, a needs assessment is completed to identify current capacities (knowledge, interests, abilities, and skills
of clinicians), state of current infrastructure, current culture, reciprocal relationships, needs, and opportunity for changes to improve the process.
■ Capacities: Current capacities include an occupational therapy team of 4 OTs and 2 OTAs; neighboring driving rehabilitation program at a hospi-
tal 75 minutes away; state that supports physician medical reporting; engaged physicians looking for support to better address driving concerns
with patients; motivated stakeholders.
■ Infrastructure: Stable therapy department with standard program guidelines to support therapy intervention; national support and guidance with
the American Occupational Therapy Association (2016) statement on driving and community mobility; will need development for communication
of recommendations to physician and client.
■ Culture: Clinicians are motivated to ensure that clients have discharge plans designed to keep them safe. Two of the practitioners are interested
in addressing driving and community mobility. They report that they do their best to address this area of practice before the client is quickly
discharged, but at times they are frustrated with the fast turnover of patients, and they have concerns about their role in addressing this area
of practice. Specifically, the practitioners report that they are unclear about what they should evaluate and what they, as generalists in practice,
may recommend versus an occupational therapy driver rehabilitation specialist (DRS). Overall, these clinicians are interested in change and
eager to learn more. The program manager is also very motivated. She recently had to discuss driving with a member of her own family and
believes that something more needs to be done. She has concerns about practice guidelines for supporting driving and community mobility.
■ Needs: Training for occupational therapy practitioners’ role with driving and community mobility; program policy and procedures to support
program and billing; identification of current best practices and guiding practice statements; method for communicating plans and changes;
developing a better understanding of state licensing reporting laws and consideration; developing understanding for role of state driver’s licens-
ing medical advisory board (Dickerson & Schold Davis, 2014; Lane et al., 2014).
Identify Approach
While many stakeholders will be involved in the success of building the capacity of the occupational therapy department to expand its services for
driving and community mobility, the skill set of the occupational therapy practitioners will be critical (Betz et al., 2014). Therefore, a bottom-up capacity
development approach will be the primary approach. This approach will start with developing the capacities of the 2 lead OTs through enrollment in courses,
including Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (McGuire & Schold Davis, 2012) and other education.
Practitioners will then use their developed capacities to work collaboratively with the program manager and hospital administration to develop methods for
documentation and billing, communication channels to internal stakeholders such as physicians and social services, and needed program guidelines or policies.
A top-down approach will be used to supplement the focused bottom-up work by developing an overarching vision and mission. OT-DRIVE (Schold
Davis & Dickerson, 2017) and AOTA’s (2016) Driving and Community Mobility statement will be used as guiding documents to educate stakeholders and
ensure the occupational therapy team is addressing needs within their scope of practice and then referring to the occupational therapy DRSs as needed.
A partnerships approach will also be important for the many varying relationships needed between stakeholders to develop the capacity plan, implement,
evaluate, and ensure sustainability. Relationships between relevant parties (e.g., among the occupational therapy practitioners, among the practitioners
and program manager, the practitioners and state Medical Advisory Board to the Department of Motor Vehicles [DMV] program manager and hospital
administration, program manager, practitioners, and physicians) will all be important to develop and evaluate for effectives, efficiency, and sustainability.
Implementation
Implementation will occur at varying levels from practitioner, to department, to hospital. Initial plans for implementation will include a plan for
education of the practitioner, followed by development of infrastructure focused on state practice acts and guiding practice documents and,
ultimately, provision of care. Implementation will require a point person to prioritize tasks, evaluate, and modify the approach. Care will be taken to
engage stakeholders and to encourage readiness for change. This will be an ongoing and continual process that needs regular evaluation and will
use measurable achievements, positive reinforcements, and goals to evaluate progress.
(Continued)
CASE EXAMPLE 13.1. Building Capacity to Improve Driving and Community Mobility Services (Cont.)
Evaluation
Plans have been made for adjusting evaluation of the capacity building at varying levels. For example, to support and ensure individual capacity
development, weekly evaluation of the practitioners by the program manager will be used to sustain growth. Weekly evaluation may also be used
to ensure that effective relationships have been developed between therapy and the physicians and social services. Monthly meetings between
the therapy departments and hospital administration will be used to evaluate program success. Program success will be measured by referrals
to occupational therapy DRS, customer satisfaction, physician satisfaction, and number of clients receiving occupational therapy driving and
community mobility interventions. Evaluation of the program’s ability to protect community interests will be evaluated annually.
Review Questions
1. In the case study above, identify the pros and cons of having 2 occupational therapy practitioners complete the training as compared with
1 practitioner who completes the training and then trains the rest of the occupational therapy team.
2. Regarding stakeholders, what strategies might be implemented to develop engagement with the risk management department? Physicians?
Social services department?
3. What are the primary and secondary gains made from developing reciprocal relationships with outside stakeholders, such as the DMV?
ACOTE STANDARDS Therapy in Health Care, 28(2), 122–126. https://doi.org/10.3109

/07380577.2014.901591
This chapter addresses the following ACOTE Standards: Dickerson, A. E., Schold Davis, E., & Chew, F. (2011, March). Driv-
■ B.5.1. Factors, Policy Issues, and Social Systems ing as an instrumental activity of daily living in the medical set-
■ B. 5.7. Quality Management and Improvement. ting: A model for intervention and referral. Paper presented at the
conference of the American Society on Aging, Washington, DC.
Eade, D. (1997). Capacity-building: An approach to people-centered
REFERENCES development. Oxford, England: Oxfam UK and Ireland.
Accreditation Council for Occupational Therapy Education. (2018). Lane, A., Green, E., Dickerson, A. E., Schold Davis, E., Rolland, B.,
2018 Accreditation Council for Occupational Therapy Education & Stohler, J. T. (2014). Driver rehabilitation programs: Defining
(ACOTE) standards and interpretive guide. American Journal program models, services, and expertise. Occupational Therapy
of Occupational Therapy, 72(Suppl. 2), 7912410005. https://doi in Health Care, 28(2), 177–187. https://doi.org/10.3109/07380577
.org/10.5014/ajot.2018.72S17 .2014.903582
American Occupational Therapy Association. (2016). Driving and Lorenzo, T., & Joubert, R. (2011). Reciprocal capacity building for
community mobility. American Journal of Occupational Therapy, collaborative disability research between disabled people’s or-
70, 7012410050. https://doi.org/10.5014/ajot.2016.706S04 ganizations, communities and higher education institutions.
Betz, M. E., Dickerson, A., Coolman, T., Schold Davis, E., Jones, J., Scandinavian Journal of Occupational Therapy, 18(4), 254–264.
& Schwartz, R. (2014). Driving rehabilitation programs for older https://doi.org/10.3109/11038128.2010.525748.
drivers in the United States. Occupational Therapy in Health McGuire, M. J., & Schold Davis, E. (Eds.). (2012). Driving and com-
Care, 28, 306–317. https://doi.org/10.3109/07380577.2014.908336 munity mobility: Occupational therapy strategies across the lifes-
Corbei-Smith, G., Bryant, A. R., Walker, D. J., Bluementhal, C., pan. Bethesda, MD: AOTA Press.
Council, B., Courtney, D., & Adimora, A. (2015). Building ca- Organisation for Economic Co-operation and Development, Devel-
pacity in community-based participatory research partnerships opment Assistance Committee (2006). The challenge of capacity
through a focus on process and multiculturalism. Progress in development: Working towards good practice. Retrieved from
Community Health Partnerships: Research, Education, and Ac- http://gsdrc.org/docs/open/cc110.pdf
tion, 9(2), 261–273. https://doi.org/10.1353/cpr.2015.0038 Schold Davis, E., & Dickerson, A. (2017). OT–DRIVE: Integrating
Crisp, B. R., Swerissen, H., & Duckett, S. J. (2000). Four approaches to the IADL of driving and community mobility into routine prac-
capacity building in health: Consequences for measurement and tice. OT Practice, 22(13), 8–14.
accountability. Health Promotion International, 15(2), 99–107. United Nations Development Programme. (2009). Supporting ca-
https://doi.org/10.1093/heapro/15.2.99 pacity development: The UNDP approach. Retrieved from http://
Dickerson, A. E., & Schold Davis, E. (2014). Driving experts address www.undp.org/content/dam/aplaws/publication/en/publications
expanding access through pathways to older driver rehabilitation /capacity-development/support-capacity-development-the-undp
services: Expert meeting results and implications. Occupational -approach/CDG_Brochure_2009.pdf
CHAPTER
Starting New Programs
Ann Burkhardt, OTD, OTR/L, FAOTA 14
LEARNING OBJECTIVES
■ State underlying principles involved in starting a new program in either a clinical or higher educational setting,
■ State a course of action that is based in the format of an accrediting body, and
■ Set priorities for developing services based on the setting.

• Accreditation • Faculty workload • Program development
• Advisory groups • Growth plan • Regulations
• Best practice models • Lab ratio • Scope of practice
• Budget • Needs assessment • Strategies
• Care mapping • Policy and procedures manual
• Certifications • Practice parameters
OVERVIEW the clinic. In contrast, academic programs change how clinical

concepts are taught in their curricula based on credentialing
C
hange has been the occupational therapy profession’s through their accreditation bodies.
mantra for a long time. Continuously changing in Change drives actions taken in professional associations
response to societal need, the profession has subse- that influence clinical practice. Health care policy research
quently grown and developed since its founding more than and global assessments of overall health influence professional
100 years ago. The change itself varies by what is driving the practice models and suggest recommended change. When so-
change. Educators may change the approach to teaching about ciety identifies a tipping point in terms of meeting the health
a given topic based on changes in education philosophy; the needs within a population, professions are poised to shift focus
scholarship of teaching and learning; or changes in what is from day-to-day practice to supporting societal needs through
taught and whether the efficacy of the knowledge that has tra- program development and implementation of changes in clin-
ditionally dominated is challenged or supported by science. ical practice care delivery. Clinical directors and academic di-
Research outcomes and recommendations may drive change rectors share similar concerns about policy development and
in clinical practice, especially when evidence from research the impact of research and policy on program development.
modifies the theory that underlies practice assumptions.
This chapter discusses commonalities and differences that
exist when starting a new clinical program or a new academic ESSENTIAL CONSIDERATIONS
program. Clinical programs often change day-to-day tasks
Role of Health Policy
such as documentation and billing in response to insurance
industry regulations. Therefore, clinical practice models tend Clinical practice is often driven by health care policy research
to develop when clinical best practice models, often referred and subsequent international agreements that change our
to as clinical pathways, emerge to improve clinical outcomes conception of what drives health for populations, communi-
and support the inclusion of evidence-based practice into ties, groups, and individuals. For example, the World Health
https://doi.org/10.7139/2019.978-1-56900-592-7.014
141
CHAPTER
Starting New Programs
Ann Burkhardt, OTD, OTR/L, FAOTA 14
LEARNING OBJECTIVES
■ State underlying principles involved in starting a new program in either a clinical or higher educational setting,
■ State a course of action that is based in the format of an accrediting body, and
■ Set priorities for developing services based on the setting.

• Accreditation • Faculty workload • Program development
• Advisory groups • Growth plan • Regulations
• Best practice models • Lab ratio • Scope of practice
• Budget • Needs assessment • Strategies
• Care mapping • Policy and procedures manual
• Certifications • Practice parameters
OVERVIEW the clinic. In contrast, academic programs change how clinical

concepts are taught in their curricula based on credentialing
C
hange has been the occupational therapy profession’s through their accreditation bodies.
mantra for a long time. Continuously changing in Change drives actions taken in professional associations
response to societal need, the profession has subse- that influence clinical practice. Health care policy research
quently grown and developed since its founding more than and global assessments of overall health influence professional
100 years ago. The change itself varies by what is driving the practice models and suggest recommended change. When so-
change. Educators may change the approach to teaching about ciety identifies a tipping point in terms of meeting the health
a given topic based on changes in education philosophy; the needs within a population, professions are poised to shift focus
scholarship of teaching and learning; or changes in what is from day-to-day practice to supporting societal needs through
taught and whether the efficacy of the knowledge that has tra- program development and implementation of changes in clin-
ditionally dominated is challenged or supported by science. ical practice care delivery. Clinical directors and academic di-
Research outcomes and recommendations may drive change rectors share similar concerns about policy development and
in clinical practice, especially when evidence from research the impact of research and policy on program development.
modifies the theory that underlies practice assumptions.
This chapter discusses commonalities and differences that
exist when starting a new clinical program or a new academic ESSENTIAL CONSIDERATIONS
program. Clinical programs often change day-to-day tasks
Role of Health Policy
such as documentation and billing in response to insurance
industry regulations. Therefore, clinical practice models tend Clinical practice is often driven by health care policy research
to develop when clinical best practice models, often referred and subsequent international agreements that change our
to as clinical pathways, emerge to improve clinical outcomes conception of what drives health for populations, communi-
and support the inclusion of evidence-based practice into ties, groups, and individuals. For example, the World Health
https://doi.org/10.7139/2019.978-1-56900-592-7.014
141
Organization’s (WHO) membership includes nations around key services to a targeted population or group. Third-party
the world. WHO asks all member nations to share knowl- payment continues to fund the majority of services, but the
edge about approaches to health care delivery within their new generation of occupational therapists also recognizes
countries and to share statistics and directionality based on that diversity of revenue streams not only supports an ongo-
what the evidence demonstrates. The evidence is then used to ing presence in traditional markets but also strengthens and
strategize how international health care policy should shift supports the inclusion of occupational therapy in developing
to deliver more efficient quality care in a defined time frame. models of care.
The 2017 Bloomberg Global Health Index, based on WHO’s Occupational therapy managers must reconsider how tra-
UN Population Division data, ranks the United States as the ditional practice settings could be alternatively staffed with
34th healthiest country out of 50 (Dhiraj, 2017). The U.S. De- a minimum of risk, with greater service delivery efficiency,
partment of Health and Human Services reviews these data and without creating extended waiting lists or denials of care.
to further recommend changes in American policy (e.g., For example, if professional-level practitioners work more
Healthy People 2020, use of the International Classification efficiently and collaboratively with occupational therapy as-
of Functioning, Disability and Health to alter care delivery sistants, more people may be served, societal needs may be
models). These recommended changes are managed by the better met, and the public will not have services delayed or be
Agency for Healthcare Research and Quality (AHRQ). diverted to other professionals who lack occupational therapy
Policy research often results in development of new ap- skills for their care.
proaches to care delivery. When service delivery changes, Current practice delivery models may need to be limited
when new populations present themselves in need, or when if they have become less viable over time. A leap of faith that
the focus of care is forced to shift, the demand for more cutting services in one area will allow for more services in
trained professionals to provide care under different cir- another area where there is more need may be indicated for
cumstances increases. If the demand is significant enough, support of the greater good. Evidence not only applies to the
professions, including occupational therapy, begin to include clinical outcomes of what we do but also depends on the eco-
knowledge about the new practice in entry-level education. nomic viability of service delivery when financial resources
Professions also use continuing education as a means to are limited, especially for the underinsured and underserved
educate occupational therapists who are already practicing in (Collins, 2013; Fisher & Friesema, 2013; Robinson et al., 2016;
the field. Authoritative rules or directives, called regulations, Williamson et al., 2016; Yousey et al., 2012). Evidence is fiscal
may mandate new training be incorporated into practice or as well as clinical.
education. For example, the number of older adults in the United
States is continually increasing. By 2030, all Baby Boomers
will be ages 65 or older, and 1 in every 5 people will be re-
Service Delivery
tirement age (U.S. Census Bureau, 2017). Yet, the number of
The Bureau of Labor Statistics (2017) states that there will be occupational therapy practitioners is finite. As the tsunami
a 27% shortage of occupational therapists in the United States of aging (also called the gray tsunami and silver tsunami)
in the next decade. In recent decades, occupational therapy increases the strain on the Medicare system, it might be
clinical practice has thrived in traditional practice mod- more efficient in terms of cost and human resources if the
els such as hospitals, nursing and long-term care facilities, professional-level occupational therapy practitioner works
home care, and private practice. Since the 1970s, pediatric with a facility as a consultant to assure that the Centers
practice has been continuously developing and has been of- for Medicare and Medicaid Services (CMS) guidelines are
fered in hospitals, at home, in schools, and in private prac- followed.
tice. Since the 1990s, an increasing number of occupational At present, the occupational therapist should complete
therapists have identified their role and practice within pub- the initial evaluation, subsequent reevaluations, and the dis-
lic health models of care delivery. AHRQ’s current focus is charge documentation. The occupational therapy assistant
on prevention and chronic care: preventing disease and help- should provide as much of the 1-to-1 direct care with clients
ing patients maximize health and function over the lifespan as possible. The therapist provides the services that the as-
(AHRQ, 2015). sistant may not complete. Therapists should retain evidence
Consultancy has continued to develop and filter into oc- of training for the assistants with whom they work to ensure
cupational therapy. This mode of service delivery strengthens that clinical competence is verified and tracked.
practitioners’ roles as changes in practice occur in clinical Occupational therapists should not regularly engage in
and higher educational settings. The introduction of the clin- direct daily client service delivery unless the professional
ical doctorate in occupational therapy has placed the profes- level of skill is warranted for a specific evaluation, treatment,
sion in a prospective stance; the scholarly applied-practice or device prescription. In the near future, therapists in such
and higher education projects that are the outcomes of many settings will be best used if they focus on management and
doctoral projects have offered possibilities for practice expan- consultancy for service delivery and follow through with
sion in novel ways. quality improvement and service delivery measures. Case
Some new practice settings are fee-for-service based. Oth- Example 14.1 provides case scenarios for starting programs
ers may be grant-funded or nonprofit organizations that offer in clinical settings.
CHAPTER 14. Starting New Programs 143
CASE EXAMPLE 14.1. Starting Programs in Clinical Settings
Scenario 1
You work as the manager of clinical services in a university-based medical center and have an opportunity to expand occupational therapy
services into a liaise-focused position with the United Way. The medical center does internal fundraising and requests that employees financially
support the United Way.
1. What are the pros and cons of the proposed relationship?
2. How would you organize the development of the relationship for both clinical expansion and student training?
Scenario 2
You have been hired to develop occupational therapy services in a primary care center that is affiliated with a tertiary care university-based
medical center. The rehabilitation department has had a long-standing physical medicine service with a physical therapy department and 1
part-time speech pathologist. There is also a psychiatry unit.
3. What would you propose for implementation of occupational therapy services?
Scenario 3
The opioid crisis has hit your community very hard. The rate of suicide associated with opioid overdose has skyrocketed. Your community has
contacted potential stakeholders to create a community response and develop intervention programming.
4. What could you propose as occupational therapy–targeted interventions to work on this in an interprofessional way?
Scenario 4
You are a manager in an acute care hospital. The director of managed care has requested a list of all the skilled experience of the occupational
therapy staff.
5. How might you develop a system for tracking this information?
6. How could you identify other stakeholders who may also benefit from access to this information?
Scenario 5
You are an occupational therapist who works in a subacute-care setting in a rural community. You are aware that CMS has changed the coverage
and rules about care delivery for skilled and maintenance care in all subacute-care facilities.
7. How would you communicate this to the administration overseeing rehabilitation services?
8. Does this change result in a loss of staffing for the facility?
9. How would you determine what services could be expanded to deliver best care to the clients?
10. Where would you look for guidance and networking about this?
Starting a New Clinical Occupational In established clinical settings, if day-to-day practice remains
Therapy Program the same for day-in/day-out care delivery and does not change
over time, practice stagnates. Traditionally in hospital settings,
Before taking on the role of manager, consultant, or direc- cost containment measures force changes in day-to-day care de-
tor of a service, an occupational therapy practitioner should livery. Some of these are a result of reimbursement changes that
develop skills and competence to enter the managerial role. occur with legislated health care reform. Others occur as a re-
There is a transitional process from being a clinician to being a sult of an adoption of management models, such as Six Sigma or
manager (Politano, 2013). Occupational therapy professional Lean, to reengineer care delivery processes (Neufeld et al., 2013).
associations offer training and networking venues for people
who are becoming or working as managers. Institutions often
Needs assessment
offer internal training for managers and supervisors through
their human resources or staff training departments. Some In clinical settings, managers should periodically do a needs
institutions have partnerships with local colleges and univer- assessment to determine whether the care they deliver is rel-
sities, and they may even fund part of a degree, such as one evant and that evidence exists that there is sufficient revenue
in public health administration or hospital management, to to more than cover expenses for the setting or institution
support managers in their role. (Improta et al., 2015). A needs assessment is a systematic ap-
It is helpful to seek training in one’s home work site or set- proach used to identify gaps between current practices and
ting, if possible. Online courses are available as continuing desired practice conditions to determine a course of correc-
education or for academic credit. Attending trainings and con- tive action. Involving employees from inside and outside of
ferences provide good networking opportunities to meet others the unit being reviewed can be insightful. Progressive plans
in the audience or approach speakers. Some of these may have and actions can assist with keeping practice in sync with so-
valuable information to share about developing management cietal needs as change is occurring. Introducing novel pro-
skills. Finding a mentor and listening and learning are key. gramming or developing successful grant-funded programs
After becoming a manager and gaining skills, mentor others. is another path one may pursue (Von Eiff, 2015).
Key players the system during a specific episode of care (“Care map,” n.d.),
what one does for a client is often prescriptive. There is not
Occupational therapists may ask or be asked to develop services
much room for creativity in how care is delivered. Standards
in a setting where services have not previously been established.
have been developed by the National Academies of Sciences,
In a setting where occupational therapy is not the sole service,
Engineering and Medicine, Health and Medicine Division
key players in the setting should be interviewed. Establishing
(2011) to develop trustworthy clinical practice. These include
services may depend on the interprofessional team’s perception
of what services are missing. Gaining insight into the direction ■ Establishing transparency,
that the team has in mind is an important factor to successful ■ Managing conflicts of interest,
integration of new services in an established microcosm. ■ Setting guidelines for development group composition, and
■ Establishing and systematically reviewing evidence to ver-
Strategy ify that care provision actually works; the clinical practice
guideline–systematic review process includes establishing
All organizations have a vision and a strategy for how change
evidence foundations for and rating strengths of recom-
will occur. Strategies require a plan inclusive of goals and ob-
mendations, articulating recommendations, undergoing
jectives, which depend on a mission (Braveman et al., 2011).
external review, and updating.
The plan for a department and a service, such as occupational
therapy, should be developed, and its implementation should
Certifying organizations
be incorporated into the department or service’s strategic
plan. Accrediting agencies will look for this link to be formal- Certifying organizations also play a role in how institutional
ized in the department’s policy and procedures manual and settings are guided in practice and how they function; these
cross-referenced in the institution’s documents. organizations grant accreditation, a formal process used to
determine if an academic institution or program is minimally
Practice parameters and scope of practice in compliance with a prescribed sets of standards. The United
States currently has 5 health care accreditation organizations:
Occupational therapy is based on concepts of practice pa-
rameters (i.e., what one does typically daily in a setting) and 1. Utilization Review Accreditation Commission,
scope of practice (i.e., possible services that one could offer 2. National Committee for Quality Assurance (NCQA),
within a setting). Practice parameters are often closely con- 3. The Joint Commission (TJC),
nected with roles a professional group assumes in that set- 4. Commission on Accreditation of Rehabilitation Facilities
ting. Some aspect(s) of care delivery could be accomplished (CARF), and
by several team members, so making a calculated move in 5. Council on Accreditation.
program development—that is, conceptualizing, formulat-
Those with specific reference to occupational therapy pro-
ing, starting, improving upon, or expanding educational,
gramming are TJC, CARF, and NCQA. Hospitals voluntarily
service delivery, or managerial-oriented work plans—could
pursue TJC accreditation. The Joint Commission is an inde-
potentially overstep into another profession’s practice in that
pendent nonprofit organization that accredits 21,000 health
setting, leading to dissonance and perceived competition.
care organizations and programs (TJC, 2017). A manager
When the roles and tasks in a setting are familiar, there is
has to be a part of the administrative group that assures the
often comfort in including those roles and tasks into a new care
TJC standards are followed in the department settings. All
delivery model. However, if everything built into a program
department members are expected to work with their man-
maintains the status quo, it can detract from including novel
ager to ensure that standards are met or exceeded. Some re-
practice within the care delivery model. Managers who are de-
habilitation settings may also carry accreditation by CARF
veloping clinical services need to keep all of the parameters in
(CARF, 2017).
mind, be attentive to new programs in development, and advo-
cate for occupational therapy to function meaningfully and ef-
fectively within the team (Collins, 2013; Fisher & Friesema, 2013; For Additional Learning
Leland et al., 2014; Persch et al., 2013; Robinson et al., 2016).
For additional learning, see Chapter 55, “Major Accrediting
Best practice models Organizations.”
In hospital-based settings, the evidence-based practice move-

ment supports efficient care delivery, which often includes best
Policy and procedures manual
practice models and clinical pathways. Best practice models
are techniques or methodologies that have proven to reliably When starting a new program in a clinical setting, managers
lead to a desired result and are often based on research and ex- generally develop a policy and procedures manual (PPM)
perience. Common examples include joint replacement mod- containing an index, sections according to topic, step-by-step
els of care delivery and cardiac surgery care delivery models. instructions, and information about official department and
Within care mapping, the systemized sequence of health institution policies. Some of the typical sections included in a
and specified related services a patient receives after entering PPM are listed in Exhibit 14.1.
EXHIBIT 14.1. Typical Sections of a Policy and Goals and continuing competence
Procedures Manual One of a manager’s most important functions is to ensure that
■ Safety procedures
each staff member has goals for their job and overall career
■ Environmental management and a plan to pursue those goals. Continued competence is
■ Material data sheets (i.e., copies of safety information concerning a high value among health care professionals. TJC also man-
all solvents and chemically active agents used in the setting) dates that health care professionals have a professional de-
■ Work scheduling and time-off requests velopment plan. Many clinical settings also require their
■ Telephone roster and a phone tree for emergency communications occupational therapy professional staff members to remain
■ Pay schedules and procedures current with the National Board for the Certification in Oc-
■
■
Emergency management information
Infection control
®
cupational Therapy (NBCOT) continuing certification.
Activities to work toward continuing competence often
■ Employee safety and workers’ compensation instructions have financial and staffing ramifications. The manager is re-
■ Commonly used forms (i.e., samples of paper and electronic forms)
sponsible for covering staff absences that support their work
on continuing competence. In this capacity, the manager may
also act as a mentor and encourage their employees to con-
The PPM also includes specific policies to the program it-
tinue their education; pursue opportunities to contribute to
self. The PPM is generally a living document that changes over
evidence-based practice (e.g., grant-funded interdisciplinary
time. It is under continuous revision and is regularly updated.
research); participate in continuing education; and mentor stu-
In some hospital settings, each policy or procedure must be
dents and junior clinicians, providing lectures or pairing with
reviewed yearly, and the review should be initialed and dated
programs, such as educational; community-based consumer-
(a best practice). If any covering occupational therapy practi-
oriented; or professional, that support those they serve.
tioner were to work at the site, they should be able to find the
information needed for efficient and effective care delivery by
looking up the procedure in the manual. Most manuals today
For More Information
are stored electronically in the institution’s internal website.
See Chapter 54, “Continuing Competence,” for more information on
Budget continuing competence and professional development.
A budget is generally distributed to a manager by an adminis-
trator. A budget is an estimate of income and expenditure for
a set period of time. Budgets generally begin with each fiscal Starting a New Academic Occupational
year and end the day before a new fiscal year. Within systems Therapy Program
of care delivery, such as hospitals, budgets are set at an ideal Similarities exist between starting and managing clinical
level. They are upwardly or downwardly adjusted quarterly in and academic programs, but distinct differences occur as
systems to determine the need to shift funding from one de- well. Academic programs are developed according to the
partment or project to another as determined by an adminis- type of college or university (e.g., community college, uni-
trator. The bottom line nominalization in budgets is intended versity) that wants to offer occupational therapy as a course
to be a baseline. Institutions attempt to remain in a positive of study. The Carnegie Classification of Institutions of
variance throughout the year, for fiduciary accountability. Higher Education (2017) provides definitions, classification
In general practice, managers are expected to adhere to their descriptions, and the methodology (flowcharts illustrating
budget. If there is a need to exceed the budget, the manager the 6 all-inclusive classifications) for classifying colleges and
work with their administrator to achieve a solution. An ad- universities. The types of degrees awarded are also related to
ministrator can move funds from one department to another these classifications.
to cover unforeseen expenses if another unit has a surplus or In some states, the college or university can include an
unspent funds. The occupational therapy manager needs to reentry-level course of study if the program can receive accredi-
view and track supplies and expenditures and oversee the bud- tation from the regional accrediting body and the professional
get in a fiduciary manner. In hospital settings, occupational accrediting body. Currently, post-professional occupational
therapy budgets can be in the millions, when salaries, benefits, therapy programs are not accredited by the national accredit-
supplies, and other expenditures are accounted for. An occu- ing body, the Accreditation Council for Occupational Therapy
pational therapy manager generally see the salaries and benefit
costs for each position they are managing. ®
Education (ACOTE) but must be accredited by the regional
accrediting body for the institution. Case Example 14.2 pro-
vides case scenarios for starting education programs.
For More Information
Consultants
See Chapter 50, “Developing a Budget,” for more information
on budgeting. Many institutions of higher learning hire a consultant
in advance of filing a letter of intent to start a program.
CASE EXAMPLE 14.2. Starting Educational Programs
Scenario 1
You have earned your doctoral degree and have been teaching as an adjunct professor at several occupational therapy and occupational therapy
assistant programs in your region for the past 5 years. You are considering changing your primary work focus to academia.
1. How would you prepare for your search for a position? Other than having earned a doctoral degree, what additional goals and skills do you need
to include in your professional development plan to make this transition? Where could you turn for advice or mentorship? Does your CV reflect
your experience in higher education?
2. Make a list of the lectures you have given, the technology you have used in the classroom, and the networking you have done to prepare
(think about professional organizations, memberships, networking, etc.).
3. Create 5 goals with time frames to assist in your pursuit of a position.
Scenario 2
You are the program director of an associate degree–granting occupational therapy assistant program. You and the educational administration at
your community college have been discussing developing a bridge program to a bachelor’s degree program.
4. What strategies would you suggest to preserve the ability to continue to train occupational therapy assistants while retaining compliance
with ACOTE standards?
5. What other institutions could you collaborate with to create that bridge?
Scenario 3
You are the program director of a master’s-degree program in occupational therapy. You must develop a plan to transition the program to a doctoral
entry-level program and determine whether it is possible at your university.
6. Where would you seek guidance about degree granting and institutions?
7. According to the ACOTE Standards (ACOTE, 2018), what are the differences between a master’s-degree program and a clinical doctoral
program?
8. What factors determine when and whether you can continue to admit students and bestow the master’s degree?
Scenario 4
You have been approached by an executive search term to apply and interview at a university that is interested in starting an entry-level clinical
doctorate in occupational therapy (OTD) program.
9. What would you need to find out in advance of the interview?
■ What questions would you want answered before deciding whether the university would be a good fit for offering an OTD program?
■ What infrastructure is needed for the program to thrive?
Consultants may be asked to develop a curriculum plan ACOTE contact

and a business plan to inform the administration’s con-
After the administration commits to a plan, the institution
sideration of the feasibility of the program. Some of the
submits a letter of intent to ACOTE to develop a program.
information needed will include guidance for what fis-
ACOTE will establish a time frame for a candidacy applica-
cal and physical investments are required to develop and
tion review and approval. After the letter is filed, the institu-
support the program (e.g., adequate space and equipment,
tion must submit a completed candidacy application within
support services, administrative and faculty personnel).
a set time frame (issued by ACOTE) to achieve candidacy
Some universities and colleges hire a consultant who has
status.
specific knowledge of ACOTE requirements and candidacy
application development during the candidacy application
Administrative collaboration
process. Consultants may have been ACOTE members or re-
viewers and, therefore, usually have a broader perspective in At a minimum, a program director and an AFWC should be
terms of the information that is being sought in the applica- hired to work with the administration to complete the can-
tion. Consultants may do this in a part-time or full-time role; didacy application. The committee that is formed to hire
their time can be contracted for a set number of hours. This is a program director often includes faculty members from
a good practice overall because the external consultant often the college that will house the program or members of the
has insights that a program director, academic fieldwork university. Many colleges invite members of the local occupa-
coordinator (AFWC), or other hired faculty may not have. tional therapy community to be part of the selection commit-
Gaining perspective can be a challenge if a program director tee for the new program.
has developed a previous academic program, if the institu- Soon after the program director and AFWC are hired,
tion is not equivalent in Carnegie classification status, or if they should be given membership on departmental, college,
the culture of the university or college is distinctly different. and university committees to gain service to the college and
community and to support their own applications for even- Unions

tual promotion, if applicable. As they develop a program,
When setting or developing policies for faculty, which are
the occupational therapy faculty will need to interface with
shared with ACOTE (e.g., through professional development
key university-wide committees, such as those for curricu-
plans), it is important to have knowledge and understanding
lum and outcomes. The faculty will also have expectations
of the structure within the university that governs day-to-day
for service to the university community (e.g., committee par-
work, ACOTE requires candidacy applicants to share work-
ticipation, service engagement, mentorship/mentee program
load expectations. Workloads have to be consistent with uni-
inclusion).
versity policy and should also be reasonable and in line with
Only some higher education institutions offer tenure.
other occupational therapy academic programs in other col-
Other institutions may have expectations for service to the
leges or universities that are similar in structure. The faculty
institution, but there may not be any formal, defining ex-
labor environment often dictates these policies, which are
pectation of how much service or scholarship is required to
then included in faculty handbooks or similar documents.
sustain an appointment. The tenure process or academic ad-
Faculty at a college or university faculty may or may not be
vancement information is generally found in a faculty man-
unionized. The American Association of University Profes-
ual. All faculty should read the manual at or before starting
sors (AAUP; 2017) is a nonprofit organization of faculty and
a position.
other academic professionals. Chapters are based at colleges
and universities across the country. There are 2 sister organi-
Candidacy application zations: the AAUP Collective Bargaining Congress, which is
The ACOTE candidacy application generally takes months a labor union; and the AAUP Foundation, which funds char-
to complete. The application is electronic, password pro- itable and educational purposes of the AAUP. Whether an in-
tected, and made through an online portal. After the insti- stitution is organized or not, the AAUP policies and rules are
tution pays its fees and establishes its intent, ACOTE staff generally followed in most academic institutions.
issues access to the portal and informs the institution’s rep-
resentatives of the due date for the completed candidacy ap- Peer faculty mentorship
plication. The institution’s program faculty, dean, provost, Peer faculty mentorship is also valued at some academic in-
and president all give input in the application and review the stitutions. If one works in an environment where faculty de-
application before it is filed. velopment is encouraged, having a mentor who “knows the
Each ACOTE Standard has a page in the application. ropes” can often provide a path to success for a new faculty
Substantiating documentation is submitted in PDF format member. Mentorship can ease adjustment to new ways of
to offer examples of policies and provide copies of fac- working and increase the probability for success. A peer men-
ulty credentials, for example. The program director and tor helps the new faculty adjust to the campus environment,
AFWC must possess the credentials defined by ACOTE practices, and values.
to be in compliance with ACOTE accreditation stan- Even before the ACOTE candidacy papers are filed, it is
dards. The Standards (ACOTE, 2018) should be referred important to establish inclusion of the faculty and obtain
to at each step in developing the document. The docu- support from the college community for the program’s devel-
ment also must demonstrate congruency among the stra- opment. Programs cannot develop without community-wide
tegic plan, vision, and mission of the university and the support.
college.
The program director and AFWC should monitor ACOTE
Program housing
actions. It is possible that proposed standards may replace
current standards while the application is in progress. In this Some occupational therapy programs are housed with physical
case, the application may need to reflect changes in the appli- medicine and rehabilitation programs, others with schools of
cation process (e.g., the program may be approved for candi- pharmacy and allied health, some with colleges of education,
dacy and working toward the self-study document; however, and some with colleges of health and wellness. Institutions
the new requirements may include additional documentation generally have historic precedents that can give insight into
or information that must be included in the self-study before why that college developed and why the program is housed
it is submitted). within a given college.
The application is detailed and somewhat complex. Space will need to be identified for the program. Potential
ACOTE offers a training seminar several times a year to on-campus buildings may require remodeling to provide an
instruct program directors on how to prepare the applica- acceptable environment for labs and classrooms. If space is
tion and to engage and enculture them into the process. The not available on campus, the university must consider either
seminars are generally offered before Academic Leadership purchasing a building (or space within a building) where the
Council meetings and throughout the year. Some may be program could be housed or building a new environment for
scheduled in between meetings when the demand is high and the program. Faculty members, staff, and interprofessional
the seminars sell out. In the recent past, the seminars have departments that will work closely with the program should
filled to capacity. be included in any building or remodeling project to ensure
that the space will be able to be used for the purposes in- a face-to-face, on-campus visit may be the best choice. If they
tended and will adequately supply the demands of use (e.g., can see the campus, witness the culture and environment,
electrical demands, WiFi and cabled computer wiring, splint- and meet the professors and support staff, they are often reas-
ing spaces, pediatric sensory labs, special sinks or plumbing, sured. Such visits may make the difference in deciding their
functional and traditional lab spaces and equipment, accessi- choice of college or university.
bility of spaces, storage). OTCAS allows a program to communicate with appli-
It will take at least a year to plan and construct the space, cants who have the credentials and profiles that adminis-
so this should be completed early in the program’s develop- trators seek, and admissions staff can encourage potential
ment on campus; contingency space may need to be defined candidates to apply. Members of the program’s admissions
before construction begins. It is shortsighted to assume that committee can access applicants and choose those who meet
standard classrooms and bench labs will be adequate for ed- the admission criteria (e.g., grade point average, writing style,
ucating occupational therapy practitioners. The occupational adequate shadowing experiences, Graduate Record Exam-
therapy faculty may need to advocate for the contextual needs ination scores [GRE]). Application deadlines vary. In recent
of the field of study and the proper environment to support it. meetings of occupational therapy academic leadership, some
programs have broached the desire to standardize a universal
Admissions application deadline, but this had not advanced in action or
discussion at the time of this writing.
Sizes of student cohorts are set in advance, usually in the ini- For some programs, rolling admission until a cohort is filled
tial program business plan. Admissions cannot be opened is the only viable approach. Some applicants may accept ad-
until accreditation is established. Students who apply should mission and submit deposits but will accept a position at their
be informed of the program’s status when they apply. Even first-choice institution if they gain acceptance after the dead-
with candidacy, if a program fails during its self-study phase, line or are advanced to candidate status from a waiting list.
the students will not be eligible to sit for the NBCOT exam Admission is a dynamic process, and each program has
with an entry-level degree. Without this credential, students to determine within their setting the admission guidelines
cannot become licensed to practice. that offer transparency to fairness and access of diverse stu-
Most academic institutions will support their programs and dent groups. If a program uses a formal interview process on
work responsibly to ensure accreditation. If an institution lacks the grounds, it may be helpful to develop a supporting group
access to resources, especially financial, to build and support a to assist with the admission process. For example, beyond
program that can meet accreditation standards, then the pro- including the faculty and admission representatives, con-
gram may not be able to progress to full accreditation status. sider including members of the program’s advisory council,
After a candidacy application is accepted and ACOTE members of the consumer community, faculty from associ-
grants candidacy status, admissions must proceed to have an ated university programs, and clinical partner groups from
opportunity to recruit a viable cohort of qualified candidates. nearby universities (medical faculty in local medical schools
Admission to occupational therapy programs has been aided and members of physical therapy or speech–pathology pro-
with the creation of the Occupational Therapy Centralized grams, if they are not a part of the campus community).
Application Service (OTCAS). A relationship with OTCAS
can be established before candidacy is sought so the platform
Teaching assignments and schedule
is ready to accept applicants as soon as candidacy is granted.
Visibility and viability are necessary to favorably market After a cohort has been accepted and confirmed, the program
programs and attract candidates. All programs must develop director and occupational therapy faculty have to plan for the
web presences. Marketing groups within the academic in- teaching assignments and schedule. ACOTE requires the in-
stitution generally use strategies that they have determined stitution to share policies about workload and staffing plans.
work best to appeal to candidates who are drawn to their pro- If they do not demonstrate a commitment to providing an ad-
gram and similarly ranked institutions. Often, there are also equate number of instructors for courses, the program could
differences in how on-ground programs versus online probe cited during the assessment process.
grams are marketed. An ongoing concern is the shortage of qualified higher
Admission processes differ from institution to institution education instructors in the field of occupational therapy.
and from program to program. Some occupational therapy Recruiting experienced faculty can be challenging. Some
programs no longer have face-to-face interviews and rely general considerations are that a program director in occu-
solely on the OTCAS application. Other programs have a pational therapy should be held to the same standard within
variety of admission experiences ranging from a 1-to-1, the institution as a peer professional. Their workloads, com-
face-to-face formal verbal interview to multimodal interviews mittee assignments, office space, and access to financial re-
that may include activity-embedded tasks that give insights sources should be equivalent.
into problem solving, insight, personal motivation, and team-
work. With developing programs, a decision must be made Growth plan. Institutions should have a commitment to
on process. If students may be concerned about entering a growth plan, if the business plan reflects an anticipated
a program with candidacy status that is not yet accredited, yearly increase until the maximum cohort size is reached.
There should be a plan to hire additional faculty yearly until Faculty recruitment
the cohort size and student-to-faculty ratio match. There may
When recruiting faculty, program managers should consider
be administrative and non-administrative faculty. Adminis-
degree and skill diversity among faculty members. Occu-
trative faculty lines tend to be non–tenure track lines. These
pational therapy educators may hold the following degrees:
faculty members may have less job security than that of the
master’s-level education at the associate-degree program, a
general faculty, and their liquidity of time may vary from
proportion of master’s to doctoral education for the master’s-
that for full-time academic faculty, but administrative faculty
degree program, and a doctoral degree for the doctoral-
often have reduced teaching loads to balance their workload.
degree program. Occupational therapy practitioners choose
In many institutions, administrative faculty are expected to
a variety of terminal degrees when they become educators.
be on campus daily for the full business day. Full-time academic
Currently, a doctoral degree is a terminal degree.
faculty have greater liquidity of time and generally are expected
There are also considerations for research versus non-
to be on campus to teach, have office hours, attend training,
research degrees. For example, clinical doctorates generally
and fulfill committee obligations. Some institutions demand
are not considered research degrees. Some academic institu-
physical presence at committee meetings. Other institutions
tions require that faculty have research degrees, while others
use virtual meeting platforms and encourage attendance in
do not. Some individuals have education degrees, such as the
person or virtually. Occupational therapy programs with mul-
educational doctorate (EdD). The EdD is often considered a
tiple sites often use virtual platforms for committee meetings.
research degree.
Some occupational therapists aspire to careers as leaders
Other instructors. Programs can use adjunct faculty and in education. An EdD may position them well to seek promo-
specific topic lecturers, lab instructors, and others to balance tion within universities to positions such as assistant dean,
the instruction within courses and to ensure that there are ad- associate dean, or dean. If they continue to gain competence
equate vetted faculty who can instruct. In most institutions, in academic leadership, they could work for further advance-
the title of adjunct faculty implies that the institution employs ment within the university. Faculty members may also take on
that level of instructor. Positions for adjunct instructors may roles within the faculty of the university, such as seek election
have to be posted, applicants sought, and positions formally to the faculty senate. Faculty with doctoral degrees often ad-
offered to the individual candidate through the institution’s vance in university-wide academic community prominence.
human resources process. Degree diversity can strengthen a department by having the
Clinical instructors (CIs) may be part of the full-time presence of many with diverse knowledge and experience.
faculty. CIs may be offered opportunities for advancement. Finally, faculty should represent a variety of clinical prac-
Some university-based medical centers give CIs assistant- or tice experience. Practice currently has avenues for obtaining
associate-level appointments. There are usually guidelines advanced clinical or board certifications. These certifications
that help determine an appropriate rank based on the appli- require specific training and experience and verify that the
cant’s curriculum vitae. CIs may be given release time from holder has a specific set of skills and knowledge. Emerging
their regular job hours to teach for the university. A CI who is practice also needs to be represented. Faculty may need to be
given release time cannot be paid additionally for the teach- part of the fieldwork experience for students in emerging en-
ing time (they are not allowed to “double dip”). Many CIs will vironments when placements cannot be offered because there
take paid time off and use their own time, versus the hospi- are no current mentors. Educators need to be prepared to lead
tal’s time, to teach. in the development of new practice.
Lab ratio. Lab ratio also must be defined institutionally,

and numbers are often based on peer laboratory groups for Advisory groups
other professions. Adequate instructors and lab sessions are Academic programs have advisory groups comprised of mem-
needed to ensure student-to-faculty ratios are preserved. The bers of the professional and academic community. Some ad
plan for staffing labs will also affect the faculty workload. visory groups also include community stakeholders. Potential
members of an advisory group may be nominated and con-
Faculty workload. A careful balance is required when plan- tacted to determine their willingness to serve in this capacity.
ning for faculty workload. Some institutions will pay faculty to Best practice is to have several meetings per year. Advi-
work overtime. If faculty cannot accept the additional hours, sory board members should be informed about overall pro-
more instructors will need to be hired. gram operations, the program application in progress, the
Adequate funding must be in the budget to plan for this in- curriculum as it is being developed, and the status of student
evitability. Deans and provosts must demonstrate a commit- applications and admissions. Advisory board members may
ment to the faculty and the program for these circumstances. also serve as a link to resources in the practice community.
Deans and provosts can look at the university’s overall budget Clinicians have a stake in ensuring that there will be a flow
and move resources from one program to another based on of trained and educated professionals to enter and sustain the
demands. The program director must have oversight on this practice environments and meet the needs of their communi-
and seek what is needed for program support. ties and populations of service.
Some universities have a national presence on their advi- EXHIBIT 14.2. Practical Considerations for
sory board. Alumni also often serve on advisory boards for Starting New Programs
the programs from which they have graduated. Universities
with large endowments may have funding to pay expenses ■ Understanding the overarching systems where we work and manage
for advisory board members to physically be present at meet- services is key to our inclusion and success in those settings.
ings. Virtual platforms such as Skype or Zoom allow for par- ■ An understanding of management within the context of
ticipation of advisory board members who live or work at a occupational therapy is a part of entry-level education.
■ Program development relies on a foundation of knowledge of
distance.
management principles.
■ It is important to have an ability to understand budgets and the
Review Questions mathematics associated with billing and remuneration.
■ Planning for growth and development is important when developing
1. If you were starting a new occupational therapy program both clinical and educational departments.
in a clinical setting, which 3 parameters should shape ■ Building skills as a manager is important for practitioners who
your decision making and direction of development? wish to advance in either a clinical or an educational setting.
a. A needs assessment, scope of practice, and practice ■ Networking skills are paramount. Know where to find consultants
parameters within an interprofessional team to help you, if the work is out of the scope of your own skills
b. How many people in the setting know about occu- and level of understanding. Consultants can offer insights into
pational therapy, how welcoming the people are to how other successful programs operate and strategies that are
the presence of occupational therapy, and perceived recognized as being successful.
competition
c. Financial considerations, restrictions on practice,
and billing procedures and their presence in the union elevates the stakes for nego-
d. Billing, reimbursement, and the ability to say the fa- tiating. Their presence also has financial ramifications; union
cility has an occupational therapist dues are a gain for the union, and an increase in numbers can
2. What is a shared value between developing programs in also lower the per-member cost for benefits such as medical
clinical and educational settings? insurance. In these settings, the manager generally is given
a. Current non–occupational therapy employees can act training in managing in an organized labor environment.
on behalf of the occupational therapy presence to es- Any disciplinary action with an employee may require a
tablish a need for a program union representative to be present at the meeting. Documen-
b. Occupational therapy practitioners in both settings tation is kept and added to the employee’s file. The member
need to have professional development plans may file a grievance against management for the action. The
c. Job security in both settings depends on union rules process may not be expedient and may be extended before
and tenure any outcome occurs.
d. Occupational therapy practitioners are never in charge
or serve in administrative positions
3. Which occupational faculty member is most visible in Fieldwork
clinical settings? Professionals have an expectation of serving as mentors to
a. The program director those who are entering the profession. With efficiency stan-
b. The AFWC dards at an all-time high, there has been some reluctance in
c. Neither; they both work out of the college or univer- new clinical settings to include students during the program
sity but do not make site visits development process.
d. Both Fieldwork and doctoral-level capstone experiences can en-
rich the development process and bring fresh eyes, contempo-
rary knowledge, and evidence into the process. In the current
PRACTICAL APPLICATIONS IN clinical environment, with a simultaneous shift in occupa-
OCCUPATIONAL THERAPY tional therapy higher education, the manager will work with
Even skilled and experienced program developers can benefit the clinical fieldwork advisory groups to discuss whether the
from oversight and advice. Exhibit 14.2 provides an overview setting can train all levels of clinical practitioners. In addi-
of practical considerations for occupational therapy manag- tion to the traditional Level I and Level II fieldwork, doctoral
ers starting new programs. project placements (which are technically not fieldwork) still
require a site mentor to work with the occupational therapy
doctorate.
Unions
Staying informed and trained in changes in administra-
In organized work environments, practitioners may be union tion and management roles as well as clinical fieldwork man-
members. When a new department is developed, the union agement roles is essential to support professional practice
will be interested in recruiting staff. Therapists generally have and to bring new concepts, ideas, and programming to the
a higher earning potential than other rank-and-file members, clinical site. In occupational therapy, AOTA’s Special Interest
Sections (SISs) provide specific training and continuing edu- LEARNING ACTIVITIES
cation that addresses these skill development and networking
needs. 1. Identify the regional or national career accrediting body
for your college or university (or your alma mater if you
have graduated). Identify some of the strengths and lim-
Advancement itations of your institution. Read the summary from the
Occupational therapy leaders can advance within practice most recent report from the regional accrediting body to
settings. Beyond being a department manager, occupational see if it agrees with your evaluation.
therapy practitioners can advance into practice management 2. Identify the role of the occupational therapy department
and administrative roles. Practitioners may advance to roles or program in the last regional accreditation review. If
that involve administration of larger groups inclusive of the the department or program was not an active partic-
occupational therapy presence, such as orthopedic services, ipant, find out who was involved. Determine how the
surgical services, and neurological services. Some of these occupational therapy program could participate. Attempt
leaders in management may advance their degree presence to secure a role on the planning committee for a repre-
and take on higher-level leadership roles, such as vice presi- sentative from occupational therapy so there is represen-
dent, president, and chief executive officer. tation in the planning process and inclusion in the next
review process.
3. Discuss with your professor or program director the
Review Questions ACOTE process for your program.
1. CMS has announced a major change in how occupa- 4. Identify the strengths and limitations of your educational
tional therapy services will be delivered and reimbursed program. Ask your professor or program director to share
in sub‑acute rehabilitation and long-term care settings. with you the ACOTE report to see if your thoughts agree
How would you approach this announcement and plan with those of ACOTE.
for change in the environment you manage (as a clinical 5. Accreditation relies on volunteers from the profession.
manager or as an academic manager)? ACOTE’s Roster of Accreditation Evaluators includes
2. With the advent of the tsunami of aging, the numbers of volunteers from both practice and academia. Iden-
persons ages 65 or older who will seek occupational ther- tify the requirements, including training, to be an
apy care will rise exponentially. Dementia management is evaluator.
a major focus of care delivery. What steps would you take
to develop a plan for inclusion of occupational therapy
services in dementia management that encompasses the ACOTE STANDARDS
education and training of both practicing clinicians as This chapter addresses the following ACOTE Standards:
well as students who are entering the profession? List who
would be a part of your networking group. ■ B.5.0. Context of Service Delivery, Leadership, and Man-
3. You are a new academic program director in an academic agement of Occupational Therapy Services
setting. Describe what you would do to build a profes- ■ B.5.2. Advocacy
sional advisory council to advise you and your faculty ■ B.5.3. Business Aspects of Practice
while developing the program. Who would you want to ■ B.5.4. Systems and Structures That Create Legislation
compose the committee, and how would you identify the ■ B.5.5. Requirements for Credentialing and Licensure
people for this group? ■ B.5.6. Market the Delivery of Services
■ B.5.8. Supervision of Personnel
SUMMARY ■ B.6.4. Locating and Securing Grants.
Developing new programs takes a pioneering spirit. The pro-
cess is never static. Standards dictate the parameters in which
practice occurs. Changes in standards occur over time. A
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changes in both clinical and higher education settings.
American Occupational Therapy Association. (2017). ACOTE 2027
Networking within and external to one’s profession is neces-
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and provoke thought processes and potential actions that can -2027.aspx
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Braveman, B., Baize, C., Malacara, M., Morris, G. S., Munoz, L., lines. Retrieved from http://www.nationalacademies.org/hmd
Scheetz, J., & Wright, D. (2011). Strategic visioning and planning: /Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust
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Cultivating a Positive and Collaborative Workplace CHAPTER
Winnie Dunn, PhD, OTR, FAOTA; Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA; Evan Dean, PhD, OTR/L;
and Lindsey Jarrett, PhD 15
LEARNING OBJECTIVES
■ Identify the characteristics of a collaborative and positive work environment,
■ Articulate the core elements of strengths-based approaches that help cultivate a positive and collaborative workplace,
■ Distinguish methods to operationalize strengths-based approaches in everyday work settings and activities, and
■ Identify core elements of strengths-based leadership in action to foster positive and collaborative workplaces.

• Coaching • Influencing leaders • Stability
• Collaboration • Inspirational communication • Strategic thinkers
• Commitment • Leadership • Strengths-based approaches
• Compassion • Mutual respect • Strengths-based leadership
• Discrimination • Positive psychology • Trust
• Execution • Relationship builders • Vision
• Hope
OVERVIEW ESSENTIAL CONSIDERATIONS
T
here are as many work environments as there are dif- What does a collaborative workplace look like? Collaboration
ferent types of leadership. Occupational therapy prac- is a process of colleagues working together to accomplish
titioners work in health care and education settings as goals. As with many important aspects of work, specific
well as industry and community programs. Each work envi- knowledge and tools foster positive work environments
ronment is organized to meet its own goals; however, some and invite collaboration. First, occupational therapy practi-
positive and collaborative methods can be effective across all tioners must embrace the idea that every person has a leader
work environments. ship role in some aspects of everyday work. One might be the
In recent years, a growing body of evidence indicates that head of a team, serving people in a clinical setting; one might
strengths-based approaches are quite effective in many fields. be the resident expert on a new evidence-based practice that
Strengths-based approaches highlight people’s interests and needs to be deployed across settings; or one might be teaching
talents to guide life planning, career decisions, parenting, and students who aspire to become occupational therapy prac
relationship building. When applied to leadership, these ap- titioners. Leadership starts with a mindset that creates a
proaches provide tools for creating a healthy, vibrant work strong basis for people to work together; that mindset frames
environment that take advantage of every person’s unique actions supportive of others and advances goal attainment
characteristics. In this chapter, we introduce the core features within the organization. Strengths-based approaches of
of strengths-based approaches and demonstrate how to apply leadership provide additional tools to support all team
them in various leadership situations. members’ potential.
https://doi.org/10.7139/2019.978-1-56900-592-7.015
153
Cultivating a Positive and Collaborative Workplace CHAPTER
Winnie Dunn, PhD, OTR, FAOTA; Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA; Evan Dean, PhD, OTR/L;
and Lindsey Jarrett, PhD 15
LEARNING OBJECTIVES
■ Identify the characteristics of a collaborative and positive work environment,
■ Articulate the core elements of strengths-based approaches that help cultivate a positive and collaborative workplace,
■ Distinguish methods to operationalize strengths-based approaches in everyday work settings and activities, and
■ Identify core elements of strengths-based leadership in action to foster positive and collaborative workplaces.

• Coaching • Influencing leaders • Stability
• Collaboration • Inspirational communication • Strategic thinkers
• Commitment • Leadership • Strengths-based approaches
• Compassion • Mutual respect • Strengths-based leadership
• Discrimination • Positive psychology • Trust
• Execution • Relationship builders • Vision
• Hope
T
here are as many work environments as there are dif- What does a collaborative workplace look like? Collaboration
ferent types of leadership. Occupational therapy prac- is a process of colleagues working together to accomplish
titioners work in health care and education settings as goals. As with many important aspects of work, specific
well as industry and community programs. Each work envi- knowledge and tools foster positive work environments
ronment is organized to meet its own goals; however, some and invite collaboration. First, occupational therapy practi-
positive and collaborative methods can be effective across all tioners must embrace the idea that every person has a leader
work environments. ship role in some aspects of everyday work. One might be the
In recent years, a growing body of evidence indicates that head of a team, serving people in a clinical setting; one might
strengths-based approaches are quite effective in many fields. be the resident expert on a new evidence-based practice that
Strengths-based approaches highlight people’s interests and needs to be deployed across settings; or one might be teaching
talents to guide life planning, career decisions, parenting, and students who aspire to become occupational therapy prac
relationship building. When applied to leadership, these ap- titioners. Leadership starts with a mindset that creates a
proaches provide tools for creating a healthy, vibrant work strong basis for people to work together; that mindset frames
environment that take advantage of every person’s unique actions supportive of others and advances goal attainment
characteristics. In this chapter, we introduce the core features within the organization. Strengths-based approaches of
of strengths-based approaches and demonstrate how to apply leadership provide additional tools to support all team
them in various leadership situations. members’ potential.
https://doi.org/10.7139/2019.978-1-56900-592-7.015
153
Core Components of Leadership to Create a new ways to think creatively and solve problems in a new way.
Positive and Collaborative Workplace The leader establishes clear expectations about judgment-free
communication that invites team members to try new ideas
This chapter considers many examples of leadership, includ- without fear of punishment if the idea does not work. The
ing informal structures (e.g., peers who provide guidance) leader blends the authority over an area of work with the
as well as more traditional structures (e.g., leadership in or- responsibility to operate independently to create solutions.
ganizations). Leadership is a skill that involves inspiration, The leader creates structures such as regular supervision
collaboration, a shared vision, and shared decision making and coaching sessions so team members can get support when
(O’Malley & Cebula, 2015). Professionals thrive when their they need it. Operationalized procedures, such as incorpo
leaders rating brainstorming sessions that accept all ideas before
■ Create safe environments, actual planning begins, also communicate the values of ac-
■ Recognize that many challenges need people to think and ceptance of others’ ideas within the team. When teams value
act in new ways, a strengths-based perspective, a new team member might
■ Create a sense of belonging, notice procedures that empower the team to test new ideas.
■ Understand they do not have all of the answers, and
■ Create shared goals (Giles, 2016; Heifetz et al., 2009; Areas of Strength-Based Leadership
O’Malley & Cebula, 2015).
Strengths-based approaches to leadership cultivate positive
Many books, articles, and websites define key attributes and collaborative workplaces. The Gallup Corporation has
of a leader. In the past decade, EMyth Team (2011) outlined researched strengths and leadership for many decades. Based
5 core components of leadership: on more than 20,000 interviews and 10,000 surveys, Gallup
1. Vision, asked people why they followed the most influential leaders in
2. Discrimination, their lives. Synthesizing the Gallup results, Rath and Conchie
3. Strategic thinking, (2008) found 3 key areas. The most effective leaders
4. Commitment, and 1. Invest in strengths (e.g., provide professional development
5. Inspirational communication. based on a member’s strengths, assign tasks based on
When leaders use these components, they create positive and each team member’s strengths),
collaborative work environments (Giles, 2016; Heifetz et al., 2. Surround themselves with diverse team members (e.g.,
2009; O’Malley & Cebula, 2015). people with different skill sets, varying backgrounds, dif-
Vision provides a means to understand the system and ferent professional training), and
imagine how the system could work better. When imple- 3. Understand their followers’ needs (e.g., learning and
menting a vision, a leader sees many opportunities that could supporting followers’ goals, guiding development of new
move the team closer to the vision. Discrimination allows the skill sets in followers; Rath & Conchie, 2008).
leader to evaluate potential opportunities and focus on the When leaders look for and foster the strengths of others,
most salient ones. After identifying the most salient oppor- group members are more engaged in their work, more pro-
tunities, leaders consider which plans will be most effective ductive in service to the team’s goals and outcomes, and less
to meet objectives (i.e., strategic thinking). Commitment is a likely to quit their job (Rath & Conchie, 2008). No single per-
dedication to a process or outcome and is essential to leader- son in a group has to have all the skills needed to accomplish
ship because systems are complex, and therefore teams must the group’s collective goals; knowing everyone’s strengths
implement plans over a long period. Finally, a leader needs provides a way to leverage everyone’s talents, which creates
to use inspirational communication to share the vision to more capacity. Another factor that emerges from exploration
inspire the team and stakeholders. of strengths-based leadership is the leader gets to know what
In occupational therapy practice and education, the core group members need to be productive and satisfied. Feeling
components of strengths-based leadership support a positive heard engenders loyalty.
culture and a spirit of collaboration. In sessions with clients
or families, an occupational therapy practitioner can inspire
Leader strengths
clients to keep their interests in mind as they plan how they
will partner with the practitioner to meet their goals. In Rath and Conchie (2008) described the actions of leaders
meetings with interprofessional colleagues, an occupational who cultivate positive workplaces. Some leaders are great at
therapy practitioner collaborates strategically to solve col- execution; they know how to implement plans and persist to
lective challenges. Strengths-based approaches are built on meet goals. Influencing leaders are focused on a wider audi-
positive psychology principles (Seligman, 2011). ence and look for opportunities to align groups with common
Occupational therapy leaders and managers can oper- interests. Other leaders are relationship builders; they see
ationalize the core competencies in everyday actions to de- how group members might connect to each other and create
velop a safe, creative, shared structure of goals and actions. outcomes that are greater than the individuals might produce
For example, the leader might provide readings that illustrate individually. Finally, some leaders are strategic thinkers; they
CHAPTER 15. Cultivating a Positive and Collaborative Workplace 155
see connections among ideas to create inspiring opportuni- Review Questions

ties. These areas of strengths-based leadership are consistent
1. How does developing a vision enable the occupational
with the core components outlined earlier in the chapter
therapy manager to formulate a plan for developing posi-
(i.e., vision, discrimination, strategic thinking, commitment,
tive communications?
inspirational communication; EMyth Team, 2011).
2. How does leadership view the strengths-based approach?
No one leader can have all these characteristics; skillful
3. Describe the needs of followers.
strengths-based leaders have insight about their own strengths
and recognize other characteristics in team members. This ap-
proach enables everyone to be a “leader” within the group, be- PRACTICAL APPLICATIONS IN
cause each person’s way of approaching a solution is uniquely OCCUPATIONAL THERAPY
theirs to contribute to the collaborative workplace.
Application of Strengths-Based Leadership in
Follower needs Community Settings
What inspires followers to connect to a leader’s vision? Fol- Consider the following example of applying strengths-based
lowers need specific things from their leaders to feel cared leadership in a community setting. Addie is an occupational
for, maintain loyalty, and be productive members of a group. therapy manager who leads a team of early intervention pro-
According to findings from Gallup’s research (see Rath & viders serving families with children with developmental dis-
Conchie, 2008), followers need 4 things from their leaders: abilities. Taking a strengths-based approach, Addie believes
that parents know how to best parent their child and uses a
1. Trust, coaching framework with families to (1) empower the family
2. Compassion, to create solutions and (2) communicate a relationship based
3. Stability, and on mutual trust.
4. Hope. Addie also believes that the child will thrive when the
Trust is a belief that one can rely on what is happening and family has the knowledge needed to incorporate the child
is at the foundation of a healthy workplace. Some organiza- into family routines. Addie uses coaching to support family
tions talk about honesty and integrity, which are also bound members to develop solutions to their challenges with their
to a trustworthy culture. Trust develops across time and is child. Additionally, Addie and her team write evaluations in
fostered when a leader is both transparent and authentic. In family-friendly language (e.g., saying the child’s name in-
trusting work environments, everyone is more engaged and stead of “patient” or “child”; not using jargon) that acknowl-
efficient, knowing that team members will follow through to edge the strengths of the child and family as well as daily life
accomplish collective goals. challenges indicated by families (for a specific example of
Compassion is a feeling of empathy for others and is an coaching in action, see Augustyn & Wallisch, 2017).
indicator that the leader cares about the people in the orga- Addie also uses the same approach when working with
nization. When people feel cared for, they are more loyal and colleagues. When a colleague comes to Addie with a chal-
engaged with the work of goal attainment. Compassion also lenging situation, Addie asks reflective questions to both
relates to people wanting the leader to create a positive envi- understand the parameters of the situation’s challenges and
ronment that inspires them. help the colleague think deeper about how to craft a satisfy-
People want a sense of stability from their leadership. ing outcome. For example, Grif, a new occupational therapy
Stability is a sense that a person can count on the steadiness practitioner, came to Addie about a family he was serving.
of the organization as a whole or within a team. When peo- The child was exhibiting behavioral patterns consistent with
ple worry about being paid, having a job, or feel unwilling a person who is a sensory seeker (i.e., needs a lot of movement
to share a divergent idea on their team, their worry diverts and stimulation), which was causing challenges with family
energy from the work. Being transparent about goals and fi- routines because the parent was a sensor (i.e., prefers little
nances is a clear way to demonstrate the organization’s status sensory input).
and makes people feel secure. The family’s main challenge was the after-school routine
Finally, followers need to feel hope about the future. In the at the end of the school and workday. The parent needed a
workplace hope involves feeling enthusiastic about the fu- quiet, calm atmosphere to settle in after a day at work; the
ture; followers who feel hopeful are highly engaged at work, child, however, wanted to interact with the parent and needed
whereas people who did not feel enthusiastic are disengaged to move around and make noise because she had to control
from their work (Rath & Conchie, 2008). Hope is especially her movements at school. This difference in sensory patterns
important during uncertain times or in chaotic circum- usually led to an argument between the parent and child.
stances. People want to see a way through the challenging In each visit with the family, Grif suggested many strategies
times to better outcomes. Sending a message of hope involves in which the child could get the movement she needed, but
being proactive (e.g., initiating plans and ideas for expansion) the family did not use the strategies in the family routine.
rather than reactive (e.g., only responding to situations as Grif was frustrated and asked Addie for suggestions on how
they occur—putting out fires). to move forward with the family.
When Grif approached Addie for advice, Addie began by ■ Identify goals of the clinicians, and
asking questions to fully understand the current situation, ■ Assess expectations for research and development.
such as
Occupational therapy practitioners add value to the re-
■ “What have you tried that worked?” search process as they actively think critically and solve
■ “Why do you think the suggestions have not worked?” problems across diverse situations in the health care con-
■ “I wonder if the parents know enough about the child and tinuum. Lindsey knows that clearly defined goals, mutually
parent’s sensory pattern differences to understand why derived expectations, and outcomes-centered planning are
you’re making your suggestions?” and crucial for producing evidence-based research and ultimately
■ “How could you involve the family in developing an more effective practices. As the research project progresses
approach that would work for them?” from design to implementation, Lindsey consistently creates
opportunities for feedback with colleagues, clinicians, and
Addie also shared a story from her past when she had dif-
study participants, as well as conducts analyses that provide
ficulty getting parent buy-in until she began asking questions
the hospital system with outcomes and actions derived from
and the family members developed strategies that fit with
evidence.
their routines. Grif creates a new plan to incorporate sensory
Lindsey is a strategic thinker; she sees the connections
processing ideas into his discussions with the parent by asking
across the stakeholders involved in discharge planning and
coaching questions. For example, Grif could ask, “What does
recognizes how to create opportunities for both growth and
your daughter seem to need when she gets home?” to foster
effectiveness. In addition, Lindsey has strengths as an exec-
discussion about the child’s need for movement. Following
utor by deriving clear goals and expectations in the research
up could be questions such as “How could your daughter get
process that will also have implications for practices in this
movement in a way that doesn’t bother you?” or “What are
hospital system.
some times your daughter gets movement, and it has been
OK for you?”
In this example, Addie executed a coaching conver- Review Questions
sation that Grif could then use with the family. The con- 1. Describe the coaching relationship with families.
versation was solution focused; Addie supports Grif in 2. What are some questions the occupational therapy prac-
considering what worked in the past, how to apply those titioner can ask the parents of a child who is having chal-
ideas to the current situation, and how to create a new lenges to get at a workable plan or solution?
strategy. Addie may offer insight based on experience but 3. Identify the characteristics of a strategic thinker and an
mainly helps Grif think through possible solutions. A key executor.
piece of this relationship is that Addie does not judge Grif ’s
actions or ideas. If the solution does not yield desired out-
comes, Addie helps explore why the solution did not work SUMMARY
and seeks to define a new solution with Grif. Addie knows
Strengths-based leadership requires a lot from everyone on
that building a nonjudgmental environment in which peo-
the team. There is a focus on everyone’s assets to build a plan
ple are empowered to find their own solutions builds a
for achieving goals, so all members have some responsibil-
culture of trust, compassion, and stability for families and
ity for the work. Creating a safe work environment for ex-
colleagues.
ploration and creativity fosters new ideas and supports team
members as they explore options. Strengths-based leadership
Application of Strengths-Based Leadership in is built on trust and compassion, with a sense of adventure
Research and Industry about finding new ways to be successful. ❖
Lindsey, an occupational therapy manager, is leading a qual-
ity assurance research project at a large hospital system. LEARNING ACTIVITIES
The intention of the project is to examine the most appro-
1. Consider your own strengths. The book Strengthsfinder 2.0
priate venue of care for people leaving the hospital. Using a
(Rath, 2007) provides a link to an online test to find your
strengths-based approach, Lindsey knows that the clinicians
top 5 strengths. How have you used these strengths in the
who provide care to the patients in the hospital will know
past? How might you use these strengths in an occupa-
the factors crucial to discharging people appropriately from
tional therapy context?
the hospital. Since occupational therapy practitioners are
2. Discuss a time when you did not feel safe to bring up new
trained to interact, collaborate, advocate, and negotiate with
ideas. What behaviors and contexts alerted you to the
other health care professionals (Brown et al., 2015), Lindsey
risk? What would you do now to reduce those fears and
decides to use coaching techniques, as well as qualitative re-
act with compassion?
search methods, to
3. What have you observed an occupational therapy practi-
■ Identify the barriers to safe and effective discharge planning, tioner do to foster trust and compassion when developing
■ Develop an understanding of the discharge planning process, a relationship with a family under her or his care?
CHAPTER 15. Cultivating a Positive and Collaborative Workplace 157
CASE EXAMPLE 15.1. Strengths-Based Leadership in Fieldwork Supervision
Students entering a fieldwork setting come with a variety of strengths and interests. At the same time, students must develop specific competencies
related to occupational therapy practice. It can be difficult to balance the strengths and interests of the student with the competencies that need to
be developed. This case describes how a strengths-based leader supervising fieldwork students approaches this challenge in a community setting
serving adults with intellectual disability.
Joseph, the fieldwork coordinator, begins by creating a culture of mutual respect. When introducing the people served at the site, Joseph
introduces them by their names and speaks of their interests and strengths instead of the support needs for everyday life. He encourages fieldwork
students to think of the people they serve as they would any other adult. “Adults with intellectual disability should have the opportunity to live lives
like anyone else, and our job is to support them in doing that,” he would say.
In supervision meetings, Joseph communicates trust and stability by establishing a safe learning environment. He does this by encouraging the
students to think deeply about the challenges they encounter and think through possible solutions. As students try their ideas, Joseph would ask,
“What kept this from working? What could you change? What insights do you have?” To model the safe environment, Joseph asks students to help
to think through practice-related challenges he is facing.
During interactions with students, Joseph is quick to point out areas of strength and encourages the students to apply their strengths to the
practice. For example, when a student displayed aptitude for organization and communicating with others (the influencing strength in leadership),
Joseph approached her about creating a training for riding the bus, which involved collaboration with a local transportation agency and close
communication with families. While the student was using her strengths of organizing and communicating, she was also gaining experience with
assessment to determine what individual support a client might need and intervention to consider when a person might need accommodations.
In another example, when a student expressed an interest in cooking, Joseph asked the student to work with an individual who needed to build
his cooking skills to achieve his goal of working in a restaurant (using the student’s execution strength). Joseph could facilitate these pairings
because he knew people’s interests and strengths. Because Joseph is committed to developing student strengths, he learns to incorporate the
strengths and interests while also ensuring they build the essential practice-related competencies.
CASE EXAMPLE 15.2. Strengths-Based Leadership in a Research Team
Eva is a doctorally prepared occupational therapy practitioner who leads a research group of interdisciplinary team members within a health
care business that is focused on improving health care outcomes by providing quality care at the lowest cost. The team is responsible for creating
innovative health care solutions from data insights (called edge development in the industry). Eva’s team consists of clinicians, data scientists,
analysts, and other PhD-level researchers, all trained from various sectors of the health care industry. As the leader, Eva uses coaching techniques
in every interaction with the team to (1) understand the individual goals of each person, (2) evaluate the strengths and skills of each team member,
and (3) strategically evaluate opportunities for collaboration and connection across the team.
These interactions afford Eva the opportunity to harness the highest quality work based on the strengths of each team member. Eva knows
from her professional training in occupational therapy and her postprofessional training in science that effective research and development
relies on collaboration among those with various skills and abilities. This knowledge is at the forefront of every research plan, analysis, and report.
For example, team members who are best at executing serve as leaders in collecting the information and organizing; those best at influencing
serve as leaders in getting the messages about their findings to others. In this way, Eva cultivated a research environment, and her team
members grew as leaders in industry while contributing to current work.
Eva is focused on relationship building because she sees how the team can connect with each other and create outcomes that are collaboratively driven.
She instills trust and compassion with the team, which allows the team to feel cared for and engaged in her vision and the work for the health care industry.
CASE EXAMPLE 15.3. Strengths-Based Leadership in an Academic Department
Jamie is a new department chair starting in a program that has been in existence for some time. The department has gone through a long period
of transition during which no one was in the chair position full-time for multiple years. Using a strengths-based approach, Jamie knows that to get
the team working together, everyone needs to collectively develop a mission, vision, and strategic plan for how they see the department developing
into the future. Jamie uses coaching techniques to help the team develop action plans around long-term strategic goals. Part of this process is
working together to match individual strengths and interests to action plans in the overall strategic plan.
The team’s strategic plan becomes the basis for all activities in the department. There is a clear division of labor for who will champion the different
components of the action plan based on faculty strengths. Every faculty member’s effort is allocated based on what that faculty member is responsible
for in the strategic plan each year; Jamie and each faculty member build professional development plans to reflect these responsibilities.
In an academic environment, expectations, resources, and leadership can change rapidly and often have a direct impact on the department’s
actions. These changes can come from the university itself (e.g., new senior leadership enacts a new strategic plan), from an accreditation body
(e.g., Accreditation Council for Occupational Therapy Education® [ACOTE]) changes academic standards), or even from the health care industry
(e.g., Medicare changes reimbursement guidelines that affect occupational therapy). Jamie empathizes with the team when plans change that are
out of the team’s control; however, Jamie also consistently works to maintain the department’s focus; the team directs efforts toward areas within
the department’s control to achieve collective goals with the university. Annually, the team revisits the strategic plan to reflect on progress and
modify action plans based on changes that have occurred over the past year.
(Continued)
CASE EXAMPLE 15.3. Strengths-Based Leadership in an Academic Department (Cont.)
Jamie is a strategic thinker and keeps the team collectively focused on long-term goals. Developing action plans for each faculty member that
utilize each faculty member’s unique strengths toward the collective goal helps build trust within the department. The team learns to rely on each other
for meeting individual and collective goals. Jamie is also influencing the team to recognize how everyone’s actions can affect not only the university
but also the community and the profession. By consistently using the faculty’s action plan to establish annual goals and allocate effort, Jamie is also
providing stability by setting clear expectations for all faculty to follow. Finally, and most important, Jamie is projecting hope to the team. It is very easy
in an academic environment to develop an external locus of control and focus on reacting to what is happening; however, establishing a clear and
collective mission and vision, establishing a strategic plan for how to achieve the mission and vision, and focusing on the action steps necessary to
work toward these goals all contribute to the faculty feeling hopeful about where they are headed and that they can influence their own future.
Review Questions
1. What do the 2 applications and 3 case examples have in common? With which behaviors do you identify? How can you foster those behaviors
in your own practice?
2. How might being an “executing” leader create challenges for a team? What could the team do to create a better sequence of work activities?
3. How might you best utilize an “influencer” occupational therapy practitioner in your practice?
ACOTE STANDARDS Occupational Therapy, 69(Suppl. 2), 1–6. https://doi.org/10.5014

/ajot.2015.016527
This chapter addresses the following ACOTE Standard: EMyth Team. (2011, January 12). The five core leadership skills
[blog post]. Retrieved from http://blog.emyth.com/the-five-core
B.4.24. Effective Intraprofessional Collaboration.
-leadership-skills
Giles, S. (2016, March 15). The most important leadership compe-
tencies, according to leaders around the world. Harvard Busi-
REFERENCES ness Review. Retrieved from https://hbr.org/2016/03/the-most
Accreditation Council for Occupational Therapy Education. (2018). -important-leadership-competencies-according-to-leaders
2018 Accreditation Council for Occupational Therapy Education -around-the-world
(ACOTE) standards and interpretive guide. American Journal Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi adaptive leadership: Tools and tactics for changing your organiza-
.org/10.5014/ajot.2018.72S217 tion and the world. Boston: Harvard Business Press.
Augustyn, J., & Wallisch, A. (2017). Occupational therapy in early O’Malley, E., & Cebula, A. (2015). Your leadership edge: Lead any-
intervention: Supporting families and children through cultural time, anywhere. Wichita, KS: KLC Press.
competency and coaching. OT Practice, 22(6), 14–17. Rath, T. (2007). StrengthsFinder 2.0. New York: Simon & Schuster.
Brown, T., Crabtree, J. L., Mu, K., & Wells, J. (2015). The next Rath, T., & Conchie, B. (2008). Strengths based leadership: Great lead-
paradigm shift in occupational therapy education: The move ers, teams, and why people follow. New York: Simon & Schuster.
to the entry-level clinical doctorate. American Journal of Seligman, M. (2011). Flourish. New York: Free Press.
CHAPTER
Promoting and Managing Diversity
Roxie M. Black, PhD, OTR, FAOTA 16
LEARNING OBJECTIVES
■ Understand and accept the need for promoting and managing diversity;
■ Identify the types of diversity in the workplace;
■ Begin an assessment of current diversity issues and needs in their programs, departments, and organizations;
■ Reflect on their own cultural competency and effectiveness; and
■ Use resources to develop a diversity training program.

• Controlling • Educating about diversity • Promotion of diversity
• Cultural assessment • Health disparities • Reflective discussion
• Cultural competence • Health equity • Self-awareness
• Cultural effectiveness • Ongoing education • Staffing
• Directing • Organizing • Valuing and maintaining diversity
• Diversity • Planning
W
hen examining or even perusing the multiple Diversity Today
chapters in this text, readers recognize that
The definition of diversity has changed over the years. Ini-
managing an occupational therapy program or
tially, people thought of only racial and ethnic diversity (and
department is complex, requiring occupational therapy
many continue to hold this notion). Black (2002) defined
managers to be highly skilled and effective in accomplish-
diversity as also “incorporating gender, age, ability, sexual
ing many roles, responsibilities, and requirements. Those
orientation, and class” (p. 140). Although expanded beyond
requirements, according to Braveman (2014), are context
race and ethnicity, this definition is still far too narrow. Cur-
dependent, and the role and expectations of occupational
rently, the concept of diversity is more inclusive, identifying
therapy managers may require flexibility within each set-
“life experiences, lifestyle choices and ideas, such as socio-
ting. Given the complexity within changing contexts, how
economic status and sexual orientation [as well as] the so-
does one also promote and manage diversity within each
cial determinants of health” (Becker’s Hospital Review, 2016,
occupational therapy program and department? Yet given
para. 2). Other scholars and authors have added the concepts
the increasing plurality in the United States and beyond,
of religious beliefs, political beliefs, and other ideologies
we must!
(Volckmann, 2012). When considering diversity’s many as-
This chapter provides theoretical background information
pects, any interaction might be considered cross-cultural.
and pragmatic guidelines to assist occupational therapy man-
The Pew Research Center (2015) reported that U.S. pop-
agers in promoting and managing diversity in the occupa-
ulation statistics (see Table 16.1) indicate that there is more
tional therapy clinic and beyond.
https://doi.org/10.7139/2019.978-1-56900-592-7.016
159
CHAPTER
Promoting and Managing Diversity
Roxie M. Black, PhD, OTR, FAOTA 16
LEARNING OBJECTIVES
■ Understand and accept the need for promoting and managing diversity;
■ Identify the types of diversity in the workplace;
■ Begin an assessment of current diversity issues and needs in their programs, departments, and organizations;
■ Reflect on their own cultural competency and effectiveness; and
■ Use resources to develop a diversity training program.

• Controlling • Educating about diversity • Promotion of diversity
• Cultural assessment • Health disparities • Reflective discussion
• Cultural competence • Health equity • Self-awareness
• Cultural effectiveness • Ongoing education • Staffing
• Directing • Organizing • Valuing and maintaining diversity
• Diversity • Planning
W
hen examining or even perusing the multiple Diversity Today
chapters in this text, readers recognize that
The definition of diversity has changed over the years. Ini-
managing an occupational therapy program or
tially, people thought of only racial and ethnic diversity (and
department is complex, requiring occupational therapy
many continue to hold this notion). Black (2002) defined
managers to be highly skilled and effective in accomplish-
diversity as also “incorporating gender, age, ability, sexual
ing many roles, responsibilities, and requirements. Those
orientation, and class” (p. 140). Although expanded beyond
requirements, according to Braveman (2014), are context
race and ethnicity, this definition is still far too narrow. Cur-
dependent, and the role and expectations of occupational
rently, the concept of diversity is more inclusive, identifying
therapy managers may require flexibility within each set-
“life experiences, lifestyle choices and ideas, such as socio-
ting. Given the complexity within changing contexts, how
economic status and sexual orientation [as well as] the so-
does one also promote and manage diversity within each
cial determinants of health” (Becker’s Hospital Review, 2016,
occupational therapy program and department? Yet given
para. 2). Other scholars and authors have added the concepts
the increasing plurality in the United States and beyond,
of religious beliefs, political beliefs, and other ideologies
we must!
(Volckmann, 2012). When considering diversity’s many as-
This chapter provides theoretical background information
pects, any interaction might be considered cross-cultural.
and pragmatic guidelines to assist occupational therapy man-
The Pew Research Center (2015) reported that U.S. pop-
agers in promoting and managing diversity in the occupa-
ulation statistics (see Table 16.1) indicate that there is more
tional therapy clinic and beyond.
https://doi.org/10.7139/2019.978-1-56900-592-7.016
159
TABLE 16.1. Racial Demographic Trends in the United Cultural competence

States, 1975–2065 by Percentage of Population Cultural competence has been defined in multiple ways.
YEAR WHITE BLACK HISPANIC ASIAN AOTA (2018) described it as “the process of actively developing
and practicing appropriate, relevant, and sensitive strategies
2065 (projected) 46% 13% 24% 10%
and skills in interacting with culturally different persons”
2035 (projected) 57% 13% 22% 8% (p. 2). In a more comprehensive and commonly used defini-
2005 64% 13% 18% 6% tion that focuses on client care, Camphina-Bacote (1999, as
cited in Rodakowski & Suarez-Balcazar, 2016) suggested that
1985 76% 12% 8% 3%
cultural competence is displayed when a practitioner
1965 80% 12% 5% 2%
■ “Recognizes differences in culturally determined health
Source. Adapted from Cohn & Caumont (2016). beliefs and behaviors,
■ Respects variations that occur within and among cultural
groups, and
ethnic and racial diversity now than in the past, and driven ■ Alters practice to provide effective services for clients from
by recent and projected immigration, such pluralism will diverse backgrounds” (p. 414).
continue to increase (Cohn & Caumont, 2016).
Yet, despite these statistics, most occupational ther- Cultural competence requires occupational therapy prac-
apy practitioners and managers are White (90.9%) and fe- titioners to be culturally aware of themselves and others, to be
male (85.3%; American Occupational Therapy Association knowledgeable about their clients’ culture and beliefs and the
[AOTA], 2015). Sullivan and Mittman (2010) argued, “Access sociopolitical systems within the dominant culture, and to be
to a health professions career should be available to all, not skilled communicators in cross-cultural interactions.
only because of issues of equity and social justice but because Self-awareness is crucial to such cultural awareness.
without such diversity, we as a nation will not benefit for de- Self-awareness is “the recognition a person has of being a unique
veloping the talent, creativity, and potential of the human person with specific background that influences his or her be-
capital that exist in all segments of our society” (p. 252). Re- liefs, values, attitudes and behaviors” (Black, 2016c, pp. 83–84).
gardless of one’s own cultural background, the likelihood Dreachslin (2007) argued, “Self-awareness is the most powerful
of working with someone who is culturally different from tool a health care leader has in managing diversity” (p. 82), and
oneself, whether a supervisor, coworker, staff member, or cli- that notion has been supported by others (e.g., Black, 2016a).
ent or patient, is high. Cultural effectiveness includes all of the aforementioned
Mor Barak (2017) identified 3 impetuses for managers aspects of cultural competence, coupled with an opportunity
to consider and plan for diversity within their programs or for several cross-cultural interactions with significant reflec-
departments: tion during and following the interactions (Wells et al., 2016).
Occupational therapy practitioners who are attempting to
1. Diversity is a reality that is here to stay, become more culturally competent are more effective if the
2. Diversity management is the right thing to do, and organization in which they work is considered a culturally
3. Diversity makes good business sense (p. 219). competent organization. To become a culturally competent
Weech-Maldonado et al. (2002) suggested that the goal of health care organization, the leadership must understand
managing diversity “is to enhance workforce and customer the local community and the role of the organization within
satisfaction, to improve communication among members of the community (HRET, 2013). Steps to move toward cultural
the workforce, and to further improve organizational perfor- competence include doing a community survey, sharing the
mance” (p. 111). Therefore, managing diversity is an import- results of the survey with the community, and educating staff
ant aspect of the occupational therapy manager’s role and about the needs of the diverse people within the community.
responsibilities. Although there is significant occupational therapy litera-
ture about cultural competency (Black & Wells, 2007; Bonder
& Martin, 2013; Gupta, 2008; Suarez-Balcazar et al., 2009)
Culturally Effective Management
and cultural effectiveness in occupational therapy practice
The majority of today’s health care organizations expect their (Wells et al., 2016), little research exists about how to be a
leaders to “help manage a new era of culturally competent, culturally effective occupational therapy manager. However,
patient-centered care that reduces health and healthcare dis- research and literature published outside the occupational
parities” (Dotson & Nuru-Jeter, 2012, p. 35). therapy field has shown that effectively dealing with diverse
However, many scholars believe that there is a lack of issues within one’s department and organization has posi-
culturally competent and culturally effective care practiced tive results on productivity (Saxena, 2014), finances (Weech-
in many health care departments (Aries, 2004; Dreachslin, Maldonado et al., 2002), and diminished health disparities
2007; Weech-Maldonado et al., 2002). Others believe that for the underserved (Betancourt et al., 2003).
diversity management itself can lead to a culturally compe- Other scholars cite some of the difficulties inherent in
tent organization (Betancourt, 2006, as cited in Dotson & developing a culturally competent department, reporting
Nuru-Jeter, 2012). that managing diversity is hard work. Parker (2015) stated,
CHAPTER 16. Promoting and Managing Diversity 161
“[M]anaging differences requires energy, commitment, toler- EXHIBIT 16.1. National CLAS Standards in
ance, and . . . appreciation among all members involved. . . . Health and Health Care
Learning to manage and ultimately appreciate differences re-
quires learning, emotional growth, and stretches the bound- The National CLAS Standards are intended to advance health
aries of all participants” (p. 38). equity, improve quality, and help eliminate health care
disparities by establishing a blueprint for health and health care
organizations to:
Health disparities
Principal Standard:
Many believe that cultural competence affects health dispar 1. Provide effective, equitable, understandable, and respectful
ities. Health disparities are defined by Smith (2011) as “dif quality care and services that are responsive to diverse cultural
ference in the quality of health care related to race or ethnicity, health beliefs and practices, preferred languages, health literacy,
gender, education or income, disability, geographic location, and other communication needs.
or sexual orientation that is not due to access-related factors or Governance, Leadership, and Workforce:
clinical needs” (p. 547). Despite continued work on diminish- 2. Advance and sustain organizational governance and leadership
ing health disparities during the last several years, reports by that promotes CLAS and health equity through policy, practices,
the National Center for Health Statistics (NCHS; 2017) indi- and allocated resources.
cate that only minimal changes have occurred. A U.S. govern- 3. Recruit, promote, and support a culturally and linguistically diverse
ment report on racial and ethnic disparities states that governance, leadership, and workforce that are responsive to the
population in the service area.
Despite improvements over time in many of the health 4. Educate and train governance, leadership, and workforce in
measures presented in this Special Feature, disparities by culturally and linguistically appropriate policies and practices
race and ethnicity were found in the most recent year for on an ongoing basis.
all 10 measures, indicating that although progress has been Communication and Language Assistance:
made in the 30 years since the Heckler Report, elimination 5. Offer language assistance to individuals who have limited English
of disparities in health and access to health care has yet to proficiency and/or other communication needs, at no cost to them,
be achieved. (NCHS, 2016, p. 21). to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance
Dotson and Nuru-Jeter (2012) believe that “the presence of services clearly and in their preferred language, verbally and
health and health care disparities indicates, in part, the lack in writing.
of a culturally competent care perspective at the management 7. Ensure the competence of individuals providing language
level” (p. 38). assistance, recognizing that the use of untrained individuals
and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and
Health Equity and Enhanced National signage in the languages commonly used by the populations in
CLAS Standards the service area.
Health equity “is the attainment of the highest level of health Engagement, Continuous Improvement, and Accountability:
for all people. Achieving health equity requires valuing ev- 9. Establish culturally and linguistically appropriate goals, policies,
eryone equally with focused and ongoing societal efforts to and management accountability, and infuse them throughout
address avoidable inequalities, historical and contemporary the organization’s planning and operations.
10. Conduct ongoing assessments of the organization’s CLAS-related
injustices, and the elimination of health and health care dis-
activities and integrate CLAS-related measures into measurement
parities” (Healthy People 2020, 2014, para. 5). The current
and continuous quality improvement activities.
cost of health disparities is estimated to be $230 billion (Riley, 11. Collect and maintain accurate and reliable demographic data to
2016). To enhance health equity for all, the United States monitor and evaluate the impact of CLAS on health equity and
developed national standards to help guide and improve an outcomes and to inform service delivery.
organization’s ability to address health care disparities. These 12. Conduct regular assessments of community health assets and
National Standards for Culturally and Linguistically Appro- needs and use the results to plan and implement services that
priate Services (CLAS) have been developed to implement respond to the cultural and linguistic diversity of populations in
Culturally and Linguistically Appropriate Services to all the service area.
clients and patients (see Exhibit 16.1). 13. Partner with the community to design, implement, and evaluate
policies, practices, and services to ensure cultural and linguistic
appropriateness.
Review Questions 14. Create conflict and grievance resolution processes that are
1. Given the information above, how culturally effective do culturally and linguistically appropriate to identify, prevent, and
you consider yourself to be as a practitioner, student, or resolve conflicts or complaints.
15. Communicate the organization’s progress in implementing
researcher?
and sustaining CLAS to all stakeholders, constituents, and the
2. How would you describe your organization’s effectiveness general public.
in promoting diversity?
3. What is the relationship between cultural competence Source. The National CLAS Standards, by U.S. Department of Health and Human
and health disparities? Services, Office of Minority Health (n.d.). In the public domain.
PRACTICAL APPLICATIONS IN Therefore, the questions a manager and his or her organiza-
OCCUPATIONAL THERAPY tion must ask are no longer should I plan for diversity or why
must I plan for diversity but rather how do I manage diversity
For many reasons cited earlier, managing diversity must be issues in my program and organization?
a goal of all occupational therapy managers. This might feel Planning involves the promotion of diversity. This in-
overwhelming to some managers, particularly those who are cludes being clear about the values and goals of the organi-
new to a position and who may wonder how these goals can zation and how promoting diversity within one’s program
be translated and incorporated into particular tasks and du- or department can help achieve those goals. Mission, vision,
ties of the role. Braveman (2014) identified 4 major functions and value statements must reflect the promotion of diversity
of management: (see Exhibit 16.2), and the strategic plan must incorporate
1. Planning, goals to achieve these tasks. However, although a diverse
2. Organizing and staffing, workforce often brings a diversity of thoughts, ideas, per-
3. Directing, and spectives, and practices, which may increase an organiza-
4. Controlling (p. 1019). tion’s competitiveness, promoting diversity may be difficult.
Volckmann (2012) stated that “promoting diversity within
To organize and simplify the complexities of managing di- organizations has been a task, a challenge to be met in the
versity, this section focuses on how managing diversity can name of values of equity and social justice, as well as an eco-
happen within these 4 areas of management function (see nomic necessity” (p. 2).
Table 16.2). Another aspect of planning is to create and implement the
department budget (Braveman, 2014). Within a culturally
competent occupational therapy department, the manager
Planning
must include the need for funding for diversity. This may
Planning is the first step in diversity management for the oc- include a wider search for new positions for diverse occupa-
cupational therapy manager and includes revising the strate- tional therapy staff, trainings that may include bringing in
gic plan, writing goals, developing timelines for training, and guest speakers or purchasing videos and other technology, or
thinking about hiring objectives. The function of planning visits to other occupational therapy departments in the area
may be considered the highest level of management because that have more experience or skills in building an inclusive
of its top-down nature. Decades of laws and regulations sup- and diverse group of people. The budget may also include
porting the rights of all people and therefore fostering inclu- increased signage in multiple languages and the hiring of
sion, such as the Civil Rights Act of 1964 (P. L. 88–352), the translators or cultural brokers. In other words, the depart-
Heckler report of 1985 (Heckler, 1985), and the Healthy Peo- ment must put money where its mouth is. If occupational
ple Initiative of 2010 (NCHS, 2010), have shifted the societal therapy managers are serious about developing a culturally
stance on inclusivity. As a result, most health organizations competent program, they must develop a budget to support it,
now recognize the importance of having a diverse workforce, which is not an easy task given the current financial stressors
particularly to reflect the population of the larger community. on health care organizations.
TABLE 16.2. Cultural Functions of Managers
MANAGEMENT FUNCTIONS
(BRAVEMAN, 2011) CULTURAL FUNCTIONS CULTURAL TASKS
Planning Promoting of diversity ■ Developing mission, vision, and value statements that reflect
the promotion of diversity.
■ Creating goals in the strategic plan to achieve the tasks above.
■ Budgeting to fund diversity.
■ Creating signage in multiple languages.
Organizing and staffing Achieving diversity ■ Reviewing and developing cultural self-awareness.
■ Hiring diverse staff and leadership.
Directing Educating for diversity ■ Becoming culturally competent, starting with one’s own cultural
self-awareness.
■ Mentoring, coaching, and training staff.
■ Committing to ongoing education.
■ Practicing reflection on training and cross-cultural interactions.
Controlling Valuing and sustaining diversity ■ Implementing and tracking of continuous quality improvement.
■ Developing performance measures for department functions.
■ Researching and publishing results of above.
EXHIBIT 16.2. Example of an Organization’s Organizing and Staffing

Value Statement Organizing and staffing are how managers hire new staff or
At MaineHealth, our values are at the very core of living our reassign duties of current staff to align and organize their depart-
mission and vision of working together so our communities are the ments to support the goals of the larger organization and to pro-
healthiest in America. Wherever and whenever you interact with us, mote diversity. Promoting diversity within one’s workplace can
you can expect our team members to embody the following values be achieved by the way in which occupational therapy managers
in action: consider and apply Braveman’s (2014) second management func-
Patient Centered: We focus on each individual’s unique needs, and
tion. Skillfully integrating these 2 tasks helps achieve diversity.
partner with the people we care for, their families, and care teams Research indicates that hiring racially diverse leader-
to develop a shared plan. ship is important in developing a diverse workforce (HRET,
■ Act with compassion and kindness. 2011; Jayne & Dipboye, 2004). Yet, even though Aries (2004)
■ Listen actively and validate concerns; focus on the individual’s reported over a decade ago that most managers were con-
needs. sciously hiring a more diverse staff, a 2015 survey found that
■ Communicate effectively with patients, clients, and families. racial/ethnic minorities still constitute only 14% of hospital
■ Treat everyone with respect and courtesy; acknowledge cultural board members, 12% of executive leadership positions, and
differences. 17% of first- and mid-level management positions (Becker’s
■ Be empowered to advocate and speak up for patient and
Hospital Review, 2016). However, given the limited numbers
client safety.
of occupational therapy practitioners in the United States
■ Partner with the people we care for, their families, and care teams
to develop a shared plan.
who are ethnically diverse (AOTA, 2015), where do managers
find them? Remember that diversity covers a wide array of
Respect: We embrace diversity and recognize the value of differences (see “Diversity Today” above). One might seek
each person. out people from another part of the country, someone with
■ Recognize all the people we care for, their family, visitors, and
age differences, sexual orientation or sexual identity differ-
coworkers as valued members of the health care team.
ences, religious or political differences from the mainstream,
■ Listen actively and respond thoughtfully.
■ Treat others as you would want to be treated.
and more. The bottom line here, summarized by Dotson and
■ Embrace diversity, acknowledging each person’s uniqueness. Nuru-Jeter (2012), is “a culturally competent care organiza-
■ Be empathetic, compassionate, and kind. tion is needed; so is a diverse workforce to operate it” (p. 8).
■ Foster a professional and healing atmosphere.
Integrity: We are honest, transparent, and ethical and maintain a Directing

culture of trust and accountability Directing includes mentoring, coaching, and staff training in
■ Demonstrate professionalism at all times, regardless of the
this area of management, (Braveman, 2014), all of which are
behavior of others.
■ Maintain confidentiality and respect the privacy of all.
addressed here under the term educating about diversity. This
■ Develop and maintain a culture of trust and accountability. is a vital, yet often overlooked, inexpertly planned, and poorly
■ Act with honesty and transparency at all levels of the accomplished task of occupational therapy managers. If the
organization. goal is to lessen health disparities and develop a culturally com-
■ Model behavior that is consistently honest and ethical. petent occupational therapy program or department, Dotson
■ Acknowledge mistakes as opportunities to learn and grow. and Nuru-Jeter (2012) argued that “a culturally competent care
Excellence: We set high standards and always strive to exceed
perspective [must be evident] at the management level” (p. 41).
expectations. It must start at the top. Therefore, it is important for each occu-
■ Consistently seek improvements in processes and performance. pational therapy manager to be culturally competent.
■ Set high standards. There is considerable occupational therapy and other health
■ Strive to exceed expectations with every interaction. care literature about how individuals may develop cultural com-
■ Lead by example. petence (Black, 2016b; Bonder & Martin, 2013; Gardenswartz
■ Work collaboratively as a team. & Rowe, 2010; Wells et al., 2016), and there are multiple ways
■ Pursue opportunities to learn and grow personally and and programs to help people become more knowledgeable
professionally. about diversity issues, sensitive to the nuances that are part of
Innovation: We welcome diverse perspectives, embrace change, and cross-cultural interactions, and skilled in communication with
are committed to lifelong learning. others. The first (and perhaps the most important) aspect to
■ Welcome change with a positive attitude. consider in any training is developing self-awareness. Other
■ Inspire others and foster creativity. areas that diversity training must include are being knowl-
■ Be courageous. edgeable about clients’ varied cultures and how to develop
■ Encourage diverse perspectives. culturally interactive skills. To be effective managers and prac-
■ Invest in people, technology, and research.
titioners, this work must be infused with self-reflection during
■ Commit to lifelong learning and educating.
and following each interaction while considering the context
Source. Our Values, by MaineHealth (n.d.). Copyright © 2019 by MaineHealth. within which the context occurs. (For more information, re-
Available at https://mainehealth.org/about/our-values view the model for culturally effective care in Wells et al., 2016.)
In 2013, the American Hospital Association published a help new staff members catch up with the others regarding
document that focused on how to develop a culturally com- knowledge and skills and evaluate ongoing development of
petent health care organization and suggested that a success- staff, which will guide further training.
ful educational program includes these 4 steps:
1. Cultural assessment, Controlling
2. Multiple training methods,
Measurement and tracking of progress coincides with
3. Ongoing education, and
Braveman’s (2014) final function of an occupational therapy
4. Measurement and tracking (HRET, 2013).
manager, which he labeled controlling. The cultural function
of this step is identified as valuing and maintaining diversity.
Cultural assessment Some of the tasks that are part of this management function
Cultural assessment includes conducting an evaluation of include implementation and tracking of continuous quality
the staff’s knowledge of cultural competence, and then using improvement and quality control, as well as performance
the data from that assessment to examine the working rela- measures for department functions and outputs (Braveman,
tionship between staff and diverse clients and the impact on 2014). When applied to diversity issues, these tasks include
clinical encounters. maintaining and reviewing data from patient satisfaction
scores, as well as ongoing health disparities data (HRET,
Multiple training methods 2013). Although there is increasing research on the positive
impact of managing diversity in the workplace in fields out-
Multiple training methods could include conducting a case side of occupational therapy (Saxena, 2014), more evidence is
study review, having observations of live interactions with needed in the occupational therapy profession as well. There-
clients followed by reflective discussions, and using online fore, this management function of valuing and maintaining
education and orientation programs (HRET, 2013). Reflective diversity must not be overlooked.
discussion is what Schon (1983) describes as “reflection on Gardenswartz and Rowe (2010) discussed how to design an
action,” which follows any interaction to judge “how success- evaluation strategy and how to measure various data, as well
fully you were and whether any changes to what you did could as include samples of typical metrics that would be useful for
have resulted in different outcomes” (Wells et al., 2016, p. 76). any occupational therapy manager. Regardless of approach
Some training programs are ineffective and, if handled to evaluation, it should focus on 2 categories: (1) process and
poorly, can result in substantial backlash (Pitts, 2005). Von (2) results (Gardenswartz & Rowe, 2010). Some questions
Bergen et al. (2002) described unintended negative effects of might include
poorly handled diversity management, which can be caused by
■ Process
■ Trainer’s own psychological values are used as training • Did we do what we set out to do?
templates;
• How well did we do it?
■ Trainers having political agendas or supporting and pro- • What needs to be changed to do better?
moting particular special interest groups;
■ Results
■ Training is too brief, too late, or only used in response to • Did it make a difference?
an existing crisis situation;
• What is the impact on organizational objectives?
■ Training is only provided as remediation and trainees are • What improvements can be seen resulting from this?
considered people with problems, or worse, are considered
• Did it achieve the results set out in the organization’s
to be the problem;
criteria?
■ People are forced to reveal private feelings or are subjected
to uncomfortable, invasive physical and psychological Establishing diversity initiatives is important but not suffi-
exercises; cient. The way to sustain these efforts is to regularly evalu-
■ Individual styles of participants are not respected; and ate the success and progress within the occupational therapy
■ Training is “canned,” often presented too shallowly or too program and the larger organization.
deeply, ignoring the needs of the group or its members.
(p. 241)
Review Questions
Robins (2016) stated that diversity or cultural competency
1. After reviewing the functions of an occupational therapy
training “should strive to achieve a commitment to appropri-
manager, what aspect of managing diversity will be the
ate practice and policies for diverse groups of people” (p. 304).
first you’ll address? Which seems most difficult for your
These include clients/patients, staff, and managers and other
department or organization?
leaders of the organization.
2. Does your organization require diversity training? If not,
how will you go about setting it up for your department?
Ongoing education
3. Do you know other occupational therapy managers who
Ongoing education (HRET, 2013) includes scheduling contin- are successfully managing diversity issues in their work-
uous staff education and periodic assessments. These activities place? How might you use them to help guide your efforts?
CASE EXAMPLE 16.1. Sarah: Managing Diversity
Sarah has worked as an occupational therapy practitioner for 9 years and is now a novice occupational therapy manager (4 months in the position)
in a midsize hospital on the West Coast. She has become aware that 30% of the clients who come through her department are Asian, mostly from
China, Japan, South Korea, and Laos. The occupational therapy department employs 6 occupational therapy practitioners—3 are White; 2 are
African American, including herself; and 1 is a new graduate originally from Puerto Rico. Their ages range between 24 and 60 years. Sarah is in
her early 30s.
At first, Sarah felt that the department had diversity “handled” because of the ethnic diversity of the occupational therapy staff. However, she
had noticed some tension between staff members, as well as between some occupational therapy staff and the clients. She knew these subtle
issues needed to be addressed, but Sarah didn’t know how to begin.
Sarah went to the rehab director to discuss these issues, and he told her that the organization had a diversity coordinator who might help.
Jessica, a biracial woman in her early 40s, helped Sarah brainstorm how to manage these issues and stated that she was beginning a series of
short training sessions soon. While talking to Jessica, Sarah realized she was becoming a little uncomfortable, and after agreeing to require the
occupational therapy members in her department to attend these training sessions, she quickly returned to her own office.
Review Questions
1. Do you think the hospital in the case is a culturally competent organization? What could Sarah do to assess this?
2. What do you think caused Sarah’s discomfort? What might she do to reflect on this?
3. Is requiring her staff to attend the trainings a good thing? What other approaches could Sarah do with the staff to address the tension she
had noticed?
SUMMARY ■ B.5.1. Factors, Policy Issues, and Social Systems

Developing effective strategies to enhance the management
■ B.5.8. Supervision of Personnel.
of diversity within one’s department, program, and organiza-
tion is complex and challenging, but it is absolutely necessary
for effective care and services. This chapter introduced meth- REFERENCES
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Volunteering: Staff Participation Outreach and CHAPTER
Contributing to the Community
Mary J. Hager, MA, OTR/L, FAOTA 17
LEARNING OBJECTIVES
After completing this chapter, readers should be able to:
■ Describe real-life examples of volunteering,
■ Recognize who can volunteer,
■ Understand the value of becoming a volunteer,
■ Identify the most common types of volunteers,
■ Recognize local opportunities for volunteering, and
■ Describe the opportunities for volunteering within the state and national occupational therapy organizations.

• Networking • Pro bono • Skill acquisition
• Occupational engagement • Service learning • Volunteer
OVERVIEW a little effort to an organization or collective project can make a

valuable difference. Volunteers are everywhere—in hospitals, re
A
volunteer is a person who donates their time or efforts for habilitation centers, schools, churches, the military, businesses,
a cause or organization without being paid (“Volunteer,” and communities. Occupational therapy practitioners can use
n.d.). Providing a service to others in the health profes their knowledge and skills in unique and beneficial ways. As
sion is called pro bono, which is a Latin phrase for professional volunteers, they are often asked to work with people with many
work done as a volunteer without payment. The reasons to vol types of disabilities 1-on-1 and in groups to identify entertain
unteer are as varied as the people who volunteer. Some people ing activities that help in skills development and social interac
volunteer because they see a need in their community, some tion, to coordinate projects with short- and long-term goals, to
have an interest they want to promote (e.g., arts, sports, politics), work with parents and caregivers, and to find funding sources.
and others may have extra time and want to use it productively.
Occupational therapy, sometimes known as a helping pro
Benefits of Volunteering
fession, is made up of caring professionals who are valuable
assets to countless volunteer endeavors, helping individuals, The many benefits of volunteering are generally recognized
communities, and the profession at large. Occupational ther by those who volunteer. Volunteering can
apy managers can encourage and influence those they su ■ Connect one to others,
pervise to pursue volunteer activities. This chapter discusses ■ Be good for one’s mind and body,
what is meant by volunteering and gives real-life examples of ■ Advance one’s career, and
the types of volunteer opportunities available. ■ Bring fun and fulfillment to one’s life (Segal & Robinson,
2018).
ESSENTIAL CONSIDERATIONS Regular volunteering positively affects subjective well-being,
Anyone can volunteer. Although many people feel that they do and that feeling of satisfaction increases over time if volunteer
not have the time, energy, or expertise to volunteer, giving even ing is sustained (Binder & Freytag, 2013). Occupational therapy
https://doi.org/10.7139/2019.978-1-56900-592-7.017
167
Volunteering: Staff Participation Outreach and CHAPTER
Contributing to the Community
Mary J. Hager, MA, OTR/L, FAOTA 17
LEARNING OBJECTIVES
After completing this chapter, readers should be able to:
■ Describe real-life examples of volunteering,
■ Recognize who can volunteer,
■ Understand the value of becoming a volunteer,
■ Identify the most common types of volunteers,
■ Recognize local opportunities for volunteering, and
■ Describe the opportunities for volunteering within the state and national occupational therapy organizations.

• Networking • Pro bono • Skill acquisition
• Occupational engagement • Service learning • Volunteer
OVERVIEW a little effort to an organization or collective project can make a

valuable difference. Volunteers are everywhere—in hospitals, re
A
volunteer is a person who donates their time or efforts for habilitation centers, schools, churches, the military, businesses,
a cause or organization without being paid (“Volunteer,” and communities. Occupational therapy practitioners can use
n.d.). Providing a service to others in the health profes their knowledge and skills in unique and beneficial ways. As
sion is called pro bono, which is a Latin phrase for professional volunteers, they are often asked to work with people with many
work done as a volunteer without payment. The reasons to vol types of disabilities 1-on-1 and in groups to identify entertain
unteer are as varied as the people who volunteer. Some people ing activities that help in skills development and social interac
volunteer because they see a need in their community, some tion, to coordinate projects with short- and long-term goals, to
have an interest they want to promote (e.g., arts, sports, politics), work with parents and caregivers, and to find funding sources.
and others may have extra time and want to use it productively.
Occupational therapy, sometimes known as a helping pro
Benefits of Volunteering
fession, is made up of caring professionals who are valuable
assets to countless volunteer endeavors, helping individuals, The many benefits of volunteering are generally recognized
communities, and the profession at large. Occupational ther by those who volunteer. Volunteering can
apy managers can encourage and influence those they su ■ Connect one to others,
pervise to pursue volunteer activities. This chapter discusses ■ Be good for one’s mind and body,
what is meant by volunteering and gives real-life examples of ■ Advance one’s career, and
the types of volunteer opportunities available. ■ Bring fun and fulfillment to one’s life (Segal & Robinson,
2018).
ESSENTIAL CONSIDERATIONS Regular volunteering positively affects subjective well-being,
Anyone can volunteer. Although many people feel that they do and that feeling of satisfaction increases over time if volunteer
not have the time, energy, or expertise to volunteer, giving even ing is sustained (Binder & Freytag, 2013). Occupational therapy
https://doi.org/10.7139/2019.978-1-56900-592-7.017
167
CASE EXAMPLE 17.1. Braille Trail
As a new occupational therapist in 1975, I moved to Cross Lanes, West Virginia, and did not know many people. Early in my career I joined the Junior
Woman’s Club and, at their first meeting, heard about a project that had not gotten off the ground. The president talked about a braille trail that they
had hoped to build in Kanawha State Forrest, but they couldn’t find members who wanted to get it going. As an occupational therapist, I knew I had
something to contribute, so I raised my hand and offered to help.
From that first moment, many exciting things began to happen, and my appreciation for volunteering began to peak. First came a meeting with
the forestry director, who looked over plans from several years in the past and agreed to help our group with the project. I had the opportunity to talk
to him about occupational therapy and how we could expand the idea to a trail that would be accessible to people who were visually and physically
challenged and all individuals who wanted to participate in nature. This encounter led to writing grants and obtaining state funding.
As a result, other organizations were willing to give their time and money to the project. I wrote letters to the West Virginia governors in different
administrations to encourage them to support the project. In every letter I explained the scope of our profession and why occupational therapy was
involved. After many months, the Spotted Salamander Accessible Trail had its grand opening. It was a thrill to take school teachers and students with
disabilities to the trail and know that they could enjoy the forest (Surber, 1987).
practitioners can set examples for their clients. For example, volunteering for scouting programs, sports such as Little League
residents in long-term care facilities improved their well-being or soccer, religious institutions, and many other organizations.
by volunteering (Yuen et. al., 2008). Most newspapers publish notices of organizations seeking
Service learning is an educational approach to volunteering volunteers and have long lists in their community sections.
that can benefit both the provider and the recipient by com Case Example 17.1 shows how an occupational therapy back
bining learning objectives with community service (Horowitz, ground can greatly enhance an important community project.
2012). Service learning has long been used in occupational Case Example 17.2 shows how an occupational therapist
therapy education and can benefit students and communities. combined the love of a sport and therapy skills to create adap
For example, occupational therapy students who volunteered tations so any child could play and participate in an activity
to help children make better nutrition choices found service that is meaningful to them.
learning to be a valuable learning experience (Lau, 2016). Sim
ilarly, occupational and physical therapy students participating Review Questions
internationally in Belize reported they felt better prepared for
interprofessional practice than their peers (Beitman et al., 2016). 1. List 3 activities that interest you (e.g., sports, art, music).
What volunteer opportunities might be available related
to these areas?
Local Opportunities
2. What is service learning? How does it benefit students
Case Examples 17.1–17.3 provide examples of local volunteer and communities?
opportunities where the skills of an occupational therapist 3. What occupational therapy skills would be useful when
were effectively applied. Local organizations may include volunteering?
CASE EXAMPLE 17.2. Challenger Baseball
Challenger Baseball (Little League Challenger Division) afforded another local opportunity to help the community and expand the knowledge of
occupational therapy to people who otherwise may not have known anything about the field. In 1983, my husband, who was on the board of the
Cross Lanes Little League, came home after a weekly meeting and asked if I knew of any children with disabilities who might like to play baseball.
This started another venture in volunteerism. Because I was working as a school-based occupational therapist, I told him that I was sure I knew
children who would like the opportunity to play baseball.
The Cross Lanes Little League president had heard about Challenger Baseball and wanted to see about starting a team in Cross Lanes, West
Virginia. I called several of the parents of the children I was treating, and many of them gladly said yes. From that first season, I worked with the
team for 23 years using adaptations and assistive devices to enable the children to be competitive in play.
It is almost impossible to explain how happy the children were while playing baseball. They performed to the best of their ability and were so
proud to play in their new uniforms. I came up with adaptations such as using an extremely soft ball and hollow plastic bat for safety so no one
would get injured. Another adaptation was using flat bases so wheel chairs could easily pass over them and did not pose a tripping hazard.
An unexpected outcome came from encouraging the regular baseball teams to take turns helping our players. They soon became friends and
buddies to our players and even helped them with school projects. The Challenger teams were also invited to play a game on the local minor league
baseball team field at the end of a regularly scheduled game. Each player was announced on the PA system when he or she came to bat, and their
picture appeared on the large screen in the stadium. The professional players from the minor league team assisted the players with special needs
during the game (Hager, 2010).
One Boy Scout and two Girl Scouts earned their Eagle Award and Gold Awards, respectively, by doing their merit projects on our Challenger Field
to make it more accessible and fan friendly. These projects resulted in newspaper articles being written, and each time occupational therapy was
mentioned, which is good recognition for the profession. I was honored to receive a Jefferson Award for this work.
CHAPTER 17. Volunteering: Staff Participation Outreach and Contributing to the Community 169
CASE EXAMPLE 17.3. Working With Veterans and Young Adults With Disabilities
I volunteered at a local community center that provides training in basic living skills for 18 young adults with physical or mental disabilities. These
young men and women had limited options or opportunities for training and social interaction from other resources. Volunteers and a paid director
run the facility.
One of my activities was to set up and coordinate a project concerning veterans. For several months, the students interviewed veterans based on
questions they had chosen during a class planning session. The veterans included family, friends, and neighbors. After the interviews, the students
wrote or typed their work, which was compiled in a finished product.
One of the students used the video feature on his smartphone to record his mother’s thoughts about her husband receiving a Quilt of Valor, which is
sponsored by the Quilts of Valor Foundation to cover service members and veterans touched by war. The quilts provide comfort and are symbolic of healing.
The interview project concluded with a parent day where the students read, to the best of their ability, their interviews with the veterans to the
audience. Two of the students used their iPads with a special voice feature to assist them with their presentation. Several students served food they
had prepared and sang patriotic songs. The event was an enormous success and, according to the school director, received many favorable comments.
I presented this information at an occupational therapy symposium attended by occupational therapy students, faculty, and clinicians to provide an
example of how occupational therapy skills can be used in volunteer activities (Hager, 2018).
PRACTICAL APPLICATIONS IN by choice. Reflecting on one’s own valued occupations is a

OCCUPATIONAL THERAPY good place to start when searching for a meaningful volunteer
role.
Occupational Engagement When volunteering, occupational therapy practitioners
As Stoffel (2015) described, are uniquely skilled at identifying what others value and
using it to engage them and improve their occupational
As occupational therapy practitioners, we use occupational well-being. Case Example 17.4 shows how young adults’ love
engagement as a key strategy to connect with the people we of the outdoors created a way to improve performance skills
serve. We get to know what matters to them and what they and occupationally engage.
view as their meaningful, necessary, and familiar activities of
everyday life that will facilitate participation so as to improve Expanding Volunteer Opportunities
health and quality of life. (p. 1, bold and italics added)
Volunteering often creates opportunities for others, includ
Like their clients, occupational therapy practitioners are oc ing occupational therapy coworkers, to become involved
cupational beings who engage in meaningful occupations in an activity or project. This also increases the amount of
CASE EXAMPLE 17.4. Love of Nature
When I first started volunteering at the local community center for adults with disabilities, I had no idea how I could help them. All I knew was
that they were looking for volunteers to work with young adults 2 mornings a week. It took a little time to get to know the students, but gradually
I did. The students were diagnosed with conditions that included autism, Down syndrome, cerebral palsy, and learning disabilities.
One of the things that struck me was their love of nature. After talking with the director, I came across the idea for “I love nature because . . .”
I wanted a topic that would interest them and one where they would be required to make decisions. This idea seemed like a perfect way to combine
their interests and mine. The topics ranged from giraffes to warm springs.
The students’ intellectual and mechanical writing abilities varied greatly. Some could print legibly, and others used a computer to communicate.
The project involved using smartphones, computers, and assistive devices to help the students with special needs participate. Smartphones were
chosen because they have cameras, they provide Internet access, they are easy to understand, and they are frequently used in real-life situations.
Taking pictures and writing stories was fun for the students. Assistive devices such as large letter keyboards and special remote keypads were used
with a standard or laptop computer to help them perform the necessary tasks.
Over several months, the students took pictures of various things in nature using smartphones. Additionally, they typed narratives into Microsoft
Word to complete the phrase “I like nature because.” All of the students, regardless of ability, were able to participate and enjoyed seeing their work
appear on the screen. For some students, computer-assistive devices facilitated data entry. They learned how to type or improve their typing skills,
how to transfer pictures from smartphones to a computer, and how to print their narratives and pictures for use in a publication. At the end of the
summer, all of the students participated in a special parent night at a local library where they read their narratives or used an iPad with Proloquo2Go
to communicate with the audience.
As an occupational therapist, I served an essential role in helping the teacher decide which devices and activities were appropriate.
Review Questions
1. What skills do you have that could be useful as a volunteer?
2. List 3 occupations that you value.
3. What technical skills could you bring to a volunteer activity?
CASE EXAMPLE 17.5. National Volunteer Opportunity
I started the Devereaux Project in the summer of 2014 with the encouragement of members of the American Occupational Therapy Foundation
(AOTF). The Devereaux Archival Project is intended to gather and archive the most important historical information from the state associations.
The information will be stored electronically in the AOTF Wilma West Library, where it can be easily accessed.
The project is named in honor of Elizabeth Devereaux, who passed away in 2010. Liz was a past president of the AOTF and held many offices in
the West Virginia Occupational Therapy Association. She was always supportive of saving the history of occupational therapy, especially of the state
associations.
Several requests were sent via the Representative Assembly (RA) and State Association Listserv with assistance from the speaker of the RA and
chair of the Affiliated State Association Presidents (Pugh, 2015). A table was designed to request historical information about the association, its
presidents, its representatives, and the people most important to the advancement of occupational therapy in the state along with a brief description
of their contributions. As of this writing, volunteers from 27 states have sent in information with many more states indicating that they plan to do
so. The project has exceeded my expectations because several state volunteers have sent not only the basic information but additional historical
documents as well.
energy that can be applied to a project and enables others otherwise interact with. Some of these people might provide
to apply their unique skills and knowledge to a specific new experiences, mentoring, and knowledge. Some organi
endeavor. These new volunteers might eventually take over zations have experienced and influential individuals on their
project leadership responsibilities. Once a person volunteers, boards of directors, and these people support the same cause
they are more likely to pursue other volunteer activities in for which one is working.
the future (Segal & Robinson, 2018). Case Example 17.5 de Advocacy is an important type of networking. Being po
scribes a project that was started and led by one person but litically active and advocating for occupational therapy of
gave many other individuals an opportunity to volunteer and fers wide-ranging volunteer opportunities for occupational
contribute. therapy practitioners and students. It is also a fantastic way
to network with individuals and groups on a local, state, or
Using Volunteering to Expand Knowledge national level. The American Occupational Therapy Associ
ation’s (AOTA’s) Hill Day brings hundreds of occupational
and Skills
therapy practitioners, students, and educators together in
Volunteering can expand one’s own skills and talents. Some Washington, DC. Advocates meet with their representa
projects require learning new skills that one otherwise tives on Capitol Hill to explain what occupational therapy
would not need to learn or apply (see Case Example 17.6). Vol is and how it benefits their constituents and communities.
unteering can help occupational therapy practitioners and AOTA’s 2018 Hill Day involved more than 500 advocates
managers gain skills in financial management, negotiation, from 39 states who advocated and networked together.
marketing, social media, technology, and so forth (Carpenter, Case Example 17.7 describes networking and advocacy at
2018). Practitioners who take on volunteer responsibilities the state level.
often develop leadership skills because they frequently have
to coordinate activities and work with many people to achieve Cultivating Volunteerism in the Workplace
the project objectives.
Occupational therapy managers can cultivate a culture of
volunteerism and inspire staff to volunteer in several ways.
Using Volunteering to Network
Some organizations sponsor volunteerism by “paid-release”
Volunteering is a form of networking in that it allows vol programs that allow volunteering on company time.
unteers to meet and get to know people who they may not Millennial workers, who, more than other generations, tend
CASE EXAMPLE 17.6. Learning New Skills
I am not especially tech savvy but wanted to learn and do as much as possible with technology. Learning a new skill is an effective way of
experiencing firsthand how difficult skill acquisition, which refers to how new behaviors and skills are learned, can be for people with disabilities.
In the example of Case Example 17.4, I needed to learn how to transfer pictures from a smartphone to a computer and then print them so I could
teach the students.
This skill may be easy for some people, but it was difficult for me. First, I had to find someone who was willing to teach me and then patient
enough to let me practice. After a few attempts, I became proficient and felt confident in transferring my learning to the students. Now I often use
this new skill in family projects. Without volunteering, I probably never would have mastered this.
CHAPTER 17. Volunteering: Staff Participation Outreach and Contributing to the Community 171
CASE EXAMPLE 17.7. Day at the Legislature
The West Virginia Occupational Therapy Association (WVOTA) conducts a Day at the Legislature every year. We ask for volunteers from the
occupational therapy community to help. This brings together occupational therapy practitioners, students, and faculty from around the state.
Participants volunteer part of the day or the entire day as they are able. We ask the students to contact their legislators and make appointments.
Often a seasoned occupational therapy practitioner will accompany a student to an appointment. In addition to the appointments, exhibits are
set up, and exhibitors speak with legislators and the general public about occupational therapy and its importance to the community.
Relevant legislation may also be discussed. For example, the 2017 WVOTA Legislative Day offered an opportunity for WVOTA members to share
their concerns about opioid abuse with their legislators and suggest how occupational therapy could help. Additionally, members of WVOTA’s
legislative committee met with the attorney general and his staff to make them aware of a motion dealing with opioid abuse in the AOTA RA. This
contributed to occupational therapy services being included in an opioid alternatives bill that became law in West Virginia (Hager, 2017).
to seek employment that aligns with their values, partic the workplace. Occupational therapy managers can play a key
ularly appreciate opportunities to volunteer while at work role in supporting and encouraging volunteerism. ❖
(Zimmerman, 2016). Such programs can increase employee
morale and commitment to the organization. In addition,
the vast majority of American workers believe that compa RESOURCES
nies that sponsor volunteer activities have a better overall ■ Little League Challenger Division (https://www.littleleague
working environment than those organizations that do not .org/play-little-league/challenger/)
(Deloitte, 2017). ■ Volunteering and Its Surprising Benefits (https://www
Occupational therapy managers can help employees un .helpguide.org/articles/healthy-living/volunteering-and
derstand how their volunteering benefits the community. -its-surprising-benefits.htm)
Supporting and engaging with the causes employees value can
also foster a volunteer culture. Managers can provide time to
work on volunteer projects and activities and recognize the ACOTE STANDARDS
volunteer’s efforts verbally or with a plaque or certificate. This chapter addresses the following ACOTE Standards:
Additionally, they can show their support by participating in
some of the volunteer activities. This helps build camaraderie ■ Preamble
that can carry over to the workplace. ■ B.7.3. Promote Occupational Therapy.
Review Questions REFERENCES

1. What leadership skills could be derived from volunteering? Accreditation Council for Occupational Therapy Education. (2018).
2. How does volunteering help with networking? 2018 Accreditation Council for Occupational Therapy Education
3. List 3 examples of what a manager could do to encourage (ACOTE) standards and interpretive guide. American Journal of
volunteering. Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org
/10.5014/ajot.2018.72S217
Beitman, C., McAfee, E., Hensley, A., Giesler, L., Linville, M., Mosier,
SUMMARY M., & Gardner, E. (2016). Service learning in Belize: Percep
tions of occupational and physical therapy students and alumni
This chapter used real-life case examples to illustrate how [poster session]. American Journal of Occupational Therapy, 70,
volunteering can benefit occupational therapy practitioners 7011510209p1. https://doi.org/10.5014/ajot.2016.70S1-PO4045
as well as those who are being helped. Indeed, occupational Binder, M., & Freytag, A. (2013). Volunteering, subjective well-being
therapy practitioners are well suited to various volunteer and public policy. Journal of Economic Psychology, 34, 97–119.
activities, both from their education and training and their https://doi.org/10.1016/j.joep.2012.11.008
interest in helping people in need. Examples were presented Carpenter, A. (2018, January 30). 5 ways volunteering can enhance
that showed the diversity of volunteer opportunities, which your career. Forbes. Retrieved from https://www.forbes.com/sites
range from local service activities to volunteering with state /alissacarpenter/2018/01/30/5-ways-volunteering-can-enhance
-your-career/#5620d01b7962
and national organizations such as the AOTA.
Deloitte. (2017). 2017 Deloitte volunteerism survey. Retrieved from
Volunteers should be occupationally engaged in the activ https://www2.deloitte.com/content/dam/Deloitte/us/Documents
ity and with the people they serve. In addition to the broadly /about-deloitte/us-2017-deloitte-volunteerism-survey.pdf
recognized benefits of volunteering, occupational therapy Hager, M. (2010, February 10). Challenger baseball: Living life to its
students can benefit from service learning activities, and es fullest: OT reflections from the heart, OT Practice, 8(2), 33.
tablished practitioners can advance their careers by expand Hager, M. (2017, July 24). West Virginia efforts against opioid abuse.
ing their knowledge and making important contacts outside OT Practice, 22(13), 3.
Hager, M. (2018, September 14). A volunteer project involving Stoffel, V. (2015). Engagement, exploration, empowerment. American
veterans and young adults with special needs. Poster presented Journal of Occupational Therapy, 69, 69061400. https://doi.org
at 75th Anniversary Symposium, University of Wisconsin– /10.5014/ajot.2015.696002
Madison. Surber, D. (1987, May 1). Project clears way for handicapped to hit
Horowitz, B. P. (2012). Service learning and occupational therapy the trail. Charleston Daily Mail, p. 1C.
education: Preparing students for community practice. Education Volunteer. (n.d.). In YourDictionary.com. Retrieved from https://
Special Interest Section Quarterly, 22(2), 1–4. www.yourdictionary.com/Volunteer
Lau, C. (2016). Impact of a child-based health promotion service- Yuen, H. K., Huang, P, Burik, J. K., & Smith, T. G. (2008). Impact of
learning project on the growth of occupational therapy students. participation in volunteer activities for residents living in long-
American Journal of Occupational Therapy, 70(5), 1–10. https:// term-care facilities. American Journal of Occupational Therapy, 62,
doi.org/doi:10.5014/ajot.2016.021527 71–76. https://doi.org/10.5014/ajot.62.1.71
Pugh, E. (2015, April). Representative Assembly meeting minutes: Zimmerman, K. (2016). Why company-sponsored volunteer programs
Devereaux Project. https://www.aota.org/aboutaota/get-involved are keeping millennials happy at work. Forbes. Retrieved from
/ra/minutes.aspx https://www.forbes.com/sites/kaytiezimmerman/2016/09/22
Segal, J., & L. Robinson (2018). Volunteering and its surprising /company-sponsored-volunteer-programs-are-keeping-millennials
benefits. Retrieved from https://www.helpguide.org/ -happy/#644188e578da
SECTION III.
Navigating Change and Uncertainty
Edited by Roger I. Ideishi, JD, OT/L, FAOTA, and
Albert E. Copolillo, PhD, OTR/L, FAOTA
173
CHAPTER
Managing Organizational Change
Patricia Laverdure, OTD, OTR/L, BCP 18
LEARNING OBJECTIVES
■ Identify the ways in which stakeholders and organizations understand, experience, and value change;
■ Recognize common characteristics of organizations that effectively implement change;
■ Describe the change implementation process and ways in which innovation can improve the efficiency, effectiveness,
and value of occupational therapy services; and
■ Discuss strategies to evaluate change outcomes in health care enterprises, organizations, and staff.

• Change management • Implementation science • Readiness for change
• Change outcome evaluation • Leadership drivers • Transformative communication
• Competency drivers • Organizational change
• Implementation drivers • Organizational drivers
OVERVIEW Change and innovation, even in the context of stable and

collaborative work environments, require team members to
T
o be successful in today’s health care market, managers adopt new practices that may produce uncertainly and anx-
must ensure that client services are effective, efficient, iety, disrupt processes that increase error in workflows, and
and affordable. Driven by regulatory, policy, and pay- affect client outcomes (Gosselin et al., 2015). Leading change
ment reforms that value high-quality, patient-centered care in the midst of increasing health care complexity and frag-
and reproducible cost-efficient results, managers are chal- mentation, shifting organizational structure and governance,
lenged to lead change and innovation in health care that and changing workforce demographics and pressures takes
minimize variations in health care and service delivery, in- time and requires agility (Allan et al., 2014). A well-designed
efficient processes and procedures, and waste that leads to change implementation plan balances the organizational press
inconsistent, unreliable, and costly outcomes. for innovation with the professional identities of diverse team
In this chapter, organizational change and change man- members and the emotions and relationships that exist within
agement strategies are examined in the context of health care the organization (Allan et al., 2014; Andre & Sjovold, 2017).
administration and service delivery. Tools that enable man-
agers to create vision and cultural urgency, identify change
drivers and build organizational engagement, and effec-
tively measure change outcomes (i.e., change outcome eval-
uation) are explored. By leveraging the power of an engaged Organizational change is a transformational, intentional, and
workforce, occupational therapy managers can identify and structured process of planning and implementing change in
overcome organizational barriers, establish transformative an organization’s structures, processes, and culture that max-
communication approaches, and design processes and pro- imizes the efficiency and effectiveness of the change effort.
grams that effectively usher in change in complex health care Change is difficult, yet it is necessary to maintain a relevant
settings. and effective service delivery system. Implementing change
https://doi.org/10.7139/2019.978-1-56900-592-7.018
175
176 SECTION III. Navigating Change and Uncertainty
in complex systems requires far more than regulatory, proce- the enterprise, a strong relationship between managers and
dural, and reporting structures. Organizational change influ- staff, and a cogent and coherent change strategy (Allan et al.,
ences the professional identities, satisfaction, and effectiveness 2014; Fitzgerald et al., 2007). Distributed leadership involving
of managers and staff alike (Allan et al., 2014). To effectively senior administrators who support the change and innova-
improve health care access and equity, service delivery pro- tion, “credible opinion leaders” (Fitzgerald et al., 2007, p. 70)
cesses, evidence-based innovation, and client outcomes, occu- who network successfully with all stakeholders and establish
pational therapy managers need to attend to all stakeholders clear priorities and support, and willing staff who engage ac-
and create agency and opportunity for the development of tively in the change effort are essential for effective change
competency and leadership in change implementation. and innovation implementation. Allan et al. (2014) suggested
that during change efforts, staff are often “uncertain about
their new roles and responsibilities, feel overworked, and are
Foundations of Organizational Change and
concerned that their effectiveness has been compromised”
Change Management
(p. 103). Effective interprofessional relationships between
Key theories, models, and frameworks of change leaders and those who implement change are critical
organizational change for success (Fitzgerald et al., 2007).
Fixsen et al. (2005) defined the agents of change as “imple-
Implementing and sustaining change in enterprises, organi- mentation drivers” (p. 28), the human and material engine of
zations, and staff members requires careful planning and is change implementation within an enterprise. Implementa-
often unsuccessful (Grimshaw et al., 2012). The complexity of tion drivers are dynamic and interact with one another to fa-
an occupation-focused, client-centered, and evidence-based cilitate innovation and empower change efforts. Fixsen et al.
practice requires integration at the enterprise level (e.g., health identified the active and integrated drivers of change as
care and social policy, organizational structure and function,
information management), the organization or service provi- ■ Competency drivers: A selection of key competencies
sion level (e.g., care coordination and collaboration, service for innovation and the resources, training, and coaching
delivery systems, communication), and the staff member or required for effective performance;
service delivery level (e.g., client-centered evaluation, collab- ■ Organizational drivers: Organization support systems,
orative goal setting and problem solving, occupation-based policies and practices, and data systems that facilitate de-
intervention; Ehrlich et al., 2009; Valentijn et al., 2013). The cision making and performance; and
field of implementation science offers clarifying concepts, ■ Leadership drivers: The adaptive (group cohesion and col-
definitions, and relationships that may help illuminate change laboration) and the technical (goals and effort) resources
mechanisms that bring about successful change at all levels in of the enterprise.
the health care system (Davidoff et al., 2015).
Several key theories, frameworks, and models (labeled Readiness for change
as models in this chapter) have been shown to have utility in
Readiness for change is an organization’s level of understand-
health care change implementation (Table 18.1). Moullin et al.
ing of the need for change, belief in the capacity to change,
(2015) conducted a systematic review of implementation mod-
and commitment to the change process. Despite a dearth of
els in health care; although these change models may vary in
evidence on organizations’ readiness for change (Spaulding
the type of innovation (e.g., setting, population, preventive/
et al., 2017), workforce culture is considered crucial to the
restorative, targeted or holistic) and the sequence and stages
success of change implementation (Jacobs et al., 2015). “An
that change moves through, they provide important guidance
organization’s culture is reflected by what is valued, the dom-
for change design and implementation. Moullin et al. identi-
inant managerial and leadership styles, the language and
fied numerous models that inform change design, implementa-
symbols, the procedures and routines, and the definitions
tion, and sustainability, and although no one model addresses
of success that make an organization unique” (Cameron &
change requirements of all practice settings, Moullin et al.
Quinn, 2006, p. 17).
suggested that occupational therapy managers should consider
In their study examining the characteristics of a work cul-
the following during the planning of change implementation:
ture that influences change, Andre and Sjovold (2017) com-
■ The innovation to be implemented and the evidence that pared the behaviors and interactions between health care
supports it, personnel in 2 different units at the same hospital—one that
■ The context in which the implementation is to occur, had successfully implemented and sustained change and in-
■ The influencing facilitators and barriers to change, novation, and one that struggled with internal and external
■ The process (stages and steps) of implementation, and barriers to change leading to unsuccessful change efforts. The
■ The evaluations that will be used to measure change success. authors found that the unit that successfully negotiated change
achieved a balance of acceptance, engagement, independence,
and loyalty. Members of the successful unit were focused on
Agents of change
task completion and achievement of common goals.
Achieving successful change in health care requires the pres- Andre and Sjovold (2017) reported a higher level of empa-
ence of effective change leaders at varying levels throughout thy and maturity both in independent and collaborative work
TABLE 18.1. Key Theories, Frameworks, and Models That May Have Utility in Implementing Change in Occupational Therapy Organizations, Programs, and Staff
TYPE THEORY, FRAMEWORK, OR MODEL KEY COMPONENTS OCCUPATIONAL THERAPY PROCESS, INNOVATION, AND CONTEXT
Capacity for Sustainability Framework Implement and sustain innovative prevention programs to Developing and establishing sustainability mechanisms for population-based occupational
(Schell et al., 2013) address issues in the public health domain therapy interventions that are geared toward health risk prevention in community-based
public health programs at the departmental, enterprise, and community levels
Conceptual Framework of Complex Design and implement effective and efficient processes Designing and implementing processes for utility and efficiency in complex health care
Innovation Implementation and organizational protocol organizations at the departmental and enterprise levels
(Helfrich et al., 2007)
Core Implementation Components Design and implement evidenced-based prevention Designing, implementing, and evaluating treatment protocols and evidence-based
(Fixsen et al., 2009) and treatment services and programs; emphasis prevention strategies and interventions in human services settings at the individual,
Intervention Implementation
on implementation stages and knowledge departmental, enterprise, and community levels

translation efforts
General Theory of Implementation Build awareness of, design, and predict impacts of Building awareness and staff buy-in, designing dynamic implementation processes,
(May, 2013) innovative and complex interventions and predicting impacts of processes in diverse clinical settings at the individual,
departmental, and enterprise levels
Normalisation Process Theory Design, embed, and implement effective and efficient Designing, embedding, and implementing processes for utility and efficiency
(May & Finch, 2009) processes and organizational protocol in complex in complex private practice organizations at the individual, departmental, and
practices; prediction of impacts of change in processes; enterprise levels
shared decision making
CHAPTER 18. Managing Organizational Change

Practical Robust Implementation Design, implement, and evaluate outcome measurement Designing, implementing, evaluating, and sustaining treatment protocols and
and Sustainability Model (PRISM; of evidence-based interventions and technologies in evidence-based interventions and technologies in health care settings at the
Feldstein & Glasgow, 2008) health care settings individual, departmental, and enterprise levels
Model Matrix of Factors in Implementation Identify determinants of change in the implementation of Identifying factors that influence change uptake to support successful practice change
of Practice Change (Hader et al., 2007) practice guidelines implementation in health care settings at the individual level
10-Step Model for Inducing Identify determinants of change implementation Identifying factors that influence change uptake, developing barriers and incentives
Change in Professional Behavior to change behaviors, and tailoring intervention to achieve desired professional
(Grol & Wensing, 2004) behaviors in health care settings at the individual, departmental, and enterprise levels
Advancing Research and Clinical Define implementation steps and sustainability in the use Designing, implementing, evaluating, and sustaining use of evidence in evaluation and
Knowledge Advancement
Practice Through Close Collaboration of evidence to improve client outcomes intervention to improve client outcomes in health care systems at the departmental
Model (Melnyk et al., 2010) and enterprise levels
Dynamic Knowledge Transfer Capacity Analyze complex systems and knowledge needed for Establishing knowledge access, uptake, integration, and transfer mechanisms to
Model of Change Implementation effective decision making; steps to support the transfer enhance data-based decision making in complex health and human services
(Parent et al., 2007) of knowledge within systems systems at the departmental, enterprise, and community levels
Promoting Action on Research Implement evidence-based practices in evaluation and Designing methods to increase use of evidence in evaluation and intervention in
Implementation in Health Services intervention hospital settings at the individual, departmental, and enterprise levels
(PARiHS; Kitson et al., 2008)
Sticky Knowledge (Elwyn et al., 2007) Identify determinants of change in the use of evidence Identifying and mitigating barriers to implementation of evidence-based practice in primary
and community-based services at the individual, departmental, and enterprise levels
177
Note. Additional research is necessary to determine applicability and utility of these models for use in diverse and emerging occupational therapy practice areas.
in the successful unit. The unit that was less successful in ne- occupational therapy managers can develop processes, tools,
gotiating change was characterized by a culture of complaints, and resources and target key strategies that effectively pre-
dissatisfaction, and passivity. Personnel on the unsuccessful pare staff for innovative change initiatives.
unit reported feelings of self-sacrifice and lack of joy in their
work. Volker et al. (2017) suggested that to effect change in Change Implementation Process
environments in which resistance is high, occupational ther-
Adapting to practice trends and improving the quality of
apy managers must improve the “value proposition” (p. 8) of
services require change. Although change challenges enter-
the change effort.
prises, organizations, and staff, when carefully planned and
Occupational therapy managers need to leverage leader-
implemented, change can be a professional growth oppor-
ship within the enterprise and organization and among their
tunity for all stakeholders involved (Oake et al., 2017). The
staff to strengthen commitment to common goals, complete
change and innovation process begins with identification of
shared tasks, and facilitate change (Berg, 2001; Sijpkens
the urgency for change and the development of a commu-
et al., 2016). To engage staff and facilitate absorption of
nication plan that enables all stakeholders to collaborate on
change and innovation, leadership must strike a balance be-
a blueprint for change implementation and sustainability
tween providing essential guidance through clear processes,
(Oake et al., 2017).
structures, and rules, and empowering staff’s creativity and
Kotter’s (2001) 8 steps of change offers occupational ther-
adaptive capacity (Brown & Eisenhardt, 1997). Engaging
apy managers a clear process by which to establish the blue-
staff members in structured and collaborative decision mak-
print of change and step through the process of creating a
ing fosters understanding, acceptance, and loyalty, laying
climate for implementing and sustaining change. In Kotter’s
the groundwork for managers to usher in necessary change
model (Figure 18.1), occupational therapy managers create a
(Craig et al., 2017).
readiness for change, leverage leadership to build buy-in, and
Spaulding et al. (2017) examined organizational read-
activate all staff to establish a vision and implementation plan
iness for change and developed a measurement scale that
for change. Kotter’s 8 steps include
can accurately and reliably be used by occupational therapy
managers to evaluate when and how to implement change in 1. Establish a sense of urgency.
their organization. The Organizational Capacity for Change 2. Create a guiding team.
Measurement Tool identifies strengths across 3 dimensions: 3. Develop a change vision.
(1) transformative leadership, (2) relational culture, and 4. Communicate a vision for buy-in.
(3) organizational technologies (administrative, clinical, in- 5. Empower action.
formation, social/communication; Spaulding et al., 2017). 6. Generate short-term wins.
The survey of 25 questions is scored on a 5-point Likert rating 7. Don’t let up.
scale, and by comparing the results across the dimensions, 8. Make it stick.
FIGURE 18.1. Kotter’s 8 steps of change.
Implement and
sustain change 8 Make it stick
7 Don’t let up
Engage and
enable 6 Generate short-term wins
5 Empower action
Create a climate
4 Communicate a vision for buy-in
for change
3 Develop a change vision
2 Create a guiding team
1 Establish a sense of urgency
Note. Steps from Kotter (2001).
CHAPTER 18. Managing Organizational Change 179
Create a climate for change often celebrated by all stakeholders. Through effective change
implementation, the culture of the organization sustains the
During Kotter’s first 4 steps of change, the occupational ther-
change effort.
apy manager identifies the need, builds consensus among
diverse stakeholders, and creates a climate for change. The
occupational therapy manager assesses the needs of stake- Methods of evaluation
holders, accesses and links research and practice, and builds Change outcome evaluation is the process by which the out-
awareness of the need for change (Parent et al., 2007). comes of the change implementation effort are measured.
In Step 1, collaborative discussions are key to persuade Measuring the outcomes of change is an essential component
staff and establish a sense of urgency. Step 2 calls for the of the change process, and outcomes communicate value to
manager to create a guiding team made up of credible and program stakeholders. Identifying explicit targets and mea-
influential organizational leaders who are empowered to sures during the planning stages and using them during the
work together with creativity and imagination to develop a implementation stages allow occupational therapy managers
change vision, Kotter’s Step 3. In Step 4, the occupational to effectively manage change effort resources and make nec-
therapy manager and the guiding team communicate a vi- essary trajectory changes in change implementation.
sion for buy-in, and the manager allocates the necessary Occupational therapy managers use both activity and
resources for successful change implementation (Packard, outcome measures to evaluate the effectiveness during and at
2017). The vision should be simply and clearly communi- the end of the change effort (Newton, 2011). Activity measures
cated; organizational leaders cannot overcommunicate the enable managers to evaluate the progress of the change effort,
urgency for change (Kotter, 2001). The guiding team’s expe- whereas outcome measures evaluate what was achieved by the
riences and early adoption of the vision for change are in- effort. When developing activity and outcome measurement
strumental in mitigating resistance and building hope in the methods, managers need to consider the recipients of the
change process. change effort and the intended impact of the change effort on
the recipients. The purpose of the data to be collected must be
Engage and enable the organization considered in the planning stages. For example, the collection
methods of specific metrics required by upper management,
Kotter’s next 2 steps build on the needs assessment and col-
funding sources, consumers, or providers can be established
laborative visioning to foster organizational commitment
when developing activity measures or outcome measures.
and competency. Staff plan and develop iterative mechanisms
To effectively develop activity and outcome measures,
to empower action (Step 5) and achieve initial short-term
Linnell (2003) suggested the following:
wins (Step 6). During this phase of planning and implemen-
tation, the occupational manager builds the commitment of ■ Begin with the end in mind: Consider the vision for the
stakeholders and prepares them for success in implementing change effort and design methods of evaluation before the
the change (Parent et al., 2007). Resources are created, and implementation stage.
training and coaching are provided. ■ Involve stakeholders: Build buy-in and determine the metrics
that will be important to maintain stakeholder commitment.
Implement and sustain action ■ Align closely with needs assessment: Maintaining alignment
with the needs assessment data allows the occupational
In the final 2 steps, the occupational therapy manager, the therapy manager to show improvement from baseline and
guiding team, and the committed stakeholders implement facilitates measure of capacity-building efforts.
the change plan. Shatpattananunt et al. (2015), in their ■ Understand the context: Customize the measures accord-
CLEVER (Context and Culture, Leader, Effective Driving ing to the specific needs of the enterprise, organization,
Change, Voice, Empowerment, and Reaudit) Model, describe and staff.
the processes of this phase as “unfreezing (increasing driv- ■ Use the evaluation for learning: “The ultimate purpose
ing forces and reducing resistance force to change), moving of evaluation should be focused on continuous learning
(taking action for change), and refreezing (stabilizing the and developing practices that move organizations toward
change at a new equilibrium)” (p. 363). The occupational greater effectiveness” (Linnell, 2003, p. 9). Organizations
therapy manager carefully monitors the stages of change, that use activity and outcomes measures for continual
utilization and absorption of new knowledge, acceptance of learning show great success in organizational change and
change, and outcomes of the change process. During this innovation (Linnell, 2003).
final stage, momentum is built, leadership is distributed,
and communication and plan mechanisms are upgraded as Change management is the art and science of designing
needed (Parent et al., 2007). and supporting individuals and organizations to adopt
The occupational therapy manager and guiding team mem- change efforts that improve processes and outcomes. Change
bers continue to reinforce the change effort until it is adopted management activity measures may include tracking mile-
and fully implemented. Once change is fully implemented, stone completion and adherence to timelines; communica-
outcomes are visible and the change effort is reinforced and tion plan effectiveness; training preparation, attendance, and
effectiveness measures; and employee engagement and par- ■ Inadequate clinical or technical skills and procedures: Lack
ticipation measures. Change management outcome measures of knowledge, preparation, training, and follow through
may include stakeholder feedback; behavioral change; effi- on best practices.
ciency, proficiency, and performance measures; compliance ■ Structural limitations: Limited or inconsistent mecha-
measures; and client outcomes. nisms to communicate and disseminate best practices.
Occupational therapy managers identify the key stake-
Review Questions holders and workplace cultural characteristics and select the
1. What are common components of implementation change change effort to be addressed. Often, occupational therapy
theories, models, and frameworks that support successful managers are faced with numerous needs and must priori-
organizational change implementation and sustainability? tize based on an analysis of the organization, its readiness for
2. Compare and contrast the roles of the key change imple- change, and the review of the evidence and the change efforts’
mentation drivers. likely impact on improvement in relevant outcomes (Heller
3. Describe the steps involved in change implementation, & Arozullah 2001). Data are collected, carefully analyzed,
sustainability, and outcome measurement in health care. and used to make decisions regarding needed change. Bar-
riers to change, including personnel resistance and organi-
zational change readiness, are identified and measured, and
PRACTICAL APPLICATIONS IN infrastructure and remediation strategies are implemented.
OCCUPATIONAL THERAPY Change leadership is empowered to develop a vision for
change, and communication structures are established.
In today’s health care environment, occupational therapy
managers must be equipped to effect change that increases
access and equity, improves service delivery processes, em- Design
braces evidence-based innovation, improves client outcomes, During the design stage, the occupational therapy manager
and increases the value of services. Through effective change works with the change leadership and, in alignment with
leadership and implementation, occupational therapy man- Kotter’s Steps 3 and 4, designs the processes that will be used
agers ensure that services delivered increase the meaningful in the innovation. Occupational therapy managers identify
occupational opportunities for the organization’s clients and which components of the change effort are compliance driven
improve the value of the service and the profession. and which are commitment driven and determine a change
Drawing on an understanding of models of change im- approach (Ireland, 2016).
plementation, change agents, and processes of change imple-
mentation, occupational therapy managers leverage change
leaders, the change effort life cycle, and tactical change lead- Build and Test
ership to adopt change in the workplace (Gocsik & Barton, Ensuring stakeholder commitment and aligning change pro-
2014). The change effort life cycle is a systematic process that cesses with a strategic vision and plans of the enterprise, occu-
enables occupational therapy managers to create a change- pational therapy managers consider the ways that the design
ready organization and implement evidence-based innova- will affect clients, staff, and the organization before, during,
tion in health care and includes and after the change effort. Targets and outcome measures
■ Define and plan, are identified.
■ Design,
■ Build and test, Train and Deploy
■ Plan and deploy, and
Consistent with Kotter’s Steps 5 and 6, occupational therapy
■ Operate and innovate.
managers train personnel and execute the change effort. Cre-
ating time and space to build capacity for change and inno-
Define and Plan vation requires access to relevant resources, formal training
Aligning with Kotter’s (2001) Steps 1 and 2, the occupational (face to face or virtual), mentoring and coaching, and su-
therapy and service delivery processes and client and staff pervision. Communication is key, and occupational therapy
needs are evaluated to determine need for change. In occupa- managers must “Communicate the right message to the right
tional therapy, change may encompass the following (Heller people using the right vehicles” (Ireland, 2016, p. 279).
& Arozullah, 2001):
Operate and Innovate
■ Strategic issues: Program policy that affects client access
and service equity, limited personnel resources, or ineffec- Opportunity to observe and emulate practice exemplars is
tive or inefficient workflow processes and procedures. a valuable tactic in change implementation in occupational
■ Cultural disputes: Beliefs, values, norms, and behavior of therapy. Aligning with Kotter’s Steps 7 and 8, occupational
the enterprise, organization, or staff that affect collabora- therapy managers create opportunities for ongoing support
tion, teamwork, and opportunities to learn from mistakes. and distributed leadership among occupational therapy staff.
Reinforcement mechanisms (e.g., reward, negative conse- Review Questions

quences) with performance expectations are used. Additional
1. What key areas of occupational therapy practice may re-
operational and quality metrics and outcome data are col-
quire systematic change efforts?
lected by soliciting feedback from stakeholders, and data are
2. What are the characteristics of transformative communi-
analyzed for additional training and advanced processes.
cation, and how can they improve change outcomes?
3. How can the change effort life cycle enable occupational
Communication therapy managers to create a change-ready organization?
In implementation science literature, communication is
largely considered a transactional process defined by struc-
tural components that facilitate dissemination of the key
SUMMARY
message of the change effort. Change in complex health care Occupational therapy managers have the opportunity and
environments and service delivery systems requires that responsibility to constantly monitor and improve services
occupational therapy managers additionally conceptualize provided and advance the practice and development of or-
communication as transformative communication and a ganizations and staff. Ushering in change in organizations
means of deepening relationships and developing shared un- influenced by regulatory, policy, and payment reforms; in-
derstanding that leads to the co-creation of new knowledge creasing health care complexity and fragmentation; shifting
and action (Manojlovich et al., 2015). organizational structure and governance; and changing
Transformative communication is especially valuable workforce demographics and pressures require more than or-
during time of uncertainty and change and enables occupa- ganizational restructure, procedural and reporting structure
tional therapy managers to more effectively align goals, facil- mandates and reporting, training, and incentives.
itate decision making, and support change readiness. Thomas To innovate in enterprises, organizations, and staff, occu-
et al. (2011) indicated that when occupational managers focus pational therapy managers must stay abreast of practice trends
on relational engagement through the change effort through and stakeholder needs; evaluate and prioritize workplace and
inviting, affirming, and clarifying communication practices, practice concerns; envision a new future and empower a lead-
they facilitate dialog and the emergence of shared meaning, ership coalition to build urgency and commitment; and con-
conceptual reframing and expansion, and the establishment tinually monitor, review, and renew. Change is inevitable, but
of new knowledge. Change efforts are successful and innova- it is also imperative. Change and innovation ensure that oc-
tion flourishes when shared meaning is established and new cupational therapy services are vital and valued, and change
knowledge is created. Case Example 18.1 illustrates building management ensures that change and innovation are incor-
a culture knowledge translation. porated and integrated into practice. ❖
CASE EXAMPLE 18.1. Building a Culture of Knowledge Translation in a School Setting
Over the past several decades, managers and practitioners have seen an explosion in the generation, dissemination, and consumption of scientific
evidence in health care. Simultaneously, health providers are serving more and more clients, addressing increasingly complex health care issues, and
producing more documentation, all limiting the time available for professional development activities (Institute of Medicine [IOM], 2001). Delays in
translating this knowledge into best practice within the health care setting can have a profound impact on client outcomes (Berwick, 2008). In fact, the
IOM (2001) suggested that it often takes 17 years for research to be effectively translated into practice. As a result, many organizations have seen a shift
in approaches to the development and implementation of continuing education in the workplace from expert-led to learner-centered training (Shojania
et al., 2012). Balancing these workplace demands and mitigating the delays associated with consuming and translating evidence to practice became my
focus as a program manager of a large suburban school district program of occupational therapy practitioners and physical therapy practitioners.
The unique body of knowledge required of school occupational therapy practitioners is dynamic and changes rapidly with local, state, and federal
regulatory changes; the advancement of scientific evidence; and the development of best practices. Yet, like most school occupational therapy
practitioners in this practice setting, staff members reported that access to relevant clinical literature, ability to interpret research findings, and translation
of knowledge to school teams are difficult (Laverdure, 2014). In contrast, occupational therapy practitioners reported using colleagues as a source of
information and to support the uptake of new learning and teams were reporting that practice change occurred most effectively in collaborative learning
contexts. Following assessment of the needs of the program and its stakeholders, I determined that creating change in evidence-based practice (EBP)
and knowledge translation (KT) was going to take more than organizational restructure, training, incentives, regulation, and mandates.
Occupational therapy managers and organizational leaders often serve as essential change leaders in the implementation and sustainability
of EBP in the work setting (Aarons et al., 2015). Aarons and Sommerfield (2012) suggested that first-level leaders, or those who provide direct
supervision of health care staff, are often essential change agents for the development of positive attitudes and for the establishment of a climate
of active innovation in establishing wide-scale adoption of EBPs within organizations. They posited that through the development of a climate of
acceptance, barriers to change implementation can be mitigated and overcome. Drawing from Kotter’s (2001) 8 Stages of Change and Parent et al.’s
(2007) Dynamic Knowledge Transfer Capacity Model of Change Implementation, a collaborative social learning environment was established to
support the development of EBP and KT. Table 18.2 illustrates the steps taken to support change in practice.
(Continued)
CASE EXAMPLE 18.1. Building a Culture of Knowledge Translation in a School Setting (cont.)
TABLE 18.2. Steps Taken to Support Change in Practice
DYNAMIC KNOWLEDGE KOTTER’S 8 STAGES OF CHANGE

TRANSFER CAPACITY MODEL STAGE PROGRAM ACTION
Inquiry: Building Awareness Establish a sense of urgency ■ Introduced state and federal regulatory requirements and national and
During this phase, I assessed state standards of practice and ethical guidelines for EBP.
the needs of all stakeholders ■ Provided training and practice examples of EBP and effective and
and empowered the staff to reproducible client outcomes.
use creativity and invention to ■ Provided exemplars of client (teacher and family) satisfaction and
achieve the goals established capacity outcomes.
through the change effort. Create a guiding coalition ■ Established a small group of practice leaders, led by an identified KT
Facilitator, to form a guiding coalition to identify the need for practice
change and exemplified change in practice.
■ The guiding coalition collaborated with stakeholders within and
outside of the program to identify the scope of the need for change in
EBP and KT practices.
Develop a change vision ■ Established a clear and succinct unifying vision and introduced
nomenclature and strategy to support the vision.
Communicate a vison for buy-in ■ The guiding coalition produced 2 evidence briefs that addressed hot
topics in practice and, with the program manager, developed reflection
and evidence appraisal models to support EBP and clinical reasoning
in the context of CLTs.
■ Staff derived immediate benefit from the recommendations included
in the practice briefs.
Planning: Building Community Empower broad-based action ■ Established 11 CLTs focused on specific practice questions.
and Competency ■ Resources, training, coaching, and mentoring were provided to the
During this phase, I networked CLTs and individual staff members.
and empowered stakeholders to ■ The aims of the CLTs were linked to individual professional
build a collaborative blueprint to development goals and performance appraisal.
implement and integrate change.
Implementation: Building Generate short-term wins ■ The CLTs disseminated the results of their collaborative learning,
Momentum practice outcomes, and recommendations.
During this phase, I monitored the
stages of change, the utilization Don’t let up ■ As the work of the CLTs expanded and staff achieved their
of new knowledge, and the professional development goals, learning expanded and staff began
outcomes of the change effort. disseminating their knowledge within and outside of the program
(practice guidelines, conference presentation, and publication).
Sustaining: Building Acceptance Anchor new approaches ■ The program manager evaluated the development and refinement of
During the final phase, I established narrative knowledge, research literacy and utilization, and knowledge
continuous improvement efforts exchange/sharing practices.
(feedback loops, qualitative ■ A competency-based performance assessment process was
and quantitative data collection) established to evaluate staff’s accomplishment of EBP and KT
and ensured resources to professional development goals.
support distributed leadership. ■ Data were analyzed and 98% of staff met the performance targets
established through the change effort.
■ Plans were put in place to begin to evaluate client outcomes.
Note. CLTs = collaborative learning teams; EBP = evidence-based practice; KT = knowledge translation.
Review Questions
1. Occupational therapy practitioners often report that they most use colleagues as a source of information to support the uptake of new learning.
Why is this an important consideration for occupational therapy managers who are implementing programs to increase the use of EBP?
2. Why is designing and implementing effective practice that increase the uptake and translation of evidence to practice an important
consideration for occupational therapy managers?
3. What steps that were taken to implement and sustain EBP in a large metropolitan school system?
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■ B.5.2. Advocacy Feldstein, A. C., & Glasgow, R. E. (2008). A Practical, Robust Im-
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■ B.5.6. Market the Delivery of Services https://doi.org/10.1016/S1553-7250(08)34030-6
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CHAPTER
Planning During Uncertainty
Jaime L. Smiley, MS, OTR/L, and Thomas Smith, MBA, OTR/L 19
LEARNING OBJECTIVES
■ Identify health care trends leading to an environment of uncertainty,
■ Recognize the importance of a health care organization’s mission and vision and how they affect planning,
■ Describe the planning process involved for each of the 4 different levels of uncertainty,
■ Describe how a rolling strategic plan is helpful during times of uncertainty,
■ Identify the occupational therapy manager’s role in communicating the changes needed to minimize uncertainty,
■ Identify the 4 characteristics of transformational leadership, and
■ Describe the Lean Six Sigma methodology as a process within transactional leadership.

• Alternate futures • Participation in decision making • Transformational leadership
• Clear-enough future • Range of futures • True uncertainty
• Full-range leadership model • Strategic planning • Uncertainty
• Lean Six Sigma • Transactional leadership • Vision
• Mission
OVERVIEW employees. In such situations, the level of uncertainty within

the organization is so complex that it affects most, if not all,
Managing During Periods of Uncertainty managerial actions.
Uncertainty can be defined as a “dynamic state in which there This chapter focuses on uncertainties that have a high
is a perception of being unable to assign probabilities to impact on the organization and are readily apparent. This
outcomes” (Penrod, 2001, p. 241). Because uncertainty is a chapter explores what occupational therapy managers must
dynamic concept, it can be present frequently and at various do to plan, organize, and maintain order while supporting
degrees of complexity in an organization. Some amount of staff and administration in times of uncertainty. Because
uncertainty in decision making is nearly always present. For managing during times of uncertainty requires planning
example, occupational therapy managers could be uncer- that has both traditional and alternative components, this
tain about such daily issues as which problems to prioritize, chapter discusses how, in uncertain situations, focusing on
who to promote, or how to manage therapy referrals. More the organization’s mission and vision is essential to minimize
broadly, 2 health care facilities might merge, creating ques- uncertainty. Additionally, leadership qualities that advance
tions about who might be retained and who dismissed from optimism, create opportunities, and provide a model for
the newly formed organization, or a governing body votes to thriving despite the uncertainty are discussed. Finally, this
close a state hospital in 1 of the city’s poorest communities, chapter emphasizes relying on evidence from well-researched
resulting in community outcry and legal action by hospital and proven methods for managing uncertainty.
https://doi.org/10.7139/2019.978-1-56900-592-7.019
185
CHAPTER
Planning During Uncertainty
Jaime L. Smiley, MS, OTR/L, and Thomas Smith, MBA, OTR/L 19
LEARNING OBJECTIVES
■ Identify health care trends leading to an environment of uncertainty,
■ Recognize the importance of a health care organization’s mission and vision and how they affect planning,
■ Describe the planning process involved for each of the 4 different levels of uncertainty,
■ Describe how a rolling strategic plan is helpful during times of uncertainty,
■ Identify the occupational therapy manager’s role in communicating the changes needed to minimize uncertainty,
■ Identify the 4 characteristics of transformational leadership, and
■ Describe the Lean Six Sigma methodology as a process within transactional leadership.

• Alternate futures • Participation in decision making • Transformational leadership
• Clear-enough future • Range of futures • True uncertainty
• Full-range leadership model • Strategic planning • Uncertainty
• Lean Six Sigma • Transactional leadership • Vision
• Mission
OVERVIEW employees. In such situations, the level of uncertainty within

the organization is so complex that it affects most, if not all,
Managing During Periods of Uncertainty managerial actions.
Uncertainty can be defined as a “dynamic state in which there This chapter focuses on uncertainties that have a high
is a perception of being unable to assign probabilities to impact on the organization and are readily apparent. This
outcomes” (Penrod, 2001, p. 241). Because uncertainty is a chapter explores what occupational therapy managers must
dynamic concept, it can be present frequently and at various do to plan, organize, and maintain order while supporting
degrees of complexity in an organization. Some amount of staff and administration in times of uncertainty. Because
uncertainty in decision making is nearly always present. For managing during times of uncertainty requires planning
example, occupational therapy managers could be uncer- that has both traditional and alternative components, this
tain about such daily issues as which problems to prioritize, chapter discusses how, in uncertain situations, focusing on
who to promote, or how to manage therapy referrals. More the organization’s mission and vision is essential to minimize
broadly, 2 health care facilities might merge, creating ques- uncertainty. Additionally, leadership qualities that advance
tions about who might be retained and who dismissed from optimism, create opportunities, and provide a model for
the newly formed organization, or a governing body votes to thriving despite the uncertainty are discussed. Finally, this
close a state hospital in 1 of the city’s poorest communities, chapter emphasizes relying on evidence from well-researched
resulting in community outcry and legal action by hospital and proven methods for managing uncertainty.
https://doi.org/10.7139/2019.978-1-56900-592-7.019
185
ESSENTIAL CONSIDERATIONS uncertainty regarding personal care and the future of health
care and their access to it.
Rapid Health Care Change Courtney et al. (1997) identified 4 levels of uncertainty, pro-
Health care is constantly changing, and the rate and number of viding a framework that will lead to better decision making
changes are rapidly rising (Johnson, 2016). Collectively, changing during planning: (1) clear-enough future, (2) alternate futures,
national demographics, escalating health care costs, and the lack (3) range of futures, and (4) true uncertainty. No framework
of access to health care services served as catalysts to the rapid can remove all of the challenges associated with uncertainty,
changes we have been experiencing with ensuing uncertainty but an organized system for examining uncertainty will help
within our health care industry. Health care organizations and facilitate a more informed process.
providers find themselves implementing anticipatory and adap-
tive changes as a means to better meet the needs of customers. Level 1. Clear-enough future
Excessive change is becoming normal practice in the health
care industry. Any health care organization must respond to At the clear-enough future level of uncertainty, a single fore-
external factors. Systems, institutions, and populations impose seeable future is clearly enough defined to develop a strategy.
change and can create and maintain a state of uncertainty. For It is impossible to know all variables in decision making, but
example, regulatory and reimbursement overhauls can be im- this level forecasts a single option for the future after research
posed by payers at any time, challenging to an organization is completed. For example, if an occupational therapy man-
that is pressured to be fiscally responsible while continuing to ager is experiencing a high level of turnover in the depart-
ensure positive clinical outcomes and find ways to improve its ment, should the manager develop better communication
operation. skills? Is there a problem with the salary or benefits package?
Despite spending more money on health care than other Are therapists not properly trained and provided with orien-
industrialized countries, the U.S. health care industry does tation to department policies and procedures? After examin-
not produce the same outcomes as its international peers. In ing all of these scenarios, the manager can develop a strategy
2016, the United States spent twice as much on health care to improve retention in the therapy department.
services than countries such as Canada, the United Kingdom, Because of this element of insight (i.e., the need for a reduc-
and Japan while achieving worse health and access outcomes tion in staff turnover and a more stable workforce over a longer
(Papanicolas et al., 2018). In addition, the U.S. population is period of time) into an otherwise unforeseeable future, manag-
aging. In 2014, 15% of the total U.S. population was age 65 years ers can use standard strategies to guide decision making. Market
or older. By 2030, the number of older Americans is expected research, cost analysis, and examination of the organization’s
to grow to nearly 21% of the U.S. population (Federal Inter- internal SWOT analysis (strengths and weaknesses and exter-
agency Forum on Aging Related Statistics, 2016). Proportion- nal opportunities and threats) are examples of such strategies.
ately fewer people will be paying into Medicare, jeopardizing
the solvency of that program. This is particularly disconcert- Level 2. Alternate futures
ing because people age 65 years or older consume the most
health care services. This alone creates uncertainty. In Level 2, alternate futures indicate several possible outcomes
Managing against this backdrop of rapid and continued exist. These 2 or 3 possible outcomes are clear and distinct, but it
change, health care organizations and occupational therapy is impossible to predict which will occur. This type of uncertainty
managers might consider asking how, in an environment of in- is often seen when working through potential regulatory or re-
creasing numbers of older adults, decreasing payment sources, imbursement changes. Consider the skilled nursing industry
and limited access to services, can we provide accessible health (SNF) in the 1990s. Prior to 1998, that industry was reimbursed
care at an affordable cost, and what services should be provided? on a fee-for-service schedule. When proposals for changing this
reimbursement structure to managed care emerged, providers
began preparing for a future that would either continue busi-
Levels of Uncertainty
ness as usual or drastically change reimbursement to a prospec-
Uncertainty is a term heavily examined across many indus- tive payment system. Changing reimbursement models would
tries when considering strategic planning and operations affect every aspect of the business from service delivery to doc-
management. Allied health, psychology, sociology, business, umentation and staffing, so planning during this time resulted
and nursing consider uncertainty when assessing need and in establishing a plan for each scenario.
planning for change. Level 2 strategies are more complex than Level 1 because of
Recall the early definition of uncertainty, which indicates a the multiple futures forecasted. It is imperative for leaders to
perceived inability to gauge probabilities to predict outcomes. identify the most probable future state through a data-driven
From an organizational standpoint, this definition reflects approach and understand the implications for their orga-
operational and clinical decisions and the unknowns that can nization or work force. Strategies should be implemented
be imposed by external factors, such as third-party payers or accordingly and monitored. If the developed strategies do not
regulatory bodies. The definition also reflects uncertainty produce the intended outcome, alternative strategies should
relating to internal organizational factors, such as restructur- be implemented. Implemented strategies that prove to be suc-
ing. Clients, patients, and families also have varying levels of cessful should continue to be monitored for sustainability.
CHAPTER 19. Planning During Uncertainty 187
Level 3. Range of futures Review Questions

A range of futures indicates that there is a continuum of pos- 1. Describe changes in the overall health care system that
sibilities for the future. Unlike Level 2 in which distinct op- have led to greater uncertainty over an extended period
tions exist, Level 3 includes a range of future possibilities. of time.
Organizations looking to expand services into a new geo- 2. How do the levels of organizational uncertainty progress?
graphic area or health care environment often face this level How is uncertainty different at Level 1 and Level 4?
of uncertainty. For example, consider a contract company
that is looking to expand business into another state. Re-
search into the available market and need for therapy services PRACTICAL APPLICATIONS IN
would indicate a range of need. Although the range is finite, OCCUPATIONAL THERAPY
the true future can be anywhere within that range. Therefore,
it is impossible to predict the exact staffing, space, and equip- Overview of Strategic Planning
ment that will be needed. Strategic planning is the process of deciding what objectives
To plan at Level 3 uncertainty, managers must predict dis- to pursue during a future time period and what to do to
tinct futures that are the most likely to occur within the range achieve those objectives (Rue & Byars, 2000). One of the pri-
of options. To accomplish this, managers can use planning mary roles of occupational therapy managers is to develop
strategies used in Levels 1 and 2 decision making for each and implement plans. These plans can affect therapy service
identified probable option. It can be difficult to predict and delivery alone, or they may be part of larger strategic plans
plan for the full range of futures, but with experience and for a hospital system, company, or other health care agency.
strategic planning, managers can gauge what is most probable Strategic planning is influenced by an organization’s cul-
to occur. ture, leaders, size, activities, mission and vision, and degree
of urgency felt for change (Strickland, 2010). Managers must
Level 4. True uncertainty plan even when uncertainty pervades.
In Level 4 multiple variables interact to create a future that Strategic planning is a key method for managing uncer-
is truly unpredictable, termed true uncertainty. Within this tainty because it allows the occupational therapy managers
level of uncertainty, so many variables and potential out- and practitioners to emphasize the more reliable aspects of
comes exist that no one can predict what changes are likely an organization and its programs (i.e., certainties). It offers an
to occur and what their effects might be. In Level 3, managers opportunity to create if–then alternatives to various futures
can determine a range of possibilities, but true uncertainty and prepare for the most likely outcomes of the period of
in Level 4 indicates that it is still not possible to determine uncertainty. Finally, strategic planning sets a reasonable
even a range of futures. For example, multiple and constantly timeline and takes into account what it is likely to be achieved
emerging technologies combine to develop artificial intelli- under the uncertain conditions.
gence. There are vast uncertainties about how to implement, Although it is beneficial to use known and familiar strat-
disseminate, and regulate such technologies. egies when managing uncertainty, traditional approaches
This level of uncertainty in health care has rarely existed may not always work. Traditional methods of planning,
in the past but is being seen more frequently. The utilization organizing, and overseeing operations have a relatively linear
of robotics is becoming more prevalent in the field of physi- approach. Steps to traditional methods of planning include
cal medicine as it theoretically offers more precise movement ■ Examining where the company or organization is now.
patterns and more repetitions required for progress. Despite ■ Considering where the company or organization wants to be.
the lack of research supporting the true efficacy of robotics ■ Developing a plan:
in recovery, many hospitals are investing significant capital • Deciding on steps needed to achieve the plan,
in this technology. Those investing in this technology believe • Fitting the plan into a traditionally identified timeframe
that early entry can differentiate them from other providers. (e.g., 5 years), and
Those who do not take a wait-and-see approach at the ex- • Identifying barriers.
pense of late entry and potential market loss. ■ Implementing the plan.
Because of the paralyzing effect of Level 4 uncertainty, ■ Measuring outcomes.
industries avoid reaching this level by developing regulatory ■ Adjusting the plan as needed.
and governing stability to allow for decisions to be made at
Levels 1, 2, or 3. However, despite the best planning efforts, In the constantly changing health care industry in which
Level 4 uncertainty can and does occur. Planning at Level 4 is there is a high level of uncertainty, these steps may not be
not necessarily targeted at making decisions but focuses insufficient. Instead, occupational therapy managers must be
stead on systematically obtaining information through con- constantly prepared for change and ready to take a more
sultation with other organizations, clarification with policy flexible approach to implementing a plan and analyzing its
makers, examination of literature, and ongoing analysis of outcomes. In times of uncertainty, the planning process must
the meaning and impact of the change, to gain perspective on consider how the organization can more rapidly take in and
possible strategies for the future. process information, adjust assumptions, build models, and
recalculate expectations. Leaders must quickly come to a full them (Jacobs & Ursitti, 2017). It is essential that a planning
understanding of the planning models being used so they team fully understand and embrace the organization’s mis-
can question assumptions, make rapid alterations in the plan sion and vision. It is equally important that managers clearly
as needed, and guide their teams to implement necessary communicate how the mission and vision influenced decision
changes. making and planning. If all members do not understand the
Rather than develop a strategic plan in the traditional lin- mission and vision, or how decisions reflect the mission and
ear fashion, occupational therapy managers may need to use vision, there may be less buy-in and acceptance of new initia-
a “rolling” strategic planning process, which allows for regu- tives and goals.
larly refreshing the plan as uncertainties continue to develop
and until a more certain path can be identified (Jacobs & Research and Information Gathering
Ursitti, 2017). When creating a strategic plan during uncer-
tainty, managers must move forward with several factors still When managing during times of uncertainty, using well-
unknown. They communicate to staff that they recognize researched information from reputable sources is impera-
and acknowledge that right now there is not enough time to tive because it adds to a sense of security and verification.
develop comprehensive plans for every possibility, nor can Focusing on known and familiar strategies and how they
they wait to take action until all regulatory information is relate to an organization’s current situation demonstrates to
provided, learned, and processed. To successfully plan during stakeholders previously trod paths for emerging from times
uncertainty, management must be able to take unknowns into of uncertainty; it allows managers to learn from what others
consideration, accept their inability to control those aspects have done in the past.
of the plan, and focus on what is achievable while continuing Furthermore, when the organization acknowledges that it
to explore ways to minimize the uncertainties. is less knowledgeable on crucial issues, it provides some assur-
The establishment of defined metrics associated with the ance to stakeholders that it is actively engaged in information
strategic plan provides a mechanism to evaluate the efficacy gathering to solve the problem. Such action can reduce anx-
of implemented tactics. Decisions to sustain current efforts or iety and fosters a feeling that despite current uncertainties,
to alter one’s course are driven by the organizational perfor- solutions are forthcoming. For example, actions like moni-
mance related to these metrics. Outcomes that do not meet toring local markets, considering new regulations, exploring
expected metrics may indicate that the strategic plan may new service delivery models and technologies, and learning
need to be refreshed. from competitors while remaining true to the organization’s
mission and vision can demonstrate how the organization is
invested in solving problems (Jacobs & Ursitti, 2017).
Determining Rationale
When determining whether a change will occur, it is im-
Engaging Staff
portant to assess the rationale for change. Are there external
changes occurring that require organizational changes to Broad changes in the health care industry yield uncertainty
continue to thrive in the market? Are there internal systems in the work environment and can greatly affect employee
that need to be revised so the organization can continue to engagement, alignment, and performance (Rafferty & Grif-
thrive? Before the planning process can begin, this rationale fin, 2006). Hallmark characteristics of uncertainty are a
must be determined. When approaching this change, an sense of doubt about future events and confusion over the
understanding of how change will continue to occur through exact cause and effect relationships in the environment that
the planning process is important. This constant change must are causing the problems that require change (DiFonzo &
be expected and embraced during the planning process. Bordia, 1998).
Upholding Mission and Vision Understand staff perceptions

A vision describes a projection toward the organization’s To build a strong strategic plan during uncertainty, managers
desired future. A mission describes the organization’s long- must carefully explore employees’ concerns about their fu-
term purpose and role. Having a clear mission and vision tures in the organization, their sense of how an uncertain sit-
statement is particularly important during periods of un- uation arose, and the impact it will have on themselves and the
certainty because these statements are designed to describe organization as a whole (Cullen et al., 2014). Managers must
the organization’s long-term purpose and role and therefore consider the employees’ perception of change and disposition
represent 1 of the most basic and fundamental certainties of toward change. Employees’ perceptions of and attitudes to-
the organization. The mission answers the question, Why ward the uncertainty and the changes proposed to minimize
does the organization exist? The vision answers the question, it correlate with their understanding of the situation and how
Where is the organization going? changes affect them (Lau & Woodman, 1995). Therefore, it is
When planning in times of uncertainty it is important for the leadership’s responsibility to clearly describe what events
each person involved in the planning process to fully under- and conditions created the uncertainty, clarify the rationale
stand both the mission and vision, to keep this information for change, and provide the objectives of the change initiative
readily available for reference, and to ensure decisions reflect and how change will be measured.
Companies value employees who recognize the impor- Leadership Skills for Uncertain Conditions
tance of change, understand the value of altering personal
It is human nature to have an aversion to uncertainty; people
expectations within a newly forming paradigm, and can cap-
desire a degree of certainty. Being able to anticipate one’s daily
italize on opportunities despite current uncertainty. Employ-
schedule, the content on the next exam, or one’s career path
ees who can be creative in exploring critical areas for personal
goes a long way in relieving stress in our lives. Uncertainly
and organizational success are considered valuable members
disrupts our sense of control and can lead to unwanted stress.
of the team (Ngo & Loi, 2008).
Skilled occupational therapy managers and leaders can assist
For example, it is critical for employees to have buy-in in
staff and the organization to manage the stress of uncertainty
an era of payment reform that rewards quality care and an en-
and to adapt responsibly to a dynamic environment.
hanced patient experience. When employees perceive strong
Although several leadership models may be referenced to
organizational support, they are more likely to feel that their
assist with organizational change, the full-range leadership
social–emotional needs are being met and to report more
model is a validated approach offering a blend of leadership
positive job satisfaction and organizational engagement.
styles to support and sustain change within an organization
Conversely, lack of organizational support, especially from a
(Bass & Avolio, 1990; Judge & Piccolo, 2004). The model iden-
direct manager, may have a deleterious impact on the orga-
tifies essential leadership behaviors within 2 primary dimen-
nization. This is especially true during times of uncertainty.
sions: (1) transformational and (2) transactional. Both forms
of leadership are required of managers when supporting orga-
Communication nizational change. Transformational leadership is important
Employee uncertainty often occurs because of missing or for developing a climate for innovation and positive attitudes
failed communication between leadership and staff. This un- toward evidence-based practice during change implementa-
certainty may lead to stress, decreased job satisfaction, and tion initiatives (Aarons & Sommerfeld, 2012). First-level lead-
employee turnover. Inadequate communication regarding ership (i.e., front-line leadership, or direct leaders of patient
the organization’s vision for the change is one of the main care employees) is critical to the transformational process.
reasons why organizational change fails (Kotter, 1995). More positive first-level leadership is associated with more
As Jiang and Probst (2014) illustrated in a study on positive provider attitudes toward adopting evidence-based
organization communication, effective communication practices (Aarons, 2006).
serves as a useful strategy to minimize stress associated
with uncertainty. Through clear communication about the
Transformational leadership
reasons for uncertainty, occupational therapy managers
can engage staff and reduce some of the associated stress. Transformational leadership is the degree to which a leader
Open dialogue not only offers a better understanding of can inspire and motivate others to follow an ideal or a partic-
what is causing uncertainty but also provides the transpar- ular course of action (Bass, 1999). It is comprised of 4 com-
ency required for the team to develop confidence and trust ponents that influence organizational change and have been
in leadership. Managers openly and transparently com- shown to lead to positive behaviors in organizations:
municating with staff is a key strategy to reduce employee
uncertainty during times of change (Lewis, 1999; Tanner 1. Individualized consideration: Appreciation of each staff
& Otto, 2017). member’s contributions and needs,
2. Intellectual stimulation: Ability to stimulate thinking and
accept different ideas or perspectives,
Participation in decision making 3. Inspirational motivation: Ability to inspire and motivate
Perceptions that an organization is supportive of its em- staff, and
ployees have been shown to explain how some workers 4. Idealized influence: Degree to which leaders act confidently,
positively adapt to the uncertainty and associated changes, and instill pride, respect, values, beliefs, and a strong sense
ultimately experience greater job satisfaction, and display of purpose (Bass & Avolio, 1990).
better job performance (Cullen et al., 2014). Participation
in decision making (PDM) is the process by which influ-
Transactional leadership
ence or decision-making is shared between supervisors and
employees (Sagie et al., 1995). Bordia et al. (2004) showed Transactional leadership is the degree to which a manager
that management communication reduces strategic uncer- focuses on the processes involved in achievement through
tainty. To reduce structural and job-related uncertainty, it use of quality standards, incentives, and rewards. This type
is imperative to fully integrate PDM and 2-way communi- of leadership also penalizes negative performance when nec-
cation. Organizations that make an effort to communicate essary. Transactional leadership focuses on organizational
with employees may reduce the negative consequences of processes and policies to assure optimal outcomes.
organizational change and job insecurity (Jiang & Probst, Transactional leaders clearly delineate goals and objec-
2014). Engagement of employees in the change initiative can tives for the organization so all employees have specific tar-
provide a sense of control to help with the emotional toll of gets to reach. Achievement of goals and objectives warrants
uncertainty. rewards, and failure to achieve them results in penalties.
Strong transactional leaders work to create processes that of imposing change. Lean Six Sigma is a pragmatic approach
avoid penalties and motivate workers to achieve rewards, that attempts to reduce variation in the delivery of services by
thereby improving the delivery of health care services. eliminating waste and defects while establishing more effective
Although there are various ways to achieve established pro- processes (Courtney et al., 1997).
cess objectives from a transactional leadership perspective, the
Lean Six Sigma philosophy provides a data-driven methodical
Review Questions
approach to enhancing performance. Using transactional lead-
ership, the approach emphasizes “lean” processes for eliminat- 1. How does planning under uncertain conditions differ
ing waste and ensuring added value and processes for reduc- from traditional strategic planning processes?
ing variation in service delivery. This 5-step process (define, 2. Why are the mission and vision of the organization
measure, analyze, improve, control) allows an organization to essential to planning during times of uncertainty?
better understand current processes, identify opportunities for 3. What can occupational therapy managers do to reduce
improvement, and use data to objectively measure the effects the negative impact of uncertainty felt by employees?
CASE EXAMPLE 19.1. Payment Methodology Adaptation
Indication of impending large-scale changes in federal payment models based on U.S. congressional health care legislation threatened to drastically
alter reimbursement and led to uncertainty about how plan for the future in the skilled nursing industry and other areas of rehabilitation, including
inpatient services, like at the Acme Nursing and Rehabilitation Center. How best to prepare for the wide range of possible alterations in current
procedures depended on finalized specifications from the Centers for Medicare and Medicaid Services (CMS), but those details were not fully
available to the management team at Acme. Managers were also aware that such changes typically required interpretation and clarification before a
final plan could be created.
Although uncertainties abounded, delays in taking action would affect Acme’s funding. This, in turn, could affect the quality of services delivered
and Acme’s overall operation and planning. Managers at Acme knew that they had prepared with various scenarios so they would be ready to
rapidly implement organizational changes to avoid loss of funding once CMS released changes in federal policies regarding payment. Management
appropriately regarded this uncertainty as a Level 3 because it could anticipate a range of possible strategies as solutions but were unable to
narrow them down to very few solutions until further information was obtained. Therefore, managers began to develop a set of alternative strategies,
a combination of which would depend upon final decisions by the CMS. The planning strategy consisted of the following actions:
■ Acme’s top management team assembled to initiate a plan. This team consisted of chief executive, operations, and financial officers and the
leaders of all major departments, including nursing, occupational therapy, physical therapy, speech–language pathology, and social work.
The chief executive officer began with a full review of Acme’s mission and vision, assuring everyone that the mission and vision remained the
foundation of the organization and that changes would be implemented to sustain them.
■ Reliable information was gathered from national associations that maintain connections with federal legislators and policy makers. These included
the American Health Care Association; the American Rehabilitation Providers Association; and all professional health care associations, including the
American Occupational Therapy Association (AOTA). Managers also consulted with reliable colleagues from other health care organizations to discover
issues they had not yet considered. The management team scrutinized the reliability and sincerity of everyone with whom they consulted. In 1 case, it
became apparent that a software vendor was taking advantage of the present uncertainties to benefit his own company at the cost of Acme.
■ The management team reconvened to analyze and interpret the gathered information and refine initial plans.
■ The team developed a proposal for how Acme would make changes. At this point, management felt they had more knowledge and understand-
ing of the proposed policy changes and clearer options for how to manage them. Team members felt they had narrowed their Level 3 uncertainty
and were closer to but not squarely at Level 2.
■ As information was being gathered and interpreted, clinical managers, including the occupational therapy manager, were instructed to inform
staff of impending changes in payment policies. Chief management offered their assistance to clinical managers in describing the current situa-
tion, easing concerns, motivating and empowering staff, and ensuring that daily operations would continue unimpeded as much as possible. The
use of transformational leadership skills was essential at this stage of the planning process. Among other communications, managers assured
staff that therapies would not be contracted to outside agencies and that the current “in-house” model would remain intact, as rumors had
spread that outsourcing might be necessary.
■ On the basis of information obtained from several sources, Acme could narrow its plan to 2 alternative strategies they were likely to use,
depending on final CMS decisions. When the final decision was announced, the management team put a plan into action that required a
reduction in group therapies and concurrent treatments, and a plan for follow-up on all discharged clients to monitor the impact of treatment
on recidivism, community engagement and health, and acquisition of durable medical equipment and medications. Transactional leadership
through use of the Lean Six Sigma method was essential at this stage of management.
Review Questions
1. How did management of a SNF organization determine the level of uncertainty about proposed payment-related changes?
2. What were the responsibilities of the occupational therapy manager during the Level 3 phase of uncertainty?
3. How did management conduct strategic planning during this time of uncertainty?
SUMMARY and organizational development. Research in Organizational

Change and Development, 4, 231–272.
Planning during times of uncertainty is a unique challenge Bass, B. M. (1999). Two decades of research and development in trans-
to an organization and its managers. Given current trends in formational leadership. European Journal of Work and Organiza-
health care, it is likely that uncertainty will always be a com- tional Psychology, 8, 9–32. https://doi.org/10.1080/135943299398410
ponent that management will be challenged to deal with. As Bordia, P., Hobman, E., Jones, E., Gallois, C., & Callan, V. J.
the need for high quality health care grows and the demand (2004). Uncertainty during organizational change: Types, con-
to control its cost remains essential, an uncertain future for sequences, and management strategies. Journal of Business
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CHAPTER
Handling Resistance During Change
Albert E. Copolillo, PhD, OTR/L, FAOTA, and Dianne F. Simons, PhD, OTR/L, FAOTA 20
LEARNING OBJECTIVES
■ Understand the reasons that workers resist change,
■ Describe resistance to change in terms of the 6 basic needs of workers,
■ Describe predispositions to negative resistance to organizational change,
■ Recognize indirect responses and direct challenges to proposed change,
■ Identify the managerial responsibilities and challenges to change resistance, and
■ Describe managers as role models for change and reliance on superiors to manage change resistance.

• Change • Inclusion/connection • Resistance to change
• Competence • Justice/fairness • Security
• Control • Power
W
orkers can experience emotional reactions when Why Resist? Amount, Intensity, and Time
changes occur in the systems, departments, and
Aspects of Change
programs of the organizations in which they work.
This chapter provides underlying reasons that workers re- Change is means to creating a difference. It can involve
sist change by examining the characteristics of the change, moving from a relatively steady state into a place of uncer-
the basic needs of workers, and predispositions to negative tainty, followed by a new state of equilibrium. We frequently
resistance to change. The need for occupational therapy use modifiers when describing change (e.g., “organizational
managers to recognize, analyze, and respond to workers’ change”) to identify the environment the change is intended
perceptions about a proposed change is discussed. This to affect. Emotional reactions and change are seen as insep-
chapter also provides strategies for creating a work envi- arable from change in many organizational change theories.
ronment that welcomes change and for effectively creating People may view change as promising, threatening, or simply
change even when negative resistance is present. Resistance inevitable, but all workers have opinions and reactions to
to change is examined and analyzed from both the perspec- change (Anderson & Anderson, 2010b; Dasborough et al.,
tive of the occupational therapy manager and the employees. 2015; Lindebaum & Jordan, 2012).
(We acknowledge that there are reasonable and acceptable People’s reactions to change are related to perceptions
rationales for resisting change but that some resistance is of the number of changes they are expected to make (i.e.,
based on limited perspectives.) amount), the impact the change will have on the way they
https://doi.org/10.7139/2019.978-1-56900-592-7.020
193
CHAPTER
Handling Resistance During Change
Albert E. Copolillo, PhD, OTR/L, FAOTA, and Dianne F. Simons, PhD, OTR/L, FAOTA 20
LEARNING OBJECTIVES
■ Understand the reasons that workers resist change,
■ Describe resistance to change in terms of the 6 basic needs of workers,
■ Describe predispositions to negative resistance to organizational change,
■ Recognize indirect responses and direct challenges to proposed change,
■ Identify the managerial responsibilities and challenges to change resistance, and
■ Describe managers as role models for change and reliance on superiors to manage change resistance.

• Change • Inclusion/connection • Resistance to change
• Competence • Justice/fairness • Security
• Control • Power
W
orkers can experience emotional reactions when Why Resist? Amount, Intensity, and Time
changes occur in the systems, departments, and
Aspects of Change
programs of the organizations in which they work.
This chapter provides underlying reasons that workers re- Change is means to creating a difference. It can involve
sist change by examining the characteristics of the change, moving from a relatively steady state into a place of uncer-
the basic needs of workers, and predispositions to negative tainty, followed by a new state of equilibrium. We frequently
resistance to change. The need for occupational therapy use modifiers when describing change (e.g., “organizational
managers to recognize, analyze, and respond to workers’ change”) to identify the environment the change is intended
perceptions about a proposed change is discussed. This to affect. Emotional reactions and change are seen as insep-
chapter also provides strategies for creating a work envi- arable from change in many organizational change theories.
ronment that welcomes change and for effectively creating People may view change as promising, threatening, or simply
change even when negative resistance is present. Resistance inevitable, but all workers have opinions and reactions to
to change is examined and analyzed from both the perspec- change (Anderson & Anderson, 2010b; Dasborough et al.,
tive of the occupational therapy manager and the employees. 2015; Lindebaum & Jordan, 2012).
(We acknowledge that there are reasonable and acceptable People’s reactions to change are related to perceptions
rationales for resisting change but that some resistance is of the number of changes they are expected to make (i.e.,
based on limited perspectives.) amount), the impact the change will have on the way they
https://doi.org/10.7139/2019.978-1-56900-592-7.020
193
perform expected work tasks (i.e., intensity), and the time 3. Power is ability to influence the change and its process,
frame they are given to create the change. The time available at least at the individual level. The potential for loss of
to react to and implement a change will be weighed against influence and authority may lead to resistance.
the perceived quantity of changes needed to be made and 4. Control is a sense of organization and predictability
the qualities of the expected tasks in relation to those of the about the change. A loss of the sense of structure in work
current work activities. A worker will judge the proposed routines and an inability to predict what one will be
change by asking the following questions: expected to do can lead to resistance. Feeling that one has
no choice but to resign to an unwanted change may also
■ Amount: How much do I need to alter the way I currently lead to negative resistance.
do things? Overall, does the change mean more or less
5. Competence is the feeling of being capable, skilled, and
work for me and my coworkers? Does the change reduce
effective and the awareness that others recognize those
or increase the amount of work I am most likely to do
characteristics in you. Workers are likely to resist any
or that I least prefer? Will the number of tasks and the
change perceived to reduce their capabilities; minimize
balance between most and least preferred work tasks be
the importance of their knowledge, skills, abilities, and
significantly altered?
experience; or be seen as less capable.
■ Intensity: Are the characteristics of the new expectations 6. Justice/fairness is the feeling of being treated equitably;
substantially different from how I currently do my job? Do
the absence of favoritism and bias. Strong feelings that
they require new learning and a different focus, that is, do
the change is unfair or unjust or inequitably applied may
I need to develop new knowledge, skills, and abilities to
lead to active resistance (Lind & van den Bos, 2002).
work within the changed expectations and environment?
■ Time: How much time do I have to make these adjustments? Extremes in any of these 6 needs can lead to negative ac-
Can the changes be implemented gradually over time, or tions. Absences and resignation may begin to increase, and
will they have to take place all at once? Can I meet pro- reductions in the quality and amount of work may also be-
posed deadlines? come apparent. In rare cases, intentional sabotage of the
change may also occur as a way to resist what is perceived
If workers conclude that the amount, intensity, and time
to be unjust, a total loss of voice, or a severe devaluing of
factors involved in the change are acceptable, then emo-
contributions.
tional reactions to change are more likely to be positive, and
managers are more likely to receive cooperation, feedback,
and suggestions meant to improve the change and change Predisposition to Negative Resistance
process and to facilitate a smoother transition to a new system
or procedure. However, if workers feel that any component of Emotional responses to change, including resistance, are
the change (i.e., amount, intensity, time) is unreasonable or generally viewed in terms of characteristic reactions within
unachievable, then the manager is likely to sense a degree of a specific context, not as the manifestation of personality
discontent, less cooperation, and difficulties in the process of traits (Frese et al., 2007). However, negative experiences
implementing the change or to encounter outright resistance in previous work and other life situations may predispose
to it. Both the positively focused feedback and suggestions individuals to react to change with negative resistance.
and the negative undertones constitute resistance to change. For example, a worker who feels she has been treated un-
fairly (i.e., affecting the need for justice/fairness), or who,
despite considerable skill, efficiency, and productivity, has
Basic Needs of Workers felt that her current or previous supervisors have not rec-
ognized those characteristics (i.e., affecting the need for
Anderson and Anderson (2010b) present 6 basic needs as part
competence) may demonstrate negative resistance when a
of a theory of the individual worker’s perspective on resis-
proposed change poses similar threats.
tance to change:
In general, changes leading to feelings of negative self-
1. Security is the feeling that the change will either create efficacy can lead to cynicism toward change and may result in
or maintain physical and emotional safety. Job security negative resistance (DeCelles et al., 2013; Fugate et al., 2012).
is the primary concern of workers when major organi- An occupational therapy practitioner who had confidence in
zational changes are proposed. However, a firm sense of the work she performed might anticipate a reduced sense of
identification with the organization and its procedures self-efficacy when considering a newly proposed method for
also creates security, which can be threatened during performing job duties that might, in turn, foster resistance to
times of change (Elstak et al., 2015). the change.
2. Inclusion/connection is a sense that an individual is In contrast, a historically positive orientation to change
invited to participate in the change process and that their may predispose a person to approaching proposed changes
views are welcomed. The feeling that someone might from a more optimistic perspective (Frese et al., 2007).
become less a part of the organization or that their views Organizational theories of change indicate that when
are less appreciated than they have been can result in workers feel a sense of control and self-efficacy in the work-
resistance to the change. place, they have positive attitudes and greater investment in
CHAPTER 20. Handling Resistance During Change 195
change and efforts to successfully implement it (Fugate et al., Active resistance, such as intentionally sabotaging the
2012). Additionally, workers frequently make decisions based change process or rallying others to do so, requires a manager’s
on their commitment to and investment in the organization prompt attention and intervention. However, whether the
itself (Jacobs & Keegan, 2016). resistance is active or passive, managers must be prepared
to recognize the presence of resistance to change within an
Managerial Responsibilities and Challenges organization, judge the degree to which resistance will either
positively or negatively affect the proposed changes, reassess
Creating change, managing resistance, and avoiding negative the proposed change process, and take action to move the
resistance to it are among the most challenging responsibil- organization in the direction of growth and development. It
ities of managers. Managing change requires creativity, col- is the responsibility of managers to make reasonable efforts
laborative planning, active listening, analysis of the purpose to reduce negative resistance to change, which can manifest
and expected outcomes of the change, avoidance of placing as underproduction while on the job, increased use of sick
one’s personal biases above the needs of the organization, and leave, active pursuit of new positions outside of the organiza-
the firm but gentle use of one’s authority. tion, and encouragement of peers to follow suit.
Because of the complexities of the process of creating
change, when resistance to change is detected, a manager
Review Questions
is at risk of perceiving it as a threat to authority or to the
well-being of the organization. This may be true in some 1. What are the 3 basic characteristics of change that a worker
cases, but in other cases workers will resist simply to expose will use to judge its acceptability and achievability? How
something that the manager or the organization has missed will attention to these characteristics help occupational
about the proposed or pending change and its impact. In therapy managers to avoid negative resistance to change?
other words, resistance to change, depending upon its pur- 2. What are the 6 basic needs of workers? How do perceived
pose and source, can have positive or destructive results. changes in these needs contribute to negative resistance
Therefore, managers must carefully analyze resistance with- to change?
out becoming defensive about the proposed change (that they 3. What are indications that workers are resisting a pro-
may have helped to develop) and make use of it to strengthen posed change?
the change process.
Detecting Resistance to Change PRACTICAL APPLICATIONS IN

Managers can detect feelings of resistance to the change in OCCUPATIONAL THERAPY
both indirect and direct ways. The way in which workers Occupational therapy managers can prevent resistance to
communicate about the upcoming change can convey an change by creating a work environment that supports change.
underlying tone of discontent, ambivalence, resignation, or Managers can also address and minimize negative resistance
anger, or workers may mask their discontent in the presence to change by making use of the evidence from organizational
of the manager. Sometimes resistance is blatant—frustration, management research, including use of authentic leadership
bitterness, or anger can be obvious in body language, tone of behaviors (Agote et al., 2016). The foundation for reducing
voice, and in what is said. However, discontent can subtler, negative resistance to change is to develop a trusting, collab-
and managers need to be sensitive to smaller, less obvious orative, and supportive foundation within the department.
changes in the attitudes of the staff toward their job duties,
clients, other staff, and the manager.
Open and Transparent Communication
Transition generally coincides with at least some increased
stress, but if a worker’s behavior or response is uncharacter- Essential to developing change that minimizes negative
istic or not in proportion to the change process or effects, resistance is the manager’s willingness to welcome affective
there may very well be issues at play that have not been fully reactions and to communicate honestly and transparently
expressed or resolved. During indirect resistance, workers about the need for change as well as the potential benefits,
may still be moving toward implementing the change but risks, and challenges the change carries (Cropanzano et al.,
in ways that make the change process less efficient and 2017). A systematic review of change resistance literature
put the outcomes at risk. Resistance to change can also be indicated that trust in management enhances commitment
manifested in direct actions taken by workers to reduce the to the organization and reduces resistance to change (Oreg
amount and intensity of the change and to increase the time et al., 2011). Early involvement of workers who will be affected
needed to meet the deadline for full implementation. In the by the change in the process of identifying problems and
vast majority of times of change, both acceptance of and re- opportunities, conducting research and inquiries about the
sistance to the change will be present across the organization change, and exploring strategies for creating the change will
and within some departments. An individual worker might help to prepare them for what is to come, encourage invest-
feel simultaneously committed and resistant to making the ment in the process, and proactively mitigate against negative
change (Appelbaum et al., 2015). resistance.
Demonstrate Pride and Confidence positions of leadership in the change process serves to in-
crease the number of staff who openly show support for the
Managers should think of themselves as facilitators, rather
change and may offer opportunities for people who are feeling
than imposers, of change. By initially emphasizing a change’s
resistant to further explore the benefits of the change with a
positive outcomes and benefits, managers can set a founda-
peer (Anderson & Anderson, 2010a; Houmanfar et al., 2017).
tion for garnering support. To approach a major change with a
sense of dread invites failure, erodes confidence, and encour-
ages avoidance of the process. In many cases, changes to sys- Use Shorter Range Objectives to Build Toward
tems and operations are welcomed and expected by workers, the Ultimate Goal
and resistance is due to investment in smoothly transitioning Just as occupational therapy practitioners break down ac-
to the new way of performing work responsibilities. tivities into component parts to achieve long-term goals,
When managers feel negative resistive undertones, open Dasborough et al. (2015) have emphasized the value of fo-
discussions and expression of pride in the proposed change cusing on changes that can be implemented in the present
can be helpful. The challenge to such discussions will be to and near future while maintaining stability within the or-
avoid the sense that an individual or group such as the direct ganization. Demonstrating how small changes can lead to a
manager or the organization administrators are the decision larger restructuring can ease tensions and maintain a sense
makers and that the workers are the ones required to carry of control, inclusion, and empowerment, thereby reducing
out the change. However, if managers instead adopt a policy the potential for resistance (Curtis & White, 2002).
of silence and plan a change in isolation, the results are likely
to be even more destructive.
For workers, simply being required to implement changes Seek Assistance From Superiors and
without any previous voice in the process of creating the Consultants
change can be seriously problematic. Workers, especially Occupational therapy managers must foster the same types
those who have professional education and training, are of bonds with their superiors that they wish to develop with
invested in using their knowledge and skills efficiently and their staff. Knowing when to seek assistance, express con-
effectively. They want to be consulted early enough in the cerns, and discuss challenges and barriers to the growth
change process to have their perspectives and insights con- and development of their departments are essential skills
sidered, and they want to be given the chance to express their in reducing negative resistance to change. Modeling such
opinions before change is imposed. Acknowledging their actions further demonstrates to employees the importance
expertise and demonstrating respect for their knowledge and of problem solving, insightfulness, and judgment as essential
skill is important. If staff feel that their ability to do their job components to addressing resistance to change.
well and properly treat clients has not been taken into con- With occupational therapy practitioners’ extensive ex-
sideration, they are likely to lack buy-in for the proposed perience with task analysis and goal setting, the process of
changes. examining potential and proposed changes and visualizing
Although it is not always possible for employees to have the means to help structure those changes in a step-by-step
a voice in all changes that they are asked to make, consult- process requires the application of a skill set that occupa-
ing with them whenever possible prior to implementing a tional therapy practitioners and managers have learned and
change can go a long way to minimize resistance because it practiced. Applying this skill set in a management context
affords them the respect they deserve as contributors to the may require consultation with superiors or with consultants
growth and betterment of the organization. Therefore, it is from outside the organization. The former increases the like-
recommended that the manager engage workers throughout lihood that all levels of the organization are seeing the change
the change process, show confidence that creating a currently similarly. The latter provides a perspective from people who
proposed change is both feasible and beneficial to the organi- are not enmeshed in the change process and can often offer
zation and its workers, and, once implemented, express and an alternative perspective on reasons for resistance to the
demonstrate pride in the positive changes that are being cre- change. Case Example 20.1 illustrates handling resistance to
ated in the work environment (Lindebaum & Jordan, 2012). change at a rehabilitation hospital.
Support Prosocial Behavior Review Questions

Occupational therapy managers can show support for be- 1. How can occupational therapy managers support proso-
haviors that create a positive social structure within the or- cial behavior to reduce resistance to change?
ganization and promote peer encouragement, confidence in 2. What is the value of developing short-term objectives
goal achievement, ability to contribute to the betterment of for change that build toward the ultimate goal of the
the organization, and feelings of empowerment. Analysis of organization?
the social context within the organization will assist the man- 3. Why is it useful for occupational therapy managers to
ager to recognize workers who strive to create a supportive, model positive communication with superiors and con-
change-oriented environment. Placing those individuals in sultants when experiencing resistance to change?
CASE EXAMPLE 20.1. Creating a New Evaluation Process
Identifying the problem

Occupational therapy, physical therapy, and nursing managers at a rehabilitation hospital affiliated with a large university medical center began
recognizing inconsistencies in the reporting of admission, progress, and discharge information among practitioners working on 3 rehabilitation units.
One unit was designated for patients with spinal cord injuries, 1 for acquired brain injuries, and 1 for general rehabilitation. Senior members of the
rehabilitation teams on each unit remained consistent, but the majority of occupational therapy practitioners and nurses rotated to a new unit every
3 months.
The management team had reviewed medical records over a 3-month period and found that evaluation measures and procedures varied across
the 3 units and had a variety of gaps and overlaps within and across disciplines. This information was consistent with what the occupational therapy
manager had been hearing from some of the members of her team. Team members also described how the inconsistences required them to reorient
themselves to a new system of evaluating patients and reporting results every 3 months. One senior occupational therapy practitioner shared with
the occupational therapy manager that, while several practitioners were in favor of a change in evaluation procedures, others felt it was prudent to
leave well enough alone and that 1 change would lead to others, making their jobs more stressful.
Seeking solutions
Having identified a basic problem, the occupational therapy manager, in collaboration with her peers in physical therapy and nursing, met with the
director of rehabilitation to share results of the medical record review, propose revision of the evaluation system, and inform the director of both
interest in and potential resistance to the change. The director tasked the 3 managers to create uniform evaluation procedures across all units,
designate specific evaluation responsibilities to each discipline, and pilot test the procedures.
Following the meeting with the director, the managers met to discuss goals of the project, concluding that the main issues were to find a
measure that addresses a majority of the needs of rehabilitation patients, covers the scope of practice of occupational therapy, physical therapy,
and nursing, has clear competency training procedures, and can be operational in 4 months as required by the director. The managers agreed that
creating the uniform system of evaluation may best be carried out by permanently assigning all staff to 1 of the 3 units. To develop and implement
the plan, the occupational therapy manager made the following list of things to do:
■ Discuss with management peers (i.e., physical therapy, nursing) when and how to present and discuss results of the medical record review with staff.
■ Within 1 week of the meeting with the director of rehabilitation, discuss findings of the medical record review at the upcoming occupational
therapy staff meeting. Inform the staff of a new decision to change the evaluation procedures, with a goal to put the plan into operation in
4 months. Emphasize their early involvement in the process and express confidence that the change will be positive. Welcome expression of
interests and concerns.
■ Appoint a senior occupational therapy staff member to chair a committee of senior and junior staff to further describe evaluation problems as
they see them and propose potential solutions.
■ Gather information and analyze reactions to the proposed changes at the initial meeting and from the chair of the committee to determine the
extent of the resistance to change.
Exploring emotional responses to change, including resistance

The occupational therapy manager concluded that the staff have both positive and negative reactions to the proposed change. Practitioners
expressed the following concerns:
■ I’ve never been good at treating people with spinal cord injuries, and I don’t like working with that population. What if I get assigned to that unit?
■ This happened at my last job, too. I was really efficient at evaluating patients the old way, but then they imposed this new system that I couldn’t
get down.
■ The hospital is just trying to come up with ways to save money by reducing the occupational therapy staff. I was one of the last people hired, so
my job is in jeopardy.
■ We have to become efficient in new assessment procedures, add new tasks to our evaluation process, and adjust to working on newly assigned
units all at once. That seems like a lot of changes to make in a short amount of time.
■ The hospital has no right to decide how I evaluate patients. My professional judgment is being undermined. We need to go to human resources
about this.
Reshaping the plan to reduce resistance to change

Much of the occupational therapy manager’s process had addressed potential resistance to change from the onset. She had carefully met with her
director and management peers to define the problem and seek ideas for how to address it. She brought her staff together to inform and involve
them early in the process. She identified supportive staff who typically encouraged prosocial behavior to be leaders of a committee that sought
input and feedback, also providing an alternative mechanism for staff to express their concerns. The occupational therapy manager anticipated
the inevitability of emotional responses to change and acted proactively, obtaining information on the level of resistance to change to revise plans
that would smooth the transition to the new evaluation process (Appelbaum et al., 2015). In doing so, she avoided becoming defensive about the
resistance and negatively labeling any individual staff member (Anderson & Anderson, 2010a). Instead, she used the information to create a more
reasonable and acceptable change process.
(Continued)
CASE EXAMPLE 20.1. Creating a New Evaluation Process (Cont.)
As a result of the information she obtained, the occupational therapy manager met with the management team, which then proposed to the
director to move the time to fully operationalize the change back by 2 months and make the original 4-month deadline implementation of a
2-month pilot phase. Prior to full implementation, the occupational therapy manager set shorter range objectives to identify appropriate assessment
tools, complete training and competency requirements, and practice use of the evaluation procedures for a range of clients on different units. The
management team also asked the director to send a memo to staff informing them that the change in the evaluation process would not reduce the
need for current positions and might even increase opportunities.
With assistance from the other managers, the occupational therapy manager invited 3 teams of occupational therapy practitioners and nurses
from other rehabilitation centers to present the evaluation methods they were using. She then brought her staff together to discuss advantages and
challenges to each evaluation procedure and to provide feedback on how each measure addressed the occupational therapy scope of practice. Once
the final assessment tool was identified, the staff was invited to propose revisions to the evaluation process that addressed the uniqueness of their
setting. In doing so, the occupational therapy manager eased some of the tension about professional autonomy in the evaluation process and was
able to acknowledge the advanced skill and competence of the staff, all resulting in less resistance to the change.
Finally, while the plan to assign all staff to working on only 1 unit was still considered an efficient change strategy, the occupational therapy
manager suggested that this change could be implemented separately from and at a different pace than the change in the evaluation procedures.
She proposed to delay it by 18 months and to establish a process whereby occupational therapy practitioners could demonstrate competencies in
skills needed for specific units for consideration of permanent placement, while also instituting new hiring practices that recruited practitioners for
roles on specific units.
Review Questions
1. What cues did the occupational therapy manager receive that indicated resistance to change?
2. How did the occupational therapy manager address resistance?
3. What assistance did the occupational therapy manager rely on to reduce resistance to change?
SUMMARY ACOTE STANDARDS

Emotional responses, including resistance, are inevitable com- This chapter addresses the following ACOTE Standards:
ponents of change (Dasborough et al., 2015). An occupational
■ B.5.1. Factors, Policy Issues, and Social Systems
therapy team will resist change for many reasons, some per-
sonal, others based on investment in the organization and
■ B.5.7. Quality Management and Improvement.
the people it serves. Not all resistance to change is negative,
and resistance should not be perceived as deviant behavior
(Mathews & Linski, 2016). Under the right circumstances when
managers create the right opportunities for resistance to be
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Agote, L., Aramburu, N., & Lines, R. (2016). Authentic leader-
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CHAPTER
Communicating During Change or Uncertainty
Sheila Moyle, OTD, OTR/L, and Bridget Trivinia, OTD, MS, OTR/L 21
LEARNING OBJECTIVES
■ Describe cultural, socioeconomic, technological, political, legislative, and competitive factors that affect change in
occupational therapy practice;
■ Explain the roles of occupational therapy managers and stakeholders during the change process;
■ Understand and analyze models for managing communication during times of change;
■ Identify steps of the change management process; and
■ Analyze effective communication strategies for use during times of change.

• Autocratic leadership • Cognitive appraisal theory of • Middle managers
• Change emotions • Participatory change model
• Change agent • Communication • Programmatic change model
• Change implementers • Democratic leadership • Resistance to change
• Change process framework • Hierarchical distance • Stakeholders
• Change recipients • Integrated conceptual model • Stakeholder mapping
• Change strategists • Laissez-faire leadership • Top management team
OVERVIEW during uncertain times and explores the management skills

necessary for navigating change.
C
hange (i.e., to alter or make different) is constant; peo-
ple of all ages experience differences between antici-
pated and actual norms and outcomes of conditions.
Change occurs across the lifespan as life unfolds, and it can
be unexpected or planned. Change demands flexibility, skill, Communication has been recognized as a significant element
and support for all stakeholders to react effectively. Change in the success of organizational change. It has been studied
is sustained through implementation and human communi- by numerous disciplines, including nursing, psychology,
cation (i.e., the act of conveying information from 1 person business, and personnel management (Baur et al., 2017; En-
to another; DeIuliis & Flinko, 2016). When change occurs in drejat et al., 2017; Matos Marques Simoes & Esposito, 2014).
the workplace, a manager’s ability to communicate will affect When we think of communication, we often think of the act
outcomes during times of uncertainty. of exchanging or imparting information from person to per-
Many factors contribute to the success of change within an son. However, communication can also be considered a so-
organization. A manager’s ability to gather, communicate, and cial process in which meaning is constructed on the basis of
share information is recognized as significantly contribut- the culture and context rather than simply a transmission of
ing to the success of organizational change (Baur et al., 2017; meaning (DeIuliis & Flinko, 2016; Nanjundeswaraswamy &
Endrejat et al., 2017; Matos Marques Simoes, & Esposito, 2014). Swamy, 2014). In the workplace, the organizational culture
This chapter examines how information is gathered and shared affects the communication process.
https://doi.org/10.7139/2019.978-1-56900-592-7.021
201
CHAPTER
Communicating During Change or Uncertainty
Sheila Moyle, OTD, OTR/L, and Bridget Trivinia, OTD, MS, OTR/L 21
LEARNING OBJECTIVES
■ Describe cultural, socioeconomic, technological, political, legislative, and competitive factors that affect change in
occupational therapy practice;
■ Explain the roles of occupational therapy managers and stakeholders during the change process;
■ Understand and analyze models for managing communication during times of change;
■ Identify steps of the change management process; and
■ Analyze effective communication strategies for use during times of change.

• Autocratic leadership • Cognitive appraisal theory of • Middle managers
• Change emotions • Participatory change model
• Change agent • Communication • Programmatic change model
• Change implementers • Democratic leadership • Resistance to change
• Change process framework • Hierarchical distance • Stakeholders
• Change recipients • Integrated conceptual model • Stakeholder mapping
• Change strategists • Laissez-faire leadership • Top management team
OVERVIEW during uncertain times and explores the management skills

necessary for navigating change.
C
hange (i.e., to alter or make different) is constant; peo-
ple of all ages experience differences between antici-
pated and actual norms and outcomes of conditions.
Change occurs across the lifespan as life unfolds, and it can
be unexpected or planned. Change demands flexibility, skill, Communication has been recognized as a significant element
and support for all stakeholders to react effectively. Change in the success of organizational change. It has been studied
is sustained through implementation and human communi- by numerous disciplines, including nursing, psychology,
cation (i.e., the act of conveying information from 1 person business, and personnel management (Baur et al., 2017; En-
to another; DeIuliis & Flinko, 2016). When change occurs in drejat et al., 2017; Matos Marques Simoes & Esposito, 2014).
the workplace, a manager’s ability to communicate will affect When we think of communication, we often think of the act
outcomes during times of uncertainty. of exchanging or imparting information from person to per-
Many factors contribute to the success of change within an son. However, communication can also be considered a so-
organization. A manager’s ability to gather, communicate, and cial process in which meaning is constructed on the basis of
share information is recognized as significantly contribut- the culture and context rather than simply a transmission of
ing to the success of organizational change (Baur et al., 2017; meaning (DeIuliis & Flinko, 2016; Nanjundeswaraswamy &
Endrejat et al., 2017; Matos Marques Simoes, & Esposito, 2014). Swamy, 2014). In the workplace, the organizational culture
This chapter examines how information is gathered and shared affects the communication process.
https://doi.org/10.7139/2019.978-1-56900-592-7.021
201
Organizational Hierarchy and Communication Reasons for Change

Many occupational therapy managers are positioned at Workplace change may occur in the workplace for several
the intersection of an intricate organizational hierarchy reasons. Just as context affects the services provided to
in which they listen, understand, translate, and interpret clients, context and the reasons for change influence effec-
information between upper management and subordinates tive communication during times of change and uncertainty.
regarding change. Information flows up, down, and sideways. In today’s economy and health care market, it is not uncom-
Hierarchical distance is the number of organizational levels mon for an organization to purchase or merge with another.
between top management and employees where change is When this occurs, combining positions and resources will
initiated by the top management team (TMT), which in- occur, resulting in a modification of organizational structure
cludes the chief officers and vice presidents directly reporting (see Figure 21.1).
to the chief executive officer (CEO; Appelbaum et al., 2012). Even without acquisition of another entity, an organiza-
The TMT’s role during change communication is to deliver tion may also make the decision to modify its current overall
trustworthy information and set the organizational direc- organizational structure or the structure of the departments
tion during the change process. The distance between the within. This change often occurs for purposes of solvency,
TMT and lower-level employees’ communication is critical improved ability to meet the organization’s desired out-
in delivering the message throughout the organization. Two comes, and—at a minimum—efficiency. With changes in or-
types of top management communication are used to convey ganizational structure, employees may experience changes in
information during times of change. position titles, job responsibilities, and reporting processes.
When this change occurs, communication (directionality,
1. Top-down communication is used to deliver information
amount, timeliness, clarity) may be affected.
about the change from the TMT.
2. Bottom-up communication is used to collect feedback
from lower-level employees. Models of Communication During Change
Both types of communications are linear and bi-directional Organizational change requires successful communication
and limits the interaction between the TMT and lower-level throughout the change process involving a systematic analysis
employees. and understanding of the driving and restraining forces of
The role of the middle manager is important in communi- the organization and stakeholders. A study conducted for
cating major decisions and changes to lower-level employees the Bridges Business Consultancy asking CEOs about im-
as well as providing information to the TMT. The literature plementing a new strategy in their organization found that
shows that top-down change does not cause above-average 90% of strategic initiatives were not successfully carried out.
level of employee support whether the change is communi- The top 2 reasons for poor execution related to communica-
cated from the TMT or middle managers. However, employee tion: (1) gaining support and action and (2) communicating
support for change is significantly improved when change the change (Beatty, 2016). This study indicates that success-
is initiated by middle managers and executed by either the ful transitions using definable approaches effectively bring
TMT or middle managers (Heyden et al., 2017). about planned organization change. This section describes
FIGURE 21.1. Sample organizational structure.
Chief Executive
Officer
Chief Medical
Officer
Chief Nursing
Chief Operating Chief Financial
Officer & Associate
Officer Officer
Vice President
CHAPTER 21. Communicating During Change or Uncertainty 203
3 approaches to change: (1) participatory, (2) programmatic, and seems less efficient, it fosters employee commitment by
and (3) integrative. These models can be used as a framework allowing stakeholders to enact the change together through
for organizational change. social dialogue, helping to frame the context and rationale
for organizational change, negotiate change-related behav-
Participatory change model iors and attitudes, and share successful change implementa-
tion (Russ, 2008).
A participatory change model assumes employees are active
participants in the change process. The model’s objective is to
facilitate compromise, encourage support for the change, and to Programmatic change model
allow stakeholders to make the improvements they feel are nec- The programmatic change model emphasizes the trans-
essary. Employee participation creates a shared understanding mission of communication through a top-down method to
and meaning, giving voice to key stakeholders affected by the generate stakeholder compliance and increase positive atti-
change. Employee participation is perceived as the facilitator tudes about the planned change (Van der Voet et al., 2016).
for implementing change (Russ, 2008; Van der Voet et al., 2016). The primary feature of this approach is that they are focused
The participatory change model uses a more dialogic com- on “telling and selling” information, new policies and pro-
munication strategy that shapes stakeholders’ understanding cedures, knowledge about the change process, and directives
of change, ultimately guiding the organization. The dialogic for how the change is implemented and cascaded in a down-
communication strategy initially allows employee stakehold- ward route (Russ, 2008). Methods of communication in a
ers to internalize and interpret their own thoughts and per- linear approach include presentations, general informational
ceptions about the desired change to facilitate understanding. meetings, memos, newsletters, brochures, posted informa-
Then, as dialogue expands within a group, a recognition of tion (e.g., posters, signs, bulletin boards), 1-way media (e.g.,
mutual and divergent understanding for change emerges. websites, videos, podcasts), informal small group meetings,
Effective managers support the relational development and word of mouth. The objective of using these methods is
among the stakeholders during this process. A participatory to convince the target population to comply with the planned
change model brings organizational administrators and em- change and to communicate the implementers’ desired vision
ployee stakeholders together to construct the change through for change. The goal is not to solicit input from stakeholders.
informal social dialogue. Through this participatory facil- A strength of a programmatic approach to change is that it
itation, mutual understanding and goals emerge creating a offers a structured change process that provides a blueprint for
sense of community, even when divergent ideas continue to the change agent (i.e., person who makes the change occur).
exist. One of the outcomes of participatory change is to cre- The dissemination of formal, high-quality information from
ate community (Pang et al., 2016). In a participatory change organizational leadership is important because communi-
model, the triggers for change are the participants; the partic- cation at this level can decrease uncertainty, increase under-
ipants are the change agents. standing about the change, aid in reducing anxiety, decrease
Communication in a participatory change model equalizes negative feelings about the expectations that the initiative will
the role of the administrative staff and the other participants fail, and lower resistance while increasing willingness to par-
instead of 1 person having a lead role (Yang et al., 2015). Com- ticipate in planned change. Programmatic approaches are also
munication activities to create co-communicating scenarios efficient in the communication process because information
include using open forums, working groups, informal conver can be transmitted quickly and at a low cost.
sations, focus groups, brainstorming sessions, and opinion There are 2 primary limitations associated with using a pro-
surveys (Beatty, 2016; Russ, 2008). Using several forms of grammatic communication approach. First, organizational
media to communicate the same message can maximize im- change is not a 1-way communication process. The downward
pact because employees take in and process information in dif- transmission of information can create resistance and be less
ferent ways (Beatty, 2016). Employee stakeholders begin to feel effective by limiting the level of interaction and participation of
they are involved in the decision making by accessing organi- communication from various levels of stakeholders. Program-
zational channels to influence future changes while reducing matic approaches may also cause an abundance of unnecessary
feelings of uncertainty during the change process (Russ, 2008). communication that may overwhelm stakeholders or cause
A limitation of the participatory change model is that it them to disengage, causing negative effects for change, imple-
can lead to ambiguity of purpose. The desire for change can mentation attempts, and the entire organization, resulting in
get lost with so many stakeholders and diverse ideas that de- employees seeking employment elsewhere (Lewis & Russ, 2012).
cisions and conclusions may be hard to come by. Stakeholders
who prefer directive and linear approaches may perceive this
Integrated conceptual model
process as inefficient and unsuccessful (Russ, 2008). Without
effective group management or a community of dialogue, The integrated conceptual model focuses on leader commu-
there is the potential for distrust, insincerity, and super nication of change. Luo et al. (2016) created the integrated
ficiality of dialogue (Yang et al., 2015). framework to understand the role of leader communication
Although a participatory change model requires an it- during change. The integrated model examines how the lead-
erative communication process that evolves at each phase er’s communication style affects the subordinate’s affective
commitment to change. This model is based on the cognitive 3. The integrated conceptual model consists of 5 dimensions
appraisal theory of emotions, which contends people’s emo- of leader communication style. In which dimension does
tional feelings arise from their own interpretations of the the leader provide complete information, including risk
circumstances (Luo et al., 2016). The 5 dimensions of leader and benefits, to address employees’ concerns during the
communication style include change process?
a. Hope orientation.
1. Hope orientation: Leaders deal with the fear of change fail-
b. Reality orientation.
ure by presenting change information in an encouraging
c. Subordinate orientation.
manner though the use of vivid language and imagery. They
d. Support orientation.
provide examples to illustrate the viability of change to help
manage concerns by fostering a belief that the change can
be achieved successfully in the future. Leaders instill hope. PRACTICAL APPLICATIONS IN
2. Reality orientation: Leaders provide complete informa-
tion to address subordinates’ fear of the consequences
of the impending change process. Incomplete or biased Communication is considered important in developing
information will increase uncertainty and fear about the readiness for change, reducing doubt, and gaining commit-
change. Leaders providing both risk and benefits of the ment from employees during times of change or uncertainty
change to employees can help employees make a more (Matos Marques Simoes & Esposito, 2014). Occupational
rational decision on the extent of involvement they want therapy managers use many of the same skills as occupa-
to take part in during the change process. tional therapy practitioners, such as identifying and catego-
3. Subordinate orientation: Leaders should listen to and con- rizing stakeholders, defining the change initiative, assessing
sider subordinates’ concerns, need to be respected, and ad- readiness for change, developing a change plan, implement-
justment to the change. Leaders can change subordinates’ ing the plan, creating a cultural fit, and measuring the plan’s
personal concerns they may not be aware of through equal, process. These are all important steps in the change manage-
balanced, friendly, and sympathetic communication styles. ment process.
4. Support orientation: Leaders address the fear of inadequate
support. The main characteristic of the support-oriented Stakeholders
communication style is to indicate that the leader is deter-
mined to push forward the change initiative and is will- Stakeholders are “persons or groups with legitimate interests
ing to offer the necessary support to employees during in procedural and/or substantive aspects of corporate activ-
the change process. Support is being used to address em ity” (Donaldson & Preston, 1995, p. 68). Organizations should
ployees’ fear of inadequate support. involve more stakeholders and 2-way communication during
5. Enforcement orientation: Leaders use commanding and times of change. According to Beatty (2016), a structured
powerful ways to communicate change by being domi- approach is recommended when determining stakeholders,
nant and commanding through the use of intimidating their interest in change, and level of communication. There
or threatening wording. are 4 steps to help make these important decisions:
In their research, Luo et al. (2016) found hope, subordinate, 1. Identify the stakeholders with whom the organization
and support orientations positively associated with employ- needs to communicate about change,
ees’ affective commitment to change. 2. Map the degree of influence and impact of each
stakeholder,
3. Define what the stakeholder’s interests in the change ini-
Review Questions
tiative are likely to be, and
1. What is the objective of a participatory change model? 4. Decide the communication and involvement approach to
a. Provide a top-down approach in delivering key take with each stakeholder.
information.
b. Facilitate compromise, encourage support for change,
Identify stakeholders
and allow stakeholder engagement in change process.
c. Offer a structured change process. The first step in communicating change is to identify the
d. Examine the leader’s communication style in relation main stakeholders affected by the change. Some stakeholders
to the subordinate’s commitment to change. will be affected more than others. Consider how the change
2. Which of the following is not a method of communica- will affect various stakeholders across the landscape of the
tion in a programmatic change model? organization. Senior executives will be affected differently
a. Memos posted in employee break area. than supervisors. Specific division heads will be affected dif-
b. PowerPoint presentation at a staff meeting. ferently than the employees.
c. 1:1 meetings with subordinate team members. In addition, other stakeholders may be external to the or-
d. Podcast from senior management posted on organi- ganization but still significantly affected, such as equipment
zation’s website. suppliers. Also consider groups such as partner organizations,
regulatory bodies, even competitor organizations. Ulti- ■ Quadrant C: Stakeholders who exercise a high degree of
mately, consider the impact on the clients being served. Each influence over the change but who are not as affected as
organizational change situation will present with different the decision makers and planners. Often includes senior
stakeholders, but a thorough scan of the stakeholder land- management who are assumed to be influential experts
scape is critical for a comprehensive understanding of any and role models.
situation. ■ Quadrant D: Stakeholders not greatly affected by the
change and who have little influence, which requires a low
Stakeholder mapping level of communication and involvement in the change
process.
The second step in Beatty’s (2016) stakeholder analysis is
stakeholder mapping, which segments recognized stake- Stakeholder mapping can be an intensive process. Beatty
holders into groups by degree of influence and the degree (2016) proposes using the following 6 steps for completing
of impact. This map helps tailor communication methods and analyzing the stakeholder map:
and involvement approaches for each stakeholder group. The
1. Use Figure 21.2 to outline the degree of influence and im-
stakeholder map can help determine how much stakeholders
pact. Write the name of each stakeholder on a Post-It note
should be involved during a change project. Figure 21.2 pres-
and then discuss where to put that stakeholder on the
ents a stakeholder map that has been a useful tool for this
map. This makes it easy to move around stakeholders in
task. Each quadrant determines the stakeholders, level of im-
each of the quadrants until a final decision and placement
pact, and degree of influence. The communication method
is made.
and involvement approach will be determined based on the
2. Decide where to place each stakeholder on the map on
quadrant position.
the basis of their degree of impact. How much will the
■ Quadrant A: Stakeholders highly affected by the change proposed change affect each stakeholder’s daily work life?
and who have great influence require a high level of 3. Discuss the degree of influence of each stakeholder. How
communication and involvement in the change process. much influence should each stakeholder be allowed in
Often includes stakeholders who are decision makers and this change, and how much should they contribute? Mak-
planners. ing a decision on a communication approach is easier to
■ Quadrant B: Stakeholders with minimal influence on determine once all stakeholders are grouped in each of
the decisions about planning and implementation, such the quadrants.
as employee groups required to adapt to the proposed 4. Analyze each stakeholder’s issues regarding the impend-
change. ing change to identify their communication concerns.
FIGURE 21.2. Stakeholder map.
C A
High
Involve Collaborate
Consult
Seek their help
Degree of Influence
D B
Inform Inform
Instruct
(Involve consult)
Low
Low Degree Impacted High
Source. From The Easy, Hard, and Tough Work of Managing Change, by C. A. Beatty, 2016, p. 119. Kingston, ON: Queen’s University Industrial Relations Center.
Copyright © 2016 by C. A. Beatty. Used with permission.
Gathered data on issues and communication should be outcome, decide what change is feasible, and choose who
based on direct evidence and obtained from the stake- should sponsor and defend the change; change imple-
holder. Surveys, interviews, and focus groups are exam- menters make the change happen by shaping and facili-
ples of methods to collect data. This process may be re- tating successful progress; and change recipients adapt to
peated until a thorough understanding is achieved. the change.
5. Design a communication strategy that aligns with each ■ Step 3: Evaluate the climate for change. Change strate-
stakeholder’s strengths and concerns. gists and implementers must implicitly understand and
6. Communication should be customized to each group’s analyze how the organization functions in its environ-
specific interests because each stakeholder group is ment and determine its strengths and weakness. People
unique. However, the message must remain consistent involved in this step should be proactive by reviewing the
across stakeholder groups. history of the organization’s past change efforts to avoid
making errors in planned change.
Stakeholder interests ■ Step 4: Develop a change plan. The implementation plan
should include specific goals, details, and responsibilities
The next step in the analysis is to investigate what the issues for change strategists, implementers, and recipients. The
are mostly likely to be for each stakeholder. This approach plan should solicit input from stakeholders with respect to
will help address stakeholder concerns during communica- the content and process of change, demonstrate a balance
tions with them. It is important not to guess what the issues of specificity and flexibility, and consider political power
are for each stakeholder. Using online, telephone, and mail for proper balance to ensure compliance and use of time
surveys are useful methods to identify issues, especially when to build commitment and implement change.
there are many stakeholders to contact. Focus groups can be ■ Step 5: Find and cultivate a sponsor. Develop a powerful
used as another method to gain information on the issues guiding coalition to support upper management for the
and to assist in developing content for survey questions. In- change effort. Developing a commitment chart can help
terviews can also be effective, but they are time consuming identify target groups and individuals committed to the
when identifying issues. It is critical to remember that this is change, gain commitment of the critical mass, and create
not a one-time process but a repetitive cycle. a monitoring system to assess progress.
■ Step 6: Prepare your target audience, the recipients of
Tailor Communications to the Stakeholder change. This stage in the change process is understood
from the perspective of the recipients of change. Speaking
The final step is to design communication appropriate for with recipients most affected by change gives immediate
each stakeholder to address issues. The communication plan feedback to change agents and allows change recipients
needs to be individualized because 1 method of communi- to express their perspectives and concerns. Actual imple-
cation does not apply to all stakeholders. Communication mentation occurs only when employees accept the change.
should be customized to each group’s specific interests be- ■ Step 7: Create the cultural fit to make the change last: For
cause each stakeholder group is unique; however, the message the change to progress, it must become rooted in the exist-
must remain consistent across stakeholder groups. ing culture. A strategic change initiative that corresponds
with the organizational culture has a high likelihood of
Change Management Process Framework success. If a disconnect exists between the organization’s
culture and the change, then the culture can diminish the
The way an organizational change initiative is received by
strength of the change initiative.
employees depends on the process of implementation (Van
■ Step 8: Develop and choose a change leader team. A leader
der Voet et al., 2016). A 12-step change process framework
plays an important role in creating an organization’s vi-
(Mento et al., 2002) can guide and instruct occupational
sion by inspiring employees to embrace the change and
therapy managers on implementing major changes in orga-
creating an organizational structure rewarding people
nizations. This change process framework combines 3 well-
who focus their efforts on pursuing the vision (Mento
known models: Kotter’s (1995) strategic 8-step model, Jick’s
et al., 2002; Van der Voet et al., 2016). A change leader may
(1991) tactical 10-step model for implementing change, and
be 1 person or a team of individuals. These change lead-
General Electric’s (Garvin, 2000) 7-step change acceleration
ers can maximize diverse leadership skill sets by invest-
process model (Mento et al., 2002).
ing time and effort to explore, shape, and agree on their
■ Step 1: Identify the vision. Highlight what needs to be purpose.
changed. The gap between the vision and current reality ■ Step 9: Create small wins for motivation. Occupational
generates a natural tension. This creative tension generates therapy managers can plan and create visible performance
intrinsic energy for change by developing new learning. improvements (i.e., employee recognition for successful
■ Step 2: Define the change initiative. Define the roles of efforts) to demonstrate progress in the change effort. The
key players in all change effort roles: change strategists longer a change effort takes, the more necessary it is for
identify the need for change, create a vision of the desired small wins to be celebrated. It is often through the small
informal victories where new ideas will surface through Regardless of the type of organizational change, occupa-
brainstorming events. tional therapy managers must remember that employees de-
■ Step 10: Constantly and strategically communicate the termine the ultimate success of change efforts. Communica-
change. Communication is critical from the start of the tion, organizational culture, and commitment are important
change effort. Communication efforts should focus on components in building and establishing change readiness
increasing staff’s understanding of, preparation for, and for the organizational change process (Matos Marques Sim-
commitment to the change to the fullest extent possible. ones & Esposito, 2014).
It is also important to tailor all communication to the au- Communicating by actively involving employees through-
dience and modify the level and frequency of communica- out the change process may make employees feel that they are
tion as necessary. part of the organization by recognizing benefits and identify-
■ Step 11: Measure progress of the change effort. Assess the suc- ing with its values to address employee reactions and create
cess of the change and chart its progress during all stages of commitment to organizational change.
the change effort by using benchmarks (i.e., Did employee Commitment to change is a force that binds the person
productivity improve by the goal of 5% within the first to a course of action necessary for successful implementation
30 days of implementing the change initiative?). This step of the change process (Oreg, 2018). Committed employees
complements developing small winning strategies in Step 9 should feel a sense of obligation and loyalty to support the
to motivate and sustain the change effort. Measurement is change based on short- and long-term benefits throughout
concerned with all members involved in the change effort the change process (Ioana, 2013).
being clear with defining roles, goals, and expectations. Organizational culture is linked to developing an envi-
■ Step 12: Integrate lessons learned. Reflect on the experience ronment that is conducive to change (Appelbaum et al., 2012;
using probing questions. Ask yourself, as the occupational Ioana, 2013). Culture is defined by each organization’s beliefs
therapy manager, and other stakeholders the follow- and values (Appelbaum et al., 2012). Organizational cul-
ing questions: What did we set out do to? What actually ture can predict level of commitment by use of the person–
happened? Why did it happen? What are we going to do environment fit incorporating individual outcomes that
next time? Examine what did and did not work to allow result from interaction of the person and the environment
the organization’s continuous refinement and evolution. (Appelbaum et al., 2012; Ioana, 2013). A smoother transition
Learn from the past. and greater receptivity to change occurs when the organiza-
tion’s employees’ values and beliefs are congruent with that of
Receptivity to Change the organization.
Employee attitudes and efforts play a fundamental role in

achieving the envisioned goals of a specific change initiative Middle Managers
(Choi, 2011; Kamarudin et al., 2014; Luo et al., 2016). How- Middle managers are staff who hold positions between upper
ever, it is common for resistance to occur during organization and lower management. These stakeholders are involved in
change. Resistance to change is defined as personal disposi- providing and receiving communication, influential in or-
tion to the idea of change (Jost, 2015; Oreg, 2018). Ash (2009) ganizations, and critical to the success of the organization
cited 3 reasons for initial resistance to organizational change: during uncertainty or change. They “are individuals who sit
1. People may have experienced negative organizational at the intersection of those at the top and those at the bot-
transitions in past change efforts, leaving them with an tom of the organization, both giving and receiving direction”
unenthusiastic view of the process. (Thomas et al., 2017, p. 2). Many occupational therapy man-
2. Change transition is viewed as a loss of employees’ nor- agers are middle managers.
mal routines, and they are content with the status quo. Middle managers are in a key position in most organiza-
3. Change causes perceptions of uncertainty and the dis- tions because they have multiple roles that are critical to the
ruption of expectations in the organization and groups ability of a company to achieve its strategic goals (Thomas
within an organization. et al., 2017). Middle managers are active listeners to ensure
employees feel they have been heard. They are also receptive
Resistance to change can negatively correlate with work to emotional concerns of their employees in times of un-
performance, job satisfaction, and decreased motivation to certainty in an effort to keep moving forward. As a coach,
work for the organization. Each of these responses can lead middle managers have an active role in helping direct reports
to high job turnover. develop their skills and competencies to improve professional
development. They connect people and ideas by facilitating
and communicating flow of information throughout the or-
ganization. Middle managers are exposed to diverse ideas
because they work closer to customers than upper manage-
For additional learning, see Chapter 20, “Handling Resistance
During Change.” ment. They know where the problems occur, resulting in
varied ideas and solutions.
Often having a broader sense of how change will affect Regardless of the leadership style used, the leader’s com-
various levels of stakeholders, middle managers can provide munication approach will affect the outcome and impact of
their interpretations of the changes to those who are their su- change. Considering what style of leadership best suits the
periors and to those who are subordinate to them. Because of project, managers or change agents can begin to work toward
their access to and knowledge of various stakeholders, they achieving change through effective communication. Case
play an important role in communicating change. Example 21.1 illustrates communicating during change.
Leadership Styles and Strategies to

Review Questions
Facilitate Success
1. Which key player’s role in Mento et al.’s (2002) change
Different leadership styles—specifically, leadership com-
process framework creates a vision of the desired change,
munication style—in the context of change may influence
feasibility of the change, and identifies the person or
affective commitment to change (Luo et al., 2016;
people responsible for implementing the change?
Nanjundeswaraswamy & Swamy, 2014; Table 21.1). Leader-
a. Change initiators
ship styles can include
b. Change strategists
■ Autocratic leadership (i.e., leadership style characterized c. Change implementers
by control over all decisions with little input from others) d. Change recipients
is regarded as predictable and can be useful in crisis situa- 2. Kim, the manager of an outpatient occupational ther-
tions (Mitchell, 2013). apy program, recently implemented a diabetes education
■ Democratic leadership (i.e., leadership style characterized program. As part of her manager role, she is required to
by team members participating in the decision-making determine if the new program is effective in increasing
process) is useful when cooperation and coordination employee productivity. Kim has identified benchmarks to
among groups, programs, or levels are necessary. There- measure the progress. This is known as
fore, it is an appropriate leadership style for implement- a. Evaluating the climate for change.
ing change (Mitchell, 2013; Tomey, 2009). However, it is b. Developing a change plan.
often less efficient than autocratic leadership (Marquis & c. Creating small wins for motivation.
Huston, 2017). d. Measuring progress of the change effort.
■ Laissez-faire leadership (i.e., leadership style character- 3. Harmony Village Subacute Rehabilitation Center is cur-
ized by team members making decisions and the leaders rently implementing a new organizational restructure. The
being hands off) can be nondirectional. Managers who rehabilitation manager will now be responsible for over-
adopt it tend to allow their subordinates to take control seeing all therapy disciplines (occupational, physical, and
(Roussel et al., 2016). It is not generally a useful style for speech therapies). Hannah has been appointed as the new
planned changes, but it can work when team members are rehabilitation manager. To facilitate effective change, the
highly motivated and self-directed. It can lead to greater most appropriate leadership communication style to use is
creativity, motivation, and autonomy than autocratic or a. Autocratic.
democratic leaderships. However, this style requires mul- b. Authoritative.
tiple change agents, and often there is much resistance c. Democratic.
from group members (Mitchell, 2013). d. Laissez-faire.
TABLE 21.1. Characteristics of 3 Leadership Styles
CHARACTERISTIC AUTOCRATIC DEMOCRATIC LAISSEZ-FAIRE

Control over group Strong control Less control Little or no control
Motivation Motivates others by coercion Economic and ego awards are Motivated by support when requested
used to motivate others
Direction Directs others by commands Directs others through guidance Provides little to no direction
and suggestions
Communication Flows downward Flows up and down Uses upward–downward communication
Decision making Does not involve others Involves others Disperses decision making throughout
the group
Focus Emphasis on different status, Emphasis on “we” Emphasis on group
“you” vs. “I”
Criticism Criticism is punitive Criticism is constructive Does not criticize
Source. Adapted from Mitchell (2013).
CASE EXAMPLE 21.1. Communicating During Change
Scenario 1
Carol, an occupational therapy assistant (OTA) student completing her second Level I fieldwork (FW), noticed OTAs did not participate with
client evaluation and were used only to provide interventions. This practice was different from what she had learned in school and previous
FW experience.
Communication issue
Carol did not understand why OTAs were used in the evaluation process at her previous FW placement but not at the current site.
Strategy
Carol discussed with her fieldwork educator (FWE) her interest in participating in the evaluation process and shared that she is trained to gather
and share data during the screening and evaluation process at her OTA education program. The FWE spoke to her manager, who then met with
the entire occupational therapy staff in that department to discuss revising procedures to allow OTAs to begin involvement in selected client
evaluations.
Review and reflection

The FWE and the rehabilitation director called Carol’s academic fieldwork coordinator (AFWC) to discuss this issue. The AFWC reviewed the
Accreditation Standards for an Educational Program for the Occupational Therapy Assistant (ACOTE, 2018) with them, indicating Carol possessed
the knowledge, technical training, and degree of readiness necessary to participate in the evaluation process under the supervision of an
occupational therapist.
Outcome
Members of the occupational therapy department worked together to develop protocols for evaluative processes for OTAs. Development of protocols
allowed OTAs and OTA students opportunities to utilize their full skill set participating in the screening and evaluation of clients.
Scenario 2
Nicholas, a Level I FW student, needed to complete an evaluation of his FW site and experience before receiving his final evaluation from his FWE.
During his FW, Nicholas experienced a change in FWEs. His original FWE allowed him numerous opportunities to work with clients and practice
clinical skills learned in his occupational therapy program. Jeff, his new FWE, provided an observation learning experience rather than an interactive
skill-practicing experience.
Communication issue
Nicholas felt uncomfortable completing the site evaluation because he was afraid his responses would influence Jeff’s performance evaluation
of him.
Strategy
Jeff assured him that his site evaluation of his performance would not affect his performance evaluation. Nicholas completed the site evaluation
with honest feedback regarding the difference between active and passive learning.

Amy, the director of occupational therapy, reviewed the site evaluations of the students from the past year, including Nicholas’s. Amy met with
occupational therapy staff to present findings, have a discussion, gather feedback, and design an action plan to address areas of concern. Nicholas
was not the only Level I student who identified the lack of hands-on opportunities during the FW experience. Many students identified hands-on
opportunities as an effective clinical teaching method for manual muscle testing, goniometry, and assessment of vital signs. Occupational therapy
staff also determined that site evaluations would be submitted after the performance evaluation to ease students’ concern that the results could
affect their evaluation. Amy sent the FW students, including Nicholas, a written summary of student feedback from the past year and ways they
planned to address issues identified in the site evaluations.
Outcome
The plan of action included Level I expectations for students to perform vital signs assessments, manual muscle testing, and goniometry with
clients.
Scenario 3
Mike, the manager of an acute inpatient occupational therapy department, values FW education and would like staff to take on more students.
He notices his department takes a relatively small number of students each year and directs Diane, the site coordinator, to increase the number
of placements.
(Continued)
CASE EXAMPLE 21.1. Communicating During Change (Cont.)
Communication issue
Diane reports that she would like to develop their FW program and place more students in their department, but she is not sure the FWEs are
willing to do so because recent changes in productivity expectations. As the FW site coordinator, Diane is trying to determine the best leadership
communication style to use in this situation.
Strategy
Mike and Diane discuss the best way to approach increasing the number of student placements by considering the culture of the department and
evaluating the climate for change.

Mike and Diane meet with current and potential FWEs to prepare them for possible change in the FW program and determine what they need to be
successful in increasing the number of FW placements. As a result of this meeting, Diane reaches out to a local AFWC to discuss the challenges,
needs, and goals of the department, FWEs, and management.
Outcome
The AFWC provides training to the FWEs on best practices, including the use of weekly schedules and site-specific learning objectives, and
collaborative supervision models to facilitate their success while adhering to productivity standards.
Scenario 4
Carly, a first-time manager, was excited to introduce new programs to the department, specifically interdisciplinary group interventions. However,
many of the occupational therapy staff members voiced concerns about Carly’s ideas.
Communication issue
Carly was unsure how to garner support. She now realized a concept she thought would be warmly embraced by staff would require more
communication, promotion, and effort to implement.
Strategy
To facilitate support of the proposed change in programming, Carly arranged visits to local facilities that were currently using interdisciplinary group
interventions and invited other rehabilitation managers and staff members from her facility to attend to obtain feedback and ask questions.

Group activities were observed and therapy staff members providing these interventions discussed their views on group treatment with Carly
and her colleagues. They described interdisciplinary group treatment as valuable for clients and therapists, but they said it required significant
planning and flexibility before and after groups were implemented. Therapists noted that clients received psychosocial benefits from group
treatment and shared how providing group activities increased efficiency, allowing therapists more time to complete documentation requirements
compared to consistently seeing clients on a 1:1 basis. Carly and her colleagues, including those previously unenthusiastic about the proposed
change, were impressed with the information learned on their visits and eager to share it with the other team members to prepare for
implementation.
Outcome
Carly identified the need to include members of her team when developing and initiating program changes and created a committee to assist in
establishing the policies and protocol for interdisciplinary group interventions.
Scenario 5
Allison, the manager of the occupational therapy department, must cut 10% of next year’s department budget to comply with the program’s overall
budget reduction plan. Reducing supplies or equipment would jeopardize client care. Therefore, the only budget item that seems possible is to
reduce staffing.
Communication issue
Allison has been given a directive from her chief executive officer to implement the necessary budget cut. She does not want to reduce staffing but
is unsure of a way to save money.
Strategy
During a staff meeting, Allison met with her team to review current practices. She communicated with her staff the need to modify the budget by
10%. Allison asked her staff to brainstorm with her and identify opportunities to reduce costs or generate revenue.
CASE EXAMPLE 21.1. Communicating During Change (Cont.)
Review and reflect

Allison guided her staff in finding a solution to the budget-cut issue by asking them to describe a typical day. This led to identification of the need
for a psychosocial group because all of the occupational therapy practitioners were spending 10–15 minutes of each treatment session discussing
psychosocial issues, such as depression and anxiety from loss of function and role disruption. Allison led the members of her department in
developing a once-per-week psychosocial group to address these issues. She encouraged her team to make referrals to this group when clients
began to discuss psychosocial issues during or after their physical rehabilitation sessions.
Outcome
Through input from her staff, Allison developed a plan allowing each therapist to treat more clients per day, generating more
revenue for the program to meet the 10% budget gap. Instead of cutting 10% from the budget, Allison’s budget remained intact, and
no jobs were lost.
Review Questions
1. In Scenario 2, Amy, the director of occupational therapy, met with staff to present findings, have a discussion, gather feedback, and design
an action plan to address areas of concern identified by several Level I FW students. Which approach did Amy use?
a. Top-down communication approach
b. Bottom-up communication approach
c. Eclectic communication approach
d. Linear communication approach
2. In Scenario 3, Diane reported she would like to develop the FW program by increasing the number of student placements within her
department. She met with current and potential FWEs to prepare them for possible changes in the FW program and determine what they
needed to be successful. Which leadership communication style did Diane employ?
a. Transformational
b. Autocratic
c. Democratic
d. Laissez-faire
3. In Scenario 5, Allison was successful in meeting her budget needs and not reducing staff. As an occupational therapy manager,
Allison has another task to address: implementing the new paid-time-off policy, which is effective immediately. Allison meets with her
staff and instructs that they are required to provide 4 weeks’ notice to request time off. Which leadership communication style did
Allison use?
a. Transformational
b. Autocratic
c. Democratic
d. Laissez-faire
SUMMARY ACKNOWLEDGMENTS
The literature has indicated that planned change is accom- The authors acknowledge Alyssa Carto, OTS; Meranda Love,
panied by optimism and enthusiasm (Kamarudin et al., OTS; and Amanda Melocchi, OTS, for their efforts in the
2014). Those affected by change need quality information literature search. Special thanks to Ellen Kolodner, MSS,
disseminated in the amounts and style appropriate to the OTR/L, FAOTA, for her guidance and mentorship.
given situation. Information provided must be “needed”
by the recipients, otherwise it may be perceived as irrele-
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CHAPTER
Adding Value During Change
Roger I. Ideishi, JD, OT/L, FAOTA 22
LEARNING OBJECTIVES
■ Distinguish among person-, population-, and organization-level occupational therapy;
■ Understand how to discover meaningful services and products of value to people, communities, organizations, and
society;
■ Identify stakeholders for new program initiatives;
■ Create innovative programs with social value; and
■ Understand the importance of assessment and sustaining innovations for continued growth during change.

• Client-centered approaches • Ecology of Human Performance • Proximal stakeholder
• Client-Centered Strategies model • Social business model canvas
Framework • Mapping system • Stakeholder mapping
• Distal stakeholder • Perspective taking • Value
OVERVIEW services and products of value to people, communities, organi-

zations, and society; creating innovative programs with social
T
his chapter will help occupational therapy managers value; and assessing and sustaining program innovations for
examine the process of change when exploring new future growth. On completing this chapter, readers will have
programming or ideas. Although change brings with it a broader perspective for bringing value-based occupational
a certain amount of uncertainty, change can foster opportu- therapy services and products to existing and unmet needs.
nity, discovery, creativity, and innovation.
In times of change, demonstrating the value of occupa-
tional therapy services strengthens the foundation of a ser- ESSENTIAL CONSIDERATIONS
vice and supports exploring new services and products. An-
Perspective Taking
alyzing occupational therapy services may mean reframing
what we do, how we do it, and why we do it; in doing so, we Exploring services based on values requires analyzing services
may need to let go of some of our long-held ideas and expe- from multiple points of view. In particular, one must take the
riences of occupational therapy. Inherently, the field’s basic perspective of “walking in another person’s shoes.” The bene-
philosophy allows for exploration of the diversity of life expe- fits of perspective taking can include increased understanding
riences, so the profession must constantly examine its known of complex situations, greater cooperation and coordination,
values, discover new values, and create new values surround- and enhanced negotiation capacities (Ku et al., 2015; Prandelli
ing occupational therapy services and products. et al., 2016). Occupational therapy managers need to guide
This chapter discusses how people can find and create value staff to take multiple perspectives and provide opportunities
of something in times of change and how managers and ad- for everyone’s voice to be heard in a supportive, noncompeti-
ministrators can facilitate it, including finding meaningful tive environment (Ku et al., 2015; Tuller et al., 2015).
https://doi.org/10.7139/2019.978-1-56900-592-7.022
213
CHAPTER
Adding Value During Change
Roger I. Ideishi, JD, OT/L, FAOTA 22
LEARNING OBJECTIVES
■ Distinguish among person-, population-, and organization-level occupational therapy;
■ Understand how to discover meaningful services and products of value to people, communities, organizations, and
society;
■ Identify stakeholders for new program initiatives;
■ Create innovative programs with social value; and
■ Understand the importance of assessment and sustaining innovations for continued growth during change.

• Client-centered approaches • Ecology of Human Performance • Proximal stakeholder
• Client-Centered Strategies model • Social business model canvas
Framework • Mapping system • Stakeholder mapping
• Distal stakeholder • Perspective taking • Value
OVERVIEW services and products of value to people, communities, organi-

zations, and society; creating innovative programs with social
T
his chapter will help occupational therapy managers value; and assessing and sustaining program innovations for
examine the process of change when exploring new future growth. On completing this chapter, readers will have
programming or ideas. Although change brings with it a broader perspective for bringing value-based occupational
a certain amount of uncertainty, change can foster opportu- therapy services and products to existing and unmet needs.
nity, discovery, creativity, and innovation.
In times of change, demonstrating the value of occupa-
tional therapy services strengthens the foundation of a ser- ESSENTIAL CONSIDERATIONS
vice and supports exploring new services and products. An-
Perspective Taking
alyzing occupational therapy services may mean reframing
what we do, how we do it, and why we do it; in doing so, we Exploring services based on values requires analyzing services
may need to let go of some of our long-held ideas and expe- from multiple points of view. In particular, one must take the
riences of occupational therapy. Inherently, the field’s basic perspective of “walking in another person’s shoes.” The bene-
philosophy allows for exploration of the diversity of life expe- fits of perspective taking can include increased understanding
riences, so the profession must constantly examine its known of complex situations, greater cooperation and coordination,
values, discover new values, and create new values surround- and enhanced negotiation capacities (Ku et al., 2015; Prandelli
ing occupational therapy services and products. et al., 2016). Occupational therapy managers need to guide
This chapter discusses how people can find and create value staff to take multiple perspectives and provide opportunities
of something in times of change and how managers and ad- for everyone’s voice to be heard in a supportive, noncompeti-
ministrators can facilitate it, including finding meaningful tive environment (Ku et al., 2015; Tuller et al., 2015).
https://doi.org/10.7139/2019.978-1-56900-592-7.022
213
Occupational therapy practitioners often view practice

from an individual person perspective. However, the Occu-
pational Therapy Practice Framework: Domain and Process For additional learning, see Chapter 25, “Understanding
(OTPF–3) identifies the client as a person, group, popula- Client-Centered Practice.”
tion, and organizational practice (American Occupational
Therapy Association [AOTA], 2014). This simultaneous per-
spective (of individuals, populations, and organizations) The Client-Centered Strategies Framework (Restall et al.,
expands the reach and impact of an individual intervention 2003) proposes a broader view of client-centered approaches
session and allows the creation of models that affect pol- that incorporate person-level to societal-level actions to sup-
icy and society, or the development of public or organiza- port people in participating in their chosen occupations. This
tional policy that affect individuals’ daily lives. Considering framework proposes information gathering and reflection
multiple perspectives at once demands that occupational from the practitioner’s personal views and from the client’s
therapy practitioners identify whose perspective is most needs and wants; it also takes into account the practice set-
affected, whose perspective is indirectly affected, what the ting context, the community needs, and public advocacy (Re-
intended effects are, and how individual and social systems stall et al., 2003; Restall & Ripat, 2008). The Client-Centered
are interconnected. Strategies Framework is a grounding tool that helps practi-
tioners draw information from the multilayered systems that
Value Finding affect occupational therapy services (Table 22.1).
Practitioners should be able to analyze value proposi-
Each person, family, community, organization, and cultural tions when embarking on new ideas or programs. Finding
group values different objects or ideas, or the same objects or value includes asking what is needed and wanted but also
ideas, for different reasons. Value is defined as the what is valued, which is a critical question. Asking what is
needed may address issues or situations on the basis of im-
regard that something is held to deserve; the importance,
mediate information and factors (e.g., What resources do
worth, or usefulness of something; the material or
you need to address a patient rights issue?). Asking what is
monetary worth of something; the principles or standards
wanted may address personal issues or situations without
of behaviour; one’s judgement of what is important in life;
full awareness or knowledge of circumstances (e.g., What
considered (someone or something) to be important or
services would enhance quality of life?). However, asking
beneficial; or the relative degree of lightness or darkness of
what is needed or wanted doesn’t necessarily determine
a particular colour. (Oxford Dictionary, n.d.)
what is useful or beneficial, its monetary value, its align-
Client-centered occupational therapy practice guides practi- ment with standards of behavior, or what is important in
tioners to focus on a person’s values and needs (Schell et al., the client’s life.
2014). A comprehensive exploration of what is of value to the For example, a person may need a long-handled shoe horn
client must be assessed from multiple perspectives that often to preserve total hip replacement precautions during self-care
extend beyond the person to families, communities, institu- activities, but the person may not necessarily value assistive
tions, employers, and potentially many others. Finding the devices because the device may imply a certain degree of de-
“thing” of value depends on the client perceiving the need, pendence in the person’s self-perception. As another exam-
want, and value of the “thing” from diverse perspectives and ple, practitioners may want the newest computer technology
multiple systems. Facilitating client engagement from multi- for their cognitive rehabilitation training program, but the
ple perspectives can lead to new ways of supporting the client organization’s management may not value investing in tech-
as well as populations (Restall et al., 2003). nology with high cost and relatively low use.
TABLE 22.1. Client-Centered Strategies Framework
CLIENT-CENTERED COALITION ADVOCACY

PERSONAL REFLECTION PROCESSES PRACTICE SETTINGS COMMUNITY ORGANIZING AND POLITICAL ACTION
■ Reflection ■ Evaluate client-centered ■ Advocate for a ■ Inform communities about ■ Demonstrate a position
■ Communication skills processes client-centered client-centered health on client-centered
■ Learn about yourself ■ Facilitate client-centered workplace services practice
■ Learn about care ■ Communicate to ■ Engage in community ■ Influence people of
client-centered ■ Model client-centered treatment team development influence
practice behaviors about client-centered ■ Engage in community
practices planning
Source. From “A Framework of Strategies for Client-Centred Practice,” by G. Restall, J. Ripat, & M. Stern, 2003, Canadian Journal of Occupational Therapy, Vol. 70, p. 106.
Copyright © 2003 by Sage. Used with permission.
CHAPTER 22. Adding Value During Change 215
When exploring a new endeavor or refining an established get to the clinic. Therefore, distal stakeholder needs and val-
service or product, one must first identify who the client is. ues can play an important role in the success of the product
This often presumes a 1-dimensional target audience or con- or service.
sumer, but a service or product has multiple stakeholders
who have a vested interest in its success. A new service or
product or the refinement of an established program or ser-
Mapping system: Identifying stakeholder needs
vice should emerge from the stakeholders’ needs, wants, and Using a mapping system to identify stakeholders is often use-
values. ful. A mapping system is a visual representation showing the
interconnectedness of the stakeholders (BSR, 2011). The map
Stakeholder Perspectives systematically identifies whose needs are critical to the ser-
vice or product’s success. Using a multi-perspective approach
Creating or improving services and products requires ac- eliminates the “if we build it, they will come” belief system be-
knowledgment, awareness, and respect that every stake- cause the practitioner can identify the diverse values and needs
holder has a significant interest. In occupational therapy, we of multiple stakeholders. A mapping system helps prevent 1
often presume the primary recipient of services or products is perspective or outcomes approach from superseding another
the individual client or patient. When occupational therapy (Wegner, 2016). Also, seemingly competing or perceived con-
managers or practitioners analyze every step of how a service straints, whether from a person, institutional, or societal level,
or product is developed, stakeholders’ interdependency be- can be analyzed, and an action plan using innovative problem
comes evident. solving can be employed (Cherrier et al., 2018).
There are 4 general strategies to consider when mapping
Proximal and distal stakeholders stakeholders (BSR, 2011):
One way to identify stakeholders is to brainstorm prox- 1. Identify as many stakeholders as possible (i.e., proximal,
imal and distal stakeholders. A proximal stakeholder is distal, multiple stakeholders);
a person, group, or organization that has a direct impact 2. Analyze and listen to the stakeholders’ perspectives and
on the implementation of the service or product. A proxi- the importance they place on their point of view;
mal stakeholder may be a person who is receiving the ser- 3. Visualize the relationships between stakeholder perspec-
vice or using the product; a family member or caregiver tives (e.g., create a drawing of each stakeholder, their re-
who supports the service implementation; a practitioner ceptivity to change, their commitment to change); and
whose services influence the use of the product; the pay- 4. Prioritize the mutual commitments, objectives, and where
ing institution, such as an insurance company or govern- the influence for change exists.
ment agency; the hospital or school administrators who Stakeholder mapping helps to identify where the knowl-
are responsible for creating a system to deliver the service; edge and willingness to create something of value exists.
or individuals within the service delivery system, such Using a stakeholder map to analyze the relationships be-
as medical records personnel, schedulers, parking atten- tween stakeholders allows practitioners to identify where ac-
dants, or security staff. tions need to take place so all stakeholders move toward high
A distal stakeholder is a person, group, or organization knowledge and high receptivity of the product or service of
that influences or is influenced by the service or product but value (see Exhibit 22.1).
does not necessarily have direct interaction with the ser-
vice or product. When identifying distal stakeholders, think
of the entire string of activities or occupations involved to Review Questions
meaningfully engage in the service or product. For example, 1. How does the OTPF (AOTA, 2014) frame the client who is
if the service is implemented at a clinic, an occupational anal- receiving occupational therapy services?
ysis of the string of activities might involve getting ready to 2. According to Restall et al. (2003), what are the 5 levels of
go to the clinic; taking a form of transportation (private or a client-centered practice?
public); getting from the transportation point (parking lot or 3. What are the 4 strategies to consider when mapping
subway station) to the clinic; and if the clinic visit occurs in stakeholders?
the middle of the day, needing a meal or snack (whether self-
brought or purchased).
In the occupation of going to a clinic appointment, dis- PRACTICAL APPLICATIONS IN
tal stakeholders include the caregiver who supports getting OCCUPATIONAL THERAPY
ready in the home; the primary driver of a vehicle; the public
Organize Stakeholder Information
transportation system, including the bus driver and the ticket
booth staff; hospital cafeteria staff; local restaurant staff; and After you’ve identified the needs, wants, and values of the
so on. If there are transportation barriers to getting to the stakeholders, what do you do? Organizing the stakeholder in-
clinic, the success of the service or product may not depend formation into a framework or model, similar to developing
on its quality but on whether the target service recipient can an occupational profile, is a valuable process. Managers can
EXHIBIT 22.1. Sample Stakeholder Mapping: Prioritizing Value, Needs, and Actions Through Stakeholder Mapping
High
SH5: Occupational therapist
SH2: Performing Arts Center education staff

Knowledge
SH1: Family of child with ASD
SH3: Center symphony orchestra
SH4: Center administration

Low
Low Willingness High
Note. ASD = autism spectrum disorder; SH = stakeholder.
Note. ASD = autism spectrum disorder; SH = stakeholder.
STAKEHOLDER KNOWLEDGE WILLINGNESS ACTION (ARROWS) ANTICIPATED OUTCOME

SH1: Family of a Medium knowledge of Medium willingness ■ Share their self-isolation from Increased community
child with ASD managing as a family to attend a concert community activities and their engagement as a
at a performing arts because of past ridicule concerns and strengths as a family family and reduced
concert and embarrassment during community activities self-isolation
by center staff and the ■ Develop trust in the center to attend a
public concert
■ Receive support from the center and
the OT
SH2: Performing Medium-high Very high willingness to ■ Support the family and the orchestra Fulfillment of their
Arts Center knowledge of how to develop an initiative in developing and implementing an mission and values as
education staff support a child with to include children SF concert educators
ASD during a concert and youth with ASD at ■ Reach out to experts in SPD
concerts ■ Understand SPD from an OT perspective
■ Educate administration and propose a
financially feasible plan for SF concerts
SH3: Symphony Low knowledge of how Medium-to-high ■ Gain knowledge from OT and Fulfillment of their
orchestra to support a child willingness to develop education staff on SPD, SF concerts, mission and values
with ASD during a ASD initiative at and accessible arts as artists and a good
concert concerts ■ Create an accessible and relaxed community citizen
environment for all families to enjoy
a concert
SH4: Center Low knowledge of how Medium-low willingness ■ Gain knowledge about inclusion, Fulfillment of their moral
administration to support a child to develop an ASD accessibility, and ASD obligation to serve all
with ASD during a initiative due to financial ■ Moral, ethical, and financial support people in society
concert constraints and public of the education staff and orchestra’s
image SF initiatives
SH5: Occupational Medium-high knowledge Medium-high willingness ■ Share knowledge of SPD with other Development of programs
therapist of how to support to develop an initiative stakeholders that promote greater
a child with ASD in due to concerns of per ■ Support the SF initiative occupational
the community but diem costs for private ■ Financially feasible to work on performance in life
not necessarily at a OT consulting SF initiative (not pro bono) skills for community
concert participation and
engagement
Note. ASD = autism spectrum disorder; OT = occupational therapist; SF = sensory friendly; SH = stakeholder; SPD = sensory processing disorder.
then use that model as a tool to guide the planning and de- sustainability over time considering economic, social, and
velopment of the service or product. Gathering stakeholder cultural resources (Fowler et al., 2017; Roy et al., 2014; Spiess-
information is similar to person-level clinical interventions Knafl et al., 2015).
in which the occupational therapy practitioner gathers oc- Clinical occupational therapy models do not intersect
cupational profile information and organizes it into a broad with business models. Therefore, using both a clinical
conceptual theory to guide priorities, decision making, and model and a business model simultaneously is beneficial. A
action planning (Cohn & Coster, 2014). social business model canvas is a tool for creating a busi-
Using an occupation-based theory to frame the infor- ness model around a social enterprise; a template is available
mation highlights the occupational lens for the potential at https://bit.ly/2vAV8s5. This template can help organize
action plan. Occupational therapists often use broad theo- stakeholder data into a business model by identifying the
ries to develop occupational profiles. Using a broad theory tasks, challenges, and revenue sources. If the financial and
helps to describe observations of human engagement, iden- human resources elements are not identified, there is a risk
tify the important factors of occupational engagement, and that the added value of the service or product will not be
identify the issues and priorities that need to be addressed sustained.
(Cohn & Coster, 2014). Several broad occupation-based
theories describe the person–environment transaction
Build Value
(Baum et al., 2015; Dunn et al., 1994; Kielhofner, 2008; Law
et al., 1996). An additional step that occupational thera- After the need and value of the need is identified, follow the
pists should integrate into their regular assessment process example given in Table 22.2 to build an intervention plan at
during the information-gathering phase is to begin to for- all levels. Building an intervention plan at all levels inter-
mulate needs at person, population, and organization levels sects with Restall et al.’s (2003) Client-Centered Strategies
(AOTA, 2014). Framework concepts and increases the value of the service
Occupational therapy models alone do not address how or product being created. The intervention also intersects
to integrate programs or services within an organization or with multiple levels of service and society, thereby increas-
society’s social system. Occupational therapy models cou- ing the impact of your intervention plan. Table 22.3 provides
pled with social business models address the clinical needs an example.
and strategies in an economically resourced and sustainable
manner. Social business or social entrepreneurial models
Assess Value
create economically sustainable enterprises that improve
the social and human conditions (Fowler et al., 2017; Wry & To have an impact is “to have a strong effect on someone or
York, 2017). something” (Oxford Dictionary, n.d.). Assessing the impact
Clinically based occupational therapy practice models, of the intervention plan determines whether the value meets
which are meant to guide practice, social business, and en- the needs of the people, population, and organization being
terprise models, seek to identify a need, implement a prac- served.
tice to address the need, and measure the impact of the Typical assessment formats include standardized clinical
implementation. Where occupational therapy practice mod- assessments, observational tools, surveys, interviews, and
els diverge from social business models is in the framing of focus groups. The assessment can also include whether the
TABLE 22.2. Sample Person-, Population-, Organization-Level Occupational Therapy Needs
PERSON POPULATION ORGANIZATION

Problem Identification A child is sound sensitive and There are no public announcements The organization has integrated mobility,
becomes dysregulated when or publicly available material hearing, and visual accommodations into its
sounds overwhelm his senses. indicating that all people in regular programming. The organization does
He is unable to attend a concert society are being served by not have accommodations or supports for
at the local performing arts the organization, including individuals with SPD.
center because of his sound individuals with sensory and The organization is not knowledgeable and
sensitivity. cognitive disabilities. does not have a clear plan on how to be
inclusive for all people in society.
Need Create a concert experience at Develop a communication, Identify the financial, human, and material
the performing arts center that marketing, and education plan to resources needed for an SF concert
accommodates for his sound build graded music experiences initiative. Then analyze how to expand the
sensitivity. in the community, within SF initiative into an inclusive accessibility
school outreach, and for public plan for individuals with sensory and
performances. cognitive disabilities and their families.
Note. SF = sensory friendly; SPD = sensory processing disorder.
218
TABLE 22.3. Sample Person, Population, and Organizational Intervention Plan
EVALUATION INTERVENTION OUTCOME

STRATEGIES TO POTENTIAL GRADED, PURPOSEFUL, METHOD FOR ASSESSING
LEVEL ISSUE LONG-TERM GOAL SHORT-TERM OBJECTIVES ADDRESS ISSUE AND MEANINGFUL ACTIVITIES OUTCOME
SECTION III. Navigating Change and Uncertainty

Person A child is sound sensitive The child will ■ By the end of the concert, ■ Use of visual Downgrades ■ Survey the family after
and becomes dysregulated engage in a the child will independently schedules and social/ ■ Previsit to the venue to familiarize the concert to identify
when sounds overwhelm SF concert. communicate 3 times sensory priming the child with the environment. the child’s behavior and
his senses. He is unable The family will a meaningful action or narratives to introduce ■ The child will watch the concert response to the concert
to attend a concert at return for at least emotion based on the the experience to child from the lobby doorway. experience.
the local performing arts 1 additional SF content of the SF concert. (Knight et al., 2015). ■ The child uses emotion cards to
center because of his experience. ■ In the week before the ■ Provide family training express his thoughts and feelings.
sound sensitivity. SF concert, the family will to support the child Upgrade
introduce the visual schedule (Bearss et al., 2015; ■ The family will attend a regular
and sensory narratives to Stadnick et al., 2015). public performance.
the child 3 times for the
child to accommodate the
expected situations.
Population There are no public A 25% increase in ■ Identify terminology and ■ Stakeholder interview Downgrade ■ Use a program for
announcements or publicly website hits on language to use on the or focus groups. Using ■ Direct email blasts to stakeholders digital use analytics to
available material indicating the organization’s accessibility webpage, and the stakeholders’ with links and materials. track website hits and
that all people in society accessibility confirm with community perspective is key Upgrades downloads.
are being served by webpage during advisory board. to understanding ■ Create a variety of support ■ Survey individuals
the organization, including the 1st quarter of ■ Create visual schedules their needs (Stoner & materials at various levels of and families to
individuals with sensory dissemination. and other support materials Stoner, 2014). ability and interest. identify best methods
and cognitive disabilities. At least 30 for attending a concert ■ Use of visual ■ Provide community outreach for communication
downloads of and make them publicly schedules and social/ with hard-copy information and and information
the support available. sensory priming personal presence at various dissemination.
materials from narratives to introduce community events.
the accessibility the experience to the ■ Plan and hold a community
website. child (Knight et al., engagement seminar to discuss
2015). issues of inclusion and diversity
with the local community.
Organization The organization has integrated Form a community ■ Schedule monthly ■ Engaging with direct Downgrade ■ Analyze attendance
mobility, hearing, and visual advisory community advisory stakeholders in ■ A scaffolded implementation of records to assess
accommodations into its committee to meetings. assessing needs and the initiative. increases in ticket
regular programming. The assess, plan, ■ Assess the organizational, building initiatives Upgrade sales and requests for
organization does not have implement, and financial, and human (Raymaker, 2016). ■ Creation of a dedicated accommodations.
accommodations or supports evaluate a SF resources needed for a SF accessibility office with the
for individuals with SPD. initiative. initiative. financial and human resources
The organization is not Build financial and to assess, develop, implement,
knowledgeable and does human resources evaluate, and expand
not have a clear plan on for a SF initiative. accessibility services.
how to be fully inclusive for
all people in society.
Note. SF 5 sensory friendly; SPD 5 sensory processing disorder.
outcome goal was met with a simple yes/no criterion as long Review Questions
as the outcome goal is measurable and meaningful. For ex-
1. Why is it important to develop programs at the person,
ample, an organization is creating a new policy on mandated
population, and organizational level?
accessibility across diverse mobility, hearing, vision, cogni-
2. What is the purpose of a social business or social enter-
tion, sensory, emotional, and psychosocial abilities. Creating
prise model within occupational therapy services?
the policy is a significant organization-level achievement,
3. What are various types of assessment methods for identi-
and outcome goals can be developed for the future (e.g.,
fying efficacy and sustainability for new initiatives?
assessing policy implementation needs). Similar to the way
occupational therapists grade activities, upgrading goals is a
suggested approach for addressing organization-level issues IMPLICATIONS FOR THE FUTURE OF
because they are often complex with evolving and changing OCCUPATIONAL THERAPY
features.
At the individual person or family level, the impact will be Even in times of economic or political uncertainty, adding
at the behavioral and participatory level. At the population value to occupational therapy, to health care and social sys-
level, the impact will be the addition of services or products tems, and to society has been a fundamental philosophy of
addressing previously unmet or unaddressed needs that serve the profession since its inception. Eleanor Clarke Slagle (1936;
clients beyond a specific individual or family to one that is Figure 22.1), one of the founders of AOTA, wrote, “[N]o mat-
serving the greater public. At the organizational level, the im- ter how wisely a structure is built to meet the present needs,
pact is a fundamental change in how the organization fulfills another era will usher in even greater changes in social un-
its mission serving the public, does business, and has institu- derstanding of mental patients” (p. 155). She referred to nag-
tionalized the added-value product. ging questions and whether what she was doing was suffi-
For example, the development of sensory-friendly expe- cient. She stated, “[J]ust getting the patient out is not enough
riences affects the person or family. They use successful to satisfy the physician. The occupational opportunities are
strategies to navigate the community as measured through provided in our hospitals. Is the most intelligent use being
standardized tools examining a particular behavior, a cus- made of these opportunities?” (p. 156).
tom survey, or an individualized interview. The individual The occupational therapist is a highly trained practitioner,
and family engage in community activities with greater fre- “possessing of imagination, ability, and a cultural back-
quency as measured through simple frequency. The person ground” (Slagle, 1934, p. 291) for healing the mind and body.
and family have increased confidence and trust in the public The philosophy and training of the occupational therapist
institution’s ability to create a welcoming, supportive, and en- practitioner is grounded in the entrepreneurial spirit. As a
couraging environment to engage in as measured through a profession, we will have those nagging questions and wonder
qualitative interview. whether we are doing enough, just as Eleanor Clarke Slagle did.
At the population level, individuals and families who are
not working directly with an occupational therapist or orga- FIGURE 22.1. Eleanor Clarke Slagle.
nization have access to the publicly available sensory-friendly
support materials to prepare for community activities. This
can be measured through increased attendance of diverse in-
dividuals and families across all programs at the institution.
At the organizational level, the organization reviews new
programs at the financial level to establish budgetary needs.
This can be measured through increased annual budget allo-
cations based on need, value, attendance, and revenue from
the program.
For additional learning, see Chapter 14, “Starting New Programs.”
Systematically evaluating, documenting, and linking value

at the person, population, and organizational levels demon-
strates the contributions the person has on the organization,
the impact the organization has on the person, the social
value the organization places on the added initiative, and
potentially how the public views and supports the needs for Source. American Occupational Therapy Association. Used with permission.
everyone in society.
During times of change and uncertainty, Slagle recognized an needs in multiple contexts and influences stakeholders. Know-
occupational therapist’s training is primed to lean into uncer- ing who the stakeholders are is critical during change. A map-
tainty and engage with change. ping system is useful for identifying stakeholders and under-
standing their needs.
Framing ideas, activities, and programs within theoretical
SUMMARY models helps to guide the decision-making process. Simul-
This chapter identified elements for occupational therapy taneously using a clinical and business model is beneficial.
managers and practitioners to consider when change occurs Occupational therapy models coupled with social business
and new programs and ideas are developed and implemented. models address the clinical needs and strategies in an eco-
Managers can frame new programs and ideas beyond the in- nomically resourced and sustainable manner.
dividual level care and begin to frame program development From the days of Eleanor Clarke Slagle, the occupational ther-
through population and organizational level perspectives as apy profession has always worked at the personal, population,
a way of navigating a changing system. and organizational levels. Scaling new programs to a broader
Part of navigating change is the ability to perceive and ana- perspective serves to add value by demonstrating occupational
lyze an idea from multiple perspectives. Occupational therapy therapy’s clinical, social, economic, and political influence
managers need to support staff as they voice their points of view within health care and social systems. Creating or improving
and seek to understand others’ perspectives. Restall et al. (2003) programs may demand a change in perspective or a change in
use client-centered principles to analyze various perspectives daily operations. How managers and practitioners perceive, re-
during a situation of change, which clarifies clients’ values and spond to, and adapt to such changes influences outcomes. ❖
CASE EXAMPLE 22.1. Person, Population, and Organizational Perspectives
Who is the client? Examine the client from the person, population, and organizational perspective.
Person Level
Family A includes Sarah (mother), Bill (father), Samantha (9-year old girl), Meredith (7-year old girl with autism spectrum disorder [ASD]), and
Tyler (5-year old girl with ASD). They live in a densely populated urban area with access to public transportation.
Meredith is a happy, spirited child. She is ambulatory and inquisitive and explores every environment in which she finds herself. Meredith verbally
communicates her needs. She is easily upset when she does not like a situation. She is attracted to colorful or moving objects in the environment.
She often gathers information through touch. Meredith likes to explore new environments regardless of whether her parents or caregivers are in her
visual field. She is easily redirected and responds to another person’s redirection.
Tyler is quiet and happy to sit and watch others. She is ambulatory with hand holding and a slow pace because of significant varus of her legs.
She attends to others and activities within her immediate environment. She does not explore her environments beyond her immediate reach.
Tyler’s verbal communication consists of short 1-word expressions or vocalizations. She shows a range of facial expressions.
Samantha, the older sibling, is social and talkative. She likes to dance and sing. The 3 girls socially interact through gestures. They do not engage
in physical play. Sarah and Bill do not take the girls into the community very often because of their challenges with negotiating spaces with 3 girls and
Meredith’s challenges with transitioning to new situations. The family uses public transportation for community outings, which is also a reason they do not go
into the community. When they do leave the house, it is primarily to walk around the block. Meredith and Tyler use strollers for 75% of the walk around the
block.
Issue: The family is isolated and does not participate in any community experiences.
Population Level
Many families with children with disabilities are isolated from participating in community experiences and self-select to remain at home.
Issue: There are few community opportunities for families with children with disabilities to participate in family-oriented community experiences,
such as going to the movies, theatre, museums, aquariums, and restaurants.
Organization Level
City Theatre, a community organization, does not have adequate accessibility plans, initiatives, or programming for children and youth with
disabilities, in particular children and youth with sensory or cognitive processing disabilities.
Issue: City Theatre does not have the knowledge nor skills to support children and youth with disabilities, in particular children and youth with
sensory or cognitive processing disabilities.
Stakeholder Needs
Stakeholder mapping reveals that stakeholders include children and youth with disabilities and siblings, parents, and caregivers, City Theatre
administrators (e.g., executive administration, marketing, communication, finance, security), community educators (e.g., music and art educators,
travel trainers), occupational therapists, special educators, local school officials, public transportation, parking lot vendors, and local retail and
restaurant vendors near the target community organizations.
Purchased from AOTA for the exclusive use of Alyssa Myers (u0871036@utah.edu 000004564714) (Continued)
CASE EXAMPLE 22.1. Person, Population, and Organizational Perspectives (Cont.)
Personal contacts, surveys, interviews, and focus groups with stakeholders identified the need: Opportunities to participate at the museum
considering the needs of children and youth with sensory or cognitive processing disabilities.
Assessment and Planning

The following program planning models were used:
Ecology of Human Performance model (Dunn et al., 1994) guides the analysis of the key features to consider when developing an accessible
museum program.
■ Person: Family A— Sarah, Bill, Samantha, Tyler, Meredith (person); children and youth with disabilities, families, local schools, parent advocacy
groups, disability advocacy groups, general public (population); City Theatre (organization).
■ Tasks: Walk to bus stop or subway, pay bus fare, ride on bus or subway, know where to get off bus or subway, walk to theatre, buy ticket, look
at art pieces, make art, eat lunch. (Roles include bus rider, art patron, art maker.)
■ Contexts: Home, public transportation (e.g., subway, bus), ticket booth, lobby, cafe, theater and its rules (e.g., sit still, be quiet).
■ Performance: Traveling to theatre via public transportation, observing art, making art, eating lunch, going to bathroom, taking a break, and
talking and interacting with theatre staff. Performance range for Family A and disability community is narrow because of few opportunities
to participate in community activities. Performance range of City Theatre is narrow due to lack of knowledge and skills to create accessible
programming.
■ Strategies: Establish skills for going to the theatre, adapt the theatre environment and activities, create opportunities for participation at the
theatre, and prevent public ridicule of individuals with sensory and cognitive processing disabilities.
Social business model canvas
■ Problem: Children and youth, and their families (e.g., Family A) are unable to go to theatre.
■ Solution: Create a supportive environment (e.g., staff training) for people with diverse abilities, modify the environment (e.g., lowering
surprising sounds), adapt activities for meaningful engagement with theatre content (e.g., preparatory materials, visual schedules, art making
activity), engage community advisors and stakeholders in the design and implementation of the initiative (e.g., hiring occupational therapist
as consultant).
■ Key metrics: (1) Frequency of return to theatre, (2) child and family participation and enjoyment level, (3) City Theatre staff skill to support all
customers.
■ Value proposition: Occupational therapy practitioner and Family A reach out to City Theatre to partner to create a Relaxed Performance initiative
to serve Family A and the broader population of families with children with disabilities. Theatres do not welcome everyone to their venue (e.g.,
the unspoken and unwritten etiquette of sitting down, being quiet). City Theatre is committed to increasing diversity, access, and inclusion for
everyone in society by providing opportunities and choices to all people for art patronage, art making, and employment.
■ Advantages: This initiative will build a new audience market and increase public awareness and promote the ideals of diversity and inclusion.
■ Target customers: Children, youth, and adults with sensory or cognitive processing disabilities and their families.
■ Channels (how to connect to target recipients): Build relationships with disability advocacy networks, parent networks, local schools, and therapy
services. Create a communication and social media plan.
■ Cost structure: Create a flexible ticketing scheme (e.g., refunds, replacement) and fund consultant fees (e.g., occupational therapy practitioner),
time (e.g., staff and performer training time), and a public media campaign.
■ Revenue stream: Family A and other families with children with disabilities have not visited museum in the past, so this is a new revenue
stream. The goal is to have enough volume in ticket purchasers to support the costs.
Implementation
The launch of City Theatre’s sensory-friendly Relaxed Performance initiative is implemented. A stakeholder advisory committee forms to guide the
City Theatre in program development. City Theatre hires an occupational therapist and Sarah as consultants to help develop preparatory materials,
lead staff trainings, and implement evaluation process.
Outcome
City Theatre launches first Relaxed Performance show. Program evaluation data indicates modifications of lights and sounds are significant factors
promoting people’s engagement in the theatre experience. Theatre staff are rated high in their knowledge and interaction skills with patrons.
A financial analysis indicates City Theatre a 3% revenue recovery on the basis of the costs and expenses. City Theatre is satisfied with the 3%
revenue recovery and the significant public awareness of arts accessibility and inclusion (as indicated from a significant increase in its social media
reach related to the Relaxed Performance). City Theatre receives a charitable donation to continue Relaxed Performances, which reduces ticket
prices. City Theatre commits to designating 4 shows per year as Relaxed Performances.
Review Questions
1. What is the most important factor in turning an idea into a viable program plan?
2. How were stakeholders identified?
3. Which models were used to build a new program initiative?
LEARNING ACTIVITIES American Occupational Therapy Association. (2014). Occupational

therapy practice framework: Domain and process (3rd ed.).
1. Distinguish among need, want, and value. American Journal of Occupational Therapy, 68, S1–S48. https://doi
a. Ask someone what is needed to create the most innova- .org/10.5014/ajot.2014.682006
tive occupational therapy program. Then, separately ask Baum, C. M., Christensen, C. H., & Bass. J. D. (2015). Person–
3 people what they want to create the most innovative environment–occupation-performance model. In C. H.
occupational therapy program. Finally, separately ask Christensen, C. Baum, & J. Bass (Eds.), Occupational therapy:
5 people to identify 3 values that contribute to creating Performance, participation, and well-being (4th ed., pp. 49–55).
Thorofare, NJ: Slack.
the most innovative occupational therapy program.
Bearss, K., Johnson, C., Smith, T., Lecavalier, L., Swiezy, N., Aman,
b. Distinguish and analyze the responses into 3 categories:
M., . . . Sukhodolsky, D. G. (2015). Effect of parent training vs
(1) personal, (2) organizational (the unit or institution parent education on behavioral problems in children with autism
that is a key stakeholder in the product or service), and spectrum disorder: A randomized clinical trial. JAMA, 313(15),
(3) societal (the value or impact the product or service 1524–1533. https://doi.org/10.1001/jama.2015.3150
has on society). BSR. (2011). Stakeholder mapping. Retrieved from https://www.bsr.org
c. Analyze and discuss the similarities and differences /reports/BSR_Stakeholder_Engagement_Stakeholder_Mapping
in responses. What is the source of the response? Why .final.pdf
did the person respond in the manner that they did? Cherrier, H., Goswami, P., & Ray, S. (2018). Social entrepreneurship:
2. Identify a social issue or problem that is important to you Creating value in the context of institutional complexity. Jour-
or a population, community, or organization you serve. nal of Business Research, 86, 245–258. https://doi.org/10.1016/j
.jbusres.2017.10.056
What specific role and actions have you taken to contrib-
Cohn, E. S., & Coster, W. J. (2014). Unpacking our theoretical rea-
ute to the resolution of the social issue or problem?
soning. In B. A. B. Schell, G. Gillen, & M. Scaffa (Eds.), Willard
■ Using the client-centered framework in Table 22.1, ana- and Spackman’s occupational therapy (12th ed., pp. 478–493).
lyze the issues based on the 5 levels of client-centered care. Baltimore: Lippincott Williams & Wilkins.
■ Identify the proximal stakeholders who have a direct Dunn, W., Brown, C., & McGuigan, M. (1994). Ecology of human per-
investment in the social issues. formance. American Journal of Occupational Therapy, 48, 595–607.
■ Identify the distal stakeholders who have an indirect re- https://doi.org/10.5014/ajot.48.7.595
lationship to the social issue or who have an impact on a Fowler, E., Coffey, E., & Dixon-Fowler, H. (2017). Transforming good
person or community’s participation in the social issue. intentions into social impact: A case on the creation and evolution
■ Using the stakeholder mapping example in Exhibit 22.1, of a social enterprise. Journal of Business Ethics. https://doi.org
create a map of the stakeholders. /10.1007/s10551-017-3754-5
Impact. (n.d.). In Oxford English Dictionary. Retrieved from https://
■ Using the needs analysis example in Table 22.2, ana-
www.oxforddictionaries.com
lyze the priority issues and needs at each level of care
Kielhofner, G. (2008). The model of human occupation (4th ed.).
(i.e., person, population, organization). Baltimore: Lippincott Williams & Wilkins.
3. Using the intervention plan in Table 22.3, complete a plan Knight, V., Sartini, E., & Spriggs, A. D. (2015). Evaluating visual
at the person, population, and organizational levels. activity schedules as evidence-based practice for individuals with
4. Identify institutional or governmental policies that autism spectrum disorder. Journal of Autism and Developmental
impact your proposed intervention plan. What are the Disorders, 45(1), 157–178. https://doi.org/10.1007/s10803-014-2201-z
implications of the policy on the implementation and Ku, G., Wang, C. S., & Galinsky, A. D. (2015). The promise and
sustainability of your proposed plan? perversity of perspective-taking in organizations. Research in
Organizational Behavior, 35, 79–102. https://doi.org/10.1016/j
.riob.2015.07.003
ACOTE STANDARDS Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L.
(1996). The Person–Environment–Occupation Model: A trans-
This chapter addresses the following ACOTE Standards: active approach to occupational performance. Canadian Jour-
■ B.1.3. Social Determinants of Health nal of Occupational Therapy, 63, 9–23. https://doi.org/10.1177
■ B.3.4. Balancing Areas of Occupation, Role of Promotion /000841749606300103
of Health, and Prevention Prandelli, E., Pasquini, M., & Verona, G. (2016). In user’s shoes: An
experimental design on the role of perspective taking in discov-
■ B.5.1. Factors, Policy Issues, and Social Systems ering entrepreneurial opportunities. Journal of Business Ventur-
■ B.5.2. Advocacy ing, 31(3), 287–301. https://doi.org/10.1016/j.jbusvent.2016.02.001
■ B.7.3. Promoting Occupational Therapy. Raymaker, D. M. (2016). Intersections of critical systems thinking
and community based participatory research: A learning orga-
nization example with the autistic community. Systemic Prac-
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https://doi.org/10.1362/204440815X14373846978624 https://doi.org/10.5465/amr.2013.0506
CHAPTER
Becoming a Change Agent
Sarah Bream, OTD, OTR/L 23
LEARNING OBJECTIVES
■ Define the term change agent,
■ Discuss the leadership qualities that support one’s capacity to serve as an effective change agent,
■ Reflect on their own capacity to function as effective change agents, and
■ Consider how they might serve as change agents within a particular context.

• Agent • Collaboration • Risk taking
• Change • Ego free • SWOT analysis
• Change agent • Purpose
“The ability to see what is possible and care enough to the profession of occupational therapy has the potential to
mobilize others for action is not limited to individuals not only strengthen the profession itself but also ultimately
with particular titles on job descriptions.” to improve the health and well-being of society as a whole.
This chapter explores the definition of the term change agent
—Marcia L. Finlayson (2013, p. 211)
and what it means to be one. The chapter introduces readers
to the knowledge, personal skill set, and qualities of effective
change agents that have been identified in the literature, offering
OVERVIEW practical guidance for occupational therapy managers to sup-
A
change agent is someone who can influence others port the effectiveness of change agents. A case example offers
for the purpose of achieving a desired outcome. Now readers an opportunity to see a change agent in action. Most
more than ever, the profession of occupational ther- important, readers will engage in critical reflection to better
apy should create change agents. With the potential move of understand their own skill set and capacity to serve as effective
the educational entry point of the profession to the doctorate change agents on behalf of the occupational therapy profession.
level, combined with the recent trend of occupational ther-
apy practice expanding into nontraditional and emerging
practice settings such as primary care, college campuses, and
nonprofit and community-based organizations, the profes- Literature on the topic of change tends to focus primarily
sion is already in the midst of significant transformation. on the process of change (Haque et al., 2016), the implemen-
Given such trends, the time is right for the profession to tation of change (Gawande, 2013, 2015; Leland et al., 2014;
continue this forward momentum and to explicitly address McCormack et al., 2013), and change management (Anand
creating change agents who will continue to create new & Barsoux, 2017), but there is limited discussion in the liter-
opportunities for occupational therapy to positively affect ature focused specifically on the topic of becoming a change
society’s health and well-being through the engagement in agent. What does it mean to be a change agent? How does one
occupation. Intentionally developing agents of change across become a change agent?
https://doi.org/10.7139/2019.978-1-56900-592-7.023
225
CHAPTER
Becoming a Change Agent
Sarah Bream, OTD, OTR/L 23
LEARNING OBJECTIVES
■ Define the term change agent,
■ Discuss the leadership qualities that support one’s capacity to serve as an effective change agent,
■ Reflect on their own capacity to function as effective change agents, and
■ Consider how they might serve as change agents within a particular context.

• Agent • Collaboration • Risk taking
• Change • Ego free • SWOT analysis
• Change agent • Purpose
“The ability to see what is possible and care enough to the profession of occupational therapy has the potential to
mobilize others for action is not limited to individuals not only strengthen the profession itself but also ultimately
with particular titles on job descriptions.” to improve the health and well-being of society as a whole.
This chapter explores the definition of the term change agent
—Marcia L. Finlayson (2013, p. 211)
and what it means to be one. The chapter introduces readers
to the knowledge, personal skill set, and qualities of effective
change agents that have been identified in the literature, offering
OVERVIEW practical guidance for occupational therapy managers to sup-
A
change agent is someone who can influence others port the effectiveness of change agents. A case example offers
for the purpose of achieving a desired outcome. Now readers an opportunity to see a change agent in action. Most
more than ever, the profession of occupational ther- important, readers will engage in critical reflection to better
apy should create change agents. With the potential move of understand their own skill set and capacity to serve as effective
the educational entry point of the profession to the doctorate change agents on behalf of the occupational therapy profession.
level, combined with the recent trend of occupational ther-
apy practice expanding into nontraditional and emerging
practice settings such as primary care, college campuses, and
nonprofit and community-based organizations, the profes- Literature on the topic of change tends to focus primarily
sion is already in the midst of significant transformation. on the process of change (Haque et al., 2016), the implemen-
Given such trends, the time is right for the profession to tation of change (Gawande, 2013, 2015; Leland et al., 2014;
continue this forward momentum and to explicitly address McCormack et al., 2013), and change management (Anand
creating change agents who will continue to create new & Barsoux, 2017), but there is limited discussion in the liter-
opportunities for occupational therapy to positively affect ature focused specifically on the topic of becoming a change
society’s health and well-being through the engagement in agent. What does it mean to be a change agent? How does one
occupation. Intentionally developing agents of change across become a change agent?
https://doi.org/10.7139/2019.978-1-56900-592-7.023
225
The answers to these questions are complex and unique to

Learning Activity
the person and the context in which they function. There is
not a single magical pathway that will result in the creation Consider your current knowledge, skill set, and abilities.
of a change agent; there is no standardized formula. From
this author’s perspective, becoming a change agent results ■ What strengths do you currently possess that will enable you to
from the dynamic interaction of experiences between the function as an effective change agent?
■ What areas will you need to further develop?
individual, the context, and the people around them.
■ If you do not possess the necessary skills, are there others
Change can be defined as “to make different in some par-
around you who possess these skills that you may call on?
ticular” or “to make radically different: transform” (Merriam-
Webster, n.d.). Agent can be defined as someone who “exerts Reflect on a situation when it became necessary for you to face your
power” and “something that produces or is capable of produc- fears and learn to be comfortable with the uncomfortable.
ing an effect” (Merriam-Webster, n.d.). Therefore, a change ■ Describe what made you most fearful about being a change
agent is someone who creates change. agent.
It is important to note that to be a change agent, one does ■ What did it take for you to take the leap to overcoming
not have to produce profound levels of change. A change can these fears?
be fairly small in nature but still make a large impact, such as ■ How did you feel after moving through the challenges to
a manager implementing a monthly journal club where occu- eventually find comfort with the uncomfortable?
pational therapy practitioners meet once per month during
their lunch hour to discuss the latest journal article inform-
ing their practice area. A large-scale transformative change,
on the other hand, could entail transitioning a hospital from EXHIBIT 23.1. Qualities of an Effective Change Agent
a paper documentation system to electronic medical records.
Change agents may produce outcomes that range from very Adaptable
small to very large in scale, but the goal is to be effective. The Advocate
change needs to serve a meaningful purpose, such as solv- Analytic
Authentic
ing a problem or improving a situation, product, or service
Believes that change is possible
(Finlayson, 2013).
Builds motivation and support
Various skills and leadership qualities support a person’s Collaborates
ability to function effectively as a change agent (Finlayson, Communicates well (both written and oral)
2013; Liao et al., 2017; Mencl et al., 2016; Reed, 2016). A com- Confidence
prehensive list of qualities drawn from the literature is pro- Conflict resolution skills
vided in Exhibit 23.1. The list of characteristics is extensive, Consistent
identifying 36 leadership qualities and skills that enable an Draws on theory and evidence
effective change agent. Designing building
At first glance this list of qualities may seem overwhelm- Disciplined
ing or even impossible to attain. How can any single person Educating
Empathetic
possess all of these qualities? Does a person need to possess
Engages in active reflection
all of these characteristics to be an effective change agent?
Flexible
The answer is no; one does not need to possess all of the High self-efficacy
qualities on this list. But any of these qualities can enhance Insightful
a manager or practitioner’s ability to function effectively as Intellectually curious
a change agent. Intentional
Readers likely identify with at least 1 of these qualities, and Knows self extremely well
it is highly likely they may possess several of them. There- Listens carefully
fore, each person has the capacity to serve as a change agent. Negotiates effectively
The literature on change supports the notion that a person Observes carefully
does not need to possess a formal title, formal leadership role, Optimistic
Patient
or particular job description to be an effective change agent
Persistent
(Finlayson, 2013; McCormack et al., 2013). Anyone has the
Problem focused rather than emotion focused
power to influence others and function as a change agent. Reflective
Resilient
Review Questions Strong or courageous
1. What is the operational definition of a change agent? Strong internal locus of control
Team oriented
2. What are some of the qualities that enable a person’s abil-
Takes bold action
ity to function effectively as an agent of change?
3. What are 3 reasons why change agents are important for Note. List is drawn from Finlayson, 2013; Liao et al., 2017; Mencl et al., 2016;
the occupational therapy profession? Reed, 2016.
CHAPTER 23. Becoming a Change Agent 227
PRACTICAL APPLICATIONS IN additional decisions to ensure the best outcome. Forward mo-
OCCUPATIONAL THERAPY mentum is crucial when functioning as an effective change
agent; thoughtfully but swiftly making decisions, and then
This section outlines 7 key principles developed by the author making them right, fosters confidence. Change agents real-
that offer occupational therapy managers and practitioners ize they are equipped to problem solve and handle whatever
practical guidance for becoming and supporting change challenges might arise from any given decision. Acting swiftly
agents. These principles are also reflected in Case Example 23.1. is not to say that people should make decisions impulsively;
decisions should always be made with thoughtful reflection.
Share Ideas Make a decision and then do what you can to make it right.
Ideas are the catalyst to change. Occupational therapy prac-
titioners have no shortage of ideas. Their knowledge and skill Take Risks
set, nestled within a professional context that is concerned
Risk taking means different things to different people. Within
with human interaction in daily life, results in a uniquely
the context of this chapter, risk taking refers to willingness
analytic yet creative perspective that fosters endless ideas—
or tolerance to take a chance with no guarantee that your
but many people are afraid to share these ideas. They might
actions will lead to the desired outcome. For some, the risk
think, “No one will listen to me”; “I am not important enough,
may be in sharing a new idea.
so no one will pay attention to me anyway”; “No one will like
Taking risks can be quite scary. At the heart of risk taking
my idea”; or “My idea is not good enough.”
is uncertainty; when individuals are uncertain, they become
Ideas may be simple, bold, or something in between, but
uncomfortable. An outcome is never guaranteed, and change
the best idea for change is the one that is told to others. If an
agents understand that feeling uncomfortable is part of
idea is never shared, it has no possibility of garnering sup-
change. When people push themselves outside of their com-
port. Many ideas have the potential to create change if they
fort zone, they stretch their capacity, tolerate risk, recover
are shared, and effective change agents recognize this. There-
from mistakes, and grow.
fore, the first step is to be brave and to share the idea. This
Asking for something that is needed or desired is an example
allows an opportunity to ask for feedback or engage in dis-
of risk taking. People may be reluctant to ask because they antic-
cussion. Sometimes an idea needs additional attention and
ipate the answer is no. But if they do not ask, the answer is always
more brainstorming to fully develop.
no. If they risk asking, the odds of getting what they want or need
instantly improve. So, go ahead and ask. Much could be gained.
Ground Ideas in Purpose
Another barrier to effective risk taking is the fear of failure.
The ideas that tend to create long-lasting impact are those that People are often scared to make mistakes and therefore play it
are grounded in a meaningful, ego-free purpose. A purpose safe. Change agents are willing to learn from their mistakes,
is the central reason why you are doing what you are doing. and there is often no better education. Making mistakes is
A clearly defined purpose can be clearly articulated to others inevitable; willingness to learn from them fosters growth.
and visualized. When thinking about it, you have a vision of When individuals possess the confidence to take risks, change
what the final result of your actions will be. is possible and great things may be accomplished.
A clear purpose offers motivation for both the change How does one know when the risk might actually be too
agent and others. The term ego free emphasizes the point that great? How do we know when there may actually be too
this purpose is not about you; it must be bigger than and ben- much at stake and not worth the risks involved? How do
efit something or someone other than you. Effective change we differentiate impulsivity and emotional decision making
agents mindfully and consistently return to the core purpose versus a thoughtful, risk-mitigating plan? One helpful tool
of why they are doing what they are doing. Creating and sus- for leaders to recognize whether the risks are reasonable
taining change is difficult, but identifying and remaining and the intended outcome is worthwhile is to use a SWOT
aligned with a purpose better prepares change agents to per- analysis (strengths, weaknesses, opportunities, threats; see
sist and overcome obstacles and challenges. Appendix 23.A, “Change Analysis”). The process of outlin-
ing key variables involved in a potential change implementa-
Make the Decision, and Then Make It Right tion allows leaders and managers to more clearly understand
the risks a change involves, analyze whether (and how) these
When faced with making decisions, there is a tendency to be-
risks might be mitigated, and identify what resources are
lieve that there is only 1 right answer. As a result, people often
needed to proceed.
get stuck worrying about making “the right” decision because
While analyzing risk, managers can ask themselves the
they believe so strongly that only 1 answer, 1 solution, 1 best
following questions:
way exists. However, any of several options might be an effec-
tive approach to a situation and lead to the desired outcome. ■ Will my actions cause harm to anyone? Do these actions
The principle of “make the decision, and then make it right” violate the Occupational Therapy Code of Ethics (2015)
begins with making a decision. This action generates the ini- (American Occupational Therapy Association [AOTA],
tial momentum required for change. Next, you ensure it is 2015)?
the right decision by thoughtfully moving forward, making ■ Will these actions harm the reputation of the organization?
CASE EXAMPLE 23.1. Celebrating a Century of Occupational Therapy
In August 2011, I was early into my 14th year as an occupational therapy practitioner and was elected to a 3-year term as a volunteer regional
director on the Occupational Therapy Association of California (OTAC) Board of Directors. At this point in time, the occupational therapy
profession was several years into the launch of the Centennial Vision (AOTA, 2007), and most practitioners around the country could recite
the national mantra verbatim and did so readily at nearly every state and national conference: “We envision that occupational therapy is a
powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s
occupational needs” (p. 613).
Several months later during an OTAC Board of Directors meeting, I presented an idea to the Board. I suggested that the profession enter a
Centennial float in the Annual Tournament of Roses® Parade on New Year’s Day 2017 to honor the 100th anniversary of the profession. The Rose
Parade is one of the largest social rituals in the world, and participation in this globally televised event would be in alignment with AOTA’s
Centennial Vision of becoming “widely recognized” and “globally connected.”
Within a few minutes, this idea evolved into my first-ever official motion to the Board. I can still visualize this day in the Board Room
after the motion passed unanimously. Several of my colleagues were jumping up and down, clapping, cheering, and ecstatic about the idea,
immediately expressing their support and desire to participate on the planning committee. The OTAC president at the time, Shawn Phipps, PhD,
OTR/L, FAOTA, expressing his belief in my leadership, appointed me chair to lead this endeavor, and went on to reference a term that I had
never before heard: B–HAG. He said, “B–HAG is a big, hairy, audacious goal.” I turned to him with a big smile on my face and said, “Go big, or
go home.”
From that day on, I found myself leading a once-in-a-lifetime endeavor on behalf of the occupational therapy profession. The Occupational
Therapy Centennial Float Initiative was a 7-year-long grassroots project to raise $300,000 to ensure that the profession was honored with a float in
the Rose Parade. More than 75 volunteers across the country, consisting of occupational therapy practitioners, students, retirees, and others, served
on this committee. At the center of this vast committee was a core group of 7 change agents (Figure 23.1). Sharing group texts, e-mails, or phone
calls nearly daily for 7 years, this core committee was involved in almost every detail of planning and execution. Committee members were engaged
in strategic activities that ranged from fundraising at state and national occupational therapy conferences to rallying occupational therapy academic
programs and students across the country. These change agents believed in a vision and remained steadfast from start to finish, even in the face
of adversity.
Core Centennial Float Committee Members, 2011–2017, and change agents in the
FIGURE 23.1.
early stages of the float’s building process.
Note. From left to right: Cyndy Garcia, COTA/L; Sarah Bream, OTR/L; Sabrena McCarley, OTR/L; Celso Delgado, Jr., OTR/L; Bryant Edwards, OTR/L; Samia Rafeedie,
OTR/L; Arameh Anvarizadeh, OTR/L (on swing).
Source. S. Bream. Used with permission.
(Continued)
CASE EXAMPLE 23.1. Celebrating a Century of Occupational Therapy (Cont.)
When faced with opposition or adversity throughout this process, the core team was able to navigate these complexities with patience and level-
headedness. The Occupational Therapy Centennial Float Initiative was grounded in the purpose to celebrate this once-in-a-lifetime milestone and
honor the history of the profession and the individuals and families occupational therapy serves. Consistently remaining grounded in this purpose
provided clarity throughout this grueling, 7-year process, whenever clarity was needed.
At every twist and turn throughout the development of the project, there were myriad decisions for the OTAC Committee to make: selecting the
float builder, designing the concept and theme, choosing images to portray on the rotating float panels, finding riders, coordinating volunteers to
decorate the float, and interfacing with media.
Like most projects, the implementation process for the float had a finite timeline. We did not always have the time to engage in in-depth, lively
debate for hours on end. The success of this endeavor depended on the committee’s ability to make decisions in a timely fashion. We often believe
that there is only 1 right answer and are afraid to act because we fear making the wrong decision. However, for the float project, there were typically
several options for any given decision that would lead to a positive outcome. Adopting the principle that we would “make the decision, and make it
right” gave us the freedom to remain action oriented and the faith to know that each decision brought us closer to achieving our goal.
The first risk for the Centennial Float Initiative was putting forth the initial idea. What if people do not like my idea? What if they think it is silly?
Or not feasible? What if someone we approach for help says “no”? Another risk was agreeing to move the idea forward into implementation. The
deeper into the process we moved, the greater the risks became. The OTAC executive director, presidents, and Board of Directors took on a huge
financial risk; the average cost of a float in the Rose Parade at the time was $300,000. Additionally, OTAC had no infrastructure to deal with a project
of this magnitude. With no experience in professional fundraising, fewer than 5 full-time office staff, and a group of passionate volunteers, OTAC also
risked its reputation: What if we couldn’t pull this off? What if all of the funds needed could not be raised? Instead of framing this project as a risk,
OTAC unanimously embraced and advanced this idea.
On January 1, 2017, the float, Celebrating a Century of Occupational Therapy, appeared in the Rose Parade in Pasadena, CA (Figure 23.2).
According to official Tournament of Roses® data, there were 700,000 in-person attendees along the 5-mile parade route of Orange Grove and
Colorado Boulevard. There were 9,144 Instagram posts about the parade on this date; 14,700 tweets; 61,195 Facebook® posts; 32, 214,714 views
of the Tournament website where all parade entries were advertised, and 73.5 million television viewers around the globe. Occupational therapy
was undoubtedly “widely recognized” and “globally connected” on this momentous day.
The float Celebrating a Century of Occupational Therapy during the Annual Tournament of
FIGURE 23.2.
Roses Parade on January 1, 2017.
Source. Photo by Paul Krugman, courtesy of the Occupational Therapy Association of California. Used with permission.
Review Questions
1. Considering the case example, what are 5 qualities from Exhibit 23.1 that you believe best supported the effectiveness of the change agents
involved in this process?
2. What key principles of an effective change agent came to life during the Occupational Therapy Centennial Float Initiative?
3. Considering that a change agent may often be faced with opposition, how do they remain committed to a vision and bolster an ability to
continue to persist as a bold leader to achieve the desired outcome?
■ Will these actions harm my personal or professional Managers should foster supportive working environments that
reputation? foster innovation and change.
■ Will these actions violate legal standards? Change agents in a continually evolving profession must
■ Do I experience a significant negative emotional response identify in what kind of professional context they flourish.
when reflecting on my analysis? Are exemplary role models and mentors within the context
willing to support the professional growth of others? Is inno-
Answering “yes” to any of these questions is a red flag that vation fostered? Do staff strive for excellence on a consistent
should likely halt any further consideration of moving for- basis? Is the context equipped with adequate resources to suc-
ward. Altering the plan is necessary, along with a newly iden- cessfully achieve its goals?
tified vision and course of action.
Cope Effectively With Setbacks
Effective change agents understand that not everyone will ap-
For additional learning, see Chapter 11, “Risk Management and preciate their idea, embrace the challenge, or be willing to share
Contingency Planning.” in the risk. Many people will ultimately say “no.” Change agents
are resilient, learning from setbacks, solving problems, and ad-
justing plans as needed to move forward to the desired outcome.
Collaborate
Change agents understand they cannot take things personally.
Collaboration is “a way of working with colleagues that is char- Potential resistance or a negative answer can be related to many
acterized by cooperation, mutual respect, and shared goals. It challenges, such as limited financial resources, time, or space, or
involves sharing information, coordinating actions, discussing philosophical differences. Change agents accept setbacks by un-
what’s working and what’s not, and perpetually seeking input derstanding the broader picture, working to understand diverse
and feedback” (Edmonds, 2012, p. 54). In occupational therapy perspectives of multiple stakeholders, and acknowledging po-
practice, leadership, and management, change agents must be tential barriers. Change agents anticipate challenges and remain
able to collaborate effectively with others, but collaboration can resilient by focusing on the purpose of a change and its end goal.
often be difficult. Successfully implementing new ideas requires
buy-in from stakeholders, including those who may initially re- Review Questions
sist or be difficult to work with. Change agents must expect that
there will be naysayers and people who will not support the ef- 1. What are 3 key principles that may support a person’s
fort. However, change agents are skilled at rallying support not ability to function as an effective change agent?
only from the champions and cheerleaders. Through adept ne- 2. What specific aspects within the context may support a
gotiation and diplomatic efforts, change agents work effectively change agent’s effectiveness?
with people resisting change in a way that garners their respect, 3. How does collaboration support the goals and vision of a
even though they may not be in favor of the initiative. change agent?
When engaged in a transformative effort or change initia-
tive, mutual respect equals victory, regardless of where people Learning Activity
stand on an issue. At the end of the day, what is collectively
achieved is often far greater than what one may achieve work- Critical Reflection
ing individually. Gawande (2013) examined the implementa-
■ Why do people hesitate to put forth new ideas or take risks?
tion of new ideas and found that keeping change manageable
■ What do you need to be a more effective risk taker?
and relevant to people and their contexts and using a personal ■ What can you do as a leader to foster a culture within your en-
touch results in the most effective and sustainable changes. vironment where people willingly share their ideas and embrace
boldness and innovation?
Change Analysis
For additional learning, see Refer to Appendix 23.A, and consider a potential change you would
like to introduce in your workplace or another context. Complete the
■ Chapter 20, “Handling Resistance During Change,” and
change analysis grid and then address the questions that follow:
■ Chapter 21, “Communicating During Change or Uncertainty.”
■ Do you have a clear vision of what is needed to implement the
desired change?
Choose a Context in Which You Thrive ■ Do you have the necessary players on your team, and are they
Occupational therapy practitioners recognize the importance motivated to embrace the change process?
of context in daily life. Change agents are most successful when ■ What elements of resistance currently exist, and what challenges
they work in a context that offers supportive leadership, em- might you anticipate as you begin to implement the desired change?
■ What strategies will you use to support the challenges that your team
braces innovation, and makes necessary resources available for
may experience throughout the change implementation process?
them to perform effectively (McCormack et al., 2013). With- ■ Are you building an infrastructure to support and sustain this
out supportive management and leadership and sufficient re- change over the long term?
sources, it becomes very difficult to achieve desired outcomes.
Learning Activity REFERENCES

Consider your role as an evolving leader in occupational therapy and 2018 Accreditation Council for Occupational Therapy Education
reflect on the following questions: (ACOTE) standards and interpretive guide. American Journal
■ What is the sense of responsibility that you feel as a change
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
agent as you approach your practice and career overall? .org/10.5014/ajot.2018.72S217
■ What grounds you in your perspective of occupational therapy
Agent. (n.d.). In Merriam-Webster’s online dictionary. Retrieved
practice? from https://www.merriam-webster.com/dictionary/agent
■ How might the occupational therapy profession successfully
American Occupational Therapy Association. (2007). AOTA’s
cultivate change agents and bold leaders who will continue to Centennial Vision and executive summary. American Journal of
strengthen the profession? Occupational Therapy, 71, 613–614. https://doi.org/10.5014/ajot
.61.6.613
Consider your role as change agent in relation to current issues American Occupational Therapy Association. (2015). Occupa-
facing the profession of occupational therapy. In small groups, reflect tional therapy code of ethics (2015). American Journal of Occu-
on and discuss your responses to the following questions: pational Therapy, 69, 6913410030. https://doi.org/10.5014/ajot
.2015.696S03
■ In what contexts do you envision occupational therapy practice
Anand, N., & Barsoux, J. (2017, November). What everyone gets
in the future?
wrong about change management. Harvard Business Review,
■ What are the considerations for faculty and professional pro-
78–85.
grams to successfully prepare occupational therapy graduates to
Change. (n.d.). In Merriam-Webster’s online dictionary. Retrieved
practice effectively in these contexts?
from https://www.merriam-webster.com/dictionary/change
■ Given your response above, how might practitioners and leaders
Edmonds, A. (2012). Teaming: How organizations learn, innovate,
advocate for funding that is needed to successfully sustain
and compete in the knowledge economy. San Francisco: John
occupational therapy programs in the future?
Wiley & Sons.
■ How might the profession effectively develop a multicultural
Finlayson, M. L. (2013). [Muriel Driver Memorial Lecture] Embrac-
and diverse workforce that mirrors the increasing diversity of
ing our role as change agents. Canadian Journal of Occupational
today’s society? Identify and discuss specific strategies that
Therapy, 80, 205–214. https://doi.org/10.1177/0008417413499505
you recommend for implementation.
Gawande, A. (2013, July 29). Slow ideas: Some innovations spread
fast. How do you speed the ones that don’t? The New Yorker.
Retrieved from http://www.newyorker.com/magazine/2013/07
/29/slow-ideas
Gawande, A. (2015). Overkill: An avalanche of unnecessary med-
SUMMARY ical care is harming patients physically and financially. What
This chapter aimed to encourage occupational therapy can we do about it? The New Yorker. Retrieved from https://www
managers and practitioners to be effective change agents .newyorker.com/magazine/2015/05/11/overkill-atul-gawande
Haque, M., Titiamayah, A., & Liu, L. (2016). The role of vision in
in the rapidly changing profession of occupational therapy.
organizational readiness for change and growth. Leadership
Everyone has the potential to serve as a change agent, re- and Organization Development Journal, 37, 983–999. https://doi
gardless of title or position. Key principles were presented to .org/10.1108/lodj-01-2015-0003
support managers and practitioners in their effectiveness as Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2014). Ad-
change agents. vancing the value and quality of occupational therapy in health
As the profession transforms itself through innovative ex- service delivery. American Journal of Occupational Therapy, 69,
pansion into new arenas and potentially launches entry-level 6901090010. https://doi.org/10.5014/ajot.2015.691001
doctorate education, occupational therapy is well suited to Liao, S., Chen, C., Hu, D., Chung, Y., & Liu, C. (2017). Assessing the
continue to foster the development of change agents who may influence of leadership style, organizational learning and organi-
successfully sustain this transformation. Effective change zational innovation. Leadership and Organization Development
agents are needed to promote occupational therapy service Journal, 38, 590–609. https://doi.org/10.1108/lodj-11-2015-0261
McCormack, B., Rycroft-Malone, J., Decorby, K., Hutchinson, A.
delivery that will have a lasting, positive effect on society’s
M., Bucknall, T., Kent, B., . . . Wilson, V. (2013). A realist review
health and well-being. ❖ of interventions and strategies to promote evidence-informed
healthcare: A focus on change agency. Implementation Science, 8,
107. https://doi.org/10.1186/1748-5908-8-107
ACOTE STANDARDS Mencl, J., Wefald, A. J., & Ittersum, K. W. (2016). Transformational
This chapter addresses the following ACOTE Standards: leader attributes: Interpersonal skills, engagement, and well-
being. Leadership and Organization Development Journal, 37,
■ B.5.0. Context of Service Delivery, Leadership, and Man- 635–657. https://doi.org/10.1108/lodj-09-2014-0178
agement of Occupational Therapy Services Reed, K. (2016). [Frances Rutherford Lecture] Possibilities for the
■ B.5.7. Quality Management and Improvement future: Doing well together as agents of change. New Zealand
■ B.7.3. Promote Occupational Therapy. Journal of Occupational Therapy, 63, 4–13.
APPENDIX 23.A. CHANGE ANALYSIS
Describe the change situation:
Factors supporting change: Factors resisting change:
Strategies to support the change implementation process:
Desired outcome: Plan for sustainability:
By Sue Bowles, OTD, OTR/L, and Sarah Bream, OTD, OTR/L. Used with permission.
SECTION IV.
Outcomes and Documentation
Edited by Shawn Phipps, PhD, OTR/L, FAOTA
233
Managing Quality and Promoting
Evidence-Based Practice CHAPTER
Pamela Roberts, PhD, OTR/L, SCFES, FAOTA, CPHQ, FNAP, FACRM;
Maria Cecilia Alpasan, MA, OTR/L, CPHQ; and Ashley Uyeshiro Simon, OTD, OTR/L, MSCS 24
LEARNING OBJECTIVES
■ Recognize the value and importance of outcome assessments in routine clinical practice;
■ Evaluate, interpret, and discuss strategies for integration of outcome assessments into clinical practice; and
■ Identify several uses of technology that aid in quality assurance and performance improvement efforts.

• Donabedian model • Outcome measures • Sustainment plan
• Electronic health records • Quality Assurance and • Technology
• Health care quality Performance Improvement plan
OVERVIEW landmark report on patient safety, To Err Is Human (Kohn et al.,

1999), which called for major changes in the health care system
T
his chapter discusses basic quality principles that are to increase the delivery of safe patient care. This report cited the
essential to the function of occupational therapy ad- different errors that have contributed to adverse events, and even
ministrators. Using theories of quality management deaths, as a result of a decentralized health care system. Shortly
with roots in the manufacturing industry, framework models after this report was published, the IOM (2001) published an-
and systems are presented to illustrate how these can be ap- other landmark resource, Crossing the Quality Chasm, which
plied in performance improvement and program evaluation called for an overhaul of the health care system.
in any practice area. This chapter addresses quality and qual- The focus on quality of health care delivery in these publi-
ity management principles, the Donabedian model, the Qual- cations highlighted the need for safe, effective, timely, efficient,
ity Assurance and Performance Improvement (QAPI) plan, and equitable patient-centered care (Berwick, 2002; IOM,
standardized assessments and outcome measures in practice, 2002). In 2010, the Patient Protection and Affordable Care Act
sustainment plans, technology (i.e., the application of materi- (P.L. 111-148) pushed the need for a shift in the reimburse-
als, tools, and practice knowledge to enhance practice) use to ment system toward value and high-quality evidence-based
improve patient care, and QAPI case examples. care (Leland et al., 2015). The National Strategy for Quality
Improvement in Health Care established 3 overarching aims:
ESSENTIAL CONSIDERATIONS 1. Better care, with the focus on improving overall quality
by making health care more patient centered, reliable,
Quality and Quality Management Principles
accessible, and safe;
According to the Institute of Medicine [IOM], health care 2. Healthy People/Healthy Communities, with the focus on
quality is defined as “the degree to which health care services for improving the health of the U.S. population by support-
individuals and populations increase the likelihood of desired ing proven interventions to address behavioral, social,
health outcomes and are consistent with current professional and environmental determinants of health in addition to
knowledge” (IOM, 1990, p. 21). In 1999, the IOM published a delivering higher quality care; and
https://doi.org/10.7139/2019.978-1-56900-592-7.024
235
236 SECTION IV. Outcomes and Documentation
FIGURE 24.1. The IHI Triple Aim.
Source. “The IHI Triple Aim Initiative,” by the Institute for Healthcare Improvement, n.d., available at http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx.
Used with permission.
3. Affordable care, which focuses on reducing the cost of comparisons and facilitation of care coordination across
quality health care (Agency for Healthcare Research and settings over time.
Quality [AHRQ], 2017). The Medicare Access and CHIP Reauthorization Act of
2015 consolidates Medicare B quality programs and estab-
The Institute for Healthcare Improvement (n.d.) has devel-
lishes a merit-based incentive payment system (MIPS) ac-
oped the Triple Aim to use as a foundation in achieving the
cording to performance measures. Occupational therapy
National Quality Strategy. The Triple Aim framework is de-
practitioners may become eligible for MIPS in 2019. Many
signed to improve the patient experience, improve the health
other reporting measures are incorporated into practice
of populations, and reduce the cost of health care concurrently
that tie reimbursement to performance. At the same time,
(see Figure 24.1).
requirements for public reporting allow consumers the abil-
The changing landscape in health care results in quality-
ity to make decisions based on quality metrics.
driven initiatives with 6 priorities for health and health care
quality:
1. Making care safer by reducing harm; The Donabedian Model
2. Engaging the person and family as partners in patient The Donabedian model (Donabedian, 2005) is a classi-
care; fication system to assess and compare the quality within
3. Promoting effective communication and coordination of health care delivery (see Figure 24.2). Structural measures
care; are those measures that address capacity, systems, and pro-
4. Addressing effective prevention and intervention practices cesses in high-quality health care provision. Some exam-
for leading causes of mortality; ples of structural measures include use of electronic health
5. Working with communities for promotion of evidence- records (EHRs; electronic versions of a patient’s medical re-
based practices to enable healthy living; and cords maintained by the provider; expressed in a percentage
6. Spreading innovative health care delivery models to ad- or ratio), number of licensed occupational therapists who
dress affordability of health care (AHRQ, 2017). hold board or specialty certifications, or number of full-time
Through various agencies such as the Centers for Medi- equivalent staff to meet productivity demands.
care and Medicaid Services (CMS), AHRQ, The Joint Process measures reflect procedures associated with pro-
Commission, The Commission on Accreditation of Reha- duction of best outcomes, such as clinical practice guidelines.
bilitation Facilities, the National Quality Forum, and the Examples include percentage of clients with documented
Institute for Healthcare Improvement, the quality move- occupational profiles as part of the occupational therapy
ment has been placed at the forefront of health care delivery. evaluations and percentage of evaluations performed within
More recent federal policies that specifically address quality a specified time frame. Outcome measures capture results
include the Improving Medicare Post-Acute Transforma- the practitioner wants to achieve, such as measuring effi-
tion (IMPACT) Act of 2014 (P. L. 13–185). The IMPACT Act cacy of a treatment intervention or quality of life measures.
requires standardized assessment data across postacute care These measures are standardized and are usually bench-
settings and quality measures to enable interoperability and marked against a similar population or setting.
CHAPTER 24. Managing Quality and Promoting Evidence-Based Practice 237
FIGURE 24.2. The Donabedian model of patient safety.
Structures of Processes of
Outcomes
Care Care
Review Questions plan provides metrics that demonstrate value of services ren-
dered and gives a direction of where to focus performance
1. What is the definition of health care quality?
improvement efforts, not only as an organization but also to
2. What are the overarching aims that are included in the
the individuals providing and receiving care.
National Strategy for Health Care Quality?
Measures included in a QAPI plan are based on scientific
3. What are the 3 elements of the Donabedian Model of
evidence, processes, outcomes, and consumer perceptions.
Patient Safety?
Measures are often shown as a percentage or ratio and can be
narrow or broad. In establishing the plan, these 4 steps can be
followed as a guideline:
OCCUPATIONAL THERAPY 1. Determine the concerns of the organization through ad-
ministrative priorities, discussion with stakeholders, and
Establishing a QAPI Plan data that are available.
2. Determine best practices through available best evidence.
CMS has established the need for essential services in the
3. Develop the indicators necessary to measure performance.
hospital systems to have a Quality Assurance and Perfor-
4. Educate and support staff involved in the plan.
mance Improvement (QAPI) plan, which addresses mea-
surement of compliance with standards (quality assurance) Exhibit 24.1 is an example of the QAPI plan project tem-
and continuous improvement of processes to meet standards plate. The QAPI plan should always include the full range of
(performance improvement). Ensuring that there is a quality services offered by the facility; governance and leadership
EXHIBIT 24.1. QAPI Plan Project Template
Project Name: Insert Project Name Here

Oversight Commitee: Insert Name Here Date: MM/DD/YYYY
SITUATION/PROBLEM STATEMENT PROJECT TEAM MEMBERS
Explain how the problem is impacting the organization Team Leader(s): <Names Here>
(why is it important to make the improvement?) Team Member(s): <Names Here>
KEY METRICS PROJECT TIMELINE
■ Create a bulleted list of the metrics that the project DATE MILESTONE
will measure and aim to impact in order to address
MM/YYYY
the problem/situation stated above.
MM/YYYY
MM/YYYY
MM/YYYY
MM/YYYY
Source. Copyright © 2019 by Cedars-Sinai Medical Center. Used with permission.

that develops a culture of receiving input from a variety of or existing best practices. During this step, the type of mea-
stakeholders; available resources to achieve desired outcome; sure may need to be determined. For example, in a specific
development of performance improvement projects that ex- population, clinical guidelines may direct the use of a par-
amine and improve care; and integration of analysis to com- ticular standardized test that addresses an impairment
pletely understand the problem, its causes, and implications common in that diagnosis. This may include clinician- ver-
of change. sus patient-reported outcome measures or a combination of
Many tests of change include some form of the Plan–Do– both. In determining which measure to use, it is important
Study–Act (PDSA) model, which is used within the QAPI to identify the type of measure (impairment, activity, or par-
plan in implementing desired change in practice. This allows ticipation), psychometric properties, patient factors, clinic
for a continuous process improvement cycle. or organization factors, and feasibility. It is then crucial to
develop strategies for integration into clinical practice, that
■ The first step (Plan) incorporates planning a test or obser- is, the practice of collecting and recording the same defined
vation and includes how to collect the data.
data elements, ensuring that all elements are implemented in
■ The second step (Do) carries out the test on a small scale, a standardized way and recorded as part of the EHR and that
such as a subset of the population.
accurate information can be extracted from the EHR.
■ The third step (Study) includes analyzing the results.
■ The last step (Act) includes using the test results to make
changes to the plan if necessary. Make a plan
These cycles of tests of change can lead to improvement of the Next, establish a plan that includes identification and con-
system. The cycle of continuous improvement involves many vening of a group of stakeholders, determine responsibilities
small tests of change using the PDSA cycle. associated with a review of the literature, establish a protocol
for prioritizing evidence-based care processes, and develop
the Population, Intervention, Comparison, and Outcomes
Using Standardized Assessments and
(PICO) question.
Outcome Measures Afterward, create a strategy for reviewing the evidence
The American Occupational Therapy Association (2018) is including which databases will be used (e.g., PubMed, OT
working on a National Quality Agenda to promote the dis- Seeker), identify the inclusion criteria (e.g., English, pub-
tinct value of occupational therapy and its contribution to lished in the past 5 years, type of study, level of evidence), and
health, well-being, quality of life, and participation. In apply- exclusion criteria (e.g., not peer reviewed, dissertations). Then
ing concepts of quality and performance improvement to a establish a plan for prioritizing 2–3 evidence-based prac-
particular practice area in occupational therapy, it is import- tices and examine the evidence-based practices in context
ant to identify the drivers of structural characteristics includ- of external factors, internal facility factors, patient priorities,
ing external factors (e.g., value-based payment requirements, resource availability, and stakeholder input.
prioritized outcomes) and internal drivers (e.g., mission and When these steps have been completed, identify the team,
values, care priorities, and quality initiatives). review the published evidence, review the PICO question,
For example, structural characteristics would include the and allocate team responsibilities. Identify practice gaps to
type of facility, documentation platform (e.g., EHR), policies target in your setting, and identify evidence-based practices
and procedures, and resources. The structural measure may that align with the organization’s goals, priorities and values,
be the percentage of occupational therapy practitioners re- available resources, and stakeholder feedback.
porting on a specific quality measure. In developing the plan,
it is important to take into consideration an organization’s Collect data
values and priorities. External factors and priorities may in-
clude priorities such as payment, outcome, or other external Determine the type of data (structure, process, and outcomes
factors affecting care delivery. Internal values and priorities measures) and the source of the data (e.g., instrument, EHR,
may include prioritized outcomes by the organization, areas billing). Collect the data, establish baseline data, and deter-
of quality concern, or care values and priorities. mine the time frame for data collection considering whether
a sample or complete data set is needed. Measure the results
and determine the impact of the intervention and quality
Identify an evidence-based strategy improvement strategy based on the data. Determine how you
Identifying and prioritizing an evidence-based strategy may in- will display and report the data (e.g., line graph, bar chart,
clude the best practices that enhance the prioritized outcomes run chart).
or practices that align with the organization’s patient values
and priorities. Examples of evidence-based care processes may
include a fall screen within 24 hours of admission or a home
safety assessment prior to discharge from the organization. For additional learning, see Chapter 10, “Using Data to Guide
Referencing published literature and clinical guidelines is Business Decisions.”
critical when determining how to link a measure to evidence
Implementation considerations time to create, monitor, improve, and maintain care processes.
These individuals know what needs to be changed, because
Implementation considerations for any quality initiative start
they work on the front lines every day and understand where
with executive management or leadership commitment to
opportunities exist. Further communication about qual-
the project, identification of the project as one of the orga-
ity improvement efforts should occur regularly, such as at a
nization’s strategies, organization assessment of the current
monthly staff meeting. These meetings provide an opportu-
culture, customer satisfaction, quality management systems,
nity for staff to hear about progress and for frontline staff to
management identification of core values and principles to
discuss their needs and expectations related to quality care.
be used and communication of these principles, and develop-
ment of a quality master plan that includes the identified proj-
ect. Other considerations include leaders contributing to the Using Technology
effort through planning, training, coaching, or other meth-
Administrators and managers can use technology to improve
ods; daily process management and standardization receiving
processes involved in patient care, administration, safety, and
support; progress evaluation and plan revision as needed; and
other facets of health care. The type of technology will depend
constant employee awareness and feedback on status being
on the specific needs and resources of the business but often
provided including a reward and recognition process.
includes software (computer or phone applications), online
The overall checklist for quality initiatives should include
databases, EHR, and sometimes even hardware. Examples of
defining the performance improvement project, the outcome,
the uses and benefits of technology for quality assurance and
and process measures; identifying team members, tests of
performance improvement are identified in the following list:
change, and guides or toolkits; and determining the educa-
tion, dissemination plan, and final sustainment plan. ■ Better accuracy of data collection. A practice often uses a
set of specific outcome measures, but patients often in-
Developing a Sustainment Plan correctly answer questions (e.g., circling 2 answers to a
single-answer question) or accidentally skip the back of
Improving quality in occupational therapy is critical in some of the measures if they are printed double-sided.
today’s health care environment. After occupational therapy Use of an online outcome measure software prevents pa-
managers have worked through the process of performance tients from circling 2 answers and ensures that patients
improvement, sustaining the gains is an important aspect to are prompted with all questions in the measures. Some
integrate into overall plans. A sustainment plan is the process online data collection tools use computer adaptive testing,
that ensures that the more effective structures or processes of which is a form of computer-based test in which the next
the quality initiatives are integrated into the workflow. Incor- item is based on the response from the previous item.
poration of ongoing processes to monitor performance must ■ Reduced errors. The rehabilitation unit or hospital staff
be developed and implemented (e.g., Exhibit 24.2). Sustain- manually perform chart reviews and enter patient mea-
ment parameters should include the team objective, goals sure scores into a database so the unit or hospital can re-
with identifiable metrics, and a specific action to take if a per- port on patient progress; however, there is a risk of human
formance indicator goes below a specific level. The sustain- error associated with data entry and cross-training
ment plan should also identify the area to be included (e.g., between various staff. Use of a software program that con-
scope), the project sponsors, and the team leaders. nects with the hospital’s EHR eliminates human errors
The project sponsors and team leaders are the key person- with data entry and saves time.
nel who monitor the sustainment of the performance gains ■ Streamlined processes. A hospital’s EHR is programmed to
and initiate any change needed to address a drop in perfor- prompt a physician with fall-risk screening questions for
mance. In addition, a sustainment plan should identify and each encounter; if the patient screens positive for fall risk,
plan resources and guidelines to give frontline staff dedicated the physician is prompted with a possible referral to occu-
pational therapy.
■ Real-time data updates and analysis. An employee has been
EXHIBIT 24.2. Sustainment Plan Example having difficulty meeting productivity standards. After
meeting with the employee last month, the manager wants
PROJECT OVERSIGHT QUALITY COUNCIL (QC) to know whether the employee’s productivity is on the right
Team Objective Reduce the number of inpatient unassisted track. Instead of having to wait until the month’s end for
falls and falls with significant injury a productivity report, the manager can access up-to-date
Goal 3 consecutive months with no greater than data and reports with analytics that show productivity.
x falls AND zero falls with significant ■ Time saving. A group of occupational therapy practi-
Scope Identify areas to be included tioners at different sites use an online HIPAA–secure
(Health Insurance Portability and Accountability Act of
Executive Sponsors
1996) database to compile their data instead of entering
Team Leaders the data separately and having a staff member spend time
Source. Copyright © 2019 by Cedars-Sinai Medical Center. Used with permission. to compile the different sets.
■ Cost savings. A private practice uses a software program c. A mission and vision statement
to track which insurance is linked to specific patients d. Scope that identifies areas to be included in the sus-
to potentially have fewer errors in billing and improved tainment plan
documentation. 3. If a manager is looking to reduce human error incurred
■ Improved safety and monitoring. A large medical group during administration of patient self-surveys (e.g., skipped
with many occupational therapy facilities uses software to questions, multiple answers selected), which technology
monitor and track adverse events to ensure that each event would best address this need?
has been remediated and resolved and to determine which a. An online database that compiles all patient survey
sites are experiencing adverse events at a higher rate. Possi- answers
ble causes are then identified, and administrative or process b. A software data collection system that can be pro-
improvements can be considered to reduce these events. grammed to restrict or require information
c. A tablet for the waiting room so patients can complete
surveys in the office
Review Questions d. A phone application that allows patients to complete
1. When designing measures for a QAPI plan, which one of surveys at home
the following are required to be included in the plan?
a. Information should be based on routine practices,
systems, and outcomes
SUMMARY
b. Information should be based on scientific evidence Quality management is an integral part of an administra-
and outcomes tor’s duties. Using different models presented in this chapter,
c. Information should be based on scientific evidence, these tools can be used as a framework to guide performance
processes, outcomes, and consumer perspectives improvement initiatives in any practice setting. These per-
d. Information should be based on routine practices, formance improvement measures, once selected and priori-
outcomes, and consumer perspectives tized, can be included in a QAPI plan. Reporting of measures
2. Once you have worked through the process of performance are incorporated in regularly held meetings that assist with
improvement, incorporation of ongoing processes to mon- analyzing and determining action plans. Staff are included
itor performance must be developed and implemented in a at all points in the quality continuum, from an educational
sustainment plan. What are the critical elements to include awareness perspective such as providing feedback on the per-
in a sustainment plan? formance of the department, determining measures needed,
a. Objective, goal, and scope that includes a time frame collecting and analyzing data, and finally planning future
and number of issues based on objective that identi- steps. It is important to ensure that the results of the quality
fies need for action plan are used to meet the performance improvement objec-
b. Objective and scope that includes need for action tives of the department. ❖
CASE EXAMPLE 24.1. Process Improvement Model
The occupational therapy manager in an acute inpatient rehabilitation unit wants to ensure that all occupational therapy practitioners are
completing an occupational profile for every patient; this is a new requirement for the updated occupational therapy evaluation Current Procedural
Terminology codes. The manager not only wants to make sure a profile is entered but also wants to audit the profiles for the first 6 months to
confirm the profiles contain all components.
The manager determines that this is a process improvement project and identifies the unit’s existing monthly chart audits as the mechanism to
track completion rates. The following QAPI plan is developed:
■ Measures for this project will be:
■ “Complete occupational profile” (a profile has been completed and has all required components documented).
■ “Incomplete occupational profile” (a profile has been completed but is missing 1 or more of the required components in documentation).
■ “No profile” (a profile has not been clearly documented).
■ Estimate the baseline rate of the 3 measures using a sample of 30 charts from the previous 3 months (make sure this is a representative
sample based on number of patients seen monthly).
■ Educate practitioners at weekly team meetings about the occupational profile requirement and provide training as to what makes a profile
“complete” or “incomplete.”
■ Modify the occupational therapy evaluation documentation template in the EHR to include a clear “Occupational Profile” section that includes
prompts to respond to each different component of the profile; make this section a mandatory field that is required to submit and sign the
document.
■ Add “Complete occupational profile” to the internal monthly chart audit checklist to ensure future continuity.
■ Reevaluate the 3 measures at 1, 3, and 6 months for individuals and overall staff; share staff results at team meetings, and schedule individual
meetings as needed if specific therapists are not completing this requirement.
CASE EXAMPLE 24.2. Outcome Measurement Model
A small pediatric clinic has started to use animal-assisted techniques in treatment sessions. The manager wants to start collecting patient outcome
data to decide whether this is a program they would like to continue and possibly grow in the future. The manager wants to measure clinical progress
with a standardized, validated outcome measure and would like to know whether patient satisfaction changes because of this new technique.
The manager identifies this as a quality assurance and performance improvement project and determines the following QAPI plan:
■ Perform a literature review to identify a standardized and valid clinical outcome measure for this population of clients and type of treatment.
■ Administer the measure at evaluation and discharge.
■ Modify the existing patient satisfaction survey to include specific quantitative and qualitative questions about the animal-assisted therapy received.
■ Have a staff member input the de-identified outcome data into a spreadsheet.
■ Analyze data from no fewer than 30 responses using paired samples t-test statistic.
■ Compare average satisfaction scores between patients who received and did not receive animal-assisted therapy and compile qualitative
responses.
■ Compile information and present to practice owners at the next quarterly meeting.
Review Questions
1. What other point of contact besides evaluation and discharge may the manager consider administering the outcome measure?
2. What are some examples of questions the manager may want to add to the patient satisfaction survey?
3. If a staff member is not available to input the data into a spreadsheet, what means could the manager use as an alternative?
ACOTE STANDARDS Improving Medicare Post-Acute Care Transformation Act of 2014,

Pub. L. 113–185, 42 U.S.C. § 1395 et seq.
This chapter addresses the following ACOTE Standards: Institute for Healthcare Improvement. (n.d.). IHI Triple Aim
initiative. Retrieved from http://www.ihi.org/engage/initiatives
• A.2.14. Library, Materials, Instructional Aids, and Tech- /TripleAim/Pages/default.aspx
nology Institute of Medicine. (1990). Medicare: A strategy for quality as-
• B.4.15. Technology in Practice surance: Vol. 2. Sources and methods. Washington, DC: National
• B.5.7. Quality Management and Improvement. Academies Press. Available at https://www.ncbi.nlm.nih.gov
/books/NBK235476/
Institute of Medicine. (2001). Crossing the quality chasm: A new
health system for the 21st century. Washington, DC: National
REFERENCES Academy Press. Retrieved from http://www.nationalacademies
Accreditation Council for Occupational Therapy Education. (2018). .org/hmd/Reports/2001/Crossing-the-Quality-Chasm-A-New
2018 Accreditation Council for Occupational Therapy Education -Health-System-for-the-21st-Century.aspx
(ACOTE) standards and interpretive guide. American Journal Institute of Medicine. (2002). Guidance for the National Healthcare
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi. Disparities Report. Washington, DC: National Academy Press.
org/10.5014/ajot.2018.72S217 Retrieved from https://www.nap.edu/catalog/10512/guidance
Agency for Healthcare Research and Quality. (2017). About the -for-the-national-healthcare-disparities-report
National Quality Strategy. Retrieved from http://www.ahrq.gov Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999).
/workingforquality/about/index.html To err is human: Building a safer health system. Washington, DC:
Berwick, D. (2002). A user’s manual for the IOM’s ‘Quality Chasm’ National Academy Press.
Report. Health Affairs, 21(3), 80–90. Retrieved from https://doi Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Health
.org/10.1377/hlthaff.21.3.80 Policy Perspectives: Advancing the value and quality of occupa-
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple tional therapy in health service delivery. American Journal of Occu-
Aim: Care, health, and cost. Health Affairs, 27, 759–769. pational Therapy, 69(1), 1–7. https://doi.org/10.5014/ajot2015.691001
Donabedian, A. (2005). Evaluating the quality of medical care. Medicare Access and CHIP Reauthorization Act of 2015, Pub. L.
Milbank Quarterly, 83, 691–729. No. 114–10.
Health Insurance Portability and Accountability Act of 1996, Patient Protection and Affordable Care Act, Pub. L. No. 111-148,
Pub. L. 104–191, 110 Stat. 1936. 3502, 124 Stat. 119, 124 (2010).
CHAPTER
Understanding Client-Centered Practice
Shawn Phipps, PhD, OTR/L, FAOTA, and Kathleen T. Foley, PhD, OTR/L, FAOTA 25
LEARNING OBJECTIVES
■ Define client-centered care,
■ Describe the Picker Principles of Client-Centered Care,
■ Identify methods of applying the principles of client-centered care in the occupational therapy process, and
■ Discuss how client-centered practice affects occupational therapy outcomes.

• Client-centered care • Interprofessional team-based care • Picker Principles of
• Client-centered practice • Leisure Client-Centered Care
• Client-centeredness • Occupational profile • Productivity
• Coordinated care • Patient-centered care • Self-care
OVERVIEW therapy practitioners must be as interested in improving percep-

tions of performance as they are in improving functional skills.
S
takeholders of contemporary health care demand The client-centered movement in occupational therapy echoes
patient-centered care—known as client-centered care these recommendations by recognizing the clients’ unique per-
in the occupational therapy profession. Since the ceptions and experiences on occupational performance rather
1900s, the foundation of occupational therapy practice has than objectifying functional observations (Law et al., 2014).
been focused on the client and their occupation-based needs. Baum (2000) also theorizes that a paradigm shift toward
However, the current environment includes more knowl- wellness is taking place in health care. Within the well-
edgeable clients seeking quality health care services that meet ness model, the client is responsible for their own decision-
their needs; it also must meet the demands of payers that re- making and is empowered to participate and influence
ward the most effective and efficient providers with the best their own health. Haas (1993) argues that in rehabilitation,
outcomes and highest client satisfaction. Client-centered care health care professionals are ethically responsible for involv-
is now considered best practice. ing patients and families in the goal-setting process before
Changing occupational therapy practice patterns also pres- treatment begins. Haas advocates for the need for objective
ent an opportunity to refocus on client-centered practice in criteria to determine if goals have been met at the end of
more traditional practice settings influenced by the medical treatment. Haas also argues that patients and families should
model. The requirement for establishing client-identified goals be involved in comparing progress to specific goals.
is also highlighted in the accreditation standards for both The A qualitative study by Wilkins et al. (2001) found that while
Joint Commission (2018) and the Commission on Accredita- occupational therapy practitioners believe in the principles of
tion of Rehabilitation Facilities (CARF) International (2019). client-centered practice, many encounter multiple challenges at
Radomski (2000) points out that patients’ perceptions of self- the level of the system, the practitioner, and the client in develop-
efficacy may be as important to the resumption of productivity ing a client-centered approach. For example, the study found that
as the specifics of occupational therapy treatment. Therefore, health care organizations and administrators sometimes did not
if perceptions of self-efficacy mediate outcomes, occupational support the values of client-centered practice. In addition, some
https://doi.org/10.7139/2019.978-1-56900-592-7.025
243
CHAPTER
Understanding Client-Centered Practice
Shawn Phipps, PhD, OTR/L, FAOTA, and Kathleen T. Foley, PhD, OTR/L, FAOTA 25
LEARNING OBJECTIVES
■ Define client-centered care,
■ Describe the Picker Principles of Client-Centered Care,
■ Identify methods of applying the principles of client-centered care in the occupational therapy process, and
■ Discuss how client-centered practice affects occupational therapy outcomes.

• Client-centered care • Interprofessional team-based care • Picker Principles of
• Client-centered practice • Leisure Client-Centered Care
• Client-centeredness • Occupational profile • Productivity
• Coordinated care • Patient-centered care • Self-care
OVERVIEW therapy practitioners must be as interested in improving percep-

tions of performance as they are in improving functional skills.
S
takeholders of contemporary health care demand The client-centered movement in occupational therapy echoes
patient-centered care—known as client-centered care these recommendations by recognizing the clients’ unique per-
in the occupational therapy profession. Since the ceptions and experiences on occupational performance rather
1900s, the foundation of occupational therapy practice has than objectifying functional observations (Law et al., 2014).
been focused on the client and their occupation-based needs. Baum (2000) also theorizes that a paradigm shift toward
However, the current environment includes more knowl- wellness is taking place in health care. Within the well-
edgeable clients seeking quality health care services that meet ness model, the client is responsible for their own decision-
their needs; it also must meet the demands of payers that re- making and is empowered to participate and influence
ward the most effective and efficient providers with the best their own health. Haas (1993) argues that in rehabilitation,
outcomes and highest client satisfaction. Client-centered care health care professionals are ethically responsible for involv-
is now considered best practice. ing patients and families in the goal-setting process before
Changing occupational therapy practice patterns also pres- treatment begins. Haas advocates for the need for objective
ent an opportunity to refocus on client-centered practice in criteria to determine if goals have been met at the end of
more traditional practice settings influenced by the medical treatment. Haas also argues that patients and families should
model. The requirement for establishing client-identified goals be involved in comparing progress to specific goals.
is also highlighted in the accreditation standards for both The A qualitative study by Wilkins et al. (2001) found that while
Joint Commission (2018) and the Commission on Accredita- occupational therapy practitioners believe in the principles of
tion of Rehabilitation Facilities (CARF) International (2019). client-centered practice, many encounter multiple challenges at
Radomski (2000) points out that patients’ perceptions of self- the level of the system, the practitioner, and the client in develop-
efficacy may be as important to the resumption of productivity ing a client-centered approach. For example, the study found that
as the specifics of occupational therapy treatment. Therefore, health care organizations and administrators sometimes did not
if perceptions of self-efficacy mediate outcomes, occupational support the values of client-centered practice. In addition, some
https://doi.org/10.7139/2019.978-1-56900-592-7.025
243
practitioners had difficulty integrating the concepts of client- implement the most appropriate, mutually agreed-on care
centered practice into everyday clinical practice and finding plan. The benefits desired include a higher quality of care, in-
the time and resources to incorporate client-centered practice creased efficiency, and greater patient satisfaction (Cliff, 2012).
principles. Clients with challenging cognitive or psychological In occupational therapy, the term client refers to the indi-
adjustment impairments after brain injury or stroke also pre- vidual receiving occupational therapy services (American Oc-
sented challenges to effective integration of client-centered prin- cupational Therapy Association [AOTA], 2017b). Historically,
ciples into practice. However, the authors point out that given the client has been a main tenet of the occupational therapy
the ethical considerations and the federal requirements man- profession. The philosophical base of occupational therapy
dated to focus on patient and family goals, it is imperative that practice focuses on the human being and changing occupations
client-centered practice is delivered and that clients feel satisfied (Hooper & Wood, 2014). The human is viewed holistically while
with their ability to engage in occupational performance. interacting with the dynamic environment. It is assumed that
This chapter provides an introduction to the concept of the human learns by experiencing life and can adapt. Quality
client-centered care, an overview of how it has evolved, an ex- of life is determined by the individual and their experiences.
planation of the importance of client and practitioner partici- The core of occupational therapy is the commitment to
pation, and strategies for occupational therapy managers and the individual. The emphasis of client-centered occupational
practitioners to develop client-centered practices. therapy practice was formally introduced by the Canadian
Occupational Therapy Association in 1983 (Law et al., 2014).
Initially, the term client-centeredness reflected the value and
ESSENTIAL CONSIDERATIONS worth of the individual receiving services (Law et al., 1995).
Client-centered care has evolved from the individual as the
Patient-Centered Care vs. Client-Centered Care
focal point to the active relationship between the client and
The Institute of Medicine (2001) identified the provision of the service provider (Maitra & Erway, 2006).
patient-centered care as 1 of 6 aims to improve health care Mroz et al. (2015) compare and contrast client-centered
quality in the 21st century. The committee described patient- care and patient-centered care; see Figure 25.1.
centered care as “respectful of and responsive to individual Value is placed on occupational therapy programs that are
patient preferences, needs, and values and ensuring that evidence based and view the client and family as the most im-
patient values guide all clinical decisions” (p. 6). In medicine, portant component to their recovery (Leland et al., 2014; Phipps
a patient-centered approach to providing care is not focused & Roberts, 2012). Going forward in this chapter, the term client-
on the diagnosis or health condition, but on the collaboration centered care is used in place of patient-centered care to reflect
between the practitioner and the patient to determine and the various contexts of practice beyond the medical model.
FIGURE 25.1. Core components of client-centered and patient-centered care.
Client-Centered Care Patient-Centered Care
Respect for values, beliefs,

experience, and contexts
Collaboration and shared

Access to care
decision making
Hope and
understanding of Coordination of
Open communication and
what is possible care across time
information sharing
and settings
Support for self-management
Inclusion of family
Source. Mroz et al. (2015). Copyright © by the American Occupational Therapy Association. Used with permission.
CHAPTER 25. Understanding Client-Centered Practice 245
Components of Client-Centered Care hallmark of client-centered care. The information should be

appropriate to their health literacy, or comprehension level,
Researchers from Harvard Medical School, on behalf of the
and in verbal as well as written forms. The communication
Picker Institute and the Commonwealth Fund, identified
should include the opportunity for the client to ask questions
7 dimensions for health care centered on the recipient:
and to participate in decision making.
1. Respect for values, preferences, and expressed needs;
2. Coordination and integration of care;
3. Information, communication, and education; For Additional Learning
4. Physical comfort;
5. Emotional support and alleviation of fear and anxiety; For additional learning, see Chapter 47, “Practitioner–Client
6. Involvement of family and friends; and Communication.”
7. Transition and continuity.
In 1987, the dimensions were renamed Picker Principles of
Physical comfort
Patient-Centered Care, and an 8th was added—access to care
(Gerteis et al.,1993). In addition to the most advanced treatments incorporating
the most current technology, clients desire and benefit from
a clean and accessible environment that supports their ability
Respecting values, preferences, and needs to continue their personal hygiene tasks or ADLs. For exam-
The principle of respecting values, preferences, and needs ple, if pain is interfering with a client’s physical comfort, the
emphasizes the relationship and shared decision making occupational therapy practitioner would need to acknowl-
between the practitioner and the client. The practitioner ac- edge and address the client’s pain level so they could modify
tively listens and interacts with the client to gather informa- an activity to either reduce or distract from the pain.
tion on personal history, cultural background, and current
issues. While respecting the client’s privacy, the practitioner Emotional support
asks probing questions with the objective of establishing a
rapport to better understand how the issues are affecting the Some clients want access to pastoral care; chaplains; social
client’s quality of life. The practitioner also encourages the workers; and mental health providers, including occupational
client to ask questions and share their own understanding of therapy practitioners. These professionals can assist clients
the issues and their thoughts on potential intervention meth- in managing anxiety and fears regarding their health con-
ods. Subsequent discussions incorporate the client’s iden- dition, their prognosis, and the financial implications. For
tified values, preferences, and needs into decision making example, an occupational therapy practitioner may provide
(Law et al., 1995). meditation, relaxation, and stress management interventions
to increase emotional support.
Coordination and integration of care Involvement of family and friends

In coordinated care, the client and the practitioners collabo-
Clients identified the need to have their family and friends
rate to identify the preferred interventions. All practitioners
aware of their status and prognosis. They also want them to
are knowledgeable of the client’s issues and the respective
be involved in the decision making regarding their care and
problems each provider is addressing; this includes clin-
regarding the needs of their family and friends as caregivers.
ical services as well as ancillary and support services. This
interprofessional team-based care is provided by an inten-
tionally created group of health professionals who have a Transition and continuity
collective identity and shared responsibility and who work Clients desire information that will help them care for them-
with the client to deliver effective and efficient health care selves when they return home. Care coordination, planning,
(Interprofessional Education Collaborative Expert Panel, and support are necessary to ease transitions between set-
2011). The care is customized to the client, and the team tings (Gibson, 2015; Schefkind, 2015). A breakdown in transi-
members change as the client’s needs change. tion of care may result in adverse effects, including elements
of the care plan not being communicated, missing diagnostic
Information, communication, and education tests, medication errors, and inadequate preparation of the
client and family.
With information readily available via the Internet, clients are
often knowledgeable about their health condition or issues
Access to care
and their intervention options. However, the client must have
access to additional education on the condition and the Clients are sensitive to time between episodes of care. For exam-
methods for self-management and healthy living. The client ple, many clients prefer on-time occupational therapy sessions;
should have timely access to information on prognosis and if there is a wait time, the occupational therapy practitioner
progress throughout their care as well. Communication is the should help the client manage their expectations for time by
providing frequent updates. There should also not be a signifi- PRACTICAL APPLICATIONS IN
cant delay for accessing an occupational therapy appointment. OCCUPATIONAL THERAPY
Client-Centered Practice Client-Centered Occupational Therapy Process
As client-centeredness in occupational therapy evolved, Client-centered care aligns with the domain and process of
Law et al. (1995) modified the concept into a definition of occupational therapy practice as outlined by the professional
client-centered practice: association (AOTA, 2017b). The occupational profile is a
summary of the important occupations, routines, and roles
Client-centered practice is an approach to providing that a client engages in and describes their occupational
occupational therapy, which embraces a philosophy of history, interests, values, and can be effectively used to doc-
respect for, and partnership with, people receiving services. ument the client’s preferences for engagement in occupation.
Client-centered practice recognizes the autonomy of The AOTA Occupational Profile Template (AOTA, 2017a;
individuals, the need for client choice in making decisions see Appendix 25.A) outlines information that occupational
about occupational needs, the strengths clients bring therapy practitioners should obtain from clients—from the
to a therapy encounter, the benefits of client–therapist clients’ perspectives.
partnership and the need to ensure that services are
accessible and fit the context in which a client lives. (p. 253) Client-Centeredness and Interprofessional
The Canadian Model of Occupational Performance Team–Based Care
(CMOP) is also grounded in the philosophical beliefs and val- Actively engaging the interprofessional team using a client-
ues of the client-centered approach to occupational therapy centered approach is also critical for successful client out-
(Pollock, 1993). In this approach, the client’s unique needs comes. Occupational therapy managers, practitioners, and
and abilities are considered, along with the environmental students should model how to actively engage the client in
and social factors that may be affecting the client’s occupa- making decisions, prioritizing the components of their treat-
tional performance. In a qualitative study to determine the ment programs, and documenting the specific methodol-
most important principles of client-centered practice to oc- ogies by which the client is at the center of their own care.
cupational therapy practitioners, Sumsion (2000) categorized Intentional collaboration could include taking the lead at
the most important themes as “joint goal setting and joint presenting the client’s occupational profile during the first
decision making, teamwork, partnership, focus on client’s interprofessional team conference for a client and provid-
needs/problems, client’s choice, client’s priorities, assessment ing updates on the status of their goal attainment in occu-
of need, and empowering [the] client” (p. 307). pational therapy. Leading the client-centered process with
The CMOP views the client as possessing physical, cog- the interprofessional team demonstrates the distinct value of
nitive, psychosocial, and spiritual components (Law et al., occupational therapy and ensures that the team sees the oc-
2014). The person is also viewed as functioning in physical, cupational therapy practitioner as central to client-centered
social, cultural, and institutional environments. Occupation programming (see Case Example 25.1).
is viewed as an interaction of the performance components
and the performance contexts in which the client is function-
Review Questions
ing. In this conceptual model, occupational performance is
classified into 3 general categories: 1. What is an occupational profile?
2. How can occupational therapy managers and practitioners
1. Self-care, which includes personal care, functional
take the lead with enacting a client-centered approach?
mobility, and community management;
3. How can occupational therapy managers effectively en-
2. Productivity, which includes paid or unpaid work, house-
sure that staff are competently using evaluation and
hold management, school, and play; and
treatment methodologies that engage clients and provide
3. Leisure, which includes quiet recreation, active recre-
opportunities for them to own and drive their client-
ation, and socialization.
centered program?
This model views the distinct value of occupational therapy
to be the integrated and balanced approach of these 3 occupa-
tional performance areas using a client-centered approach For Additional Learning
(Phipps & Richardson, 2007).
For additional learning, see Section V, “Interprofessional Practice and
Review Questions Teams:”
■ Chapter 33, “Advocating Occupational Therapy’s Distinct Value
1. What is client-centered practice?
Within Interprofessional Teams”
2. How does the CMOP support the tenets of client-centered ■ Chapter 34, “Supervising Other Disciplines”
practice? ■ Chapter 35, “Building Effective Teams.”
3. What are the Picker Principles of Client-Centered Care?
CASE EXAMPLE 25.1. Lynn: Client-Centered Practice
Lynn, a 22-year-old graduate student, was admitted to the inpatient unit for rehabilitation after a spinal cord injury (SCI) from a diving accident.
An occupational therapist was assigned to the rehabilitation team.
During the medical record review, the occupational therapist documented that Lynn had a C5 incomplete (ASIA B) SCI after accidentally diving
into an above-ground pool. Her past medical history was unremarkable. Lynn was extremely depressed and was not able to fully participate in her
rehabilitation program.
The occupational therapist took the lead on the interprofessional team in activating a client-centered approach to give Lynn opportunities for
decision-making, goal setting, communication preferences, and ensuring physical and emotional support. By asking for Lynn’s input, the therapist
slowly achieved Lynn’s full participation and engagement in her treatment program. Lynn developed a trusting and collaborative relationship with
the occupational therapist.
The occupational therapist took the lead on conducting an occupational profile assessment with Lynn. The occupational profile revealed that
she was a graduate student studying marine biology and enjoyed being in the classroom and laboratory, connecting with friends over the phone
and through social media, and getting dressed up to go out to dinner with family and friends.
Review Questions
1. What Picker Principles of Client-Centered Care reviewed in this chapter were directly applied in Lynn’s case?
2. What is an occupational profile, and what did it reveal in Lynn’s case?
3. How can occupational therapy practitioners take the lead with integrating a client-centered approach with the interprofessional team and
how was this accomplished in Lynn’s case?
SUMMARY American Occupational Therapy Association. (2017a). AOTA oc-

cupational profile template. American Journal of Occupational
Occupational therapy managers have a role in facilitating Therapy, 71, 7112420030. https://doi.org/10.5014/ajot.2017.716S12
client-centered practice. This chapter focused on defining American Occupational Therapy Association. (2017b). Occupa-
the client-centered care approach. The Picker Principles of tional therapy practice framework: Domain and process (3rd ed.).
Client-Centered Care identify respect for values, preferences, American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
and expressed needs; coordination and integration of care; https://doi.org/10.5014/ajot.2014.682006
information, communication, and education; physical com- Baum, C. (2000). Occupation-based practice: Reinventing ourselves
for the new millennium. OT Practice, 5(1), 12–15.
fort; emotional support and alleviation of fear and anxiety;
CARF International. (2019). CARF’s mission, vision, core values,
involvement of family and friends; transition and continuity;
and purposes. Retrieved from http://www.carf.org/AboutCARF
and access to care. The CMOP further articulates the dis- /MissionPurposes.htm/
tinct value of occupational therapy using a client-centered Cliff, B. (2012). The evolution of patient-centered care. Journal
model that supports the client’s unique needs and abilities, of Healthcare Management, 57, 86–88. https://doi.org/10.1097
involves the client in joint goal setting and joint decision /00115514-201203000-00003
making, and views the distinct value of occupational therapy Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L.
to be the integrated and balanced approach of occupational (1993). Through the patient’s eyes: Understanding and promoting
performance. ❖ patient-centered care. San Francisco: Jossey-Bass.
Gibson, R. W. (2015). Health care transition. In M. L. Orentlicher,
S. Schefkind, & R. W. Gibson (Eds.), Transitions across the lifes-
pan: An occupational therapy approach (pp. 175–190). Bethesda,
ACOTE STANDARDS MD: AOTA Press.
This chapter addresses the following ACOTE Standards: Haas, J. (1993). Ethical considerations of goal setting for patient
care in rehabilitation medicine. American Journal of Physical
■ B.4.0. Referral, Screening, Evaluation, and Intervention Plan Medicine and Rehabilitation, 72, 228–232. https://doi.org/10.1097
■ B.4.1. Therapeutic Use of Self /00002060-199308000-00011
■ B.4.3. Occupation-Based Interventions Hooper, B., & Wood, W. (2014). The philosophy of occupational
■ B.5.0. Context of Service Delivery, Leadership, and Man- therapy. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard
agement of Occupational Therapy Services and Spackman’s occupational therapy (12th ed., pp. 35–46).
■ B.5.1. Factors, Policy Issues, and Social Systems. Philadelphia: Lippincott Williams & Wilkins.
Institute of Medicine. (2001). Crossing the quality chasm: A new
health system for the 21st century. Washington, DC: National
Academies Press.
REFERENCES Interprofessional Education Collaborative Expert Panel. (2011).
Accreditation Council for Occupational Therapy Education. (2018). Core competencies for interprofessional collaborative practice:
2018 Accreditation Council for Occupational Therapy Education Report of an expert panel. Washington, DC: Author.
(ACOTE®) standards and interpretive guide. American Journal Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H. J., &
of Occupational Therapy, 72(Suppl. 2), 721241005. https://doi Pollock, N. (2014). Canadian Occupational Performance Measure
.org/10.5014/ajot.2018.72S217 (5th ed.). Ottawa, ON: CAOT Publications ACE.
Law, M., Baptiste, S., & Mills, J. (1995). Client-centered practice: American Journal of Occupational Therapy, 66, 422–429. https://
What does it mean and does it make a difference? Canadian Jour- doi.org/10.5014/ajot.2012.003921
nal of Occupational Therapy, 62, 250–257. https://doi.org/10.1177 Pollock, N. (1993). Client-centered assessment. American Journal of
/000841749506200504 Occupational Therapy, 47, 298–301. https://doi.org/10.5014/ajot
Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2014). .47.4.298
Advancing the value and quality of occupational therapy in health Radomski, M. V. (2000). Self-efficacy: Improving occupational ther-
service delivery. American Journal of Occupational Therapy, 69, apy outcomes by helping patients say “I can.” Physical Disabilities
6901090010. https://doi.org/10.5014/ajot.2015.691001 Special Interest Section Quarterly, 23, 1–3.
Maitra, K. K., & Erway, F. (2006). Perception of client-centered Schefkind, S. (2015). Occupational therapy and transition. In M. L.
practice in occupational therapists and their clients. American Orentlicher, S. Schefkind, & R. W. Gibson (Eds.), Transitions
Journal of Occupational Therapy, 60, 298–310. https://doi.org across the lifespan: An occupational therapy approach (pp. 31–48).
/10.5014/ajot.60.3.298 Bethesda, MD: AOTA Press.
Mroz, T. M., Pitonyak, J. S., Fogelberg, D., & Leland, N. E. (2015). Sumsion, T. (2000). A revised occupational therapy definition of
Client centeredness and health reform: Key issues for occupa- client-centered practice. British Journal of Occupational Therapy,
tional therapy. American Journal of Occupational Therapy, 69, 63, 304–309. https://doi.org/10.1177/030802260006300702
6905090010. https://doi.org/10.5014/ajot.2015.695001 The Joint Commission. (2018). Facts about patient-centered com-
Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for munications. Retrieved from https://www.jointcommission.org
clients with traumatic brain injury and stroke using the Canadian /facts_about_patient-centered_communications/
Occupational Performance Measure. American Journal of Occupa- Wilkins, S., Pollock, N., Rochon, S., & Law, M. (2001). Implement-
tional Therapy, 61, 328–334. https://doi.org/10.5014/ajot.61.3.328 ing client-centered practice: Why is it so difficult to do? Canadian
Phipps, S., & Roberts, P. (2012). Predicting the effects of cere- Journal of Occupational Therapy, 68(2), 70–79. https://doi.org
bral palsy severity on self-care, mobility, and social function. /10.1177/000841740106800203
APPENDIX 25.A. AOTA’S OCCUPATIONAL PROFILE TEMPLATE
AOTA OCCUPATIONAL PROFILE TEMPLATE

“The occupational profile is a summary of a client’s occupational history and experiences, patterns of daily living, interests, values, and needs”
(AOTA, 2014, p. S13). The information is obtained from the client’s perspective through both formal interview techniques and casual conversation
and leads to an individualized, client-centered approach to intervention.
Each item below should be addressed to complete the occupational profile. Page numbers are provided to reference a description in the
Occupational Therapy Practice Framework: Domain and Process, 3 rd Edition (AOTA, 2014).
Why is the client seeking service, and what are the client’s current concerns relative to engaging in occupations and
Reason the client is seeking in daily life activities? (This may include the client’s general health status.)
service and concerns related
to engagement in occupations
In what occupations does the client feel successful, and what barriers are affecting his or her success?
Occupations in which the
client is successful (p. S5)
What are the client’s values and interests?

Client Report
Personal interests
and values (p. S7)
What is the client’s occupational history (i.e., life experiences)?

Occupational history
(i.e., life experiences)
What are the client’s patterns of engagement in occupations, and how have they changed over time? What are
the client’s daily life roles? (Patterns can support or hinder occupational performance.)
Performance patterns
(routines, roles, habits, &
rituals) (p. S8)
What aspects of the client’s environments or contexts does he or she see as:
Supports to Occupational Engagement Barriers to Occupational Engagement
Physical (p. S28)
(e.g., buildings, furniture,
Environment
pets)
Social (p. S28)
(e.g., spouse, friends,
caregivers)
Cultural (p. S28)

(e.g., customs, beliefs)
Personal (p. S28)

(e.g., age, gender, SES,
Context
education)
Temporal (p. S28)
(e.g., stage of life, time,
year)
Virtual (p. S28)
(e.g., chat, email,
remote monitoring)
Consider: occupational performance—improvement and enhancement, prevention, participation, role competence,
health and wellness, quality of life, well-being, and/or occupational justice.
Client Goals
Client’s priorities and

desired targeted outcomes:
(p. S34)
Copyright © 2017, by the American Occupational Therapy Association.

This document is designed to be used in occupational therapy practice and education.
For all other uses, such as republishing or digital hosting and delivery, contact www.copyright.com or copyright@aota.org.
Copyright © 2017 by the American Occupational Therapy Association. Used with permission. Originally published by American
Occupational Therapy Association. (2017). AOTA’s occupational profile template. American Journal of Occupational Therapy, 71, 7112420030.
https://doi.org/10.5014/ajot.2017.716S12
APPENDIX 25.A. AOTA’S OCCUPATIONAL PROFILE TEMPLATE (Cont.)
ADDITIONAL RESOURCES
For a complete description of each component and examples of each, refer to the Occupational Therapy Practice Framework:
Domain and Process, 3rd Edition.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68, S1–S48. https://doi.org/10.5014/ajot.2014.682006
The occupational profile is a requirement of the CPT® occupational therapy evaluation codes as of January 1, 2017.
For more information visit www.aota.org/coding.
Evaluating Occupational Therapy Services and CHAPTER
Client Satisfaction
Shawn Phipps, PhD, OTR/L, FAOTA 26
LEARNING OBJECTIVES
■ Define outcome measure,
■ Discuss the importance of measuring the quality of occupational therapy services,
■ Describe how client satisfaction affects quality, and
■ Discuss why the Canadian Occupational Performance Measure is an evidence-based gold standard for evaluating
occupational therapy services and client satisfaction.

• Canadian Occupational • Outcome measures • Quality measurement
Performance Measure • Process measures • Structural measures
• Client satisfaction
OVERVIEW for Healthcare Research Quality (2015), within the U.S. Depart-
ment of Health and Human Services, identifies 3 classes of mea-
T
o determine whether occupational therapy is meeting cli- sures for determining the quality of health care:
ents’ needs, practitioners must evaluate the quality of ser-
vices. Using evidence-based interventions is the first step 1. Structural measures include the provider’s characteristics,
toward effective treatment. Client reevaluation is included in the such as the setting, physical environment, number of per-
occupational therapy process (American Occupational Therapy sonnel, availability of specialists, and staff-to-client ratios.
Association [AOTA], 2014). Practitioners identify the clients’ 2. Process measures focus on the delivery of care and the
progress toward attaining their goals and may modify the in- adherence to best practice treatment protocols.
tervention methods or goals. By regularly reevaluating, formally 3. Outcome measures determine the impact of the care pro-
or informally, the occupational therapist is essentially evaluating vided on the client’s overall health and wellness.
the effectiveness of the services provided to that client.
Health care reform has heightened awareness about the
The reimbursement environment is changing to be more
importance of the health care consumer’s satisfaction. Reim-
quality focused. Insurers are rewarding those practitioners
bursement initiatives include financial incentives to reward
who provide efficient and effective services that result in
performance—the use of unique, evidence-based interventions
positive outcomes, which must also include consumer satis-
to improve health in a timely manner and at a reduced cost.
faction. This chapter provides an overview of the concept of
Occupational therapy practitioners must demonstrate the pos-
quality and the role of client satisfaction.
itive impact of their services on the client’s overall health and
wellness using quality measures in practice (Leland et al., 2014).
Quality Data
In health care, quality measurement refers to using data to mea- Data to use in measuring quality can come from several
sure the performance of the health care provided. The Agency sources, such as medical records and billing databases.
https://doi.org/10.7139/2019.978-1-56900-592-7.026
251
Evaluating Occupational Therapy Services and CHAPTER
Client Satisfaction
LEARNING OBJECTIVES
■ Define outcome measure,
■ Discuss the importance of measuring the quality of occupational therapy services,
■ Describe how client satisfaction affects quality, and
■ Discuss why the Canadian Occupational Performance Measure is an evidence-based gold standard for evaluating
occupational therapy services and client satisfaction.

• Canadian Occupational • Outcome measures • Quality measurement
Performance Measure • Process measures • Structural measures
• Client satisfaction
OVERVIEW for Healthcare Research Quality (2015), within the U.S. Depart-
ment of Health and Human Services, identifies 3 classes of mea-
T
o determine whether occupational therapy is meeting cli- sures for determining the quality of health care:
ents’ needs, practitioners must evaluate the quality of ser-
vices. Using evidence-based interventions is the first step 1. Structural measures include the provider’s characteristics,
toward effective treatment. Client reevaluation is included in the such as the setting, physical environment, number of per-
occupational therapy process (American Occupational Therapy sonnel, availability of specialists, and staff-to-client ratios.
Association [AOTA], 2014). Practitioners identify the clients’ 2. Process measures focus on the delivery of care and the
progress toward attaining their goals and may modify the in- adherence to best practice treatment protocols.
tervention methods or goals. By regularly reevaluating, formally 3. Outcome measures determine the impact of the care pro-
or informally, the occupational therapist is essentially evaluating vided on the client’s overall health and wellness.
the effectiveness of the services provided to that client.
Health care reform has heightened awareness about the
The reimbursement environment is changing to be more
importance of the health care consumer’s satisfaction. Reim-
quality focused. Insurers are rewarding those practitioners
bursement initiatives include financial incentives to reward
who provide efficient and effective services that result in
performance—the use of unique, evidence-based interventions
positive outcomes, which must also include consumer satis-
to improve health in a timely manner and at a reduced cost.
faction. This chapter provides an overview of the concept of
Occupational therapy practitioners must demonstrate the pos-
quality and the role of client satisfaction.
itive impact of their services on the client’s overall health and
wellness using quality measures in practice (Leland et al., 2014).
Quality Data
In health care, quality measurement refers to using data to mea- Data to use in measuring quality can come from several
sure the performance of the health care provided. The Agency sources, such as medical records and billing databases.
https://doi.org/10.7139/2019.978-1-56900-592-7.026
251
Standardized measures must be used to make accurate com- the practitioner’s unique role in the rehabilitation process by
parisons between providers (Phipps & Roberts, 2012). Most grounding occupational therapy’s assessment and treatment
organizations are now required to have electronic health approaches in an occupation-centered framework.
records, which provides an opportunity for occupational Baum and Law (1997) state that occupational therapy
therapy managers and practitioners to evaluate occupational practitioners must focus on clinical outcomes to be account-
therapy services and measure outcomes by extracting data able to clients and third-party payers. The authors state that
from the electronic medical record rather than utilizing man- “Outcomes are being defined as well-being and quality of life.
ual methods of capturing data. Improved occupational performance is a critical construct in
measuring quality of life” and is measured through instru-
ments such as the COPM (Baum & Law, 1997, p. 284, italics
Client Satisfaction
added; Law et al., 2014).
The Patient Protection and Affordable Care Act (2010; P.L.
111–148) has requirements for health-related outcome mea-
Perception and life satisfaction
sures that include client satisfaction. Satisfaction refers to ex-
pectations that correspond with the actual experiences (Custer Several emerging studies have used the COPM to demonstrate
et al., 2015). Although clients demand the most up-to-date the efficacy of occupational therapy treatment in improving
interventions using the most advanced technology, these fac- life satisfaction for clients with disabilities (Law et al., 2014). In
tors do not have the greatest impact on their satisfaction level. a study by Trombly et al. (1998), the authors found that 16 par-
Client satisfaction is most often related to the client–provider ticipants with traumatic brain injury (TBI) reported signifi-
relationship, their inclusion in the treatment plan, communi- cant changes in self-perceived performance and satisfaction on
cation, and the physical environment (Gerteis et al., 1993). the COPM after outpatient occupational therapy. In Phase II
Maitra and Erway (2006) explored the perceptions of of the same study, Trombly et al. (2002) used a repeated-mea-
occupational therapy practitioners and their adult clients on sures design with 31 people with TBI of mixed chronicity at
client-centered practice related to goal setting. Although the 3 sites in the United States. Eighty-one percent of the goals
practitioners described client-centered practice, the clients identified using the COPM were achieved, and self-ratings for
were unaware of this practice approach. Only some of the performance and satisfaction showed significant changes from
clients perceived themselves as having an active role in the admission to discharge after goal-specific outpatient occupa-
goal-setting process. tional therapy treatment.
Another study found similar results on an inpatient neuro
rehabilitation unit (Bodiam, 1999). The investigator found
COPM
that the 17 participants reported a statistically significant in-
The Canadian Occupational Performance Measure (COPM; crease in perceived performance and satisfaction with ADLs
Law et al., 2014) is an instrument used to identify problem after occupational therapy treatment. Patients with cognitive
areas in occupational performance and establish goals for deficits demonstrated a less marked increase in satisfaction
treatment; provide a rating of the client’s priorities in occu- with performance from admission to discharge.
pational performance; evaluate self-perceived performance An additional research study used a randomized controlled
and satisfaction with those activities the client has identified trial and the COPM to investigate whether receiving home-
as important; and measure outcomes by assessing changes in based occupational therapy services versus conventional out-
a client’s perception of their occupational performance over patient follow-up care improved the participants’ satisfaction
the course of occupational therapy intervention (Law et al., with occupational performance (Gilbertson & Langhorne,
2014). If used as an outcome measure, the administration of 2000; Law et al., 2014). The investigators found that those
the assessment should occur at the beginning of occupational patients who received 6 weeks of home-based occupational
therapy services and at the termination of treatment. therapy reported significantly greater changes in perceived
Pollock (1993) states that the COPM incorporates these performance and satisfaction with ADLs than those patients
client-centered principles during the assessment process by who received conventional outpatient care. This research
helping “engage the client from the beginning of the occupa- highlights the evidence that occupational therapy managers
tional therapy experience and increas[ing] client involvement and administrators can use to advocate for policy and pay-
in the therapeutic process” (p. 299). In addition, the COPM ment changes that prioritize providing occupational therapy
“supports the notion that clients are responsible for their health services in the client’s natural environment. The home and
and their own therapeutic process. It permits the therapist and community provide contextual advantages to evaluating the
client to identify and deal with life span issues and permits the true ability of a client to engage in occupational performance
evolution of the use of purposeful tasks and activities” (p. 299). in real-life environments.
The COPM (Law et al., 2014) addresses a much larger
scope of occupational performance and encourages the oc-
Outcome measure
cupational therapy practitioner to assist clients in identify-
ing occupation-based goals that are relevant to the client’s The COPM is a standardized tool because the administra-
performance in their environment. The COPM also defines tion and scoring of the test are based on specific instructions
CHAPTER 26. Evaluating Occupational Therapy Services and Client Satisfaction 253
and methods (Law et al., 2014). The assessment includes a client-centered, occupation-based, and evidence-based occu-
semi-structured interview format and structured scoring pational therapy services throughout the continuum of care
method. The assessment was also designed as an outcome and in a variety of occupational therapy practice settings.
measure to detect perceived changes in occupational per-
formance over time. However, Law et al. (2014) state that Review Questions
because the client is compared to themselves over time, the
administration of the test is individualized. The COPM was 1. What are the 3 classes of health care quality measures?
designed to meet the client’s individual needs by having some 2. Why is there an emphasis on value and quality in health
inherent flexibility and is not norm referenced because occu- care?
pational performance has been conceptualized as individu- 3. How is the COPM used to measure outcomes of occupa-
ally determined. tional therapy and client satisfaction?
In a study designed to evaluate the community utility of
the COPM (Law et al., 2014), 75% of patients surveyed re- PRACTICAL APPLICATIONS IN
ported that they found the COPM useful in identifying and
rating their occupational performance problem areas, and
100% reported no problems in understanding the COPM In measuring outcomes, standardized measures must be
(McColl et al., 2000). used. Outcome measures should focus on the distinct value
The COPM (Law et al., 2014) has demonstrated accept- provided by occupational therapy (Leland et al., 2014).
able test–retest and interrater reliability in various studies The outcomes measured should be related to occupational
conducted with adult clients. One early study found that engagement and performance level to reflect the contribu-
the Interclass Correlation Coefficient (ICC) for test–retest tion of occupational therapy. A stronger measure will link
reliability was .63 for ratings of performance and .84 for rat- to health, well-being, and quality of life. The measure should
ings of satisfaction with adult clients (Sanford et al., 1994). be valid and reliable. It should be appropriate for the popu-
In addition, Bosch (1995) found test–retest reliability to be lation served and measure what the intervention is focused
.80 for performance scores and .89 for satisfaction scores on. The instrument should be sensitive to change to demon-
with adult participants. Bosch also found the interrater re- strate improvement. An outcome measurement that enables
liability to be .41–.56 for the performance scores and .71 for comparison to similar providers of that group shows a prac-
the satisfaction scores. titioner’s effectiveness.
The COPM (Law et al., 2014) has also demonstrated ac- The occupational therapy process supports this focus on
ceptable content, criterion, and construct validity. Content the client, beginning with the initial evaluation and devel-
validity is supported by the process in which the assessment oping an occupational profile of the client (Tickle-Degnen,
tool was developed, with its emphasis on occupational per- 2002). In response to revised Medicare B reimbursement,
formance in self-care, productivity, and leisure; the impor- AOTA (2017) developed a template to support practitioners in
tance of the environment, social roles, and developmental developing and documenting a comprehensive occupational
level; its client-centeredness; and its measurement of both a profile for each client. Information, gathered at admission, is
performance and a satisfaction dimension. The COPM has based on the individual’s perception of their need for occu-
also come to represent a national and international standard pational therapy services, environment, context, and goals
for measurement in research, practice, and education in oc- based on their past, current, and desired occupational perfor-
cupational therapy. It has achieved international recognition mance. Care preferences, personal values, and cultural char-
and has been translated into more than 8 languages with dis- acteristics should be reflected in this profile. Client-identified
tribution agreements in countries around the world. goals are then obtained and prioritized using the COPM
Construct validity has been established through positive (Law et al., 2014) by rating importance on a scale of 1–10 and
correlations in scoring with other assessments that are theo- the client’s self-perceived performance and satisfaction on a
retically related, including the Satisfaction with Performance scale of 1–10. Outcomes are then measured at the conclusion
Scaled Questionnaire (Yerxa et al., 1988), the Reintegration to of the occupational therapy program to determine whether
Normal Living Index (Wood-Dauphinee et al., 1988), the Life the client’s perceptions of their performance and satisfaction
Satisfaction Scale (Michalos, 1980), and the Perceived Prob- improved as a result of the occupational therapy program.
lem Check List (McColl et al., 2000). In evaluating client-centered occupational therapy pro-
Criterion validity was supported through a study that grams, managers and practitioners should be utilizing data-
compared problems reported on the COPM (Law et al., 2014) driven methods of assessing whether their client population is
and problems reported spontaneously in response to the fol- improving and are reporting higher levels of performance and
lowing question: “What are the 5 most important problems satisfaction with ADLs. Data can be extracted routinely from
that you experience with daily living?” (McColl et al., 2000, the electronic health record and in hospital organizations; in-
p. 26). Results showed that 53% of respondents named at least formation technology personnel can assist with generating
1 identical problem spontaneously and on the COPM. Re- weekly, monthly, and quarterly reports. Managers should look
search has effectively demonstrated evidence for more than for opportunities to implement quality improvement initiatives
2 decades that the COPM is the gold standard for evaluating and introduce ongoing training opportunities for occupational
CASE EXAMPLE 26.1. Client-Centered Evaluation
In Case Example 25.1 from Chapter 25, “Client-Centered Care,” the occupational therapist used the COPM (Law et al., 2014) to collect data and
develop Lynn’s occupational profile. The occupational therapist sought input from the client, which reflects the Picker principle on respect.
The results reflected the value Lynn placed on her occupation as a graduate student and her need to continue that journey. Her goals on the COPM
were to return to school, be able to type on an adapted laptop, use her smartphone, and dress with only a little assistance from her caregiver.
The intervention planning process supports client-centered care. Evaluation data are analyzed to identify strengths and prioritize the issues;
intervention methods are then identified in collaboration with the client (Tickle-Degnen, 2002). In this case, the occupational therapist presented
the evaluation results to Lynn, discussed them with her, and collaborated with her to create occupation-based goals. At this point, the occupational
therapist discussed potential intervention methods and the respective evidence. The therapist clearly communicated with Lynn on her status and
educated her on treatment options; this is aligns with the Picker communication principle.
At the end of Lynn’s occupational therapy program, the occupational therapy practitioner had Lynn reassess her self-perceived level of
performance and satisfaction on the COPM (Law et al., 2014); she indicated a clinically significant change in both performance and satisfaction,
indicated by an increase of 2 or more points over her COPM scores at admission for each activity.
Review Questions
1. What is the COPM, and how did the occupational therapy practitioner utilize this evaluation tool to obtain Lynn’s goals for occupational therapy?
2. What does the occupational therapy evaluation and intervention process unfold in a client-centered framework and how did this apply
in Lynn’s case?
3. How was the COPM utilized as an occupational therapy outcome measure in Lynn’s case?
therapy practitioners to enhance their effectiveness when a cli- ACOTE STANDARDS

ent population shows an overall decrease in performance and
satisfaction with occupational performance. This chapter addresses the following ACOTE Standards:
■ B.4.0. Referral, Screening, Evaluation, and Intervention
Review Questions Plan
■ B.4.1. Therapeutic Use of Self
1. How should client-centered outcomes be measured? ■ B.5.0. Context of Service Delivery, Leadership, and
2. How does the COPM measure outcomes? Management of Occupational Therapy Services
3. How can occupational therapy managers monitor whether ■ B.5.1. Factors, Policy Issues, and Social Systems.
a population of patients is improving due to their client-
centered occupational therapy program?
REFERENCES
For Additional Learning Accreditation Council for Occupational Therapy Education. (2018).
For additional learning, see Chapter 25, “Understanding Client- (ACOTE) standards and interpretive guide. American Journal
Centered Practice,” including Appendix 25.A, “AOTA’s Occupational of Occupational Therapy, 72(Suppl. 2). https://doi.org/10.5014
Profile Template.” /ajot.2018.72S217
Agency for Healthcare Research and Quality. (2015). Types of health care
quality measures. Retrieved from http://www.ahrq.gov/professionals
SUMMARY /quality-patient-safety/talkingquality/create/types.html
American Occupational Therapy Association. (2014). Occu-
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Patient Protection and Affordable Care Act. Pub. L. No. 111–148, tionnaire (SPSQ). American Journal of Occupational Therapy, 42,
3502. 124 Stat. 119, 124 (2010). 215–221. https://doi.org/10.5014/ajot.42.4.215
Measuring Outcomes CHAPTER
Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH ® Certified Instructor, and
Jess Anthony Holguin, OTD, OT/L 27
LEARNING OBJECTIVES
■ Discuss the importance of measuring outcomes in health care;
■ Discuss approaches to staying current with policy and industry-related literature, as well as incorporating findings
into outcomes data initiatives;
■ Explain how measuring outcomes contributes to quality of care;
■ Describe considerations affecting outcome measure selection for occupational therapy practitioners;
■ Describe 5 types of health care quality measures;
■ Describe the pros and cons of existing outcome measurement tools;
■ Describe pragmatic considerations affecting outcome measure selection;
■ Discuss occupational therapy’s role in measuring outcomes; and
■ Discuss how occupational therapy practitioners can implement the process of measuring outcomes in their daily practice.

• AOTA National Quality Strategy • Payers • Regulatory bodies
• Global scale impact • Quality • Standardized assessments
• Habits of knowledge acquisition • Quality benchmarking • Value
• Health outcomes
OVERVIEW care service delivery (Porter & Teisberg, 2006). Agencies that
shape reimbursement policy, such as the Centers for Medicare
A
central issue shaping contemporary health care prac- and Medicaid Services (CMS), have bolstered this trend through
tice models, including the role of allied health profes- the introduction of value-based programs and payment
sions such as occupational therapy, is the link between methodologies (CMS, 2017b). Moreover, health care consumers
value metrics and reimbursement for services rendered have grown increasingly savvy and are beginning to demand
(Micklos & Sweany, 2017). Overall, health care spending in greater value for their health care dollar (Barasz & Ubel, 2018).
the United States, per capita, far exceeds that of other coun- To remain viable, both health care systems and smaller scale
tries with similar or superior life expectancy and health out- providers must deliver more affordable care that yields superior
comes (i.e., outcomes that encompass physical, mental, and health-focused outcomes. As such, providers assume responsi-
social well-being, and not merely the absence of disease or bility for service provision as well as value-tracking initiatives
infirmity; World Health Organization [WHO], 2018). This linked to outcomes data. Importantly, there is precedent for
trend has been widely recognized as unsustainable and re- occupational therapy providing unique quantifiable value in
sponsible for prompting reactionary shifts in service reim- challenging practice areas. For example, Rogers et al. (2017),
bursement practices (Conway, 2017). in their study involving patients with heart failure, pneumo-
Today there is a greater focus on value, defined as the health nia, and acute myocardial infarction, found that occupational
outcomes achieved per dollar spent, achieved through health therapy was “the only spending category where additional
https://doi.org/10.7139/2019.978-1-56900-592-7.027
257
Measuring Outcomes CHAPTER
Phuong Nguyen, OTD, OTR/L, CLT, Neuro–IFRAH ® Certified Instructor, and
Jess Anthony Holguin, OTD, OT/L 27
LEARNING OBJECTIVES
■ Discuss the importance of measuring outcomes in health care;
■ Discuss approaches to staying current with policy and industry-related literature, as well as incorporating findings
into outcomes data initiatives;
■ Explain how measuring outcomes contributes to quality of care;
■ Describe considerations affecting outcome measure selection for occupational therapy practitioners;
■ Describe 5 types of health care quality measures;
■ Describe the pros and cons of existing outcome measurement tools;
■ Describe pragmatic considerations affecting outcome measure selection;
■ Discuss occupational therapy’s role in measuring outcomes; and
■ Discuss how occupational therapy practitioners can implement the process of measuring outcomes in their daily practice.

• AOTA National Quality Strategy • Payers • Regulatory bodies
• Global scale impact • Quality • Standardized assessments
• Habits of knowledge acquisition • Quality benchmarking • Value
• Health outcomes
OVERVIEW care service delivery (Porter & Teisberg, 2006). Agencies that
shape reimbursement policy, such as the Centers for Medicare
A
central issue shaping contemporary health care prac- and Medicaid Services (CMS), have bolstered this trend through
tice models, including the role of allied health profes- the introduction of value-based programs and payment
sions such as occupational therapy, is the link between methodologies (CMS, 2017b). Moreover, health care consumers
value metrics and reimbursement for services rendered have grown increasingly savvy and are beginning to demand
(Micklos & Sweany, 2017). Overall, health care spending in greater value for their health care dollar (Barasz & Ubel, 2018).
the United States, per capita, far exceeds that of other coun- To remain viable, both health care systems and smaller scale
tries with similar or superior life expectancy and health out- providers must deliver more affordable care that yields superior
comes (i.e., outcomes that encompass physical, mental, and health-focused outcomes. As such, providers assume responsi-
social well-being, and not merely the absence of disease or bility for service provision as well as value-tracking initiatives
infirmity; World Health Organization [WHO], 2018). This linked to outcomes data. Importantly, there is precedent for
trend has been widely recognized as unsustainable and re- occupational therapy providing unique quantifiable value in
sponsible for prompting reactionary shifts in service reim- challenging practice areas. For example, Rogers et al. (2017),
bursement practices (Conway, 2017). in their study involving patients with heart failure, pneumo-
Today there is a greater focus on value, defined as the health nia, and acute myocardial infarction, found that occupational
outcomes achieved per dollar spent, achieved through health therapy was “the only spending category where additional
https://doi.org/10.7139/2019.978-1-56900-592-7.027
257
spending has a statistically significant association with lower across geographical, socioeconomic, and political bound-
readmission rates” (p. 668). aries bolsters large-scale collaborative learning.
In addition to providing foundational background on 2. Improved performance: Improving services can hinge on
measuring outcomes, this chapter discusses the challenge using one’s own outcomes data to inform responsive, de-
from 2 overarching perspectives. The first examines the in- sirable changes.
terrelationship between outcome-focused policies and the 3. Demonstration of superior outcomes: Outcomes must be
provision of quality care. The second delves into strategic more comprehensive than merely tracking mortality or
and pragmatic use of outcome measures in daily practice. life expectancy. Using universal language, occupational
Together, they provide the rationale behind endorsing robust therapy can more effectively communicate results from a
outcomes metrics, clarify the manner in which gathered data broader perspective with regard to demonstrating supe-
are strategically used, and specify how such efforts are consis- rior outcomes. Foregrounding quality of life, functional
tent with the central tenets of occupational therapy. capacity, and occupational performance, occupational
therapy can transcend traditionally reported foci and tar-
ESSENTIAL CONSIDERATIONS get consumer-defined meaningful change as value-based
metrics.
Why Measure Outcomes? 4. Preparation for value-based payment: Value-based pay-
Recognizing the link between the profession’s viability and its ment programs are already in place for many health
capacity for adaptation within the contemporary health care care sectors, with public and private payers increasingly
landscape, the American Occupational Therapy Association following suit. In this light, it is imperative that occupa-
(AOTA) developed the 2017 AOTA National Quality Strategy tional therapy works to clearly demonstrate the capacity
(NQS), which aims to bolster treatment-derived value by ad- to efficiently deliver timely services to target populations.
dressing gaps in clinical practice, as well as harnessing general
outcomes data and consumer-defined value metrics to measure Outcome Measures and Quality of Care
and track improvement (Furniss, 2017). The NQS prioritizes the
Quality can be defined as the degree to which health care ser-
integration of consumer-derived data and supports occupational
vices increases the likelihood of desired health outcomes, as
therapy practitioners in their use. Successful implementation of
measured by structural, process, outcome, patient experience,
the NQS will strengthen the profession’s ability to more clearly
and composite measures. Despite quality care being a central
articulate its positive, quantifiable influence on value-based
concern for health care providers, contemporary approaches
health care metrics. Failure, in this regard, risks occupational
to measurement lack uniformity. The Agency for Healthcare
therapy being perceived as an irrelevant service provider.
Research and Quality (2011) of the U.S. Department of Health
Beyond an objectively circumscribed rationale for focusing
and Human Services and the National Quality Forum (NQF;
on outcomes data, occupational therapy’s core principles lend
n.d.), a not-for-profit organization, created to develop and im-
philosophical support for their inclusion. From the mission
plement a national strategy for health care quality measure-
espoused by the founders of occupational therapy (Gordon,
ments and reporting, endorse 5 specific types of measures:
2009) to the current Occupational Therapy Code of Ethics
(AOTA, 2015) and the recently published guiding principles 1. Structural: Targets quality measurement via providers’
for the future of occupational therapy practice (i.e., Vision capacity, systems, and processes
2025; AOTA, 2017), there is ample support for a deeper con- 2. Process: Targets how providers specifically maintain or
sideration of this issue. In sum, in addition to focusing on improve health outcomes
individual care, occupational therapy clearly articulates the 3. Outcome: Focuses on the impact services have on patients’
obligation to contribute more broadly within the scientific health status
community while simultaneously honing services that ben- 4. Patient experience measures: Records patients’ perspectives
efit humanity at large (Blum, 1926). Properly harnessed, the on the care they received
depth and breadth of occupational therapy’s unique, ser- 5. Composite: Combines multiple metrics for a comprehen-
vice-driven practice framework (AOTA, 2014) can have a sig- sive examination of overall care.
nificant impact on the overall health of the populace.
Outcome measures have historically been considered the
The International Consortium for Health Outcomes Mea-
“gold standard” through which quality of health care services
surement (ICHOM), an influential nonprofit organization
can be determined. Toward this end, the NQF has devoted
that is separate from occupational therapy, seeks “to trans-
resources to identify and develop risk-adjusted quality and
form health care systems worldwide by measuring and re-
performance measures. However, risk adjustment methods,
porting patient outcomes in a standardized way” (ICHOM,
used to reduce population-specific confounding factors in
n.d.-c, para. 1; n.d.-d) and outlines 4 benefits associated with
outcomes data, are still evolving. As such, payers and gov-
measuring outcomes:
ernment entities have historically relied on structural and
1. Learning: Learning can occur at a local and global scale. process measures to quantify quality of care. Consider that
Individuals and groups can learn from their own outcomes of the 1,958 quality indicators within the National Quality
to improve the services they provide. Sharing outcomes Measures Clearinghouse, fewer than 9% are actual types of
CHAPTER 27. Measuring Outcomes 259
FIGURE 27.1. Categories of quality measures listed in the National Quality Measures Clearinghouse.
Total
2000 1958
Other Not true outcomes or duplicate
79 measures (e.g., blood pressure
Outcomes control)
218
No. of Quality Measures
1500 Patient 5 Other (e.g., inpatient falls, delirium)

experience
427 13 Mortality
32 Patient-reported health status

1000
43 Adverse events
Process
1181 46 Clinician-reported health status
500
NQMC
Outcome
Measures
0
All NQMC
Measures
Source. From “Standardizing Patient Outcomes Measurement” by M. Porter et al., 2016, New England Journal of Medicine, 374, p. 504. Used with permission.
outcome measures (Porter et al., 2016; see Figure 27.1). Process currently used by key stakeholders (e.g., provider organiza-
measures, however, do not differentiate between providers, tions, specialty societies, payers, countries, individual occu-
inherently incentivize their use, or offer guidance for im- pational therapy practitioners). Ultimately, this hinders efforts
proved health care quality. Conversely, quantified outcomes targeting the use of uniform terminology among health care
more intuitively bolster efforts addressing perceived value providers, undermines consensus regarding essential psycho-
and incorporation of quality care metrics. metric properties, and confounds attempts at rigorous out-
comes comparisons.
Measuring Outcomes: The Challenge To improve outcomes on a national and global scale, collab-
orative efforts, such as the previously discussed ICHOM, work
Myriad factors confound the collection of high-quality data to ensure that pertinent knowledge is developed and shared.
to capture positive health outcomes. First and foremost, out- Drawing from the expertise of multidisciplinary, international
come measures often incorrectly and inadequately quantify collaborators, ICHOM provides condition-specific standard
impact of various service lines on consumer health status. sets of outcome measures. Derived from best-available re-
The sophistication required to develop meaningful and sen- search, information from patient surveys, advisory groups,
sitive outcome measures has prompted specialty groups to and experts in the field, these sets facilitate prudent selection
become the primary drivers of next-generation instrument of assessment tools (ICHOM, n.d.-a.; see Figure 27.2). Tools
development. According to Porter et al. (2016), this has led of this sort reflect the intent of evidence-based practice as set
to development of measures that cater to the needs of select forth in the seminal work by Sackett et al. (1996). In the more
stakeholder subgroups, such as physicians, by offering mea- than 2 decades following its publication, the evidence-based
sures that they can reliably control. Moreover, this has rein- practice has become widely recognized for its iterative contri-
forced the use of narrowly focused, although objective, lab- bution to state-of-the-art, patient-relevant care.
derived values, and displacing measures that otherwise reflect
patient concerns over compromised functional capacities.
Measuring Outcomes: The Pragmatics
From a different perspective, Porter et al. (2016) also cau-
tioned against the incessant tweaking of existing measures In day-to-day practice, occupational therapy practitioners
or the unnecessary creation of new instruments. Such efforts and organizational leadership must assume responsibility for
contribute to the varied patchwork of inconsistent metrics selecting relevant target outcomes and practical approaches
FIGURE 27.2. ICHOM standard set for dementia.
1 Includes anxiety, depression, behavior, apathy,

and psychosis. Tracked via the Neuropsychiatric
Inventory (NPI).
2 Includes memory, orientation, verbal fluency,

and executive function. Tracked via the Montreal
Cognitive Assessment (MoCA).
3 Includes community affairs and relationships.
4 Includes instrumental and basic activities of

daily living. Tracked via the Bristol Activity Daily
Living Scale (BADLS).
5 Includes finance, enjoyment of activities,

pain, and side effects of medication. Tracked via
the Quality of Life-AD (QOL-AD) and Quality of
Wellbeing Scale-Self Administered (QWB-SA).
6 Tracked via the EuroQol-5D (EQ-5D).
7 Tracked via the Clinical Dementia Rating (CDR).
Source. From “Standard Sets: Dementia” by International Consortium for Health Outcomes Measurement, 2016. Retrieved from http://www.ichom.org/medical-conditions
/dementia. Used with permission.
to measurement. Choices should be scrutinized from the as mortality rates, general complications, and health care–
purview of clinical and institutional viability, and occupa- associated infections. More refined performance-related
tional therapy practitioners and leaders must recognize that outcome measures are available to address overall process,
every action has potentially unforeseen consequences. Fur- efficiency, cost reduction, and patient experience and safety
thermore, outcome measurement practices must yield suffi- (CMS, 2017a).
cient value to an organization to justify startup and mainte- This type of approach to assessing quality of care reflects
nance costs. Taking a broader view, organizations must also organizational awareness that poor performance metrics
consider perspectives of state- or national-level accrediting often have punitive monetary implications. For example, if
bodies, as their conceptual or operational vetting can signifi- patients admitted to an inpatient acute care facility develop
cantly shape policy formulation. Next, we discuss pragmatic a hospital-acquired Stage III–IV pressure injury, the hospi-
considerations with an eye toward payers, regulatory bodies, tal will be responsible for additional costs of care (Meddings
quality benchmarking, and global scale impact. et al., 2015).
Payers Regulatory bodies

Payers are entities that pay providers for health care services. Health care organizations face institution-specific require-
These can include individuals, insurance carriers, employers, ments mandated by regulatory bodies that are charged with
and the government. As health care remains a business in providing public or governmental oversight, guidance, and
the United States and is therefore driven by financial con- control over health care organizations, such as state depart-
siderations, the likelihood that a chosen outcome metric ments of public health and The Joint Commission accredita-
will influence reimbursement is of prime importance. For tion body. For example, The Joint Commission (2018) requires
example, consider that policies and practices clearly reflect accredited behavioral health care programs to iteratively
evaluation-relevant standards of performance for institu- use outcomes data in tracking responses to care informing
tions participating in the Hospital Value-Based Purchasing service provision. Meeting accrediting body requirements is
Program. Foundational metrics include concrete data, such a crucial institution-level concern within the current health
care environment. Failure to maintain documentation of Habits of knowledge acquisition. A final point to con-
good standing is equated with subpar dedication to quality sider regarding the selection and use of outcomes measures is
and patient safety. Further supporting the value of compli- the inherent challenge of staying current with service delivery
ance, accreditation can affect a facility’s or organization’s policies and trends. Habits of knowledge acquisition are rou-
ability to participate in and receive reimbursement from both tine activities that enhance one’s understanding and hone the
federal and private payers. precision with which insight is obtained. Given the ever-shift-
ing health care reimbursement landscape, managers must
Quality benchmarking prioritize the regular allocation of time to research key issues
and cultivate effective means for translating knowledge into
Quality benchmarking involves voluntary, active collabora- action plans. To bolster their insight on topics influencing out-
tions targeting use of optimally efficient indicators, practices, comes and reimbursement issues, managers are encouraged
and costs. to consult the government-sponsored Institute for Healthcare
Improvement and the National Patient Safety Foundation re-
Performance improvement collectives. In addition source list (https://bit.ly/2sCBNV8). This site lists 55 resourc-
to the aforementioned regulatory and payer-driven actions, es, organized according to categorical subdivisions of federal
individual health care providers and institutions often join government, health care resources, medical organizations,
performance improvement collectives. Membership within medication safety and pharmaceutical organizations, patient
such organizations provides access to pooled-data analytics, education, advocacy and support, and quality of care organi-
strategic research, and advocacy resources. A common, basic zations. The degree to which managers incorporate such hab-
application of the data is to select outcome measures target- its into their routine ultimately shapes their capacity to both
ing robust comparisons among peer providers. predict and respond to change in a timely, agile manner.
Within the United States, Vizient is one of the larg-
est member-driven health care performance improvement Global scale impact
groups. Its membership includes academic medical centers,
A global scale impact is a broadly resonating, potentially
pediatric facilities, community hospitals, integrated health
long-lasting effect of targeted initiatives. As an industry, health
delivery networks, and non–acute health care providers
care has profound, multilevel effects on the health, well-being,
(Vizient, n.d.). Membership grants access to benchmark
and financial status of individuals and nations alike. There-
data from key CMS-driven datasets, such as the Consumer
fore, energies invested in improving key performance aspects
Assessment of Healthcare Providers and Systems (CAHPS),
of care should be thoughtfully considered for their potentially
the Hospital CAHPS, and the Clinician and Group CAHPS.
long-reaching, global effects. One important move that will
Access to these datasets can significantly bolster efforts tar-
have a notable impact is greater use of universal terminology,
geting internal performance-improvement initiatives.
which can enhance contributions to science for the sake of
humanity. Developing more effective communication would
Customized and emerging performance batteries. facilitate the use of outcome measures that are more likely to
Beyond participating in established performance improvement resonate with health care providers both nationally and glob-
collectives, facilities should work to quantify the value of oc- ally. With the use of more meaningful and consistent charac-
cupational therapy intervention in novel ways. For example, terizations, outcome measures would have the advantage of
managers can develop customized clinical assessment batteries building on common ground. In doing so, initiatives would
to highlight unique and valuable aspects of service. They can more effectively achieve the lofty goal of transcending arti-
draw from the National Institutes of Health (NIH)-developed facts born of geographical boundaries and socioeconomic sta-
Patient Reported Outcomes Measurement Information System tus, as well as political, cultural, and religious beliefs.
(PROMIS), a free-access repository of standardized, psycho- To inform the rationale for pursuing such a goal, one
metrically robust assessments (NIH, n.d.). should consider what people deem to be meaningful in terms
From a larger organizational perspective, managers of health outcomes. Consistent with this notion, ICHOM has
can also lobby for the early institutional adoption of next- adopted a functional, holistic, and international perspective
generation, government-sponsored metrics. One such tool is toward identifying consumer-defined meaningful change.
the CMS continuity assessment record evaluation (CARE). ICHOM’s philosophy is to conceptualize ideal health out-
Developed in accordance with Congress’s Improving Medi- comes as “results people care most about when seeking treat-
care Post-Acute Transformation Act of 2014, CARE metrics ment, including functional improvement and the ability to live
determine Medicare reimbursement rates for post–acute normal, productive lives” (ICHOM, n.d.-b, “What Is a Health
care facilities. This evolution in refined functional metrics Outcome?”). Such a definition aligns well with the mission
has far-reaching implications as private payers also model and vision of occupational therapy. AOTA’s Vision 2025 is
CMS reimbursement guidelines. Moving forward, this re-
quirement may potentiate an unprecedented shift away from Occupational therapy maximizes health, well-being, and
historically entrenched measures such as the Functional quality of life for all people, populations, and communities
Independence Measure (FIM™; Uniform Data System for through effective solutions that facilitate participation in
Medical Rehabilitation, 1997). everyday living. (AOTA, 2017, p. 1)
Rationales driving selection of outcome measures must go ■ Sensitive and responsive enough to capture meaning-
beyond short-sighted considerations, such as evaluator prefer- ful change, and
ence, interest, or degree to which one believes the outcomes ■ Able to measure the impact of the intervention on the
are subject to one’s control. Ideally, selection logic derives from specified outcomes.
a complex interplay of pragmatic, philosophical, theoretical, 3. Use of measurement approaches that reduce confounding
and scientific considerations. This symbiotic collection of per- factors
spectives can bolster efforts to demonstrate value while help- ■ Standardized procedures
ing reinforce a universal language for collective growth and ■ Focus on methodology and experimental design.
improvement. Once these issues have been considered, health 4. Enhanced data collection, interpretation, and analysis
care providers and leaders will be more effectively positioned 5. Effective dissemination of results to meet objectives.
to measure outcomes and meet these 5 overarching objectives.
1. Identification of specific outcomes to be measured
Review Questions
■ Relevant to patients, consumers, payers, scientists,
scholars, and others. 1. The concept of value in health care is defined as
■ Health status, quality of life, health-related quality of a. The greatest number of services rendered per dollar spent.
life (Patrick, 1998). b. Health outcomes achieved per dollar spent.
2. Selection of assessment tools and outcome measures that are c. Patient and client perceptions of the efficacy of health
■ Standardized, reliable, and valid (see Table 27.1, “Mea- care.
surement Properties for Health Outcomes”), d. All of the above.
TABLE 27.1 Measurement Properties for Health Outcomes
Measurement of health outcomes is a highly complex task due to the varying methods of qualifying and quantifying the construct of interest.
Measurement properties, nevertheless, are useful in helping occupational therapy practitioners evaluate whether the assessment tools and
outcome measures they are considering will provide useful, trustworthy, and clinically meaningful information.
TERM DESCRIPTION
Reliability The degree to which an instrument can produce consistent results, on different occasions and across
(Bowling, 2001; CDC, 2016; different contexts.
COSMIN, n.d.; Magasi et al.,
2017)
Interrater reliability Consistent results across different occupational therapy practitioners or raters.
Test–retest reliability Consistent results across repeated tests or measures in an individual who has not changed.
Intrarater reliability Consistent results produced by a single rater over multiple tests.
Internal consistency Consistent results across items of measure; degree of interrelatedness among items.
Validity Validity is the degree to which an instrument measures the construct it intends to measure.
(CDC, 2016; Scientific Advisory
Committee of the Medical
Outcomes Trust, 2002)
Content validity Content of measure covers and comprehensively samples all aspects or elements of
attribute being measured.
Construct validity “Degree to which scores are consistent with hypotheses with regard to internal
relationships, relationships to scores of other instruments, or differences between
relevant groups” (Magasi et al., 2017, p. 33). Aspects of construct validity include
structural validity, hypothesis testing, and cross-cultural validity.
Criterion validity Degree to which scores on instrument are adequate reflection of a “gold standard”
measure, for situations where there is an agreed upon gold standard assessment
for the construct being measured.
Sensitivity Sensitivity to change of an instrument is the ability to measure change in a state, regardless of whether it is
(Liang, 2000; Liang et al., 2002) relevant or meaningful to the decision maker. It is a necessary condition for responsiveness.
Responsiveness Responsiveness is an instrument’s ability to detect and measure a meaningful or clinically important change in
(CDC, 2016; Magasi et al., 2017; a clinical state over time. It can be considered a long-term construct validity.
Liang, 2000; Liang et al., 2002)
Note. CDC = Centers for Disease Control and Prevention.
2. As one of the metrics to measure quality of care provided, given target outcomes. Thoughtfully considered, these com-
an acute care hospital decides to track the amount of time bined perspectives may be more effectively used to bolster con-
that passes from a physician placing a discharge order to sumer-centric occupational performance metrics. Achieving
when a patient actually leaves. This type of metric is a this balance is difficult, however, as managers are tasked with
a. Structural measure. simultaneously operationalizing organizational priorities and
b. Process measure. representing the perspectives and needs of their direct reports.
c. Outcome measure.
d. Patient experience measure. Payers
3. What are some pragmatic considerations associated with
measuring outcomes for a health care system or institution? Reimbursement drives practice. To more clearly understand
the influential perspective of payers in this process, it helps to
consider their overarching priorities related to occupational
PRACTICAL APPLICATIONS IN therapy services. For individuals working in postacute physi-
OCCUPATIONAL THERAPY cal rehabilitation settings (e.g., acute inpatient rehabilitation,
skilled nursing, subacute, long-term care facilities), payers
Remaining Authentic to Occupational Therapy value data supporting an intervention’s ability to enhance
Philosophy and Central Tenets ADL performance. Within these settings, the FIM is currently
The core of occupational therapy intervention derives from the predominant instrument for comparison of rehabilitation
theoretical and practical aspects associated with occupa- outcomes (Uniform Data System for Medical Rehabilitation,
tional performance. Occupational performance is defined as 1997). Without documentation and tracking gains on FIM
participating in “occupations that satisfy life needs” (Law & metrics, facilities risk being denied reimbursement by fed-
Baum, 2017, p. 4); this concept is featured prominently in eral payers. However, as previously discussed, newer tools
the Occupational Therapy Practice Framework: Domain and such as the CMS-developed CARE may eventually supplant
Process (OTPF–3), an official document of the profession the FIM, reinforcing the importance of staying current with
that characterizes the occupational therapy scope of prac- reimbursement literature.
tice (AOTA, 2014). The OTPF–3 was written to coalesce our
founders’ historical and philosophical roots with sociocul- Regulatory bodies
tural factors that have shaped occupational therapy practice
Regulatory bodies heavily rely on standardized instruments
over the past 100 years. It uses terminology from WHO’s
to objectively inform their efforts. In this vein, The Joint
(2001) International Classification of Functioning, Disability
Commission (2017) revised the outcome measure standard
and Health to clarify the interrelationship between domains
for behavioral health care providers, stipulating that as of
of occupational performance and the WHO-measured con-
January 1, 2018, organizations must use “a standardized tool
structs of health and disability.
or instrument to monitor the individual’s progress in achiev-
In addition to maintaining a circumscribed focus on daily
ing his or her care, treatment, or service goals. . . . Ideally, the
operational issues and leading their direct reports, occupa-
tool or instrument monitors progress from the individual’s
tional therapy managers are tasked with balancing hierarchi-
perspective” (p. 2). This specificity of language endorses the
cal priorities of the profession with those of their respective
regulatory body’s mandate to not only quantify progress but
organizations. This can seem to be a daunting task given the
to do so with fidelity to the health consumer’s perspective.
ever-changing health care landscape and numerous settings
in which occupational therapy practitioners practice (e.g.,
mental health, pediatrics, medical and physical rehabilitation Quality benchmarking
settings, emerging areas of practice, alternative settings). Each Quality benchmarking is voluntary, active collaborations
practice context brings unique constraints and considerations, targeting use of optimally efficient indicators, practices and
ranging from occupational needs specific to population sub- costs (Ettorchi-Tardy et al., 2012). Outcome measures allow
sets to site-driven issues with payers and regulatory bodies. organizational benchmarking via substantive comparison
Yet there is a common thread connecting these challenges, in among peer facilities As such, health care providers must
that managers can effectively address them by strategically continually evolve their measurement initiatives to capture
aligning quantifiable strengths of the profession with over high-quality data. Therefore, it is important for occupational
arching measurement-fueled administrative agendas. therapy services to strategically highlight how it may directly
or indirectly affect such metrics. The degree of success in such
Identifying Specific Outcomes to Be Measured undertakings ultimately affect marketability, reimbursement,
and institutional viability.
Management plays a fundamentally important role in the
selection of outcome measures for their respective facilities.
Global scale impact
While occupational therapy practitioners bring expertise-
informed preferences for relying upon various measures, man- Addressing the broader question of which outcomes matter
agers lend additional pragmatic and philosophical support for most to patient and consumer populations on a national or
global scale, occupational therapy managers should target managers and occupational therapy practitioners must care-
the most robust instruments available. For example, if one fully consider a tool’s psychometrics properties. As previously
is looking to gather outcome data related to treating patients suggested, managers are encouraged to participate in perfor-
with heart failure, the ICHOM’s (2016) Standard Set provides mance improvement collectives and consult the PROMIS
population-specific measures. This bank of items includes database to gain access to robust candidate measures.
assessments of mortality, symptom control, ADLs, indepen-
dence, psychosocial issues, health, complications, treatment Existing Tools and Resources
side effects, and hospital visits. Many of these items, which
are deemed important and relevant by oversight committees, A progressive occupational therapy manager draws from
align well with the profession of occupational therapy. psychometrically sound tools and resources to measure out-
comes of interest in line with their organizational priorities.
Fortunately, considerable outcomes research has been con-
Selecting Assessment Tools or Instruments
ducted by occupational therapy scholars. Their work has led
Standardized assessments have specific guidelines for ad- to the development of numerous databases that aggregate
ministration and data analysis for consistent evaluation and outcome measures and assessment tools, overview their psy-
testing experiences and ability to compare results. As reim- chometric properties, and provide specific research evidence
bursement models increasingly rely on data from standard- supporting their use. To ensure viability of occupational
ized assessments, it behooves occupational therapy managers therapy services in a given organization, as well as bolster-
and practitioners to refine their approach to metric selec- ing the status of the profession at large, occupational therapy
tion. When choosing from candidate measures, managers managers and practitioners must use such resources to better
should consider several practical issues that guide clinical understand, purposefully collect, and analyze outcomes data
implementation. First, ease of access influences consistency (see Tables 27.2 and 27.3).
of use. This includes both time associated with occupational
therapy practitioners’ in situ retrieval of instruments and the
Developing New Tools
managerial onus to justify using potentially fee-based met-
rics. Failure to account for productivity-draining tasks and Keeping pace with the exponential rate of technological ad-
for using financially oppressive tools may result in collateral vancement, health care models have evolved by continually
damage to other sustainability-based metrics. expanding services and supporting emerging areas of prac-
Second, test burden degrades instrument utility. This ap- tice. Given the multifocal nature of the occupational therapy
plies not only to patient endurance but also to a less intuitive therapeutic lens, this trend serves as a quantum multiplier for
notion regarding staffing allocation. Consider that within an the complexity of occupational therapy. Consequently, it is in-
acute care hospital setting, patients often lack the tolerance creasingly challenging to find tools that adequately capture oc-
for protracted interactions, and managers having the ability cupational therapy’s positive impact on health and well-being.
to consistently staff 2-hour outcome gathering sessions is un- One solution is to allocate resources for the development of
realistic. To guide the selection of assessment tools or instru- more parsimonious, ecologically valid, and occupational ther-
ments, consider the following: apy–centric outcome measures. Doing so would enable prac-
titioners, managers, and leadership within the profession to
■ Does use of the instrument or tool require licensing rights? quantify direct and causal relationships between occupational
■ Can the tool be easily accessed by occupational therapy therapy interventions and key health outcomes achieved.
practitioners (e.g., online or electronic retrieval, ease of
Developing meaningful and sensitive outcome measures
ordering, bulk purchasing)?
is a complex and time-consuming process. It will require
■ Is the assessment tool compatible with integration into
collaboration among occupational therapy administrators,
existing documentation systems, including considerations
managers, occupational therapy practitioners, and scholars to
associated for electronic health records?
ensure that overarching pragmatic, philosophical, and care-
■ What is the cost to use the tool? Is there a cost per tool, per
delivery perspectives are adequately considered. Multilevel
user, or a licensing fee?
collaboration also mitigates the risk of redundant efforts
■ Is there an established budget for acquiring assessment
while maximizing the likelihood that the objectives align with
tools?
perspectives within the occupational therapy clinical commu-
■ How long does the tool take to administer and to analyze
nity, academia, and the broader health care community.
results?
■ Are there organizational considerations regarding allot-
ment of time for occupational therapy practitioners to ad- Establishing Processes for
minister standardized assessments? Measuring Outcomes
Moving beyond initial practical considerations, assess- Outcome measurement must be integrated into daily practice,
ment tools should also be scrutinized in terms of psychometric yet managers have to be mindful of secondary considerations.
rigor. Selected tools must provide useful, trustworthy, and For example, they need to account for temporal and financial
clinically meaningful information (see Table 27.1). Therefore, implications, and therefore they benefit from quality control
TABLE 27.2. Assessing Existing Tools
SAMPLE TOOLS PROS CONS

General tools ■ WHO–Disability Schedule II (WHO, 2017) Generalizable across populations May not be sensitive or responsive to
■ CDC Health-Related Quality of Life HRQOL–14 and settings specific interventions; may not account
“Healthy Days Measure” (CDC, 2017) for population differences
Condition or ■ Stroke Impact Scale (Jenkinson et al., 2013) Specific to occupational Narrows focus away from whole individual;
population ■ Clinical Dementia Rating (Knight Alzheimer’s considerations for individuals consumers may have multiple conditions
Disease Research Center, n.d.) with that particular condition affecting performance
Occupational ■ Canadian Occupational Performance Measure Addresses central tenet of impact May have increased difficulty generalizing
performance (Law et al., 2014) on occupational performance; or comparing outcomes
can be individualized
Client factors ■ Montreal Cognitive Assessment (Nasreddine Improved sensitivity and May require extensive number of client
et al., 2005) responsiveness to specific factor assessment tools to capture all
■ Beck Depression Inventory (Beck et al., 1996) interventions pertinent changes in outcomes
Note. CDC = Centers for Disease Control and Prevention; WHO = World Health Organization.
via procedure standardization. For facilities or entities that Managers should consider advocating for budget allocations
do not already devote resources to comprehensive outcomes separate from service production and clarify potentially re-
measuring initiatives, managers must anticipate and budget vised expectations in line with extant productivity standards.
for the likely impact on productivity and service provision. Otherwise, there is a risk that the demands may be unrealistic
Startup costs and efforts to sustain such measurement pro- in terms of incorporating and sustaining such practices in the
grams are not insignificant. Therefore, advocating for time clinical daily work flow. Such a turn of events would not only
and resources is crucial to not only instantiate but also cement undermine the sustainability of progressive outcomes-driven
outcome data initiatives as ongoing institutional priorities. practice but also negatively affect morale of one’s direct reports.
TABLE 27.3. Measurement Resources
WEBSITE URL DESCRIPTION

American Physical Therapy www.neuropt.org/professional-resources Includes recommendations for clinical use of outcome measures by practice
Association Neurology /neurology-section-outcome-measures settings and acuity level.
Section -recommendations
Center for Outcome www.tbims.org/combi/ Provides psychometrics and clinical utility about instruments used to assess
Measurement in Brain individuals with brain injury. Frequently asked questions and testing
Injury documents are available when possible.
Evidence-Based Review www.abiebr.com/module/17 Includes evidence-based information on outcome measurement and
of Moderate to Severe -assessment-outcomes-following interventions in brain injury rehabilitation.
Acquired Brain Injury -acquiredtraumatic-brain-injury
Evidence-Based Review of www.ebrsr.com/reviews_details.php Evidence-based website that includes outcome measurement and intervention
Stroke Rehabilitation ?Outcome-Measures-9 information. The website focuses only on stroke rehabilitation.
Rehabilitation Measure www.rehabmeasures.org Provides concise summaries that include psychometrics and clinical utility for
instruments that can be used to assess a variety of conditions commonly
seen in rehabilitation. A link to the instrument is included whenever possible.
Spinal Cord Injury www.scireproject.com/outcome-measures Evidence-based website that includes outcome measurement and
Rehabilitation Evidence intervention information for spinal cord injury rehabilitation.
StrokEngine Assess www.strokengine.ca Describes stroke-specific psychometric properties and clinical utility, and
provides a link to the instrument whenever possible.
Find more outcome measurement resources on the links page at www.rehabmeasures.org.
Source. From “Measuring Progress: Using the Rehabilitation Measures Database to Increase Knowledge About Outcome Measurement” by J. Moore & C. Baum, 2014,
OT Practice, 19(7), p. 13. Copyright © 2014 by American Occupational Therapy Association. Used with permission.
Review Questions inefficient processes shaped by imprecise terminology and a

historical lack of consensus on key targets and measurement
1. In addition to focusing on fiscal and regulatory issues, oc-
approaches. From a philosophical and pragmatic standpoint,
cupational therapy managers should consider how services
there is a symbiotic relationship between outcomes measure-
rendered can both affect quality benchmarking initiatives
ment and the viability of health care practices.
and have global scale impact. What do these concepts mean,
To ensure occupational therapy’s future as a valued compo-
and how do they align with the profession’s central tenets?
nent within modern health care systems, occupational ther-
2. Discuss several combinations of overarching philosoph-
apy managers, practitioners, and scholars must collaboratively
ical perspectives and practical clinical concerns that can
and iteratively construct outcomes-driven approaches to prac-
guide prudent selection of assessment tools.
tice. Importantly, managers are a powerful source of insight
3. Which of the following are psychometric properties used
regarding clinical-service-based considerations affecting key
to evaluate candidate outcome metrics?
stakeholders (e.g., patients, payers, regulatory bodies, the in-
a. Validity
ternational community of health care scholars). In addition,
b. Reliability
as intermediaries between occupational therapy practitioners
c. Sensitivity
and other parties of interest, managers play a foundationally
d. Responsiveness
important role in the pragmatic selection of assessment tools.
e. All of the above By scrutinizing the psychometric properties of candidate
measures and allocating resources to positively influence in-
herent cost–benefit considerations, managers are the linchpin
SUMMARY of any successful outcome measurement program.
Measuring outcomes is a critically important, but complex, From a broader perspective, the future of outcome mea-
undertaking. In practice, efforts are often confounded by surement in health care will be indelibly shaped by the degree
CASE EXAMPLE 27.1. Demonstrating Value in an Evolving Reimbursement Landscape
Emma is the occupational therapy manager at a metropolitan acute care hospital. Recently, there has been talk of budget cuts stemming from
diminished Medicare reimbursement rates linked to poor performance on key CMS metrics. Recognizing that every department may soon endure
pointed scrutiny in terms of inherent operating costs, Emma begins to collect outcomes data to quantify value added by occupational therapy
service. She first consults CMS websites to gain a clearer perspective on measures to which the hospital is held accountable (e.g., structural,
process, outcome, patient experience, composite). Then she works to identify measures valued by regulatory bodies (e.g., The Joint Commission),
payers (e.g., Medicare, third-party payers), and quality benchmarking organizations (e.g., Vizient, Hospital CAHPS). Next, she focuses on
measures likely to be influenced by occupational therapy services.
Having completed preliminary research on relevant perspectives and measures, Emma meets with her occupational therapy practitioners to
debate the merits of candidate variables. Specifically, they discuss the items’ psychometric properties and intuitive link to OTPF–3 (AOTA, 2014).
Having produced a refined list of target measures, they form subcommittees to further vet candidate variables’ potential to capture relevant data.
Each subcommittee is further tasked with outlining the utility of a given item, with emphasis on the hospital’s perception of added value. Essential
consideration will be given to resource burden, including elements such as employee time and financial cost. Finally, they clarify the practicality
of incorporating the tool into the organization’s daily work flow. The team schedules appropriate deadlines and follow-up meetings to (1) update
findings, (2) finalize target outcomes, (3) select final assessment tools, and (4) initiate the outcomes tracking initiative.
Review Questions
1. Measuring outcomes is important, because it allows occupational therapy practitioners to
a. Learn from the collected data.
b. Improve performance through quality and process improvement initiatives.
c. Demonstrate their distinct value by way of producing superior outcomes.
d. Demonstrate added value that positively influences reimbursement for services.
e. All of the above
2. How do outcomes measurement initiatives support occupational therapy’s ability to demonstrate its distinct value as well as contribute to the
quality of health care services?
3. You are an occupational therapy practitioner working with Emma in the case example above. Your subcommittee’s task is to vet candidate
measures of occupational therapy’s impact on value for patients who have experienced neurological insults. Each subcommittee member is to
present 3 potential assessment tools at the next team meeting. Create a table for your 3 assessment tools and include the following for each:
a. What is the target health outcome?
b. How does the tool capture occupational therapy’s influence on the metric, thereby adding value?
c. Describe the psychometric properties of the tool.
d. Describe the resource burden of the tool (e.g., financial, time).
e. Describe pros and cons of these 3 vs. similar tools.
f. Suggest ideas for incorporating the tool into clinical daily workflow with consideration for productivity standards.
to which health care providers, occupational therapy practi- Agency for Healthcare Research and Quality. (2011, July). Types of qua
tioners, and scholars achieve consensus regarding essential lity measures. Retrieved from https://www.ahrq.gov/professionals
constructs, metrics, and their place within evolving systems /quality-patient-safety/talkingquality/create/types.html
of care. Once achieved, it falls to administrators, occupational American Occupational Therapy Association. (2007). AOTA’s Centen-
nial Vision and executive summary. American Journal of Occupa-
therapy practitioners, and scholars to identify approaches for
tional Therapy, 61(6), 613–614. https://doi.org/10.5014/ajot.61.6.613
• Learning from the data gathered: What can be learned about American Occupational Therapy Association. (2014). Occupational
occupational therapy interventions and their impact on the therapy practice framework: Domain and process (3rd ed.).
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of health outcomes for consumers? American Occupational Therapy Association. (2015, May 22).
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from https://www.aota.org/Publications-News/AOTANews/2015
improve efficacy and effectiveness of interventions? Can
/distinct-value-of-occupational-therapy.aspx
process or quality improvement initiatives be instituted to
American Occupational Therapy Association. (2017). Vision 2025.
change the outcomes? American Journal of Occupational Therapy, 71, 7103420010.
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peer providers? What steps need to be taken to disseminate Public Policy, 2, 41–55. https://doi.org/10.1017/bpp.2017.5
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be translated to communicate added value and in turn Blum, W. (1926). Science for humanity’s sake. Science, 64, 77–80.
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Bowling, A. (2001). Measuring disease (2nd ed.). Buckingham, UK:
can the outcomes data justify continued or increased
Open University Press.
reimbursement for occupational therapy services?
Centers for Disease Control and Prevention. (2016). Health-Related
Once in place, these components will significantly further Quality of Life (HRQOL): Measurement properties. Retrieved
the AOTA NQS aim of clearly articulating the distinct value from https://www.cdc.gov/hrqol/measurement.htm
of occupational therapy. AOTA developed the following Centers for Disease Control and Prevention. (2017). CDC HRQOL–14
Distinct Value Statement as a part of its Centennial Vision “Healthy Days measure.” Retrieved from https://www.cdc.gov
(AOTA, 2007) journey: /hrqol/hrqol14_measure.htm
Centers for Medicare and Medicaid Services. (2017a, January 11).
Occupational therapy’s distinct value is to improve health The Hospital Value-Based Purchasing (VBP) program. Retrieved
and quality of life through facilitating participation and from https://www.cms.gov/Medicare/Quality-Initiatives-Patient
engagement in occupations, the meaningful, necessary, -Assessment-Instruments/Value-Based-Programs/HVBP
/Hospital-Value-Based-Purchasing.html
and familiar activities of everyday life. Occupational
Centers for Medicare and Medicaid Services. (2017b, November 9).
therapy is client-centered, achieves positive outcomes, and What are value-based programs? Retrieved from https://www
is cost-effective. (AOTA, 2015, para. 6) .cms.gov/Medicare/Quality-Initiatives-Patient-Assessment
Measuring outcomes is a crucial component of efforts -Instruments/Value-Based-Programs/Value-Based-Programs.html
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COSMIN. (n.d.). COSMIN definitions of domains, measurement
use meaningful outcome measures is the shared responsi-
properties, and aspects of measurement properties. Retrieved
bility of occupational therapy managers, practitioners, and
from http://www.cosmin.nl/images/upload/files/Tabel%20met
supporters, so as to secure an enduring, valued position in %20definities-new.pdf
the ever-changing arena of health care. ❖ Ettorchi-Tardy, A., Levif, M., & Michel, P. (2012). Benchmarking: A
method for continuous quality improvement in health. Healthcare
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ACOTE STANDARDS Furniss, J. (2017, March). The AOTA National Quality Strategy. Paper
This chapter addresses the following ACOTE Standard: presented at the Academic Leadership Council, Philadelphia, PA.
Gordon, D. M. (2009). The history of occupational therapy. In
■ Preamble. E. B. Crepeau, E. S. Cohn, & B. A. Boyt Schell (Eds.), Willard
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(n.d.-d). Why measure outcomes. Retrieved from http://www /otp.2014.197f2
.ichom.org/why-measure-outcomes Nasreddine, Z., Phillips, N., Bédirian, V., Charbonneau, S.,
International Consortium for Health Outcomes Measurement. Whitehead, V., Collin, I., . . . Chertkow, H. (2005). The Montreal
(2016). Standard set: Heart failure. Retrieved from http://www Cognitive Assessment, MoCA: A brief screening test for mild
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Jenkinson, C., Fitzpatrick, R., Crocker, H., & Peters, M. (2013). The 53, 695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x
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The Joint Commission. (2017). Approved: Revisions to behav- https://www.nia.nih.gov/research/resource/patient-reported
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https://www.jointcommission.org/assets/1/6/Approved_BHC National Quality Forum. (n.d.). The right tools for the job. Retrieved
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Knight Alzheimer’s Disease Research Center, Washington Uni- tics (Vol. 5, pp. 3609–3613). West Sussex, UK: Wiley.
versity in St. Louis. (n.d.) CDR™. The Clinical Dementia Rating. Porter, M. E., Larsson, S., & Lee, T. H. (2016). Standardizing patient
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Guidelines for Effective Documentation and CHAPTER
Quality Reporting
Karen M. Sames, OTD, MBA, OTR/L, FAOTA 28
LEARNING OBJECTIVES
■ Distinguish between effective and ineffective documentation,
■ Describe how high-quality documentation supports the distinct value of occupational therapy,
■ Understand the manager’s role in documentation, and
■ Recognize the requirements for quality reporting.

• Discharge report • Negative payment adjustment • Screening
• Documentation • Occupational profile • Service contact
• Evaluation report • Positive payment adjustment • Third-party payer
• Intervention plan • Progress report • Transition plan
• Measure domains • Quality reporting
OVERVIEW occupations; and records the story of the client’s recovery
I
n most clinical settings, occupational therapy practitioners need from illness or injury (Sames, 2015; Scott, 2013). It paints
to document their evaluations, interventions, and outcomes to a step-by-step picture of a client’s journey through the oc-
get paid, to communicate with other care providers, to provide cupational therapy process.
a chronological record of the care provided in case of litigation, 2. Comply with reimbursement: Documentation must com-
and to demonstrate our clinical reasoning. Documentation is ply with requirements for reimbursement to justify pay-
an essential function of occupational therapy practitioners, yet ment for occupational therapy services (Sames, 2015).
it is not what draws people into the profession. No one chose Conversely, poorly written documentation can be used by
occupational therapy as a career because they wanted to spend a payer to justify not paying for occupational therapy ser-
a lot of time documenting the services they provide. The man- vices. Documentation may also be used to demonstrate
ager’s job is to help those providing services to document well, compliance with standards for accreditation of health
while not spending too much time doing it. This chapter explains care facilities (Scott, 2013).
how to document efficiently and meet quality standards. 3. Communicate: Occupational therapy practitioners use
documentation to communicate with others on the cli-
ent’s intervention team when telling each person individ-
ESSENTIAL CONSIDERATIONS ually is not practical (Sames, 2015). This communication
Purpose of Documentation can enhance the continuity of care and reduce redun-
dancy of effort by others on the team.
Documentation serves many purposes and can be remem- 4. Clinical reasoning: Documentation can demonstrate clin-
bered by its 6 Cs: ical reasoning. The purpose of an occupational therapy
1. Chronological record: Documentation provides a chrono- practitioner’s choice of intervention may not be obvious
logical record of the client’s participation in occupa to onlookers but can be explained in the documentation
tional therapy; tells the story of the client’s engagement in (Cronin & Graebe, 2018; Sames, 2015). Clinical reasoning
https://doi.org/10.7139/2019.978-1-56900-592-7.028
269
Guidelines for Effective Documentation and CHAPTER
Quality Reporting
Karen M. Sames, OTD, MBA, OTR/L, FAOTA 28
LEARNING OBJECTIVES
■ Distinguish between effective and ineffective documentation,
■ Describe how high-quality documentation supports the distinct value of occupational therapy,
■ Understand the manager’s role in documentation, and
■ Recognize the requirements for quality reporting.

• Discharge report • Negative payment adjustment • Screening
• Documentation • Occupational profile • Service contact
• Evaluation report • Positive payment adjustment • Third-party payer
• Intervention plan • Progress report • Transition plan
• Measure domains • Quality reporting
OVERVIEW occupations; and records the story of the client’s recovery
I
n most clinical settings, occupational therapy practitioners need from illness or injury (Sames, 2015; Scott, 2013). It paints
to document their evaluations, interventions, and outcomes to a step-by-step picture of a client’s journey through the oc-
get paid, to communicate with other care providers, to provide cupational therapy process.
a chronological record of the care provided in case of litigation, 2. Comply with reimbursement: Documentation must com-
and to demonstrate our clinical reasoning. Documentation is ply with requirements for reimbursement to justify pay-
an essential function of occupational therapy practitioners, yet ment for occupational therapy services (Sames, 2015).
it is not what draws people into the profession. No one chose Conversely, poorly written documentation can be used by
occupational therapy as a career because they wanted to spend a payer to justify not paying for occupational therapy ser-
a lot of time documenting the services they provide. The man- vices. Documentation may also be used to demonstrate
ager’s job is to help those providing services to document well, compliance with standards for accreditation of health
while not spending too much time doing it. This chapter explains care facilities (Scott, 2013).
how to document efficiently and meet quality standards. 3. Communicate: Occupational therapy practitioners use
documentation to communicate with others on the cli-
ent’s intervention team when telling each person individ-
ESSENTIAL CONSIDERATIONS ually is not practical (Sames, 2015). This communication
Purpose of Documentation can enhance the continuity of care and reduce redun-
dancy of effort by others on the team.
Documentation serves many purposes and can be remem- 4. Clinical reasoning: Documentation can demonstrate clin-
bered by its 6 Cs: ical reasoning. The purpose of an occupational therapy
1. Chronological record: Documentation provides a chrono- practitioner’s choice of intervention may not be obvious
logical record of the client’s participation in occupa to onlookers but can be explained in the documentation
tional therapy; tells the story of the client’s engagement in (Cronin & Graebe, 2018; Sames, 2015). Clinical reasoning
https://doi.org/10.7139/2019.978-1-56900-592-7.028
269
shows why an occupational therapy practitioner’s skills therapy because it does not contain the most important infor-
are necessary and keeps our jobs robot-proof. mation. For example, it might list the types of activities that the
5. Collect data: Occupational therapy practitioners collect client engaged in without describing how the client performed
and use data for research, education, and quality im- those activities (Sames, 2015). Ineffective documentation may
provement. The data gathered through documentation, provide interpretations of the client’s performance without pro-
especially data gathered through an electronic health viding evidence to support that interpretation. Such ineffective
record, can be reviewed, analyzed, and used to inform documentation can result in nonpayment for services or having
future occupational therapy practice. to pay back money received before the retrospective case review.
6. Courtroom defense: Documentation provides a legal re-
cord of care provided in cases of neglect and malpractice Best Practices in Clinical Documentation
and other types of lawsuits that can end up in court (Scott,
Good documentation is timely, clear, free from jargon, in-
2013). Documentation can be used to support either the
dividualized, and reflects the distinct value of occupational
defense or the prosecution (Sames, 2015; Scott, 2013).
therapy (AOTA, n.d.-a). It focuses on the most important as-
Documentation written at the time an event occurred is
pects of occupational therapy services; it does not try to cover
considered more accurate than a person’s memory 1 or
everything the client said and did (Yamkovenko, 2014). There
2 years after the event. Common practice considers that
is an obvious link between evaluation or reevaluation results
what was not documented did not happen. Expert wit-
and the interventions provided (AOTA, 2015a). The evalu-
nesses can form opinions about the care delivered from
ation or reevaluation provides a baseline from which prog-
the quality of the documentation (Sames, 2015).
ress can be measured (Yamkovenko, 2014). The link between
objective information, such as test scores, and occupational
For Additional Learning performance is clear (AOTA, 2015a).
See Chapter 10, “Using Data to Guide Business Decisions,” and Timeliness
Chapter 61, “Malpractice,” for more information on uses of data
and malpractice. Timeliness of documentation is important. Delays in docu-
mentation can raise questions by payers and lawyers about
the accuracy of documentation written well after the client
Effective Documentation interaction occurred (Sames, 2015). Late documentation may
be seen as an indication that the occupational therapy practi-
Documentation that serves all of the 6 Cs can be considered
tioner is overworked, resulting in carelessness (Sames, 2015).
to be effective documentation. Effective documentation gives
readers a mental picture of what transpired during occu-
Avoid jargon
pational therapy and conveys the essential information for
other providers on the team. The clinical reasoning is obvi- Occupational therapy practitioners need to be careful about
ous and demonstrates the distinct value of occupational ther- using jargon that is well understood by other occupational
apy. Effective documentation contains essential information therapy practitioners but also could be misunderstood by
without a lot of extraneous verbiage. other health care providers or the client or client’s family. Be-
If the documentation is timely and efficiently written, it is ef- ware overuse of abbreviations that may mean different things
fective documentation. Documentation must be written as close to different professions (AOTA, n.d.-a; Sames, 2015). An oc-
to the time the service was delivered as possible (Sames, 2015). cupational therapy practitioner should document as clearly,
Late documentation is ineffective because it is placed in the succinctly, and specifically as possible. Shorter, direct state-
electronic health record (EHR) out of sequence, which makes it ments are preferred over long, wordy, winding statements.
harder for the reader to get an accurate picture of what happened.
Documentation contains data that can be useful in the Practical considerations
evaluation of the quality of the occupational therapy program.
Practical considerations are also important. For example, always
Effective documentation includes a clearly stated outcome of
check to see that the right documentation is being entered into
occupational therapy. Goals are simple and measurable, and
the right client’s record. It is important to proofread all written
the measurements are reported at regular intervals. Written
documentation before submitting it to the EHR (Sames, 2015).
notes provide evidence of what happened, evidence of the
It is much easier to correct an error before documentation is sub-
patient’s response to intervention, and the occupational ther-
mitted than after. If an error is found after the documentation is
apy practitioner’s interpretation of that evidence.
submitted, the occupational therapy practitioner can add an ad-
Effective documentation answers questions that third-
dendum to a previously submitted document. You should never
party payers, such as insurance companies or Medicare, ask
correct anyone’s documentation but your own.
when they review cases. It shows the payers that occupational
therapy was a necessary service and that the client is better
Ethics standards
able to participate in life as a result of that intervention.
Ineffective documentation is often too wordy or too stingy All documentation needs to comply with the ethical stan-
with words. It fails to convey the distinct value of occupational dards of the profession, the Occupational Therapy Code of
CHAPTER 28. Guidelines for Effective Documentation and Quality Reporting 271
Ethics (2015) (AOTA, 2015b). Several principles of the Code a more appropriate provider (AOTA, 2018). Screening docu-
apply to documentation: mentation should include
■ 1.A. Provide appropriate evaluation and a plan of inter- ■ Background information such as the client’s name, date of
vention for recipients of occupational therapy services birth, gender, diagnoses, precautions, and contraindications.
specific to their needs. ■ Referral information including the date or time the refer-
■ 1.B. Reevaluate and reassess recipients of service in a timely ral was made, who made it, what services should be pro-
manner to determine whether goals are being achieved vided, and the reason for the referral.
and whether intervention plans should be revised. ■ Brief occupational profile to establish the client’s perspec-
■ 4.O. Ensure that documentation for reimbursement pur- tive on why they are in need of occupational therapy ser-
poses is done in accordance with applicable laws, guide- vices and to begin to gather information on the client’s
lines, and regulations. past occupational history, priorities, and environments or
■ 5.C. Refrain from using or participating in the use of any contexts in which the desired occupational performance
form of communication that contains false, fraudulent, takes place.
deceptive, misleading, or unfair statements or claims ■ Types of assessments used and what they revealed. This can
(AOTA, 2015b, pp. 2–7). include interviews, record reviews, tests, or observations.
■ Recommendations; the professional judgment of the oc-
Reflect clients as individuals cupational therapist on the need for occupational therapy
services including further evaluation (AOTA, 2018).
Documentation must reflect the unique needs and circum-
stance of each client. It is easy to use certain words or phrases Evaluation. The evaluation report is one of the most crit-
over and over again when writing documentation. When ical pieces of documentation that an occupational therapist
documentation looks repetitive, almost machine-like, read- can write. It establishes the need for occupational therapy
ers get the impression that the writer is not treating the clients intervention. Poorly written evaluation reports may put re-
as individuals but as objects. A payer might read that docu- imbursement for occupational therapy services at risk. Man-
mentation and determine that an occupational therapy prac- agers also need to be up-to-date on their understanding of
titioner’s skills are not needed to treat the client. payer expectations and professional standards for documen-
tation of evaluations.
Distinct value of occupational therapy The evaluation report starts with an occupational profile
of the client. AOTA recommends using the AOTA Occupa-
Documentation that shows the distinct value of occupational tional Profile Template (AOTA, 2017), which is available in
therapy is an act of advocacy for the profession (Mann & Appendix 25.A. The template provides questions to answer
Tressider, 2016). It demonstrates that the skills and expertise regarding the client’s perspective, space to document envi-
of an occupational therapy practitioner are needed to provide ronmental and contextual supports and barriers to occupa-
the client with the best possible outcomes in occupational tional performance, and a section on the client’s priorities
performance. It shows that occupational therapy has contrib- and desired outcomes.
uted to the health and well-being of the clients served. In addition to the occupational profile, the evaluation re-
port should also contain information on the assessments used
and the results of those assessments, the analysis of occupa-
For Additional Learning tional performance, the occupational therapist’s summary
and interpretation of the data gathered, and recommenda-
See Chapter 33, “Advocating Occupational Therapy’s Distinct
tions for occupational therapy services or referral to other
Value Within Interprofessional Teams,” for more information on
services (AOTA, 2014). The summary and interpretation of
communicating occupational therapy’s distinct value.
the data should relate back to both the occupational profile
and reason for referral (AOTA, 2017). Reevaluation reports
should contain similar content (AOTA, 2017).
AOTA’s guidelines for documentation
The AOTA Guidelines for Documentation of Occupational Intervention. Documentation occurs throughout the in-
Therapy (AOTA, 2018) apply across practice settings and de- tervention phase of the occupational therapy process. In-
scribe the suggested contents of documentation of screening, tervention documentation includes the intervention plan,
evaluation, intervention, and outcomes. The guidelines are documentation of service contacts, progress reports, and a
consistent with AOTA’s (2014) Occupational Therapy Practice transition plan.
Framework, 3rd Edition (OTPF–3), which provides an over- An intervention plan documents the mutually agreed-on
view of the occupational therapy process. goals for intervention, the expected approaches and types of
interventions that occupational therapy practitioners will use
Screening. A screening is a brief assessment of the client’s with the client, and the outcomes targeted by the client. The
need for an occupational therapy evaluation or, if occupation- intervention plan is based on the evaluation or reevaluation.
al therapy would not be appropriate for the client, a referral to It may also include recommendations for referrals to other
professionals or agencies. Consistent with the OTPF–3 (AOTA, system (AOTA, 2018). The contents of a transition plan are es-
2014), it includes sentially the same as those of a progress report, but instead of
a summary of services provided, the transition plan describes
■ Client information (background information like name, the setting the client will transfer to, when the transfer will
date of birth, gender, precautions, etc.);
occur, and what activities will be carried out during the tran-
■ Intervention goals (occupation-based long- and short-term sition (AOTA, 2018).
goals);
■ Intervention approaches (create or promote, establish or Outcomes. The outcomes of occupational therapy interven-
restore, maintain, modify, prevent) and types of intervention are documented in a discharge report (AOTA, 2018). The
tion (therapeutic use of occupations or activities, educa- discharge report includes client (background) information, a
tion, advocacy, consultation); summary of the client’s intervention process, and the occupa-
■ Service delivery mechanisms (who is providing the ser- tional therapist’s recommendations (AOTA, 2018). As part of
vice, where, how often, for how long); the summary, include the dates of the initial and final services,
■ Plan for discharge, including discontinuation criteria and the number of services provided and how often they were pro-
anticipated setting, and recommended follow-up care; vided, a summary of the interventions provided, a summary of
■ Outcome measures (tools used to assess outcomes of occu- the client’s progress toward goals, and the client’s starting and
pational therapy intervention); and ending occupational performance (AOTA, 2018; Sames, 2015).
■ Signature of person overseeing the plan and the date when
the plan was developed or modified (AOTA, 2018).
Quality Reporting
Service contacts may be called contact, daily, or treatment
Anyone paying for occupational therapy services wants to
notes. These are short notes that document contact between
know that their money is being well spent. Whether the client
an occupational therapy practitioner and a client or the cli-
is paying for the services themselves or a third-party payer is,
ent’s caregivers (AOTA, 2018; Sames, 2015). The contact may
occupational therapy practitioners need to demonstrate their
be face to face or through electronic means (i.e., phone, video
contribution to the client’s health and wellness. Medicare in
conferencing, telehealth). As always, the notes must include
particular has rules that require occupational therapy prac-
client or background information (AOTA, 2018; Sames,
titioners to document certain things to get paid. Medicare
2015). In addition, the note should identify who the contact
wants to pay for quality over quantity and has published rules
was with, a summary of what transpired, and intervention or
for quality reporting.
procedure coding, if applicable (AOTA, 2018).
In 2015, Congress passed the Medicare Access and Children’s
If the service contact includes the provision of occupa-
Health Insurance Program (CHIP) Reauthorization Act of
tional therapy interventions, the documentation must in-
2015, popularly called MACRA, to address quality reporting for
clude the types of intervention provided and how the client
outpatient care. This law requires many health care providers,
responded to that intervention. A simple listing of activities
not just occupational therapy practitioners, to document cer-
that the client participated in is insufficient. To show that the
tain things to demonstrate that quality care is being provided.
skills of an occupational therapy practitioner were necessary,
Beginning in 2017, occupational therapy practitioners had the
the documentation needs to demonstrate that the expertise
choice to submit quality data to Medicare or receive a small cut
of an occupational therapy practitioner was required and
in reimbursement rates, called a negative payment adjustment.
that the unique clinical reasoning and expertise of the oc-
If the occupational therapy provider chose to submit quality
cupational therapy practitioner were necessary to obtain the
data, they could either keep their same reimbursement rates or
results (AOTA, 2018). If a client misses an occupational ther-
get a small increase (positive payment adjustment) depending
apy session, this should also be documented in a contact note.
on the degree to which they report quality data.
Progress reports are different from contact notes. Although
According to AOTA (n.d.-d), examples of the types of
contact notes document an individual intervention session, the
measures occupational therapy practitioners might docu-
progress report summarizes a series of intervention sessions
ment include
and the progress the client is making toward goal achieve-
ment (AOTA, 2018). A progress report is written at regular ■ 128—Preventative Care and Screening: Body Mass Index
intervals; for example, Medicare requires a progress report (BMI) Screening and Follow-Up (domain: community/
every 30 calendar days or 10 treatment days, whichever is less population health)
(CMS, 2012). A progress report contains at least 4 elements: ■ 130—Documentation of Current Medications in the Med-
ical Record (domain: patient safety)
1. Client (background) information,
■ 131—Pain Assessment Prior to Initiation of Therapy and
2. Summary of services provided during the reporting
Follow-Up (domain: community/population health)
period,
■ 134—Preventative Care and Screening: Screening for
3. Description of the client’s current occupational perfor-
Clinical Depression and Follow-Up Plan (domain: com-
mance, and
munity/population health)
4. Plan or recommendations (AOTA, 2018, p. S36).
■ 154—Falls: Risk Assessment (domain: patient safety)
A transition plan is written when the client is moving ■ 155—Falls: Plan of Care (domain: communication and
from one setting to another within the same service delivery care coordination)
■ 181—Elder Maltreatment Screen and Follow-Up Plan through our documentation. If occupational therapy docu-
(domain: patient safety) mentation looks like it could have been written by a physical
■ 182—Functional Outcome Assessment (domain: commu- therapist, nurse, or other health care practitioner, then the
nication and care coordination) practitioner has not represented the profession well and risks
■ 226—Preventative Care and Screening: Tobacco: being replaced by other professions (Sames, 2015).
Use: Screening and Cessation Intervention (domain: Occupational therapy practitioners can practice daily
community/population health) acts of advocacy for the profession by demonstrating the
■ 282—Dementia: Functional Status Assessment (domain: distinct value of occupational therapy through documen-
effective clinical care) tation (Mann & Tressider, 2016). This is accomplished by
■ 286—Dementia: Counseling Regarding Safety Concerns keeping the focus on occupation in all documentation.
(domain: patient safety) Describe what the client can now do that they could not do
■ 288—Dementia: Caregiver Education and Support before occupational therapy. For example, say that the client
(domain: communication and care coordination. can now comb her own hair rather than that the client has
increased her upper extremity range of motion.
For occupational therapy services provided in post-acute set- Explicitly state the adjustments to the intervention plan
tings (e.g., skilled nursing facilities, home health, inpatient rehab), that occurred during a particular intervention session that
Medicare also seeks to improve quality of care and save costs required the clinical expertise of the occupational therapy
by requiring providers to document quality measures (AOTA, practitioner. This shows our clinical reasoning and helps keep
n.d.-b, n.d.-c). Under the Improving Medicare Post-Acute Care occupational therapy a robot-proof profession.
Transformation Act of 2014 (IMPACT), occupational therapy
practitioners should standardize documentation of the following Managers’ Role in Documentation
measure domains (indicators of quality that can be measured):
The occupational therapy manager’s role is to ensure that
■ Skin integrity and changes in skin integrity; those under their supervision provide great occupational
■ Functional status, cognitive function, and changes in therapy services and that those services get paid for. The best
function and cognitive function; way to ensure that the services occupational therapy practi-
■ Medication reconciliation; tioners provide are paid for is to document the services so
■ Incidence of major falls; well that whoever is paying the bill has no questions about the
■ Transfer of health information and care preferences when outcomes of occupational therapy.
an individual transitions; Managers may perform random or routine audits of the
■ Resource use measures, including total estimated Medi- documentation of occupational therapy services. In perform-
care spending per beneficiary; ing the audit, managers may examine
■ Discharge to community; and
■ All-condition risk-adjusted potentially preventable hospi- ■ Timeliness of all documentation,
tal readmissions rates (AOTA, n.d.-b, para. 2). ■ Documentation of the client’s baseline (evaluation) and
terminal (outcomes) occupational performance,
AOTA’s website has the latest information on Medicare regula- ■ A clear and concise occupational profile,
tions and how they affect occupational therapy documentation. ■ Evidence of the necessity of occupational therapy services,
■ Documentation of the reason for missed intervention
Review Questions sessions,
1. Why is it important to include an occupational profile in ■ Evidence that the client or caregiver understood any instruc-
each client’s documentation? tions provided by the occupational therapy practitioner,
2. What are some best practices in occupational therapy ■ Documentation of any adaptive equipment or assistive
documentation? technology provided to the client,
3. How can documentation show that occupational therapy ■ Whether the documentation reflected the unique needs
services were necessary? and circumstances of each client, and
4. What are some reasons why we document occupational ■ Whether the documentation complied with the ethical
therapy services? standards of the profession.
Case Example 28.1 describes a manager auditing an occupa-
PRACTICAL APPLICATIONS IN tional therapist’s documentation.
Review Questions
Demonstrating Occupational Therapy’s
1. In what ways does documentation show the distinct value
Distinct Value Through Documentation
of occupational therapy?
Like most other health care practitioners, occupational ther- 2. What is the best way to assure that occupational therapy
apy practitioners document their services throughout the services are paid for?
care delivery process. Unlike other health care practitioners, 3. What might a manager look for when auditing health
we have a distinct perspective that needs to be demonstrated records?
CASE EXAMPLE 28.1. Hannah’s Documentation Challenge
Hannah is a new occupational therapist at Mountain View Health and Rehabilitation Center. She has been employed at Mountain View for the past
4 months. The productivity expectations are high, and Hannah has been challenged to meet them. She finds that she has to do her documentation
at the end of the day, and she is often the last person to leave for the day. Becca is a friend and former classmate of Hannah’s. They meet for coffee
one day, and Becca suggests that Hannah find a note that she thinks is well written and copy it into other clients’ records with just minor tweaks.
Becca thinks this will save Hannah some time.
Hannah takes this advice. She is seeing 4 clients who are recovering from cerebrovascular accidents and begins to use the same note with minor
tweaks to each of them. She does the same for the 4 hip replacements and 3 knee replacements she sees each day. She makes a few edits on each
note, enough to look like they are individualized. Two months later, as her caseload has increased, she is making fewer and fewer edits, and the
notes are looking remarkably similar regardless of who the client is. Hannah is getting her documentation done more quickly and is no longer the
last person to leave the department each day.
Maria is the occupational therapy manager at Mountain View, and she has decided to audit the documentation of the occupational therapy
personnel in her department. She quickly sees the changes in Hannah’s documentation. She asks Hannah to join her in her office to discuss her
documentation. Hannah admits she has been cutting and pasting much of her documentation. Maria explains the importance of finding the right
balance between customization and efficiency. She emphasizes the importance of demonstrating the distinct value of occupational therapy through
documentation. Hannah says it is hard to remember which client did what by the end of the day. Maria suggests that Hannah use the last 5 minutes
of each intervention session to document the session rather than waiting until the end of the day. While she is typing, she can summarize what
was accomplished with the client and discuss the plan for the next session. Maria discusses ways to engage the client while documenting. Hannah
agrees to give this method a try. She soon finds she can customize her documentation, incorporate documentation into the therapy sessions, and
emphasize the distinct value of occupational therapy without having to stay late.
Review Questions
1. What might the manager have done differently to prevent Hannah’s situation from developing in the first place?
2. What is your biggest concern about using the copy-and-paste method of note writing?
3. Besides saving time, what is another advantage of doing documentation of a therapy session while you are with the client?
SUMMARY American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.

Documentation has many uses, but to be of any use, it has to be American Occupational Therapy Association. (2015a). Maximize
well written, demonstrate the distinct value of occupational clinical documentation. Retrieved from: https://www.aota.org
therapy, and comply with payer demands. The manager’s role /Practice/Manage/Reimb/maximize-clinical-documentation
in documentation is to ensure that the staff document in a -tips.aspx
timely fashion and that the documentation contains essential American Occupational Therapy Association. (2015b). Occupa-
information. One of the best ways to advocate for the profes- tional therapy code of ethics (2015). American Journal of Occu-
pational therapy 69, 6913410030. https://doi.org/10.5014/ajot
sion on a daily basis is to make sure documentation shows
.2015.696S03
how occupational therapy increases participation in life and
American Occupational Therapy Association. (2017). AOTA’s
improves the health and wellness of the clients we serve; these occupational profile template. American Journal of Occupa-
demonstrate the distinct value of occupational therapy. ❖ tional Therapy, 71, 7112420030. https://doi.org/10.5014/ajot
.2017.716S12
ACOTE STANDARDS American Occupational Therapy Association. (2018). Guidelines
for documentation of occupational therapy. American Journal of
This chapter addresses the following ACOTE Standards: Occupational Therapy, 72(Suppl. 2), 7212410010. https://doi.org
/10.5014/ajot.2018.72S203
■ B.3.3. Distinct Nature of Occupation
American Occupational Therapy Association. (n.d.-a). Do’s and
■ B.4.6. Reporting Data don’ts of documentation: Tips from OT managers. Retrieved from
■ B.4.8. Interpret Evaluation Data https://www.aota.org/Practice/Manage/Reimb/documentation
■ B.4.22. Need for Continued or Modified Intervention -dos-donts-tips-from-OT-managers.aspx
■ B.4.28. Plan for Discharge American Occupational Therapy Association. (n.d.-b). The IMPACT
■ B.4.29. Reimbursement Systems and Documentation. act: What you need to know. Retrieved from https://www.aota
.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare/Guidance
/IMPACT-act-what-you-need-to-know.aspx
REFERENCES American Occupational Therapy Association. (n.d.-c). Improving
Accreditation Council for Occupational Therapy Education. (2018). measures for occupational therapists. Retrieved from https://
2018 Accreditation Council for Occupational Therapy Education www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare
(ACOTE) standards and interpretive guide. American Journal of /Improving-Medicare-Post-Acute-Care-Transformation.aspx
Occupational Therapy, 72, 7212410005. https://doi.org/10.5014 American Occupational Therapy Association. (n.d.-d). Individual
/ajot.2018.72S217 measures for occupational therapy. Retrieved from https://www
American Occupational Therapy Association. (2014). Occupational .aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare
therapy practice framework: Domain and process (3rd ed.). /MACRA/individual-measures.aspx
Centers for Medicare and Medicaid Services [CMS]. (2012). Phys- Sames, K. M. (2015). Documenting occupational therapy practice.
ical, occupational, and speech therapy services. Retrieved from Upper Saddle River, NJ: Pearson.
http://www.cms.gov/Outreach-and-Education/Outreach/Open Scott, R. W. (2013). Legal, ethical, and practical aspects of patient
DoorForums/Downloads/090512TherapyClaimsSlides.pdf care documentation: A guide for rehabilitation professionals
Cronin, A., & Graebe, G. (2018). Clinical reasoning in occupational (4th ed.). Boston: Jones & Bartlett.
therapy. Bethesda, MD: AOTA Press. Yamkovenko, S. (2014). How to be more effective with documenta-
Mann, D. & Tressider, A. (2016). Advocacy through daily docu- tion: Q & A with Cathy Brennan. Retrieved from https://www
mentation: Creating the evidence base. Presentation at the 2016 .aota.org/Publications-News/AOTANews/2014/QA-Cathy
AOTA Annual Conference & Expo, Chicago. -Brennan-Effective-Documentation.aspx
CHAPTER
Federal Health Care Programs and Outcomes
Jeremy R. Furniss, OTD, OTR/L, BCG 29
LEARNING OBJECTIVES
After completing the chapter, readers should be able to
■ Discuss the role of outcome performance measures in determining the value of health care services;
■ Discuss the role of the National Quality Forum and the National Quality Strategy related to outcomes in federal
programs;
■ Describe the Quadruple Aim;
■ Describe at least 1 federal program that requires outcome performance measures in each of the following settings:
inpatient, outpatient, and alternative payment models; and
■ Use external resources to identify at least 1 outcome performance measure that relates to occupational therapy services.

• Alternative payment models • National Quality Forum • Quadruple Aim
• Bundled payments • National Quality Strategy • Quality improvement
• Efficiency • Outcome performance measures • Quality Positioning System
• Electronic health record • Patient experience measures • Structural performance measures
• Episode of care • Performance-based payment • Triple Aim
• Health care performance measure • Private reporting • Value
• Merit-based Incentive Payment • Process performance measures • Value-based purchasing
System • Public reporting
OVERVIEW reimburse providers based on a full episode of care rather than

for each individual service within an episode. Doing so en-
To achieve the Triple Aim of improving the client experi- courages efficiency and eliminates fee-for-service incentives
ence of care, reducing the per capita cost of health care, and to provide unnecessary care to produce additional revenue
improving the health of populations (Berwick et al., 2008), opportunities (Perla et al., 2018). The episode of care includes
federal programs are introducing performance metrics services provided related to a specific condition experienced
to measure the processes and the outcomes of care. Public by the client. It is not necessarily limited to a single setting or
and private insurers are transitioning from passive payers provider type (National Quality Forum [NQF], 2017c).
of health care services to active purchasers of high-quality Understanding the performance measures used in fed-
services that produce measurable outcomes. Outcome per- eral programs is critical to clinical and operational success
formance measures are used by these programs to differen- in occupational therapy. This chapter provides an overview
tiate high-value services that achieve desirable outcomes and of NQF and the National Quality Strategy (NQS), describes
low-value services that are less effective. outcome performance measures used in each of the three cat-
The outcome performance measures are far from perfect, egories of federal programs, and discusses the implications
but they greatly affect service reimbursement and decisions for occupational therapy managers from the perspective of
related to the services included in bundled payment initia- the Quadruple Aim, which adds provider experience to the
tives. Bundled payments, also called episode-based payments, triple aim (Sikka et al., 2015).
https://doi.org/10.7139/2019.978-1-56900-592-7.029
277
CHAPTER
Federal Health Care Programs and Outcomes
Jeremy R. Furniss, OTD, OTR/L, BCG 29
LEARNING OBJECTIVES
■ Discuss the role of outcome performance measures in determining the value of health care services;
■ Discuss the role of the National Quality Forum and the National Quality Strategy related to outcomes in federal
programs;
■ Describe the Quadruple Aim;
■ Describe at least 1 federal program that requires outcome performance measures in each of the following settings:
inpatient, outpatient, and alternative payment models; and
■ Use external resources to identify at least 1 outcome performance measure that relates to occupational therapy services.

• Alternative payment models • National Quality Forum • Quadruple Aim
• Bundled payments • National Quality Strategy • Quality improvement
• Efficiency • Outcome performance measures • Quality Positioning System
• Electronic health record • Patient experience measures • Structural performance measures
• Episode of care • Performance-based payment • Triple Aim
• Health care performance measure • Private reporting • Value
• Merit-based Incentive Payment • Process performance measures • Value-based purchasing
System • Public reporting
OVERVIEW reimburse providers based on a full episode of care rather than

for each individual service within an episode. Doing so en-
To achieve the Triple Aim of improving the client experi- courages efficiency and eliminates fee-for-service incentives
ence of care, reducing the per capita cost of health care, and to provide unnecessary care to produce additional revenue
improving the health of populations (Berwick et al., 2008), opportunities (Perla et al., 2018). The episode of care includes
federal programs are introducing performance metrics services provided related to a specific condition experienced
to measure the processes and the outcomes of care. Public by the client. It is not necessarily limited to a single setting or
and private insurers are transitioning from passive payers provider type (National Quality Forum [NQF], 2017c).
of health care services to active purchasers of high-quality Understanding the performance measures used in fed-
services that produce measurable outcomes. Outcome per- eral programs is critical to clinical and operational success
formance measures are used by these programs to differen- in occupational therapy. This chapter provides an overview
tiate high-value services that achieve desirable outcomes and of NQF and the National Quality Strategy (NQS), describes
low-value services that are less effective. outcome performance measures used in each of the three cat-
The outcome performance measures are far from perfect, egories of federal programs, and discusses the implications
but they greatly affect service reimbursement and decisions for occupational therapy managers from the perspective of
related to the services included in bundled payment initia- the Quadruple Aim, which adds provider experience to the
tives. Bundled payments, also called episode-based payments, triple aim (Sikka et al., 2015).
https://doi.org/10.7139/2019.978-1-56900-592-7.029
277
ESSENTIAL CONSIDERATIONS Process and (2) the Measure Applications Partnership. The
Consensus Development Process brings groups together to
Demonstrating the value of occupational therapy services review measures for endorsement. NQF endorsement is con-
is now an imperative. Value can be defined as outcomes sidered the gold standard of a performance measure. The
achieved by care weighed against the cost of services (NQF, American Occupational Therapy Association (AOTA) par-
2017c). To identify value, health care performance measures ticipates in this process and currently has seats on several
are used to identify best practices and quantify outcomes of the standing committees to ensure that the occupational
achieved by health care consumers (NQF, 2017c). Managers therapy perspective is included in the endorsement process.
must understand how outcomes are measured in each set- (See the NQF website at www.qualityforum.org for more
ting to successfully demonstrate value in federal health information about this process; NQF, 2017a.) NQF main-
care programs. Measuring processes and outcomes is key tains a database of all currently endorsed measures called
to improving the quality of services provided. High-quality the Quality Positioning System, which can be accessed by
health care is considered “the right services, at the right visiting www.qualityforum.org/qps/.
time, and in the right way to achieve the best possible health” The Measure Applications Partnership reviews all mea-
(NQF, 2017a, p. 4). No matter the current score, performance sures that are used in federal programs. The Measure Ap-
measures can be used to improve practice and achieve mean- plications Partnership brings together diverse stakeholders
ingful outcomes. to review measures for use in 17 federal programs such as
For the purposes of this chapter, federal programs are Medicare and Medicaid. The external, multi-stakeholder re-
considered in 3 major categories: view of measures was mandated by Congress in the Patient
1. Programs that reimburse for inpatient services, Protection and Affordable Care Act (ACA; P.L. 111–148,
2. Programs that reimburse for outpatient services, and 2010; NQF, 2017b). Although, the legislation does not include
3. Programs that reimburse for services using alternative specific outside organizations to convene stakeholders, NQF
payment models. has maintained the contract to complete this process.
AOTA participates in Measure Applications Partnership
Although each of these settings uses different outcome perfor- by providing comments on measures that relate to the prac-
mance measures and considers outcomes in different terms, tice of occupational therapy and by having seats in various
there are some similarities. First, the NQF reviews all perfor- groups. This ensures that the perspective of occupational
mance measures used in federal programs. Second, all perfor- therapy is included in the feedback to HHS. Each year depart-
mance measures follow the NQS. ments at HHS and external groups submit performance mea-
sures to be considered for use in federal programs. Through
this program, the public and private stakeholders have the op-
National Quality Strategy
tion to write comments to be considered by the workgroups
The NQS was developed by the Agency for Healthcare Re- and coordinating committee. Measures cannot be imple-
search and Quality (AHRQ) on behalf of the U.S. Department mented into federal programs without being reviewed by the
of Health and Human Services (HHS). The strategy identi- contracted third-party organization, currently the Measure
fies 3 aims to improve health and health care quality in the Applications Partnership at NQF. This particular process is
United States: (1) better care, (2) healthy people and healthy the first opportunity to voice concerns about and support for
communities, and (3) affordable care. The NQS also identifies measures that occupational therapy practitioners may use to
top priorities to achieve the aims. Finally, there are 9 levers describe the quality of services provided.
recommended by NQS that stakeholders can use to align with
the strategy. These levers include measurement and feedback Best Practice Processes May Lead to
as well as public reporting (AHRQ, 2016a). See Figure 29.1 for
Optimal Outcomes
a diagram of the NQS. The center ring identifies the aims of
the NQS, the blue ring identifies the priorities, the green ring Performance measures can be divided into several types:
identifies the levers, and, finally, the outermost ring identifies structural measures, process measures, outcome measures,
stakeholders. patient reported measures, and patient experience measures.
Most of the work by payers and health care systems to Federal health care payment programs vary drastically from
improve the quality of health and health care in the United program to program. The largest payers of health care in
States can be traced back to the NQS (AHRQ, 2016b). the United States are Medicaid and Medicare. Each payer
maintains various fragmented programs, each with a unique
set of rules. A common element among federal public pay-
National Quality Forum
ers and private payers is the focus on outcome performance
Using the framework of the NQS, the NQF works to im- measures, which identify and quantify the results of health
prove health care in the United States by reviewing and rec- care services that clients achieve (NQF, 2017c). Payers also in-
ommending performance measures (NQF, 2017a). NQF has clude information on process performance measures, which
several major programs. Two of these programs directly recalculate whether a best practice was implemented by the
late to occupational therapy: (1) the Consensus Development practitioner (NQF, 2017c).
CHAPTER 29. Federal Health Care Programs and Outcomes 279
FIGURE 29.1. The National Quality Strategy.
Source. From “National Quality Strategy Stakeholder Toolkit,” by the Agency for Healthcare Research and Quality, 2016, p. 10. In the public domain. Retrieved from https://www
.ahrq.gov/sites/default/files/wysiwyg/nqstoolkit2016.pdf
The overarching goal of mandating outcome performance more adequately capture health care outcomes while balanc-
measures is to provide information that practitioners can use ing provider burden. Each discussion below includes resources
for quality improvement efforts to execute best practice and that should be reviewed for up-to-date information about the
achieve optimal results for program beneficiaries. Quality programs. See Table 29.1 for a reference to outside resources
improvement includes all of the systematic and individual that should be reviewed by occupational therapy managers.
efforts to improve the results of health care and the health of
people and populations (NQF, 2017c). Although less likely to
Federal programs: Outpatient services
be used for reimbursement, structural performance measures
are important and identify whether the appropriate infra- The most comprehensive quality program for outpatient services
structure is in place to deliver high-quality care (NQF, 2017c). was created by the Medicare Access and CHIP (Children’s Health
Each program and each payer address outcome perfor- Insurance Program) Reauthorization Act of 2015 (MACRA).
mance measures differently. But most programs are moving MACRA created Medicare’s Quality Payment Program (QPP) in
toward performance-based payment, where reimbursement an effort to simplify and combine 3 distinct programs in Medi-
for services is contingent at some level on processes and care Part B. The program has 2 tracks: (1) Merit-based Incentive
outcomes achieved by providers (NQF, 2017c). In general, pro- Payment System (MIPS) for traditional fee-for-service Medicare
grams can be grouped into outpatient, inpatient, and alterna- Part B outpatient claims and (2) Advanced Alternative Payment
tive payment models. Much of the systematic measurement of Models (APM). See “Medicare Alternative Payment Models” for
outcomes is still experimental, changing rapidly in an effort to more information about APM outcomes.
TABLE 29.1. Resources for Current Federal Programs and Outcomes
PROGRAM LINK NOTES

Centers for Medicare and Medicaid Innovation (CMMI) https://innovation.cms.gov Summarizes the current APMs being tested by CMS
Home Health Quality Reporting Program https://go.cms.gov/2NFJ1ju
Home Health Value-Based Purchasing https://go.cms.gov/2nxdmov
Hospital Quality Initiative https://go.cms.gov/2yi1zBh Includes QRP for:
■ Hospital inpatient
■ Hospital outpatient
■ Inpatient psychiatric facility
■ PPS exempt cancer hospitals
IMPACT Act https://go.cms.gov/2RPXaxz Medicare postacute care payment
Inpatient Rehabilitation Facility Quality Reporting Program https://go.cms.gov/2QSW8jl
Long-Term Acute Care Hospital Quality Reporting Program https://go.cms.gov/2OpPDHJ
Medicaid Adult Core Measure Set https://bit.ly/2hSM6Cq
Medicaid Child Core Measure Set https://bit.ly/2gfvcdA
QPP Alternative Payment Models (APM) https://bit.ly/2tgLAmW Medicare Part B Alternative Payment Models
Quality Payment Program (QPP) Merit-based Incentive https://bit.ly/2fUtzoX Medicare Part B Fee For Service
Payment System (MIPS)
Skilled Nursing Facility Quality Reporting Program https://go.cms.gov/2EnsUrh
Skilled Nursing Facility Value-Based Purchasing https://go.cms.gov/2auWquW
Note. CMS = Centers for Medicare and Medicaid Services; PPS = prospective payment system; QRP = quality reporting program.
MIPS. The Merit-based Incentive Payment System (MIPS) the program. Practitioners who do not meet the threshold are
replaces the Physician Quality Reporting System, the Value exempt from the program. However, practitioners who are
Based Modifier, and health information technology Mean- not exempt must submit measures or will have their Medi-
ingful Use. Starting in 2018, MIPS grades clinicians in 4 cat- care payments reduced in future years’ billing.
egories: (1) quality, (2) improvement activities, (3) advancing The future of MIPS is uncertain. The Medicare Payment
care information, and (4) costs. Clinicians or groups who Advisory Council (MedPAC) recently recommended drastic
perform the best will receive additional incentive payment in changes to (or even the elimination of) the program. Recent
future years’ billing, and clinicians or groups who perform research on efficacy of the relatively new program has also
the worst will receive reduced payments as a penalty in future highlighted challenges. However, it is clear that services pro-
years’ billing. MIPS intends to quantify value by comparing vided must be linked to value. Occupational therapy must
quality and costs—those who achieve the best outcomes with demonstrate that the right outpatient services are being pro-
the lowest costs are rewarded at the cost of clinicians who vided to the right clients at the right time. If mandated to
are more expensive or report worse outcomes. Clinicians who report under MIPS, practitioners must choose performance
use certified electronic health records (EHR) that patients can measures that allow for quality improvement and measure
access and those who systematically use their scores to inform the impact of the services provided.
quality improvement as described in the improvement activi- Although Medicaid is the nation’s largest health insurance
ties category can receive additional points in the comparison. program, the performance metrics used for Medicaid outpa-
Medicare maintains a list of performance measures that can tient services are not standardized. Each state designs its own
be submitted by clinicians who are part of MIPS at https:// Medicaid program that is funded by a federal and state part-
qpp.cms.gov/mips/quality-measures. nership. The NQF Measure Applications Partnership brings
Not all clinicians who bill Medicare Part B fee-for-service together various stakeholders to develop 2 core sets of perfor-
must participate in MIPS. Occupational therapy practi- mance measures for the program: (1) the Core Set for Adults
tioners were not required to participate in 2018 but may be and (2) the Core Set for Children. The Core Set reports also
required to participate starting in 2019. The program also has identify measurement gap areas and recommend improved
a low-volume threshold that may change from year to year. measurement. States are not required to use the core sets
This combines a minimum number of beneficiaries and a but are encouraged to report on all of the performance mea-
minimum dollar amount that must be met to participate in sures (NQF, 2017d, 2017e). Occupational therapy managers
should review local Medicaid quality programs. These local Value-based purchasing. Value-based purchasing (VBP)
programs should include lists of performance measures used takes the quality reporting programs beyond public or private
by the payer. Occupational therapy practitioners should re- reporting and changes Medicare payment based on the perfor-
port any of these performance measures that are applicable mance measures. VBP was authorized across Medicare by the
to their practice. ACA in an effort to reward effective quality improvement across
The Medicaid Waiver program is a nontraditional reim- inpatient facilities. Although the programs are still relatively
bursement system that often pays for long-term supports and new and the effectiveness of the programs has yet to be realized,
services in the community. In 2015, waivers in 21 states and performance on the key indicators can significantly change the
the District of Columbia reimbursed for occupational therapy amount a facility is reimbursed under Medicare (Figueroa et al.,
services (Friedman & VanPuymbrouck, 2018). Standardized 2016; Krinsky et al., 2017; Ryan et al., 2015). Value-based pur-
performance measures are being developed for long-term chasing programs have also recently rolled out to skilled nurs-
supports and services. In 2018, 4 process performance mea- ing facilities and home health agencies (CMS, 2015; Grabowski
sures were submitted to NQF for review. Occupational ther- et al., 2017). See Table 29.1 for links to the current information
apy practitioners who understand the performance measures for these programs.
that are used for accountability in waiver programs can tar-
get the value proposition to the measures that matter to the Efficiency. Federal programs are searching for the right
payers and ensure that documentation of interventions and performance measures to trigger the carrot (increased reim-
outcomes aligns with the measures that are affected by the bursement) and stick (decreased reimbursement) to force sys-
intervention. tems to improve the quality of services and achieve optimal
outcomes while balancing efficiency. Efficiency looks at the
Medicare inpatient services cost and the quality of services. True efficiency is achieved
when the quality of services is increased and the cost of ser-
Quality reporting. Nearly all inpatient care reimbursed vices is decreased (NQF, 2017c). Occupational therapy has a
by Medicare Part A has a corresponding Quality Reporting clear role to play in many of the performance measures in
Program (QRP) that reports outcomes. Unlike MIPS, which use. Spending on quality occupational therapy services can
scores individual clinicians or groups of clinicians, QRPs reduce readmissions following hospitalization (Rogers et al.,
score facilities as a whole on the performance measures. 2017). Occupational therapy services focus on the ability of a
Facility scores for these performance measures are publicly person to engage in meaningful activities and self-care. It is
reported on websites such as Medicare’s Hospital Compare critical that the occupational therapy manager understands
(www.medicare.gov/hospitalcompare/) and Nursing Home the performance measures that grade the inpatient facility in
Compare (www.medicare.gov/nursinghomecompare/) sites. which they work to clearly articulate the value of services in
Public reporting of the measures allows the public (and each setting.
insurers) to see the facility’s performance on key indicators
of quality (NQF, 2017c). Often these outcome performance
Medicare alternative payment models
measures include readmission rates and client or patient
experience measures (commonly from Consumer Assess- Alternative payment models (APM) hope to “produce better
ment of Healthcare Providers and Systems surveys; AHRQ, care at a lower cost by inducing changes in the way that clini-
2014). Patient experience measures score facilities and pro- cians and organizations deliver health care” (Rajkumar et al.,
viders based on feedback directly from clients (NQF, 2017c). 2014, para. 16). The ACA created the Centers for Medicare and
The Centers for Medicare and Medicaid Services (CMS) Medicaid Innovation (CMMI), which is the home for many
also provides private reporting of the measures when CMS APMs. Although each APM is unique, the common elements
provides current performance and comparisons of similar include reimbursing for care outside of the fee-for-service
facilities directly to stakeholders to encourage systematic system and an effort to improve the quality of care received
quality improvement based on the measure results (NQF, by beneficiaries (Rajkumar et al., 2014).
2017c). CMS anticipates that facilities will engage in quality Accountable care organizations (ACOs) are perhaps one
improvement and work as a team to provide more efficient of the best-known types of APMs. These organizations com-
and effective care to beneficiaries. One such example is a pro- bine providers across settings to take responsibility for the
gram to reduce the incidence of sepsis following QRP results quality and cost of care for a population. The actual makeup of
(Barbash et al., 2017). the ACO can vary significantly based on the target population,
The Improving Medicare Post-Acute Care Transforma the institutions and clinicians involved, and the contracts. It is
tion (IMPACT) Act of 2014 (P.L. 113–185) required the possible that occupational therapy practitioners could provide
standardization of data elements and the implementation of care as a part of an ACO and not be aware of the agreements
performance measures across postacute care QRPs. Several made between institutions and payers (Kaufman et al., 2017).
performance measures implemented as a result of IMPACT APMs offer significant opportunity for occupational therapy
are directly influenced by the practice of occupational ther- practitioners to demonstrate the value of the profession.
apy, including change in self-care function and discharge As with traditional inpatient and outpatient services, un-
self-care function (Kroll & Fisher, 2018; Sandhu et al., 2018). derstanding the process performance measures and outcome
performance measures are important. But an occupational measurement and care improvement without consideration
therapy manager’s first question should be, “Does our facility of the demands on providers may contribute to the incidence
participate in any accountable care organizations or other al- of burnout. To combat this issue, many organizations have
ternative payment models?” That answer should be followed now adopted the Quadruple Aim—adding a 4th goal of im-
closely by asking which performance measures are used to proving the provider experience (Henkel & Maryland, 2015).
determine success. Visit https://innovation.cms.gov to see the As occupational therapy managers look to improve prac-
current APMs that are part of the CMMI. tice and attain measurable outcomes, the joy of occupational
After understanding the performance measures used to therapy practice cannot be overlooked. It is important to
quantify the value of services, occupational therapy managers consider the burden and work flow of practitioners when
can integrate performance areas into practice as appropriate implementing new processes and emphasizing performance
for the services offered. This also allows occupational therapy measurement. Value-based care can be compatible with
managers to clearly articulate the value of occupational ther- recapturing the joy of practice by focusing on what practi-
apy based on performance measures that payers are using to tioners do best and empowering practitioners to collaborate
determine the value of services provided by the organization. with clients to achieve outcomes.
Review Questions Occupational Therapy Process

1. Describe the role of the NQF in relationship to outcomes Occupational therapy is client centered; this provides an
performance measures in federal programs. opportunity to demonstrate a distinct value using perfor-
2. What is the difference between a process performance mance measures (Mroz et al., 2015). It is critically import-
measure and an outcome performance measure? Visit ant that occupational therapy practitioners follow and doc-
the Quality Positioning System webpage and identify one ument the occupational therapy process to demonstrate best
NQF-endorsed example of each. practices that lead to outcomes. The occupational therapy
3. Using the websites in Table 29.1, identify 1 performance process, as described in the Occupational Therapy Practice
measure in a QRP or MIPS that relates to the practice of Framework: Domain and Process, 3rd Edition, provides a
occupational therapy. framework for common elements of practice while allowing
the flexibility to use any appropriate model in any setting
(AOTA, 2014).
PRACTICAL APPLICATIONS IN The occupational therapy process includes the evalua-
OCCUPATIONAL THERAPY tion, intervention, and targeting of outcomes. The evaluation
includes the occupational profile and the analysis of occu-
Occupational therapy can greatly affect outcomes that are pational performance. The AOTA Occupational Profile Tem-
important to clients, the health care system, and payers. Oc- plate (https://bit.ly/2GUQOKk; see Appendix 25.A) can be
cupational therapy managers should be familiar with which used to guide practitioners on executing and documenting
performance measures are being used to quantify the value the complete profile to gather the client’s experiences and
of services in the setting in which they practice. These per- perspectives, which should guide the evaluation. When ap-
formance measures are meant to provide information to propriate, the analysis of occupational performance should
clinicians to improve practice. After identifying the perfor- include the targeting of outcomes associated with outcome
mance measures used by payers, it is important to examine performance measures. One example is the self-care and
best practice occupational therapy to compare to the current mobility items in postacute care (Sandhu et al., 2018). Best
practice in the clinic (Leland et al., 2015). A formal quality practice interventions and recommended assessments can be
improvement program such as the Model for Improvement or found in the AOTA Occupational Therapy Practice Guide-
audit, feedback, and education can be used to identify oppor- lines Series (www.aota.org/pg).
tunities and determine the best path forward to better care
and better outcomes (Vratsistas-Curto et al., 2017). Documentation
Although it is extremely important that practitioners imple
The Triple Quadruple Aim
ment best practices, it is also critical that documentation
The ACA is grounded in the Triple Aim. As previously dis- demonstrates best practices that occur with clients. Recent
cussed, the Triple Aim’s 3 goals are “improving the individ- documentation reviews have shown a gap between best prac-
ual experience of care; improving the health of populations; tice and documentation (Leland et al., 2017). Ideally, docu-
and reducing the per capita costs of care for populations” mentation will occur in an electronic health record (EHR),
(Berwick et al., 2008, p. 760). The Triple Aim is used to guide which facilitates the collection of health and health care–
the transition from volume-based to value-based health related data in a systemic way (NQF, 2017c). Many EHR
care. programs have the capability to monitor performance mea-
Health care reimbursement models have led to an in- sures and integrate best practices such as the occupational
creased emphasis on provider productivity and measurable profile. Occupational therapy managers who are aware of the
performance across professions (Gergen Barnett, 2017). To- measures being used may be able to use the documentation
gether with productivity demands, emphasizing performance system to provide regular feedback to practitioners.
CASE EXAMPLE 29.1. Quality Improvement in a Skilled Nursing Facility Under Medicare
After reviewing the details of the skilled nursing facility (SNF) QRP, Silvia, the occupational therapy manager, met with facility administration to review
current scores for performance measures. The report indicated that their facility was performing worse on the “Change in Self-Care” outcome performance
measure than the comparison facilities. The facility administration has identified this outcome performance measure as a priority for improvement.
Silvia reviewed the performance measure information in the SNF QRP resources online and discovered that the self-care measure is based on
data elements from Section GG of the Medicare assessment used in SNFs, the Minimum Data Set (MDS).
Silvia reviewed occupational therapy documentation in 10 random charts from the previous measurement period. Starting with the evaluation,
she found that none of the charts contained a specific occupational profile. Although some information from the occupational profile was included
in 2 of the 10 evaluations, she also noted that none of the evaluations or discharge summaries used the descriptions or definitions in Section GG
of the MDS. Finally, only 3 of the 10 evaluations used a standardized assessment related to self-care.
The occupational therapy team met to review their current practices and decided to use a practice improvement model, The Plan, Do, Study,
Act (PDSA) method to identify small changes in practice and measure results. After completing several rounds of a formal quality improvement
program, the department decided 2 major items were helpful: (1) completing and documenting the occupational profile in every evaluation and
(2) scoring all self-care items for each client at evaluation and discharge. Every occupational therapy practitioner completed the Medicare training
on scoring the self-care items. Silvia added these items to her chart review process to provide regular feedback to practitioners.
Silvia communicated the plan to administration, which began to review occupational therapy documentation before submitting final scores on the
self-care items to Medicare. When connected by the occupational profile, occupational therapy practitioners included improvement in self-care as
part of the client’s plan of care. The facility began actively tracking the “Change in Self-Care” measure, which demonstrated steady improvement.
Review Questions
1. Why would Silvia choose the “Change in Self-Care” outcome performance measure as a focus?
2. Do you think communication across departments is important when undertaking clinical quality improvement efforts? Why or why not?
3. Describe how occupational therapy practice may be connected to outcomes in federal programs.
Distinct Value of Occupational Therapy and programs that are applicable to their practice setting to under-
Performance Measures stand how occupational therapy can affect the overall value cal-
culation for the organization.
No performance measure captures the full scope or value of Performance measures offer an opportunity for feedback
services provided by occupational therapy practitioners or any and quality improvement. It is important for an occupational
other health care provider. The distinct value of occupational therapy manager to review and understand the scores on per-
therapy cannot be summarized in any set of measures. Simi- formance measures. Although the scores do not capture the
larly, not all performance measures are affected by occupational complete value of occupational therapy, they can provide a
therapy. But performance measures offer an opportunity for reference point and impetus to improve the quality of occu-
occupational therapy practitioners to discuss how best practice pational therapy services provided and outcomes achieved by
services contribute to the performance areas and outcomes that the occupational therapy clients. ❖
affect organizations’ public reporting and even reimbursement
amount. The primary goal of reporting performance measures
is to provide feedback to consumers for improved choice and ACOTE STANDARDS
to organizations and clinicians for improved practice. The
true value of occupational therapy services are the meaningful This chapter addresses the following ACOTE Standards:
outcomes achieved by each individual client, but performance ■ B.4.29. Reimbursement Systems and Documentation
measures offer an opportunity to quantifiably articulate the ■ B.5.1. Factors, Policy Issues, and Social Systems
value of services to payers, organizations, and systems. ■ B.5.7. Quality Management and Improvement.
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Advancing the value and quality of occupational therapy in health tion in a multidisciplinary stroke unit. BMJ Open Quality, 6(2).
service delivery [Health Policy Perspectives]. American Journal https://doi.org/10.1136/bmjoq-2017-000212
CHAPTER
Private Health Insurance
Katie Jordan, OTD, OTR/L, and Sharmila Sandhu, JD 30
LEARNING OBJECTIVES
■ Describe the history and current state of private health insurance,
■ Identify benefits and challenges of private health insurance,
■ List and describe 4 models of managed care common in the private health insurance industry, and
■ Discuss the regulatory mechanisms and climate for private health insurance.

• ACA marketplace exchanges • Employer-sponsored insurance • Indemnity
• Affordable Care Act • Essential health benefits • Noncovered health care services
• Balance bill • Exclusions • Out-of-network
• Claim • Fee-for-service • Out-of-pocket expense
• Coinsurance • Health benefits • Preexisting medical condition
• Copayment • Health Care Payment Learning • Premium
• Coverage policy and Action Network • Provider agreement
• Covered health care services • In-network • Surprise medical bill
• Deductible
OVERVIEW being employer based, also known as employer-sponsored
H
ealth insurance is a means of financing health care ex- insurance (ESI; Barnett & Berchick, 2017). Individuals in the
penses. In the United States, most insured individuals United States can also obtain coverage through government-
finance their health expenses through private health based programs or workers’ compensation, or they may be
insurance coverage offered by their employer or union or uninsured. Access to health care coverage is a shifting land-
purchased directly from an insurance company or Afford- scape made up of public and private financing options, state
able Care Act (ACA) marketplace exchange (U.S. Census and federal policy and legislation, and consumer capacity and
Bureau, 2017; Figure 30.1). The Patient Protection and Af- choice (Claxton, 2002).
fordable Care Act of 2010 (P.L. 111–148), commonly called Occupational therapy practitioners, managers, and lead-
ACA or Obamacare, is a U.S. federal statute signed into law ers need to consider the changing landscape; understand and
by President Barack Obama on March 23, 2010. ACA mar- weigh each factor; and recognize how shifts in health insur-
ketplace exchanges are organizations created by the ACA ance funding, reform, and coverage policies affect consumer
to allow individuals and families to compare and purchase access to medically necessary occupational therapy services.
private health insurance plans and to facilitate access to tax A coverage policy is a contract between the health insurance
credits that may make those plans more affordable to individ- organization and the policy holder (individual, group, or orga-
uals with low and moderate incomes. nization) that delineates covered and noncovered health care
In 2016, private health insurance accounted for 67.5% of services. A health care service that is paid for in whole or in
all health care coverage, with the majority subtype (55.7%) part under a coverage policy is considered a covered service.
https://doi.org/10.7139/2019.978-1-56900-592-7.030
285
CHAPTER
Private Health Insurance
Katie Jordan, OTD, OTR/L, and Sharmila Sandhu, JD 30
LEARNING OBJECTIVES
■ Describe the history and current state of private health insurance,
■ Identify benefits and challenges of private health insurance,
■ List and describe 4 models of managed care common in the private health insurance industry, and
■ Discuss the regulatory mechanisms and climate for private health insurance.

• ACA marketplace exchanges • Employer-sponsored insurance • Indemnity
• Affordable Care Act • Essential health benefits • Noncovered health care services
• Balance bill • Exclusions • Out-of-network
• Claim • Fee-for-service • Out-of-pocket expense
• Coinsurance • Health benefits • Preexisting medical condition
• Copayment • Health Care Payment Learning • Premium
• Coverage policy and Action Network • Provider agreement
• Covered health care services • In-network • Surprise medical bill
• Deductible
OVERVIEW being employer based, also known as employer-sponsored
H
ealth insurance is a means of financing health care ex- insurance (ESI; Barnett & Berchick, 2017). Individuals in the
penses. In the United States, most insured individuals United States can also obtain coverage through government-
finance their health expenses through private health based programs or workers’ compensation, or they may be
insurance coverage offered by their employer or union or uninsured. Access to health care coverage is a shifting land-
purchased directly from an insurance company or Afford- scape made up of public and private financing options, state
able Care Act (ACA) marketplace exchange (U.S. Census and federal policy and legislation, and consumer capacity and
Bureau, 2017; Figure 30.1). The Patient Protection and Af- choice (Claxton, 2002).
fordable Care Act of 2010 (P.L. 111–148), commonly called Occupational therapy practitioners, managers, and lead-
ACA or Obamacare, is a U.S. federal statute signed into law ers need to consider the changing landscape; understand and
by President Barack Obama on March 23, 2010. ACA mar- weigh each factor; and recognize how shifts in health insur-
ketplace exchanges are organizations created by the ACA ance funding, reform, and coverage policies affect consumer
to allow individuals and families to compare and purchase access to medically necessary occupational therapy services.
private health insurance plans and to facilitate access to tax A coverage policy is a contract between the health insurance
credits that may make those plans more affordable to individ- organization and the policy holder (individual, group, or orga-
uals with low and moderate incomes. nization) that delineates covered and noncovered health care
In 2016, private health insurance accounted for 67.5% of services. A health care service that is paid for in whole or in
all health care coverage, with the majority subtype (55.7%) part under a coverage policy is considered a covered service.
https://doi.org/10.7139/2019.978-1-56900-592-7.030
285
FIGURE 30.1. Percentage of people by type of health insurance coverage and change from 2013 to 2016.
Percentage-point change: Percentage-point change:

Percent in 2016 2015 to 2016 2013 to 2016
0 20 40 60 80 100 –6 –4 –2 0 2 4 6 –6 –4 –2 0 2 4 6
Uninsured
With health insurance
Any private plan

Employment-based
Direct-purchase
Any government plan

Medicare
Medicaid
Military health care*
Changes between the estimates are not statistically different

from 0 at the 90% confidence level.
This chapter examines the history and role of private Initially, medical prepayment plans were developed in spe
health insurance as one mechanism for health care financ- cific industries, such as railways, logging, and mining, to en-
ing. Exploration of private insurance structure, regulatory sure that workers had access to physicians and hospitals in
environments, and reimbursement mechanisms are also dis- remote areas (Reed, 1965). These earliest private plans, called
cussed. This chapter focuses on historical and current issues hospital associations, were created by employers to cover
influencing private health insurance, consumers, and occupa- workers who were injured. Commercial accident and health
tional therapy practitioners. Finally, the chapter discusses the insurance plans, first written in the United States in 1847, were
current and potential future state of private health insurance. funded by a worker payroll deduction and were later expanded
to cover disability caused by accident or illness and reimburse-
ment for some medical expenses (Williams, 1932). Similar
ESSENTIAL CONSIDERATIONS prepayment health plans were later developed by employers in
other industries and by private medical groups in the 1920s.
Origin of Private Health Insurance
Most often referenced as the first model of modern private
The landscape and scope of the private health insurance market insurance are the Blue Cross and Blue Shield (BCBS) health
have shifted significantly since its inception in the mid-1800s; plans. With the deepening of the Great Depression in the early
however, the basic idea on which private health insurance was 1930s, hospitals experienced a simultaneous decline in pur-
founded has remained consistent. Private health insurance chased health care services and increase in the need for free
plans generally pool the resources of a community of individu- or greatly discounted care. Baylor University Hospital of Texas
als. Costs and risks are shared through different mechanisms, had created a prototype of a hospital health plan in 1929 that
including premiums, deductibles, copayment, and coinsurance. gained momentum as a mechanism to counteract this trend.
An insurance plan’s premium to “subscribers” or clients is School teachers in Dallas were eligible for a limited amount
an out-of-pocket expense that the client must pay to access the of hospital care if they contributed a monthly premium to the
plan, usually charged on a monthly basis. Out-of-pocket health hospital. This model gained traction with other hospitals and
care expenses must be paid by the consumer. Costs paid by eventually caught the attention of the American Hospital As-
the consumer may or may not be recouped depending on the sociation, which created formal requirements for these plans
health plan policy. A deductible is a set amount of money that a and labeled them with a solid blue Greek cross design, resulting
client must pay for health care each year out of pocket, prior to in the plans being called “Blue Cross” health plans (“Blue Cross
being authorized to obtain certain services at no or lower cost and Blue Shield: A Historical Compilation,” n.d.; Reed, 1965).
under the plan. Copayment is the set amount of money clients A similar evolution occurred in health plans to cover physi-
must pay for each health care practitioner visit, often for pri- cian services. The first provider-based plans were developed by
mary care visits, as well as for visits to specialists depending on the California Physicians’ Services in 1939 as indemnity plans
the plan’s benefits. Coinsurance refers to money that a client (Morrisey, 2014). Indemnity plans allow clients to visit almost
is required to pay for services and is often specified by a per- any doctor or hospital they prefer. The insurance company
centage; for example, the insured client pays 20% toward the then pays a set portion of the total charges. Indemnity plans
charges for a service and the insurance company pays 80%. are also referred to as fee-for-service plans. Additional types
CHAPTER 30. Private Health Insurance 287
of plans were created with backing from medical professional

associations and later labeled “Blue Shield” health plans. TABLE 30.1. Several Common Managed Care Plans
By 1946, a total of 44 private health plans covered 4.4 mil-
MANAGED CARE PLAN PLAN DESCRIPTION
lion enrolled participants (Reed, 1965). Insurance compa-
nies began to enter the field by constructing plans to cover Health maintenance These plans usually pay only for medical
organizations (HMOs) care within their network of health care
discrete events such as hospitalization and surgery, initially
providers. HMOs generally cost less
for the employees of private companies and later expanded
than plans that offer a greater choice
to include dependents. Other notable group plans formed in of providers.
these early years include Kaiser Permanente, which opened to
public enrollment in 1945 (Kaiser Permanente, n.d.). Preferred provider These plans cover more medical costs if
During World War II, employers began expanding ESI as organizations (PPOs) the patient gets care within the network
a fringe benefit of employment to attract workers. Following of care providers, but they still pay some
the Taft–Hartley Act of 1947 (P.L. 80–101), health benefits costs for care outside of the network.
were designated a condition of employment and therefore Point of service (POS) Patients can choose between an HMO or
subject to collective bargaining, allowing unions to play a role a PPO each time they get medical care.
in the expansion of the market. Health benefits are health care These plans are the newest form of
products and services that are covered in whole or in part by managed care plan commonly offered
the health plan. The ESI market was further largely bolstered by employers and offer more flexibility
by federal and tax legislation (Internal Revenue Act of 1954, in choosing doctors and hospitals.
P.L. 83–591) that supported this mechanism for private health Exclusive provider A managed care plan in which services
care financing (Gruber, 2011). organization (EPO) are covered only if patients go to doctors,
The percentage of the U.S. population with health care in- specialists, or hospitals in the plan’s
surance more than doubled by the end of World War II and network (except in an emergency).
doubled again by 1950, bringing the total of privately covered
individuals in the country up to 70% by 1960 (Morrisey, 2014).
The concept of corporate self-insurance as a mechanism re-
ceived a boost in 1974 when the Employee Retirement Income that integrate the financing and delivery of health care. Pur-
Security Act (P.L. 93–406) prohibited states from applying chasers contract with selected providers to deliver a defined
coverage mandates to self-insured plans. Additional refine- set of services at an agreed per-capita or per-service price. In
ments in the calculation of risk pools and the emergence of a reality, managed care encompasses a wide range of arrange-
variety of plan structures from the 1970s to 2010 allowed pri- ments, some of which resemble discounted fee-for-service (e.g.,
vate health insurance, particularly ESI, to remain the domi- preferred provider organizations, in which the member receives
nant mechanism of health care financing in the United States. better benefits with lower copayments by using contracted
providers rather than nonpreferred providers) and others
Contemporary Private Health Insurance using capitation and gatekeepers or primary care practitioners
to manage client care and authorize referrals (Sekhri, 2000).
Although the majority of private insurance coverage is still Several common managed care plans are listed in Table 30.1.
provided by ESI, the establishment of ACA insurance market Managed care stands in contrast to the concept of fee-for-
places in 2014 provided new options for consumers to pur- service reimbursement, which is a common payment struc-
chase their own private insurance plans. In 2013, about 197 ture seen in publicly funded programs, such as traditional
million Americans had commercial health insurance through Medicare and Medicaid practices, in which the health care
employers or through individual purchases or policies with professional bills for and is reimbursed a set amount (pre-
public subsidies (National Council of State Legislators [NCSL], suming coverage criteria are met) for each individual clin-
2018). Since then, federal health care reform has added to ex- ical service provided. However, Medicare and Medicaid
isting state regulation, mandates, and consumer protections. programs may also contract with private insurance entities
The opening of ACA-authorized health insurance market to provide Medicare managed care and Medicaid managed
places resulted in about 12 million individuals purchasing new care, further blurring the lines between the private and public
health policies between October 2013 and January 2018. Large health insurance landscape.
employers are still required to offer health insurance, whereas
smaller employers can obtain an incentive subsidy if they opt
to offer coverage (NCSL, 2018). Among employers that offer
health insurance, some offer only one type of plan, whereas For Additional Learning
others may allow choice from more than one plan option.
Many employers offer health insurance plans based on For information on federal and state-funded health insurance
programs such as Medicare, Medicaid, the Children’s Health
standard managed care options. In traditional managed care
Insurance Program, and insurance provided to service members
plans, the money follows the subscriber or member, whether ill and veterans, see Chapter 29, “Federal Health Care Programs
or not. Although there are many definitions of managed care, and Outcomes.”
generally the term describes a continuum of arrangements
Impact of ACA Implementation on Emerging Payment Models

Private Health Insurance Private health insurance has also been significantly affected
Health coverage through the workforce continues to be the by the health care landscape’s movement to maximize quality
most common source of health insurance financing in the care and client preferences while minimizing the costs of care.
United States (Fronstin, 2010). However, ESI coverage began Federal programs initially established pay-for-performance
to erode during the 2007–2008 recession, and there was a models at the end of 2003 in response to a call to strengthen
subsequent decline in workers receiving health benefits, with quality measures, improve client outcomes, and maintain
workers at lower earnings levels affected disproportionately physician accountability (Sura & Shah, 2010). At that time, the
(Fronstin, 2010). One of the most significant innovations in goals were simple: If various health care stakeholders could
the structure of private health insurance, however, occurred not only demonstrate higher quality but also publicly report
with the 2010 enactment of the ACA. such results, financial incentives would follow. Outside of the
Several key provisions of the ACA fundamentally altered Centers for Medicare and Medicaid Services (CMS), major
the private insurance industry, requiring substantial changes corporations joined efforts to improve quality of care through
to health plans (Institute of Medicine [IOM], 2009). Some of a framework whereby clinicians were rewarded per client for
the required changes included the addition and inclusion of quality improvements made in health information technol-
10 essential health benefits (IOM, 2011), the requirement to pro- ogy, care coordination, and decision support teams. Addi-
vide coverage to persons with a preexisting medical condition tional models that created incentives for clinician high-quality
without excluding that condition, and the ability for young performance and payment penalties for poor performance
adults to remain on their parents’ health plan. The essential emerged (CMS, 2018a). In addition, models that emphasize
health benefits that must be covered by health insurance plans in the provision of primary care across systems emerged, such as
the individual and small-group markets (unless an exclusion ap- accountable care organizations (CMS, 2018b).
plies) include ambulatory patient services; emergency services; Anthem Blue Cross and Blue Shield of New Hampshire
hospitalization; maternity and newborn care; mental health and is one example of a private health insurance company that
substance use disorder services, including behavioral health embraced payment and innovative health delivery early.
treatment; prescription drugs; rehabilitative and habilitative Anthem’s program focused on rewarding practices for im-
services and devices; laboratory services; preventive and well- plementing preventive measures, such as cancer screening,
ness services and chronic disease management; and pediatric well child examinations, and childhood immunizations.
services, including oral and vision care (Cassidy, 2013). A preex- Under this program, physicians who rank in the top 25% of
isting condition is a medical or mental health condition that was adherence to metrics relative to other providers within the
diagnosed before commencement of the health plan coverage. network receive an additional $20 per patient per year. This
The ACA also greatly expanded individual access to private type of trend has become more prevalent with the creation of
health insurance for people without access to ESI through the advanced integrated primary care models.
workplace (Collins et al., 2017). The financial performance In 2015, the U.S. Department of Health and Human Ser-
of private health insurers showed strain in 2014 as they devices (DHHS) launched the Health Care Payment Learning
veloped ACA-compliant health plans, competed for market and Action Network, or LAN, to help advance the work being
share, and attempted to appropriately price their health plans done across private, public, and nonprofit sectors to increase
(Coleman, 2013; Hall & McCue, 2016). the adoption of value-based payments and additional new,
Despite drastic changes that went into effect in 2014, the innovative payment and care delivery models, often called
private insurance industry remained strong (Semanskee alternative payment models (APMs).
et al., 2017). Some preexisting plans within the employer-
sponsored market were exempted from many of the ACA re-
quirements through the Section 13 provision (Kaiser Family For Additional Learning
Foundation & Health Research and Educational Trust, 2014).
Although some insurers struggled, leaving the marketplace For information on LAN and APMs, see Chapter 49, “Designing a
in their states altogether, others adapted by reforming prod- Payment Structure.”
ucts, gaining actuarial prowess that resulted in premium
increases, and entering into mergers and acquisitions that
began to consolidate the market and narrow the network of New payment and delivery models challenge the pro-
insurers and providers (Holahan et al., 2016). fession of occupational therapy to demonstrate the distinct
The ACA faced significant challenges starting in 2017 as value of its services to enhance patient outcomes over not
the Trump administration made revisions to key policies, only the short term but also the long term by, for example,
including repealing the individual mandate requiring health decreasing hospital readmissions and reducing caregiver bur-
insurance coverage for eligible individuals. Because of con- den. The development of setting-specific or clinician-specific
tinual changes in the health care industry and in the insur- quality measures or indicators has been a key component of
ance industry, the future of ACA marketplaces for individual emerging payment and delivery models. Scientific validity
subscribers remains uncertain. and feasibility for quality measures are frequently required
by both public and private health insurance payers (National without purchasing health insurance from an issuer, are
Quality Forum, 2018). called self-funded group health plans. Private employment-
New payment models have been developed in all dif- based group health plans are typically regulated by the U.S.
ferent shapes and sizes and with varying objectives. Some Department of Labor. Nonfederal governmental plans are
payment models bundle care into an episode, such as mod- regulated by DHHS.
els targeting joint replacements. Other models are focused Market regulation attempts to ensure fair and reasonable
on specific conditions, such as the Oncology Care Model. insurance prices, products, and trade practices to protect
Others are deemed pay-for-performance. Although it is too consumers. With improved cooperation among states, regu-
early to tell what the outcome of this trend will be, literature lators hope to ensure continued consumer protections at the
is being produced to evaluate the impact to cost, quality, state level. When violations are found, the insurance depart-
and patient experience (Mendelson et al., 2017). The land- ment makes recommendations to improve the company’s op-
scape for emerging health care payment and delivery mod- erations and to bring the company into compliance with state
els continues to change, but it is clear that quality care and law. In addition, a company may be subject to civil penalties
quality measurement for health care services are trends that or license suspension or revocation.
will persist.
Review Questions
Overview of Regulatory Climate
1. What was the purpose of the earliest private health in-
Health care coverage provided by insurance health plans is surance plans?
subject to multiple regulatory environments, including state a. The earliest private insurance plans—hospital
and federal level requirements. The current state insurance associations—were created by employers to cover
regulatory framework has its roots in the 19th century, with workers who were injured.
New Hampshire appointing the first insurance commis- b. Private insurance health plans were originally created
sioner in 1851. Insurance regulators’ responsibilities grew by the government to cover children and families.
in scope and complexity as the industry evolved. Congress c. Early private health insurance was funded by em-
adopted the McCarran–Ferguson Act of 1945 (15 U.S.C. ployers to only cover family members.
§§ 1011–1015) to declare that states should regulate the busi- d. Private insurance health plans were originally cre-
ness of insurance and to affirm that the continued regulation ated by hospitals to reduce their risk when admitting
of the insurance industry by the states was in the public’s best patients.
interest (National Association of Insurance Commissioners 2. What factors allowed private health insurance to be-
[NAIC], 2011). come and remain the dominant mechanism for health
The Financial Modernization Act of 1999, also called care financing in the United States?
the Gramm–Leach–Bliley Act (P.L. 106–102), established a. The enactment of the Taft–Hartley Act of 1947
a comprehensive framework to permit affiliations among b. The enactment of the Internal Revenue Act of 1954
banks, securities firms, and insurance companies. Gramm– c. The enactment of the Employee Retirement Income
Leach–Bliley once again acknowledged that states should Security Act of 1974
regulate the business of insurance. However, Congress d. All of the above
also called for state reform to allow insurance companies 3. How do the majority of insured Americans finance their
to compete more effectively, all while continuing to pro- health care coverage?
tect consumers, which is the hallmark of state regulation a. Federally funded public insurance
(NAIC, 2011). b. Private health insurance
State legislatures and state insurance departments set c. Most Americans are not insured
broad policy for the regulation of all types of insurance (e.g., d. State-funded public insurance
health, life, auto, renters/owners). They establish and oversee 4. Of private insurance plans, what subtype is most com-
state insurance departments, regularly review and revise state mon in the United States?
insurance laws, and approve regulatory budgets. Increases a. Employer-based or employer-sponsored insurance
in state regulatory personnel and enhanced automation b. Individual plans on the ACA marketplace
have allowed regulators to substantially boost the quality c. Union-based or union-sponsored insurance
and intensity of their financial oversight of insurers and ex- d. Workers’ compensation plans
pand consumer protection activities (Burman et al., 2007; 5. How is managed care generally described?
NAIC, 2011). a. Only HMOs can be described as managed care.
Employment-related group health plans may be either b. All private insurance is managed care, while all pub-
insured (purchasing insurance from an issuer in the group licly funded health insurance is fee-for-service.
market) or self-funded. The insurance that is purchased, c. Managed care is defined as a continuum of arrange-
whether by an insured group health plan or in the indi- ments that integrate the financing and delivery of
vidual market, is regulated by the state’s insurance depart- health care.
ment. Group health plans that pay for coverage directly, d. Only PPOs can be described as managed care.
6. How is fee-for-service generally described? PRACTICAL APPLICATIONS IN

a. Only publicly funded health insurance (i.e., Medicare OCCUPATIONAL THERAPY
or Medicaid) can be described as fee-for-service.
b. Private health insurance plans operate only on a fee- How Private Health Insurance Works
for-service payment model.
Occupational therapy practitioners interacting with clients
c. Fee-for-service is defined as a reimbursement model
within the private health insurance market must be more
where providers are not paid for their service but for
attentive and detail oriented than ever before to ensure that
the outcome of their service.
their clients receive medically necessary care and that they
d. Fee-for-service is defined as a reimbursement model
are equitably reimbursed for therapy services rendered.
in which health providers are reimbursed a set
Insurance coverage is complex and requires occupational
amount for an individual clinical service as long as
therapy practitioners to use clinical judgment to ensure that
coverage criteria are met.
the client is provided with the correct intervention at the
7. What is one way in which the implementation of the
right time at the most appropriate dosage. Moreover, occu-
ACA affected private health insurance?
pational therapy practitioners must have a strong knowl-
a. The ACA marketplaces only offered private health
edge and understanding of the private insurance company’s
insurance plans.
coding and billing rules; stay up to date on coverage policies
b. The ACA eliminated private health insurance
and medical necessity standards for the services provided;
coverage.
and keep succinct, clear documentation records for each
c. The ACA expanded individual access to private
client.
health insurance for people without ESI through
Adding to the confusion, private insurance coverage poli-
their workplace.
cies and coding requirements for occupational therapy often
d. The ACA implementation converted private health
differ from company to company (e.g., Cigna vs. BCBS), or
insurance plans into public health insurance plans.
even from region to region within one company (e.g., BCBS
8. Which of the following are not an essential health
of California vs. BCBS of Florida). For this reason, new oc-
benefit?
cupational therapy practitioners must be prepared to go that
a. Adult oral and vision care
extra mile to stay informed of changes in health insurance
b. Rehabilitative and habilitative services
policies by seeking out continuing education when available
c. Mental health and substance use disorder services
to support their learning and understanding of health insur-
d. Emergency services
ance. In addition, practitioners should read and keep avail-
9. How can private health insurances participate in emerg-
able for reference all coverage and coding policies related to
ing payment models, such as pay for performance?
occupational therapy services, opt in to receive provider up-
a. Incentivizing health providers to meet evidence-
dates from the private health insurers, and identify key con-
based practice standards such as timely screenings
tacts to call with questions about coverage criteria and private
and immunizations.
insurance claims denials and appeals processes. A claim is
b. Penalizing health providers that fail to meet quality
a request for health care service payment or reimbursement
standards of care.
based on the services rendered by a qualified health care
c. Creating both incentive and penalty models to en-
provider.
courage and support high-quality, cost-effective,
evidence-based patient care. Occupational Therapy Practitioner
d. None of the above because private health insurance
Responsibilities
does not participate in emerging payment models.
10. Which of the following statements best describes the Occupational therapy practitioners may be required to
regulatory climate for private health insurance? contract with a private health insurance plan as a provider.
a. Private health insurance is regulated only by the This is more common for practitioners in private practice
U.S. Department of Labor. than for those who work for school districts, large com-
b. Private health insurance is subject to multiple reg- panies, or facilities. If occupational therapy practitioners
ulatory environments, including state and federal choose to enter into a contract as a provider for a private
level requirements. health insurance plan, they must carefully consider the
c. Private and public health insurance are both regu- plan’s rules and policies. They need to find out the cost of
lated by DHHS. the plan’s premium to subscribers (clients), what medical
d. Private health insurance is deregulated. services are covered, how the payments work, and how
11. What is the primary goal of insurance market regulation? much choice subscribers will have when choosing providers
a. To set equitable prices for insurance and hospitals.
b. To protect consumers Premiums are usually charged on a monthly basis. Sub-
c. To protect insurance companies scribers are also usually required to pay a set amount for
d. To improve cooperation among states, regulators, health care each year (known as a deductible) before the
and Congress insurer will begin to cover the costs of certain services.
Next, even after the subscriber meets the insurer’s deductible, payment), insurance market competition, and precedent of
subscribers frequently must pay for a proportion of medi- government payers (Clemens & Gottlieb, 2016). Prices for
cal expenses (coinsurance). Finally, it is common for private health care services are negotiated with providers who are
insurers to require subscribers to pay a set amount for each participating in that particular health care plan and would
health care practitioner visit (copayment) for primary care be considered in-network for the services they provide to the
visits, as well as for visits to specialists (often ranging from plan subscriber.
$10 to $30, depending on the plan; NAIC, 2011). Providers who have not negotiated prices for health care
Occupational therapy practitioners should always review services for a particular plan are considered out-of-network.
the list of medical and therapy services that are not cov- It can be challenging, especially in emergency and facility set-
ered by the insurance plan (sometimes called exclusions, tings, for health care consumers to parse out which providers
limitations, or noncovered services) because it is possible are in-network and which providers are not, which may result
that the services they frequently provide are on that list. in significant out-of-pocket costs for involuntarily seeking
Exclusions are health care products or services that are not services out-of-network, a phenomena referred to as surprise
covered by the health plan. The federal Medicare program medical bills (Kyanko et al., 2013). Out-of-network providers
represents a gold standard in health insurance in terms of may issue a balance bill to consumers for the amount beyond
requiring notice and comment rulemaking and obtaining what their insurance plan is prepared to pay. Some states have
stakeholder input into coverage and payment policies. In enacted laws to regulate this activity and protect consumers,
contrast, most private insurance companies do not require but few are comprehensive enough to safeguard consumers in
the same level of input and vetting from providers and all settings (Lucia et al., 2017).
subscribers. When individuals hold more than 1 health insurance
Providers may request a summary of the plan’s benefits plan, each plan must participate in coordination of benefits
and a sample provider contract. Health care providers may rules to determine which plan pays first as a primary payer
be participating providers in a health insurance plan, mean- and which pays second as a secondary payer (“How Medi-
ing they operate as one of the private insurance company’s care Works With Other Insurance,” n.d.). The primary payer
group of in-network health care practitioners through a pays up to its limits of coverage first. The secondary payer
provider agreement contract. Health care providers that may cover costs not paid by the first payer if it is within the
are contracted into a health plan are considered in-network, scope of coverage. Having more than 1 insurance plan does
whereas those not contracted or excluded from participating not ensure that the individual will not pay out-of-pocket for
as a provider are considered out-of-network. Provider agree- health care services
ments are contracts for services rendered and establish com- To remain solvent, occupational therapy practices and
pensation between the health insurance organization and the departments must provide high-quality clinical services and
clinical professional providing services to clients under the must also develop expertise in multiple payer requirements
insurance contract. for such issues as network enrollment, coding, billing, and
Alternatively, a practitioner can provide out-of-network appeals (AOTA, 2018).
services, meaning the client may incur extra expenses for
services. Health care providers may choose to provide ser-
Special Considerations
vices on a cash-pay basis and not accept health insurance. In
that scenario, clients may submit a reimbursement request to Certain populations have been given separate and special
their health insurance for the services in which they paid out consideration regarding health care coverage. In addition,
of pocket. consumers are challenged with maintaining the appropriate
Occupational therapy practitioners must be able to review level of health care insurance coverage due to high variability
and interpret the provider contract to ascertain certain infor- in private health insurance plans.
mation about private insurance plans to provide the optimal
covered care to clients. Case Example 30.1 provides a detailed
Mental health care coverage
example of how an occupational therapist researched and
successfully appealed an improper private insurance denial The Mental Health Parity Act of 1996 (MHPA; Pub. L.
on behalf of her client. Exhibit 30.1 is a checklist that outlines 104–204) established that large group health plans must not
key questions to ask. impose lifetime maximum or annual limits on health care
services to apply only to mental health benefits. The MHPA
provided that large group plans may impose limits to men-
How Reimbursement Works
tal health coverage but that those limits must not be less fa-
Health care prices in the private insurance industry are nego- vorable than limits on medical and/or surgical benefits. The
tiated between insurance carriers and providers with whom Mental Health Parity and Addiction Equality Act of 2008
they contract for services (Clemens & Gottlieb, 2016). Deter- (MHPAEA; H.R. 6983, 110th Cong.) bolstered the initial
minants of health care pricing in the private market include efforts of the MHPA, added new provisions, and expanded
differences in plans, performance of providers and/or facil- the protection of coverage to the treatment of addiction and
ity (with high performers possibly able to negotiate higher substance use disorders.
CASE EXAMPLE 30.1. Navigating the Maze of Private Health Insurance
Veena is an occupational therapy practitioner with 15 years of experience. She has consistently worked in an outpatient private clinic setting,
but recently she, along with her therapy colleagues, reviewed and signed a new provider agreement with Golden Health of Maryland, a new private
health insurance provider for employer-based health insurance being offered in Maryland, Virginia, and the District of Columbia. Golden Health
visited Veena’s clinic seeking additional therapy providers to expand their network and gave a PowerPoint presentation about their benefits and
reimbursement structure. Veena was given a detailed provider agreement to review and sign if she wanted to join the network. As an in-network
provider, Veena’s clients would receive the plan’s occupational therapy services and would not have to pay additional costs for services out of
pocket, with the exception of a per-visit copayment.
In addition, Veena felt that the coverage for occupational therapy seemed to be good under the plan. Golden Health did not present information
on the specific interventions or Current Procedural Terminology (CPT)™ codes that they permit for billing; however, they did share that occupational
therapy and physical therapy should follow a specific treatment plan that
■ Details the treatment and specifies frequency and duration,
■ Provides for ongoing reviews and is renewed only if continued therapy is medically necessary, and
■ Consists of a visit of no more than 1 hour of therapy.
Those parameters all seemed reasonable to Veena and were those within which she worked on a daily basis and did not have many problems with
her reimbursement. Overall, she received reimbursement consistently from the various insurance payers with whom she contracted, both federal
(Medicare, Medicaid, Veterans Administration) and private (United Health, BSBS, Aetna). Moreover, her clients were receiving skilled, medically
necessary occupational therapy and seemed pleased with their care.
In the first 5 months after Veena signed her contract with Golden Health, she did not experience any issues with coverage or payment on the
claims that she submitted on her clients’ behalf. However, starting in her 6th month as an in-network provider, Veena was notified by her clinic’s
billing department that every claim she submitted for the self-care home management code was being denied by Golden Health under a denial
code for being “not medically necessary.” Veena did not understand the logic for the denials because just the previous month, her claims for
the same code were paid by the Golden Health for the same types of clients experiencing very similar medical conditions and with very similar
functional status concerns.
For example, one of her denials was for a stroke patient named William, who was able to return to his home environment following a
hospitalization but continued to need skilled occupational therapy services to improve functional independence with dressing, especially tying
his shoes and buttoning his shirts. Veena worked with William on these tasks because doing these activities independently was a key plan of
care goal. She also developed modifications to his tasks to create compensatory strategies for dressing, including use of an adaptive shoe
horn, a button hook, and use of shirts that do not require buttons.
Veena was frustrated by these denials because her clinic management stated that she would have to request out-of-pocket payment from
her clients for these services if she wished to continue providing the self-care/home management intervention. Veena believed that providing
skilled therapy to clients to improve or maintain their functional abilities in critical ADLs, such as dressing, grooming, and bathing, was foundational
to her distinct value as an occupational therapy practitioner. Occupation-based practice is at the heart of the services she provided and
differentiated her from other health professionals.
Veena called the Golden Health representative to learn why her services were being denied. She learned that Golden Health had recently
undergone a coverage policy revision for occupational therapy services and had determined the billing code should no longer be deemed
medically necessary under the plan, so they designated it as an excluded service that would not be covered. When Veena explained the skilled
intervention and pressed the plan representative to provide more details about the change, she was forwarded to a series of other plan customer
service representatives, none of whom could answer her questions. The last representative, however, provided Veena with a website where
the new occupational therapy coverage policy was posted and informed Veena that she could seek an appeal by following the instructions on
that page.
The next day Veena found the coverage policy and appeal instructions. She was determined to fight the denials and make sure her clients
received the therapy that they greatly needed, but she was confused about how to write an appeal letter. She knew from her occupational therapy
training that the services were necessary for William, but she was unsure how to draft a letter explaining her intervention and support it with
relevant professional documents and research. Veena was a member of the American Occupational Therapy Association (AOTA), and it occurred to
her that she might contact her national professional association for guidance. She was forwarded to staff in AOTA’s Regulatory Affairs Department
for guidance. AOTA staff discussed the scenarios with Veena and armed her with key resources, such as a template appeal letter, shared AOTA’s
official documents that addressed the critical skills and interventions that occupational therapy practitioners provide to clients, and pointed Veena
to relevant research that demonstrates the benefits of occupational therapy.
Veena was confident that she could develop a strong appeal letter to advocate against Golden Health’s denial of the billing code with these
resources. She drafted a concise letter and attached supporting professional documentation, including excellent notes and documentation
pulled from the plan of care in William’s medical record, and sent this package of material into the plan’s Appeal’s Division for review. She also
copied staff at AOTA and her clinic billing department staff on her letter and materials so that they could offer advice and guidance during the
appeals process.
Within 6 weeks, Veena received a positive appeal decision from Golden Health that affirmed that all her claims for the billing code would
be reimbursed retroactively. Even better, the retroactive payment decision allowed Veena’s outpatient clinic to reimburse each of her clients for
the out-of-pocket expenses they incurred when the services were denied. Veena had successfully navigated the maze of private health insurance.
She proactively learned to gather information from the health plan, to reach out to experts in the profession, and to fight for her professional
skills, as well as for her clients’ right to appropriate, medically necessary occupational therapy.
(Continued)
CASE EXAMPLE 30.1. Navigating the Maze of Private Health Insurance (Cont.)
Review Questions
1. As an in-network provider with the Golden Health insurance plan, Veena’s clients
a. Would receive the plan’s occupational therapy services.
b. Would have to pay a per-visit copayment.
c. Would not have to pay additional costs for services out of pocket, besides a co-payment.
2. As a contracted provider with Golden Health insurance, Veena has a right to request
a. Personal health information for clients whom she does not treat.
b. Appeals review of a claims denial for services she deems medically necessary.
c. Higher reimbursement rates than those set by the insurance company.
d. Special treatment as an occupational therapy practitioner.
3. Which of the following was not a resource that Veena used when developing a claims denial appeal letter for William?
a. A template appeal letter
b. AOTA’s official documents that addressed the critical skills and interventions that occupational therapy practitioners provide to clients
c. Research that demonstrated the benefits of speech–language pathology services
d. Documentation pulled from the plan of care in William’s medical record
Full MHPAEA regulations went into effect July 1, 2014, Children and families
but there are complex exceptions, inclusion, and exclusion
Additional considerations for families and children also af-
criteria. Provisions of the MHPAEA may or may not apply
fect the private health insurance industry. The Newborns’
to private insurance health plans depending on the way in
and Mothers’ Health Protection Act of 1996 (NMHPA; P.L.
which the individual plan is structured, administered, and
104-204) established protections for hospital stay coverage
regulated. Some elements of ACA expanded the provisions
for mothers and newborns in connection to labor, delivery,
of MHPAEA, extending its influence even to plans that
and recovery. This federal law applies to group health plans
would have previously been exempted from compliance. In
that are employer or union funded and to individual health
addition, states may have mental health, addiction, and sub-
insurance plans and mandates that health plans may not re-
stance use disorder parity requirements that differ in scope
strict hospital stays to less than 48 hours following vaginal
from the federal act.
delivery or 96 hours following cesarean section.
Uninsured rates for children have reached historically
low rates of 5% (Artiga & Ubri, 2017). This achievement is
EXHIBIT 30.1. Checklist of Key Questions to
attributed to the expansion of Medicaid programs, most im-
Ask About Insurance Plan Coverage
portantly, the Children’s Health Insurance Program (CHIP),
✓ What is the plan’s definition of occupational therapy? and to the implementation of the ACA. As demonstrated in
How does the plan define the occupational therapy scope Figure 30.2, slightly more than half (53%) of children in the
of practice? United States are covered through private insurance, which
✓ Are there limitations in number of visits, sites at which includes plans held by their parents’ ESI and individual fam-
services may be received, or yearly costs incurred for ily plans purchased on the ACA marketplace. Medicaid and
occupational therapy services? CHIP cover the rest of children, including 44% of children with
✓ Is there a network of providers that an occupational therapy special health care needs (Kaiser Family Foundation, 2016a).
practitioner must join to bill? Can a client “opt out” of the
network, and if so, what financial disincentives exist?
✓ Does the plan offer case management services for some For Additional Learning
conditions?
Does the plan pay a fee-for-service or is payment for For additional information on federal- and state-funded health
✓ insurance programs such as Medicaid and CHIP, see Chapter 29,
occupational therapy bundled into a group of services
(e.g., a set amount for all rehabilitation services)? “Federal Health Care Programs and Outcomes.”
✓ Does the payer require specific credentials for occupational

therapy practitioners?
Does the payer require that the occupational therapy Risks and Value of Adequate Health
✓
practitioner or health care facility or clinic join a provider Care Coverage
network?
Access to health care insurance protects against health care
✓ Is the subscriber responsible for copayments, deductibles, or costs of severe or catastrophic injury or illness, improves ac-
other out-of-pocket expenses? Under what circumstances? cess to preventive screenings and care, and may, by providing
2. Which of the following statements are true for in-network

Health insurance coverage of
FIGURE 30.2. occupational therapy providers?
children, 2015.
a. Prices for health care services are negotiated with
in-network providers that are participating in that
Uninsured particular health care plan for the services they pro-
5% vide to the plan subscriber (client).
b. Prices for health care services are not negotiated with
in-network providers who are participating in that
particular health care plan but are paid at the rate the
provider sets.
c. Providers in-network may issue a balance bill to
collect more for their services.
Employer/Other
Medicaid/CHIP 3. Which of the following are key questions to ask about
Private
39%
53% insurance plan coverage?
a. What is the definition of occupational therapy?
b. Are there limits to occupational therapy visits or
services?
c. Does the payer require specific credentials for the
occupational therapy practitioners?
4. What is the intended impact of MHPA on private health
Other Public insurance?
2%
a. Private health insurance was not affected by MHPA.
Total: 78.2 Million Children b. Large group health plans could not impose limits on
mental health coverage that were more restrictive
Note. Percentages may not add up to 100 due to rounding.
than medical health or surgical coverage.
Source. Kaiser Family Foundation (2016b), p. 2. Used with permission.
c. MHPA required large group health plans to cover
more mental health services than medical health or
surgical services.
care earlier, result in improved health outcomes (Bittoni et al., d. MHPA was voluntary for private health insurance
2015; Maciosek, 2010). Uninsured persons do not receive all plans.
the health care they need and are in fact more likely to go 5. In addition to bolstering the MHPA, what additional pro-
without preventive services and regular care for chronic and vision was included in the 2008 MHPAEA?
serious conditions (Bailey, 2012). a. Expansion of the protection of coverage for the treat-
Uninsured adults are more at risk for premature death due ment of addiction and substance use disorders.
to late diagnosis, lack of access to consistent care, and lack of b. Expansion of wellness services.
access to life-saving measures (Davis, 2003). Lack of health c. The MHPAEA actually limited the MHPA.
insurance is the 6th leading cause of death in the United d. Expansion of only maternal mental health services.
States (IOM, 2009). While sustaining full-time employment 6. What is the intended impact of NMHPA on private health
does increase an individual adult and his or her family’s like- insurance?
lihood of ESI coverage, 80% of families who are uninsured a. Private health insurance was not affected by
have wage earners present in the home (IOM, 2009; National NMHPA.
Immigrant Law Center, 2014). b. NMHPA required large group health plans to cover
100% of labor and delivery costs for mothers and
newborns.
Review Questions
c. NMHPA was voluntary for private health insurance
1. How can occupational therapy practitioners stay in- plans.
formed regarding private health insurance coverage d. NMHPA established protections for hospital stay
policies? coverage for mothers and newborns in connection to
a. Read coverage policies, including criteria for coverage labor, delivery, and recovery.
and coding of occupational therapy services. 7. Uninsured rates for children are at historic lows. How do
b. Opt in to provider updates to receive notification most children gain health care insurance coverage?
when policies are added, deleted, or changed. a. Medicaid/CHIP
c. Identify key contacts to call with questions about cov- b. Other public plans
erage criteria or private insurance claims. c. Employer/other private insurance
d. All of the above. d. None of the above
8. Which of the following are related to access to health care Barnett, J. C., & Berchick, E. R. (2017). Health insurance in the United
insurance? States: 2016. Retrieved from https://www.census.gov/content
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and/or illness. Bittoni, M., Wexler, R., Spees, C. K., Clinton, S. K., & Taylor, C. A.
(2015). Lack of private health insurance is associated with higher
b. Improved access to preventive screenings and care.
mortality from cancer and other chronic diseases, poor diet quality,
c. Earlier care that may result in improved health out-
and inflammatory biomarkers in the United States. Preventive
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access to life saving measures. “Blue Cross and Blue Shield: A Historical Compilation.” (n.d.). Re-
d. All of the above are related. trieved from https://advocacy.consumerreports.org/wp-content
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surance is the leading cause of death in the -compilation.pdf
United States. Burman, L. E., Furman J., Leiserson, G., & Williams, R. (2007). The
a. 2nd President’s proposed standard deduction for health insurance: An
b. 5th evaluation. Washington, DC: Urban Institute. Retrieved from
c. 6th http://webarchive.urban.org/publications/411423.html
Cassidy, A. (2013, May 2). Essential health benefits. Health Affairs/
d. 10th
RWJF Health Policy Briefs. Retrieved from https://www.rwjf.org
/en/library/research/2013/05/essential-health-benefits.html
SUMMARY Centers for Medicare and Medicaid Services. (2018a). Physician
quality reporting system. Retrieved from https://www.cms.gov
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for across private health plans or within specific companies. /PQRS/index.html?redirect=/pqri/
Health care insurance plans, whether publicly or privately Centers for Medicare and Medicaid Services. (2018b). Shared saving
funded, consist of contracts that specify the rules or condi- program. Retrieved from https://www.cms.gov/Medicare/Medicare
tions under which they will cover an array of services. -Fee-for-Service-Payment/sharedsavingsprogram/index.html
Claxton, G. (2002, March 31). How private insurance works: A
Health care practitioners today, more than ever before,
primer. Retrieved from https://www.kff.org/health-costs/report
must expect to balance the needs and goals of the client with /how-private-insurance-works-a-primer/
state practice regulations, employer priorities, and payer re- Clemens, J., & Gottlieb, J. (2016). In the shadow of a giant: Medicare’s
quirements, all within a framework of the ethical standards influence on private physician payments. Journal of Political
of their profession. This chapter has provided some strategies Economy, 125, 1–39. https://doi.org/10.1086/689772
and guidelines for getting the most out of insurance benefits Coleman, K. (2013, March 7). Almost no existing health plans meet
for the client and the practitioner. ❖ new ACA essential health benefit standards. Retrieved from
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ACOTE STANDARDS -benefit-standards#.XG3VhdJKiJA
Collins, S. R., Gunja, M. Z., Doty, M. M., & Beutel, S. (2017). How
This chapter addresses the following ACOTE Standards: the Affordable Care Act has improved Americans’ ability to buy
■ B.3.3. Distinct Nature of Occupation health insurance on their own. Retrieved from https://www
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/how-affordable-care-act-has-improved-americans-ability-buy
■ B.5.2. Advocacy
Davis, K. (2003). The costs and consequences of being uninsured.
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CHAPTER
Workers’ Compensation
Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA 31
LEARNING OBJECTIVES
■ Describe the impact of the historical foundation of workers’ compensation and relevant regulations on the no-fault,
compulsory workers’ compensation insurance systems used in the United States;
■ Differentiate among federal, state-run, privatized, and mixed-model workers’ compensation systems, distinguishing
how each system operates and provides benefits for injured workers;
■ Discuss contemporary issues relative to the provision of workers’ compensation in the United States;
■ Identify key considerations for the provision of clinical and community-based occupational therapy services within
workers’ compensation systems for employers and claimants; and
■ Discuss the requirements for providing coverage and administering workers’ compensation claims for employees in
an occupational therapist–owned practice or as an occupational therapy manager.

• Direct medical expenses • Medical-only claims • State-run workers’ compensation
• Essential functions • No-fault workers’ compensation programs
• Gainful employment • OSHA recordable events • Temporary total disability
• Indemnity costs • Permanent partial disability • Vocational rehabilitation
• Independent medical examination • Permanent total disability • Work-related injuries and illnesses
• Lost-time claims • Return-to-work hierarchy
• Maximum medical improvement • Self-insurance
OVERVIEW compensation systems to employees, and discusses the ways in
N
early 3 million workplace injuries occur every year which workers’ compensation insurance claims are managed
in the United States, with approximately one-third of in the United States. An overview of key contemporary issues
these injuries being severe enough to require time away related to workers’ compensation is provided, and the impli-
from work (Bureau of Labor Statistics [BLS], 2017a). Since the cations for occupational therapy practice and management are
early 1900s, workers’ compensation insurance programs have discussed. Finally, the key concepts presented throughout the
been in place to cover the costs of medical and other expenses chapter are illustrated through a case study example provided
related to recovery from a workplace injury. Although work- at the conclusion of the chapter.
ers’ compensation programs have now reached nearly every This chapter aims to equip occupational therapy practi-
corner of the world, the format of services and systems varies tioners and managers with general knowledge of workers’
greatly across different states and countries. compensation to serve as a foundation upon which to examine
This chapter provides a brief historical overview of workers’ specific characteristics of workers’ compensation programs
compensation, describes common benefits provided by workers’ and relevant issues within the local practice context.
https://doi.org/10.7139/2019.978-1-56900-592-7.031
297
CHAPTER
Workers’ Compensation
Shawn C. Roll, PhD, OTR/L, RMSKS, FAOTA 31
LEARNING OBJECTIVES
■ Describe the impact of the historical foundation of workers’ compensation and relevant regulations on the no-fault,
compulsory workers’ compensation insurance systems used in the United States;
■ Differentiate among federal, state-run, privatized, and mixed-model workers’ compensation systems, distinguishing
how each system operates and provides benefits for injured workers;
■ Discuss contemporary issues relative to the provision of workers’ compensation in the United States;
■ Identify key considerations for the provision of clinical and community-based occupational therapy services within
workers’ compensation systems for employers and claimants; and
■ Discuss the requirements for providing coverage and administering workers’ compensation claims for employees in
an occupational therapist–owned practice or as an occupational therapy manager.

• Direct medical expenses • Medical-only claims • State-run workers’ compensation
• Essential functions • No-fault workers’ compensation programs
• Gainful employment • OSHA recordable events • Temporary total disability
• Indemnity costs • Permanent partial disability • Vocational rehabilitation
• Independent medical examination • Permanent total disability • Work-related injuries and illnesses
• Lost-time claims • Return-to-work hierarchy
• Maximum medical improvement • Self-insurance
OVERVIEW compensation systems to employees, and discusses the ways in
N
early 3 million workplace injuries occur every year which workers’ compensation insurance claims are managed
in the United States, with approximately one-third of in the United States. An overview of key contemporary issues
these injuries being severe enough to require time away related to workers’ compensation is provided, and the impli-
from work (Bureau of Labor Statistics [BLS], 2017a). Since the cations for occupational therapy practice and management are
early 1900s, workers’ compensation insurance programs have discussed. Finally, the key concepts presented throughout the
been in place to cover the costs of medical and other expenses chapter are illustrated through a case study example provided
related to recovery from a workplace injury. Although work- at the conclusion of the chapter.
ers’ compensation programs have now reached nearly every This chapter aims to equip occupational therapy practi-
corner of the world, the format of services and systems varies tioners and managers with general knowledge of workers’
greatly across different states and countries. compensation to serve as a foundation upon which to examine
This chapter provides a brief historical overview of workers’ specific characteristics of workers’ compensation programs
compensation, describes common benefits provided by workers’ and relevant issues within the local practice context.
https://doi.org/10.7139/2019.978-1-56900-592-7.031
297
ESSENTIAL CONSIDERATIONS Workers’ Compensation Benefits

History of Workers’ Compensation Direct medical expenses
In the early 1900s, industrialization led to a staggering increase As a primary benefit, all workers’ compensation programs
in workplace deaths and work-related injuries and illnesses, provide financial coverage for direct medical expenses related
which are medical conditions directly resulting from activities, to an injury sustained, or illness obtained, while conducting
incidents, or exposures related to the workplace and occurring work-related activities. Direct medical expenses include hos-
during the course of employment. Original workplace injury pitalization and physician visits, diagnostic tests and surgical
laws required that workers prove employers were negligent to procedures, outpatient procedures and rehabilitative inter-
receive compensation for an injury or other losses (Fishback & ventions, and drug and prescription costs. Payment of these
Kantor, 2000). Unfortunately, workers often faced difficulties benefits will typically continue to be covered until an indi-
in obtaining benefits due to an inability to prove negligence. vidual has exhausted all reasonable medical interventions
An outcry for government oversight and demand for in- to improve his or her condition and recovery has reached a
creased employer responsibility resulted in the widespread plateau, a status termed maximum medical improvement
development of no-fault workers’ compensation insurance (MMI). Depending on individual program regulations, some
systems. These systems guarantee payment for medical ex- rehabilitation services, prescription costs, and other routine
penses for a work-related injury or illness without either the direct medical expenses may still be covered by workers’
employer or the employee being identified to have been at compensation for individuals who have reached MMI status.
fault. The first program of this kind in the United States was
established by the Federal Employers Liability Act of 1908
Wage loss
(45 U.S.C. §51), which provided compensations for railroad
workers injured on the job. Soon after, in 1911, New Jersey Workers’ compensation programs are inherently different
and Wisconsin were the first 2 states to establish workers’ from other health insurance systems in that these programs
compensation insurance laws (Krohm, 2011), with many provide indirect disability benefits in addition to covering di-
states to follow in the ensuing decade. rect medical costs (Cloeren et al., 2016). These disability ben-
There was an initial hesitancy to move away from the efits, or indemnity costs, primarily provide financial support
negligence-based system, and most new legislation was chal- to cover wages lost by a worker who has sustained an injury.
lenged. Some of the first workers’ compensation laws allowed Temporary total disability (TTD), the most common wage
employers to voluntarily elect into a no-fault system (Ohio loss benefit, is paid to an employee who must take time away
State Bar Association, 2001); however, voluntary systems did from work while initially recovering from a workplace injury.
not receive widespread public approval, and most were soon Although each state has different restrictions and maximum
replaced with requirements for all employers to participate in limits are often set, TTD typically provides up to two-thirds
a no-fault program (Fishback & Kantor, 2000). By 1949, com- of an employee’s salary. Employees can usually purchase addi-
pulsory, no-fault systems were established in nearly all states. tional voluntary disability insurance to supplement the TTD
Texas is currently the only state that allows employers to opt provided by their employers’ workers’ compensation plan if
out of workers’ compensation coverage, an option taken by they sustain an injury that requires them to stop working.
approximately one-third of Texas employers (Insurance In- When an individual reaches MMI and impairments in
formation Institute, 2017). Although the provision of workers’ function persist that reduce the ability to perform job tasks at
compensation is compulsory in all other states, exemptions a previous level, the employee may receive permanent partial
are often available for employers with a small number of disability (PPD). PPD may be calculated based on a count of
employees and for those hiring employees for agricultural, body parts or the percentage of the body affected or impaired
seasonal, or other types of casual employment. by the injury or calculated the same way as other types of dis-
Although no-fault systems eliminate the need for litigation, ability, that is, based on the severity of the resulting disability
it remains important to understand workers’ compensation as due to impairments in functional performance. Permanent
a legal system. Workers’ compensation is developed through total disability (PTD) is provided in extreme cases where
statute, and government-sanctioned agencies, commissions, impairments from an injury restrict an individual’s abil-
or boards provide oversight of relevant policies, procedures, ity to return to work of any sort. When death results from
and guidelines. Given differences in state statutes, there is a work-related incident, accident, injury, or illness, workers’
significant variability in how workers’ compensation systems compensation death benefits are typically available to an
are organized, how claims are managed, and what benefits are employee’s dependents.
available to employees and employers. Occupational therapy
practitioners and managers should know about the workers’
Vocational rehabilitation
compensation coverage policies and guidelines within their
jurisdiction; the majority of federal, state, and other workers’ In some states, workers who have reached MMI or have been
compensation programs have detailed websites providing all awarded PPD or PTD may still qualify for additional ser-
the information needed for occupational therapy practitioners vices through vocational rehabilitation programs. Vocational
and managers to stay abreast of local policies. rehabilitation programs provide support for people with
CHAPTER 31. Workers’ Compensation 299
disabilities through a comprehensive regime of services meant (e.g., small laceration, needle stick); however, some medi-
to maximize their ability to participate in productive activities cal-only claims can require more in-depth medical interven-
(Rubin & Roessler, 2001). tion with longer recovery times and more services (e.g., muscle
The first vocational rehabilitation programs in the United strain, broken bone). Regardless of the service needs, impair-
States were established as a result of the Soldier’s Rehabilita ments are not severe enough for employees of medical-only
tion Act of 1918 (P. L. 65–107) and the Smith–Fess Act of claims to require an extended period of time off work.
1920 (P. L. 66–236), also referred to as the Civilian Vocational In contrast, lost-time claims occur when an injury or ill-
Rehabilitation Act. Contemporary vocational rehabilitation ness prohibits an employee from continuing to carry out the
services exist due to the civil rights movements and numer- essential functions of a job in a safe or effective manner. Essen
ous other political advances that led to the Rehabilitation Act tial functions are the activities and tasks that constitute the
of 1973 (P. L. 93–112) and its various amendments (Froehlich reason a particular job exists and are the components of a job
& Linkowski, 2002; Hein et al., 2005). Additionally, affirma- an employee must be able to perform with or without reason-
tive action enforced by the Equal Opportunity Employment able accommodation to maintain employment. The number of
Commission (EEOC) and other disability rights legislation, days away from work before a claim becomes categorized as
such as the Americans With Disabilities Act of 1990 (ADA; lost time varies by state, but designation as lost time typically
P. L. 101–336, U.S.C. 42 §12101), have played an integral role in occurs when an employee is unable to work for 3–7 consecutive
supporting the advanced rehabilitative needs of persons with business days. Once a claim is classified as lost time, the em-
disabilities (Rubin & Roessler, 2001). Because of the variety ployee qualifies for wage replacement through TTD or other
of disabilities and services supported, vocational rehabilita- indemnity benefits until the claim is resolved.
tion is provided in multiple ways, including federal systems Workers’ compensation claims can be closed and con-
(e.g., Veterans Affairs), state-run rehabilitation departments sidered resolved under a variety of circumstances, each de-
(e.g., Bureaus of Vocational Rehabilitation), state-run work- pending on the regulations of the local jurisdiction. Ideally,
ers’ compensation systems, and private consulting firms. an individual will make a full recovery from his or her injury
Within a workers’ compensation framework, vocational and return to work with no limitations, resulting in closure
rehabilitation programs primarily provide support when in- of the claim. Lost-time claims will often be closed, or pay-
dividuals are unable to immediately return to work due to ments will become restricted, when an individual has been
resulting disability but have potential for returning to gainful deemed MMI or when PPD is awarded. In most states, even
employment, which refers to a situation in which individuals though workers’ compensation claims may be closed, regu-
are able to maintain continuous participation and successful lations usually allow for any claim to be reactivated if a sub-
performance of job duties, realizing benefits through finan- stantial aggravation of the injury occurs within a given time
cial or other positive rewards. Core services in vocational re- frame. Regulations for the number of years that a claim may
habilitation are focused on assisting individuals to identify lie dormant before becoming closed, as well as requirements
new career options, training to improve job prospects, and for documenting substantial aggravation, vary by state.
providing skills for finding employment. Specific services Although U.S. workers’ compensation programs provide
provided as part of vocational rehabilitation include voca- benefits without assigning fault, in most cases, employees
tional evaluations, work adjustment training, personal skill retain the right to enter into litigation for the settlement of
development training, job-seeking skills training, and job a claim. After winning a settlement, the worker forfeits any
search support. rights to future workers’ compensation benefits for the specific
Although job training may be limited to support for work- injury or illness and receives a lump-sum payment meant to
shop or certificate programs, in certain cases, vocational support future medical or indemnity costs. Because it is diffi-
rehabilitation will fully support, or partially offset, costs cult to predict future medical expenses, settlements often do
incurred for an individual to obtain an educational degree not provide adequate funds, and most noncommercial legal
that will allow the individual to obtain gainful employment counselors will rarely recommend that a client settle a work-
in a new occupation. In some vocational rehabilitation pro- ers’ compensation claim. Similarly, workers should be well
grams, additional support is available to promote successful informed prior to joining a class action lawsuit, as they may
retraining or job seeking, such as payment for child care or surrender individual rights to workers’ compensation benefits
car repair. When deemed necessary, physical rehabilitation or future claims for an injury or illness.
services are sometimes allowable within a vocational rehabil-
itation program.
Types of Workers’ Compensation Programs
More than 100 years after the foundation of workers’ com-
Workers’ Compensation Claims
pensation, significant variation continues in how workers’
Up to 75% of workers’ compensation claims are medical-only compensation is managed. More than 80% of workers’ com-
claims; however, these claims account for less than 10% of all pensation costs in the United States flow through third-party
workers’ compensation costs (National Council on Compen- private insurance or employer self-insurance, with the re-
sation Insurance, 2014). Medical-only claims are often eas- maining 15% and 5% attributed to state and federal pro-
ily resolved and do not require significant medical services grams, respectively (Sengupta & Baldwin, 2015). In contrast
to individual employee health insurance wherein premium In contrast to the global reimbursement policies set by a
and deductibles costs are shared between the employee and third party, self-insured companies set their own rules for
employer, all workers’ compensation costs are paid solely by reimbursement of injury claims following the guidelines of
the employer and are considered a cost of doing business. their local jurisdiction. As a result, advocating for approval
As of 2017, 26 states required employers to select a third of additional services or extending the length of treatment
party to administer their workers’ compensation claims or that goes beyond the standard is sometimes more success-
develop a self-insurance program, whereas the remaining ful. Moreover, by providing direct management of claims for
states offered state-run insurance programs. Private and their own employees, self-insured companies are often able
self-insurance options are available in most of these states, but to promote more efficient and compassionate care, which can
4 states (North Dakota, Ohio, Washington, and Wyoming) help to reduce indemnity costs. In addition to these savings,
require employers to enroll in the state-run insurance system self-insured employers avoid paying unreimbursed premium
(Insurance Information Institute, 2017). Regardless of the way and deductible costs charged by a third party. When suc-
workers’ compensation claims are managed (i.e., third-party, cessfully managed, these employers are often able to reinvest
self-insured, state-run), all programs must follow the regu- more resources into their own company or provide dividends
lations set forth by their state legislature. This ensures that or other benefits directly to their employees or shareholders.
all employees are treated in an equitable manner and mini-
mum standards are applied to promote recovery following a
work-related injury or illness. General descriptions of the var-
State-run programs
ious types of workers’ compensation programs are provided State-run workers’ compensation programs are administered
in the following sections. by a state agency, commission, or board following general reg-
ulations set forth by the individual state’s legislative body. The
state will often provide fee schedules and publish clear guide-
Third-party/private insurance
lines of approved services within the system.
In most cases, employers establish a contract with a private, As a public entity focused solely on management of
third-party company that manages all workers’ compen- work-related injuries, state-run workers’ compensation pro-
sation claims on behalf of the employer. Employers pay a grams sometimes provide a more robust list of approved ser-
premium and any negotiated deductible costs to the private vices focused on return-to-work than do other systems that
insurance company, which then manages reimbursements tend to focus primarily on medical management. Adminis-
for direct medical services and indirect indemnity costs in trative funding for these programs is provided through the
accordance with state regulations and privately negotiated state budgeting process and is further supported by premi-
provider contracts. ums paid by employers. In states where private insurance
Approved reimbursable services within these private sys- is not available, employers may have limited choice and are
tems tend to follow a similar pattern as traditional health bound to the premiums set by the state.
insurance, which means that services are often limited. Com- In contrast to private or self-insurance programs, un-
petition in this private, open-market workers’ compensation spent surplus funds from premiums in state-run workers’
system can help to maintain lower premiums, and by using compensation programs are either returned to employers
a third-party guarantor, the employer is insured against po- (e.g., rebates, lowered premiums) or used to support public
tential risk of significant financial losses should numerous or programs. State surplus funds have been used to develop and
extensive employee injuries occur. However, as with any in- support vocational rehabilitation programs, safety and well-
surance plan, employers paying a third party to manage their ness training, and conferences. In other cases, surplus funds
workers’ compensation claims usually pay in excess of the are used to develop incentive programs that provide rebates to
plan’s actual costs. In these cases, overpayments are typically employers who adopt measures to improve employee safety.
not recovered, and profits are shared by the stakeholders of
the third-party insurance company.
Federal programs
Workers’ compensation for all federal, civil service employees
Self-insurance
was established by the Federal Employees’ Compensation Act
Large employers that can demonstrate the financial ability of 1916 (H.R. 15316, 39 Stat. 742, 9-7-16). Claims are managed
to pay for anticipated injuries of their employees often opt to through the U.S. Department of Labor’s Office of Workers’
become self-insured. These employers absorb all direct medi- Compensation Programs, and all benefits are paid through
cal and indirect indemnity costs, as well as all administrative funding that is appropriated by Congress in the federal budget
costs associated with each claim. This can place an employer process. The federal workers’ compensation program offers
at risk for significant financial loss in the case of a severe similar benefits to most state-run systems, ensuring employ-
injury or high rates of individual injuries. As a result, self- ees receive compensation for direct medical and indirect in-
insured businesses often establish robust risk-management demnity costs related to an injury or illness sustained in the
programs and continuously implement quality improvement workplace. In addition to these benefits, vocational rehabilita-
measures. tion services are available to federal employees who have PPD.
Additional federal workers’ compensation programs exist established specific utilization guidelines for determining the
to provide coverage for employees who do not work in any provision of services; set a fee schedule for payment of medi-
certain federal or state jurisdiction, as well as for workers in cal services; implemented caps on chiropractic, physical, and
occupations with high rates of specific types of injuries. Prac- occupational therapy services (i.e., 24 visits); and eliminated
titioners engaging with any of the following types of clients vocational rehabilitation services (State of California Depart-
should be aware of the relevant programs and legislation: ment of Industrial Relations, 2007).
Many other states have enacted legislation to implement
■ Railroad employees: Federal Employers’ Liability Act of similar cost-saving measures, especially related to fee sched-
1908 (45 U.S.C. § 51)
ules and utilization policies, each following evidence-based
■ U.S. Merchant Marines, dockworkers, and other seafarers: practice guidelines. Many states follow guidelines published
Jones Act (i.e., Section 27 of the Merchant Marine Act
by the American College of Occupational and Environmen-
of 1920; P. L. 66–261); Longshore and Harbor Workers’
tal Medicine (ACOEM), which are meant to provide the best
Compensation Act (P. L. 98–426)
evidence for promoting efficient and effective recovery from a
■ Individuals working at U.S. military bases, conducting work-related injury or illness by physicians and other health
work in a foreign country under a contract with a U.S.
care providers (Harris et al., 2017). ACOEM guidelines have
government agency, or providing aid-based services as an
been developed for a wide range of topics, including work-
employee of a U.S.-based employer (e.g., American Red
related musculoskeletal and neurological conditions often
Cross): Defense Base Act (42 U.S.C. § 1651–1654)
treated by occupational therapy practitioners.
■ Coal mine workers with pneumoconiosis (i.e., black lung)
Using evidence-based guidelines to develop incentive pro-
or other lung diseases: Black Lung Benefits Act (30 U.S.C.
grams for health care providers for higher quality services
§ 901–944).
and achieve positive clinical outcomes is becoming standard
practice in health care. Within workers’ compensation pro-
Contemporary Issues in Workers’ grams, implementing provider metrics for quality care has
Compensation been shown to reduce both worker disability and overall costs
More than a million workplace injuries occur each year (BLS, (Wickizer et al., 2011). These quality review programs require
2017a), resulting in significant costs due to direct and indirect providers to pay closer attention to evidence-based practice
benefits paid through workers’ compensation. At the start of guidelines, encourage stakeholders in the workers’ compen-
the 21st century, it was estimated that by 2005, workers’ com- sation system to communicate more effectively, and promote
pensation costs would reach $55.5 billion worldwide, with efficiency in care provision (Cloeren et al., 2016). This is im-
25% of spending (i.e., $13.8 billion) occurring in the United portant for all practitioners to consider, because increasing
States (Icon Group International, 2002). Unfortunately, evidence suggests that more efficient care that promotes early
workers’ compensation spending has far surpassed that num- provision of services can reduce disability and time away
ber and has grown exponentially in recent years. In 2007, from work (Asih et al., 2018; Phillips & Shoemaker, 2017),
$24.85 billion was paid by workers’ compensation insurance which are key goals for the provision of any occupational
in the United States for both direct and indirect indemnity therapy service.
costs following workplace injuries (Leigh & Marcin, 2012),
and by 2013, workers’ compensation spending in the United Claim disputes
States reached $63.6 billion (Sengupta & Baldwin, 2015). As
of 2013, employer costs for workers’ compensation coverage Another increasingly prevalent issue in an era of cost contain-
in the United States averaged $1.37 per every $100 of wages, ment is the difficulty workers face in establishing a workers’
with costs as high as $2.58 in Alaska and as low as $0.74 in compensation claim. Despite all U.S. workers’ compensation
Massachusetts (Sengupta & Baldwin, 2015). The immense programs operating within a no-fault framework, approval of
fiscal impact of workers’ compensation in the United States a claim and provision of benefits depend on whether the in-
has given rise to multiple issues, among the most prevalent jury or illness is in fact work related. In the absence of a trau-
of which are cost containment efforts, claim disputes, injury matic accident or acute injury, determining the work-related
reduction measures, and coverage debates. impact on the development of a condition can be challenging
(Knoblauch & Cassaro, 2018). This is often the case with re-
petitive strain injuries, such as carpal tunnel syndrome and
Cost containment and utilization guidelines
epicondylitis, as well as certain exposure disorders, such as
The high spending on workers’ compensation in the United hearing loss. Similarly, establishing a work-related cause for
States has prompted numerous cost-saving efforts. In psychological stress and other mental health conditions can
California, the largest spender of workers’ compensation be even more challenging, not to mention that numerous so-
dollars, employer costs for workers’ compensation reached a cial and cultural stigma–related psychological impairments
high of $6.29 per $100 of payroll in 2003 (Workers’ Compen- often create additional barriers for successful claim manage-
sation Insurance Rating Bureau of California, 2016), prompt- ment after the initial claim is approved (Harpur et al., 2017).
ing one of the most significant legislative reforms of a state In unclear or challenging cases, it is important for all
workers’ compensation system in recent history. This reform health care practitioners who interact with the employee to
conduct comprehensive history interviews that explore po- are excellent resources for comparative data. According to
tential factors leading up to the employee’s decision to file a these sources, approximately 43% of dollars spent on con-
claim and seek care. When the preponderance of evidence temporary workers’ compensation claims are for injuries re-
suggests that the onset or substantial aggravation of an insulting from physical overexertion, such as when lifting or
jury or illness was likely due to exposure in the workplace, carrying an item, or to falls on the same level, such as when
standing will usually fall on the side of the employee, and tripping or slipping (Marucci-Wellman et al., 2015). When
workers’ compensation claims will be approved (Knoblauch these injuries were examined across employer types, skilled
& Cassaro, 2018). nursing facilities had the highest rates of employees with
In most circumstances, the employer, employee, or ad- lost-time claims due to overexertion, and the freight truck-
ministrator of the workers’ compensation program has the ing industry had the highest rates of lost time from falls
option of requesting an independent medical examination (Meyers et al., 2018).
(IME) by a physician or health care provider who has not In addition to OSHA and state-fund databases, the Na-
been previously involved in the determination or manage- tional Institute for Occupational Safety and Health (NIOSH)
ment of the claim for a second opinion on the severity of funds 49 occupational health surveillance programs across
the injury or impairments, recovery prognosis, or disability the country. NIOSH’s (2018) surveillance programs provide
status. The IME’s findings can be used to substantiate or re- capacity for the continuous monitoring of trends in work in-
fute any determinations made by the primary physician on a juries and illnesses within specific regions and industries to
claim. Information documented by all health care providers, promote more effective, time-sensitive, and targeted outreach
including primary providers and IMEs, will be considered and support directly needed by local workers and employers.
by the workers’ compensation administrator in the process NIOSH also funds training, education, and research cen-
of making final determinations on the status of a claim. Any ters across the United States to meet the needs of employers
further disputes regarding a claim status by either the em- within each specific region. These support centers are fo-
ployer or the employee require additional litigation. cused on high-risk occupational sectors, such as agriculture,
construction, and emergency responders. Resources are also
available to support the development of Total Worker Health®
Surveillance and injury reduction programs focused on promoting health and well-being of
workers through a comprehensive shift in workplace culture
Multiple surveillance programs have been established to
(Schill, 2017; Schill & Chosewood, 2013).
identify areas of concern and guide risk management strat-
Trends identified in surveillance data from OSHA record-
egies to mitigate the increased costs associated with workers’
able events, BLS SOII, workers’ decompensation programs,
compensation. The Occupational Safety and Health Admin-
and NIOSH each directly affect state workers’ compensation
istration (OSHA) is the primary organization overseeing
legislation, and these data are used to develop safety and
workplace injury management. As its primary role, OSHA
health regulations, standards, and other special initiatives
monitors the rates of different injuries, illnesses, and fatali-
focused on reducing workplace injuries. These data also in-
ties across occupational sectors. Employers with more than
form the National Occupational Research Agenda, now in its
10 employees must regularly report any work-related injuries
3rd decade, which provides a roadmap for key areas of need
and illnesses that require more than simple first-aid manage-
for understanding the impact, development, and prevention
ment, known as OSHA recordable events.
of work-related injuries and illnesses (NIOSH, 2017a).
These recordable events are captured in the Survey of Oc-
cupational Injuries and Illnesses (SOII) administered by BLS,
which releases annual reports of all workplace injury, illness,
Vulnerable populations
and fatality data. These reports include information on the
types, sources, costs, and lengths of time off work across var- A final contemporary issue often tied to containment of in-
ious types of industries and occupational categories. More- creasing workers’ compensation costs relates to coverage and
over, all data are searchable and downloadable through the claims approval for individuals from multiple vulnerable pop-
BLS’s website, which can be a useful tool for occupational ulations. Each jurisdiction has different regulations related
therapy practitioners and managers interested in identifying to workers’ compensation coverage for individuals who may
trends in injuries, developing marketing strategies, or con- be considered to be vulnerable, including specific regulations
ducting any internal quality improvement audits. for children, pregnant mothers, and individuals of protected
Unfortunately, a third or more of workers’ compensation classes. Of increasing discussion and debate in recent years
claims may not be captured by the BLS SOII (Wuellner et al., are the rights of immigrants or undocumented workers. Most
2017), requiring practitioners and employers to rely on other states include protections for undocumented workers and re-
means of informing risk management. Data collected in mo- quire, by statute, that workers’ compensation provide cover-
nopolistic state-run systems, such as in Washington (Marcum age for these individuals.
& Adams, 2017; Wuellner et al., 2017) and Ohio (Meyers et al., Although individuals from vulnerable populations have
2018), or from third-party providers of workers’ compensation a right to workers’ compensation benefits, numerous addi-
insurance across the nation (Marucci-Wellman et al., 2015), tional factors must be considered relative to management of
their work-related injuries. A primary concern is that workers PRACTICAL APPLICATIONS IN

from low-income, minority, immigrant, and undocumented OCCUPATIONAL THERAPY
groups are much more likely to work in more dangerous
occupations or jobs with high injury rates (Orrenius & Occupational Therapy Services Within
Zavodny, 2009). Workers’ Compensation
Additionally, workers who are immigrants or undocu-
The focus on work has long been a cornerstone of occupa-
mented tend to sustain more severe work-related injuries
tional therapy, noted as one of Adolph Meyer’s (1977) “big 4”
than other working populations and have significantly lower
in the very early days of the profession, persisting as one of
rates of reporting the work-related nature of their injury
the key areas of occupation in the Occupational Therapy Prac-
when seeking care (Boggess et al., 2017). The fear of retribu-
tice Framework: Domain and Practice, 3rd Edition (American
tion by the employer that could result in punishment or being
Occupational Therapy Association [AOTA], 2014). Therefore,
fired from a job is often reported by these workers as a rea-
it is logical that occupational therapy practitioners should
son for not reporting injuries (Azaroff et al., 2002). Although
play a key role in providing rehabilitation services for cli-
this may be true in select cases, these cultural beliefs often
ents with work-related injuries, especially those that result in
persist despite little evidence supporting a reality of employer
functional impairments and time away from work (i.e., OSHA
retribution. Instead, the most pervasive reason for underre-
recordable events).
porting workplace injuries in vulnerable populations is poor
Among all injuries and illnesses, musculoskeletal condi-
promotion of culturally relevant workplace safety programs,
tions are the leading reason that U.S. employees are unable to
combined with a lack of knowledge or understanding of ways
work, affecting more individuals than the next most prevalent
to access the workers’ compensation program and a lack of
categories of heart conditions (including stroke) and psycho-
awareness of other legal rights (Topete et al., 2018).
logical conditions combined (Weinstein et al., 2014). Accord-
ing to BLS SOII, approximately one-third of OSHA-recorded
events in 2016 were considered musculoskeletal disorders
Review Questions
(e.g., carpal tunnel syndrome, sprains/strains, tendonitis; BLS,
1. Ryan, a nursing assistant, strains his back while assisting 2017b). When these disorders were combined with fractures
with a patient transfer and finds himself unable to sus- and other categories of injuries involving musculoskeletal tis-
tain a full workday or carry out the essential functions of sues, more than half of all nonfatal, OSHA-recorded events
his job. Which of the following disability benefits would were musculoskeletal conditions. Given the significant impact
his employer’s workers’ compensation program provide on functional performance, and as the second greatest cause
to Ryan at the outset of his injury while he is off work of worldwide disability across all types of medical conditions
recovering? (Vos et al., 2012), it is essential for occupational therapy practi-
a. Permanent partial disability (PPD) tioners to be involved in the provision of services for individu-
b. Permanent total disability (PTD) als with work-related musculoskeletal conditions (Roll, 2017).
c. Temporary total disability (TTD) Before providing services or interventions for a work-related
d. Voluntary supplemental disability (VSD) injury, occupational therapy practitioners should ensure
2. Administrators of a large, multisite manufacturing com- they have a full understanding of allowable reimbursement
pany in Florida are interested in reducing workers’ com- for services within their jurisdiction, as well as the approved
pensation costs by improving the efficiency of processing services within the specific workers’ compensation program
workers’ compensation claims in the hopes that they can supporting the client. In acute, inpatient settings and sub-
return cost savings to their employee shareholders. Given acute, outpatient/ambulatory rehabilitation sites, approved
the company’s location and goals, what is likely to be the services and reimbursements are typically similar to other
most appropriate program model for providing workers’ payer types. This will include approvals for occupational
compensation for this company? therapy evaluations and conservative treatment plans such
a. Federal insurance program as preparatory activities (e.g., physical agent modalities) and
b. Private insurance program occupation-based interventions (AOTA, 2014). Once a client
c. Self-insurance program has completed traditional medical management of an injury,
d. State-run insurance program additional services focus more on return to work, includ-
3. Which of the following resources would be most useful ing functional capacity evaluations, ergonomic evaluations,
for a business interested in identifying national trends in work conditioning, work hardening, and transitional work.
the rates of various types and causes of injuries within Although these services are sometimes listed on the workers’
their industry sector to inform the development of tar- compensation program’s fee schedule, it is more common
geted injury prevention measures? for such advanced services to require individual review sup-
a. ACOEM’s practice guidelines ported by a documented request by the medical provider.
b. BLS’s report of occupational injuries and illnesses There is significant variability in the type and amount of
c. Liberty Mutual’s workplace safety index services approved across each jurisdiction and type of work-
d. NIOSH’s surveillance program network ers’ compensation insurance program. Third-party, private
workers’ compensation systems tend to have the most restric- therapy practitioners. Most important and comprehensive
tive listing of approved services and often provide specific among these resources is the Occupational Therapy Prac-
limits on the number of visits based on the severity or type tice Guidelines for Adults With Musculoskeletal Conditions
of injury. These insurance programs are commonly less likely (Snodgrass & Amini, 2017). In addition to these comprehen-
to approve payment for more advanced return-to-work spe- sive practice guidelines, practitioners can find recent sum-
cific services beyond direct services for medical/rehabilitative maries of current evidence for occupational therapy inter-
management of the claim. In contrast, self-insured employers ventions in multiple systematic reviews for the treatment of
will often determine service needs and make approvals on a musculoskeletal conditions of the shoulder (Marik & Roll,
case-by-case basis and are more likely to provide individual 2017); forearm, wrist, and hand (Roll & Hardison, 2017); and
return-to-work services to promote efficient return of employ- lower extremities (Dorsey & Bradshaw, 2017).
ees to their jobs following an injury. Self-insured companies
often employ their own medical and rehabilitation staff or Workplace Safety, Health Promotion,
contract with individual occupational therapy practitioners
and Client Advocacy
to provide on-site services for workers with injuries.
State and federal workers’ compensation programs tend to Occupational therapy practitioners should be aware of oppor-
have mechanisms for reimbursement of both acute and subacute tunities to support workplace safety and health promotion
rehabilitation services, as well as advanced return-to-work ser- in the workplace, as well as consulting with companies for
vices. In many cases, these systems will manage medical claims workplace injury risk management. Common workplace ser-
through the workers’ compensation program, referring clients vices are either job analyses to identify essential functions of
who require additional services to a vocational rehabilitation a job regardless of the individual worker or ergonomic anal-
program for more advanced return-to-work interventions. yses to evaluate the fit of the work to an individual worker to
Regardless of the workers’ compensation system, a crucial ensure safety. These evaluations are often completed to meet
component for providing services is identifying the client’s ADA and EEOC requirements by providing a summary of
return-to-work goal. As part of the occupational profile, oc- essential functions of a job, as well as evidence of safety com-
cupational therapy practitioners should not only determine pliance with OSHA and other risk-monitoring organizations.
the client’s occupation and current work status but also iden- Although many professions conduct workplace evaluations,
tify the client’s specific return-to-work goal according to the occupational therapy practitioners provide a unique perspec-
widely accepted return-to-work hierarchy. This hierarchy es- tive from that of other professions. In contrast to a purely bio-
tablishes a preferential structure of return-to-work goals based mechanical or engineering approach, occupational therapy
on the highest probability of success due to the least amount practitioners are trained to conduct assessments using a biopsy-
of challenges or barriers. Accordingly, services should first be chosocial perspective with a focus on examining the positive
targeted toward assisting a client to return to the same job with and negative interactions among the worker, the work, and the
the same employer or, if necessary, a different employer. When environment. Moreover, occupational therapy practitioners are
these first 2 goals are not likely because of the severity of a cli- well situated to conduct in-depth task analyses relative to the
ent’s impairments, it is typically most preferable to set a goal components of the work, which typically results in a final re-
for returning to a different job with the same employer. As a port that includes more detailed physical requirements of a job.
last resort, practitioners can work with their clients to identify Job and ergonomic assessment reports that focus on a
options for obtaining a different job with a different employer. combination of biopsychosocial and detailed physical job re-
For all workers’ compensation claims, it is important that quirements not only meet regulatory requirements but also
this return-to-work goal be clearly documented and that the can be useful in managing workers’ compensation claims.
occupational therapy practitioner develop a treatment plan Specifically, both the employer and the treating provider can
specifically targeted toward achievement of this goal. Reas- use the detailed report to help clients identify a feasible re-
sessment of the primary return-to-work goal should be con- turn-to-work goal, as well as assist practitioners in develop-
ducted regularly to ensure that the targeted goal remains ing a treatment plan and/or identifying needs for TTD, PPD,
feasible; reassessment is especially important when a client PTD, MMI, and other claim statuses.
reaches MME or when PPD/PTD is awarded. Beyond workplace evaluations and ergonomics, occupa-
Occupational therapy practitioners should establish an in- tional therapy practitioners have numerous opportunities to
dividual treatment plan that includes approved services tar- become involved in other safety and health promotion services,
geted toward achievement of a client’s return-to-work goal. including executive health and employee education program-
Services should be within the occupational therapy scope ming related to stress management, time management, inter-
of practice (AOTA, 2014) and focus on the distinct value of personal relations, diet and sleep management, and other health
occupational therapy that uses occupation-based interven- and wellness training. Workers’ compensation programs will
tions and work tasks to support recovery and return to work sometimes provide a structure that supports these services, pri-
(Hardison & Roll, 2017). The aforementioned ACOEM prac- marily in locations with state-funding or self-insurance options.
tice guidelines that are used to guide policy decisions may Most states that provide a state-funded workers’ compen-
be useful; however, multiple and more specific resources are sation option will either require or provide incentives to em-
available to support evidence-based practice for occupational ployers to participate in health promotion training or provide
specific programming for their employees. In these states, oc- In larger organizations, occupational therapy managers
cupational therapy practitioners can often identify opportuni- may immediately refer employees to an occupational health
ties to provide training for employers through local or state- department, risk manager, or other human resources person-
wide safety council meetings. In some states, practitioners may nel whose job it is to impartially assist employees through the
even be able to leverage workers’ compensation regulations to process. In smaller companies, occupational therapy manag-
incentivize employers to directly contract workplace health ers may be directly responsible for assisting employees with
promotion training for their employees. reporting and managing their claim.
Opportunities for providing health promotion and pre- Although trained as health care providers, occupational
vention services are even more common in large, self-insured therapy managers should be cautious of providing any initial
companies. Given the need to closely manage workers’ com- evaluations, treatments, or other services beyond immediate
pensation costs, self-insured employers are often more proac- first aid. Provision of services could place both the manager
tive and involved in risk management within their own com- and the company at increased risk for liability concerns or
panies. As a result, these companies will either directly employ other complications in establishing and managing the result-
or establish contracts with occupational therapy practitioners ing workers’ compensation claim. In cases in which the man-
to provide ongoing training and other on-site services for their ager serves as the company’s primary workers’ compensation
employees to reduce workplace injuries. In addition to preven- resource person and an employee sustains a work-related
tion, ongoing direct contact with workers who have been in- injury, the occupational therapy manager should work with
jured and visits to the workplace by an occupational therapy the company to establish clear conflict of interest policies and
practitioner to evaluate the job, understand the context, and procedures to minimize risk to the company and/or potential
meet with individuals in person may reduce risk of lost-time for unfair treatment of the employee.
claim occurrence for employers (Schofield et al., 2017). Occupational therapy entrepreneurs who establish their
Workers are spending a significant portion of their wak- own therapy practices or consulting companies should become
ing hours at work, which means that the workplace environ- familiar with workers’ compensation statutes of the states and
ment and worker tasks directly affect the entirety of worker municipalities within which their business is registered. In
health and well-being. This link between work and health some states, even sole business owners must carry workers’
has prompted the development of multiple initiatives aimed compensation insurance, whereas other state regulations may
at modifying workplace conditions to promote all aspects of or may not include the business owner as an employee or es-
health and wellness. Total Worker Health® is currently the tablish a minimum number of employees (e.g., 3, 5) before a
largest and most prolific of these programs, with growing company is required to provide workers’ compensation bene-
evidence to support positive effects on general worker health fits. Additional considerations may apply for a company that
(Feltner et al., 2016). The overall goal of the Total Worker establishes individual contracts with each professional em-
Health program is to support the development of workplace ployee rather than directly hiring the employees. Regardless
policies and cultures that comprehensively promote protec- of the company’s size or requirements for providing workers’
tion from work-related injuries, prevention of chronic ill- compensation, liability for worker injuries sustained in the
nesses, and development of employee well-being (NIOSH, workplace or during the course of work will typically be shoul-
2017b). This paradigm creates multiple opportunities for oc- dered by the business owner. In cases where workers’ compen-
cupational therapy practitioners to engage with employers to sation is not required, business owners typically must carry a
develop and promote positive, safe, and healthy work environ- minimum level of liability insurance to cover such instances.
ments, which may be especially vital for addressing the needs In addition to providing oversight of workers’ compensa-
of vulnerable and low-wage populations (Topete et al., 2018). tion claims, both managers and entrepreneurs should strive to
develop a positive culture of workplace health and safety (Roll,
2012). Although occupational therapy practitioners are well
Management of Occupational
trained to provide services for other individuals, the profes-
Therapy Services
sion has a long history of poor self-management and preven-
In addition to understanding workers’ compensation reim- tion, resulting in high rates of work-related injuries (Campo &
bursement systems to ensure appropriate care for clients and Darragh, 2010, 2012; Darragh et al., 2009; King et al., 2009).
identifying opportunities for building occupational therapy When evaluating risk for employee safety, occupational
services within a workers’ compensation framework, the com- therapy managers and practitioners must be sensitive to both
plexities involved in providing workers’ compensation benefits internal threats (e.g., back injuries incurred during patient
to employees, as well as preventing and reporting injuries, war- transfers) and external threats (e.g., tripping and falling while
rant brief discussion. Occupational therapy managers should attempting to navigate the cluttered home of a home health
ensure that injury prevention, monitoring, and management are client). In addition to physical health, it is important to at-
priorities for the staff and employees under their supervision. tend to the psychosocial health and wellness of employees to
Additionally, managers should be familiar with the workers’ ensure they are not experiencing excessive stress, burnout,
compensation program offered by the company and be knowl- or other chronic conditions. Taken together, it is vital for all
edgeable about the internal process for reporting a work-related occupational therapy managers and entrepreneurs to create
injury or recordable event for any of their employees. a supportive and health-promoting workplace culture where
all of their employees feel safe, are knowledgeable about their b. Different job same employer, same job same em-
rights, and feel supported relative to prevention and manage- ployer, same job different employer, different job dif-
ment of workplace injuries. ferent employer
c. Same job same employer, same job different employer,
different job same employer, different job different
Review Questions employer
1. Two weeks after having surgery to repair a flexor tendon d. Same job same employer, different job same employer,
that was cut while opening a package at work, a client is different job different employer, same job different
being treated in an outpatient occupational therapy clinic. employer
Which of the following billable services would likely be 3. Which of the following describes the key principle of a
approved and reimbursed by any workers’ compensation Total Worker Health® program?
system for this client? a. Establishing an employee health department to con-
a. Functional capacity evaluation duct monthly physical and psychological evaluations
b. On-site ergonomic assessment and safety training on all workers can reduce workers’ compensation
c. Thermal ultrasound followed by dexterity training claims
activities b. Focusing on employee surveillance and encourag-
d. Work conditioning ing increased reporting of negative behaviors by
2. When discussing return-to-work goals with a client to coworkers can reduce the occurrence of workplace
develop a treatment plan, which of the following cor- injuries
rectly lists the targeted return-to-work hierarchy begin- c. Integrating workplace injury prevention and health
ning with the preferred outcome in most cases to the goal promotion strategies through policies and practices
usually held as the last resort? can improve overall worker health and well-being
a. Different job different employer, different job same d. Using a top-down approach to develop and imple-
employer, same job different employer, same job same ment stricter administrative strategies for managing
employer employee complaints can improve worker morale
CASE EXAMPLE 31.1. Best Practices for Managing a Workers’ Compensation Claim
Jennifer, a 42-year-old woman, worked as an order picker in a regional warehouse for a large national online retailer with offices in multiple
locations across the country. Toward the end of her shift, as she was filling her final order of the day, Jennifer needed to retrieve an item from the
overhead bin of a storage shelf, which required the use of a stool. As she pulled the item from the shelf, the plastic packaging became caught on
the metal shelving, preventing it from freely sliding from the shelf. In a rush to complete her order so that she could end the day, Jennifer began
jerking on the item with quick movements to dislodge it. Jennifer felt a pop in her right shoulder and simultaneously lost her balance on the stool.
She fell to the ground, landing on her outstretched right arm.
Jennifer had a good relationship with her manager, Maria, and knew that she could report her injury without fear of any retribution. Jennifer
also felt confident reporting her injury because the company worked very hard to establish a compassionate and caring culture. This was especially
true for employee health and wellness, as the company recently established a Total Worker Health program organized by a committee consisting
of employees at all levels. As part of the program, the company provided monthly safety and wellness training for all employees. The company also
employed multiple full-time safety professionals, including an industrial engineer and an occupational therapy practitioner, who conducted regular
assessments and adjustments for workstations and consulted with employees on how to manage their daily activities. In addition, Jennifer was
aware that the company managed their own workers’ compensation claims because she had previously seen a case manager from the human
resources department on the warehouse floor talking with her coworkers who had been injured.
Although Jennifer had worked at the company for 10 years and had never before sustained an injury, she recalled from the ongoing training the
company provided relating to workplace injuries that she must immediately report the injury to Maria before doing any further work. Although Maria
did not witness the fall, she could tell that Jennifer had been injured when she arrived at the office unable to move her right arm. Understanding the
importance of proper reporting and management of a work-related injury, Maria immediately called the paramedics instead of attempting to treat
the injury or request that Jennifer seek care on her own. While waiting for the paramedics to arrive, Maria retrieved an injury report form developed
by the company to document the injury, and Jennifer provided as detailed an account of the event as she could.
Jennifer was transported to the emergency department of the local hospital, where she was diagnosed with a mild shoulder dislocation and sprained
wrist. She was placed in an immobilization sling, provided with a prescription for pain medication, and referred to an occupational health physician for
follow-up. Jennifer called Maria to report that she would not be at work for the next 2 days until she could see the occupational health physician. At
her follow-up visit, the occupational health physician completed a full evaluation of her injuries and finalized the necessary paperwork to fully establish
a workers’ compensation claim. The physician placed Jennifer on leave, for which she immediately qualified for TTD, and Jennifer was referred to
outpatient occupational therapy for treatment of her shoulder and wrist.
Marquis, who was Jennifer’s occupational therapy practitioner, began the first session with an occupational history interview and completed a
full occupational evaluation for Jennifer’s shoulder and wrist. During the history interview, Jennifer indicated that she was currently unable to work,
but she expressed a strong desire to return to her job and her employer. Not fully knowing about the job based on the title, Marquis asked her to
(Continued)
CASE EXAMPLE 31.1. Best Practices for Managing a Workers’ Compensation Claim (Cont.)
provide a more detailed description of the work activities and physical requirements of the job. Jennifer noted that the onsite occupational therapy
practitioner had recently spent a half-day observing her, taking a lot of measurements with scales and other devices to determine all of the physical
components of her job.
After the visit, Marquis contacted the case manager on the claim paperwork to provide an update and confirm some additional information.
Although the clinic’s insurance manager had already called to verify approval of treatment on Jennifer’s claim, Marquis confirmed with the
case manager that the insurance plan would only initially cover 4 weeks of therapy before a reassessment would be required to continue
treatment. In addition, Marquis requested a copy of the job analysis report and any other job description documentation that the company might
be willing to provide. Using the information from the initial evaluation, the job analysis report, and approval information from the case manager,
Marquis developed a treatment plan that consisted of 4 weeks of treatment for Jennifer’s right shoulder and wrist. Treatment sessions began
with thermal modalities as preparatory activities for pain management and tissue pliability. These modalities were followed with manual therapies
and occupation-based activities, including simulated work activities in which Jennifer pushed a lightweight cart around the clinic and collected
various items of differing weights and heights.
After the initial 4 weeks of treatment, Jennifer had full return and use of her right wrist; however, she continued to have significant pain and
functional limitations in her shoulder. On returning to the occupational health physician, Jennifer was referred to an orthopedic surgeon, who
conducted imaging evaluations and discovered a partial supraspinatus tear and SLAP (superior labral tear from anterior to posterior) lesion in her
right shoulder. Jennifer subsequently underwent surgical repair for her rotator cuff and SLAP lesion and returned to outpatient occupational therapy.
Although she initially made progress, after 3 months of therapy, Jennifer began losing range of motion and had an increase in pain in her shoulder
with activity. She returned to the surgeon, who discovered she had adhesive capsulitis, sometimes referred to as “frozen shoulder.” Jennifer
underwent a shoulder manipulation under anesthesia to break the capsule free, which was then followed by 8 additional weeks of outpatient
occupational therapy.
Jennifer had now been off work for nearly 9 months, and she was no longer making significant progress in therapy. Although range of motion
had fully returned to her shoulder, she avoided raising her arm over her head due to slightly increased pain and a self-identified fear of reinjury.
She was no longer experiencing any significant pain while at rest, but she had increased pain in her shoulder with resistive or sustained activities.
Finally, Jennifer had developed mild radicular sensory symptoms in her right hand that decreased her fine motor dexterity and often caused her
to drop lightweight items. At her follow-up visit, the occupational health physician determined that she no longer had any significant medical
complications and that there were no further evidence-based medical interventions that would be necessary. As a result, he updated her status,
indicating that she had reached MMI.
Because of Jennifer’s continued impairments and poor tolerance for functional activities, the physician did not release her to return to work;
instead, he referred her back to Marquis for a functional capacity evaluation to determine her overall ability to return to work or need for further
services. Through this formal testing of her abilities, it was discovered that Jennifer’s maximum lifting capability was 20 pounds up to shoulder
height and she could only tolerate 5 pounds of weight overhead. Her gross motor coordination and fine motor manual dexterity were below average,
and pain in her shoulder began to incrementally increase after about 90 minutes of completing functional activities. Marquis created a detailed
report that directly compared her abilities to the physical capacities required for her previous job, indicating that she would not currently be able to
return to her previous position.
Although she was not able to return to her previous position, Jennifer remained highly motivated in returning to work, and her employer remained
supportive. Supported by the detailed documentation from the functional capacity evaluation, Jennifer was approved to receive a work hardening
program to assist her in improving her work-specific capacities for the occupational tasks required at her job. An additional benefit of the work
hardening program was the interdisciplinary team approach that also provided Jennifer with consultations with a psychologist to assist her with
pain management and overcoming her fears of reinjury.
After 8 weeks of participation in the work hardening program, Jennifer had increased her tolerance for lifting up to 35 pounds and sustaining
work up to 6 hours a day before her pain limited activity participation. The case manager at Jennifer’s company provided all of the reports of her
functional abilities to the occupational therapy practitioner who worked onsite for the company. The occupational therapy practitioner conducted
a meeting with the case manager, Jennifer, and Maria to discuss a plan for transitioning Jennifer back to full-time duties. On the recommendation
from this group, the company agreed to an 8-week transitional work program, whereby Jennifer worked her full shift but was only assigned orders
with items and total order weight that were less than 35 pounds. Over the 8-week period, the occupational therapy practitioner worked with
Jennifer to slowly increase the weight amount, number of orders, speed of work, and total continuous working hours until she was able to fully
return to her previous capabilities.
Although it took just over 1 year to fully recover from her injury and return to full duty, Jennifer’s case represents a highly successful management
of a workers’ compensation claim. The success in this case is primarily attributed to a proactive and engaged employer that developed a supportive
culture of workplace safety and health promotion. In addition, all individuals working on Jennifer’s case were highly responsive to her needs, and
the team had excellent overall communication.
Delays in claim processing, poor management and lack of communication, limited service approvals, or a general lack of information or
knowledge of the system and Jennifer’s rights would likely have contributed to less-than-ideal outcomes. Slower initial processing of the claim
or increased wait-time between follow-up or referral to service could have contributed to more long-term impairments that would not be able to
be remediated. Additionally, limitations on the number of occupational therapy visits, or lack of opportunity to participate in the advanced services
(i.e., work hardening and transitional work), likely would have resulted in Jennifer also receiving PPD at the time MMI status was determined.
In such a scenario, Jennifer likely would have had a new return-to-work goal of finding a different job either with her employer or with a
new employer.
(Continued)
CASE EXAMPLE 31.1. Best Practices for Managing a Workers’ Compensation Claim (Cont.)
Review Questions
1. Based on the description of how workers’ compensation claims were managed and approved, what type of workers’ compensation system
did Jennifer’s company use to manage her claim?
a. Federal insurance program
b. Private insurance program
c. Self-insurance program
d. State-run insurance program
2. When it was determined that Jennifer had reached a recovery plateau and no more medical interventions would be of benefit to her despite
not having full return of function, what determination was added to her claim file?
a. Maximum medical improvement (MMI)
b. Permanent partial disability (PPD)
c. Permanent total disability (PTD)
d. Temporary total disability (TTD)
3. Who had primary responsibility for determining and changing the status of Jennifer’s workers’ compensation claim and providing approval
for her to return to work?
a. Workers’ compensation case manager
b. Manager (Maria)
c. Occupational health physician
d. Occupational therapist (Marquis)

In the United States, workers’ compensation is provided This chapter addresses the following ACOTE Standards:
through third-party payments, self-insurance, state-run
■ B.4.10. Provide Interventions and Procedures
programs, and federal systems. Each state is responsible for
■ B.4.20. Care Coordination, Case Management, and Tran-
regulating workers’ compensation programs through legis-
sition Services
lation, leading to significant variability. The high prevalence
■ B.4.29. Reimbursement Systems and Documentation
and incidence of work-related injuries, combined with in-
creasing health care costs, have led to an exponential increase
■ B.5.2. Advocacy
in workers’ compensation spending in recent decades. These
■ B.5.4. Systems and Structures That Create Legislation
increased costs have prompted numerous changes in workers’
■ B.7.5. Personal and Professional Responsibilities.
compensation legislation, resulting in increased cost contain-
ment efforts, including program restructuring and reduction
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CHAPTER
Delivering Services Through Telehealth
Jana Cason, DHSc, OTR/L, FAOTA, and Tammy Richmond, MS, OTR/L, FAOTA 32
LEARNING OBJECTIVES
■ Define key telehealth terms and technologies;
■ Identify administrative, technical, clinical, and ethical telehealth considerations;
■ Describe evidence-based clinical applications of telehealth in occupational therapy; and
■ Identify available practice guidelines, official documents, resources, and state regulations to ensure legal and ethical
practice using telehealth technologies.

• Asynchronous technologies • Mobile or digital health • Telehealth
• Direct-to-business model • Originating site • Telehealth models of care
• Direct-to-consumer model • Remote patient monitoring • Telemedicine
• Hub-and-spoke model • Synchronous technologies • Telerehabilitation
• Information and communication
technology
OVERVIEW communication technology (ICT; e.g., computer, tablet, vid-

eoconferencing software, telephone). When applied to the re-
T
elehealth is becoming a mainstream delivery model for habilitation disciplines, telehealth is the provision of services
health care services, including within occupational ther- wherein the practitioner and the client are in different phys-
apy. This progressive adoption is the result of a need to
ical locations (American Occupational Therapy Association
decrease health care costs, implement alternative payment
[AOTA], 2018; World Federation of Occupational Therapists
models, and remove regulatory barriers while increasing
[WFOT], 2014). Telemedicine describes remote services pro-
consumer satisfaction (Cason, 2015; Cason & Richmond, 2016).
vided by physicians, nurses, and other health professionals
Therefore, managers should become familiar with essential
within a medical model. The American Telemedicine Associ-
considerations and evidence-based applications of delivering
ation (ATA; 2016) uses the terms telehealth and telemedicine
occupational therapy services through telehealth. This chapter
interchangeably with the intended meaning being “the use
provides an overview of key terminology; administrative, tech-
of remote health care technology to deliver clinical services”
nical, clinical, and ethical practice considerations; telehealth
applications in occupational therapy; and a case example. (para. 2).
Before 2013, AOTA endorsed the term telerehabilitation
to describe remote occupational therapy service provision
ESSENTIAL CONSIDERATIONS through ICT; however, this term became limiting in its scope.
In 2013, AOTA officially endorsed the term telehealth (AOTA,
Terminology 2013). Telehealth more accurately reflects the broad scope of
Telehealth is a broad term that encompasses service provi- occupational therapy to provide habilitative and rehabilitative
sion and health education provided through information and services in medical and educational systems and has emerged
https://doi.org/10.7139/2019.978-1-56900-592-7.032
311
CHAPTER
Delivering Services Through Telehealth
Jana Cason, DHSc, OTR/L, FAOTA, and Tammy Richmond, MS, OTR/L, FAOTA 32
LEARNING OBJECTIVES
■ Define key telehealth terms and technologies;
■ Identify administrative, technical, clinical, and ethical telehealth considerations;
■ Describe evidence-based clinical applications of telehealth in occupational therapy; and
■ Identify available practice guidelines, official documents, resources, and state regulations to ensure legal and ethical
practice using telehealth technologies.

• Asynchronous technologies • Mobile or digital health • Telehealth
• Direct-to-business model • Originating site • Telehealth models of care
• Direct-to-consumer model • Remote patient monitoring • Telemedicine
• Hub-and-spoke model • Synchronous technologies • Telerehabilitation
• Information and communication
technology
OVERVIEW communication technology (ICT; e.g., computer, tablet, vid-

eoconferencing software, telephone). When applied to the re-
T
elehealth is becoming a mainstream delivery model for habilitation disciplines, telehealth is the provision of services
health care services, including within occupational ther- wherein the practitioner and the client are in different phys-
apy. This progressive adoption is the result of a need to
ical locations (American Occupational Therapy Association
decrease health care costs, implement alternative payment
[AOTA], 2018; World Federation of Occupational Therapists
models, and remove regulatory barriers while increasing
[WFOT], 2014). Telemedicine describes remote services pro-
consumer satisfaction (Cason, 2015; Cason & Richmond, 2016).
vided by physicians, nurses, and other health professionals
Therefore, managers should become familiar with essential
within a medical model. The American Telemedicine Associ-
considerations and evidence-based applications of delivering
ation (ATA; 2016) uses the terms telehealth and telemedicine
occupational therapy services through telehealth. This chapter
interchangeably with the intended meaning being “the use
provides an overview of key terminology; administrative, tech-
of remote health care technology to deliver clinical services”
nical, clinical, and ethical practice considerations; telehealth
applications in occupational therapy; and a case example. (para. 2).
Before 2013, AOTA endorsed the term telerehabilitation
to describe remote occupational therapy service provision
ESSENTIAL CONSIDERATIONS through ICT; however, this term became limiting in its scope.
In 2013, AOTA officially endorsed the term telehealth (AOTA,
Terminology 2013). Telehealth more accurately reflects the broad scope of
Telehealth is a broad term that encompasses service provi- occupational therapy to provide habilitative and rehabilitative
sion and health education provided through information and services in medical and educational systems and has emerged
https://doi.org/10.7139/2019.978-1-56900-592-7.032
311
as the preferred term in regulatory language. AOTA (2018) State policy

defined telehealth as “the application of evaluative, consulta-
Practitioners must abide by any and all state laws, regu-
tive, preventive, and therapeutic services delivered through
lations, and policies governing the use of telehealth and
information and communication technology” (p. 1). WFOT
state occupational therapy licensing board regulations
(2014) also formally defined telehealth and endorsed its use in
and policies (e.g., scope of practice). Some states have ad-
ditional requirements associated with the use of telehealth
Occupational therapy practitioners provide services re-
such as a verbal or written informed consent, specific clin-
motely using both synchronous technologies (real-time
ical or nonclinical documentation requirements, required
interactive technologies that include video and audio;
presence of a support person (e.g., “e-helper”), and more
e.g., videoconference, gaming technologies with tele-
(AOTA, 2017b).
health application) and asynchronous technologies (also
Although many disciplines—including physicians, nurses,
referred to as store-and-forward data; e.g., videos, digital
emergency management service providers, psychologists,
images, archived wearable device or sensor data) in the de-
and physical therapists—have achieved or are working to-
livery of occupational therapy services through telehealth
ward licensure portability via interstate licensure compacts
(AOTA, 2018).
(Adrian, 2017), occupational therapy practitioners do not
yet have a mechanism in place for licensure portability. In
Administrative Considerations most cases, the practitioner must be licensed in the state
Federal policy where the client is located, deemed the “location of service”
or originating site. Exceptions to this licensure requirement
All practitioners, regardless of service delivery model, must exist in the Veterans Affairs health system and in some states
adhere to the Health Insurance Portability and Accountabil- with consultation and licensure exemption (e.g., temporary
ity Act of 1996 (HIPAA; P. L. 104–191). The rules on privacy practice) provisions (Cason & Brannon, 2011). Inconsistent
and security of protected health information (PHI) require laws, regulations, and policies among states (and even within
specific attention by managers and providers of telehealth states) necessitate the need to continually check state statutes
(Cason & Brannon, 2011). The Health Information Technol- and occupational therapy practice regulations and policies
ogy for Economic and Clinical Health Act of 2009 (HITECH; to ensure compliance when delivering services via telehealth
P. L. 111–5) provides additional compliance regulations for (AOTA, 2017b; Cason & Brannon, 2011).
the protection of PHI (Watzlaf et al., 2017). Managers and
practitioners should ensure that telehealth systems (e.g.,
Reimbursement
hardware, software, data storage vendors, servers) meet min-
imal technical requirements to protect privacy and security Many states have enacted private (commercial) insurance
of PHI. telehealth parity laws (ATA, 2018; CCHP, 2017, 2018). How-
Additionally, operational or contractual agreements such ever, it is important to note that reimbursement parity
as a business associate agreement, obligating any contracted (i.e., requiring reimbursement) is not the same as payment
vendor to the same privacy and confidentiality standards as parity (i.e., requiring the same rate of payment; CCHP,
the practitioner, must be administered (Peterson & Watzlaf, 2018). Payment parity laws require commercial insurers to
2014). Various encryption and user authentication methods pay for clinical services provided through telehealth at the
should be used for desktop computers, mobile devices same rate as those same services provided in-person. Man-
(including smartphones), and telehealth platforms to ensure agers and organizations will need to understand, negotiate,
compliance (Peterson & Watzlaf, 2014; Smith et al., 2017; and implement billing as well as coding and reimbursement
Watzlaf et al., 2010, 2011). methodologies that are in agreement with current laws and
Federal health care policies continue to promulgate laws regulations; they will also need to adhere to any required
and regulations inclusive of telehealth services and pay- payment or billing methods, including the use of a telehealth
ment methods. These policies are influenced by advocacy modifier (e.g., Modifier 95 for real-time, live, and interactive
efforts to eliminate utilization barriers such as geographic or synchronous service).
or location restrictions; billing, coding, reimbursement, At the time of this writing, occupational therapy practi-
and payment disparity; overly restrictive telehealth service tioners are not recognized by the Centers for Medicare and
and implementation standards; and licensure requirements Medicaid Services (2016) as telehealth providers eligible for
associated with multi-state practice (ATA, 2017). Manag- Medicare reimbursement. Managers should contact their
ers and practitioners play an active role in these advocacy organization’s lawyer or a lawyer with expertise in telehealth
efforts through engagement in state and national profes- before providing and billing any services through telehealth
sional associations, including those focused solely on the for Medicare recipients.
advancement of telehealth (e.g., ATA, Center for Con- Medicaid—a program primarily providing medical and
nected Health Policy [CCHP], Center for Telehealth and health-related services to low-income families, older adults,
e-Health Law). and people with disabilities—is jointly funded by federal and
CHAPTER 32. Delivering Services Through Telehealth 313
state government. States have flexibility in how they admin- Models of care
ister the program, and several states have elected to include
Sometimes referred to as business models or service models,
occupational therapy practitioners as eligible telehealth pro-
the following telehealth models of care provide a conceptual
viders. Currently, there is expanding use of telehealth to de-
framework for health care organizations and managers:
liver health care services for Medicaid recipients.
Occupational therapy managers will need to check with ■ Hub-and-spoke model: Consists of 1 hospital with sev-
their state Medicaid regulations to understand which services eral community clinics sharing the same technology and
can be delivered through telehealth, any restrictions on how the providers.
services can be delivered (e.g., synchronous vs. asynchronous), ■ Direct-to-consumer model: A website or portal where
and state-specific billing requirements. In states where occu- consumers purchase and receive select services through
pational therapy practitioners are not recognized as telehealth telehealth.
providers, managers and practitioners are encouraged to work ■ Direct-to-business model: Vendors license service plat-
with state and national organizations to advocate for inclusion forms or applications to businesses for service delivery.
of occupational therapy practitioners as eligible telehealth pro- ■ Remote patient monitoring: Uses technologies in the
viders within the Medicaid-sponsored telehealth programs. client’s home to record physiological data (e.g., vital signs)
and transmit the data remotely to a contracted health care
Malpractice insurance entity.
■ Mobile or digital health: Uses mobile devices (e.g., note-
A general consensus exists among professional liability in- book computers, tablets, smartphones) to deliver health care
surers to provide coverage for occupational therapy services services (see https://www.telehealthresourcecenter.org/).
regardless of how these services are delivered (i.e., in-person,
through telehealth). This coverage is contingent on the prac-
titioner working within the scope of practice at the location Technical Considerations
of service (i.e., state where client is located). Managers and Technological advances and a competitive marketplace have
practitioners should confirm coverage for services provided driven down the cost of technologies. The type of business
through telehealth with their malpractice insurance carrier model and clinical services to be provided through telehealth
(Cason & Brannon, 2011). will dictate the type of technology needed. For example, a
client who will be seated throughout the session may use a
desktop or laptop computer, whereas a caregiver of a pediatric
client who will be moving throughout the room may benefit
See Chapter 53, “Professional Liability Insurance,” for more detailed from the use of a mobile device (e.g., laptop computer, tablet,
information on insuring against malpractice. smartphone) that can be moved around the room to capture
various angles throughout the session.
Similarly, use of a mobile device is most beneficial during a
Program development home assessment in which the provider views multiple rooms
throughout the home. Some health care systems or organi-
With the increased use of telehealth in health care, many
zations may already be using telemedicine or telehealth plat-
health care organizations are developing new telehealth pro-
forms and electronic medical record software. Managers and
grams or expanding existing telehealth programs to include
occupational therapy practitioners will be expected to learn
additional disciplines and services. A needs assessment and
and adapt service delivery through the existing ICT.
analysis of strengths, weaknesses, opportunities, and threats
In addition to hardware, software and data storage should
will give managers important information to guide telehealth
conform to HIPAA and HITECH requirements. Videocon-
program development and implementation. The California
ferencing and data storage vendors should provide a business
Telehealth Resource Center (CTRC; 2014) has offered a free,
associate agreement obligating the vendor to the same privacy
online Telehealth Program Developer Kit, providing a stan-
and confidentiality standards as the practitioner (Peterson &
dardized approach to telehealth program development and
Watzlaf, 2014; Richmond et al., 2017). Many options for secure,
implementation.
HIPAA-compliant videoconferencing and data storage are
Other organizations have also created telehealth pro-
available and should be used for telehealth programs.
gram startup and resource guides (Telligen & Great Plains
Telehealth Resource and Assistance Center, 2014). The U.S.
Department of Health and Human Services’ Office for the Clinical Considerations
Advancement of Telehealth funds 2 national and 12 regional
Practitioner competencies
telehealth resource centers. These federally funded cen-
ters provide education, assistance, and training to support Occupational therapy practitioners may acquire competen-
telehealth program development and implementation (see cies related to telehealth through various means: continuing
https://www.telehealthresourcecenter.org/). education courses and webinars, conference programs, live
training sessions, and formal and informal mentoring rela- its members, with possible sanctions being reprimand, cen-
tionships. Areas of competency include knowledge, critical sure, probation of membership subject to terms, suspen-
reasoning, interpersonal skills, performance skills, and eth- sion, or permanent revocation of association membership
ical practice (AOTA, 2015c). In addition to competencies in (AOTA, 2015a).
these areas, practitioners using videoconferencing should be Managers and practitioners should consult AOTA’s
able to demonstrate the ability to set up and use the various (2015b) Occupational Therapy Code of Ethics (2015) and
technology features (e.g., camera, audio, screen sharing, an- adhere to the core values and principles and standards of
notation, text chat) and to provide basic technical support conduct outlined within the document regardless of how
for clients. Information technology staff or technical support occupational therapy services are delivered (e.g., in-person,
from the videoconferencing vendor should be available to telehealth). AOTA’s (2017a) “Telehealth Ethics Advisory
assist with more complex technical issues (Richmond et al., Opinion” is a helpful resource as it relates to ethical con-
2017). Technology can fail for various reasons (e.g., user error, siderations for the application of telehealth in occupational
lack of adequate bandwidth); therefore, a backup plan such as therapy. Additionally, ethical principles for the delivery of
a follow-up telephone call is critical in the event of a disrup- services via telehealth are outlined in the resource, “Guide-
tion during the therapy session. lines for Delivering Telerehabilitation Services” (Richmond
Many popular occupational therapy assessments are et al., 2017).
available for electronic administration and scoring, in-
cluding remote administration and scoring via telehealth
(e.g., Q-global®: https://bit.ly/2WOxSm0; Online Evaluation Review Questions
System™: https://bit.ly/2TyZsBD). When administering as- 1. Which term describing remote service provision is en-
sessments through telehealth, especially if modifications dorsed by AOTA because it most accurately reflects the
are made to the assessment protocol or assessment materi- broad scope of occupational therapy and has emerged as
als, practitioners should consider the potential impact on the preferred term in regulatory language?
the reliability and validity of the scores and meaningful a. Telemedicine
interpretation. b. Telehealth
c. Telerehabilitation
Environmental considerations d. Teleconsultation
2. Which term means real-time interaction with video and
Room location, room size, equipment placement, lighting,
audio between a client and a health care provider located
position of the camera(s), wall color (light blues and light
at a distant site?
greys are considered optimal), and acoustics may affect the
a. Asynchronous
quality of telehealth sessions (CTRC, 2014). The CTRC’s
b. Store and forward
Telehealth Program Developer Kit provides helpful informa-
c. Virtual
tion and a useful environmental considerations checklist.
d. Synchronous
3. Which 2 federal laws aim to protect privacy and security
End-user considerations of health information and require that telehealth systems
Managers and practitioners should be cognizant of how (e.g., hardware, software, data storage vendors, servers)
clients’ impairments affect technology access and use. Practi- meet minimal technical requirements to protect privacy
tioners should be familiar with accessibility features available and security of protected health information (PHI)?
within popular devices and software (Apple, 2017; Google, a. Health Insurance Portability and Accountability Act
2017; Microsoft, 2017). Clinical judgment can further inform of 1996 (HIPAA) and Health Information Technol-
the need for assistive technology and adapted therapeutic ogy for Economic and Clinical Health Act of 2009
materials and equipment to improve access for clients with (HITECH)
physical, cognitive, and sensory impairments (e.g., visual, au- b. Health Insurance Portability and Accountability Act
ditory, touch). Practitioners must comply with copyright laws of 1996 (HIPAA) and Telehealth Modernization Act
when using and adapting materials for telehealth purposes of 2015
(AOTA, 2015b; Richmond et al., 2017). c. Health Information Technology for Economic and
Clinical Health Act of 2009 (HITECH) and Federal
Technology Transfer Act of 1986 (FTTA)
Ethical Considerations
d. Federal Information Security Management Act of
It is important to keep in mind that telehealth is a ser- 2014 (FISMA) and Federal Technology Transfer Act
vice delivery model—the service is occupational therapy. of 1986 (FTTA)
Most, if not all, existing occupational therapy state prac- 4. What resource does the U.S. Department of Health and
tice regulations and standards address ethics in practice Human Services’ Office for the Advancement of Tele-
whether the service is provided in-person or through telehealth fund to support telehealth program development
health. AOTA also investigates ethical complaints against and implementation?
5. Identify a minimum of 2 factors that influence the type of

technology that is used in a telehealth session. EXHIBIT 32.1. Key Telehealth Resources
6. As required by HIPAA, what contractual agreement
obligates a videoconferencing or data storage vendor to ■ American Occupational Therapy Association
the same privacy and confidentiality standards as the (AOTA; https://www.aota.org/telehealth)
practitioner? ■ Occupational Therapy and Telehealth State Statutes, Regulations
a. Corporate compliance letter and Regulatory Board Statements Chart
■ Advisory Opinion for the Ethics Commission: Telehealth
b. Corporate cooperation letter
■ Telehealth Position Paper
c. Business associate agreement
■ American Telemedicine Association
d. Business partnership agreement (ATA; http://www.americantelemed.org/home)
7. Identify a minimum of 3 areas of competency for practi- ■ Telehealth Policy Resources (home page → policy tab)
tioners engaged in telehealth. ■ Telerehabilitation Special Interest Group (TR SIG)
8. Identify a minimum of 3 environmental factors that ■ Principles for Delivering Telerehabilitation Services
affect the quality of a telehealth session. ■ California Telehealth Resource Center
9. Identify 2 AOTA ethics resources that managers and (CTRC; http://www.caltrc.org)
practitioners can consult to ensure ethical telehealth ■ CTRC Telehealth Program Developer Kit (https://bit.ly/2SuOZtZ)
practice. ■ Center for Connected Health Policy
10. How is telehealth best characterized? (CCHP; http://www.cchpca.org/)
■ Center for Telehealth and eHealth Law (CTEL; http://ctel.org/)
a. Service delivery model
■ International Journal of Telerehabilitation
b. Specialized interventions
(IJT; https://bit.ly/2Gfy9tc)
c. Skilled clinical services ■ Telehealth Resource Centers
d. Virtual consultations (TRC; https://www.telehealthresourcecenter.org/)
OCCUPATIONAL THERAPY Review Questions
Telehealth is being used across occupational therapy prac- 1. Which resource provides a step-by-step guide for tele-
tice settings (AOTA, 2018). Comparative efficacy studies health program development and a useful environmental
and systematic reviews support the use of telehealth with considerations checklist?
clients with cardiac disease (Agostini et al., 2015; Rawstorn A. AOTA’s Telehealth Position Paper
et al., 2016), hand injuries (Worboys et al., 2018), orthope- B. AOTA’s Telehealth Ethics Advisory Opinion
dic impairments (Agostini et al., 2015), stroke (Chen et al., C. CTRC’s Telehealth Program Developer Kit
2015), and other health conditions. The use of telehealth is D. ATA’s Principles for Delivering Telerehabilitation
associated with positive clinical outcomes; client satisfac- Services
tion; decreased caregiver stress; and improved access to 2. Identify a minimum of 2 clinical outcomes associated
care, quality of life, and well-being (AOTA, 2018; Hu et al., with the use of telehealth.
2015). See Case Example 32.1 for an example of telehealth 3. Identify a minimum of 2 clinical populations where ef-
program development. Key telehealth resources are outlined ficacy studies and systematic reviews support the use of
in Exhibit 32.1. telehealth with clients.
CASE EXAMPLE 32.1. Telehealth Program Development
Nancy manages an occupational therapy department at a large hospital with 8 community clinics located in surrounding counties. She has been
asked by the hospital’s telehealth program director to research and provide a proposal for expanding the existing telehealth program to include
pediatric occupational therapy. The hospital uses a hub and spoke model with their community clinics. The pediatric occupational therapy telehealth
program will fill the need for follow-up occupational therapy services for children and their parents after inpatient discharge. Nancy is expected to
use the hospital’s existing hardware and software for the Occupational Therapy Pediatric Telehealth Community Program.
Review Questions
1. Using the CTRC’s Telehealth Program Developer Kit (see Exhibit 32.1), what are the first 3 steps Nancy should complete to assess the
environment and define the proposed program?
2. Identify a minimum of 3 essential considerations (e.g., administrative, technical, clinical, ethical) that Nancy should keep in mind as she
develops the Occupational Therapy Pediatric Telehealth Community Program.
3. What pediatric occupational therapy services might Nancy include in the Occupational Therapy Pediatric Telehealth Community Program?
SUMMARY /corporate/files/secure/advocacy/state/telehealth-state-statutes
-regulations-regulatory-board-statements.pdf
As telehealth becomes increasingly used for health care de- American Occupational Therapy Association. (2018). Telehealth in
livery, managers and practitioners should become familiar occupational therapy. American Journal of Occupational Therapy,
with administrative, technical, clinical, and ethical con- 72(Suppl. 2), 7212410059. https://doi.org/10.5014/ajot.2018.72S219
siderations associated with its use in occupational therapy. American Telemedicine Association. (2016). About telemedicine. Re-
Available resources assist managers and practitioners with trieved from http://www.americantelemed.org/about/telehealth
the systematic development, implementation, and evalua- -faqs-
American Telemedicine Association. (2017). Transforming health
tion of telehealth programs. When laws, regulations, stat-
care for patients: 2017 policy priorities. Retrieved from https://
utes, and policies limit occupational therapy practitioners’
higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED
use of telehealth, advocacy opportunities exist. Managers /3c09839a-fffd-46f 7-916c-692c11d78933/UploadedImages
and practitioners can partner with national and state profes- /Policy/2017%20Policy%20Priorities.pdf
sional associations as well as organizations dedicated solely American Telemedicine Association. (2018). State policy resource
to the advancement of telehealth (e.g., ATA, CCHP, Center center: States with parity laws for private insurance coverage of
for Telehealth and e-Health Law) to support advocacy initia- telemedicine (2018). Retrieved from http://www.americantelemed
tives and expand telehealth applications within occupational .org/policy-page/state-policy-resource-center
therapy. ❖ Apple. (2017). Accessibility [Video file]. Retrieved from https://
www.apple.com/accessibility/
California Telehealth Resource Center. (2014). The CTRC telehealth
ACOTE STANDARDS program developer kit. Retrieved from https://www.telehealth
resourcecenter.org/wp-content/uploads/2018/09/Complete
This chapter addresses the following ACOTE Standard: -Program-Developer-Kit-2014.pdf
Cason, J. (2015). Telehealth and occupational therapy: Integral
■ B.4.15. Technology in Practice. to the Triple Aim of health care reform. American Journal of
Occupational Therapy, 69, 6902090010. https://doi.org/10.5014
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-startup-and-resource-guide.pdf /telehealth
SECTION V.
Interprofessional Practice and
Teams
Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA
319
Advocating Occupational Therapy’s Distinct Value CHAPTER
Within Interprofessional Teams
Craig E. Slater, PhD, MPH, BOccThy, and Anne Cusick, PhD, OTR(Australia) 33
LEARNING OBJECTIVES
After reading this chapter, readers should be able to
■ Describe the characteristics of interprofessional teams and interprofessional collaborative practice,
■ Discuss the distinct value of occupational therapy in interprofessional teams,
■ Identify strategies that enable occupational therapists to advocate the distinct value of occupational therapy in inter-
professional teams, and
■ Apply advocacy strategies to a scenario involving an occupational therapist in an interprofessional team.

• Interprofessional collaborative • Interprofessional Education • Multidisciplinary teams
practice Collaborative • Triple Aim
• Interprofessional education • Interprofessional teamwork
OVERVIEW serve the interests of clients in ways the team or provider or-
ganization recognizes are efficient and effective. This chapter
I
nterprofessional collaboration between health profession- provides an overview of interprofessional collaborative prac-
als is imperative for the coordination and delivery of high tice and the features of interprofessional teams that warrant
quality, client-centered health care. Interprofessional col- attention when advocating for the distinct value that occupa-
laborative practice occurs “when multiple health workers tional therapy can bring. Application is demonstrated in a case
from different professional backgrounds provide compre- example.
hensive services by working with patients, their families, car-
ers, and communities to deliver the highest quality of care”
(World Health Organization [WHO], 2010, p. 13). ESSENTIAL CONSIDERATIONS
Occupational therapy practitioners work in a range of
Working in Teams
settings and contexts in which they are members of an es-
tablished interprofessional team, or they work collaboratively Occupational therapy managers and practitioners have al-
with other professionals to provide coordinated, integrated ways worked with other professionals. In the early days of
care for their clients. Occupational therapy managers and the profession, occupational therapy practitioners worked
practitioners who have a good understanding of their profes- in army, asylum, hospital, and other contexts with insti-
sional identity and scope of practice can engage confidently tutional administrators, doctors, nurses, and other allied
and competently in these teams. They are open to the dia- health professionals. Roles and responsibilities of each pro-
logue and negotiation needed to share responsibility, pool fession were codified into position descriptions, and recruit-
expertise, and coordinate roles to build an interprofessional ment, supervision, performance management, and service
team focused on clients’ needs and goals. allocation were organized along professional lines. The as-
When advocating the need for occupational therapy within sumption was that the aggregate of expertise would culmi-
interprofessional teams, real influence and positional power nate in comprehensive service to help address the patient’s
comes from shared commitment and demonstrated ability to “problem.” In this model of service, health professionals
https://doi.org/10.7139/2019.978-1-56900-592-7.033
321
322 SECTION V. Interprofessional Practice and Teams
each had distinct roles and scopes of practice. Each disci- clinicians are primarily working toward meeting disciplinary
pline addressed clients’ needs through evaluation and inter- goals. Table 33.1 presents the differences between interprofes-
vention of problems that fell within their professional area sional and multidisciplinary teams.
of expertise. Interprofessional teamwork is “cooperation, coordination,
This “compartmentalization” of patient needs, the spe- and collaboration characterizing the relationships between
cialization of services, and boundary setting in professional professions in delivering patient-centered care” (Interprofes-
roles was characteristic of 20th-century health care. Multi- sional Education Collaborative, 2016, p. 8). Through interpro-
disciplinary teams emerged as an organizational strategy to fessional teamwork, health professionals engage in collabo-
harness the strengths and mitigate the risks of specialization rative communication and coordinate efforts to work toward
by using coordination, case management, and client-centered common client-centered goals. To do this, health profession-
care. Multidisciplinary teams occur when health professionals recognize the unique value of their own and other profes-
als are administratively organized to bring different clinical sions so that the strengths of the varying professions can be
perspectives and specialist knowledge to planning and pro- coordinated and best used to deliver high-quality health care.
viding care for service recipients in a manner where coordi- WHO (2010) describes this type of team functioning as inter-
nation and communication between members is supported professional collaborative practice.
and required (Mitchell et al., 2008). Interprofessional education (IPE) occurs when “2 or
However, such risks of specialization did not always work, more health professions learn about, from and with each
and sometimes clients or client problems would “fall through other to enable effective collaboration and improve health
the cracks” in services organized around professional roles. The outcomes” (WHO, 2010, p. 13). IPE aims to prepare future
mismatch between professional roles and client needs was par- health professionals with the knowledge, skills, and atti-
ticularly evident when complex or atypical client issues arose tudes for collaborative, team-based, person-centered practice
that did not neatly fit within professional scopes of practice. during their training program so they are ready for inter-
The beginning of the 21st century saw global, national, professional collaborative practice upon entry to the health
and local health policies shift from provider-driven, problem- workforce. Recognizing that health professional programs
oriented, professionally streamed, and administratively coor- needed guidance to develop IPE curricula, 6 national health
dinated services. Instead, health professionals were encouraged professional associations formed the Interprofessional Edu-
to communicate among themselves and collaborate with con- cation Collaborative (IPEC) in 2009 to promote and advance
sumers to provide services that would build clients’ capacity to interprofessional collaborative practice (IPEC, 2011). Since
manage and promote their own health in ways relevant to their then, many other professional associations have become in-
own life situations. Collaboration between professionals and stitutional members of IPEC, including the American Occu-
consumers required a different type of team, one in which the pational Therapy Association (AOTA).
disciplinary expertise of team members would be integrated, IPEC (2016) identified 4 competencies, each with up to
rather than collated, to provide comprehensive, seamless per- 11 subcompetencies, that are necessary for interprofessional
son-centered care. collaborative practice:
1. Values/ethics for interprofessional practice: Work with
Interprofessional Teams individuals of other professions to maintain a climate of
mutual respect and shared values.
Interprofessional team is a term aimed at capturing the mean-
2. Roles/responsibilities: Use the knowledge of one’s own
ing behind this new approach to service organization in which
role and those of other professions to appropriately assess
team members are integrated in providing patient-centered
and address the health care needs of patients and to pro-
care. These teams maintain the depth of expertise brought
mote and advance the health of populations.
by professionals with different backgrounds while broaden-
3. Interprofessional communication: Communicate with pa-
ing their shared responsibility. An interprofessional team
tients, families, communities, and professionals in health
approach aims to achieve collaboratively developed and clin-
and other fields in a responsive and responsible manner
ically significant health outcomes for clients. What makes in-
that supports a team approach to the promotion and
terprofessional teams different from multidisciplinary teams
maintenance of health and the prevention and treatment
is a focus on shared responsibility for a common client goal
of disease.
rather than distributed roles targeting discipline-driven areas
4. Teams and teamwork: Apply relationship-building values
of performance.
and the principles of team dynamics to perform effec-
For interprofessional teams, common client-centered goals
tively in different team roles to plan, deliver, and evalu-
guide disciplinary interentions to achieve outcomes that are
ate patient- and population-centered care and population
driven by and in the best interests of the client. Therefore,
health programs and policies that are safe, timely, effi-
collaboration among providers is critical when working to-
cient, effective, and equitable.
ward achieving the common client-centered goal. In contrast,
goals are likely to be set by each individual clinican relevant Although these competencies were primarily developed
to their discipline in a multidisciplinary approach. Collabo- to guide IPE curriculum development in health professional
ration is less important in a multidisciplinary model because schools, the document also outlines the interprofessional
CHAPTER 33. Advocating Occupational Therapy’s Distinct Value Within Interprofessional Teams 323
TABLE 33.1. Key Characteristics of Multidisciplinary and Interprofessional Teams
CHARACTERISTIC MULTIDISCIPLINARY TEAMS INTERPROFESSIONAL TEAMS

Roles Each profession has clearly defined roles and scope of Roles and scope of practice often overlap.
practice.
Collaboration Health professionals work in parallel and share Care provision is integrated and health professionals work
information with others in the team as necessary. interdependently.
Communication Communication is characterized by hierarchical reporting Communication is characterized by inclusive and

to the care coordinator or discipline-specific targeted collaborative whole-of-team networks.
liaison relating to a specific client problem or goal that
“crosses” perceived professional responsibilities.
Client goals Health professionals work collaboratively with clients to Teams work collaboratively with clients to identify shared
identify individual health care goals framed in ways health care goals framed in ways that are person centered
that are discipline specific. and reflect the client’s unique life situation. Determining
how the involvement of various disciplines will best help
meet these goals, the team as a whole is responsible for
goal attainment.
Leadership Team structures are largely hierarchical and are often There is an emphasis on shared responsibility across
physician led. disciplines.
Team contributions Cumulative and coordinated expertise of specific Integrated and collaborative expertise of specific disciplines
disciplines builds a team of aggregated expertise. creates a social system of client-centered and goal-
Recognition of the expertise of other disciplines is directed team expertise. Contributions from each of the
considered from a profession-specific standpoint. disciplines are determined in the context of the expertise
in the team.
Problem solving Problem identification and problem solving is largely Health professionals participate in a micro “community of
framed with respect to issues within disciplinary practice” centered on the particular needs and goals of a
scopes of practice. client using collaborative, negotiated approaches to team-
based problem solving.
practice requirements for clinicians working in interprofes- In other settings, interprofessional team members, or
sional teams. Understanding these competencies can be use- other professionals with whom occupational therapy practi-
ful for occupational therapy managers who supervise more tioners engage in collaborative practice, may not be co-located
than 1 discipline to further develop successful interprofes- (e.g., home health, community, outpatient, private practice).
sional teams in clinical settings. In these teams, geographical distance, varying health profes-
sional schedules, and separate record-keeping systems may
pose challenges for interprofessional collaborative practice
Settings and Systems Influence
(Supper et al., 2014). It is imperative that health profession-
Occupational therapy practitioners work in interprofessional als use other communication strategies (e.g., email, tele-
teams in a wide range of settings and contexts. These settings phone communication, handoffs) to effectively collaborate
can enable or impede the social interaction needed for effec- in the interests of coordinating and providing high-quality,
tive team function. In many settings, most members of the client-centered care.
interprofessional team are co-located (e.g., inpatient hospital Across all settings, interprofessional collaborative prac-
or rehabilitation care, skilled nursing facilities, mental health tice may be hindered by organizational culture, systems
facilities, many school-based or early intervention teams). In operation, resource availability, or policy issues. Workplace
these settings, interprofessional collaboration might be en- cultures may cultivate stereotyping of professions and hier-
hanced through regular interprofessional meetings or rounds archical team structures (Braithwaite et al., 2016), creating
or through the use of interprofessional workflow and commu- “turf wars” among professionals, restricting collaborative
nication checklists (Reeves et al., 2016). Patient co-treatment relationships, and influencing the power or respect a profes-
with other professionals, access to shared health records, and sional has within the team.
increased opportunities for informal communication with High caseloads, time poverty, and insufficient resources may
members of the interprofessional team can also support in- also limit opportunities for genuine interprofessional collabo-
terprofessional teams to work collaboratively. rative practice (Washington et al., 2017). Similarly, operational
methods of team functioning or reimbursement structures In interprofessional teams, occupational therapy managers
may influence collaboration and communication, leading to and practitioners need to apply their expertise in interper-
professionally segregated health care provision. Managers and sonal communication in written, verbal, and nonverbal ways
adiministrators can successfully manage such barriers to inter- to share this value proposition and demonstrate their value in
professional collaborative practice to enhance the experience of achieving positive outcomes for both clients and teams. Inter-
working in interprofessional teams and increase the likelihood professional team members must come to believe that “facil-
of successful client outcomes. itating participation and engagement in occupations” is not
only an essential part of serving the client but that it will also
Occupational Therapy and Interprofessional be achieved as efficiently as possible when performed by an
occupational therapy practitioner. Therefore, managers must
Collaborative Practice
ensure that every practitioner is prepared to describe, explain,
Interprofessional collaborative practice is integral to ethical and demonstrate the difference they make in client lives be-
occupational therapy practice. AOTA’s (2015b) Occupational cause they are occupational therapists.
Therapy Code of Ethics (2015) (hereinafter, the “Code”) de- When advocating in interprofessional teams, occupational
scribes behaviors that show what this type of collaboration therapy practitioners work collaboratively with professionals
looks like in practice. References to interprofessional collabo- in other disciplines in an attitude of shared commitment to
rative practice in the Code are presented in Exhibit 33.1. coordinated and collaborative person-centered care. There-
Occupational therapy practitioners who demonstrate the fore, advocating occupational therapy’s distinct value must
behaviors described in Exhibit 33.1 will not only be ethical be respectful of the practices, competencies, roles, and re-
but also will contribute to a practice environment and health sponsibilities of other health professions and the advocacy
care service that is safe, high quality, and client centered. Oc- efforts of the respective health professionals.
cupational therapy practitioners who adhere to the Code are
thus primed for interprofessional collaborative practice with
Review Questions
requisite values and training in interpersonal communica-
tion skills previously identified to be so important. 1. How do roles and responsibilities differ between multi-
In addition, because interprofessional collaborative prac- disciplinary and interprofessional teams?
tice is inherently person centered, occupational therapy 2. What are the key characteristics of interprofessional col-
practitioners are well placed to understand the performance laborative practice, and how do these align with AOTA’s
component, task, and participation issues facing clients. In- (2015b) Occupational Therapy Code of Ethics?
terprofessional practice is a great opportunity for occupa- 3. How can settings and systems influence interprofessional
tional therapy practitioners to work collaboratively with a team function?
wide range of health and helping professionals to help clients
improve health and reach their goals.
Advocating Occupational Therapy’s OCCUPATIONAL THERAPY
Distinct Value Building Collaborative Relationships
Regardless of interprofessional setting or service system, occu- Interprofessional teams create service and system-wide op-
pational therapy’s distinct value is “to improve health and qual- portunities to advocate for the distinct value of occupational
ity of life through facilitating participation and engagement in therapy. Individually, each occupational therapy practitioner
occupations, the meaningful, necessary, and familiar activities on a team is a powerful agent of change—through strategic
of everyday life” (AOTA, 2015a, para. 6). Occupational therapy conversations, cumulative evidence of positive impact, supe-
practitioners work in a way that is client centered, achieves pos- rior interpersonal communication to support collegial net-
itive outcomes, and is cost-effective. works, and respectful engagement to implement coordinated
care. To the individual health professional, their experience
EXHIBIT 33.1. Occupational Therapy Code of Ethics with an occupational therapy colleague will be far more com-
References to Interprofessional Collaborative Practice pelling than any amount of promotional collateral, research
evidence, or success stories made available.
Occupational therapists will:
Managers can support occupational therapy practitioners
H. Promote collaborative actions and communication as a member on these teams by ensuring competence, currency with clin-
of interprofessional teams to facilitate quality care and safety for ical knowledge and skill, and interpersonal communication
clients. skills appropriate to the complex demands of these unique
I. Respect the practices, competencies, roles, and responsibilities of and ever-changing social systems. Managers can keep inter-
their own and other professions to promote a collaborative environ- professional team members engaged with their disciplinary
ment reflective of interprofessional teams. community so they can stay up-to-date; rehearse their value
(AOTA, 2015b, p. 4) proposition; and explore in safe spaces the difference they
could, should, or are making to the clients and their team.
and clearly documenting services that result in positive

outcomes is a crucial part of demonstrating occupational
For additional learning, see Chapter 23, “Becoming a Change Agent.” therapy’s distinct value (Amini & Furniss, 2018).
Triple Aim is health policy framework for improving
the performance of health systems (Berwick et al., 2008).
They can also protect the reputation of the profession, the The 3 goals of the Triple Aim are to
function of the team, and quality of care by managing poor 1. Improve the individual experience of care,
performers or providing a disciplinary perspective to those 2. Improve the health of populations, and
who are given that difficult task. 3. Reduce the per capita costs of care for populations
Managers can also support occupational therapy prac- (Berwick et al., 2008).
titioners on interprofessional teams by modeling collegial,
collaborative, and goal-directed engagement with staff from Lamb and Metzler (2014) advocate the Triple Aim as a
other disciplines. Senior and peer support programs help so- useful mechanism for occupational therapy practitioners to
cialize new interprofessional team recruits to this different demonstrate value, through which they can articulate the ev-
organizational context. Where staffing levels, allocation of idence of occupational therapy’s role in improving individual
responsibilities, or access to resources have inhibited occu- care, the health of populations, and system cost-efficiency.
pational therapy service provision, managers can consult and
use research evidence or clinical guidelines to create strategic Evidence-based practice
conversations with stakeholders (including consumers). These To demonstrate that occupational therapy achieves positive
conversations can advance occupational therapy’s proposition outcomes and is cost-effective, occupational therapy practi-
of distinct value and alert stakeholders to the gap in service tioners must actively use evidence to inform their practice in
quality or scope by the omission of occupational therapy ex- interprofessional teams. They must also use it to inform the
pertise. Case Example 33.1 describes an approach to establish- development of new roles and areas of practice where occupa-
ing occupational therapy services in a setting in which there tional therapy can benefit patient care (Arbesman et al., 2014).
previously had been no occupational therapy practitioners. Using research evidence is a central component of ad-
vocating occupational therapy’s distinct value, particularly
Using Language Accessible by when advocating at team, service, and systems levels.
Other Professions
To negotiate a layered disciplinary terrain among team mem- Using the OTPF–3
bers, it is important that health professionals on interpro- Aligning occupational therapy practice with AOTA’s (2014)
fessional teams invest in building common understandings Occupational Therapy Practice Framework: Domain and
and collaborative approaches through formal and informal Process (OTPF–3) is another way in which practitioners can
interpersonal communication using written, verbal, and non- demonstrate and document occupational therapy’s distinct
verbal means. To do this, health professionals need to be able value. The OTPF–3 can be used to describe to the interpro-
to communicate in a shared language that best supports the fessional team the aspects of client functioning that occupa-
collaborative functioning of the team. tional therapy practitioners may evaluate and in which they
The International Classification of Functioning, Disability may intervene (i.e., occupations, client factors, performance
and Health (ICF; WHO, 2001) is a common, international tax- skills, performance patterns, contexts and environments), and
onomy or “language” that can be used by any professional in- the process in which occupational therapy practitioners de-
volved in health service provision, and its domains reflect the liver client-centered services. Using language and constructs
full scope of interprofessional collaborative practice. The ICF presented in the OTPF–3 equips managers and practitioners
can provide useful terminology for interprofessional teams to articulate the unique value of the occupational therapy per-
to use when discussing client care and can lead to a better spective in achieving collaborative, client-centered outcomes.
understanding of each profession’s unique contribution. In
advocating the distinct value of the profession, occupational Review Questions
therapists must use language that is accessible by the team’s
other professions, such as the ICF, to clearly describe, explain, 1. What are examples of ways managers can build collabo-
and demonstrate their influence on client care and outcomes. rative relationships with staff?
For example, client occupational performance issues might be 2. Which of the following is not a key goal of the Triple Aim?
discussed in interprofessional teams using ICF language like a. Improve the individual experience of care
“activity limitations” or “participation restrictions.” b. Improve the health of populations
c. Reduce the per capita costs of care for populations
d. Improve the individual experience of care,
Triple Aim
e. Increase productivity of interdisciplinary teams.
Ongoing changes in reimbursement that focus increasingly 3. How can the OTPF–3 be used toward the goals of the
on quality vs. quantity of services, providing interventions Triple Aim?
CASE EXAMPLE 33.1. Establishing a New Occupational Therapy Service
Jo is an occupational therapist who has been working in mental health service for 3 months as a program manager of an interprofessional team.
Jo liked the client-centered approach to goal setting and service organization but noticed that a recent surge in referrals had led to a “cookie-cutter”
approach of clients getting admitted, stabilized, and then safely discharged with little individualization of service provision. Service management
rewarded fast turnaround; every cycle of care was new center income, whether it was a 1st or 50th presentation.
Health providers had large caseloads and continually made attempts to reduce wait and care cycle times. During interprofessional team
meetings, providers regularly discussed that client representations were becoming both increasingly frequent and severe. To investigate this further,
Jo examined client files and identified that little attention had been paid to a person’s occupations or life situation beyond an assessment of housing
stress, as if their mental illness was somewhere or something outside their daily life.
Jo knew that for most of the center’s clients, living with mental illness meant a lifelong journey and mental illness was an inherent and
meaningful part of their personal story. It seemed imperative that this journey be acknowledged in center services because recovery-oriented care
was now the “gold standard” for community mental health service. Recovery-oriented care made best sense in the context of everyday occupations
and life situations. This meant introducing a new dimension to the services provided by the center as occupational therapy had never previously
been one of the specializations offered.
Jo thought that introducing occupational therapy to facilitate occupational engagement would not only help reduce re-presentation severity to
shorten cycles of care but would also help the center stay client—not problem—focused. In addition, it would extend collaboration beyond health
providers to the clients. Consumer consultation was a service attribute yet to be embraced by the center and essential to recovery-oriented mental
health practice.
After consulting the research, professional, and consumer literature and examining practice guidelines and recommendations, Jo developed an
advocacy plan to include occupational therapy services. Jo hoped this plan would to gain support from the service director to invest, at the very
least, in a pilot of the service and that it would have the support of colleagues and clients. Client outcomes should then “speak for themselves” and
an evidence-based case would be made to support recommendations.
Jo formulated a 4-week plan that would culminate in a go-ahead for the pilot. As a courtesy, Jo first informed the service director of this interest
and received approval for several things that would advocate the distinct value of occupational therapy in filling a service gap, such as
■ Corridor conversations with colleagues and clients to seed key terms and common understanding,
■ Holding inservice training,
■ Preparing narrated slides for online access,
■ Using case conferences to model how occupational therapy could benefit client outcomes and seeking feedback on barriers,
■ Demonstrating the specialization required for high-quality implementation (and therefore why this gap in service delivery must be done by
occupational therapy practitioners),
■ Involving colleagues in estimating costs and benefits,
■ Preparing brief written summaries of information available online,
■ Inviting clients and consumers to service feedback events,
■ Showing how the service would be helpful to the team as a whole,
■ Illustrating how a successful intervention would reduce team workload and enhance team success, and
■ Describing how the proposed pilot could attract local attention as a “good news story” by showcasing new initiatives to assist clients to
re-engage in meaningful and purposeful occupations (e.g., employment, independent living, community engagement).
After this pitch and consultation, Jo prepared a protocol for a pilot and took it to senior management, who approved it. Jo hoped the pilot would
provide the most compelling evidence of all in this sustained and strategic advocacy campaign by way of positive client outcomes. The pilot would
also provide an opportunity to demonstrate occupational therapy’s distinct value in this unique service delivery and interprofessional care planning.
After 8 weeks of advocacy using written, verbal, nonverbal, and demonstration strategies, Jo initiated the occupational therapy service, receiving
referrals from colleagues on the interprofessional team. Jo completed occupational therapy evaluation and intervention (aligned with the OTPF–3
as part of the standard care cycle). Jo’s caseload was adjusted to accommodate this new role. As occupational therapy referrals increased, re-
presentations became less severe, care cycles became shorter, and client volume increased.
The service director chose to invest the additional resources in another team position, and being an occupational therapist was identified as a
“desirable” appointment criteria. Client collaboration with the team was enhanced and the recovery orientation gave all team members common
terms, tools, and trajectories.
Jo’s advocacy with consumers, team members, and management paid off. Jo’s efforts were planned, patient, purposeful, and strategically
targeted at demonstrating occupational therapy’s distinct value to all stakeholders in the service. By the end of Jo’s campaign, everyone had
determined there was more to gain than lose, individually and collectively, by including occupational therapy as a new specialized service within the
interprofessional team.
Review Questions
1. How can research evidence inform the scope and strategy of your advocacy campaign?
2. How might your advocacy efforts be similar to and different from those presented by Jo in the case example?
3. How might the outcomes of your advocacy efforts promote a shared, collaborative approach to person-centered care?
SUMMARY American Occupational Therapy Association. (2015b). Occupa-

tional therapy code of ethics (2015). American Journal of Occu-
Interprofessional collaborative practice is critical in the de- pational Therapy, 69(Suppl. 3), 69134100301. https://doi.org/10
livery of high-quality, coordinated, person-centered care. .5014/ajot.2015.696S03
All occupational therapy managers and practitioners need to Amini, D., & Furniss, J. (2018, October). The Occupational Therapy
develop competencies for effective interprofessional collabo- Practice Framework: A foundation for documentation. OT Prac-
rative practice. In interprofessional teams, occupational ther- tice, pp. CE1–CE6.
apy practitioners need to have a good understanding of their Arbesman, M., Lieberman, D., & Metzler, C. A. (2014). Using
evidence to promote the distinct value of occupational ther-
professional identity and scope of practice to engage confi-
apy. American Journal of Occupational Therapy, 69, 381–385.
dently and competently in these teams.
Occupational therapy managers and practitioners may need Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Tri-
to advocate the distinct value of the profession to enhance cli- ple Aim: Care, health, and cost. Health Affairs, 27, 759–769.
ent outcomes, increase professional respect in a team, estab- https://doi.org/10.1377/hlthaff.27.3.759
lish new roles, or expand collaborative practice relationships. Braithwaite, J., Clay-Williams, R., Vecellio, E., Marks, D., Hooper,
To advocate the distinct value of the profession, occupational T., Westbrook, M., . . . Ludlow, K. (2016). The basis of clinical
therapy practitioners and managers might engage in written, tribalism, hierarchy and stereotyping: A laboratory-controlled
verbal, or nonverbal communication to present a case, demon- teamwork experiment. BMJ Open, 6(7), e012467. https://doi
strate how occupational therapy affects client outcomes, or rec- .org/10.1136/bmjopen-2016-012467
ommend the need for occupational therapy. Interprofessional Education Collaborative. (2011). Core competen-
cies for interprofessional collaborative practice: Report of an expert
Although occupational therapy managers and practitioners
panel. Washington, DC: Author. Retrieved from https://www
must be skilled in advocating the distinct value of the profes-
.ipecollaborative.org/resources.html
sion, they must also remain true to ethical standards that re- Interprofessional Education Collaborative. (2016). Core compe-
quire mutual respect for the practices, competencies, roles, and tencies for interprofessional collaborative practice: 2016 up-
responsibilities of other professions in the interprofessional date. Washington, DC: Author. Retrieved from https://www
team so that it will achieve its goal to provide high-quality, co- .ipecollaborative.org/resources.html
ordinated, and collaborative person-centered care. ❖ Lamb, A. J., & Metzler, C. A. (2014). Health Policy Perspectives:
Defining the value of occupational therapy: A health policy lens
on research and practice. American Journal of Occupational
ACOTE STANDARDS Therapy, 68, 9–14. https://doi.org/10.5014/ajot.2014.681001
Mitchell, G. K., Tieman, J. J., & Shelby-James, T. M. (2008). Mul-
This chapter addresses the following ACOTE Standards: tidisciplinary care planning and teamwork in primary care.
Medical Journal of Australia, 188(Suppl. 8), S61–S64. https://doi
■ B.4.24. Effective Intraprofessional Communication .org/10.5694/j.1326-5377.2008.tb01747.x
■ B.4.25. Principles of Interprofessional Team Dynamics Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M.
■ B.5.2. Advocacy (2016). Interprofessional collaboration to improve professional
■ B.7.3. Promote Occupational Therapy practice and healthcare outcomes. Cochrane Database of Sys-
■ B.7.4. Ongoing Professional Development. tematic Reviews, 6, CD000072. https://doi.org/10.1002/14651858
.CD000072.pub3
Supper, I., Catala, O., Lustman, M., Chemla, C., Bourgueil, Y., &
Letrilliart, L. (2014). Interprofessional collaboration in primary
REFERENCES health care: A review of facilitators and barriers perceived by in-
Accreditation Council for Occupational Therapy Education. (2018). volved actors. Journal of Public Health, 37, 716–727. https://doi
2018 Accreditation Council for Occupational Therapy Education .org/10.1093/pubmed/fdu102
(ACOTE) standards and interpretive guide. American Journal Washington, K. T., Guo, Y., Albright, D. L., Lewis, A., Parker
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi Oliver, D., & Demiris, G. (2017). Team functioning in hospice
.org/10.5014/ajot.2018.72S217 interprofessional meetings: An exploratory study of providers’
American Occupational Therapy Association. (2014). Occupational perspectives. Journal of Interprofessional Care, 31, 455–463.
therapy practice framework: Domain and process (3rd ed.). https://doi.org/10.1080/13561820.2017.1305950
American Journal of Occupational Therapy, 68(Suppl.1), S1–S48. World Health Organization. (2001). International classification of
https://doi.org/10.5014/ajot.2014.682006 functioning, disability and health. Geneva: Author.
American Occupational Therapy Association. (2015a). Articulat- World Health Organization. (2010). Framework for action on inter-
ing the distinct value of occupational therapy. Retrieved from professional education and collaborative practice. Geneva: Author.
https://www.aota.org/Publications-News/AOTANews/2015 Retrieved from http://www.who.int/hrh/resources/framework
/distinct-value-of-occupational-therapy.aspx _action/en/
CHAPTER
Supervising Other Disciplines
Debra Margolis, MS, OTR/L 34
LEARNING OBJECTIVES
■ Describe the basic roles of a supervisor;
■ Identify health care professionals who may be supervised by occupational therapy practitioners;
■ Describe the importance of supervising other disciplines in occupational therapy practice;
■ Describe how supervising other disciplines can enhance interprofessional care;
■ Describe the various processes of supervising others, including the importance of job descriptions and behavioral
interviewing process; and
■ Identify the role of orientation, training, competency, and clinical ladder systems on successful performance.

• Behavioral interviewing • Health-related disciplines • Performance evaluation
• Clinical ladders • Interprofessional collaborative • Reflective practice
• Continuing competency practice • Supervision
• Core values • Job description • Task inventory questionnaire
• Functional job analysis • Orientation • Training
OVERVIEW the role of the supervisor; importance of supervising other

disciplines outside of occupational therapy practice; and pro-
O
ccupational therapy managers and practitioners have cesses of hiring, orienting, training, and developing clinical
many opportunities to work in a variety of roles across expertise of other disciplines.
the health care continuum. In addition to the role of
clinician, occupational therapy practitioners can have formal
or informal roles in their departments that contribute to or-
ganizational goals that focus on quality care, reducing costs,
and increasing access to rehabilitation services. Occupational As of 2015, 17.8% of the U.S. gross domestic product was spent
therapy managers and practitioners who work in supervisory on health care (Centers for Medicare and Medicaid Services,
roles of multiple disciplines should have knowledge of the im- 2017). Initiatives such as the Triple Aim from the Institute for
pact of quality, cost, and access to care to make informed de- Healthcare Improvement (2009) hope to reduce health care
cisions that affect an organization. Having a single supervisor spending while maintaining population health and improv-
for an integrated rehabilitation department, which may be an ing quality of care. One initiative that can influence health
occupational therapy practitioner, may help reduce cost and care improvement is interprofessional collaborative practice.
offer cohesive and coordinated care. Interprofessional collaborative practice occurs when
Because occupational therapy managers may supervise “multiple health workers from different professional back-
other disciplines, it is important to understand the complex- grounds work together with patients, families (caregivers),
ities of this role for optimal success. This chapter describes and communities to deliver the highest quality of care”
https://doi.org/10.7139/2019.978-1-56900-592-7.034
329
CHAPTER
Supervising Other Disciplines
Debra Margolis, MS, OTR/L 34
LEARNING OBJECTIVES
■ Describe the basic roles of a supervisor;
■ Identify health care professionals who may be supervised by occupational therapy practitioners;
■ Describe the importance of supervising other disciplines in occupational therapy practice;
■ Describe how supervising other disciplines can enhance interprofessional care;
■ Describe the various processes of supervising others, including the importance of job descriptions and behavioral
interviewing process; and
■ Identify the role of orientation, training, competency, and clinical ladder systems on successful performance.

• Behavioral interviewing • Health-related disciplines • Performance evaluation
• Clinical ladders • Interprofessional collaborative • Reflective practice
• Continuing competency practice • Supervision
• Core values • Job description • Task inventory questionnaire
• Functional job analysis • Orientation • Training
OVERVIEW the role of the supervisor; importance of supervising other

disciplines outside of occupational therapy practice; and pro-
O
ccupational therapy managers and practitioners have cesses of hiring, orienting, training, and developing clinical
many opportunities to work in a variety of roles across expertise of other disciplines.
the health care continuum. In addition to the role of
clinician, occupational therapy practitioners can have formal
or informal roles in their departments that contribute to or-
ganizational goals that focus on quality care, reducing costs,
and increasing access to rehabilitation services. Occupational As of 2015, 17.8% of the U.S. gross domestic product was spent
therapy managers and practitioners who work in supervisory on health care (Centers for Medicare and Medicaid Services,
roles of multiple disciplines should have knowledge of the im- 2017). Initiatives such as the Triple Aim from the Institute for
pact of quality, cost, and access to care to make informed de- Healthcare Improvement (2009) hope to reduce health care
cisions that affect an organization. Having a single supervisor spending while maintaining population health and improv-
for an integrated rehabilitation department, which may be an ing quality of care. One initiative that can influence health
occupational therapy practitioner, may help reduce cost and care improvement is interprofessional collaborative practice.
offer cohesive and coordinated care. Interprofessional collaborative practice occurs when
Because occupational therapy managers may supervise “multiple health workers from different professional back-
other disciplines, it is important to understand the complex- grounds work together with patients, families (caregivers),
ities of this role for optimal success. This chapter describes and communities to deliver the highest quality of care”
https://doi.org/10.7139/2019.978-1-56900-592-7.034
329
(World Health Organization et al., 2010, p. 7). Occupational that are part of the interdisciplinary team and the depart-
therapy, speech–language pathology, physical therapy, so- ment where these supervisors can exist. Depending on the
cial work, and case management are all examples of health- setting, supervising another discipline may include some or
related disciplines that may be involved in interprofessional all of the following disciplines:
collaborative practice. Facilitation of this collaborative prac-
■ Art therapy,
tice may be overseen by an occupational therapy practitioner
■ Audiology,
who may be in a supervisory role.
■ Child life,
■ Music therapy,
Role of the Supervisor ■ Nursing,
■ Nutrition,
The Guidelines for Supervision, Roles, and Responsibili-
■ Occupational therapy,
ties During the Delivery of Occupational Therapy Services
■ Physical therapy,
(American Occupational Therapy Association [AOTA], 2014)
■ Psychology,
describes supervision as “a process aimed at ensuring the safe
■ Respiratory therapy,
and effective delivery of occupational therapy services and fos-
■ Social work,
tering professional competence and development” (p. S16). It
■ Speech–language pathology,
also states that supervision is “a cooperative process in which
■ Therapeutic recreation, and
2 or more people participate in a joint effort to establish, main-
■ Other disciplines as determined by the organizational
tain, and/or elevate a level of competence and performance”
structure.
(p. S16). Although these definitions of supervision were writ-
ten for occupational therapy practitioners, both can be used as Supervisors of interdisciplinary staff must understand the
an effective guide in developing a supervisory relationship be- national and state regulations of each discipline they supervise,
tween occupational therapy managers and other disciplines. including the requirements for licensure and continuing edu-
All allied health professionals have a responsibility to teach cation, scope of practice, and the ethical and core values of each
and train future clinicians to carry on the distinct value of discipline. Core values are “principles or beliefs that a person
their own profession; however, practitioners may be in lead- or organization views as being of central importance” (English
ership roles supervising more than 1 discipline. Occupational Oxford Living Dictionaries, 2017). Understanding core values
therapy practitioners who supervise another discipline, such of the disciplines that one supervises can provide a better un-
as physical therapy or speech–language pathology, have an derstanding of the foundational ideas that frame a profession.
opportunity to develop an in-depth knowledge of the stan- A supervisor who is of a different discipline does not need
dards of practice and values of other disciplines. This knowl- to demonstrate clinical expertise in all disciplines, but having
edge can be used to facilitate interprofessional practice and an understanding of what values guide a profession can in-
enhance patient care. crease communication, respect, and morale between supervi-
Evidence shows that supervisors are most successful when sor and supervisees. Table 34.1 identifies the ethical and core
understanding the teaching and learning methods of var- values of many allied health disciplines as defined by their
ious disciplines. Following a study of students in medical, national organization. Many of the values are similar across
physical medicine, physical therapy, occupational therapy, allied health professions. Further information regarding core
and speech–language pathology programs, Chipchase et al. values and specific scope-of-practice documents can be found
(2012) identified that supervisors needed clear understanding at the national organization’s website for each discipline.
of all disciplines to best establish expectations for students As important as it is to develop an understanding of
and practitioners. The study also identified that supervisors another profession’s values, ethics, and practice standards,
who work with professionals in a variety of disciplines must it is equally important to consider the practitioner as an in-
understand the teaching and learning methods and cultural dividual. Although supervisees of the same discipline share
norms used in the supervisory context of each profession. similar education and training, each person has unique
Understanding teaching and learning methods and cul- motivations and goals. Just as occupational therapy practi-
tural norms of each profession helps foster better supervision tioners consider each client as a unique person, supervisors
and mentorship of individuals in other professions. Attend- should consider each person and discipline they supervise as
ing in-person workshops that include strategies to support a unique.
variety of disciplines is also an effective strategy for supervi-
sors because it can increase confidence and preparedness to
supervise across professions (Martin et al., 2017).
Hiring Another Discipline
Supervisors are routinely included in the hiring process of
practitioners they are responsible for supervising. This may
Understanding and Valuing Other Disciplines
include developing and revising job descriptions, which are
Occupational therapy practitioners may have the opportu- written statements that describe the duties, responsibilities,
nity to supervise a variety of disciplines. The type of setting and scope of a job, as well as the working conditions, qual-
and reimbursement often determines the health professions ifications of the person, and to whom the person reports.
CHAPTER 34. Supervising Other Disciplines 331
TABLE 34.1. Ethical and Core Values of Allied Health Professions
DISCIPLINE CORE VALUES AND PRINCIPLES

Art therapy Autonomy, nonmaleficence, beneficence, fidelity, justice, and creativity (AATA, 2013).
Audiology Advocacy, education, leadership, public awareness, and research (AAA, n.d.).
Child life Accountability, collaboration, honesty, influence, relevance, and vision (ACLP, n.d.).
Music therapy Integrity, honesty, fairness, and respect for others (AMTA, 2014).
Nursing Caring, integrity, diversity, and excellence (National League for Nursing, 2017).
Nutrition Customer focus, integrity, innovation, social responsibility, and diversity (AND, 2017).
Occupational therapy Altruism, equality, freedom, justice, dignity, truth, and prudence (AOTA, 2015a).
Physical therapy Accountability, altruism, compassion and caring, excellence, integrity, professional duty, and social responsibility
(APTA, 2009).
Psychology Beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, respect and for people’s rights and
dignity (APA, 2017).
Respiratory therapy Professionalism, service, collaborative leadership, accountability, transparency, and excellence (CARC, n.d.).
Social work Service, social justice, dignity and worth of the individual, importance and centrality of human relationships, and
integrity and competence (NASW, 2017).
Speech–language pathology Excellence, integrity, diversity, commitment, responsive, member centric, and research based (ASHA, n.d.).
Therapeutic recreation Beneficence, nonmaleficence, autonomy, justice, fidelity, veracity, informed consent, confidentiality and privacy,
competence, and compliance with laws and regulations (ATRA, 2009).
Note. AAA = American Academy of Audiology; AATA = American Art Therapy Association; ACLP = Association of Child Life Professionals; AMTA = American Music
Therapy Association; AND = Academy of Nutrition and Dietetics; AOTA = American Occupational Therapy Association; APA = American Psychological Association;
APTA = American Physical Therapy Association; ASHA = American Speech–Language–Hearing Association; ATRA = American Therapeutic Recreation Association;
CARC = Commission on Accreditation for Respiratory Care; NASW = National Association of Social Workers.
Reviewing job descriptions on a periodic basis ensures that Selecting the right person for the job should be based on
the expectations of the position, which may evolve over time the skills that are required for a position. Behavioral inter-
because of changes in regulatory requirements or advances in viewing is an effective strategy for hiring managers within an
practice, match the job description. interdisciplinary department. Behavioral interviewing is a
Raymond (2001) summarizes different strategies of de- systematic process that uses job-related, open-ended questions
veloping job descriptions for health care professionals, in- to help measure a candidate’s skills for a job. The open-ended
cluding using task inventory questionnaires, the professional questions are based on the skills required for each position
performance situation model, and functional job analysis. A and provide the structure for the interview. This ensures that
task inventory questionnaire is a list of job activities based all applicants are asked the same questions and allows the in-
on direct observation of a job, interviews, and job descrip- terviewer to compare applicants based on their responses.
tions of similar positions. Task statements are developed into Behavioral questions elicit additional information from a
a questionnaire and then rated by subject matter experts on candidate based on their past experiences. Asking candidates
certain attributes such as frequency, difficulty, or time spent. questions about their past behavior has been shown to pre-
The goal of the professional performance situation model is dict their future behavior and job performance (Srinivasan &
to provide a comprehensive description of an occupation, Humes, 2017). An example of a behavioral interviewing ques-
including job responsibilities and context factors (e.g., social tion would be, “Describe a time where one of your colleagues
and technological factors). did not agree with your intervention plan.” If the candidate’s
Last, a functional job analysis is a detailed and compre- response is not descriptive enough to find the information the
hensive approach that includes the specific job tasks and sit- supervisor is looking for, clarifying questions should follow
uational factors that influence job performance. Whatever (Strasser, 2005).
method is chosen, the job description should reflect the es- Two types of questions are not constructive in the context
sential job duties and skills of the position and the values of of a job interview because these questions essentially prompt
the organization. Ideally the job description is the template an interviewee to “answer questions correctly”: (1) hypothet-
for interviewing potential candidates and for the perfor- ical and (2) leading. These types of questions often do not
mance appraisal. This ensures consistency in the assessment elicit additional information about the applicant. When a
of skills throughout all phases of employment from interview supervisor asks candidates to picture themselves in a hypo-
to initial orientation and training to performance appraisal. thetical situation, they may be more likely to give an answer
they think is correct (Bowen & Leger, 2013). The other type of The Joint Commission is an independent, nonprofit orga-
question that is not useful in an interview is a leading ques- nization that accredits and certifies nearly 21,000 health care
tion, which indicates the correct responses the interviewer organizations and programs in the United States. Its Hospital
wants to hear from the way the questions are asked. Bowen Accreditation Standards provide the framework for a compre-
and Leger (2013) give the example of “‘I have a problem with hensive orientation, training, and competency program for
tardiness. You’re not going to be tardy, are you?’” (p. 35). The human resources (The Joint Commission, 2017). The stan-
question leads the interviewee to the correct response. Novel dards require the following:
information is not attained from these questions. Exhibit 34.1 ■ Hospital leaders to define and verify staff qualifications.
provides a summary of behavioral interviewing questions to This is usually accomplished through job descriptions and
use and to avoid. primary site verification of credentials.
Hiring the right candidates is essential to meeting the ■ Facilities orient new staff to the organization and the
organization’s goals. Developing job descriptions and using department, unit, or area in which they will work
behavioral interviewing through standardized interview and to their job. This can be accomplished through
processes that are consistent and reflect the skills and values an organized hospital orientation program and a de-
needed for each position facilitate the development of a suc- partment and role-specific orientation. Both must be
cessful workforce. documented.
■ Establish a process to validate staff competency by the end
Orientation and Training of orientation. This can be accomplished via training that
may include demonstration, tests, and so on.
All health care settings, regardless of size, need to ensure ■ Provide continuing education and in-service training
that all staff receive the orientation and training needed to courses.
perform their job and keep patients safe. Orientation often ■ Establish a process for validating ongoing competency of
includes factors related to quality and safety, patient cen- staff.
teredness, and cultural competence, including strategies to ■ Periodically conduct staff performance reviews.
support these goals related to health care outcomes (Cun-
ningham et al., 2014). Continuing education and on-the-job
Competency
training allow occupational therapy practitioners who super-
vise other disciplines to improve their knowledge and skills In addition to The Joint Commission standards, another use-
on an ongoing basis so that they can keep up with practice ful resource for developing competency standards is AOTA’s
trends in the professions they supervise. (2015b) Standards for Continuing Competence. Although it is
EXHIBIT 34.1. Examples of Behavioral Interviewing Questions
Appropriate format: Ask open-ended questions that reflect the skills needed for the job and that prompt the interviewee to give examples based
on their past experiences.
Inappropriate format: Don’t ask close-ended or “yes/no” questions. Avoid hypothetical questions or ones that prompt the interviewee to answer
questions “correctly.”
Time management
Avoid: Good time management is essential in this position. How are your time management skills?
Instead, say: Describe a time when you had to meet a strict deadline.
Teamwork
Avoid: Fostering teamwork is essential in this position. Are you a good team player?
Instead, say: Fostering teamwork is essential in this position. Describe a time when you were part of a team and you prioritized the team’s needs
above your individual needs.
Client interaction
Avoid: Good customer service skills are important in this position. How would you handle a difficult patient or family member?
Instead, say: It can sometimes be difficult to be courteous to a patient or family member. Describe a time when you were faced with this
challenge.
Flexibility
Avoid: Have you been flexible in your prior positions? Will you stay late if needed?
Instead, say: Tell me about a time when the demands on you changed quickly, possibly before you finished what you were doing. How did you
handle the situation?
intended for occupational therapists and occupational therapy ■ To enhance staff satisfaction; and
assistants, it is applicable to other allied health professionals ■ To recognize staff for initiative, creativity, productivity,
as well. The standards define continuing competency as continuous learning, and increased clinical and profes-
sional responsibility.
a process involving the examination of current competence
and the development of capacity for the future. It is a Clinical ladder programs are primarily criteria based and
component of ongoing professional development and define several standards of advancement that are clear and
lifelong learning. Continuing competence is a dynamic measurable. Applicants may create a portfolio demonstrating
and multidimensional process in which the occupational how they meet the ladder’s behavioral and performance cri-
therapist and occupational therapy assistant develop and teria. Although clinical ladder programs may differ between
maintain the knowledge, performance skills, interpersonal sites, sample activities may include presentation of a poster,
abilities, critical reasoning, and ethical reasoning skills paper, or platform session for a professional conference;
necessary to perform current and future roles and demonstration and effective integration of an advanced or
responsibilities within the profession. (p. 1) specialized skill; development and implementation of a pro-
cess improvement project; or staff mentoring or training in
One way supervisors of other disciplines can facilitate pro- their area of specialty.
fessional growth is through the use of reflective practice, an A review board, consisting of leadership and peers of
adult learning principle used in health care practice that allows various disciplines, reviews applications and determines
practitioners to conceptualize personal strengths and weak- whether a candidate will be promoted or given recommen-
nesses and improve practice skills by learning from past ex- dations for improvement. The case example of Sue, who
periences (Koshy et al., 2017). Supervisors can help guide this is an occupational therapy practitioner working with a
process by providing specific opportunities for supervisees to therapeutic recreation team, provides an example of how
reflect on their performance. These opportunities may include participation in a clinical ladder program can look both
keeping a journal of positive and negative experiences or pre- similar and different for different disciplines (see Case
senting case studies. The supervisor can assist in the process Example 34.1).
by prompting further reflection and by delving more deeply
into what the supervisee reflects on in their performance. The
supervisor is also responsible for reinforcing what the super- Review Questions
visee has learned about their strengths and areas needing im- 1. What are some challenges when supervising other
provement to be an exemplary health care provider. disciplines?
2. How can a supervisor incorporate reflective practice
Developing Clinical Expertise into their clinical fieldwork? What would the advan-
tages be?
One of the main challenges in supervising other disciplines 3. How would one go about developing a job description for
is guiding the development of clinical skills and professional another discipline?
growth. More experienced clinicians of the same discipline
may assist the supervisor in orienting and training new and
experienced staff. They may also assist in developing initial PRACTICAL APPLICATIONS IN
and advanced competencies for staff. When another clinician OCCUPATIONAL THERAPY
of the same discipline is not employed by the organization,
the supervisor may consult with a staff member experienced Understanding and Valuing Other Disciplines
in the same discipline in a like setting outside the organiza- Through Behavioral Interviewing
tion. Having a role in orienting and training staff may en-
Occupational therapy practitioners who work in super-
courage experienced staff members to take the next step in
visory roles of other disciplines have opportunities to be
their professional growth.
leaders in valuing other disciplines through an organiza-
Many facilities have instituted clinical ladders to recognize
tion’s hiring and orientation. Behavioral interviewing is
and retain qualified staff. Clinical ladders are professional
one strategy to better understand perspectives of those in
development tools that offer practitioners a well-defined pro-
different disciplines while also interviewing and orienting
cess for clinical advancement. They are most frequently used
new employees.
in nursing, but the model can be applied to other allied health
For example, Michelle is a certified therapeutic recreation
professionals. Clinical ladder systems have also been shown
specialist (CTRS) interviewing for a vacant position on a
to be a cost-effective method to improve overall satisfaction
rehabilitation unit in a large rehabilitation hospital. The di-
and retention of staff (Drenkard & Swartwout, 2005).
rector of the therapeutic recreation department is an occu-
In general, the objectives of clinical ladder programs are
pational therapist and is interviewing Michelle. Excellence,
■ To recognize clinical expertise and promote professional team work, and customer focus are key values of the orga-
growth; nization. During the interview, the supervisor asks specific
■ To recruit and retain qualified staff by providing positions questions to determine if Michelle has the skills that will sup-
with increasing challenges and recognition; port the organization’s values.
To assess teamwork, the interviewer asks, Performance evaluations are usually performed on an annual
basis. Although an occupational therapy manager or practi-
■ In this position teamwork is essential. Tell me about a
tioner is not an expert of other disciplines, using a clinical
time when you were part of a team and you prioritized the
ladder system is effective for showcasing professional devel-
team’s needs above your individual needs.
opment and performance.
To assess excellence, the interviewer asks, For example, Emily is an occupational therapy practitioner
and Jenna is a therapeutic recreation specialist. They both
■ Describe a time when you went above and beyond to en-
have more than 2 years of experience in a large rehabilitation
sure exceptional care.
hospital. Their supervisor is an occupational therapist who
To assess customer focus, the interviewer asks, has been encouraging them to apply for a promotion on the
■ It can be challenging sometimes to provide excellent cus- therapy clinical ladder from entry-level clinician to advanced
tomer service. Describe a time when it was difficult to pro- clinician. They each must submit a portfolio that describes
vide excellent customer service and what you did. how they meet the criteria. The criteria are specific and objec-
tive but general enough so they can be applied to both disci-
Probing questions are added if the responses need clari- plines. An example of some of the criteria follows:
fication or more explanation so the interviewer can evaluate
whether the candidate has the values required for the position. ■ Demonstrate competency and effective integration of an
Questions can also elicit responses to better understand and advanced or specialized skill.
value a profession that is different from occupational therapy. • Emily submitted evidence of completion of an ad-
vanced assistive technology course and demonstrated
how she integrated this knowledge into direct patient
Using Clinical Ladders in Supervisory Role
care, whereas Jenna demonstrated this objective by
Performance evaluation is a role many occupational therapy submitting evidence of completion of an adapted row-
practitioners have in supervisory roles. Performance eval- ing course and describing how she integrated this into
uation is the assessment of an employee’s job performance. the adaptive sports program.
CASE EXAMPLE 34.1. Supervising Interdisciplinary Teamwork
As the director of occupational therapy in a large rehabilitation hospital, Sue supervised the therapeutic recreation (TR) department for many years.
In 2013, the TR department received a grant that enabled the hospital to purchase a wheelchair-accessible van. The grant also provided funding
for the cost of recreational outings. The TR staff was thrilled to have the department recognized by the grant and to be able to provide enhanced
programming for patients. As the director of the department, Sue was responsible for the purchasing the van, developing programs appropriate for
the donor’s intention, and overseeing the use of the funds.
Sue assembled a committee, representing hospital leaders and clinicians, to select a van that was accessible and met the grant’s financial
parameters. After several months, the van was delivered to the hospital. They had a ribbon-cutting ceremony and invited the donor, hospital staff,
and patients to see the new van. The TR staff learned how to operate the vehicle and how to safely secure patients and wheelchairs for transport.
They developed a log so they could track the number and types of outings so Sue could report back to the donor. They were all set to go!
As the initial excitement of the new van wore off, Sue noticed that it was barely being used. It is important to point out that outings at the hospital
had always been interdisciplinary. Depending on the goals of the outing, occupational therapy, physical therapy, and occasionally speech would
accompany TR on outings. During regularly scheduled TR meetings, Sue asked staff why they weren’t using the van. One of the main reasons they
reported was that occupational and physical therapy staff were resistant was because the outings were too long and the focus was on recreation
and not occupational or physical therapy. As the director of occupational therapy, Sue knew how important it was for patients to receive the required
amount of therapy per day to meet reimbursement and regulatory requirements. Sue also knew that the outings could incorporate functional goals
for patients, especially the interdisciplinary goal of being able to function in the community upon discharge.
At a scheduled meeting with the leadership of occupational therapy, physical therapy, and speech–language pathology, Sue brought up the topic
of outings. She explained that the goal of the outings was to prepare patients to function as independently as possible in the community. Depending
on the patient’s needs, the goals may be related to mobility, cognition, communication, socialization, or leisure skills. Sue emphasized that practicing
these skills in the hospital may be more convenient but practicing them in the community was more functional; the practitioners would be better
preparing patients for discharge because of interdisciplinary outings. Sue also reinforced this with the TR staff at their weekly meetings so they
would have talking points to convince their peers of the importance of the outings. As an occupational therapist, Sue could explain to them how TR
was integral to the team and to the patients’ successful return to the community.
Community outings are now an integral part of patients’ rehabilitation programs. Many patients expressed their appreciation for the experience
and stated how important the outings were in giving them the skills and confidence to return to the community on discharge from the hospital.
Review Questions
1. What actions did Sue take that were helpful in creating a positive work environment?
2. What aspects of this case may be supported on a clinical ladder review?
3. What are some of the outcomes of this case that can be used as part of orientation and training?
■ Participate in program- or therapy-based patient or family REFERENCES

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an opportunity to learn more about other disciplines that are Association of Child Life Professionals. (n.d.). Vision, mission,
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www.nln.org/about/core-values ?sequence=1
CHAPTER
Building Effective Teams
Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP 35
LEARNING OBJECTIVES
■ Describe key characteristics of effective teams,
■ Explain the link between teamwork and quality patient outcomes, and
■ Apply evidence-based strategies for successful communication and teamwork.

• Collaboration • Interprofessional care team • Interprofessional teamwork
• Contingency teams • Interprofessional collaborative • Rounds
• Coordinating teams practice • Teams
• Core teams • Interprofessional rounds • Team functioning
• Handoffs
OVERVIEW distinguishable set of 2 or more people who interact dynam-

ically, interdependently and adaptively towards a common
T
eamwork is the foundation for successful intra- and and valued goal/objective/mission, who have been assigned
interprofessional, collaborative practice in the delivery specific roles or functions to perform and who have a limited
of client-centered care. Occupational therapy managers lifespan of membership” (Salas et al., 1992, p. 3). Some care
must build efficient and effective teams that work collabora- teams are specific to a health care system; others transcend
tively to ensure the client’s interests are front and center. Col- systems to coordinate care across people, organizations, net-
laboration is “a way of working with colleagues that is char- works, and geographic locations. An effective team ensures
acterized by cooperation, mutual respect, and shared goals. It that the right care is delivered to the right person, at the right
involves sharing information, coordinating actions, discuss- time, by the right team, in the right setting.
ing what’s working and what’s not, and perpetually seeking Various types of teams include core teams, which are gen-
input and feedback” (Edmonds, 2012, p. 54). erally smaller in size and comprised of direct care providers
Occupational therapy managers and practitioners who (e.g., nurse, physician, occupational therapist, physical thera-
have a good understanding of how teams function are well pist); coordinating teams, which include those within an or-
poised to deliver quality care across a variety of settings. ganization who coordinate care but are not direct providers
This chapter highlights the essential features of teamwork as (e.g., admitting personnel); and contingency teams, which in-
related to collaborative care delivery. Application is demon- clude both direct care and support personnel brought together
strated in a case example. to coordinate around a specific event or task (e.g., emergency
response team). Teams include many members and roles,
ESSENTIAL CONSIDERATIONS transcending departments, organizations, and networks.
How teams function is crucial. Team functioning is ev-
Working in Teams
ident when “learners/practitioners understand the princi-
Health care today is coordinated and delivered by an in- ples of team work dynamics and group/team processes to
creasing number of teams. A team can be defined as “a enable effective interprofessional collaboration” (Canadian
https://doi.org/10.7139/2019.978-1-56900-592-7.035
337
CHAPTER
Building Effective Teams
Regina Ferraro Doherty, OTD, OTR/L, FAOTA, FNAP 35
LEARNING OBJECTIVES
■ Describe key characteristics of effective teams,
■ Explain the link between teamwork and quality patient outcomes, and
■ Apply evidence-based strategies for successful communication and teamwork.

• Collaboration • Interprofessional care team • Interprofessional teamwork
• Contingency teams • Interprofessional collaborative • Rounds
• Coordinating teams practice • Teams
• Core teams • Interprofessional rounds • Team functioning
• Handoffs
OVERVIEW distinguishable set of 2 or more people who interact dynam-

ically, interdependently and adaptively towards a common
T
eamwork is the foundation for successful intra- and and valued goal/objective/mission, who have been assigned
interprofessional, collaborative practice in the delivery specific roles or functions to perform and who have a limited
of client-centered care. Occupational therapy managers lifespan of membership” (Salas et al., 1992, p. 3). Some care
must build efficient and effective teams that work collabora- teams are specific to a health care system; others transcend
tively to ensure the client’s interests are front and center. Col- systems to coordinate care across people, organizations, net-
laboration is “a way of working with colleagues that is char- works, and geographic locations. An effective team ensures
acterized by cooperation, mutual respect, and shared goals. It that the right care is delivered to the right person, at the right
involves sharing information, coordinating actions, discuss- time, by the right team, in the right setting.
ing what’s working and what’s not, and perpetually seeking Various types of teams include core teams, which are gen-
input and feedback” (Edmonds, 2012, p. 54). erally smaller in size and comprised of direct care providers
Occupational therapy managers and practitioners who (e.g., nurse, physician, occupational therapist, physical thera-
have a good understanding of how teams function are well pist); coordinating teams, which include those within an or-
poised to deliver quality care across a variety of settings. ganization who coordinate care but are not direct providers
This chapter highlights the essential features of teamwork as (e.g., admitting personnel); and contingency teams, which in-
related to collaborative care delivery. Application is demon- clude both direct care and support personnel brought together
strated in a case example. to coordinate around a specific event or task (e.g., emergency
response team). Teams include many members and roles,
ESSENTIAL CONSIDERATIONS transcending departments, organizations, and networks.
How teams function is crucial. Team functioning is ev-
Working in Teams
ident when “learners/practitioners understand the princi-
Health care today is coordinated and delivered by an in- ples of team work dynamics and group/team processes to
creasing number of teams. A team can be defined as “a enable effective interprofessional collaboration” (Canadian
https://doi.org/10.7139/2019.978-1-56900-592-7.035
337
Interprofessional Health Collaborative, 2010, p. 14). Effec- efficiency and effectiveness. When all team members are rec-
tive teams improve health outcomes and have been shown ognized and empowered to speak up, integrated care plans
to increase quality of care, improve the coordination of care can be implemented. Renowned surgeon and author Atul
delivery for clients with complex conditions, reduce medical Gawande (2011) recognized this, stating, “Others can save
errors, reduce hospitalization time and costs, enhance acces- you from failure, no matter who they are in the hierarchy”
sibility for clients, and contribute to improve client satisfac- (p. 6). Although professional accountability varies across de-
tion and workforce well-being (HRH Global Resource Center, livery settings and contexts, all teams rely on “an intricate
2018; World Health Organization [WHO], 2012). Occupa- system of professional supervision, delegation, and collabora-
tional therapy practitioners work on teams of all sizes across tion among caregivers from many disciplines” (Dineen, 2009,
a variety of clinical, community, and educational settings. p. 247). The principles of collaboration and communication
Occupational therapy managers are often responsible for su- apply to all members of the care team, no matter how large or
pervision of intraprofessional and interprofessional teams. how small their role.
Interprofessional Teams Review Questions

Interprofessional collaborative practice occurs “when mul- 1. Does teamwork differ between licensed and unlicensed
tiple health workers from different professional backgrounds health care personnel? If so, how?
work together with patients, families, carers, and communities 2. What are the key responsibilities of the members of the
to deliver the highest quality of care” (WHO, 2010, p. 13). Col- health care team?
laborating within and across professions for effective and ef- 3. What does collaboration mean to clients and their fami-
ficient care delivery requires a focus on shared responsibility lies? What does it mean to you as a health professional?
and accountability. In this chapter, we reflect on the attributes
of collaboration-ready individuals and how members of care
teams contribute to the delivery of client-centered, safe, effec- PRACTICAL APPLICATIONS IN
tive, efficient, and compassionate care. OCCUPATIONAL THERAPY
Groups of providers are assembled every day in health care,
but interprofessional care teams have a distinct definition and Successful occupational therapy managers and practitioners
purpose. The interprofessional care team is a group of people know that they will face much uncertainty in the delivery of
who are committed to a common purpose for which they hold client-centered care. To face this uncertainty, teams require
themselves mutually accountable (Weiss et al., 2014). They support to collaborate, share, learn, and thrive. Occupa-
hold a common goal at the center of their work: the client and tional therapy practitioners and managers can employ sev-
family. Just like all teams, care teams go through the natural eral methods to create and support environments that shape
processes of forming, storming, norming, and performing. effective teams.
The training occupational therapy practitioners undergo in
understanding and facilitating these group processes serves Case Rounds
to inform their work on teams as various stages progress and
group dynamics present themselves. One of the most basic collective learning activities used in
clinical practice is clinical case discussions or rounds. This
active process of asking questions, sharing information, seek-
Team Means Everyone
ing help, talking about mistakes, and seeking feedback allows
Many experts believe that the volume and complexity of the practitioners to reflect on care delivery and consider ways to
knowledge required for the safe practice of health care far ex- adapt and improve their practice (Edmonds, 2012). Rounds
ceeds our ability to properly deliver it (Gawande, 2010). This is can be intraprofessional or interprofessional. Managers who
1 of the factors driving the shift to interprofessional care teams implement rounds on a routine basis create a collaborative
for planning, delivering, and evaluating quality care (Tsou et al., learning environment that allows teams to improve, solve
2015). Direct care providers serve on these teams, but a great problems, and innovate together.
number of individuals are often forgotten as core members of A common misconception is that rounds are time consum-
the team. Team means everyone—most important the client ing or need to be implemented as a formal process. Rounds or
and the family, who must be included in the decision-making case discussions take many forms: 5-minute “case of the day”
and care-planning process. Clients and families who are re- huddles, walk rounds, hour-long presentations, and retro-
garded as part of the team report improved satisfaction with spective case reviews. All offer benefits, and the time invested
their care providers and outcomes. returns in dividends when it comes to promotion of profes-
The second frequently forgotten members of the team sional reasoning and quality care.
are support personnel such as housekeeping, nutrition, and Interprofessional rounds are an effective way to build
transportation staff. These individuals make health care de- teams and ensure effective collaboration for client-centered
livery happen, serving as key observers and participants in care (Beaird et al., 2017; Kadivar et al., 2016). Interprofessional
the care delivery process. Teams who recognize that all voices rounds often take place in the form of unit rounds (or walk
matter, regardless of power or hierarchy, experience greater rounds) in the acute hospital setting and discharge planning
CHAPTER 35. Building Effective Teams 339
rounds in the inpatient rehabilitation setting. Although some

may question the effectiveness of dedicating therapy time to EXHIBIT 35.1. Key Elements of Effective Teams
attend these rounds, the benefits of participation in interpro-
fessional care rounds is clear. Interprofessional approaches to Clear goals
discharge planning and post-discharge care lead to improved Specialized knowledge and skills
patient outcomes, reduced hospital readmissions, and im-
proved quality of life and satisfaction in high-risk patients Shared identity and vision
(Jeffs et al., 2014; Kadivar et al., 2016).
Shared values
Interprofessional rounds are an example of a dynamic
team-based activity that requires teamwork on the fly. All Role clarity
role groups must share knowledge quickly and integrate
Mutual respect
diverse expertise to design a coordinated and efficient care
plan. Occupational therapy practitioners who ask questions Interdependence
clearly and communicate effectively in interprofessional
Collaboration
rounds demonstrate their distinct value to client-centered
care. They are often sought out for their expertise in effec- Situational awareness and monitoring
tively matching client needs, abilities, and environments to
best inform care. Ethical literacy and moral courage
Effective communication skills (e.g., listening, speaking up,

Respectful Communication and Collaboration conflict resolution)
Communication is often referred to as the most common Mutual accountability

procedure in health care. Good communication skills are the Collaborative decision making
core of effective teamwork (WHO, 2012). A health profes-
sional’s experience of teamwork and collaboration is a pro- Cooperation
cess supported by users’ needs. It includes integration, trust,
Shared leadership
respect, openness to collaboration, a feeling of belonging,
humility, and time to listen and talk (Sangaleti et al., 2017). Trust
Responsible and responsive communication has a foundation
Flexibility
of dignity and respect and is a core competency of interpro-
fessional collaborative practice. Diversity
To be an effective team member, occupational thera-
Creativity
pists must be self-aware and competent communicators.
Exhibit 35.1 lists key elements of effective teams identified Commitment to reflection
throughout the literature (Babiker et al., 2014; Haddad et
al., 2019; Interprofessional Education Collaborative, 2016; Sources. Babiker et al. (2014); Haddad et al. (2019); Reeves et al. (2010);
Rochon et al. (2015); Sangaleti et al. (2017); Weiss et al. (2014).
Reeves et al., 2010; Rochon et al., 2015; Sangaleti et al., 2017;
Weiss et al., 2014). These elements warrant keen reflection
by practitioners and occupational therapy managers. Teams
that safely share ideas, hold themselves mutually accountable, Managers can help teams learn and maintain productivity
and commit to excellence are positioned to actualize the best during times of conflict by helping them identify the nature
health outcomes for their clients and practices. of the conflict, modeling good communication (including ac-
tive listening, reframing, and strategies for difficult conversa-
tions), and reorienting teams to the shared goal of delivering
Tension and Conflict compassionate, client-centered care. Teams often get wrapped
An inevitable part of working in teams is dealing with ten- up in friction and emotion, leaving the client behind. Reori-
sion. When stress rises and conflict heats up, teamwork and enting the team to the shared goal of client-centered care cre-
creativity decline. Health care delivery frequently includes ates a safe space for all to step back and learn from rather than
uncertainty, high stakes, limited data, differing belief sys- avoid conflict. Supervision, mentorship, and team debriefings
tems, and stressful work environments—all conditions that that promote reflection on group dynamics serve to enhance
can serve as a precursor for conflict. A variety of tensions performance, allowing teams to more effectively achieve
present to teams, including those surrounding conflicting shared goals.
values, knowledge, or background differences; conflicting
opinions regarding the plan or care; personality differences;
resource allocations; moral distress; or organizational fac-
tors, such as reimbursement. Misunderstandings can lead to
team dysfunction, and managers in particular must be pre- For additional learning, see Chapter 37, “Conflict Resolution.”
pared to learn from and manage team conflict.
Tools and Strategies for Successful Teamwork effective team leaders (AHRQ, 2013). Whether you are an oc-
cupational therapy manager or serve in a shared leadership
Effective interprofessional teamwork involves high “levels
role on an interprofessional team, these responsibilities can
of cooperation, coordination and collaboration characteriz-
help guide you in your approach to teamwork.
ing relationships between professions in delivering patient-
centered care” (Interprofessional Education Collaborative,
2016, p. 8). Communication Models
Because communication is so vital to collaborative care Shared mental models are a common technique for ensuring
delivery, many national accreditation standards are in accurate and succinct communication about patients within
place to ensure that health communication is both safe and and across teams. SBAR (situation, background, assessment,
effective. Shared models for communication support inter- recommendation) is an example of a mental model for com-
professional teamwork and collaborative decision making. municating critical information to team members about a
Occupational therapy practitioners and managers should fa- patient’s status requiring immediate attention and action.
miliarize themselves with these models, tools, and strategies SBAR, which is used throughout the health care system, is an
for effective team communication. This section summarizes acronym that covers the following:
several evidence-based strategies used in both intra- and in-
terprofessional care delivery settings. ■ Situation: What is going on with the patient.
Various research has evaluated how prebriefings, debrief- ■ Background: Clinical background or context.
ings, checklists, handoffs, situational monitoring, shared ■ Assessment: What you think the problem is.
mental models, and mutual support can help teams function ■ Recommendation: What you would do to correct it.
better (Agency for Healthcare Research and Quality [AHRQ], Mental models support teams in communicating so they
2017). Checklists can be implemented before, during, and listen, understand, and communicate a complete message.
after a task. Items to check off can be as simple as, “Who is Never is this more important than in a transition of care.
on the team?” and “What is our goal for the session?” Tak- Handoffs are the transfer of information during transi-
ing the time to introduce all present on the team, share the tions of care. These may occur during shift changes, during
plan, monitor and modify the plan, and evaluate the team’s weekend or vacation coverages, or in transition between
performance are best practices and improve patient safety. systems of care. There are several best practices in handoffs,
Teams who ask themselves, “How are we doing as a team?” including IPASS (introduction, patient, assessment, situa-
and “What can we improve as a team?” commit to a learning tion, safety concerns), a communication strategy to enhance
culture. communication. Handoffs are an excellent opportunity to
Managers who use data-driven decision making and ask questions and participate in shared decision making so
commit to asking teams to share their performance build a the patient’s high quality of care remains seamless (Haddad
culture of excellence. Table 35.1 lists the responsibilities of et al., 2019).
TABLE 35.1. Responsibilities of Effective Team Leaders
RESPONSIBILITY EXAMPLES
Organize the team. Schedule, organize, and run effective team meetings.
Identify and articulate clear goals Keep agenda at meetings, post mission statement in visible area, and articulate the link between shared goals
(i.e., the plan). and actions.
Assign tasks and responsibilities. Allocate roles for presentations or task groups, and match the knowledge and skills of team members to
specific tasks.
Monitor and modify the plan; Send email updates, and make time for daily announcements or correspondence.
communicate changes.
Review the team’s performance; Review team’s work in timely manner, set and achieve deadlines, communicate regarding team performance,
provide feedback when needed. and review data to inform a learning culture.
Manage and allocate resources. Set budget, organize staffing, and monitor decisions related to frequently used resources.
Facilitate information sharing. Provide opportunities for team to share work with others in person and virtually.
Encourage team members to assist Provide opportunities for safe working environment, including time for group work, and foster supportive
one another. team milieu.
Facilitate conflict resolution in a Share strategies for conflict management and resolution, provide opportunity for group decision making, and
learning environment. support ethical practice and moral culture.
Model effective teamwork. Lead by example, and demonstrate behaviors that are desirable in the workplace.
Source. Adapted from AHRQ (2017). In the public domain.
CHAPTER 35. Building Effective Teams 341
Team Training and Continuous Improvement Why is it important for team members or leaders to self-
reflect on these key elements throughout their career?
Occupational therapy managers who train their staff in
3. There are many responsibilities that come with being
team skills will find that this training pays off. Research
an effective team leader (see Table 35.1). What are some
findings suggest that team training interventions are a
examples in which occupational therapy managers and
viable approach organizations can take to enhance team
practitioners can be effective team leaders?
outcomes. They have been shown to improve team perfor-
mance (e.g., cognitive outcomes, affective outcomes, team-
work processes) and select patient outcomes (Salas et al.,
2008; Weaver et al., 2014). SUMMARY
Occupational therapy managers are also in key roles to Teamwork is critical in the delivery of high-quality, coordi-
serve as coaches to intraprofessional or interprofessional nated, person-centered care. Well-functioning teams have
teams. Coaching allows the manager to observe the team’s synergy and are able to think creatively to solve complex
performance and provide structured feedback, including problems (Doherty & Purtilo, 2016). Occupational therapy
strategies that help team members learn at higher levels and practitioners and managers must develop competencies for
suggestions for improvement to better achieve shared goals effective teamwork and collaborative practice. An under-
(Fiscella et al., 2017). Case Example 35.1 highlights how es- standing of best practice in interprofessional team commu-
sential communication models and team training are to con- nication will help occupational therapists engage confidently
tinuous improvement and patient outcomes. and contribute to teams.
The occupational therapy manager sets the tone for col-
laborative practice, proactively engaging team members in
Review Questions
learning conversations and empowering shared leadership
1. What are ways in which interprofessional rounds may and decision making. Modeling best practice in effective
foster effective teamwork? communications supports both intra- and interprofessional
2. To be an effective team member, occupational ther- teams in their pursuit of excellence to deliver high-quality,
apy managers and practitioners should be self-aware of coordinated, collaborative, and compassionate person-
the key elements of an effective team (see Exhibit 35.1). centered care. ❖
CASE EXAMPLE 35.1. Patrice: Intra- and Interprofessional Communication
Patrice is an occupational therapist working in the acute care setting. Because the inner-city hospital where she practices is a Level 1 trauma
center, occupational therapy services are provided 7 days a week, and all occupational therapy staff rotate through the weekend assignment. Patrice
is assigned to cover the Sunday shift with 1 other occupational therapist and receives a consult for a 33-year-old man who was in a motor vehicle
collision and suffered multiple fractures and a traumatic brain injury. The consult states “please fabricate right wrist splint.” Patrice is not familiar
with the trauma floor because she works primarily on the medicine unit, where she does very little splinting.
Patrice reviews the electronic medical record (EMR) and notes that this patient was followed by her colleague, Ray, during the week. Ray
completed an initial evaluation and recommended that the orthopedic team clarify the plan for the client’s newly diagnosed distal radius fracture,
given that the client exhibited no active movement in that limb because of his brain injury. Upon receiving this revised order, Patrice called the
covering orthopedic resident to ask their thoughts on the splint. The resident reported, “I’m just covering today and don’t really know. We generally
go with a wrist cock-up splint, but it seems like he may need more. You decide what is best.” “Okay,” Patrice says. Patrice does some research
over lunch and talks to the other weekend staff. She decides to fit the client with a cock-up splint even though she is still ambivalent. She tells the
nurse on the floor, “I fit him with this splint because it will stabilize the fracture. He may need something else in the future.”
Patrice documents the splint wear and care schedule in the client’s EMR. In the occupational therapy coverage notes, she writes a brief
note stating that she fit the patient with a cock-up splint, per orthopedic resident’s request. The next day the occupational therapy service is fully
staffed. Ray, the primary occupational therapist on the trauma team, sees the weekend coverage note and says to Patrice, “I can’t believe you fit
my patient with a cock-up splint. That’s not the right choice for him given all he has going on, and I told the trauma team that when they asked me
about it in unit rounds on Friday.” Patrice is upset and tells Ray that was what they asked for, and because there were no notes in the occupational
therapy coverage system, she had to make a decision. You are the occupational therapy manager on the acute care service and walk in to find
tensions rising between the 2 colleagues.
Review Questions
1. How might you, as the manager, best support the acute care occupational therapy team at this point in the discussion?
2. How might the communication strategies presented earlier in the chapter be implemented in this practice intra- and interprofessionally to
support more effective teamwork and collaboration?
3. How might the occupational therapy staff and manager modify weekend coverage routines to support best practice for a shared, collaborative
approach to person-centered care?
ACOTE STANDARDS Interprofessional Education Collaborative. (2016). Core compe-

tencies for interprofessional collaborative practice: 2016 update.
This chapter addresses the following ACOTE Standards: Retrieved from www.ipecollaborative.org/resources.html
Gawande, A. (2010). The checklist manifesto: How to get things right.
■ B.4.23. Effective Communication
New York: Macmillan/Holtzbrinck.
■ B.4.24. Effective Intraprofessional Collaboration Gawande, A. (2011, May 26). Cowboys and pit crews. The New Yorker.
■ B.4.25. Principles of Interprofessional Team Dynamics Retrieved from www.newyorker.com/news/news-desk/cowboys
■ B.7.3. Promote Occupational Therapy -and-pit-crews
■ B.7.4. Ongoing Professional Development. Jeffs, L., Dhalla, I., Cardoso, R., & Bell, C.M. (2014). The perspectives
of patients, family members, and healthcare professionals on re-
admissions: Preventable or inevitable? Journal of Interprofessional
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Accreditation Council for Occupational Therapy Education. (2018). Kadivar, Z., English, A., & Marx, B. D. (2016). Understanding the
2018 Accreditation Council for Occupational Therapy Education relationship between physical therapist participation in inter-
(ACOTE) standards and interpretive guide. American Journal disciplinary rounds and hospital readmission rates: Preliminary
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi study. Physical Therapy, 96, 1705–1713. https://doi.org/10.2522
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Agency for Healthcare Research and Quality. (2013). TeamSTEPPS ® Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2010). Interpro-
2.0 Pocket Guide: Team strategies and tools to enhance perfor- fessional teamwork for health and social care. West Sussex, UK:
mance and patient safety (AHRQ Pub. No. 14–0001–2). Re- Wiley–Blackwell.
trieved from www.ahrq.gov/sites/default/files/publications/files Rochon, A., Heale, R., Hunt, E., & Parent, M. (2015). Teamwork and
/pocketguide.pdf patient care teams in an acute care hospital. Nursing Leadership,
Agency for Healthcare Research and Quality. (2017). Team- 28(2), 28–39. https://doi.org/10.12927/cjnl.2015.24352
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STEPPS 2.0 leadership briefing. Retrieved from www.ahrq.gov Salas, E., DiazGranados, D., Klein, C., Burke, C. S., Stagl, K. C.,
/teamstepps/about-teamstepps/leadershipbriefing.html Goodwin, G. F., & Halpin, S. M. (2008). Does team training
Babiker, A., El Husseini, M., Al Nemri, A., Al Frayh, A., Al Juryyan, improve team performance? A meta-analysis. Human Factors,
N., Faki, M. O., . . . Al Zamil, F. (2014). Health care professional 50(6), 903–933. https://doi.org/10.1518/001872008X375009
development: Working as a team to improve patient care. Suda- Salas, E., Dickinson, T. L., Converse, S. A., & Tannenbaum, S. I.
nese Journal of Paediatrics, 14, 9–16. (1992). Toward an understanding of team performance and
Beaird, G., Dent, J. M., Keim-Malpass, J., Muller, A. J., Nelson, N., & training. In R. W. Swezey & E. Salas (Eds.), Teams: Their training
Brashers, V. (2017). Perceptions of teamwork in the interprofes- and performance (pp. 3–29). Norwood, NJ: Ablex.
sional bedside rounding process. Journal for Healthcare Quality, Sangaleti, C., Schveitzer, M. C., Peduzzi, M., Zoboli, E. P., & Soares,
39, 95–106. https://doi.org/10.1097/JHQ.0000000000000068 C. B. (2017). Experiences and shared meaning of teamwork and
Canadian Interprofessional Health Collaborative. (2010). A na- interprofessional collaboration among health care professionals
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Dineen, K. (2009). Responsibility and collaboration in health team 2723–2788. https://doi.org/10.11124/JBISRIR-2016-003016
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.org/HRH_Info_Teamwork.html /curriculum/who_mc_topic-4.pdf
SECTION VI.
Supervision
Edited by Donna Costa, DHS, OTR/L, FAOTA
343
CHAPTER
Recruiting, Hiring, and Retaining Personnel
Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA 36
LEARNING OBJECTIVES
■ Describe factors to be considered in posting a job description and recruiting a new employee,
■ Identify strategies to promote success when interviewing applicants for a new position, and
■ Explore activities that assist in retaining employees.

• Career ladder • Mentor • Preceptor
• Competency • Onboarding • Return demonstration
• Competency-based questions • Orientation
OVERVIEW a goal to achieve a balance between work and nonwork envi-

ronments? These factors could determine whether an appli-
T
his chapter focuses on the process of recruiting, hiring, cant accepts a job offer (Falcone, 2016).
and retaining personnel. The identification and hiring It is also important to consider past hiring practices of
of high-performing individuals into a newly formed or the facility. Processing a new staff member for a position
existing team is often the goal within the health care market. with the federal government will take longer than hiring
The objective is to bring the best person to the position. Now someone for a small private outpatient clinic (Liff, 2009).
the challenge of recruiting and hiring the best candidate for Working with an efficient human resources team member
the position must be addressed. Starting with the “end in is recommended. Being able to describe the needs of the
mind” allows each step of the process to be addressed with department and how a new employee would fit into the en-
heightened focus to detail. This attention to each step of the vironment requires honest communication. Working with
process will promote an atmosphere where the new employee a human resources representative also limits the legal pit-
will want to establish professional roots. Hiring smart can be falls that could result in a negative outcome. Often an es-
a difficult process (Muller, 2009). tablished protocol for the hiring process and onboarding
(i.e., orienting new staff) exists. Just remember that the en-
ESSENTIAL CONSIDERATIONS tire process takes time.
Before writing the perfect job description, it is important to

Job Advertisements
carefully consider factors surrounding the actual work en-
vironment. What makes the facility a place in which people Have you ever read a job description and wondered how
want to be employed? There are more factors to consider in accurately the posting described the actual position? At a
a job than the paycheck, although competitive pay is often minimum the job description should describe the facility
a strong consideration. Does your facility provide ongoing and list the desired strengths that an applicant should pos-
learning opportunities with funding? Are advancement op- sess for the position. This description of the facility should
portunities seen as an option for internal applicants? Is there include work schedules and the range of clients typically
https://doi.org/10.7139/2019.978-1-56900-592-7.036
345
346 SECTION VI. Supervision
treated for the open position. Applicant expectations should attractive to qualified applicants. Next, the manager deter-
include previous experience and advanced training as well mines attributes that the applicant must possess to meet the
as the degree required for consideration, specialty certifica- goals of the department. What will the ideal applicant offer
tions, and licensure requirements. The clients served within the organization? These factors should match the qualifiers
the facility and typical work schedule should also be high- identified when establishing the job advertisement. Opti-
lighted. Other items may also be required as part of the mally, these qualifiers will lead to establishing a rating scale
hiring process and should be indicated on the job advertise- to assess the applicants.
ment. These include, but are not limited to, previous work Recruitment of new employees is also subject to legal ac-
experience, a criminal background check, physical exam, tion should the employer discriminate on the basis of “race,
and a credit check. color, religion, sex (including gender identity, sexual orien-
Posting the open position to internal applicants should tation, and pregnancy), national origin, age (40 or older),
be a first step in the process. Should no internal appli- disability, or genetic information” (EEOC, 2010, para. 1).
cants meet the requirements (or apply), then the position is Retaliation against a person because of a complaint regard-
posted externally (e.g., Internet billboards, profession-spe- ing discrimination, filing charges of discrimination, or par-
cific employment listings, job fairs, professional search firms; ticipating in an employment discrimination investigation or
Muller, 2009). lawsuit must be avoided (EEOC, 2010).
It is equally important to know what must be avoided in For some positions, applicants must complete a test to de-
the job advertisement. The U.S. Equal Employment Opportu- termine competence. When this is the case, the test must be
nity Commission (EEOC; 2010) states that it is related to the job and necessary for the position. Tests cannot
discriminate against the applicant based upon the factors
illegal for an employer to publish a job advertisement identified by the EEOC. Employers must also provide accom-
that shows a preference for or discourages someone from modation for applicants with a disability as long as it does
applying for a job because of his or her race, color, religion, not cause the employer “significant difficulty or expense”
sex (including gender identity, sexual orientation, and (EEOC, 2010).
pregnancy), national origin, age (40 or older), disability, or Another factor involves retaining applications and re-
genetic information. (para. 4) sumes received for posted employment positions. These doc-
uments must be maintained for a period of 1 year. Federal
Expectations requirements for record keeping stipulate the following:
The Reference Manual of the Official Documents of the Amer- Any personnel or employment record made or kept by
ican Occupational Therapy Association, Inc. (American Oc- an employer (including but not necessarily limited to
cupational Therapy Association, 2018) includes many official requests for reasonable accommodation, application
documents that list technical standards, education require- forms submitted by applicants and other records having to
ments, and competency for occupational therapy practi- do with hiring, promotion, demotion, transfer, lay-off or
tioners and assistants (these are also archived permanently in termination, rates of pay or other terms of compensation,
the American Journal of Occupational Therapy). Competency and selection for training or apprenticeship) shall be
refers to actual performance of one’s knowledge, critical preserved by the employer for a period of one year from the
thinking, characteristics, or skills to achieve a specific goal date of the making of the record or the personnel action
or perform job responsibilities (AOTA, 2015b). Phrases that involved, whichever occurs later. (Muller, 2009, p. 14)
indicate an applicant’s competency may be used in the job de-
scription to include fundamentals of practice, management of
occupational therapy services, communication, professional Interview
behaviors, and components of the occupational therapy The next step is to identify candidates from among the pool
process (i.e., screening, evaluation, intervention, outcomes). of applicants who will move onto the next stage of the hiring
Typical requirements for occupational therapy practitioners process, the interview. Occupational therapy practitioners
often include may view the interview as a natural process due to experi-
■ Communicates effectively in verbal and nonverbal formats, ence interviewing and interacting with clients. However,
■ Demonstrates judgment to establish priorities, the interview process must be completed in such a way that
■ Applies effective time management, and all applicants have the same opportunity to highlight their
■ Uses clinical reasoning for interpretation of evaluation credentials for the position. The rating scale used in the re-
data to develop occupation-based treatment plan. cruitment phase is a springboard to the creation of a rating
scale for the interview process. It is essential that a standard-
ized process be adopted to ensure fairness for all applicants
Recruitment
who are interviewed (Hess, 2010).
Recruiting the right person for a vacancy should be a delib- Establishing an agenda prior to the first interview will
erate process. The hiring manager should be able to artic- provide a format to the process. Determining who will
ulate the strengths of the department and why it might be be involved in the interview process from the facility is
CHAPTER 36. Recruiting, Hiring, and Retaining Personnel 347
also essential. Managers often determine who should be PRACTICAL APPLICATIONS IN

present in the interview and usually include team members OCCUPATIONAL THERAPY
who will be working alongside the new hire. The questions
that will be asked of all applicants and touring the work Occupational therapy practitioners possess many skills to as-
space should be planned with time frames for completion. sist clients achieve their goals as well as management skills
An overview of the interview and agenda should be shared to promote team building and leadership. Entry-level practi-
with applicants prior to the scheduled date or at the start of tioners are taught in their educational programs the impor-
the interview (Hess, 2010). tance of leadership and management with several Accredita-
Questions that are focused job-related concepts will keep tion Council for Occupational Therapy Education® (ACOTE;
interviewers from drifting into areas open to discrimination 2018) standards allocated in this content area. Considerations
charges. It is also important to ask all applicants the same discussed in this chapter about the hiring process are to serve
questions. For example, at the pre-offer stage, an employer only as a guide. It is important to seek guidance when in
cannot ask questions that are likely to elicit information doubt! It is preferred to take the required time necessary to
about a disability, including directly asking whether an ap- secure the optimal person for the existing work environment.
plicant has a particular disability or requires accommodation
(Muller, 2009). A range of questions can be established in ad- Laws Affecting Employment
vance to guide the interview process (Hess, 2010). The follow-
ing questions are standard: Occupational therapy practitioners should have awareness
of and be up-to-date on laws enforced by the EEOC as they
■ What interested you in this position? relate to the workplace.
■ How would your experience contribute to our facility?
■ What professional goals have you established for the next ■ Title VII of the Civil Rights Act of 1964 (Title VII; P. L.
5 years? 88–352): It is illegal to discriminate on the basis race,
color, religion, national origin, or sex and provision of
Competency-based questions are an excellent method in reasonable accommodations for religious practices.
which to elicit answers from an applicant and provide struc- ■ Pregnancy Discrimination Act of 1978 (Amendment to
ture while allowing the applicant to give expansive responses Title VII; P. L. 95–555): It is illegal to discriminate because
when a thorough job analysis has been completed (Muller, of pregnancy, childbirth, or related medical condition.
2009). Questions that elicit a greater depth of critical reason- ■ Equal Pay Act of 1963 (P. L. 88–38): It is illegal to pay dif-
ing give the interviewer additional information about the ap- ferent wages to men and women for performance of equal
plicant that corresponds with the facility: expectations in the workplace.
■ Describe a challenging situation with a co-worker and how ■ Age Discrimination in Employment Act of 1967 (P. L.
you facilitated a positive outcome. 90–202): It is illegal to discriminate against people who
■ How have you managed work-related stress in the past? are 40 years of age or older in employment.
■ Tell me about a challenging client you have worked with ■ Title I of the Americans With Disabilities Act of 1990
and how you obtained additional information in the best (P. L. 101–336): It is illegal to discriminate against quali-
ways to provide treatment. fied persons with a disability and to deny them reasonable
accommodations.
Overall, it is important to ask effective questions and care- ■ Rehabilitation Act of 1973 (Sections 501 and 505; P. L.
fully listen to the responses and monitor oneself for personal 93–112): It is illegal to discriminate against qualified per-
biases. sons with a disability in the federal government and to
deny them reasonable accommodations.
Review Questions ■ Genetic Information Nondiscrimination Act of 2008 (P. L.
110–233): It is illegal to discriminate against applicants or
1. The job description for a new occupational therapy as- employees on the basis of genetic information.
sistant position indicates that the setting is a youthful
environment and that recent graduates are encouraged
to apply. How could this be viewed as a violation of For Additional Learning
EEOC law?
2. Which of the following agencies oversees employment For additional learning, see Chapter 64, “Understanding Employment
laws in the workplace? Laws.”
a. Equal Employment Opportunity Commission
b. Right to Work Commission
Workplace Orientation
c. Commission on Equal Rights
3. True or False: It is illegal for an employer to publish a job The new employee has been hired and it is time to proceed with
advertisement that shows a preference for or discourages the orientation process, during which the employee is given
someone from applying for a job based upon national information about the overall organization, including safety
origin. and health guidelines as well as an introduction to coworkers.
Even the new employee with previous work experience is boards and the National Certification Board for Occu-
expected to go through the orientation and onboarding pational Therapy ® (NBCOT) have specific requirements
processes. Companies continue to engage new employees regarding “competence using professional development
through the onboarding process, which may involve peer activities” and the required CE units or contact hours
mentoring and ongoing orientation sessions so the new em- (NBCOT, 2018, p. 7). With advances in technology there are
ployee is successful in their new position. more options than traditional face-to-face courses to obtain
Knowledge skills and tasks required in the work environ- CE credits.
ment often require return demonstration; in other words, AOTA’s (2015a) Occupational Therapy Code of Ethics
the new employee is asked to demonstrate what he or she has (2015) states, “Occupational therapy personnel shall take
just been taught or seen demonstrated. Having a checklist responsible steps (e.g., CE, research, supervision, training)
of required onboarding components will guide the orienta- and use careful judgment to ensure their own competence
tion process. Ongoing orientation with regular scheduled and weigh potential for client harm when generally recog-
check in time frames provides the new employee with an nized standards to not exist in emerging technology or areas
opportunity to revisit concepts and progressively learn ad- of practice” (p. 3). Many employers offer funding to attend
ditional requirements within the work setting. Even the CE opportunities as incentives for continued employment.
seasoned practitioner needs to learn the nuances of the new When this occurs, employees may be required to provide an
work environment. These scheduled continued orientation inservice for their peers on the information learned at the
time frames often occur at 1 month, 3 months, 6 months, CE or maintain employment for a specified amount of time
and 1 year. on the basis of the cost of the CE.
Job Assignments and Promotions

The newly hired employee often benefits from working with a
designated preceptor (i.e., tutor) or mentor. The mentor pro- For additional learning, see
vides clinical relevance and competence; as an experienced
and trusted adviser, the mentor engages the new employee ■ Chapter 54, “Continuing Competence,” and
■ Chapter 71, “Professional Development.”
for success in the work setting. Having a mentor for the first
year of practice has been found to be correlated with greater
job satisfaction and professional competence (McCombie &
Antanavage, 2017). Another way to describe an employee’s trajectory from an
Effective training which begins during the orientation entry-level position to one with more responsibility is through
phase often leads to increased job satisfaction and motiva- a career ladder. Job promotions involve higher rates of pay and
tion among employees. Training has been correlated with a seniority. It is important for employees to have a plan so CE
reduction in employee turnover (Muller, 2009). All job as- and other work-related opportunities can be channeled toward
signment and promotion decisions must be based upon the climbing the career ladder for career growth and promotion.
performance of the employee and free from practices prohib- Sharing this plan with one’s supervisor is helpful during an-
ited by EEOC laws. Occupational therapy practitioners must nual performance reviews, so specific, employee-focused goals
have requisite treatment and documentation knowledge to can be determined.
work effectively within the setting and with the assigned cli-
ents. The employee is accountable to perform and complete Review Questions
assigned duties.
1. This law prohibits discrimination against qualified per-
sons with a disability.
Retention
a. Title VII of the Civil Rights Act of 1964
Keeping good employees is important for overall produc- b. Rehabilitation Act of 1973 (Sections 501 and 505)
tivity and efficiency within any organization. Finding the c. Title I of the Americans with Disabilities Act of 1990
right formula to encourage growth and development of 2. An educational technique in which someone demonstrates
staff members while ensuring that the objectives of the de- what they have just been taught or had demonstrated to
partment are achieved is unique to each employment set- them is known as
ting. Two prominent areas discussed within health care a. Orientation
environments are (1) continuing education and (2) career b. Return demonstration
laddering, on which this section focuses. However, readers c. Mentoring
are encouraged to seek other avenues of retention to broaden 3. This practice was correlated with greater job satisfaction
their overall knowledge related to employee retention and professional competence:
strategies. a. Orientation
Continuing education (CE) is necessary for competence b. Continuing education
as occupational therapy practitioners. Most state licensure c. Mentoring
CHAPTER 36. Recruiting, Hiring, and Retaining Personnel 349
CASE EXAMPLE 36.1. Kids Therapy Seeks New Therapist
Kids Therapy is an outpatient pediatric clinic that includes physical, speech–language, and occupational therapy. Most of the therapists have
worked at the facility for more than 3 years, and the majority of employees were hired through personal connections. Over 80% of the children
receiving services at Kids Therapy and their families are Spanish-speaking and first-generation American.
The caseload at Kids Therapy has increased and the owner wants to expand operations to include evening and weekend hours for treatment.
This operational change will require the owner to hire additional therapists. To facilitate the process a job advertisement was completed and
provided to the existing employees for distribution to their colleagues outside of Kids Therapy. The advertisement states that only Spanish-speaking
Hispanic therapists will be considered for the positions.
Review Questions
1. Yes or No: Is the statement in the job description indicating that only Spanish-speaking Hispanic therapists will be considered a violation
of EEOC law?
2. List 3 important factors to be considered in rewriting the job description.
3. What elements would be important to address for a new employee during the orientation process?
SUMMARY American Occupational Therapy Association. (2015b). Standards

for continuing competence. American Journal of Occupa-
Our current work environments require that employees are tional Therapy, 69, 6913410055. https://doi.org/10.5014/ajot.2015
efficient and effective. High-performing individuals are de- .696S16
sired, and the goal is to decrease turnover in the workplace. American Occupational Therapy Association. (2018). The reference
Recruiting and hiring the best candidate requires a thought- manual of the official documents of the American Occupational
ful process that begins with an assessment of the work envi- Therapy Association, Inc. (22nd ed.). Bethesda, MD: AOTA Press.
ronment and writing an accurate job announcement through Americans with Disabilities Act of 1990, Pub. L. 101–336, 104
Stat. 327.
hiring the new person and providing orientation. Attention
Civil Rights Act of 1964, Pub. L. No. 88–352, 78 Stat. 241.
to each step of the process is important. Retaining employees
Equal Pay Act of 1963, Pub. L. No. 88–38, 77 Stat. 56.
starts with the hiring process. ❖ Falcone, P. (2016). 75 ways for managers to hire, develop and keep
great employees. New York: AMACOM.
Genetic Information Nondiscrimination Act of 2008, Pub. L.
ACOTE STANDARDS No. 110–233, 122 Stat. 881.
This chapter addresses the following ACOTE Standards: Hess, V. (2010). The nurse manager’s guide to hiring, firing, and in-
spiring. Retrieved from https://ebookcentral.proquest.com/lib
■ B.5.1. Factors, Policy Issues, and Social Systems /touronv-ebooks/detail.action?docID=3383889
■ B5.2. Advocacy Liff, S. (2009). Complete guide to hiring and firing government em-
■ B.5.3. Business Aspects of Practice ployees. Retrieved from https://ebookcentral.proquest.com/lib
■ B.5.4. Systems and Structures That Create Legislation /touronv-ebooks/detail.action?docID=472573
■ B.5.5. Requirements for Credentialing and Licensure McCombie, R. P., & Antanavage, M. E. (2017). Transitioning
■ B.5.6. Market the Delivery of Services from occupational therapy student to practicing occupational
■ B.5.7. Quality Management and Improvement therapist: First year of employment. Occupational Therapy in 1.
Health Care, 31(2), 126–142. https://doi.org/10.1080/07380577
■ B.5.8. Supervision of Personnel.
.2017.1307480
Muller, M. (2009). Manager’s guide to HR: Hiring, firing, perfor-
mance evaluations, documentation, benefits, and everything else
REFERENCES you need to know. New York: AMACOM.
Accreditation Council for Occupational Therapy Education. (2018). National Board for Certification in Occupational Therapy. (2018).
2018 Accreditation Council for Occupational Therapy Education NBCOT professional practice standards for OTR. Retrieved from
(ACOTE) standards and interpretive guide. American Journal https://www.nbcot.org/-/media/NBCOT/PDFs/Practice-Standards
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi -OTR.ashx?la=en
.org/10.5014/ajot.2018.72S217 Pregnancy Discrimination Act of 1978, Pub. L. No. 95–555, 92
Age Discrimination in Employment Act of 1967, Pub. L. No. 90–202, Stat. 2076.
81 Stat. 602. Rehabilitation Act of 1973, Pub. L. No. 93–112, 87 Stat. 355.
American Occupational Therapy Association. (2015a). Occupational U.S. Equal Employment Opportunity Commission. (2010). Prohib-
therapy code of ethics (2015). American Journal of Occupational ited employment policies/practices. Retrieved from http://www
Therapy, 69, 6913410030. https://doi.org/ 10.5014/ajot.2015.696S03 .eeoc.gov/laws/practices/index.cfm
CHAPTER
Conflict Resolution
LEARNING OBJECTIVES
■ Define conflict and conflict resolution,
■ Identify 2 core principles of conflict resolution,
■ Identify differences between individualistic and collectivistic cultural perspectives on conflict resolution,
■ Identify 10 strategies for effective conflict resolution, and
■ Develop conflict resolution strategies using case scenarios.

• Active communication • Conflict • Individualistic culture
• Authentic listening • Conflict resolution • Negotiation
• Collectivistic culture
OVERVIEW conflict, whether between an employee and an employer

or between a practitioner and a client, has created a ripple
C
onflict is a disagreement or clash between ideas, effect of costly litigation and wasted productivity that is felt
principles, or people (Almost et al., 2016). Conflict throughout the health care system (Maximin et al., 2015).
is unavoidable and can result from value clashes, Premium and legal costs are passed on to consumers, which
distressed relationships, discrimination, poor communi- furthers patient dissatisfaction with the health care system
cation, or personal gain (Caspersen, 2015; Harmer, 2006). (Skjørshammer, 2001).
Conflict can occur during interactions with clients, care- Conflict resolution focuses on strategically reducing or
givers, colleagues, and organizations and many health care resolving conflicts that arise in the context of occupational
professionals feel unprepared to effectively resolve con- therapy practice. Effective conflict resolution promotes staff
flicts in their work settings (Kfouri & Lee, 2018; Lask, 2003; retention, work satisfaction, and quality client care (Pettrey,
Rotarius & Liberman, 2000). Ambiguity, role conflict, and a 2003; Maximin et al., 2015). This chapter discusses the princi-
leader’s affinity for conflict can also be contributing factors to ples of conflict resolution and effective strategies for resolving
conflict in the workplace (Almost et al., 2016; Ebbers & Wi- conflict.
jnbern, 2017; Porter-O’Grady, 2004). Occupational therapy
managers and practitioners need to be prepared to effectively
manage and resolve conflict. ESSENTIAL CONSIDERATIONS
Unresolved conflict can lead to job dissatisfaction, absen-
Principles of Conflict Resolution
teeism, turnover, and burnout (McKibben, 2017; Rosenstein,
2011). One study in a hospital setting found that interper- Negotiation is the process of determining a win–win compro-
sonal conflict could be linked to 67% of adverse patient harm mise between competing ideas (Lewicki et al., 2015) Negotia-
events, 58% of compromised patient safety events, and 28% tion research shows that mutual problem solving encourages
of patient mortality events (Mantone, 2006). Unresolved resolution of a conflict (De Dreu et al., 2000). In contrast,
https://doi.org/10.7139/2019.978-1-56900-592-7.037
351
CHAPTER
Conflict Resolution
LEARNING OBJECTIVES
■ Define conflict and conflict resolution,
■ Identify 2 core principles of conflict resolution,
■ Identify differences between individualistic and collectivistic cultural perspectives on conflict resolution,
■ Identify 10 strategies for effective conflict resolution, and
■ Develop conflict resolution strategies using case scenarios.

• Active communication • Conflict • Individualistic culture
• Authentic listening • Conflict resolution • Negotiation
• Collectivistic culture
OVERVIEW conflict, whether between an employee and an employer

or between a practitioner and a client, has created a ripple
C
onflict is a disagreement or clash between ideas, effect of costly litigation and wasted productivity that is felt
principles, or people (Almost et al., 2016). Conflict throughout the health care system (Maximin et al., 2015).
is unavoidable and can result from value clashes, Premium and legal costs are passed on to consumers, which
distressed relationships, discrimination, poor communi- furthers patient dissatisfaction with the health care system
cation, or personal gain (Caspersen, 2015; Harmer, 2006). (Skjørshammer, 2001).
Conflict can occur during interactions with clients, care- Conflict resolution focuses on strategically reducing or
givers, colleagues, and organizations and many health care resolving conflicts that arise in the context of occupational
professionals feel unprepared to effectively resolve con- therapy practice. Effective conflict resolution promotes staff
flicts in their work settings (Kfouri & Lee, 2018; Lask, 2003; retention, work satisfaction, and quality client care (Pettrey,
Rotarius & Liberman, 2000). Ambiguity, role conflict, and a 2003; Maximin et al., 2015). This chapter discusses the princi-
leader’s affinity for conflict can also be contributing factors to ples of conflict resolution and effective strategies for resolving
conflict in the workplace (Almost et al., 2016; Ebbers & Wi- conflict.
jnbern, 2017; Porter-O’Grady, 2004). Occupational therapy
managers and practitioners need to be prepared to effectively
manage and resolve conflict. ESSENTIAL CONSIDERATIONS
Unresolved conflict can lead to job dissatisfaction, absen-
Principles of Conflict Resolution
teeism, turnover, and burnout (McKibben, 2017; Rosenstein,
2011). One study in a hospital setting found that interper- Negotiation is the process of determining a win–win compro-
sonal conflict could be linked to 67% of adverse patient harm mise between competing ideas (Lewicki et al., 2015) Negotia-
events, 58% of compromised patient safety events, and 28% tion research shows that mutual problem solving encourages
of patient mortality events (Mantone, 2006). Unresolved resolution of a conflict (De Dreu et al., 2000). In contrast,
https://doi.org/10.7139/2019.978-1-56900-592-7.037
351
standing firm on one’s proposals or making threats encour- some distance between the parties or from the issue, so that
ages failure to reach resolution. Conceding makes agreement communication is solution based with a focus on resolving
more likely in the short term but favors the other party’s the conflict (DelBel, 2003).
interest and may not always effectively resolve the conflict. In addition, delivering a sincere apology can be a produc-
As a result, the disagreement may manifest as a greater con- tive means of opening up the possibilities for active com-
flict at a future point in time. Small concessions can facilitate munication. Many times, people struggle with the idea of
compromise (Barsky, 2017). apologizing because it makes them appear vulnerable. How-
Research has shown that the party who makes the first ever, research indicates that apologies are considered to be
offer during the negotiation process tends to achieve greater a sign of strength and can serve as a key conflict resolution
benefits than the other party (Pruitt & Carnevale, 1993). In strategy (Porter, 2005).
addition, viewing a compromise as a loss can limit the effec-
tiveness of a resolution. Focusing on one’s own goals can limit Discuss needs using I statements
the successful resolution of conflict. In contrast, focusing on
mutually beneficial goals can improve the outcome of conflict Communicate your needs to the party you are in conflict
resolution (Lewicki et al., 2015). with by using I statements rather than you statements.
Individualistic culture focuses on a direct approach to Blame is not a productive means of resolving conflict. One
ensuring that individuals’ needs are met. Individualistic should not expect the other party to accept responsibility.
Western cultures tend to take a more contentious approach to Instead, the person initiating conflict resolution should
conflict resolution by confronting conflicts in the workplace discuss their perspective using I statements that center the
more directly. A collectivist culture focuses on the needs of discussion around their own needs rather than on how the
a collective group. Collectivist Eastern cultures tend to value other party has violated those needs (e.g., “I would like to
maintaining positive working relationships by minimizing better understand how I can address your concerns”). It
confrontation (Arredondo et al., 2018). When you are work- is also important to note that other persons not directly
ing with a client, caregiver, or colleague, it is important to be involved in the conflict should not be referred to or involved
cognizant of cultural factors that influence the strategies the (Baltimore, 2006).
parties take in resolving conflict.
Use authentic listening
Strategies for Effective Conflict Resolution Authentic listening is a genuine approach to active listen-
The following strategies outline evidence-based solutions for ing that involves reflecting on the feeling and meaning of
effectively resolving conflict: the other party’s needs (Hinyard et al., 2018). When you
communicate your own needs, you should also maintain
■ Foster active communication. an authentic focus on understanding the other party’s per-
■ Discuss needs using I statements. spective and their needs (Almost et al., 2016; Fontaine &
■ Use authentic listening. Gerardi, 2005). Active listening should be the central focus
■ Engage in mutual problem solving. with this strategy, so that the other party feels that their
■ Strive for a win–win resolution. perspective is valued and understood as you proceed with a
■ Remain positive. compromise for resolving the conflict (Hendel et al., 2005;
■ Control emotions. Wolff et al., 2018). Summarizing what the other person has
■ Respond to ideas, not people. said is also an effective active listening strategy for conflict
■ Aim for resolution. resolution, because it assures the other party that you have
■ Deal with 1 specific topic at a time. listened intently to their perspective and builds trust (Saulo
■ Observe nonverbal communication. & Wagner, 2000).
Foster active communication Engage in mutual problem solving

Active communication is intentionally concentrating on Once the problems resulting in a conflict have been identi-
what is being said rather than just passively hearing the mes- fied, you must advance to active problem solving by propos-
sage of the speaker (Wolff et al., 2018). Research shows that ing potential solutions to those problems (Briles, 2005). Each
the first step to bridging the communication process is initi- party should come to the table to compare their individual
ating dialogue with the client, colleague, or organization with requests or needs and decide on specific areas where collab-
whom you are experiencing conflict. oration and mutual problem solving can be prioritized and
Although it might be tempting to hope that the conflict acted on. Compromise can then be used to address areas
resolves on its own or to use an avoidance strategy, the con- where there are differences in each individual’s requests or
flict may fester and grow without open dialogue and com- needs. Active problem solving requires a mutual determina-
munication (Almost et al., 2016). However, if the conflict is tion to find a solution that works for both parties. At times, a
resulting in aggressive or unproductive dialogue, open com- neutral third party is required to facilitate these discussions
munication can be pursued at a time when there has been to ensure an optimal outcome.
CHAPTER 37. Conflict Resolution 353
Strive for a win–win resolution areas of discussion that are not pertinent to the goal of resolving
the conflict (Almost et al., 2016; Lachman, 1999). Instead, the
Occupational therapy managers should aim for a win–win
focus should be on discussing a single specific topic and person
solution to the conflict or problem that has been identified.
at a time to avoid confusion and an escalation of conflict.
The result should be a mutually satisfying alternative rather
than 1 person or organization achieving their goal at the
expense of the other party (Herzog, 2000; Payne et al., 2005). Observe nonverbal communication
During direct conflict resolution discussion, it is important to
Remain positive pay close attention to nonverbal communication. Nonverbal
Conflict can create stress and negative morale in the work- communication accounts for more than 50% of communi-
place. As the conflict is being managed proactively, it is cation and can provide insights into the other party’s read-
important to remain positive, with a “can-do” attitude toward iness to resolve the conflict. Strategies can be implemented
resolving the conflict. Emphasize mutual respect and solidar- to ensure that all parties have an opportunity to voice their
ity with all parties involved in a conflict as a collaborative concerns, opinions, and proposed solutions (Almost et al.,
approach to resolving the conflict (Jameson, 2004). In addi- 2016; Kelly, 2005). Occupational therapy managers should
tion, avoid workplace gossip as a means to dealing with con- create an inviting, safe, timely, and nonjudgmental setting to
flict; gossip can often create or add to negative staff morale. improve direct communication with clients and staff through
the facilitation of active listening, the validation of under-
standing, and matching of nonverbal and verbal messages.
Control emotions
Emotional control and emotional intelligence are critical Review Questions
components of conflict resolution (Casperson, 2015). Although
many conflicts might negatively affect your emotional state, it 1. Identify a conflict you have had in your personal life or
is critical to remain focused on the problem rather than the the workplace. What strategies did you use to resolve the
person or situation that is the perceived cause of the conflict conflict? What specific strategies could you have used to
(Desivilya & Dana, 2005). Effective communication supports resolve this conflict more effectively?
controlling your emotional responses, seeking understanding, 2. Are you more individualistic or collectivistic in your
identifying common needs and interests, and seeking mutual approach to resolving conflicts? What strategies would
benefits (Casperson, 2015; Pettrey, 2003). you implement to balance your approach to more effec-
tive conflict resolution?
3. How authentic is your listening strategy? What strategies
Respond to ideas, not people
could you implement to be a more effective listener?
The old adage of being hard on problems and not hard on
people applies to the conflict resolution process. Those in-
volved in the resolution of a conflict must focus on the ideas PRACTICAL APPLICATIONS IN
and solutions that are generated to reach an effective compro- OCCUPATIONAL THERAPY
mise rather than on the person bringing those ideas forward
Conflict can arise during the delivery of occupational ther-
(Casperson, 2015; Haraway & Haraway, 2005). When the focus
apy services and programs, often because of productivity
is on ideas, the open conversation strays away from the poten-
requirements, miscommunication, and differing perceptions
tial defensiveness that occurs when each party is determined
of expectations. In addition to the strategies for effective con-
to demonstrate that they are “right.” Instead, the conversation
flict resolution discussed, occupational therapy managers
becomes laser focused on ideas and solutions to problems.
should be careful to ensure that they are constantly abiding
by the organizational or departmental policies and proce-
Aim for resolution dures as they relate to employee and employer responsibilities
Conflicts can sometimes produce situations in which indi- for employee misconduct. Human resources should always be
viduals or organizations go through the intellectual exercise consulted when conflicts escalate beyond a reasonable level
of meeting without an intent to resolve the conflict. Instead, to ensure that employee law and regulations are adhered to.
the focus should be on effectively resolving the conflict by When conflict arises when working with clients, occupa-
hearing all perspectives rather than passively going through tional therapy managers and practitioners must demonstrate
the motions of interaction (Casperson, 2015; Jormsri, 2004). respect for clients, involve clients in decision making, advo-
cate with and for clients in meeting the client’s needs, and
otherwise recognize the client’s experience and knowledge.
Deal with 1 specific topic at a time
Given the ethical considerations and the federal accredita-
During the conflict resolution process, discussions should con- tion requirements mandated to focus on patient and family
centrate on 1 specific topic at a time, without straying into other goals, it is imperative that more occupational therapy manag-
problem areas. Conflict is often complex, and if it has not been ers, practitioners, and students practice with a client-centered
dealt with effectively over time, the conflict can easily flare into focus and ensure that clients feel satisfied with their ability
to engage in occupational performance (Mroz et al., 2015; Case Example 37.1 illustrates practical applications of con-
Phipps & Richardson, 2007). The principles for conflict res- flict resolution in occupational therapy practice.
olution among colleagues also apply to working with clients
and families, but practicing in a client-centered way requires
practitioners to always put the client first. Review Questions
Occupational therapy managers should empower staff to 1. How should occupational therapy managers respond
use the principles of effective conflict resolution presented in when conflict rises to a more critical level with their
this chapter and create opportunities for role play or practice employees?
in communicating with patients and families. If these meth- 2. How should conflict be resolved when clients and fami-
ods have been exhausted, managers can also mediate conflicts lies are involved?
by joining the practitioner, client, and family to ensure that 3. How are policies, procedures, laws, and regulations
effective conflict resolution strategies are effectively used. involved when occupational therapy managers are man-
aging conflict?
SUMMARY
For additional learning, see
Occupational therapy managers are challenged to use con-
■ Chapter 25, “Understanding Client-Centered Practice,” and
flict resolution strategies that focus on reducing or resolving
■ Chapter 47, “Practitioner–Client Communication.”
conflicts that arise in the context of occupational therapy
CASE EXAMPLE 37.1. Conflict Resolution
Scenario 1
Sally has been an occupational therapy practitioner for more than 20 years in a large school-based practice, where she has developed long and
enduring relationships with her coworkers and the school staff. Sally was recently promoted to a management position and is now supervising her
former coworkers directly.
The school system is requiring increased caseloads, up to 50 students per occupational therapy practitioner, so she is beginning to change
the productivity requirements in her department. Sally is dealing with emerging conflict with staff who are resisting the change. The occupational
therapy practitioners perceive that they are being assigned more children to their caseload than they can reasonably treat, given the new
productivity requirements. Sally feels an internal conflict: On the one hand, she wishes to maintain good relationships with the staff she previously
worked alongside. On the other hand, she realizes that the department is best served when the children are receiving timely, high-quality services.
Scenario 2
Jane is a Level I occupational therapy fieldwork student on an acute rehabilitation unit. On her first day of fieldwork, she experiences conflict with
her fieldwork supervisor, who has provided feedback that Jane’s dress is unprofessional for the setting. Jane reacts defensively and explains that
professional dress is open to interpretation.
Jane now feels that her fieldwork supervisor is purposely trying to find deficits in Jane’s performance because they do not share the same values
regarding professional attire in the workplace.
Scenario 3
Tom is in his 10th week as a Level II occupational therapy fieldwork student in an outpatient pediatric clinic. Tom is working with a young girl with
autism on sensory integrative strategies for her poor social skills. The client’s mother is upset that her daughter is being treated by an “intern” and
expresses dissatisfaction with Tom’s effectiveness.
Tom is unsure how to approach the client’s mother. He is fearful that if he addresses the conflict or informs his supervisor, he might not pass
his fieldwork.
Scenario 4
Roger is a director of a large occupational therapy department in an acute hospital setting. Roger has served in various management roles over the
past 10 years. He recently assumed responsibility for the physical therapy and speech therapy departments, because the hospital is attempting to
reduce costs by integrating all rehabilitation disciplines under 1 department.
Roger is experiencing conflict with the physical therapy and speech therapy staff, who are resisting the idea of a merged department under the
direction of someone from another discipline. In trying to appease his new direct reports, he begins to focus his energy on the needs of the other
departments, leaving his former occupational therapy department feeling abandoned in the midst of change.
Review Questions
1. In Scenario 1, how should Sally address the emerging conflict with her staff?
2. In Scenario 2, what strategies should Jane implement to effectively resolve the conflict with her fieldwork supervisor?
3. In Scenario 3, how should Tom effectively resolve this conflict with his client’s mother?
4. In Scenario 4, how should Roger effectively deal with the emerging conflict from his former staff and his new staff?
CHAPTER 37. Conflict Resolution 355
practice. This chapter reviewed the principles of conflict res- Haraway, D. L., & Haraway, W. M., III. (2005). Analysis of the effect
olution and effective strategies for resolving conflict in the of conflict-management and resolution training on employee
workplace. This chapter also focused on the practical applica- stress at a healthcare organization. Hospital Topics, 83(4), 11–17.
tion of conflict resolution strategies through 4 case examples https://doi.org/10.3200/HTPS.83.4.11-1
Harmer, B. M. (2006). Do not go gentle: Intractable value differ-
in occupational therapy practice. ❖
ences in hospice. Journal of Healthcare Management, 51, 86–93.
Hendel, T., Fish, M., & Galon, V. (2005). Leadership style and choice
ACOTE STANDARDS of strategy in conflict management among Israeli nurse man-
agers in general hospitals. Nursing Management, 13, 137–146.
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Herzog, A. C. (2000). Conflict resolution in a nutshell: Tips for
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CHAPTER
Mentoring and Motivating Others
Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, C/NDT, PAM 38
LEARNING OBJECTIVES
■ Describe how mentoring can be an effective method to motivate employees in organizations;
■ Describe the benefits of mentoring for the mentor, mentee, and the organization;
■ Identify effective strategies for motivating employees through the mentoring process; and
■ Identify best practices in mentoring and in the application of effective motivational strategies.

• Closure • Group mentoring • Mentors
• Continuing professional • Informal mentoring • Motivation
development • Intrinsic motivation • Negotiating
• Culture of mentoring • Leadership • Peer-to-peer mentoring
• E-mentoring • Mentees • Preparing
• Enabling • Mentoring • Professional development
• Extrinsic motivation • Mentoring activities • Welcoming
• Formal mentoring
OVERVIEW work performance and professional growth of their employees

but are also instrumental in influencing job satisfaction and
O
ccupational therapy managers are challenged to pro- employee retention, which ultimately contributes to achieving
duce and attain high standards of performance within organizational goals. Mentoring motivates employees to per-
their organizations. Mentoring and motivating oth- form and maintain the organization’s high standards.
ers are fundamental and essential skills that can be used to This chapter provides an overview of information and con-
build on and improve the work performance and professional cepts on mentoring and motivation relevant to occupational
development of employees aligned with meeting and helping therapy managers, which can be facilitated, implemented,
organizations achieve shared mission and vision goals. and applied in organizations. Best practices in mentoring
Carr et al. (2003) stated that mentoring relationships are and use of motivational strategies in general and standards
not only key to developing productive careers in any field; they specific to occupational therapy practice are presented and a
are also crucial to building an organization’s success. Along case example illustrates applying the concepts discussed.
with mentoring, applying motivational strategies inspires em-
ployees and others in the organization and creates a positive
environment that increases morale leading to organizational ESSENTIAL CONSIDERATIONS
productivity. Using guidance, feedback, clinical skills training,
What Is Mentoring?
and career advancement, managers can effectively motivate
employees as part of the mentoring process (Phipps, 2011). Mentoring is a situational relationship between an experi-
Through mentoring and motivating, occupational therapy enced individual (i.e., mentor) and a novice (i.e., mentee) to fa-
managers are not only a vital key in encouraging improved cilitate and support mutual professional growth. The process
https://doi.org/10.7139/2019.978-1-56900-592-7.038
357
CHAPTER
Mentoring and Motivating Others
Luis de Leon Arabit, OTD, MS, OTR/L, BCPR, C/NDT, PAM 38
LEARNING OBJECTIVES
■ Describe how mentoring can be an effective method to motivate employees in organizations;
■ Describe the benefits of mentoring for the mentor, mentee, and the organization;
■ Identify effective strategies for motivating employees through the mentoring process; and
■ Identify best practices in mentoring and in the application of effective motivational strategies.

• Closure • Group mentoring • Mentors
• Continuing professional • Informal mentoring • Motivation
development • Intrinsic motivation • Negotiating
• Culture of mentoring • Leadership • Peer-to-peer mentoring
• E-mentoring • Mentees • Preparing
• Enabling • Mentoring • Professional development
• Extrinsic motivation • Mentoring activities • Welcoming
• Formal mentoring
OVERVIEW work performance and professional growth of their employees

but are also instrumental in influencing job satisfaction and
O
ccupational therapy managers are challenged to pro- employee retention, which ultimately contributes to achieving
duce and attain high standards of performance within organizational goals. Mentoring motivates employees to per-
their organizations. Mentoring and motivating oth- form and maintain the organization’s high standards.
ers are fundamental and essential skills that can be used to This chapter provides an overview of information and con-
build on and improve the work performance and professional cepts on mentoring and motivation relevant to occupational
development of employees aligned with meeting and helping therapy managers, which can be facilitated, implemented,
organizations achieve shared mission and vision goals. and applied in organizations. Best practices in mentoring
Carr et al. (2003) stated that mentoring relationships are and use of motivational strategies in general and standards
not only key to developing productive careers in any field; they specific to occupational therapy practice are presented and a
are also crucial to building an organization’s success. Along case example illustrates applying the concepts discussed.
with mentoring, applying motivational strategies inspires em-
ployees and others in the organization and creates a positive
environment that increases morale leading to organizational ESSENTIAL CONSIDERATIONS
productivity. Using guidance, feedback, clinical skills training,
What Is Mentoring?
and career advancement, managers can effectively motivate
employees as part of the mentoring process (Phipps, 2011). Mentoring is a situational relationship between an experi-
Through mentoring and motivating, occupational therapy enced individual (i.e., mentor) and a novice (i.e., mentee) to fa-
managers are not only a vital key in encouraging improved cilitate and support mutual professional growth. The process
https://doi.org/10.7139/2019.978-1-56900-592-7.038
357
Higher levels of performance, job satisfaction, and orga-

EXHIBIT 38.1. Common Mentor and Mentee Benefits nizational success have also been reported in vocational and
organizational management research due to mentoring (Foss,
Mentor Benefits 2011). Scandura (1992) found that mentoring encourages
effective organizational socialization and reduced turnover
■ Exposure to fresh perspectives, ideas, and innovative approaches
■ Opportunity to reflect on personal or professional goals and
of employees. Through the mentoring process, occupational
practices therapy managers can support and motivate employees
■ Development of personal leadership and coaching styles in their work and professional growth while strategically
■ Personal satisfaction through supporting the development of helping the organization achieve its goals.
others
Mentee Benefits Types of Mentorships

■ Exposure to new ideas and ways of thinking Occupational therapy managers need to be aware of the
■ Guidance in developing strategies and building confidence 5 types of mentoring to facilitate and apply the most appro-
■ Opportunity to develop new skills and knowledge priate approach for mentoring relationships in the organiza-
■ Networking and increased visibility to advance career or tion: (1) formal, (2) informal, (3) peer to peer, (4) group, and
leadership development (5) e-mentoring (U.S. Office of Personnel Management, 2008).
■ Formal mentoring—mentoring that is structured with
oversight and clear and specific organizational goals
assists professionals to grow, develop, and pursue goals ■ Informal mentoring—mentoring that is natural or
throughout the span of their careers. Mentors are those who spontaneous with minimal to no structure and oversight
provide training and guidance to mentees at the beginning and may or may not have clear and specific goals
of their careers, working toward competent clinical, behav- ■ Peer-to-peer mentoring—mentoring between individuals
ioral, and professional practice. Mentees, on the other hand, at the same level or status providing skill training and
are those seeking training and guidance from mentors who experience sharing
will potentially assist in advancing identified professional ca- ■ Group mentoring—mentoring that is conducted within a
reer goals. network of mentors with multiple perspectives
Mentoring is often thought of as a more experienced ■ E-mentoring—mentoring that is conducted virtually by
person sharing information, advice, knowledge, or training email, phone call, social media, or national mentorship
with a novice (Gruber-Page, 2016). In fact, mentoring is databases
mutually beneficial for both the mentor and the mentee.
Harshavardhana et al. (2013) considered it as an active 2-way Mentoring in Professional Development
process that promotes professional excellence. The mentor
and mentee work together in a reciprocal relationship where Professional development is the process of growing and
both share, develop, and learn from each other. The success developing professionally in one’s career. The growth in
of any form of mentoring relationship is dependent on the knowledge and skills for occupational therapy practi-
parties’ acknowledgment of the process as one of collabora- tioners is a continuing and evolving process throughout
tion, wherein all contribute with opportunities for mutual one’s professional career. Lifelong learning is necessary to
learning and growth. Exhibit 38.1 lists the most common sustain growth in the practitioner’s knowledge, skills and
mentor and mentee benefits (American Occupational Ther- attitudes spanning the length of a career (Foss, 2011). How-
apy Association [AOTA], 2017). ever, the continued growth and development throughout
one’s professional career does not follow a standard path and
often the progression is solely dependent on the individual
Benefits of Mentoring to Organizations
practitioner’s personal stance to improve and motivation to
The mentoring process is not only valuable to mentors and pursue excellence.
mentees but is also beneficial to organizations. Because of The Occupational Therapy Code of Ethics (2015) (AOTA,
its benefits, mentoring has increased in popularity and is 2015a) stipulates that practitioners “maintain competency by
being implemented in numerous organizations (Cooper & ongoing participation in education relevant to one’s practice
Miller, 1998). Based on a review of the literature, “because area” (p. 3). Although continuing education (CE) courses
of mentoring, a health care organization may experience less are needed to meet licensure and certification requirements,
staff turnover, see improvement in employee morale, and em- there are no specific recommended standard continuing
ploy staff who are more committed to and have a better un- competence that extends beyond the mere completion of
derstanding of the organization” (Gruber-Page, 2016, p. 422). courses, which can potentially guide practitioners toward
Mentoring benefits include improved employee interaction, meeting individualized needs within and beyond their prac-
development of partnerships, enhanced positive environ- tice. Robertson and Savio (2003) stated that the profession
ment, increased retention, and higher level of commitment has fostered independence in designing and defining individ-
and loyalty to the organization (Lamm & Harder, 2008). ual career goals and direction for practitioners.
CHAPTER 38. Mentoring and Motivating Others 359
AOTA encourages occupational therapy practitioners to of practice found that the support of colleagues and peers
develop a continuing professional development (CPD) plan was critical to their learning and eased their adjustment from
using a systematic self-assessment that includes reflection student to occupational therapist (Toal-Sullivan, 2006). Thus,
and an understanding of current and future professional the offerings and availability of mentoring opportunities and
needs (AOTA, 2003). AOTA asserts that a structured plan for initiatives in the organization can attract the attention and
each practitioner’s CPD is necessary for the advancement of increase the chances of new occupational therapy graduates
the profession and practitioners and the clients they serve. applying for open positions.
The CPD is vital to the profession and facilitates growth and
availability of evidence-based, relevant, and best practice Who Can Be a Mentor?
within traditional and emerging practice areas to achieve the
goals of high quality and safe occupational therapy services It is essential for occupational therapy managers to recognize
(AOTA, 2015b; Schultz-Krohn, 2017). One method espoused that every staff member in an organization can be a potential
by the Commission on Continuing Competence and Profes- mentor. The mentoring relationship that could develop may
sional Development to meet CPD is the engagement of prac- be based on the potential mentor’s experiential background,
titioners in mentoring relationships. established practice competencies, and the context where the
mentoring relationship might occur regardless of the mentor’s
rank in the organization’s hierarchy. Occupational therapists
For Additional Learning (OTs) may have opportunities to mentor fellow OTs, occu-
pational therapy assistants (OTAs), new practitioners, OTA
For additional learning, see graduates, students, and volunteers. OTAs may have oppor-
■ Chapter 54, “Continuing Competence,” and tunities to mentor fellow OTAs as well as new graduates and
■ Chapter 71, “Professional Development.” students including volunteers. In addition, senior occupa-
tional therapy students may have opportunities to provide
mentoring to junior occupational therapy students during
The National Board for Certification in Occupational their fieldwork experience within the organization.
Therapy (NBCOT®; n.d.) uses mentoring activities as a There may be instances in an organization where more
method for practitioners to accrue professional development experienced OTAs with established practice competencies in
units for certification renewal. The certification renewal chart specific work settings may be assigned to provide short-term
of the NBCOT lists Items 12 and 18 as both “mentoring” and mentorship to novice OTs and new OT graduates entering
“receiving mentoring,” respectively, as valid professional de- their first year of practice. Such situations are acceptable when
velopment activities for renewal of certification. Hence, the considering the experiential background, established practice
mentoring process offers an avenue and an option for manag- competencies, and the specific work setting where the OTAs
ing and engaging new and experienced practitioners into op- will be providing mentorship. However, recommendations
portunities for guidance and direction in their practice and from a descriptive study by McCombie and McElroy (2016)
for continued growth and professional development. assessing variables supporting the positive transition from
student to practicing therapist by new OT graduates over
Mentoring for New Practitioners the first year of employment revealed that new OT graduates
being required to supervise OTAs tended to undermine the
The presence of formal mentoring programs in organizations transition experience. Therefore, in this study, the authors
can be an effective recruitment strategy that occupational recommended that employers refrain from having new OT
therapy managers can use to their advantage to attract prac- graduates supervise OTAs. On the other hand, it is recom-
titioners entering their first year of practice. New graduates mended for new OT graduates to engage in discussion with
seeking employment often prefer to work in organizations employers on expectations regarding supervision of OTAs.
where mentoring is offered and available from more seasoned
therapists to ease transition from student to practitioner.
Findings in a study by McCombie and McElroy (2016) recom- Mentoring Stages
mended that new occupational therapy graduates investigate There are 4 stages in the mentoring process: (1) preparing,
the prospective place of employment and engage in discus- (2) negotiating, (3) enabling, and (4) closure (Zachary, 2012).
sion with employers regarding work and clinical caseload and
availability of a mentor.
Preparing stage
Furthermore, the study revealed that having a mentor was
related to receiving adequate feedback, high job satisfaction, In the preparing stage, the mentor and the mentee agree
and good clinical fit. Hummell and Koelmeyer (1999) inves- on the groundwork for the relationship. Zachary (2012)
tigated perceptions of occupational therapists 6 months after maintained that preparing is the most critical stage in the
graduation and found that the provision of support or super- mentoring process because it is where both parties explore
vision from a senior colleague was of critical importance to the and evaluate the appropriateness of the mentoring relation-
successful transition from student to graduate. In addition, a ship. In formal mentoring, a matching process is usually
qualitative study of 6 occupational therapists in the first year accomplished, where mentors and mentees are paired based
on common professional interests. Occupational therapy Motivation

managers may be able to assign or pair mentors with men-
Motivation is the act or process of providing a need or desire
tees based on their employees’ expertise and clinical practice
that causes a person to take some action (Shanks, 2007). In
interests. In informal mentoring, the pairing is based more
personnel management, Ambrose and Kulik (1999) defined
on professional or social interactions in a spontaneous and
motivation as the act of inspiring others to move toward
natural setting, where mentors and mentees search for the
goal-directed action. Schunk et al. (2008) defined motivation
appropriate mentor–mentee match themselves.
in education as a process whereby goal-directed activities are
instigated and sustained. Motivation has also been defined
Negotiating as a state, feeling, or thinking in which one is engaged or
In the negotiating stage the mentor and mentee discuss how aroused to perform a task or engage in a particular behavior
learning will occur throughout their mentoring relationship (Pointer, 2006). The word motivation is derived from the word
(Zachary, 2012). This stage includes developing framework of “motive,” which means a desire, need, and intention to act
specific measurable goals and benchmarks that will signify or behave toward meeting specific goals. Once fulfilled, the
success (Lamm & Harder, 2008). Both mentee and mentor motive that prompted the act most of the time culminates in
will also need to formally agree on the logistics of the mento- an intrinsic or extrinsic reward.
ring relationship such as frequency of meetings, boundaries, According to Shanks (2007), managers are continually
and confidentiality. Well-defined goals and expectations at challenged to motivate a workforce to do 2 things: (1) to
this stage will produce better results toward the culmination motivate employees to work toward helping the organization
of the mentoring process. achieve its goals and (2) to motivate employees to work toward
achieving their own personal goals. Determining the motiva-
tion of employees can assist occupational therapy managers
Enabling in understanding intrinsic and extrinsic factors that con-
In the enabling stage the mentor offers support, guidance, tribute to behaviors exhibited by high- and low-performing
and encouragement for the mentee regarding specific goals employees in the organization.
initially set or on any anticipated or unanticipated issues that Intrinsic motivation refers to behavior that is driven by
may arise during the process. According to Zachary (2012), internal rewards (Cherry, 2017). An individual engages in
this phase puts emphasis on the importance of mentors as a specific behavior to achieve goals because the drive to act
they manage the relationship with mentees using active is internally satisfying. Extrinsic motivation, on the other
support, communicating with mentees as agreed on during hand, refers to behavior that is driven by external rewards
the negotiating phase, and taking the initiative to bring out such as money, fame, grades, and praise (Cherry, 2017). An
issues as they rise to the surface. Monitoring and evaluating individual engages in a specific behavior to achieve goals
progress and encouraging continued growth help to main- because the drive to act comes from external sources.
tain momentum (Lamm & Harder, 2008). Zachary stated Both intrinsic and extrinsic motivations are important
that mentors should also encourage mentees to reflect and drivers of desired behaviors in employees. Effective occupa-
evaluate their progress in the mentoring relationship at this tional therapy managers and administrators must be creative
stage in the mentoring process. in understanding the various methods of intrinsically and ex-
trinsically motivating their employees, keeping them feeling
inspired about their work, preventing burnout, improving
Closure
morale, and helping to lower rates of employee turnover and
The final stage in the mentoring process is closure, which is job dissatisfaction.
described by Zachary (2012) as the most difficult phase in the Motivation for better performance is dependent on pro-
mentoring process attributed to possible anxiety and resent- fessional growth, job satisfaction, recognition, and achieve-
ment especially when the relationship ends abruptly. Hence, ment (Boyett & Boyett, 2000). Although money is important
once the mentee has attained the professional competencies to employees, research shows that what motivates them to
in the goals outlined in the negotiating stage of the mentoring perform—and to perform at higher levels—is the thoughtful,
process, it is important to be clear that the end of the men- personal kind of recognition that signifies true appreciation
toring relationship is nearing. Zachary stated that long-term for a job well done (Nelson, 2005). Therefore, occupational
dependence on an influential person is not helpful during therapy managers can show intangible outward actions of
this stage. This phase also marks the need to evaluate goals appreciation such as praising, verbally saying thank you,
and outcomes achieved and to acknowledge and celebrate writing a card or note of gratitude, or even just a simple pat
accomplishments. on the back. Such actions further motivate and encourage
In addition, the mentoring relationship at this phase might the employee to strive harder to achieve set personal goals.
undergo renegotiation based on the outcome of the process. Shanks (2007) stated that successful managers can pro-
Some mentoring relationships that are successful have led vide extrinsic rewards that will help their employees to be
to lifelong friendships, and some mentees may have even intrinsically motivated to become high performers in the
surpassed the accomplishments of their mentors. organization.
In addition, occupational therapy managers need to be acknowledged value of mentoring, not many health care or-
cognizant of multigenerational differences when motivating ganizations have formal mentoring programs in place. Most
employees in their work settings. Multigenerational work- of the mentoring that happens occurs informally or spon-
force differences challenge occupational therapy managers taneously. Rossi (2017) stated that for most organizations
to be creative and to integrate applicable and appropriate “mentoring is performed on a piecemeal basis and is likely
motivational approaches to manage and lead accordingly. For not as effective as it could be.” Far too often, mentoring efforts
example, Traditionalists (born 1928–1945) are extremely loyal are disorganized and lack a dedicated trainer.
and enjoy being respected for it; they are conformists and A culture of mentoring requires a personal commitment
value job titles and money (Rampton, 2017). Baby Boomers on the part of organizational leaders. According to Zachary
(born 1946–1964) are often ambitious, loyal, work centric, (2010), mentoring culture
and cynical. They are goal-oriented and motivated by promo-
tions, professional development, and having their expertise encourages the practice of mentoring excellence by
valued and acknowledged (Rampton, 2017). continuously creating readiness for mentoring within the
Generation X (born 1965–1980) are often credited for pro- organization, facilitating multiple mentoring opportunities
moting work–life balance and prefer to work independently and building in support mechanisms to ensure individual
with minimal supervision; they are motivated by flexible and organizational mentoring success. (para. 3)
schedules; benefits like telecommuting; recognition from the
boss; and bonuses, stock, and gift cards as monetary rewards Therefore, given the current state in mentoring, occupa-
(Rampton, 2017). Generation Y (born 1981–1995) thrive when tional therapy managers are challenged to work in unison
there is structure, stability, continued learning opportunities, with their organizations to develop a culture of mentoring,
and immediate feedback. Generation Z (born 1996–2012) taking into consideration the responsibility of encouraging
are motivated by social rewards, mentorship, and constant and inspiring employees for professional development
feedback (Rampton, 2017). For the first time in history, there and in their work for the organization. Whether using for-
are 5 generations in the workplace with older members of mal or informal mentoring, managers can help keep their
Generation Z entering the workforce (Gravesande, n.d.). employees feeling motivated using a variety of strategies such
Although these multigenerational attributes are broad, as giving support and guidance, effectively communicating
they have implications for how occupational therapy man- and providing feedback, offering training in clinical skills,
agers might communicate and relate to each generational and encouraging professional growth with opportunities
group. It is important for managers to consider and find out for career advancement. When managers and organizations
the values of each of these generational groups and apply ap- work together to create and develop a culture of mentoring,
propriate motivational strategies accordingly. As generations employees and employers both achieve their respective
work together, conflicts are inevitable because each group goals—a win–win situation for the organization.
may approach work from varied perspectives. Managers must
be prepared to meet these challenges by learning to blend the Managers as Mentors
various and differing multigenerational perspectives into a
It is important to keep in mind that occupational therapy
management approach that motivates and inspires all em-
managers can be called on to play dual roles of managing and
ployees to achieve the shared vision and mission of their
mentoring interchangeably or simultaneously in organiza-
organizations.
tions. If this is the case, it is important for both manager and
employee (the mentee) to be clear from the beginning about
Mentoring as a Motivational
the inherent variations in purposes and responsibilities of
Tool in Organizations
these roles. Youngstrom (2014) cautioned that holding both
Mentoring can serve as a channel and effective tool to mo- roles of supervisor and mentor simultaneously can lead to
tivate employees in organizations and to provide training role conflicts, hence the need for both parties to have clarity
opportunities for new skills (Benson & Dundis, 2003). An at the inception of the mentoring relationship.
organization that values and facilitates mentoring can benefit In a mentor–mentee relationship, the goals benefit the
from employee retention, improved morale, organizational mentee; in a manager–employee relationship, the goals
commitment and vitality, transference of organizational benefit the organization. Therefore, it might not be advisable
knowledge, and accelerated professional and leadership de- for occupational therapy managers to act in dual roles, espe-
velopment (Zachary, 2005). Mentoring also helps maintain cially in situations where decisions are made that prioritize
the organization’s professional standards and continuity. the goals of the organization over that of the mentee.
A culture of mentoring within organizations requires For example, a manager acting in the role of mentor might
the concerted efforts and support of organizational leaders, surmise that a new employee (mentee) might benefit from
middle management personnel, and employees. Culture of learning the basics of inpatient rehabilitation to strengthen
mentoring is an organizational philosophy that values and clinical foundational skills and knowledge before transition-
supports the presence and development of mentoring pro- ing to the more demanding acute care setting. However, the
grams, relationships, and processes. However, despite the same manager acting in a supervisory role may encounter
staffing challenges and decide the employee (mentee) should in welcoming is to introduce the mentee to the workplace
be introduced immediately to the acute care setting to fill culture and to suggest methods for successful engagement
staffing needs. Because of the manager’s administrative and and immersion in the organization. This may include orien-
supervisory role in the organization, she must be cognizant tation to the work spaces; explaining basic routines, cultural
and act judiciously in situations where clear delineation is norms, and role expectations; and introducing the employee
needed to act either in a supervisory or mentor role or instead to other team members as well as the leadership team. Jakubik
to facilitate the delegation of mentoring to an experienced et al. (2016a) stated that welcoming also leads to a sense of
employee (i.e., peer-to-peer mentoring) within her staff. belonging where the mentee is incorporated in the work-
place culture. For managers, welcoming is an opportunity to
Review Questions establish rapport and to get to know the employee and vice
versa. Research has shown that welcoming is very important
1. The following are all benefits of mentoring for the mentor in health care and has an impact on employee motivation and
except: satisfaction (Vital & Alves, 2010).
a. Opportunity to reflect on personal or professional
goals and practices
Mapping the Future and
b. Development of personal leadership and coaching
styles Fostering Career Optimism
c. Exposure to new ideas and ways of thinking The focus of the mapping the future activity is for the mentor
d. Personal satisfaction through supporting the devel- to demonstrate various career paths and opportunities with
opment of others the goal of enabling mentees to begin to envision and become
2. The stage in the mentoring process where the mentor optimistic about their overall career development within the
offers support, guidance, and encouragement for the organization (Jakubik et al., 2016b). During this mentoring
mentee is: activity, the occupational therapy manager schedules meet-
a. Negotiating ings with the employee and finds out the employee’s interests,
b. Closure skills, and career ambitions while discussing other future role
c. Preparing development opportunities in the organization.
d. Enabling Exchanging and sharing information related to profes-
3. Motivation in personnel management is best defined as: sional growth and identifying points of connections and
a. The act of inspiring others to move toward goal-directed interests can help occupational therapy managers and em-
action ployees to identify levels of motivation necessary in a mento-
b. A need or desire that causes a person to take some ring relationship. Managers can demonstrate active listening,
action encouragement, support, facilitation, and optimism toward
c. A tool used by managers to keep employees engaged advancing employees professionally in their careers as practi-
d. A process whereby goal-directed activities are insti- tioners in the organization. Active listening creates a positive
gated and sustained and accepting environment that can lead to effective and
open communication. Encouraging, supporting, and facili-
tating the professional development of the employee in the
PRACTICAL APPLICATIONS IN organization shows employees that the manager is sincerely
OCCUPATIONAL THERAPY interested in helping them develop and be successful.
According to Jakubik et al. (2016a), mentoring practices are In a mentoring relationship that is formal, well-defined
embedded in the workplace through mentoring activities. goals by the employee are necessary to be established between
Mentoring activities are the specific actions of the mentor the mentor and mentee. In mentoring relationships that are
and the workplace that facilitate the protégé’s professional informal in nature, defined goals are not necessary as the re-
growth (Jakubik, 2015). This section describes some recom- lationship happens spontaneously. Occupational therapy man-
mended, evidenced-based mentoring activities and practices agers can promote a culture of mentoring in the organization
adopted from Jakubik et al.’s (2016a) Leadership Series: “How by using formal or informal mentoring processes to motivate
to” for Mentoring. Although written specific for nursing employees. There may be times when managers should step
leadership and practice, these mentoring activities can be back and act as a facilitator of the mentoring process between
suitably implemented by occupational therapy managers in 2 employees who share the same passion and interests.
their organizations to motivate employees, whether acting in If appropriate, occupational therapy managers sharing
a managerial role, mentor, or as facilitator of the mentoring career and personal goals with employees can be an accept-
process. able gesture during the mentoring process. Doing so can in-
spire and motivate employees to determine and identify their
own career path and personal goals. Managers can be role
Welcoming and Belonging
models and inspirations to guide and motivate employees
The essence of welcoming is that employees need to know the in developing the capacity for learning and for achieving
workplace social and cultural norms and feel valued and in- goals. Managers can impart knowledge and skills, assist the
cluded (Jakubik, 2015). Occupational therapy managers’ role employee in locating resources needed, help employees gain a
broader view of their responsibilities in the organization, and incrementally delegate more tasks while also being support-
discuss career experiences. ive and empathetic. This steadily builds employees’ confi-
dence level.
Effective occupational therapy managers encourage and
Teaching the Job and Competence
inspire employees. Giving encouragement has been reported
The focus of the mentor is to teach skills and impart knowl- to be the mentoring skill most valued by mentees (Center for
edge inherent in the job. The goal is to enable the mentee to Health Leadership Practice, 2003). Examples of methods to
know how to demonstrate competence and confidence in the encourage, inspire, and motivate employees in mentoring
new role (Eliades et al., 2016). While teaching the employee relationships include offering positive comments for accom-
about a job and learning how to be competent on the job, plishments; believing in the employee’s capacity to grow
occupational therapy managers should be present at all the personally and professionally to reach established goals;
initial stages and slowly and gradually lessen the supervision and providing support, understanding, encouragement, and
as the employee shows competency. praise when challenges occur. Managers can assist employees
Occupational therapy managers must make themselves in ensuring that they are meeting personal goals established
available for employees for support and to answer questions. at the beginning of the mentoring relationship. If the goal of
Managers should also check in intermittently with employees an employee is to acquire skills and gain more knowledge
to find out how they are doing in the job or a new assigned in an area of practice, the manager’s role is to facilitate the
task, role, or project. Offering frequent support and encour- growth of the employee in that area. Actions such as plotting
agement through open communication and identifying the and planning appropriate CE courses or scheduling an obser-
resources needed to accomplish the job aligned with em- vation session with other fellow employees might be appro-
ployee’s personal goals are important for employees to feel priate actions to consider.
confident in their abilities and be steadily optimistic and mo-
tivated. The mentoring effort should also allow adequate time
Providing Protection and Security
each day to summarize the skills and learning that transpired.
Providing immediate and consistent feedback is also an Providing protection involves the mentor creating a support-
important skill when occupational therapy managers are ive practice environment and conveying genuine interest in
training and instructing employees on the job. When pro- the protégé’s success (Jakubik et al., 2016d). In this mentoring
viding feedback during scheduled meetings, it is important activity, occupational therapy managers provide a safe prac-
for managers to consistently provide constructive comments tice environment that facilitates employees’ learning and pro-
as part of effective communication. Being supportive of the fessional growth, ensuring career success in the job despite the
employee, using a calm voice with a tone of respect, and en- presence, if any, of workplace politics. Managers can accom-
suring that the manager does not undermine the employee’s plish this by supporting and speaking well of the employee
self-esteem are all necessary in keeping the employee moti- during meetings and by providing constructive feedback and
vated and interested on staying in the mentoring relationship. recommendations in areas of work performance needing im-
provement. In this manner, employees will recognize that the
manager or perhaps even another peer employee is working
Supporting Transition and Professional Growth
on creating a safety net where they can openly discuss or share
The mentor’s focus in supporting the transition is to foster mistakes or issues encountered in practice while in the process
within the mentee self-confidence and communication skills also learning how to accept constructive feedback.
while modeling professionalism (Jakubik et al., 2016c). In this Rossi (2017) stated that a good mentoring program allows
mentoring activity, the occupational therapy manager needs to for the development of a new employee’s skills in a safe and
develop a strong interpersonal relationship with the employee controlled environment. Employees needs to feel that the
through skills of building trust, active listening, and providing occupational therapy manager or another peer employee is
empathy to achieve goals of professional growth. The mentor interested and looking out for their success on the job and in
encourages the mentee’s growth by challenging movement the organization. Such support motivates employees to con-
beyond his or her comfort zone to master communication and tinue the mentoring relationship and stay satisfied with the
problem-solving skills in different roles and contexts. organization.
Therefore, as employees begin to gain self-confidence, Building mutual trust between occupational therapy man-
learn the job, and imbibe the work culture, it is important agers and employees is also important in any mentoring rela-
that new tasks delegated by occupational therapy managers tionship and is an essential motivational strategy. However,
are tasks that employees can successfully perform. If tasks trust takes time. As the manager and employee begin to have
are too difficult, employees may become uninterested and more meetings and conversations, building on clinical skills
unmotivated to continue. It is extremely important not to capacities and on-the-job competencies, trust can be steadily
set up an employee for failure in a delegated task, because developed. Actions such as honesty and fairness; keeping com-
doing so might lead to demotivation. Managers can ensure munications confidential; following through with scheduled
that tasks delegated are introduced gradually from easy to meetings and phone calls; and consistently showing interest,
difficult. As employees continue to be successful at each stage support, and encouragement throughout the mentoring process
of the task, managers can make decisions to gradually and by managers is vital and can keep the employee motivated.
Equipping for Leadership and Review Questions

Leadership Readiness
1. The following are evidence-based mentoring activities
Equipping for leadership involves the mentor promoting and practices recommended by Jakubik et al. (2016a),
opportunities for the protégé to lead others and develop which can be applied by occupational therapy managers
leadership abilities (Eliades et al., 2017). In this mentoring in the workplace except:
activity, occupational therapy managers attempt to provide a. Teaching the job and competence
emotional, intellectual, and other resources to prepare the b. Welcoming and belonging
employee to lead. As the employee continues to gain in con- c. Rewarding and recognizing
fidence, the manager’s stance becomes focused on facilitating d. Providing protection and security
the development of the employee’s leadership abilities. 2. The focus of this mentoring activity is to foster within the
Leadership can be defined as the art of motivating a group mentee self-confidence and communication skills while
of people to act toward achieving a common goal (Ward, modeling professionalism:
2019). Leadership comes in many forms and levels and as a. Supporting the transition and professional growth
the mentoring relationship progresses, occupational therapy b. Mapping the future and career optimism
managers can take incremental steps in delegating depart- c. Equipping for leadership and leadership readiness
mental projects to the employee as appropriate and designate d. Teaching the job and competence
the employee as a team leader, working with other employees 3. Building trust is a motivational strategy in mentor-
(see Case Example 38.1). This motivates employees on the ing and can be built steadily by the following actions
job and creates a sense of ownership in a project. Regardless except:
of what form or level of future leadership role or position a. Keeping communications confidential
an employee might be delegated to or assigned in, whether b. Honesty and fairness
a departmental team leader or a hospital initiative project c. Meetings and conversations
leader, every occupational practitioner is a leader in their own d. Following through with scheduled meetings and
right and can benefit from leadership mentoring and support. phone calls
CASE EXAMPLE 38.1. Mary: New Occupational Therapy Manager
Mary, an occupational practitioner with more than 20 years of experience, was recently hired by a large urban hospital as the new
occupational therapy manager. On her first day, the organization and its leaders greeted her with welcome banner signs, a welcome packet,
and an announcement in the hospital newsletter and bulletin boards. Mary was also introduced to all staff and leaders and was given a hospital
orientation tour.
The next day, Mary attended the organization’s mandated new manager orientation, where she learned of the hospital’s mission, vision,
workplace culture, and numerous resources the organization offered that are essential to her new role. Mary was also introduced to other fellow
managers during the first week of her hospital orientation tour as well as to all the physical, occupational, and speech therapy staff; office
personnel; and schedulers in outpatient and inpatient areas. The director of rehabilitation met with her as well and went over all the basic job
routines and competencies inherent in the manager position. Mary was feeling excited and motivated to get started and settled in her new position
as the occupational therapy manager for the organization.
The first item on Mary’s list of things to do was to get familiarized with the workplace culture and work spaces and to get to know all employees
in the occupational therapy department by scheduling 1:1 meetings. As a new manager in the organization, it was essential for Mary to establish
rapport and get to know each of her employees. One of Mary’s scheduled meetings was with Evan, a new occupational therapist with 1.5 years
of experience working primarily at the inpatient rehabilitation unit. Evan completed his Level II fieldwork (FW) at the hospital and was hired by the
organization immediately after his graduation.
After the usual introductions, Mary began the meeting by asking Evan about his professional development interests and career goals. Mary found
out that one of Evan’s goals was to be able to supervise occupational therapy FW students now that he is past the 1-year mark as a therapist. Evan’s
second goal was to learn more about neurodevelopmental techniques (NDT) used for clients with neurological challenges. Throughout the meeting,
Mary demonstrated active listening, with good body language and eye contact, letting Evan know that she was sincerely interested in helping him
achieve his identified professional goals. Mary’s approach was very supportive, encouraging, and reassuring.
Along the course of the meeting, Mary opted to share with Evan the progression of her own career as an occupational therapist and how
gratifying it was for her to handle FW students in the past. She also shared that early in her career, she wanted to learn various treatment
techniques to hone her skills and help her clients improve. This inspired Evan and further motivated him to look forward to achieving his identified
professional goals. After the meeting Mary thanked Evan and told him that she will follow up with him on the 2 goals by setting up another meeting
in a couple of weeks.
Mary, who was also in charge of the occupational therapy department’s student program, had been receiving many requests from universities for
Level I and II FW placements. She immediately thought about Evan’s goal of supervising students. She surmised that Evan might benefit from taking
a Level I FW student to start with and when appropriate and ready, gradually progress him to taking Level II FW students. Two weeks later, Mary met
with Evan and asked him to supervise a Level I FW student to start him gradually; he was excited about the idea.
(Continued)
CASE EXAMPLE 38.1. Mary: New Occupational Therapy Manager (Cont.)
The Level I FW student was not scheduled to begin for 2 months, which gave Mary time to schedule weekly meetings with Evan to review
information or questions related to supervising students and mentoring him in his foreseeable new role as a fieldwork educator. In addition,
Mary pointed Evan to several resources on the AOTA website and gave him some excellent information about student supervision. She also provided
Evan information on the AOTA Fieldwork Educator Certificate Program and encouraged him to attend in the future.
During scheduled meetings with Evan, Mary reassured him that she and other experienced FW educators (FWEs) on staff would be
available for support should he encounter any issues or problems related to student supervision. During the next few weeks prior to the arrival
of the student, Mary met with Evan 12 times to go over the informational materials on student supervision and perform role-playing scenarios.
At the last meeting with Mary, she noticed that Evan’s confidence was high and that he appeared to be finally ready to supervise his first
student. Evan felt supported by Mary in his goal of becoming an occupational therapy FWE.
Mary proceeded to address Evan’s other goal, which was learning how to use NDT techniques. Supporting the goal of learning NDT was
personally important to Evan because he felt it would help him be a better occupational therapist and contribute to improving clients’ outcomes.
Mary knew this activity would further motivate Evan and stimulate his own professional growth in the organization.
Mary recalled that in an earlier meeting with other occupational therapy staff that Tara, an occupational therapist with 15 years of experience,
was also NDT certified. Mary immediately scheduled a meeting with Tara to determine whether she would be interested in mentoring Evan to learn
NDT; Tara gladly consented. Mary, now acting as a facilitator of Evan and Tara’s mentoring relationship, scheduled a meeting with both employees to
draw up a formal mentoring program. This included specific learning objectives with scheduled meetings and time frames. The plan included Evan
observing Tara 3 times a week for 1 hour each in the treatment of patients with neurological challenges using the NDT approach. Mary ensured that
the schedule was followed, and she guided and supported Tara as she mentored Evan.
Mary scheduled meetings with Tara and Evan to ensure that they were on target with the goals set at the start of the mentoring relationship.
In addition, Mary also provided information and directed both Evan and Tara’s attention toward the NBCOT professional development activity
of mentoring and receiving mentoring. Mary informed both that they could use this formal mentoring activity as a tool for gaining professional
development units in the renewal of their respective certifications and licenses.
Review Questions
1. The type of mentoring relationship that Mary facilitated between Evan and Tara is considered to be
a. Formal mentoring.
b. Peer-to-peer mentoring.
c. Informal mentoring.
d. a and b.
2. The mentoring practice and benefit that Mary experienced when she was hired by the organization as the new occupational therapy
manager is
a. Mapping future and career optimism.
b. Teaching the job and competence.
c. Providing protection and security.
d. Welcoming and belonging.
3. What is best practice when an occupational therapy manager holds simultaneous roles of manager and mentor within the organization?
a. The manager should never be the mentor of the mentee
b. The manager should only act as mentor to the mentee
c. The manager should clarify purposes and responsibilities of these roles
d. The manager should delegate the mentee to another mentor
SUMMARY well as improve employee morale, job satisfaction, and em-

ployee retention in the organization. ❖
As occupational therapy managers are challenged to attain
high levels of performance in organizations, mentoring and
motivating others are fundamental skills that improve the ACOTE STANDARDS
work performance and professional growth of employees
aligned with helping organizations achieve performance
goals. Developing a culture of mentoring is important in the ■ B5.1. Factors, policy issue & social system
workplace, and it requires full support from organizational ■ B5.2. Advocacy
leaders and employees. ■ B5.3. Business aspects of practice
Occupational therapy managers can influence and work ■ B5.5. Requirements for credentialing
collaboratively with their organizations to facilitate and pro- ■ B5.6. Marketing delivery of services
mote a culture of mentoring, which includes mentoring ac- ■ B5.7. Quality management and improvement
tivities and practicing motivational strategies that foster the ■ B5.8. Supervision of personnel
professional development and career growth of employees as ■ B7.4. Ongoing professional development.
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CHAPTER
Promoting Professionalism
Sean M. Getty, MS, OTR/L 39
LEARNING OBJECTIVES
■ Identify the core values and beliefs that signify professionalism in occupational therapy,
■ Identify occupational therapy–based theoretical approaches used to promote professionalism,
■ Identify stage-specific approaches to promoting professionalism,
■ Identify how generational differences influence professional behaviors, and
■ Identify how social media can be used in promoting professionalism.

• Intergenerational • Netiquette • Professionalism
professionalism • Professional behaviors • Promoting professionalism
P
rofessionalism was first addressed in occupational Professionalism is a core standard and expectation for any
therapy literature in 1968 (“What Is Professional- health care practitioner (Bryden et al., 2010). Although most
ism?” 1968). Professionalism is not a concept that individuals can identify traits of professionalism or unprofes-
is new or unique to the occupational therapy profession. sional behaviors, it is a concept that is not easily delineated in
However, the importance of strong professional behaviors occupational therapy literature (Aguilar et al., 2013; Sullivan
in occupational therapists and occupational therapy as- & Thiessen, 2015). Professionalism is defined as “the conduct,
sistants cannot be overstated. As new generations of ther- aims, or qualities that characterize or mark a profession or pro-
apists enter the workforce, their values and beliefs shape fessional person” (Merriam-Webster, 2017, para. 1). Therefore,
their professionalism. An intergenerational approach to one needs to identify those qualities of occupational therapy
understanding professional behaviors is necessary to com- in order to operationally define the term for the profession.
prehend the unique values, beliefs, experiences, and ac- Wood (2004) identifies the components of professionalism
tions that have developed professionalism within different in occupational therapy as related to the heart, mind, and
groups (Gleeson, 2007). soul. The heart of professionalism correlates with the reasons
This chapter defines professionalism, highlighting the core why most therapists enter the profession: to help others. The
values of the profession and how they align with promot- mind relates to scholarly progressions and is necessary for
ing professionalism. Occupational therapy theory is used to the heart. Wood (2004) suggests that the therapist who relies
identify strategies for facilitating professional behaviors and predominantly on the heart of professionalism is left “decap-
development. An approach to promoting professionalism itated.” A balance among these components must be met for
within interdisciplinary teams is featured. Developing appro- the therapist to flourish, which is the function of the soul of
priate professional social media use is also discussed. professionalism (Wood, 2004).
https://doi.org/10.7139/2019.978-1-56900-592-7.039
369
CHAPTER
Promoting Professionalism
Sean M. Getty, MS, OTR/L 39
LEARNING OBJECTIVES
■ Identify the core values and beliefs that signify professionalism in occupational therapy,
■ Identify occupational therapy–based theoretical approaches used to promote professionalism,
■ Identify stage-specific approaches to promoting professionalism,
■ Identify how generational differences influence professional behaviors, and
■ Identify how social media can be used in promoting professionalism.

• Intergenerational • Netiquette • Professionalism
professionalism • Professional behaviors • Promoting professionalism
P
rofessionalism was first addressed in occupational Professionalism is a core standard and expectation for any
therapy literature in 1968 (“What Is Professional- health care practitioner (Bryden et al., 2010). Although most
ism?” 1968). Professionalism is not a concept that individuals can identify traits of professionalism or unprofes-
is new or unique to the occupational therapy profession. sional behaviors, it is a concept that is not easily delineated in
However, the importance of strong professional behaviors occupational therapy literature (Aguilar et al., 2013; Sullivan
in occupational therapists and occupational therapy as- & Thiessen, 2015). Professionalism is defined as “the conduct,
sistants cannot be overstated. As new generations of ther- aims, or qualities that characterize or mark a profession or pro-
apists enter the workforce, their values and beliefs shape fessional person” (Merriam-Webster, 2017, para. 1). Therefore,
their professionalism. An intergenerational approach to one needs to identify those qualities of occupational therapy
understanding professional behaviors is necessary to com- in order to operationally define the term for the profession.
prehend the unique values, beliefs, experiences, and ac- Wood (2004) identifies the components of professionalism
tions that have developed professionalism within different in occupational therapy as related to the heart, mind, and
groups (Gleeson, 2007). soul. The heart of professionalism correlates with the reasons
This chapter defines professionalism, highlighting the core why most therapists enter the profession: to help others. The
values of the profession and how they align with promot- mind relates to scholarly progressions and is necessary for
ing professionalism. Occupational therapy theory is used to the heart. Wood (2004) suggests that the therapist who relies
identify strategies for facilitating professional behaviors and predominantly on the heart of professionalism is left “decap-
development. An approach to promoting professionalism itated.” A balance among these components must be met for
within interdisciplinary teams is featured. Developing appro- the therapist to flourish, which is the function of the soul of
priate professional social media use is also discussed. professionalism (Wood, 2004).
https://doi.org/10.7139/2019.978-1-56900-592-7.039
369
There is also recognition that professionalism embodies These components of a therapeutic relationship are a key to
both values and behaviors (Cruess et al., 2006). The Core Val- providing quality treatment. More than 90% of therapists
ues of occupational therapy are defined in the Occupational identify the therapeutic relationship as significantly affecting
Therapy Code of Ethics (2015) (American Occupational Therapy their clients’ commitment to therapy, and 4 out of 5 thera-
Association [AOTA], 2015a). The behaviors associated with pro- pists identified that therapeutic use of self positively affected
fessionalism in occupational therapy must further be identified treatment (Taylor et al., 2009). Promoting professionalism
to compose a clear expectation of standards. The standards for must include the development of skills to foster therapeutic
educational practice highlight the importance of ethical behav- relationships because they have a significant impact on the
ior and competency in practice and supervision (Accreditation quality of services being delivered.
Council for Occupational Therapy Education [ACOTE®], 2018).
However, the concept of professional behaviors, defined as ac- Professional Behaviors in Occupational Therapy
tions and characteristics that align with the values, standards,
and expectations for occupational therapy practitioners, ex- Although the profession’s Core Values and Standards of Prac
tends beyond these principles, and expected behaviors must be tice for Occupational Therapy (AOTA, 2015b) have been clearly
explicitly identified to ensure consistency in expectations. identified, there are behaviors that exemplify professionalism
that lie outside of these domains. A practitioner might demon-
strate adherence to all of these components while still exhibit-
Professional Values in Occupational Therapy
ing behaviors that might not be considered professional.
The Core Values of occupational therapy have been identified Let us consider the case of appearance. The Core Values
as “Altruism, Equality, Freedom, Justice, Dignity, Truth, and and Standards of Practice do not state that a practitioner
Prudence” (AOTA, 2015a, p. 1). These fundamental standards must be dressed in a particular manner. However, wearing
help to define the characteristics of occupational therapy prac- scrubs that are not wrinkled or dressing appropriately to the
titioners and ensure that ethical treatment is being provided. treatment setting is an obvious expectation for professional
Promoting professionalism by developing therapists’ behaviors behavior. Similarly, reliability, poise, etiquette, humility,
and actions based on the profession’s values, standards, and ex- cleanliness, consistency, and demeanor are professional be-
pectations lies within these Core Values. Professionalism must haviors that are required of therapists but not clearly iden-
be understood and demonstrated by students before their field- tified in the AOTA documents. Social interaction that is
work placements because these values guide our contacts with respectful of colleagues and appropriate for the workplace
clients. Although they are not imposed standards, these values is an integral behavior. Professionals need to understand the
also guide our ethical decision making (AOTA, 2015a). proper use of social media as it relates to both professional
The Ethical Principles and Standards of Practice for Occu and personal use. AOTA has established guidelines regard-
pational Therapy (AOTA, 2015b) are the essential compo- ing social media use for association volunteers (AOTA, 2017).
nents of professionalism that guide behavior. The Ethical Often, one of these areas leads to what might be characterized
Principles include as unprofessional and must be addressed by the supervisor.
A literature search reveals multiple components of behav-
■ Beneficence: Ensuring that the treatment being provided is ior that have been identified as components of professional
safe and helpful to the client
behavior in occupational therapists. Selflessness that presents
■ Nonmaleficence: The principle of no harm and reasonable as empathic, caring, and hopeful are attributes that thera-
risk
pists reported as important (Aguilar et al., 2012). Adam et al.
■ Autonomy: Treatment must align with clients’ wants and (2013) conducted a systematic review of occupational therapy
preferences
literature to identify professional behaviors. The researchers
■ Justice: Nondiscriminatory provision of occupational identified three key areas: “self-reflection and evaluation,”
therapy services and adherence to regulations
“professional presence,” and “confident and comfortable in a
■ Veracity: Practitioners have a duty to be truthful in com- wide range of settings” (p. 82).
munication with clients
A wide array of professional behaviors is expected of oc-
■ Fidelity: Respectful treatment of clients that is equal and cupational therapy practitioners. Some are obvious, overt ex-
unbiased (AOTA, 2015a).
pectations, such as professional dress and timeliness, which
Occupational therapy practitioners must consistently can be measured through observation or tracking perfor-
demonstrate these components of professional behavior, and mance. Other behaviors, such as empathy, are more obscure
failure to adhere to any one of these components constitutes and difficult to measure. Is it possible to determine that
an ethical violation. 1 therapist has more empathy than another? Although mea-
Aguilar et al. (2012) conducted semi-structured interviews surements for empathy exist, such as the Jefferson Scale of
with 15 Australian occupational therapists to determine the Empathy (Hojat & Gonnella, 2015), it might not be reasonable
ideals of the profession. The researchers identified a theme to have staff complete these assessments. With diverse values
relating to the collaborative relationship between the cli- and behaviors related to professionalism, managers must take
ent and therapist, which included communication, respect a systematic and theoretically based approach to promoting
for self-direction, empowerment, trust, and collaboration. professionalism in occupational therapy.
CHAPTER 39. Promoting Professionalism 371
Review Questions (Westfall et al., 2007). This correlates with other researchers
who have identified a 17-year gap in incorporating evidence
1. Using evidence-based practice to ensure that the treatment
into practice (Grimshaw et al., 2012; Morris et al., 2011). Several
being provided is the most beneficial treatment for the client
reasons exist as to why therapists do not use research, includ-
aligns with which of the following standards of conduct?
ing, but not limited to, their ability to locate and understand it.
a. Fidelity
If the demand put on practitioners to use evidence in guiding
b. Beneficence
practice was greater, therapists would create strategies to meet
c. Veracity
this demand based on the theory of occupational adaptation.
d. Autonomy
Promoting professionalism using the occupational adapta-
2. What values of an occupational therapy practitioner
tion theory requires the manager to set clear expectations re-
demonstrate professionalism?
garding professional standards. These standards could include
3. Which of the following components of professionalism
tasks required for professional knowledge and competence,
has been identified through research as essential in pro-
such as
viding quality treatment to clients?
a. Therapeutic use of self ■ Ensuring membership in national and state professional
b. Empathy organizations. These organizations promote profession-
c. Responsibility alism through advocacy, knowledge acquisition, and
d. Humility scholarly dialogue.
■ Expectations of the staff forming an internal community
of practice that is focused on evidence-based practice
within the facility. Communities of practice are an ef-
OCCUPATIONAL THERAPY fective method for professional growth in occupational
Using Occupational Therapy Theory in therapy (Barry et al., 2017).
Promoting Professionalism ■ Expectations for staff to present the work they are doing
at conferences. Again, this accelerates growth and creates
Several theories of professionalism have been established based connections that facilitate professionalism. The scholarly
on sociology and further refined for particular professions, connection and dialogue nurture the soul of professional-
such as law and midwifery (Freidson, 1999; Halldorsdottir & ism (Wood, 2004).
Karlsdottir, 2011; Jecker, 2004; Spaulding, 2012). Occupational
therapy practitioners, especially those in pediatrics and men- The concept of developing and evaluating adaptive re-
tal health, use theory to change clients’ behavior. Therefore, sponses is an important feature of professional growth be-
we can apply these same theories and frames of reference in cause it focuses on self-reflection. Therapists who copy the
nurturing the professional behaviors of staff. practices that they see without questioning or reflecting on
them fail to develop professionally (Whitcombe, 2013).
Occupational Adaptation
Behavioral Frame of Reference
Schkade and Schultz (1992) identified the theory of occupa-
tional adaptation as a way of understanding how individuals Reflecting back to one’s first-year mental health course in oc-
adjust to meet the demands for occupational accomplishment. cupational therapy, one might recall the professor discussing
The theory recognizes a demand for mastery that is put on Ivan Pavlov, B. F. Skinner, and Anne Cronin Mosey in the
an individual; the mastery requires them to formulate an development of the behavioral frame of reference. Therapists
adaptive response for performance. Facilitating professional- will often use this approach in motivating clients, addressing
ism within this model is based on management’s demand for performance and skill deficits, and setting goals to achieve
professionalism. If the demand for professionalism is low and adaptive performance (Cole, 2018). Promoting professional-
specific behaviors are not expected from employees, individu- ism involves stimulating staff to develop; addressing profes-
als do not need to adapt considerably. However, if demand for sional performance; addressing the skills, like interpreting
behavior is great, employees will find an adaptive strategy to research, that are needed to advance; and setting individual
meet this demand. Therefore, expectations must be made for goals for growth. Therefore, the frame of reference aligns well
behaviors that require the therapist to adapt in order to achieve with developing professional skills and behaviors.
the occupational performance of professional behavior. The first component of this frame to consider is motivation,
Using this model, we can analyze expectations for using which is influenced by reinforcement. Of course, there is a de-
evidence-based practice in the treatment of clients. Evidence- sire that motivation for therapists will be an internal desire for
based practice is a component of promoting professionalism mastery and advancement. However, the reality is that thera-
that falls under the concept of Beneficence, in that it facilitates pists can get caught in ruts and burn out over time. This is true
therapists providing the treatment that is most beneficial to the especially for those who rely primarily on the heart of profes-
client. It is also an area of treatment that many therapists do not sionalism (Wood, 2004). Therefore, reinforcement is necessary
practice on a regular basis, as evident by an average of only 14% for these therapists to continue to develop as professionals. Mo-
of knowledge translated to practice 17 years after publication tivation may come in forms of paying for continuing education
or conference costs for those who are presenting, recognizing stagnant in their profession. Occupational therapy practitioners
those who are taking steps to advance their practice, or allot- understand the importance of setting goals that are behavioral,
ting time for groups to work on evidence-based practice or measurable, and observable for clients. Professional development
conduct research. These activities promote scholarly interac- plans with clear goals and time frames facilitate the therapist’s
tion, which promotes professionalism in general but also ad- development and provide unmistakable expectations for career
dresses the mind and soul of professionalism (Wood, 2004). development. They also give the therapist a vision of themselves
Accomplishment in these activities and delivering a higher in the future, which facilitates an internal reinforcement.
quality of care to clients will also foster internal reinforce-
ment as they strive to achieve what psychologist Abraham Stage-Specific Strategies to Promote
Maslow (1968) described as self-actualization. Reinforcement
Professionalism
can also play a role in enabling maladaptive professional be-
haviors. Allowing unprofessional behavior in the workplace The process of growth as a professional has been identified
to go without being addressed, even if it is only occasional, as a stage-based developmental course that aligns with Erik
provides reinforcement to the individual that it is permissi- Erikson’s phases (as cited in Kasar & Muscari, 2000). These
ble. Consistency is vital in promoting professional behaviors; stages include
failure to address issues, even if they are occasional, sets a
■ Beginning student,
precedent for expectations.
■ Senior student,
Another concept from the behavioral frame of reference
■ New graduate occupational therapist/orientation stage,
relevant to professionalism is modeling. The manager is the
■ Graduate occupational therapist/novice,
role model for all employees whom they supervise. Role mod-
■ Role identification,
eling has been identified as an essential factor in promoting
■ Collaborative,
the development of professionalism (Schafheutle et al., 2013).
■ Proficient, and
The importance of this concept cannot be overstated. It sets
■ Reflective (pp. 46–48).
the precedent that the supervisor must engage in their own
process of professional promotion at or above the level ex- This sequential progression is also seen in occupational ther-
pected of their employees. Timeliness, etiquette, demeanor, apy students (Sullivan & Thiessen, 2015). This sequential
and all of the other components of professional behavior that process provides an understanding of expectations for pro-
were identified as the values and beliefs of occupational ther- fessional behavior at various developmental periods. It also
apy must be consistently adhered to. Failure to do so results in highlights that promoting professionalism must start with
employees modeling unprofessional behavior and a hypocrit- the student and continue through the therapist’s career, and
ical approach in the manager correcting them. different strategies should be used at the different levels. A
The final concept to draw from this frame has to do with summary of strategies for each stage identified by Kasar and
goal setting. As identified earlier, therapists can easily become Muscari (2000) is identified in Table 39.1.
TABLE 39.1. Stage-Specific Strategies for Promoting Professionalism
PROFESSIONAL STAGE STRATEGIES

Beginning Student ■ Develop a relationship between the student and teacher to model professionalism and professional relationships.
■ Educate student regarding ethics and standards of conduct in occupational therapy.
Senior Student ■ Facilitate self-learning and independence.
■ Build confidence in the student.
■ Use case studies and simulated experiences to assist the student in application of ethics and standards of conduct knowledge.
New Graduate ■ Assist the therapist in setting realistic goals.
■ Do not get frustrated with the therapist’s mistakes; facilitate self-reflection to use mistakes as a platform for learning.
■ Value and recognize the therapist’s progress.
Graduate ■ Encourage the therapist to build a professional network.
■ Encourage supervision of students to build a sense of competence.
Role Identification ■ Encourage the therapist to identify a mentor.
■ Be aware of role conflict in therapists that can lead to burnout and decreased professionalism.
Collaborative ■ Encourage attendance at professional conferences and active participation in professional organizations to expand
professional network and share knowledge.
■ Begin to build skills necessary for management responsibilities.
Proficient ■ Encourage presentations at professional conferences, participation in research, and article submission to professional magazines.
■ Facilitate them in providing education to future or new therapists.
Reflective ■ Focus on accomplishments to provide a sense of pride and fulfillment.
Intergenerational Professionalism This concept of intergenerational professionalism is im-

portant in multiple aspects of promoting professionalism.
Today’s workforce is comprised primarily of 3 categorical
A manager must recognize the communication styles of the
generations: (1) Baby Boomers, including individuals born
different groups to facilitate their interactions with others in
between 1946 and 1964, (2) Generation X, those born between
an appropriate fashion. They must work with Millennials to
1965 and 1980, and (3) Millennials, those born between
assist them in understanding how their approach to stating
1981 and 1996 (Pew Research Center, 2018). Understand-
their opinions might be viewed as disrespectful by older staff
ing the different values, beliefs, communication styles, and
while still encouraging them to provide this input to the team.
learning styles is important in promoting intergenerational
They must work with Gen Xers to prepare them for their fu-
professionalism, that is, the generational influence on com-
ture roles in management and develop their understanding of
munication and learning styles that affect an individual’s
completing all of the steps in a project.
professional behaviors. It also assists the manager in identify-
The different generations all have significant value to the
ing where conflict may occur between staff or between man-
others. The older provide the younger with knowledge on
agement and staff.
clinical skills they have gained through the years and how
Consider the following scenario: A manager, who has
to manage difficult situations. The younger generations are
been practicing occupational therapy for 30 years, holds a
more technology savvy and have been taught the steps of
team meeting to inform the therapy team that they need to
evidence-based practice that the older generations have not.
implement a certain technique related to documentation for
The manager must work with each group in developing the
ordering adaptive equipment. A young staff therapist does
awareness of intergenerational characteristics to facilitate
not understand why the manager has implemented this and
this transaction of knowledge.
believes she has a better method to accomplish this. She tells
the manager during the meeting that she might have a better
strategy. The manager listens but decides to continue with the For Additional Learning
path that they chose. The young therapist continues to ex-
plain her case as to why she thinks a different way is better. For additional learning, see Chapter 44, “Communicating Across
The manager becomes frustrated with the therapist and con- Generations and Cultures.”
siders her behavior to be unprofessional.
Gleeson (2007) identified communication and learning
Social Media in Promoting Professionalism
styles used by different generations. Baby Boomers tend to
prefer that things are documented and use small talk to build Social media plays a role in individuals’ daily lives. Twitter and
connections on a team. They value learning and educating Facebook transverse intergenerational boundaries and unify
others; however, they do not like to be “put on the spot.” Indi- people from different parts of the world. In the professional spec-
viduals in Generation X prefer streamlined written commu- trum, social media can be both destructive and constructive.
nication (i.e., bullet points) and verbal communication that is Promoting appropriate use of this medium, especially among
direct. They need to understand why the information being young practitioners, is an essential component of promoting
learned is important to them, prefer to work alone, and will professionalism. Practitioners must recognize that information
often take shortcuts to complete a task. Millennials tend to or comments made on social media represent themselves and
desire prompt feedback from their supervisors, and text mes- the profession of occupational therapy (Sau, 2013).
saging is their preferred method of communication (Barry, The transition from personal to professional use of social
2014). This method of communication tends to be more in- media can be challenging for students and young practi-
formal based on the transmission platform. tioners. I can recall the looks on my 1st-year students’ faces
Millennials have been educated to take an active voice in when I presented a PowerPoint titled “Social Media Gone
expressing their opinions and contributing to the treatment Wrong,” which included numerous questionable pictures and
team (Das, 2013). This approach deviates from prior gener- comments they had made on the Internet. Understanding
ations, who were taught that not speaking up was a compo- that posts are public is critical because it can have adverse ca-
nent of respecting authority (Phillips, 2016). As opposed to reer effects. Approximately 70% of employers conduct a social
the previous generation, Millennials often favor learning in a media search on potential candidates (Salm, 2017).
group setting (Gleeson, 2007). Social media can also have significant advantages for the
Understanding these different communication and learning professional. LinkedIn is a professional social media platform
styles assists in recognizing the generational intricacies of the that enables professionals to make connections with other
manager and young therapist. For example, the Baby Boomer professionals and can bolster a career. Creating a profile that
manager identifies the younger therapist as challenging him highlights skills and accomplishments allows potential em-
inappropriately in front of the staff. His focus is on thorough ployers to get a better understanding of the candidate and
documentation, and he wants to bring the team together in this demonstrates appropriate use of social media. Other plat-
approach. The therapist desires clarification and does not see an forms such as Twitter and Facebook also enable professionals
issue in bringing this out in a group. Both parties feel that they to establish connections and share practices. The dialogue
are correctly going about the situation based on their identified that takes place over these mediums is an example of nour-
communication patterns and styles of learning. ishing the soul of the professional without having to travel to
a conference or take a continuing education course. Groups,

such as #OTalk and #OTalk2US, have regular discussions via
Twitter with a guest tweeter who is an expert on the topic For additional learning, see Chapter 45, “Using Social Media
being discussed. Social media has also allowed the creation of Appropriately.”
communities of practice as a way of advancing the spread of
knowledge translation (Novakovich et al., 2017).
Part of promoting professionalism is helping individu-
als understand appropriate netiquette and social media use. Review Questions
Netiquette is the guidelines for social media usage that all
1. Promoting professionalism should involve immediate
therapists should be aware of (Sau, 2013). AOTA embraces so-
feedback and group work for which of the following
cial media, including hosting an annual TweetUp at AOTA’s
generations?
Annual Conference & Expo, providing resources to assist
a. Generation X
with social media use, and the establishment of the online
b. Baby Boomers
CommunOT platform. AOTA (2016) has issued an advisory
c. Millennials
statement regarding the ethical concerns with social media.
d. All of the above
It is recommended that employers create clear social
2. A manager implements a standard that all senior
media rules for their employees. The following guidelines are
therapists should submit abstracts for presentations
helpful in establishing professional social media usage:
at state conferences. Which of the following theories
■ Read over your post, and consider its level of professional- identifies that the therapists will respond to this de-
ism before posting. mand by using strategies to meet the expectation of
■ Use correct grammar in the post (Sau, 2013). management?
■ Remember that this is a public forum. Do not write or post a. Behavioral frame of reference
pictures of things that you would not want your employer b. Occupational adaptation
to see. c. Model of Human Occupation
■ Maintain your clients’ confidentiality. Disclosing protected d. Person–Environment–Occupation
health information is a violation of the Health Insurance 3. What 3 strategies can be used to promote professionalism
Portability and Accountability Act of 1996 (HIPAA; P. L. through social media?
104–191).
■ Assess if the person you are connecting to professionally
is an appropriate person to engage with on a social media
SUMMARY
platform. LinkedIn might be an appropriate medium for The concept of professionalism can be abstract and difficult
a manager and employee to connect. However, Facebook, to formulate. Promoting professionalism is a necessary func-
where an individual is recognized as a friend, might not be tion for anyone supervising occupational therapy services.
acceptable for the same connection. This chapter provided an overview of the key concepts re-
■ Managers should role model the appropriate use of social lated to professionalism. Occupational therapy theories were
media for their employees. used in understanding professional development, and specific
CASE EXAMPLE 39.1. Developing Staff Professionalism in a Rehabilitation Setting
An occupational therapy manager at a rehabilitation facility has implemented a policy that therapists should be conducting research in order to
promote professionalism among the therapy staff. The staff is comprised of occupational therapists and occupational therapy assistants ranging
in age from 25–50 years old and experience in the field ranging from 2 to 25 years. All of the practitioners are expected to play some role in the
research process. The final product is expected to be submitted for publication and presentation at a national conference.
The responses of the therapy staff varied across the different groups of practitioners. Many of the more experienced staff were frustrated
because they did not learn about research in their schooling that only required a bachelor’s degree. They expressed that they did not feel confident
in having to conduct a research project. The midrange Generation X group expressed that they did not need to do research to be proficient in their
job. Despite this grievance, several of them began to independently start collecting data on clients they were treating. The newest practitioners,
comprised of Millennials, wanted to gain a better understanding of the expectations and were concerned about conflict with the older therapists,
resulting in a lack of communication among the groups.
As a result of the tension created within the department, the manager decided that the department would organize into groups comprised of
various experience levels. Each group would conduct one research study.
Review Questions
1. What roles would each generation of practitioners take in the implementation of the research project?
2. What communication techniques should the manager use in explaining the process to the different staff groups?
3. Identify what social media sites staff could use to share their research. Write a professional post explaining the research that was conducted.
strategies for the various developmental levels of therapists Cole, M. B. (2018). Group dynamics in occupational therapy: The
were provided. The concepts of intergenerational professional theoretical basis and practice application of group intervention
ism and the professional use of social media were discussed. ❖ (5th ed.). Thorofare, NJ: Slack.
Cruess, R., McIlroy, J. H., Cruess, S., Ginsburg, S., & Steinert, Y.
(2006). The Professionalism Mini-evaluation Exercise: A prelim-
ACOTE STANDARDS inary investigation. Academic Medicine, 81(Suppl. 10), S74–78.
https://doi.org/10.1097/00001888-200610001-00019
This chapter addresses the following ACOTE Standards: Das, R. (2013). Audiences: A cross-generational dialogue. Commu
nication Review, 16(1/2), 3–8. https://doi.org/10.1080/10714421
■ B.4.25. Principles of Interprofessional Team Dynamics
.2013.757162
■ B.5.8. Supervision of Personnel. Freidson, E. (1999). Theory of professionalism: Method and
substance. International Review of Sociology, 9(1), 117–129.
https://doi.org/10.1080/03906701.1999.9971301
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Sullivan, T. M., & Thiessen, A. K. (2015). Occupational therapy 37–42. https://doi.org/10.4276/030802213X13576469254739
students’ perspectives of professionalism: An exploratory study. Wood, W. (2004). The heart, mind, and soul of professionalism in
Open Journal of Occupational Therapy, 3(4), 1–17. https://doi.org occupational therapy. American Journal of Occupational Therapy,
/10.15453/2168-6408.1154 58(3), 249–257. https://doi.org/10.5014/ajot.58.3.249
CHAPTER
Providing Constructive Feedback
Jeanette Koski, OTD, OTR/L 40
LEARNING OBJECTIVES
■ Define key terms relative to providing feedback,
■ Understand elements of a safe feedback environment,
■ Apply the concept of mutual goals in feedback situations, and
■ Use a feedback model to analyze a feedback scenario.

• Constructive feedback • Formative feedback • Reflective feedback model
• Culture • Informal feedback • Self-efficacy
• Destructive feedback • Mutual goals • SKS method
• Feedback • PEARLS approach • Summative feedback
• Formal feedback • Pendleton model • Transformative learning model
OVERVIEW I felt inadequate and unsupported. I have also been in situ-

ations where I gave feedback. Early in my career, I tended to
S
killed feedback provision is a challenge for many approach these situations in a nervous state because either
managers. Understanding the elements of feedback the situation was an emotional one for me or I was afraid of
and how to facilitate the feedback process will help the receiver’s potential response.
managers build a supportive, positive, and progressive work A great deal of an occupational therapy manager’s effort
environment for all team members. Using the transformative goes toward fostering individual professional development,
learning model and mutual goals, an occupational therapy team cohesiveness, and achievement of organizational ob-
manager can delve deeper into barriers to goal attainment jectives. Giving feedback is a basic element of these respon-
and guide the process of generating solutions to employee sibilities; however, many people struggle with this essential
performance concerns. This chapter presents several feed- communication task. As I did in my early experiences, they
back models as options for managers to structure feedback approach feedback situations with trepidation and have a diffi-
situations and facilitate positive outcomes for all parties. cult time separating emotional reactions from the facts of per-
formance. The good news is that giving feedback well is a skill
ESSENTIAL CONSIDERATIONS and therefore can be learned, practiced, and honed over time.
I had a colleague tell me once that she hated the word feed-
Defining Feedback
back because it always meant that she was about to get crit-
icized and she’d never had a positive feedback experience. Distilled, feedback is defined as information that promotes
I listened sympathetically because I, too, had received feed- learning or provides an achievement summary about a person
back in my life framed in a way that felt disparaging. The neg- or performance (Branch & Paranjape, 2002). Many variables
atively framed critique did not motivate me to make changes can be modulated to improve the efficacy of both the delivery
to my work; rather, I felt like giving up on the job because and reception of feedback. For the purposes of this chapter,
https://doi.org/10.7139/2019.978-1-56900-592-7.040
377
CHAPTER
Providing Constructive Feedback
Jeanette Koski, OTD, OTR/L 40
LEARNING OBJECTIVES
■ Define key terms relative to providing feedback,
■ Understand elements of a safe feedback environment,
■ Apply the concept of mutual goals in feedback situations, and
■ Use a feedback model to analyze a feedback scenario.

• Constructive feedback • Formative feedback • Reflective feedback model
• Culture • Informal feedback • Self-efficacy
• Destructive feedback • Mutual goals • SKS method
• Feedback • PEARLS approach • Summative feedback
• Formal feedback • Pendleton model • Transformative learning model
OVERVIEW I felt inadequate and unsupported. I have also been in situ-

ations where I gave feedback. Early in my career, I tended to
S
killed feedback provision is a challenge for many approach these situations in a nervous state because either
managers. Understanding the elements of feedback the situation was an emotional one for me or I was afraid of
and how to facilitate the feedback process will help the receiver’s potential response.
managers build a supportive, positive, and progressive work A great deal of an occupational therapy manager’s effort
environment for all team members. Using the transformative goes toward fostering individual professional development,
learning model and mutual goals, an occupational therapy team cohesiveness, and achievement of organizational ob-
manager can delve deeper into barriers to goal attainment jectives. Giving feedback is a basic element of these respon-
and guide the process of generating solutions to employee sibilities; however, many people struggle with this essential
performance concerns. This chapter presents several feed- communication task. As I did in my early experiences, they
back models as options for managers to structure feedback approach feedback situations with trepidation and have a diffi-
situations and facilitate positive outcomes for all parties. cult time separating emotional reactions from the facts of per-
formance. The good news is that giving feedback well is a skill
ESSENTIAL CONSIDERATIONS and therefore can be learned, practiced, and honed over time.
I had a colleague tell me once that she hated the word feed-
Defining Feedback
back because it always meant that she was about to get crit-
icized and she’d never had a positive feedback experience. Distilled, feedback is defined as information that promotes
I listened sympathetically because I, too, had received feed- learning or provides an achievement summary about a person
back in my life framed in a way that felt disparaging. The neg- or performance (Branch & Paranjape, 2002). Many variables
atively framed critique did not motivate me to make changes can be modulated to improve the efficacy of both the delivery
to my work; rather, I felt like giving up on the job because and reception of feedback. For the purposes of this chapter,
https://doi.org/10.7139/2019.978-1-56900-592-7.040
377
examples refer to a situation where 2 parties are involved in them as a professional. It is essential for the giver to be mind-
any interaction involving feedback: the giver and the receiver. ful of the receiver’s self-efficacy when providing feedback.
Feedback given at different intervals may have variable Destructive feedback falls short of this goal in that it tends
outcomes and therefore can be conceptualized as either for- to be judgmental and directed at personal qualities instead of
mative or summative. Formative feedback is characterized as job performance. Constructive feedback is based on objec-
a low-stakes comparison of current performance to goals or tive information and related to performance rather than the
objectives and is meant to facilitate improvement by provid- person. In contrast, the term constructive should indicate that
ing status of achievement. Summative feedback is a report of the feedback would build up the giver; however, constructive
goal achievement and therefore the stakes are higher for both feedback delivered in a frustrated, harsh, sarcastic, or other-
the giver and receiver (Cantillon & Sargeant, 2008). wise emotional tone of voice can lead to decreased self-esteem
Another type of feedback is formal feedback. Most managers and a decline in performance (Sarkany & Deitte, 2017).
are required to give formal feedback (Branch & Paranjape, 2002)
at least annually as part of the summative performance review
Self-Efficacy
process. However, additional opportunities to provide formal
feedback include sharing information from patient satisfaction Self-efficacy describes an individual’s perception of their
surveys, synthesizing peer reviews of an employee, and present- own likeliness for success. In any given situation, a person’s
ing employee awards or recognition. Formal feedback situa- self-efficacy will determine whether they will initiate coping
tions, like those just described, can be contrasted with informal strategies, how much effort will be directed toward a complex
feedback, which is not structured and is generally task specific task, and how long a person will persist in the face of a chal-
and situated in the context of the task or daily work practices. lenge (Bandura, 1977). Success, vicarious experiences such
Regardless of the formality of the format, information as viewing another’s success or failure, and external encour-
transmitted nonverbally during a feedback session should agement or discouragement (verbal persuasion) can increase
not be discounted. William Carlos Williams is credited with or decrease self-efficacy, respectively. According to Bandura
stating, “It is not what you say that matters but the man- (1977), the effect of verbal persuasion is less substantial than
ner in which you say it; therein lies the secret of the ages” personal success or vicarious experience.
(Azquotes.com, n.d.). Sources vary with respect to actual per- A person with low self-efficacy may also be affected by psy-
centages, but all agree that most day-to-day communication chological stress. Bandura (1977) noted that a person with high
happens nonverbally (Mehrabian, 1981). Therefore, the im- self-efficacy will interpret stress-related body responses as nor-
portance of nonverbal communication during formal or in- mal or unrelated to feedback. This is in contrast to a person with
formal feedback should be recognized and maximized. Facial low self-efficacy who may feel that the physiological reactions to
expressions, body posture, and contextual factors in the en- stress are a manifestation of additional personal shortcomings.
vironment can all contribute to the tone of the feedback and Therefore, a person who has low self-efficacy who experi-
contribute to the receiver’s perception of the giver’s intent. ences failure, receives destructive feedback, or has negative
vicarious experiences may then be subject to a further de-
crease in self-efficacy. A downward spiral of negativity, given
For Additional Learning the definition of self-efficacy, may be difficult for this person
to surmount. Therefore, people with low self-efficacy may
For additional information on working with members of different
need more support and carefully constructed feedback to ex-
generations, see
perience success in achieving goals.
■ Chapter 39, “Promoting Professionalism,” and A manager should be adept in the strategies identified by
■ Chapter 44, “Communicating Across Generations and Cultures.” Mackay (2007) to positively affect a person’s self-efficacy:
■ Accepting and valuing the employee as an individual with
Feedback Focus unique strengths;
Feedback is most effective and useful when it is goal related,
■ Praising performance in a sincere and specific way, giving
examples of positive behavior;
which means the feedback is used to help the receiver com-
pare their actual performance with the goal. Additional con-
■ Appreciating individual achievement or performance of
the team or program goals;
siderations include ensuring a safe environment; ensuring
that the feedback is accurate, factual, and useful; and ensur-
■ Encouraging employees to take ownership of errors and
credit for corrective action; and
ing that feedback supports goal achievement (Feys et al., 2008;
Kinicki et al., 2004; Sadler, 1989; Sarkany & Deitte, 2017).
■ Reassuring an employee after an error and providing on-
going support toward correction.
Each consideration is elaborated on in this chapter as con-
cepts and strategies are presented.
Setting the Stage for Accurate, Factual,
Creating a Safe Environment Useful Feedback
For feedback receivers to feel safe, they need to know that Accurate, factual, and useful feedback is best received when
feedback is coming from a person who cares and supports both the giver and the receiver are open to the process as a
CHAPTER 40. Providing Constructive Feedback 379
stepping-stone for improved performance. A challenge of related to this skill and Kent has not asked for continuing ed-
giving constructive feedback can be ensuring that feedback is ucation (CE) funds or time off for either (fact). Sylvia might
based on behavior rather than personal factors. As discussed feel (emotion) that Kent is lazy and seems to require extra
earlier, if the giver feels an emotional reaction to the receiver, encouragement to get things done. Sylvia also acknowledges
the situation, the feedback process, or a combination of these that the budget allows for only $300 of CE money, which
factors, constructive feedback can be perceived as a personal is enough to cover the cost of a course but would not cover
attack and can potentially decrease the receiver’s self-efficacy. travel expenses (fact).
Directing the receiver to performance goals, department Second, the receiver reflects on their assumptions. Con-
goals, or professional development goals will ensure that the tinuing with the professional development example, Kent
giver and receiver feel the shared investment in the outcome. notes that although the goal of learning a new treatment
Identifying mutual goals (Patterson et al., 2012) is an aspect of technique is important, his current skill set is still developing
setting the stage for giving feedback. Additional considerations (fact), and he is nervous (emotion) about his ability to pro-
include reflection on the part of both parties, timeliness of feed- vide care at his current level. Kent also reflects that he is the
back, and creating a culture of feedback in the organization. sole support of a family of 4, so despite adequate professional
development funds for course registration, he does not have
personal funds to cover the cost of travel (fact). Kent also fears
Mutual goals (emotion) that Sylvia will be disappointed in his skill set and
Mutual goals are outcomes that have meaning and value to will judge him unfairly because he is struggling financially.
involved parties. The concept of mutual goals is expansive in The third part of the transformative model involves both
that the identified objective can be specific or general and is parties. Both giver and receiver perceive any given situation
agreed on by both parties. For example, a giver might cite a or set of circumstances based on “mental models related to
general departmental goal as the target for behavioral change: internal frames of reference” (Sarkany & Deitte, 2017, p. 741);
“As a team we are working toward ensuring quality of care for this explains why, in any given situation, perceptions vary
our clients.” Another approach could be to cite a specific pro- and may or may not be known to the other party. In other
fessional goal of the receiver to pinpoint the feedback more words, emotions often lead people to make assumptions. In
closely: “You had identified at the first of the year that you the professional development example, it would be import-
wanted to increase your practice of [a particular treatment ant for Sylvia to separate her emotional response (frustra-
method] to become a more skilled occupational therapist.” tion) to Kent from the facts (CE covers only so much, more
When identifying the mutual goal, the goal must carry mean- opportunities might be offered in the future). Kent will also
ing and motivate both the giver and receiver; as a result, both need to identify which of his responses are emotional and
parties will use the feedback to take corrective action. which are factual. After both parties’ assumptions have been
identified, factual information can be shared between both
parties, and feedback can be structured around behaviors in-
Reflection stead of emotions.
The preceding 3 parts flow into the last part, developing
As part of setting the stage for providing feedback, it is im-
strategies, which happens naturally in this environment of
portant for the giver and receiver to reflect on their percep-
collaboration and mutual understanding.
tions about the situation. What are the facts of the situation
and what are the emotional reactions that each party is ex-
periencing? This step is essential for delineating between ac-
Timeliness
tuality and sentiment in any given interaction or situation.
Educational literature provides a useful tool for this purpose, Constructive feedback should be provided in a timely fashion,
the transformative learning model. This model focuses on de- but that does not mean hastily; rather, it refers to a time when
veloping a foundation of insight and understanding essential all information has been gathered and after parties have had
for taking effective social action (Mezirow, 2008). a chance to reflect (Branch & Paranjape, 2002). Timeliness
The transformative learning model is characterized as can be interpreted in several ways and may vary situationally.
constructivist in that the learner’s experience is central to how Some feedback needs to be provided in the moment if imme-
the learner makes meaning and therefore learns (Mezirow, diate correction is needed (e.g., a client’s safety is in jeopardy).
2008). The transformative learning model consists of 4 parts However, timeliness could also refer to information provided
that involve both the giver and receiver in any given feedback at developmental intervals (e.g., providing reminders of pro-
situation. fessional goals before a summative annual review or provid-
First, the giver reflects on their perceptions and identifies ing resources that will aid in professional goal achievement).
bias, emotional reactions, and the facts of the case. Let us con- An additional aspect of timeliness is the amount of feed-
sider an example in which the mutual goal is for the receiver back provided at any given time. In other words, the giver
to develop treatment skills. In this scenario, the giver is Sylvia should be mindful of providing too much feedback at once.
and the receiver is Kent. Sylvia feels frustrated (emotional Information should be given in manageable units (Schartel,
reaction) that although Kent has this goal, no progress has 2012) according to factors related to the receiver such as
been made. Sylvia also notes that 2 courses have been offered learning style, self-efficacy, and complexity of the problem.
Feedback culture This model, along with the Pendleton model, is simple and
therefore easy to apply in informal formative feedback situa-
Culture is the shared patterns of behavior in a particular
tions. As with all the models in this section, the giver should
group. If an organization’s culture includes an expectation
keep in mind the principles discussed earlier in the chapter:
of positive and constructive feedback provided regularly,
being mindful of nonverbal communication, ensuring that
formally and informally, and across the board (Sarkany &
the feedback is relevant to performance, and so on.
Deitte, 2017), everyone in the organization is more likely not
only to openly receive but also to provide feedback. Manag-
ers who are transparent about their own strengths and areas Formal feedback models
for growth; dedicated to the common goal; and model giving, The reflective feedback model (Cantillon & Sargeant, 2008)
receiving, and incorporating feedback are more likely to have is similar to the Pendleton model but provides more struc-
employees who emulate these qualities (Sarkany & Deitte, ture for both the giver and receiver. It is essential with this
2017). Managers also create a culture of feedback when they model that the giver have the skill to facilitate reflection and
set up clear and reasonable expectations and are perceived as be perceived by the receiver as a trustworthy feedback source,
a confident, nonjudgmental, and credible source of feedback as discussed in the “Creating a Safe Environment” section
(Branch & Paranjape, 2002; Sarkany & Deitte, 2017). (Branch & Paranjape, 2002).
Although this model is sequential, any of the steps can be
Feedback Models repeated to gain additional understanding:
Several models offer different ways of structuring feedback, ■ Step 1. The giver asks the receiver to share their concerns
and all of them incorporate concepts covered in the previ- about the completed performance.
ous sections of this chapter. All of these models can be used ■ Step 2. The receiver shares, and the giver provides the
during formative or summative situations, but certain mod- receiver with their view on the performance and offers
els may lend themselves to individual feedback opportunities support.
better than others. The giver should select the model that ■ Step 3. The giver asks the receiver to reflect on and identify
works best for the receiver and fits best with the giver’s style. what could be done differently to improve performance.
Four models are presented in this chapter: 2 informal feed- ■ Step 4. After the receiver responds, the giver elaborates on
back models (the Pendleton model and the SKS method) and and possibly corrects the response.
2 models for more formal feedback situations (reflective feed- ■ Step 5. The giver checks for receiver understanding.
back model and the PEARLS approach). Sample questions and statements to facilitate reflection in-
clude, “Help me understand your reasoning.” “How did your
Informal feedback models plan work?” “What went differently than you anticipated?”
“Were you able to achieve your aim?” “What would you do
Pendleton et al. (2003) developed the Pendleton model. This
differently next time?” “Say more about that.” “What did you
model, developed for a classroom setting, has applicability in
mean by that?”
a variety of feedback situations:
The PEARLS approach (Milan et al., 2006) is described in
■ In Step 1, the receiver states what was good about their the mnemonic below. This approach is not sequential; rather,
performance. it describes elements that should be present in all feedback
■ In Step 2, the giver states areas of agreement and elabo- situations.
rates on good performance.
■ Partnership for joint problem solving: This concept de-
■ In Step 3, the receiver states what was poor or could have scribes the collaboration of both the giver and receiver
been improved.
and how mutual goals fit well within this element of the
■ In Step 4, the giver states what they think could have been process.
improved.
■ Empathic understanding: The giver needs to view the re-
At each step, the giver provides the receiver with prompts ceiver with empathy when listening to the receiver’s reflec-
to help the receiver to understand the process. The focus of tions during the feedback process.
this model is mainly reflection and does not include anything ■ Acknowledgement of barriers to the receiver’s progress: In
about goals. most situations, contextual features exist that are out of
The SKS method developed by Sarkany and Deitte (2017) the receiver’s control that may present barriers to goal
is simple to recall during informal, in-the-moment feedback. achievement. The giver should acknowledge these and at-
The acronym (SKS) is also the method: Stop doing, Keep tempt to either help the receiver overcome the barriers or
doing, Start doing. In other words, the giver asks the receiver consider them as a part of the assessment.
to stop doing a behavior, keep doing a behavior, and start ■ Respect for the receiver’s values and choices: Respecting
doing a behavior. Similar to the sandwich method of flanking values takes nonjudgment a step further and should dove-
constructive feedback with 2 positive forms of feedback, the tail with the reflection process.
SKS method suggests that the giver weigh the constructive ■ Legitimization of feelings and intentions: The receiver may
feedback with a positive in the middle. have fallen short of goals or need feedback to get on track
with goal achievement despite having made efforts. The PRACTICAL APPLICATIONS IN
giver should acknowledge the receiver’s efforts when pro- OCCUPATIONAL THERAPY
viding feedback about performance.
■ Support for efforts at correction: Feedback should be con- Situating Feedback Performance
tinuous; once the receiver begins to address the problem, Appraisal Context
the giver should provide ongoing acknowledgment of the
According to Braveman (2016), the performance appraisal
receiver’s efforts.
has 4 parts: (1) assessment (review of job description, em-
ployee self-assessment, and employer assessment), (2) per-
Supporting Goal Achievement formance planning (setting goals, identifying resources),
(3) intermittent review (formative), and (4) accomplishment
Feedback should inform the receiver’s efforts toward goal
review (summative). Feedback techniques discussed in this
achievement. Whether provided informally or formally, in
chapter can facilitate effective performance review processes,
a formative or summative situation, the information should
particularly at the intermittent review and accomplishment
identify barriers, provide resources, and support the receiver’s
review stages.
ongoing efforts to achieve the mutual goals (Ende, 1983;
After gathering all applicable information about the em-
Schartel, 2012; Shute, 2008). A skilled giver will facilitate the
ployee’s performance, the manager and employee meet to set
receiver’s development of their own plan.
mutual goals. At this time the manager needs to make explicit
Using the earlier example of Sylvia and Kent, let us apply
that feedback is provided at intervals to establish the culture
the concept of using the feedback process to support goal
of feedback. The employee then proceeds to work on the goals
achievement. Sylvia and Kent have a mutual goal of Kent
until the intermittent review and accomplishment review
increasing his skill in treatment. Both Sylvia and Kent have
process. At each formal interval and during opportunities
shared their reflections on the problem of Kent not achieving
for informal feedback, the manager can watch for and assess
this goal, as related above. Sylvia has recognized the barrier
the employee’s self-efficacy and ensure a safe feedback envi-
of the continuing education budget and Kent’s personal fi-
ronment by attending to nonverbal communication during
nancial constraints. At this point Sylvia can identify other
interactions.
potential sources to supplement continuing education funds
When providing formal feedback in the summative and
that Kent may not be aware of, such as grants provided by
formative phases, the manager can apply feedback mod-
the corporation they work for, or perhaps Sylvia is aware that
els such as the reflective feedback model or the PEARLS
the course will be offered locally in 2 years and is willing to
approach (see Case Example 40.1).
extend the goal due date.
If Sylvia were to offer this second option, she would also
want to ensure that Kent was working toward the goal in Review Questions
smaller increments until he takes the course. She would facil-
1. Give a specific example of how a manager could establish
itate Kent’s problem solving by asking him to formulate ideas
a positive culture of feedback in the performance review
about how he could work on smaller steps to learn about this
process.
treatment method. Kent might note that he could do a litera-
2. Describe an example of providing informal feedback
ture search and present information to the team, or he might
to an employee between the formative and summative
identify a mentor whom he can shadow as an apprentice.
phases using the SKS model.
If Kent were unable to come up with solutions, Sylvia could
3. How might you facilitate reflection during the formative
prompt him with possible solutions and ask him to determine
review phase if the employee is not on track to meet goals?
which would be most realistic for his individual situation or
how he might tailor her suggestions to meet his personal situ-
ation. Once the solutions were determined, Sylvia would pro-
vide ongoing feedback by checking in periodically with Kent
SUMMARY
and providing verbal or resource support as needed. This on- Giving constructive feedback well is based on a foundation
going support is essential to ensure that the receiver and the of elements that are best established early and developed over
giver maintain the open channel of communication, thereby time. A manager should assess an employee’s self-efficacy and
reinforcing the culture of feedback. attend to their nonverbal communication as part of creating
a safe environment for feedback. Using mutual goals as the
basis for providing feedback ensures that the employee is able
Review Questions
to compare their current performance with the goal. Devel-
1. What are the features of the transformative learning oping skills related to facilitating reflection and providing
model? feedback at the optimal time are also foundational to creat-
2. This chapter suggests several questions a manager can use ing a safe environment. Application of any of the feedback
to facilitate reflection. Generate 1 additional question that models presented here will have more successful outcomes in
could be used for this purpose. the context of a supportive, factual, and goal-oriented work
3. Develop a personal definition of empathic understanding. setting. ❖
CASE EXAMPLE 40.1. Application of the Reflective Model of Feedback
After 3 years of satisfactory performance, an employee begins to display a negative attitude through the following behaviors:
■ Late to work at least once per week
■ Often leaving before seeing all of her daily patients
■ New concerns raised by colleagues about her interactions with patients (sharp, unfriendly tone)
■ New concerns raised by colleagues about her language and tone with other staff members (sharp, negative comments about staff and patients)
■ Late charting being completed beyond the policy timelines.
Because this was a change in communication style and behavior patterns, the manager met with the employee to discuss the concerns.
Step 1: The giver asks the receiver to share their concerns about the completed performance.
The manager used guiding questions to ask the employee if she noticed anything different about her work or relationships with the staff and
patients. This gave the employee a forum to talk about any problems or issues she was having.
Step 2: The receiver shares, and the giver provides the receiver with their view on the performance and offers support.
The employee opens up, stating that she was frustrated with her job role, not the organization or patient population. She stated that she did not
enjoy health care and felt she had made a mistake in pursuing her degree in a therapy field. She had discovered her true passion was geology.
The manager then talked about some specific examples of the employee’s current performance that were having a negative impact on the team,
the patients, and the unit.
Step 3: The giver asks the receiver to reflect on and identify what could be done differently to improve performance.
The manager and employee began to formulate a plan to look at local academic programs that would allow the employee to work full-time and
pursue a new direction academically. After these personal goals were stated and solutions were jointly identified, the manager asked the employee
to identify what could be done in the short term to meet the departmental goals.
Step 4: After the receiver responds, the giver elaborates on and possibly corrects the response.
The employee stated that she felt she could meet the departmental objectives better now that she was able to envision a different future for herself.
Step 5: The giver checks for receiver understanding.
The manager asked her to check in with him informally every month so he could continue to support her efforts toward immediate correction of the
problems and to provide additional support of her long-term goals.
Within 6 months, the employee had entered a new academic program and altered her work schedule to be more weekend oriented. Her work
performance improved dramatically, and for the next 2 years, she was a model employee with only positive feedback from staff and patients.
Review Questions
1. Describe how the manager demonstrated his understanding of the employee’s values.
2. How did the manager apply the concept of mutual goals in this scenario?
3. Describe how the manager supported the employee’s long-term and short-term goal achievement.
ACOTE STANDARDS Braveman, B. (2016). Leading and managing occupational therapy

services: An evidence-based approach (2nd ed.). Philadelphia:
This chapter addresses the following ACOTE Standard: F. A. Davis.
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CHAPTER
Working With Occupational Therapy Assistants
Heather Thomas, PhD, OTR/L 41
LEARNING OBJECTIVES
■ Describe the educational background and requirements of the occupational therapy assistant (OTA),
■ Identify the OTA’s role in evaluation and intervention,
■ Distinguish how service competency and state regulations influence the delegation of service provision to the OTA,
■ Relate the ethics and regulations associated to the OTA’s role in intervention progression and discontinuation of
services,
■ Differentiate the different levels of supervision of the OTA and when they would be used, and
■ Recognize and value the managerial and leadership roles the OTA may assume.

• Accreditation Council of • Indirect supervision • Service competency
Occupational Therapy Education • Minimal supervision • State licensure regulations
• Close supervision • Minimum supervision (or laws)
• Direct supervision • Occupational therapy assistant
• General supervision • Routine supervision
OVERVIEW provided are safe and effective in enabling clients to success-

fully engage in meaningful occupations. As the title therapy
O
ccupational therapy assistants (OTAs) provide an es- assistant (not therapist’s assistant) implies, the role of the
sential role in the occupational therapy profession. To OTA is to “deliver occupational therapy services under the
provide safe and effective services, occupational ther- supervision of and in partnership with an occupational ther-
apists (OTs) and OTAs must follow ethical and regulatory apist” (American Occupational Therapy Association [AOTA],
requirements. Both OTs and OTAs must be aware of these 2014b, p. S1). OTs and OTAs work together to establish a plan
requirements and their role in meeting them. This chapter for supervision, enacting that plan as required by state and
guides readers through the background and educational re- federal regulations as well as funding source requirements.
quirements of an OTA; describes the role of OTAs in service
provision, supervision, and delegation; and provides strate-
gies for building a collaborative supervisory relationship. OTA Education and Training
Becoming an OTA requires completing an associate’s de-
gree (or bachelor’s degree) in occupational therapy at a
ESSENTIAL CONSIDERATIONS school accredited by the Accreditation Council of Occu-
In 1956, the title of occupational therapy assistant was created
to help address the increased need for occupational therapy
®
pational Therapy Education (ACOTE ), the organization
that determines the education requirements for and gov-
professionals (Cottrell, 2000). Since then, OTs and OTAs have erns accreditation of all occupational therapy programs;
worked together to ensure that occupational therapy services completing 16 weeks of Level II fieldwork; passing the
https://doi.org/10.7139/2019.978-1-56900-592-7.041
385
CHAPTER
Working With Occupational Therapy Assistants
Heather Thomas, PhD, OTR/L 41
LEARNING OBJECTIVES
■ Describe the educational background and requirements of the occupational therapy assistant (OTA),
■ Identify the OTA’s role in evaluation and intervention,
■ Distinguish how service competency and state regulations influence the delegation of service provision to the OTA,
■ Relate the ethics and regulations associated to the OTA’s role in intervention progression and discontinuation of
services,
■ Differentiate the different levels of supervision of the OTA and when they would be used, and
■ Recognize and value the managerial and leadership roles the OTA may assume.

• Accreditation Council of • Indirect supervision • Service competency
Occupational Therapy Education • Minimal supervision • State licensure regulations
• Close supervision • Minimum supervision (or laws)
• Direct supervision • Occupational therapy assistant
• General supervision • Routine supervision
OVERVIEW provided are safe and effective in enabling clients to success-

fully engage in meaningful occupations. As the title therapy
O
ccupational therapy assistants (OTAs) provide an es- assistant (not therapist’s assistant) implies, the role of the
sential role in the occupational therapy profession. To OTA is to “deliver occupational therapy services under the
provide safe and effective services, occupational ther- supervision of and in partnership with an occupational ther-
apists (OTs) and OTAs must follow ethical and regulatory apist” (American Occupational Therapy Association [AOTA],
requirements. Both OTs and OTAs must be aware of these 2014b, p. S1). OTs and OTAs work together to establish a plan
requirements and their role in meeting them. This chapter for supervision, enacting that plan as required by state and
guides readers through the background and educational re- federal regulations as well as funding source requirements.
quirements of an OTA; describes the role of OTAs in service
provision, supervision, and delegation; and provides strate-
gies for building a collaborative supervisory relationship. OTA Education and Training
Becoming an OTA requires completing an associate’s de-
gree (or bachelor’s degree) in occupational therapy at a
ESSENTIAL CONSIDERATIONS school accredited by the Accreditation Council of Occu-
In 1956, the title of occupational therapy assistant was created
to help address the increased need for occupational therapy
®
pational Therapy Education (ACOTE ), the organization
that determines the education requirements for and gov-
professionals (Cottrell, 2000). Since then, OTs and OTAs have erns accreditation of all occupational therapy programs;
worked together to ensure that occupational therapy services completing 16 weeks of Level II fieldwork; passing the
https://doi.org/10.7139/2019.978-1-56900-592-7.041
385
National Board for Certification in Occupational Ther- OTA Role

®
apy (NBCOT ) exam; and obtaining state licensure in the
states in which the OTA plans to work. The rigors of an
OTAs and OTs work together through all phases of the occu-
pational therapy process to assist clients in meeting their oc-
ACOTE-accredited OTA program prepare graduates to
cupational therapy goals. The scope to which OTAs can deliver
apply and enact occupational therapy principles in a vari- specific aspects of occupational therapy services is outlined in
ety of practice settings and use evidence-based interventions AOTA’s (2014a) Guidelines for Supervision, Roles, and Respon-
with individuals experiencing physical, sensory, cognitive, sibilities During the Delivery of Occupational Therapy Services
or psychosocial impairments that limit engagement in ev- and in state and funding regulations. All 50 states, the District
eryday activities (ACOTE, 2018). of Columbia, Puerto Rico, and Guam have licensure laws for
Coursework in an OTA curriculum includes biological, occupational therapy practitioners. Although AOTA docu-
physical, social, and behavioral sciences; basic tenets of occu- ments provide helpful guidelines, state laws supersede these
pational therapy; contexts of service delivery; screening and standards and must be followed when occupational therapy
assessment; intervention implementation; scholarship; man- services are provided under their jurisdiction. Medicare and
agement concepts; and professional ethics (AOTA, 2014b). other funding sources may also have regulations regarding
Students are prepared to implement service delivery under the the OTA’s role in service provision and what supervision must
direction of an OT and are educated on how to take responsi- take place. OTs and OTAs must abide by those guidelines and
bility for their role in the supervisory process (ACOTE, 2018). regulations that are most stringent (Foster & Smith, 2016).
According to AOTA (2015c), OTA education provides diver- During the initial evaluation process, the OT must direct
sity in the workforce by offering the opportunity to enter the all aspects of the occupational therapy evaluation. Although
profession with a reduced time commitment to a broader the OT can direct the OTA to use specific assessments or
spectrum of the population because OTA academic programs screening tools to collect information regarding the client,
are typically located in institutions within communities that the OT must be the one to initiate the evaluation and deter-
serve a diverse student body. mine the need for service. The OT determines what data are
Part of an OTA education includes teaching future OTAs to be collected and which assessment tools are to be used. On
the basis of state regulations, the OT may delegate the collec-
how they can contribute to the evaluation process. Under
tion of data using standardized or nonstandardized assess-
the direction of the OT, OTAs can administer standard-
ment tools (some states allow only standardized assessments
ized and nonstandardized screening and assessment tools
to be delegated to the OTA).
(ACOTE, 2018). OTA students learn that they can collect
The OTA can provide the supervising OT written or verbal
and report assessment data, and the OT then interprets and information regarding the assessment or screening data as
reports the data from those assessments. Although educa- well as any observations of the client’s capacities and behav-
tional standards prepare OTAs with the skills necessary to iors. The OT then interprets this information and establishes
contribute to the evaluation, competency and state licensure the client’s goals, intervention priorities, and intervention
regulations (or laws) (a government-issued legal document plan. The OT and OTA can collaborate on this plan; however,
detailing requirements for practice for a particular state) dic- it must be the OT who documents the evaluation and sub-
tate what OTAs are able to contribute to the service delivery sequent intervention plan. The OTA is responsible for being
process (discussed later in the chapter). Understanding the aware of all evaluation results and intervention plans, col-
depth of occupational therapy education provides perspec- laborating with the OT to provide input to each client’s plan
tive regarding the foundation each practitioner gains before as appropriate (AOTA, 2014a). Case Example 41.1 illustrates
entering the profession. how this process can be challenged in practice.
CASE EXAMPLE 41.1. Joe: Evaluation Process Challenge
Joe is an OTA in a subacute unit of a small community hospital where he is supervised by Sara, an OT. Sara was on vacation when an order for
an occupational therapy evaluation for a patient with a hip replacement was sent to the occupational therapy department. The order was received
on a Thursday night, and Sara would not return from vacation until Monday. The doctor who wrote the order asked Joe to initiate the evaluation,
stating, “It is just a standard hip replacement” and requested, “Just tell me what equipment she needs.” The patient was going to be discharged
over the weekend, and Joe knew that if he did not provide this patient with occupational therapy, she would not receive any occupational therapy
services before being discharged home.
According to AOTA guidelines and state practice acts, an OTA cannot initiate an occupational therapy evaluation. Joe needed to notify his
supervisor of the urgent matter so another OT could be contacted to provide the necessary services. It is the OTA’s responsibility to understand
the law and supervisory requirements and follow them, despite any other professional’s requests. In instances where the manager or staffing
coordinator is unaware of the scope of practice for an OTA or the supervisory requirements, the OT or OTA should be prepared to provide a copy
of any and all regulations as they relate to the state and setting in which they will be providing services (Foster & Smith, 2016).
CHAPTER 41. Working With Occupational Therapy Assistants 387
Review Questions intervention techniques or modalities. Some states that re-

quire this grant advanced certification to OTAs, while others
1. Describe the differences between OT and OTA education.
do not and require the OTA be supervised by an OT who is
2. What determines what an OTA can do during each as-
certified to provide that intervention technique or modality.
pect of service provision?
Although an OTA may be knowledgeable of a particular in-
3. Who is responsible for being aware of the legal and ethi-
tervention method, state law may prohibit them from imple-
cal implications of OTA supervision?
menting this without supervision by an OT who is certified to
4. What actions should an OTA or OT take if a manager or
provide this intervention method.
supervisor is requesting services or supervision beyond
For example, in California, OTs are required to have advanced
legal or ethical guidelines?
practice certification to provide hand therapy; address swallow-
ing; or use physical agent modalities (PAMs), such as hot packs,
ultrasound, or electric stimulation. If a seasoned OTA who is
PRACTICAL APPLICATIONS IN proficient in the use of hot packs is not supervised by an OT who
OCCUPATIONAL THERAPY has advanced practice certification in PAMs, the OTA would not
Delegation be able to use hot packs. Even if state regulations do not specify
this, according to the AOTA position paper on the use of PAMs,
Both group and individual occupational therapy interven- only those OTs who have competency in the use of these modali-
tion can be provided by either an OT or OTA, as determined ties may supervise an OTA using them (AOTA, 2012).
by the supervising OT. Ultimately, the OT is responsible for As intervention progresses, it is the OT’s responsibility
all aspects of intervention and thus must delegate only those to review the client’s response to invention and determine
tasks that they can ensure the OTA is competent to perform. if the intervention plan needs to be modified, continued, or
The OTA is responsible for following the written intervention discontinued. The OTA helps the OT with this by commu-
plan, including understanding the client’s goals for occupa- nicating the client’s response to intervention through docu-
tional therapy. It is also the OTA’s responsibility to not accept mentation and verbal exchange (AOTA, 2014a). Consistent
delegated tasks that are beyond their ability or the scope of and thorough reviews of documentation of intervention ses-
what an OTA should be performing. sions and discussions of each case provide the OT with the
Both the OT and OTA should demonstrate service com- information needed to modify or discontinue intervention
petency in the specific techniques or interventions being plans as appropriate. Without adequate communication, the
used as well as any particular assessment tools to be used. client is at risk for receiving inadequate, unsafe, or unneeded
Service competency is defined as having the skills necessary services. Although the OTA should not modify intervention
to provide identical performance of an intervention tech- plans, they should not limit their response to a client’s needs
nique as the supervising OT would provide (Foster & Smith, in acute or emergency situations, but any adjustments made
2016). When deciding on what to delegate to the OTA, the to the plan in this type of situation must be conveyed to the
OT should keep in mind Principle 1D of the Occupational supervising OT.
Therapy Code of Ethics (2015) (hereinafter, the Code), that oc- The OTA cannot independently decide to discontinue
cupational therapy personnel must “ensure that all duties del- treatment. The OTA may assist with gathering data related
egated to other occupational therapy personnel are congruent to outcomes, as directed by the OT. The OTA should be
with credentials, qualifications, experience, competency, and aware of and understand the client’s established goals and
scope of practice with respect to service delivery, supervision, intended outcomes and communicate the progression to-
fieldwork education, and research” (AOTA, 2015b, p. 3). ward these outcomes to the OT (AOTA, 2014a). According
When delegating tasks to the OTA, the OT must consider to Principle 1H of the Code, occupational therapy personnel
not only the OTA’s service competency but also the complex- must “terminate occupational therapy services in collabora-
ity of the client and intervention as well as the specific require tion with the service recipient or responsible party when the
ments of the practice setting and state laws. For example, when services are no longer beneficial” (AOTA, 2015b, p.3). Thus,
working with a medically complex client in an intensive care the OTA must communicate with the OT when they see the
unit, the client’s needs may rapidly change, requiring on-the- need for discontinuation of services.
spot reevaluation and modification of the intervention plan.
In this case, the OT should not delegate intervention to the
OTA Supervision
OTA because the OT may need to reevaluate and revise the
intervention plan during a session. According to the Code, All occupational therapy services provided by an OTA must
occupational therapy practitioners must “reevaluate and rebe supervised by an OT. The extent to which that supervi-
assess recipients of service in a timely manner to determine sion is provided is based on the number and diversity of the
whether goals are being achieved and whether intervention client population, complexity of the client and intervention,
plans should be revised” (AOTA, 2015b, p. 2). the skill level of both the OT and OTA, type of practice set-
Although an OTA may have the skills to provide a broad ting, the requirements of that setting, and any funding or
array of individual and group interventions, some states re- state regulations (AOTA, 2014a). Several documents provide
quire advanced practice certification to implement certain supervision guidelines: Guidelines for Supervision, Roles,
and Responsibilities During the Delivery of Occupational ■ Routine supervision is when regular face-to-face contact
Therapy Services (AOTA, 2014a); Standards of Practice for occurs. Routine supervision may be required to occur on
Occupational Therapy (AOTA, 2015a); the Code (AOTA, a weekly, biweekly, or monthly basis, based on the state
2015b); and the occupational therapy state licensure act for requirements.
the states in which the supervisory relationship is occurring. ■ Minimal supervision is face-to-face interaction between the
According to Principle 4H of the Code, occupational ther- OT and OTA at least monthly (applicable in Arizona only).
apy personnel must “provide appropriate supervision in ac- ■ General supervision occurs when the supervising OT is
cordance with AOTA Official Documents and relevant laws, available by telephone or written communications while
regulations, policies, procedures, standards, and guidelines” the OTA is providing services; face-to-face contact occurs
(AOTA, 2015b, p. 5). at an interval set by state licensure regulations. Some states
Most states designate the frequency by which direct super- mandate that the OT review each client at a regular interval,
vision or on-site observation of client care must occur. Both the regardless of the required level of supervision. For example,
OT and OTA must ensure that the minimum supervision— in California, the OT is required to conduct weekly review
defined as the least amount of supervision a practitioner needs of all services provided by the OTA (AOTA, 2016).
in order to provide safe and effective services—parameters
Supervision can take place directly (with the OT and OTA
are met. Supervision may need to occur more frequently than
interacting in person) or indirectly. Examples of direct super-
the minimum requirement if the client needs are complex,
vision include face-to-face interactions such as discussions, ed-
the client needs change frequently and quickly, the practice
ucation, or instruction. The OT may provide direct supervision
setting demands diverse services, or additional supervision
by observing intervention sessions, co-treating clients, or ob-
is required to ensure client or practitioner safety and the ef-
serving meetings or interactions with family members. During
fective delivery of services. Years of experience should not be
face-to-face meetings, the OT and OTA may choose to share
the determining factor for the level of supervision; instead, the
ideas and demonstrate or model interventions or strategies.
level of supervision should be based on the client’s safety needs
Indirect supervision involves conversations over the phone,
and what will foster professional development and competence
email, written notes, and other confidential electronic com-
(AOTA, 2014b).
munications. Confidentiality and security must be assured
Although previous editions of the AOTA Guidelines for
because all Health Insurance Portability and Accountability
Supervision delineated levels of supervision, the current edi-
Act of 1996 (HIPAA, P. L. 104–191) laws and regulations must
tion does not provide defined levels. Some state practice acts
be followed when communicating regarding client care.
and licensure regulations delineate levels of supervision using
Reviewing the documentation of intervention session is a
the terms direct, close, routine, minimal, and general.
form of indirect supervision. The OT may also communicate
■ Direct supervision is when the supervising OT is in the with other professionals who have had interaction with the
immediate area while the OTA is providing occupational OTA or with family members of clients. The OT must use a
therapy services, but the extent to which that direct super- variety of methods to ensure they have a well-rounded under-
vision is required varies in each state. In some states, direct standing of each client as well as the OTA’s performance and
supervision requires the supervising OT to be in audible competence. In addition, the level of supervision may change
and visual range of the OTA while providing client care. over time or based on client needs. Case Example 41.2 shows
■ Close supervision is daily, direct contact with the OTA at an example of how levels of supervision can change over time
the work site. and in different circumstances.
CASE EXAMPLE 41.2. Consuela: Levels of Supervision
Consuela is an OT who works for a skilled nursing facility where she supervises Ivan, an OTA. Ivan has been an OTA for more than 20 years.
Consuela and Ivan have established a mutually respectful working relationship and have learned much from each other over the year that they
have worked together. When Consuela began working with Ivan, she spent the first several weeks observing Ivan working with clients, having
him demonstrate techniques, and ensuring he was competent with certain pieces of equipment. Although she knew Ivan had many years of
experience, Consuela also knew it was her responsibility to assure Ivan was competent and that she understood his skill set.
Over time, Consuela began reducing the amount of direct contact she provided for Ivan. According to the regulations in the state they were working
in, on-site supervision was only required weekly, which Consuela and Ivan agreed was adequate. However, a medically complex patient with a spinal
cord injury was admitted to the facility last week. Ivan and Consuela met to discuss the client’s case and determined that more frequent supervision was
needed because Ivan had little experience with this diagnosis and the client’s condition was fragile. During the patient’s stay, the intensity and frequency
of supervision will be increased; the supervision level will become less frequent on patient discharge or a mutual decision by Ivan and Consuela.
Review Questions
1. What level of supervision was being provided prior to the medically complex patient described in this case?
2. What documents can be used in this situation to decide on what level of supervision is appropriate?
3. At what point can Consuelo and Ivan go back to a lower intensity of supervision?
Supervision Documentation a list of items to discuss and questions to ask so the time is
used efficiently. Those lists can also help guide the docu-
OTs and OTAs are equally responsible for determining the
mentation of supervision. Open communication is key, and
level of supervision required, deciding on the frequency of
being receptive to and providing honest feedback are essen-
supervision, and developing a collaborative plan for docu-
tial to building a solid relationship. Feedback should always
menting the supervision that takes place. Documentation of
be constructive and focused on the primary objectives of the
the supervision plan and how it is implemented should fol-
supervisory relationship: safety and professional competence
low all requirements of the facility in which the supervision is
and development. Both the OT and OTA need to be open to
taking place and any state or funding regulations.
receiving feedback.
AOTA guidelines suggest that at a minimum documenta-
tion of the supervision plan and implementation should include
■ Frequency at which contact occurs For Additional Learning
■ Type of supervision provided and methods of supervision
■ Content areas covered For additional learning, see Chapter 40, “Providing Constructive
Feedback.”
■ Evidence provided to show service competency
■ Names and credentials of all personnel involved (AOTA,
2014a).
Despite best efforts toward being respectful and provid-
Some states require specifics to be included in the docu- ing avenues for open communication, conflicts will arise.
mentation of the supervision including: number of hours the Addressing the conflicts immediately and professionally will
OTA worked, exact amount of time in direct contact the OT assure that the supervisory relationship will grow with the res-
has with the OTA, number of patients the OTA has provided olution of each conflict. According to Principle 6J of the Code
care for, outcome of each supervisory meeting, and signa- of Ethics, occupational therapy personnel must “use conflict
tures of both the OT and OTA on all supervisory records resolution and internal and alternative dispute resolution re-
(AOTA, 2016). The OT and OTA must decide who will docu- sources as needed to resolve organizational and interpersonal
ment the supervision, when the documentation will be com- conflicts, as well as perceived institutional ethics violations”
pleted, and where it will be stored. Some facilities require all (AOTA, 2015b, p. 7). Conflicts and issues can often be avoided
supervisory meeting notes and minutes be filed by the human by establishing clear expectations about job performance and
resources department, while in other facilities, the supervisor role delineation at the initiation of any supervisory relation-
stores all documentation of the supervisory meetings. Both ship. Written expectations from the beginning help to inform
the OT and OTA must take responsibility for determining both the supervisee and supervisor of what is required of the
what the state and facility requirements are for documenting job and the working relationship (Foster & Smith, 2016).
supervision and assuring that all are met.
State Regulations
Fostering a Collaborative Supervisory
The supervising OT must be licensed in the state in which
Relationship
the OTA is licensed and providing services. This may mean
The supervisory relationship between the OTA and the OT that the OT or OTA holds licensure in several states if pro-
should be collaborative and built out of mutual respect. The viding intervention in more than one state or via telehealth.
OT has the opportunity to learn from the OTA and vice versa; States vary in regard to the regulations or statutes that define
thus, the supervisory relationship should be viewed as recipro- what an OTA can do, establish supervision requirements, and
cal in nature. Both the OT and OTA must commit to creating determine how many OTAs an OT may supervise. If an OT
a solid working relationship. New supervisory relationships or OTA is working on a temporary license or limited permit
should begin with establishing a mutual understanding of before passing the NBCOT board exam or completing the
each practitioner’s experience, competence, and learning style. requirements for licensure, additional supervision may be
It is helpful to keep in mind the purpose of supervision, which, required.
according to AOTA, is a “process aimed at ensuring the safe and The extent to which each state regulates the supervision
effective delivery of occupational therapy services and fostering and scope of practice of OTAs varies widely. Some states re-
professional competence and development” (AOTA, 2014a, p. quire that the regulatory board be notified of each supervisory
S16). Keeping this in the forefront of supervision will help curb relationship before the OT can begin supervising an OTA. In
ego issues. No matter what experience or education each practi- regard to the ratio of OTAs to supervising OTs, at the time of
tioner brings to the relationship, both the OT and OTA should this writing, only 14 states regulate the number of OTAs an
be humble and open to learning from each other (Rowe, 2016). OT can supervise. In those states in which there is no statute
A solid and trusting supervisory relationship is devel- or regulation regarding ratio of OTAs to OTs, practitioners
oped over time through respectful and clear communication. and managers must place safety and ethics at the forefront
Setting consistent and uninterrupted meeting times in which when deciding how many OTAs an OT can supervise safely.
the OT and OTA can openly communicate with each other The regulations in one state may be different from those in a
is essential. Before the meetings, both parties should create bordering state, so clinicians must understand the laws in each
state in which they practice. Practitioners who provide home Balancing these dual roles will require the OTA to be clear
health in multiple states, live and practice in bordering states, or about the distinction between each role and be open in their
provide telehealth must ensure they are following the state licen- dialogue about the difference between the two with the OT
sure laws in each state in which they provide services. A list of all providing clinical supervision (McCracken & Winistorfer,
state regulations regarding supervision is available on the AOTA 2016). The OT being managed by an OTA must also under-
website under “Practice—Occupational Therapy Assistants” stand that the OTA has job responsibilities that are not con-
(http://www.aota.org/Practice/OT-Assistants.aspx). sidered as a provision of occupational therapy services and as
However, it is strongly recommended that each practi- such do not require the supervision of an OT.
tioner look up their state regulations regularly to ensure they
are following the most up-to-date standards. In states where
there are limited regulations, practitioners should use the Stan- For More Information
dards of Practice for Occupational Therapy (AOTA, 2015a); the
For more information on OTAs working as managers, see Chapter 42,
Guidelines for Supervision, Roles, and Responsibilities During “Occupational Therapy Assistants as Managers.”
the Delivery of Occupational Therapy Services (AOTA, 2014a);
the Code (AOTA, 2015b); and any funding source regulations
to guide supervisory practices. According to Principle 4E, Review Questions
occupational therapy personnel must take the responsibility to
“maintain awareness of current laws and AOTA policies and 1. What should be considered before delegating tasks to
Official Documents that apply to the profession of occupational an OTA?
therapy” (AOTA, 2015a, p. 5). 2. What is the role of the OTA in progression of a client
(i.e., adapting or changing the intervention plan or dis-
continuing treatment)?
OTAs as Managers 3. What potential issues may come up if an OTA is in a
The OTA’s role has expanded over the years and can include managerial role?
management positions or employment in arenas in which they 4. What are examples of indirect supervision, and when
are not delivering occupational therapy services. In situations would this occur?
in which occupational therapy services are not being provided, 5. List the 5 minimum elements of the supervision plan and
the OTA does not need to be supervised by an OT (AOTA, implementation that should be documented.
2014a). For example, Joanna worked as an OTA in a hospital 6. Identify and describe 3 strategies that can be used to fos-
for 5 years before she accepted a new position as the director ter a collaborative relationship between an OT and OTA.
of an adult day care center. As the director, she uses her occu-
pational therapy experience and perspective, but she does not SUMMARY
provide occupational therapy services. Thus, Joanna functions
independently in her role as the program director with super- Fostering a collaborative relationship between an OT and
vision provided by the CEO of the company, not an OT. OTA has broad ranging benefits for practitioners and clients.
OTAs can serve as managers of occupational therapy clin- Ultimately, the goal of supervision of occupational therapy
ics or services, providing administrative oversight of pro- services is to “ensure the safe and effective delivery of occu-
grams. In these situations, an OTA could be responsible for pational therapy services and fostering professional compe-
budgeting, planning, staffing, and handling other organiza- tence and development” (AOTA, 2014a, p. S16). Although the
tional tasks for a business or program. Common job titles for OTA’s role in service provision is broad, the scope of practice
these roles include rehab manager, director of rehab, or team and supervision of OTAs must follow all state, funding, and
leader. OTAs who meet the job requirements and possess the ethical guidelines regarding supervision requirements, and
skill set required to meet the challenges of these roles can carry the supervisor and supervisee must understand those regu-
them out competently. However, if an OTA serves as both a lations and uphold them. ❖
manager and a practicing clinician in the same organization,
they must be aware of potential ethical and legal issues when
managing those who supervise them in service provision.
LEARNING ACTIVITIES
As a manager, the OTA could be responsible for managing 1. Visit the AOTA website and find the list of state regula-
the annual reviews for and performing any disciplinary actions for OTA supervision. Find the section for the state
tions against the OT who is supervising them clinically. This in which you reside and identify the following:
poses potential for conflict and possible retaliation. To avoid a. How many OTAs may an OT supervise in your state?
this, the OTA must be cognizant of these potential ethical is- b. How is supervision defined?
sues and uphold the specific boundaries of each role. Having c. How are the levels of supervision defined?
a written job description for each role—the position as man- d. What time requirements are specified (how often
ager and the position as occupational therapy provider—will supervision must occur, frequency at which supervi-
help both the supervising OT and the OTA/manager under- sion must occur, or time in which the OTA has been
stand the expected responsibilities of each. out of school)?
2. Role play how you might address a supervisor who is ask- American Occupational Therapy Association, (2014a). Guidelines
ing you to violate ethical or state requirements for super- for supervision, roles, and responsibilities during the delivery of
vision or scope of practice for an OTA. occupational therapy services. American Journal of Occupational
3. Identify a practice setting in which you plan to work or Therapy, 68, S16–S22. https://doi.org/10.5014/ajot.2014.686S03
American Occupational Therapy Association. (2014b). Occupa-
are currently working. Develop a service competency
tional therapy practice framework: Domain and process (3rd ed.).
plan for OTAs in that setting.
American Journal of Occupational Therapy, 68(Suppl.1), S1–S48.
4. Create a list of possible ways to provide indirect super- https://doi.org/10.5014/ajot.2014.682006
vision. How would you ensure all information shared in American Occupational Therapy Association. (2015a). Standards of
each method is confidential? practice for occupational therapy. American Journal of Occupa-
tional Therapy 69(Suppl.3), 6913410057. https://doi.org/10.5014
/ajot.2015.696S06
ACOTE STANDARDS American Occupational Therapy Association. (2015b). Occupa-
tional therapy code of ethics (2015). American Journal of Occupa-
tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014
■ B.3.1. Occupational Therapy History, Philosophical Base, /ajot.2015.696S03
Theory, and Sociopolitical Climate American Occupational Therapy Association. (2015c). Value of oc-
■ B.4.4. Standardized and Nonstandardized Screening and cupational therapy assistant education to the profession. Amer-
ican Journal of Occupational Therapy, 69(Suppl. 3), 6913410070.
Assessment Tools
https://doi.org/10.5014/ajot.2015.696S07
■ B.4.6. Reporting Data
American Occupational Therapy Association, State Affairs Group.
■ B.4.22. Need for Continued or Modified Intervention (2016). Occupational therapy assistant supervision requirements.
■ B.4.23. Effective Communication Retrieved from www.aota.org/~/media/corporate/files/secure
■ B.4.24. Effective Intraprofessional Collaboration /advocacy/licensure/stateregs/supervision/occupational%20
■ B.4.28. Plan for Discharge therapy%20assistant%20supervision%20requirements%20
■ B.5.1. Factors, Policy Issues, and Social Systems oct%202016%20final.pdf
■ B.5.5. Requirements for Credentialing and Licensure Cottrell, R. (2000). COTA education and professional development:
■ B.5.8. Supervision of Personnel A historical review. American Journal of Occupational Therapy,
■ B.7.1. Ethical Decision Making 54(4), 407–412. https://doi.org/10.5014/ajot.54.4.407
■ B.7.5. Personal and Professional Reponsibilities. Foster, L. & Smith, R. (2016). The American Occupational Therapy
Association advisory opinion for the Ethics Commission: Occu-
pational therapist-occupational therapy assistant partnerships:
Achieving high ethical standards in a challenging health care
REFERENCES environment. Retrieved from www.aota.org/~/media/Corporate
Accreditation Council for Occupational Therapy Education. (2017). /Files/Practice/Ethics/Advisory/OT-OTA-Partnership.pdf
PD Newsletter Summer/Fall 2017, Accreditation Council for Occu- Health Insurance Portability and Accountability Act of 1996
pational Therapy Education. Retrieved from www.aota.org/~/media (HIPAA), Pub. L. 104–191, 42 U.S.C. § 300gg, 29 U.S.C § 1181-1183,
/Corporate/Files/EducationCareers/Accredit/Announcements and 42 USC 1320d-1320d9.
/PDenews/PD-Newsletter-Summer-Fall-2017.pdf McCracken, K., & Winistorfer, W. (2016). The American Occupational
Accreditation Council for Occupational Therapy Education. (2018). Therapy Association advisory opinion for the Ethics Commission:
2018 Accreditation Council for Occupational Therapy Education Ethical considerations for occupational therapy assistants in man-
(ACOTE) standards and interpretive guide. American Journal of agement roles. Retrieved from www.aota.org/~/media/Corporate
Occupational Therapy, 72, 7212410005. https://doi.org/10.5014 /Files/Practice/Ethics/Advisory/Ethical-Considerations-for
/ajot.2018.72S217 -Occupational-Therapy-Assistants-in-Management-Roles.pdf
American Occupational Therapy Association. (2012). Physical Rowe, N. (2016). 10 tips to building a strong OT/OTA relationship.
agent modalities. American Journal of Occupational Therapy, 66, Retrieved from www.aota.org/Education-Careers/Students/Pulse
S78–S80. https://doi.org/10.5014/ajot.2012.66S78 /Archive/career-advice/OT-OTA-Relationship.aspx
CHAPTER
Occupational Therapy Assistants as Managers
Melissa Tilton, OTA, BS, COTA, ROH, and Donna Costa, DHS, OTR/L, FAOTA 42
LEARNING OBJECTIVES
■ Identify the differences between leadership and management,
■ Identify ways to provide feedback,
■ Describe several ways to grow as a leader, and
■ Identify strategies to use their OTA service competencies to move into management roles.

• Administrative supervision • Fairness • Rounding
• American Occupational Therapy • Leadership • Servant leadership
Association • Leadership styles • State regulatory boards
• Behavioral leadership theories • Management • Therapeutic use of self
• Caring • National Board for Certification • Transformational leadership
• Clinical supervision
• Contingency leadership theories
in Occupational Therapy
• Respect
® • Trustworthiness
• Emotional intelligence • Responsibility
O
ccupational therapy assistants (OTAs) work as managers OTAs in Management
in a variety of settings. American Occupational Ther-
Some might ask, can I, as an OTA, be a manager? The an-
apy Association (AOTA) Past President Virginia C. St-
swer is yes, an OTA can be a manager and a leader. At times,
offel (2013) stated that “leaders influence others to take action”
the management role requires more task-based duties such
(p. 634). OTAs working as managers have the opportunity to in-
as scheduling patients, managing practitioners’ time-off re-
fluence action and should be encouraged to move into these roles.
quests, and preparing reports. At other times, this role re-
Taking action to improve the functioning of the therapy quires leadership duties that move the department forward
team and implementing strategies to improve patient care and as a collective unit, such as strategic planning or budgeting.
outreach to the community are all activities that may be done Although an OTA cannot clinically supervise an occupa-
by a manager. OTAs can use the same managerial and lead- tional therapist (OT), a manager who is also an OTA can lead
ership skills as other managers to make the changes needed a department and administratively supervise any OTs who
in the population they serve. OTAs working in management are on the team.
will need to balance all aspects of supervision, role delinea- Clinical supervision aims to develop therapeutic compe-
tion, and practice acts; they will also need to work to ensure tence (Costa, 2007), but administrative supervision refers
that the rehabilitation team is meeting the expectations of all to “leadership, the oversight of staff performance, and other
customers. This aspect will include all roles of management personnel management tasks” (Pecora et al., 2010, p. 16).
but additionally the roles of a treating OTA. There can be conflicts that arise when an OTA is leading
https://doi.org/10.7139/2019.978-1-56900-592-7.042
393
CHAPTER
Occupational Therapy Assistants as Managers
Melissa Tilton, OTA, BS, COTA, ROH, and Donna Costa, DHS, OTR/L, FAOTA 42
LEARNING OBJECTIVES
■ Identify the differences between leadership and management,
■ Identify ways to provide feedback,
■ Describe several ways to grow as a leader, and
■ Identify strategies to use their OTA service competencies to move into management roles.

• Administrative supervision • Fairness • Rounding
• American Occupational Therapy • Leadership • Servant leadership
Association • Leadership styles • State regulatory boards
• Behavioral leadership theories • Management • Therapeutic use of self
• Caring • National Board for Certification • Transformational leadership
• Clinical supervision
• Contingency leadership theories
in Occupational Therapy
• Respect
® • Trustworthiness
• Emotional intelligence • Responsibility
O
ccupational therapy assistants (OTAs) work as managers OTAs in Management
in a variety of settings. American Occupational Ther-
Some might ask, can I, as an OTA, be a manager? The an-
apy Association (AOTA) Past President Virginia C. St-
swer is yes, an OTA can be a manager and a leader. At times,
offel (2013) stated that “leaders influence others to take action”
the management role requires more task-based duties such
(p. 634). OTAs working as managers have the opportunity to in-
as scheduling patients, managing practitioners’ time-off re-
fluence action and should be encouraged to move into these roles.
quests, and preparing reports. At other times, this role re-
Taking action to improve the functioning of the therapy quires leadership duties that move the department forward
team and implementing strategies to improve patient care and as a collective unit, such as strategic planning or budgeting.
outreach to the community are all activities that may be done Although an OTA cannot clinically supervise an occupa-
by a manager. OTAs can use the same managerial and lead- tional therapist (OT), a manager who is also an OTA can lead
ership skills as other managers to make the changes needed a department and administratively supervise any OTs who
in the population they serve. OTAs working in management are on the team.
will need to balance all aspects of supervision, role delinea- Clinical supervision aims to develop therapeutic compe-
tion, and practice acts; they will also need to work to ensure tence (Costa, 2007), but administrative supervision refers
that the rehabilitation team is meeting the expectations of all to “leadership, the oversight of staff performance, and other
customers. This aspect will include all roles of management personnel management tasks” (Pecora et al., 2010, p. 16).
but additionally the roles of a treating OTA. There can be conflicts that arise when an OTA is leading
https://doi.org/10.7139/2019.978-1-56900-592-7.042
393
the department, and these disagreements need to be ad- and to use both to carry out the duties of a manager. The dif-
dressed before issues arise. In the same thinking of develop- ferentiation between managers and leaders is that managers
ing supervision and collaborative relationships between OTs are largely responsible for getting work tasks done, whereas
and OTAs, the OTA who is the manager needs to identify leaders are focused on influencing others.
what roles they can hold, discuss who is clinically supervising Phipps (2015) described several differences between man-
the OT, and discuss who will clinically supervise the OTA. agers and leaders. One difference pertains to the scope of
Management “is the process of guiding an organization focus, with managers being more internally focused, and
by planning for future work obligations, organizing employ- leaders being more externally focused. Leaders influence
ees into functional units, directing employees in the process others by building consensus among people on a vision for
of completing daily work tasks, and controlling work pro- the future and what action steps are required for goal attain-
cesses and systems to ensure adequate quality of work out- ment. Another difference is that managers tend to focus on
put” (Braveman, 2016, p. 6). These types of duties fit within the short term, but leaders focus on the big picture or long
an OTA’s scope of practice and align with the role of an term. Managers control and direct the work that needs to
OTA who is carrying out a treatment protocol. Throughout be done, and leaders operate by inspiring and empowering
occupational therapy practice, one must find a theory or best others to succeed.
practice to use when deciding how to best approach the task Recognizing and solving problems is the primary focus of
at hand. managers, whereas leaders focus on empowering people to en-
Management literature includes many theories of manage- gage in decision making and problem solving. It is important
ment. Henri Fayol, a 19th-century executive and developer of to recognize that a combination of leadership and manage-
the 14 Principles of Management, described 5 key functions ment is needed to ensure success in the organization as well
of management: (1) planning, (2) organizing, (3) command- as to help others within that organization embrace change.
ing, (4) coordinating, and (5) controlling (Van Vliet, 2011; An effective department will depend on a manager who is
Wren et al., 2002): able to lead the team toward a collective goal or outcome.
■ Planning—determining the action you will take. Be sure to
look at the big picture when planning and to look beyond Leadership styles
the immediate time frame and the project at hand. Try Behavioral leadership theories are those theories that focus
to determine what the future brings (Braveman, 2016; on the behaviors of leaders and posit that leadership can
McCormack, 2010). be learned and nurtured. Leadership styles are approaches
■ Organizing—mobilizing resources. Organize the resources that leaders use to motivate followers. The type of leadership
into teams and groups, and use a variety of skill sets style that one adopts should be chosen on the basis of the
to best move forward. Make the most of each resource needs of the organization, situation, group, and individuals
(McCormack, 2010). (Amanchukwul et al., 2015). Therefore, it is useful for an OTA
■ Commanding—providing direction. Provide clear exam- who is a manager or leader to have a thorough understanding
ples, taking into account each person’s learning style. Be of the different styles so that they can increase the number of
sure to demonstrate and model to allow carryover and tools they have to lead effectively:
further understanding (Braveman, 2016; McCormack,
2010). ■ Autocratic: Makes the decision; may need to do so in cases
■ Coordinating—moving toward 1 goal. Be sure to take all of safety or policy.
constituents (e.g., staff, teammates, clients, peers, orga- ■ Democratic: Gathers input from the team; listens to ideas
nization) into consideration when moving toward 1 goal. and thoughts.
Determine how each member will carry this out and how ■ Laissez-faire: Typically makes no decision; may let the
they will be affected by these efforts. process work itself out.
■ Controlling—circling back and following up. Determine ■ Transformational: Takes action and uses innovation to
whether the job was done, whether further training make the changes.
is needed, and whether there were adequate time and ■ Charismatic: Is inspirational and joyful to be around; pos-
resources to achieve the desired outcome. sesses high energy that may motivate other teammates.
■ Transactional: Uses a reward-based system and is able to
OTAs as Leaders identify the “carrot” for each teammate—that is, identify
what is of value to the teammate and the outcome that can
OTAs, just as anyone else, can serve in leadership positions. support his or her desires (adapted from Lussier, 2010).
Being a leader is not tied to an academic credential or pro-
fessional title but rather to the ability to influence others.
Contingency leadership theories
Leadership is “the process of influencing employees to work
toward the achievement of objectives” (Lussier, 2010, p. 273). Contingency leadership theories are based on the notion
One can substitute the word employees for peers, colleagues, that leaders can change on the basis of the situation at hand.
teammates, staff, and so forth. OTA managers need to under- These theories suggest that there is no single way of leading
stand the various aspects of leadership versus management that works well in all situations. As a result, this theory is
CHAPTER 42. Occupational Therapy Assistants as Managers 395
more applicable in health care organizations because of the PRACTICAL APPLICATIONS IN

dynamic nature of the health care delivery system (Ledlow & OCCUPATIONAL THERAPY
Coppola, 2010). Because OTA managers and leaders work in
ever-changing health care organizations, these theories are Learning to be a Manager
important for them to learn and apply to their work:
Every OTA starts somewhere on their management and
■ Normative: Decision tree is used to weigh the pros and leadership journey, and one of the first places OTAs are in-
cons and work through the process. troduced to leadership concepts is in OTA school. The Ac-
■ Situational: Manager matches the maturity level with creditation Council for Occupational Therapy Education
each teammate, looking at what each one may bring to the
table and how that will affect the outcome (adapted from
®
(ACOTE ) OTA Standards outline minimal expectations
that an OTA must have to practice as an entry-level practi-
Lussier, 2010). tioner (ACOTE, 2018). These standards lay the foundation to
support OTAs moving into management roles. The standards
Servant leadership that are learned in school are a great jumping off point for
learning about an OTA’s role in management and leadership
Servant leadership focuses on serving for the good of others activities.
and has been espoused by several occupational therapy leaders, For example, look at ACOTE Standard B.5.2—“Explain
including Stoffel (2013). Servant leadership involves “putting the role and responsibility of the practitioner to advocate
the needs of others before his or her own [to] be truly effective” for changes in service delivery policies, effect changes in the
(Dillon, 2001, p. 443). This type of leader is focused on system, recognize opportunities in emerging practice areas,
■ Helping others before themselves, and advocate for opportunities to expand the occupational
■ Helping improve the community, and therapy assistant’s role” (ACOTE, 2018, p. 34). Effecting
■ Being engaged. change and being a change agent is a key task in being a man-
ager. Every manager needs to articulate the changes needed
Because this is a popular theory in occupational therapy lead- in either policy changes or system changes to meet AOTA’s
ership, it is suggested that OTA managers and leaders study (2017) Vision 2025, which states that as an inclusive profes-
this theory. It is particularly applicable to those who become sion, “occupational therapy maximizes health, well-being,
involved in local, state, and national associations where one is and quality of life for all people, populations, and communi-
working to achieve the “greater good.” ties through effective solutions that facilitate participation in
everyday living” (p. 1).
Transformational leadership While maintaining role delineation and scope of practice,
the OTA manager will need to be able to generate conversa-
Transformational leadership is a dynamic theory that sug-
tions to do so, and being aware of the responsibility is a first
gests that the leaders’ situation influences them to adapt a
place to start (AOTA, 2014a). Additionally, the OTA will need
style that fits the situation at hand (Ledlow & Coppola, 2010).
to understand how advocacy affects the team that he or she is
“Transformational leaders are charismatic; they have vision,
responsible for. Advocating not only for the client but also for
empathy, self-assurance, commitment and the ability to as-
the team will assist the OTA in being a successful manager.
sure others of their own competence, and they are willing to
take risks” (Ledlow & Coppola, 2010, p. 75). OTAs are en-
couraged to learn about this theory because it is viewed as For Additional Learning
critical for success in today’s health care environment. The
ability to influence, encourage, motivate, and inspire others is For additional learning, see
critical to success of the transformational leader. Such qual-
■ Chapter 18, “Managing Organizational Change,” and
ities include ■ Chapter 23, “Becoming a Change Agent.”
■ Inspiring others through actions and words,
■ Reflecting on decisions and actions and using that review
to mold the next decision or action, OTA leadership is also described in ACOTE Stan-
■ Sharing a vision that all teammates work toward, and dard B.5.6, which states that OTAs should “identify the need
■ Not being fearful to make a change (adapted from Phipps, and demonstrate the ability to participate in the develop-
2015). ment, marketing, and management of service delivery op-
tions” (ACOTE, 2018, p. 34). This standard speaks directly
to management of service delivery options but also to how
Review Questions
OTAs need to be able to market the services in an appropriate
1. What are 2 task-based duties that an OTA manager manner. OTA managers will need to be able to support the
might do? team in identifying what it is they want to be providing and
2. What are 2 leadership tasks that an OTA manager ensuring that it is done ethically for clients.
might do? ACOTE Standard B.6.1 speaks to ensuring that the
3. What are 3 ways that managers differ from leaders? OTA is able to identify the use of scholarly activities such
as application of evidence-based practice and to promote Practical tips for growth include the following recommendations:
evidence-based practice in leadership: “Locate and demon-
■ Review tools and resources on the AOTA website and dis-
strate understanding of professional literature, including the
cuss during team meetings.
quality of the source of information, to make evidence-based
• The OTA page (https://bit.ly/2TOfmIz) includes re-
practice decisions in collaboration with the occupational
sources, a leadership toolkit, suggested reading, and
therapist. Explain how scholarly activities and literature
quick links to supervision tools and resources.
contribute to the development of the profession” (ACOTE,
■ Identify and review 1 article on management each quarter
2018, p. 35). OTA managers need to ensure that the services
and give a presentation to the team.
provided are evidence based and involve proven techniques.
■ Attend a workshop geared toward the policy in your area
They also need to understand how to share knowledge of
of practice to further your knowledge on how to advocate
evidence-based practice with others.
for occupational therapy services.
ACOTE Standard B.7.3 aims to position OTAs as ad-
■ Join or start a journal club with a focus on becoming a
vocates for occupational therapy: “Promote occupational
manager.
therapy by educating other professionals, service providers,
■ Find a mentor who has been a manager before.
consumers, third-party payers, regulatory bodies, and the
public” (ACOTE, 2018, p. 37). OTA managers need to ad-
vocate for the services provided; they will need to be able Essential Values of an OTA Manager
to speak to the plan of care written by the OT and help to
McCracken and Winistofer (2017) identified the core values
justify the need for services to payer sources. This standard
of managers as “trustworthiness, respect, responsibility and
speaks to an OTA being able to educate others on what oc-
fairness and caring” (p. 18). These core values apply to oc-
cupational therapy is, why it is important, and to assist in
cupational therapy practitioners who fill the role of manager
ensuring that occupational therapy’s distinct value is recog-
and leader and reflect the Occupational Therapy Code of Eth-
nized. This standard builds a foundation for advocacy at the
ics (2015) (hereinafter, the Code; AOTA, 2015), which delin-
center, state, and federal levels. It also lays the foundation for
eated ethical practice for all OTAs and OTs.
educating the team about what occupational therapy is and
is not.
ACOTE Standard B.5.8 is of particular importance to Trustworthiness
OTA managers who supervise staff: “Develop strategies for
Trustworthiness refers to the ability of a person to be relied
effective, competency-based legal and ethical supervision of
upon by others as being honest or truthful:
occupational therapy assistants and non-occupational ther-
apy personnel” (ACOTE, 2018, p. 35). OTAs and OTs alike ■ Openness—Be willing to talk about things and hear feed-
need to continue to grow and learn, and OTA managers can back, whether good or bad.
support staff and team members in lifelong learning and pro- ■ Transparency—Be honest and demonstrate the willing-
fessional development. OTA managers can ensure that each ness to share information and answer questions.
teammate has a professional development plan and is actively ■ Maintaining confidentiality—Be willing to maintain con-
using and accessing current resources and tools to build the fidentiality for the team, department, and customer. There
profession and enhance the outcomes of occupational ther- may be times when an employee asks a manager to keep
apy practice. something confidential, and they trust that the manager
will do that. However, this may or may not conflict with
transparency. In those cases, the manager may need to
Creating a Vision for Growth
say to the employee that they cannot remain confidential
People often become managers out of necessity, being pro- about the issue.
moted because there is a vacancy rather than actively apply- ■ Walking the walk—Be willing to do what you ask others
ing for the position. In these situations, it is important that to do.
the new manager access further learning to grow in the role
of manager. As part of professional development, OTAs and
Respect
managers can develop a long-term goal and personal vision
for becoming a strong manager and leader. Using this per- Respect refers to having a feeling of admiration for someone
sonal vision, an OTA can make a change and begin to inspire because of the abilities they possess, their qualities, or what
others, which is a key to success as a manager (Phipps, 2015). they have achieved:
Building a vision statement is an ongoing process, 1 that
■ Demonstrate therapeutic use of self (i.e., “common con-
OTAs will modify and tweak as they grow in their careers.
cerns for how therapists achieve and demonstrate under-
When building a vision statement,
standing, caring, and concern for clients’ perspectives and
■ Identify what you want to become, experiences”; Taylor et al., 2009, p. 199);
■ Identify where you want to go, and ■ Understand the unique role of each teammate and disci-
■ Identify how you want to get there. pline and what they bring to the table;
■ Ask questions rather than assume; The same clinical reasoning process used with clients applies
■ Allow time to research issues before reacting; and to providing feedback as a manager. Stoffel et al. (2014) stated
■ Provide encouragement in the format that each teammate that “effective leaders must be able to manage their emotions
prefers to receive it. as they lead their teams” (p. 10), and this ability is crucial
when providing feedback to others. Effective managers are
aware of their emotions and recognize how their feelings af-
Responsibility and fairness
fect them and their job performance. This awareness leads
Responsibility refers to having the authority to be account- them to speak openly about their emotions or with convic-
able for other people or have control over certain tasks. Fair- tion about their guiding vision (Goldman et al., 2002).
ness means acting objectively or impartially without showing One key to providing feedback is to ensure it is timely,
favoritism to others: honest, consistent, and objective. Do not provide feedback
when you are frustrated, angry, or emotional. To ensure feed-
■ Do what you say you will do and own up to times when
back is genuinely constructive, it is best to prepare yourself
you did not;
first. Some managers find it useful to write down the feedback
■ Be consistent with what you say and what you do;
and practice delivering it before actually doing so, especially
■ Follow up in a timely manner, and ask others to do the
if it is the first time with that employee. You need to provide
same; and
the feedback with confidence while being mindful of tone,
■ Be structured in systems and processes.
body language, timing, and approach.
Not providing feedback can lead to disengagement, en-
Caring abling, and putting teammates in strife. When there is no
Caring refers to the demonstration of concern for others’ feedback, one may tend to think that everything is okay and
welfare: that nothing needs to change, which may not necessarily be
true. Moreover, staff may feel unsure whether they are meet-
■ Demonstrate compassion for self and others; ing expectations without feedback on their strengths and
■ Be patient, with yourself and others; weaknesses. After all, there may be positive things occur-
■ Use and understand emotional intelligence (i.e., the abil- ring that also require giving feedback. Strife can occur when
ity to work collaboratively with a team of health care pro- teammates do not feel supported, when they see issues oc-
fessionals: identifying and managing patient emotions to curring and no one addressing them, and when stress levels
adeptly address patient concerns and needs; identifying rise and no one takes any action. Teammates in strife may be
and managing team member emotions to promote pa- more apt to leave or demonstrate apathy (Penny et al., 2014).
tient advocacy and diffuse possible professional domain Managers might only give feedback when something
conflicts; communicating with patients, family members, is not right; however, taking the time to provide feedback
caregivers, health care providers, and insurers to ensure when things are going well can make an even bigger im-
optimal patient care; educating caregivers who may feel pact. Spend time to address what needs correcting, but also
overwhelmed and ill-prepared to assume caregiving spend time acknowledging and cultivating the good. Be
responsibilities; and working cooperatively and compas- mindful of the environment when feedback is being given.
sionately with people from varied and diverse cultural Does it allow a calm approach that is unhurried? Is there
groups; Gutman & Falk-Kessler, 2016); and the physical space for both parties to comfortably discuss
■ Demonstrate empathy. the information? Is there time to fully discuss the matter
It is imperative that OTA managers ensure that their own at hand, with limited interruptions? Note the following tips
practice, and those who report to them, are following the Code. for managers:
■ Proactively schedule regular rounding with teammates at
For Additional Learning a time that is convenient for both parties. Rounding is the
process of “proactively engaging, listening to, communi-
For additional learning, see Chapter 59, “Ethics for OTA Managers.” cating with, building relationships with, and supporting
your employees” (Saver, 2015, p. 1). The practice of round-
ing establishes a personal connection with the employee,
Providing Feedback and Communicating which leads to increased trust. It also provides an oppor-
Expectations tunity to check in with each teammate, build a relation-
ship, and use the time to offer any support. By rounding
Like other managers, OTA managers need to provide timely,
regularly, a manager will develop a level of trust, respect,
accurate, and objective feedback. Consider a treatment session
and open communication.
in which you were explaining a new task or technique to a client:
■ Use this time to have conversations before an issue might
■ How did they know whether they were successful? arise; get to know one another and varied ways that each
■ How did they know what changes they need to make to teammate may communicate.
achieve the outcome? ■ Follow up on conversations in a summary email.
■ Ask the employee for feedback on the result of your com- Ensure that goals reflect the professional development of
munication at the end of the rounding and incorporate the teammate and their role. Look at the teammate’s desire to
their feedback into the next rounding session. learn new treatment techniques, obtain certification, take on
■ Provide timely and relevant examples. leadership roles and tasks, attend a conference, take a student,
■ Avoid assumptions. and so forth. Consider doing a quarterly or midyear check-in
to provide feedback and time to discuss opportunities. By
When feedback is provided in the best possible way, success doing so, it allows teammates to adjust professional plans to
can be measured in good client outcomes and dynamic and increase or decrease activities in 1 area or another; it also al-
well-functioning teams (Stoffel et al., 2014). lows for an opportunity to share the positive changes since
the last meeting.
Managing Within Your Practice Act
For additional learning, see Chapter 40, “Providing Constructive
Feedback.” OTAs must be aware of, follow, and educate others on the role
delineation of OTAs versus OTs as well as ensure that the super-
vision processes and regulations are being followed at all times.
Set Expectations Three separate entities have standards of practice estab-
lished for both OTs and OTAs. Each of these entities stands on
As a manager, a basic first step is to become aware of all ex-
its own and has its own process for grievances and sanctions:
pectations for yourself and the team. Then, ensure these
expectations are clearly shared and reviewed with each team- ■ American Occupational Therapy Association (AOTA)
mate. As an OTA manager, you also have to emphasize your • AOTA is a professional organization for OTs and OTAs.
service competencies as a manager and keep foremost in your • AOTA has an Ethics Commission to develop and
mind that you are a manager because of your knowledge and address ethical concerns that arise.
skills. This ability will serve to offset any negative reactions ■ State regulatory boards
from others who may question why they are being supervised • State regulatory boards are bodies that have jurisdic-
by an OTA. Note the following tips for managers: tion over clinical practice; they are responsible for
defining the scope of practice of the profession.
■ Review job descriptions, job duties, and departmental • Each state has licensure and regulatory requirements. It is
processes and polices with all teammates;
the responsibility of each practitioner to remain current
■ Ensure documentation occurs, is provided to both parties, in knowledge of these regulations and to follow them.
and that the expectations were reviewed and understood;
■ National Board for Certification in Occupational Therapy
■ Use rounding to review anything that may need further
clarification;
(NBCOT ) ®
• NBCOT is a national not-for-profit organization that
■ Ask yourself, “Was I clear when reviewing the expecta- provides certification for occupational therapy profes-
tions, and did I provide adequate training to meet the
sionals. NBCOT develops, administers, and continu-
expectations?”; and
ally reviews its certification process based on current
■ Ask for feedback on your own performance. and valid standards that provide reliable indicators of
competence of occupational therapy practice. Their
Performance Appraisals mission is to serve the public interest (https://bit.ly
Each manager should have a documented system for provid- /2N6Npcp).
ing reviews and performance appraisals on an annual basis. • NBCOT maintains the credentials of Registered Occu-
OTA managers should clarify the role of the performance ®
pational Therapist (OTR ) and Certified Occupational
review from clinical versus overall performance. Using a ®
Therapy Assistant (COTA ) for those who maintain
the credentials and has enforcement policies.
peer (e.g., having an OT complete core competencies on an-
other OT) to complete a clinical performance review allows
for appraisal of skill sets outside the scope of OTA. The OTA
manager reviews the overall performance on the basis of the Resources for OTA Managers
job description and duties of each teammate within the de-
The following documents are helpful resources for OTA managers:
partment, but they will leave the clinical review of the OT to
another OT or a different manager to support the OTA’s role ■ Standards of Practice for Occupational Therapy: This document
as the administrative leader and supervisor. describes the minimum standards for the practice of
Use a structured system that allows for self-reflection and occupational therapy (see AOTA, 2015b).
a self-appraisal by the teammate. Compare the self-appraisal ■ Guidelines for Supervision, Roles, and Responsibilities During
the Delivery of Occupational Therapy Services: This document
with the appraisal completed by the manager to discuss any
provides guidelines for the supervision, roles, and responsibilities
items that may not align with each other. Provide feedback of OTs, OTAs, and occupational therapy aides during the delivery
with specific examples to help bring the differences into of occupational therapy services (see AOTA, 2014).
alignment.
CASE EXAMPLE 42.1. Sharon: First Steps as an OTA Manager
Sharon, an OTA, was a treating clinician 40 hours per week under the supervision of 1 OT. Her current manager goes out on leave, and there is no
one to cover the manager duties. Sharon has a desire to further her career, so she volunteers to help cover the opening until her manager returns.
When making this offer, she asks for training on what the job entails, what the expectations are, and how she will be measured for success. As
she reviews what her role is, Sharon reviews how this changes the team, making sure there is adequate supervision for herself as an OTA but also
supervision for her as she enters the administration role.
To get to the know the teammates who are now reporting to her, Sharon sets up 1-on-1 rounding sessions to get to know each teammate, learn
about their clinical passions and strengths, and identify their communication style. Because she needs to treat and complete management duties,
she sets up a schedule that everyone can see. She outlines when she is completing her treatment as well as her supervision and management
tasks. She allows open office time so that teammates can bring forth questions and concerns. This policy demonstrates her willingness to hear their
needs and allows time to address any future needs.
As a new manager, Sharon chooses to review with all teammates the structured supervision and collaboration meetings and to also review the
practice acts. She asks for feedback from her new boss and those who are reporting to her. She sets goals for herself, reflects back on successes of
each, and identifies new action plans to be successful in the goals that she has not yet achieved.
Review Questions
1. What was the first thing that Sharon did after volunteering to assume the manager’s role?
2. What method did Sharon as manager use to get to know the teammates assigned to her?
3. How did Sharon demonstrate her willingness to hear employees’ needs?
Review Questions ■ B.5.8. Supervision of Personnel

1. Which of these is not an example of constructive feedback?
■ B.6.1. Professional Literature and Scholarly Activities
a. You were late today; you can’t be late like this.
■ B.7.3. Promote Occupational Therapy.
b. You were late today; is there anything I can help you
with in regard to your current schedule? REFERENCES
c. When you are late, you make the day harder for the
whole team. Accreditation Council for Occupational Therapy Education. (2018).
2. When giving feedback, what type of environment is 2018 Accreditation Council for Occupational Therapy Education
important? ®
(ACOTE ) Standards and interpretive guide. American Journal
3. What are 2 things that come out of giving good feedback? .org/10.5014/ajot.2018.72S217
4. Who is responsible for knowing the state practice act and Amanchukwul, R., Stanley, G., & Ololube, N. (2015). A review of
regulatory rules for an OTA? leadership theories, principles and styles and their relevance to
educational management. Management, 5(1), 6–14.
SUMMARY American Occupational Therapy Association. (2014). Guidelines
for supervision, roles, and responsibilities during the delivery
This chapter discussed the basics of management and lead- of occupational therapy services. American Journal of Occupa-
ership within the context of OTAs serving as managers, pro- tional Therapy, 68(Suppl. 3), S16–S22. https://doi.org/10.5014
viding theories to understand the mechanics of management /ajot.2014.686S03
and how to approach becoming a manager and leader. It dis- American Occupational Therapy Association. (2015a). Occupa-
cussed the foundations of standards learned while in school, tional therapy code of ethics (2015). American Journal of Occupa-
which can assist in developing OTAs into strong and devel- tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014
/ajot.2015.696S03
oped managers—knowing these are entry-level skills, and
American Occupational Therapy Association. (2015b). Standards of
that moving into management is not entry level.
practice for occupational therapy. American Journal of Occupa-
OTAs have a responsibly to themselves, clients, and team- tional Therapy, 69(Suppl. 3), 6913410057. https://doi.org/10.5014
mates to further their knowledge and skills to become suc- /ajot.2015.696S06
cessful managers. Knowing the values and roles of a manager American Occupational Therapy Association. (2017). Vision 2025.
will assist OTAs in moving their teams forward toward a uni- American Journal of Occupational Therapy, 71, 7103420010.
fied goal, which is an important characteristic of managers in https://doi.org/10.5014/ajot.2017.713002
today’s ever changing health care world. Case Example 42.1 Braveman, B. (2016). Leadership: The art, science, and evidence. In
describes an OTA new to the manager role. ❖ B. Braveman (Ed.), Leading and managing occupational therapy ser-
vices: An evidence-based approach (2nd ed., pp. 3–34). Philadelphia:
F. A. Davis.
ACOTE STANDARDS Costa, D. (2007). Clinical supervision in occupational therapy:
This chapter addresses the following ACOTE Standards: A guide for fieldwork and practice. Bethesda, MD: AOTA Press.
Dillon, T. H. (2001). Authenticity in occupational therapy leadership:
■ B.5.2. Advocacy A case study of a servant leader. American Journal of Occupa-
■ B.5.6. Market the Delivery of Services tional Therapy, 55, 441–448. https://doi.org/10.5014/ajot.55.4.441
Goldman, D., Boyatzis, R., & McKee, A. (2002). Primal leadership: Penny, N., Ewing, T., Hamid, R., Shutt, K., & Walter, A. (2014). An in-
Learning to lead with emotional intelligence. Boston: Harvard vestigation of moral distress experienced by occupational therapists.
Business School Press. Occupational Therapy in Health Care, 28, 382–393. https://doi.org/10
Gutman, S. A., & Falk-Kessler, J. P. (2016). Development and psycho- .3109/07380577.2014.933380
metric properties of the Emotional Intelligence Admission Essay Phipps, S. (2015). Leading with a vision. Administration and Man-
scale. Open Journal of Occupational Therapy, 4(3), 6. https://doi.org agement Special Interest Section Quarterly, 31(4), 1–4.
/10.15453/2168-6408.1233 Saver, C. (2015). The three R’s of staff engagement: Relationships,
Ledlow, G., & Coppola, M. (2010). Leadership for health profes- rounding, and recognition. OR Manager, 31(1), 1–4.
sionals: Theory, skills, and applications. Sudbury, MA: Jones & Stoffel, V. C. (2013). From heartfelt leadership to compassionate
Bartlett. care. American Journal of Occupational Therapy, 67, 633–640.
Lussier, R. N. (2010). Human relations in organizations: Applications https://doi.org/10.5014/ajot.2013.676001
and skill building (8th ed.). Boston: McGraw Hill/Irwin. Stoffel, V., Lamb, A., Nagel, L., Dumitrescu, C., Sullivan, C., &
McCormack, G. (2010). Historical and current perspectives on Addison, L. (2014). Leading lights: Essays on leadership and
management. In K. Jacobs & G. McCormack (Eds.), The occupa- occupational therapy. OT Practice, 19(15), 7–12.
tional therapy manager (5th ed., pp. 3–16). Bethesda, MD: AOTA Taylor, R. R., Lee, S. W., Kielhofner, G., & Ketkar, M. (2009). Thera-
Press. peutic use of self: A nationwide survey of practitioners’ attitudes
McCracken, K., & Winistofer, W. (2017). Ethical considerations for and experiences. American Journal of Occupational Therapy, 63,
occupational therapy assistants in management roles. OT Practice, 198–207. https://doi.org/10.5014/ajot.63.2.198
22(11), 18–21. Van Vliet, V. (2011). Five functions of management (Fayol). Retrieved
Pecora, P. J., Cherin, D., Bruce, E., & Arguello, T. (2010). Admin- from https://www.toolshero.com/management/five-functions-of
istrative supervision within an organizational context. In P. J. -management/
Pecora, D. Cherin, E. Bruce, & T. Arguello (Eds.), Strategic su- Wren, D. A., Bedeian, A. G., & Breeze, J. D. (2002). The foundations
pervision: A brief guide for managing social service organizations of Henri Fayol’s administrative theory. Management Decision,
(pp. 1–25). Thousand Oaks, CA: Sage. 40, 906–918. https://doi.org/10.1108/00251740210441108
CHAPTER
Management of Fieldwork Education
Donna Costa, DHS, OTR/L, FAOTA 43
LEARNING OBJECTIVES
By the end of this chapter, readers should be able to
■ Identify the administrative competencies necessary to manage a fieldwork program,
■ Self-assess their skill level for those administrative competences using the Self-Assessment of Fieldwork Educator
Competency, and
■ Create a professional development plan related to fieldwork administration competencies.

• Academic fieldwork coordinators • Fieldwork educator • Student Evaluation of Fieldwork
• Clinical site coordinators • Self-Assessment of Fieldwork Experience
• Competency Educator Competency
• Fieldwork education
Our students and their learning are our most scheduling placements with academic institutions, assigning
important focus as educators. Their learning is our students to FWEs, and managing contracts.
principal goal. They are our customers, our reviewers, Much of the initial planning takes place long before stu-
and in the near future our colleagues. dents begin their fieldwork placement at a facility. It is essen-
tial to have a well-organized plan before students start so that
—Dwyer & Higgs (1999, p. 125)
everything proceeds smoothly during a fieldwork placement.
This chapter closely follows the Administration Competen-
cies section of the Self-Assessment of Fieldwork Educator
OVERVIEW Competency (SAFECOM). Readers will then assess their
level of knowledge and skills using the SAFECOM and create
F
ieldwork education is 1 of the 2 components of profes- a professional development plan for themselves. A case study
sional education for occupational therapy students in is provided to illustrate the competencies described.
clinical practice settings. The other component is their
academic or classroom education. This chapter focuses on
fieldwork education and what administrative tasks occupa-
tional therapy managers need to know about and complete as
a fieldwork educator (FWE) or clinical site coordinator. The SAFECOM was created by the American Occupational
FWE is the currently preferred term in the United States Therapy Association (AOTA) Commission on Education in
for occupational therapy practitioners who supervise and 1997, and revised in 2009, as a voluntary self-assessment tool
educate entry-level students during Level I or Level II field- for the skills necessary to be an effective FWE. It provides a
work; other terms used previously include clinical educator, structure for FWEs to assess their own level of competence
clinical instructor, or fieldwork supervisor. Outside the United and to identify areas for further development and improve-
States, the term used is practice educator. Clinical site coordi- ment of their skills. Competency as a FWE means that one is
nators are employed by a clinical site and are responsible for able to guide student development from novice to entry-level
https://doi.org/10.7139/2019.978-1-56900-592-7.043
401
CHAPTER
Management of Fieldwork Education
Donna Costa, DHS, OTR/L, FAOTA 43
LEARNING OBJECTIVES
By the end of this chapter, readers should be able to
■ Identify the administrative competencies necessary to manage a fieldwork program,
■ Self-assess their skill level for those administrative competences using the Self-Assessment of Fieldwork Educator
Competency, and
■ Create a professional development plan related to fieldwork administration competencies.

• Academic fieldwork coordinators • Fieldwork educator • Student Evaluation of Fieldwork
• Clinical site coordinators • Self-Assessment of Fieldwork Experience
• Competency Educator Competency
• Fieldwork education
Our students and their learning are our most scheduling placements with academic institutions, assigning
important focus as educators. Their learning is our students to FWEs, and managing contracts.
principal goal. They are our customers, our reviewers, Much of the initial planning takes place long before stu-
and in the near future our colleagues. dents begin their fieldwork placement at a facility. It is essen-
tial to have a well-organized plan before students start so that
—Dwyer & Higgs (1999, p. 125)
everything proceeds smoothly during a fieldwork placement.
This chapter closely follows the Administration Competen-
cies section of the Self-Assessment of Fieldwork Educator
OVERVIEW Competency (SAFECOM). Readers will then assess their
level of knowledge and skills using the SAFECOM and create
F
ieldwork education is 1 of the 2 components of profes- a professional development plan for themselves. A case study
sional education for occupational therapy students in is provided to illustrate the competencies described.
clinical practice settings. The other component is their
academic or classroom education. This chapter focuses on
fieldwork education and what administrative tasks occupa-
tional therapy managers need to know about and complete as
a fieldwork educator (FWE) or clinical site coordinator. The SAFECOM was created by the American Occupational
FWE is the currently preferred term in the United States Therapy Association (AOTA) Commission on Education in
for occupational therapy practitioners who supervise and 1997, and revised in 2009, as a voluntary self-assessment tool
educate entry-level students during Level I or Level II field- for the skills necessary to be an effective FWE. It provides a
work; other terms used previously include clinical educator, structure for FWEs to assess their own level of competence
clinical instructor, or fieldwork supervisor. Outside the United and to identify areas for further development and improve-
States, the term used is practice educator. Clinical site coordi- ment of their skills. Competency as a FWE means that one is
nators are employed by a clinical site and are responsible for able to guide student development from novice to entry-level
https://doi.org/10.7139/2019.978-1-56900-592-7.043
401
practitioner to ensure the continued advancement of the pro- read, and give a copy of the article by Ozelie et al. (2014) to the
fession (AOTA, 2009). administrator and be prepared to summarize it in the event
The SAFECOM (AOTA, 2009) can be used by both novice he or she does not have time to read it.
and experienced occupational therapy/occupational therapy
assistant FWEs to self-assess an initial baseline measure of 4. Designs and Implements the Fieldwork
competency and then periodically as they develop skills to- Program in Collaboration With the Academic
ward higher levels of competency. The Administration Com-
Programs Served and in Accordance to
petencies section contains 16 skills, each of which is discussed
in detail in this section. ACOTE Standards for Level I and Level II
Fieldwork
1. Communicates and Collaborates With For this competency, FWEs have some background reading
Academic Programs to Integrate the Academic to do. They should familiarize themselves with AOTA poli-
Curriculum Design During Fieldwork cies related to fieldwork education, all of which are on AOTA’s
website (www.aota.org). The first task is to read the Accredita-
Before starting a new fieldwork program, FWEs should first tion Standards related to fieldwork education (i.e., Section C in
identify what occupational therapy/occupational therapy as- the ACOTE Accreditation Standards; Accreditation Council
sistant academic programs are in the local area, because that for Occupational Therapy Education [ACOTE], 2018). FWEs
is most likely where fieldwork placements will come from. It also need to review other official AOTA documents that may
is best practice to reach out to those academic programs by have been updated since they were in school. These include
contacting the academic fieldwork coordinators (AFWCs),
who are employed by the occupational therapy education ■ Standards of Practice for Occupational Therapy (AOTA,
program and are responsible for arranging placements, secur- 2015b)
ing contracts, and overseeing all of the educational program’s ■ Occupational Therapy Code of Ethics (2015) (AOTA, 2015a)
fieldwork sites. ■ Commission on Education Guidelines for Level I Fieldwork
Every educational program at the occupational therapy (AOTA, 1999)
practitioner or assistant level must assign a faculty member ■ Commission on Education Guidelines for Level II Fieldwork
designated to function in this role to maintain accreditation (AOTA, 2013)
status. AFWCs will most likely want to come visit the site and ■ Fieldwork Level II and Occupational Therapy Students
schedule a discussion with the FWE. The FWE should ask (AOTA, 2018)
for copies of the curriculum outline to have an idea of what ■ Occupational Therapy Practice Framework: Domain and
courses students will have had prior to coming to the fieldwork Process (AOTA, 2014).
site. The FWE should also request copies of the course syllabi
for the practice area to know what students are being taught 5. Ensures That the Fieldwork Program Is
in their practice courses. Once meeting with the AFWCs, the Sensitive to Diversity and Multicultural Issues
FWE can start designing the fieldwork program and creating
FWEs must be able to effectively work with students from di-
a sequenced outline of learning experiences for students.
verse cultural backgrounds, adapting the fieldwork program
when necessary to accommodate student learning needs.
2. Implements a Model Fieldwork Program Diversity not only means cultural origin but also includes re-
That Supports the Curriculum of the ligion, sexual orientation, age, gender, and level of academic
Academic Program degree, among others.
The fieldwork program designed by the FWE should be flexible
and able to change in response to changes in the academic pro- 6. Documents an Organized, Systematic
grams. Remaining in close contact with the AFWC will keep Fieldwork Program
FWEs informed of those changes and maintain the respon-
Just as students have a course syllabi in school that gives them
siveness of the fieldwork program to student learning needs.
a roadmap of their sequence of learning and assignments, the
FWE also needs to create a plan for students’ learning. Two of
3. Seeks Support From Fieldwork Site these documents include
Administration and Staff to Develop and
■ Fieldwork manual: The fieldwork manual is a guide for the
Implement the Student Fieldwork Program
student that will inform them of the policies and proce-
It is important for FWEs to get buy-in from their supervisor dures of the fieldwork site, provide documentation guide-
or administrator prior to implementing a fieldwork program. lines, confidentiality policies, and information related to
Typically, administrators are resistant to approving the de- planning interventions (AOTA, 2000).
velopment of new fieldwork programs because they fear that ■ Weekly sequence: Giving students an 8-week or 12-week
productivity will go down, so FWEs need to be armed with outline of what to expect and when assignments are due is
information that demonstrates this will not occur. Download, an invaluable aid to the student (Costa et al., 2015).
CHAPTER 43. Management of Fieldwork Education 403
7. Schedules Formal and Informal 12. Provides Student Work Areas Appropriate
Meetings With the Student to Guide the to Fieldwork Site
Fieldwork Experience The student needs a place to work. That does not necessarily
FWEs need to build in time on a daily or weekly basis to mean a separate office, but it does mean an area where the
meet with students. The biggest complaint that students student can put their belongings and work on assignments
have is that they do not feel they receive adequate feedback. during the day. Part of what a FWE does is socialize students
Therefore, set aside time to find out from students how the to their professional role.
fieldwork experience is going—whether it is too fast, too
slow, provides enough detail, or includes enough variety of
patients/treatments. 13. Provides a Complete Orientation for
Student to Fieldwork Site
A thorough orientation at the beginning of fieldwork is a
8. Collaborates With the Student to Develop
must. Students should be introduced to the site’s policies,
Student Learning Objectives procedures, expectations, and responsibilities. Orientation
The student is a partner in the learning process, and there- can be provided by the human resources department or the
fore the FWE should find out what the student wants to learn FWE and can be a combination of print and verbal resources.
during the fieldwork experience. This means having a conver- Be mindful of how much a student can absorb in 1 day; it may
sation with the student and asking the student for input into be wise to spread out orientation over several days, particu-
the creation of learning objectives. larly if the site is a large health care facility.
9. Documents Behavioral Objectives to 14. Requires Student Compliance With

Achieve Fieldwork Objectives and Learning the Fieldwork Site Policies and Procedures,
Experiences Appropriate for Entry-Level Mission, Goals, Philosophy, and Safety
Practice Standards
Behavioral objectives are essential if one wants students to Students must comply with all of the policies and proce-
understand what is expected of them. For each of the items dures of the fieldwork site that were reviewed during ori-
on the Fieldwork Performance Evaluation (FWPE), the FWE entation. Some of these policies may be so important that a
should write a site-specific objective (AOTA, n.d.) that tells student’s failure to comply might be grounds for termination
students how this item will be assessed. from fieldwork. These are usually stated in the contract or
memorandum of understanding (MOU) between the school
and the fieldwork site.
10. Is Knowledgeable in Legal and Health Care
Policies That Directly Influence Fieldwork
15. Submits Required Fieldwork Documents
FWEs need to be aware of state and federal policies that
to Academic Program in a Timely Manner to
affect fieldwork education. This includes the Health Insur-
Ensure Current Data Are Available
ance Portability and Accountability Act of 1996 (HIPAA;
P. L. 104–191), Family Educational Rights and Privacy Act No job is done until the paperwork is done. It is essential that
(FERPA; 20 U.S.C. § 1232g; 34 CFR Part 99), Americans fieldwork documentation, such as the FWPE and the Student
With Disabilities Act of 1990 (ADA; P. L. 101–336), Individ- Evaluation of Fieldwork Experience, which provides feed-
uals With Disabilities Education Act of 1990 (P. L. 101–476), back about the site and FWE, need to be returned to the
and reimbursement policies such as Medicare, which may school immediately following the conclusion of the place-
limit the services a fieldwork student may provide. The ment. Sometimes schools ask the students to bring them back
AOTA Fieldwork Educator Certificate Program is a 2-day to the school.
course that FWEs should take to obtain this information.
16. Conducts Ongoing Fieldwork Program

11. Defines Essential Functions and Roles Evaluations and Monitors Changes in the
of a Fieldwork Student, in Compliance With Program With Student and Staff Input
Legal and Accreditation Standards
FWEs are responsible for evaluating how effective the field-
Essential function statements are specific to each fieldwork work program is in meeting students’ learning needs. A good
site and provide specific information about what tasks the start is to create a file and keep copies of the Student Evalu-
student needs to be able to perform at the fieldwork site. These ation of Fieldwork Experience. Another mechanism is to re-
are particularly helpful when an individual has a disability tain copies of the SAFECOM documents that FWEs complete
and is asking for reasonable accommodations. periodically.
Review Questions making clear what is expected of students and encour-

aging them to self-reflect on their own performance,
1. Which of the following documents assesses a FWE’s
and completing the evaluation in a timely and accurate
competency?
manner.
a. SAFECOM
b. FWPE
c. SEFWE Other Resources
d. OTPF This chapter has reviewed the SAFECOM, which identifies
2. If a student has a disability, which of the following docu- competencies in the FWE. This is the first step in preparing
ments will be most helpful to review? to take a student. Readers are encouraged to enroll in the
a. Essential Functions AOTA-sponsored Fieldwork Educator Certificate Program
b. Standards of Practice workshop, which goes into much greater detail about all of
c. Code of Ethics the topics covered in the SAFECOM. In addition, The Essen-
d. Memorandum of Understanding tial Guide to Fieldwork Education (Costa, 2015) is a compre-
3. Which section of the ACOTE accreditation standards hensive text that provides much more detailed information
focuses on fieldwork? about the management of fieldwork education. Although so
a. Section A much information may all seem overwhelming to new FWEs,
b. Section B remember that the AFWC serves as an ongoing resource and
c. Section C can respond to any questions new FWEs may have. Case ex-
d. Section D ample 43.1 describes an occupational therapist bringing on
her first fieldwork student.
OCCUPATIONAL THERAPY Review Questions
Other Competencies 1. Being aware of your own supervisory style is a compe-
tency in which section of the SAFECOM?
In addition to the Administration Competencies of the a. Supervision
SAFECOM, there are 4 other sections that FWEs need to b. Professional Practice
complete: c. Education
■ Professional Practice Competencies: The focus of this sec- d. Administration
tion is on FEWs’ ability to evaluate; develop the client’s 2. Articulating a theoretical frame of reference is an item in
occupational profile; provide evidence-based treatment in- the SAFECOM under which competency section?
terventions; articulate theoretical frames of reference; work a. Professional Practice
collaboratively with colleagues, families and support sys- b. Supervision
tems, and other staff or professionals; address psychosocial c. Education
factors; adhere to ethics and standards of practice; and be d. Evaluation
prepared to continue professional development. 3. Developing a learning contract is an item under which
■ Education Competencies: This section focuses on the competency section of the SAFECOM?
teaching aspect of fieldwork, identifying student learning a. Education
needs, developing learning contracts, sequencing learning b. Professional Practice
activities for students, using a varied approach to teach- c. Supervision
ing, adapting the teaching approach when student learn- d. Evaluation
ing needs require it, and guiding student learning toward
entry-level competence.
■ Supervision Competencies: These competencies reflect an SUMMARY
understanding of the supervisory process, including using Using the SAFECOM as a springboard to examine compe-
supervision theories and models, providing clear expec- tencies, this chapter presented information on management
tations to students, providing feedback to students, being of fieldwork education for occupational therapy managers
aware of one’s own supervisory style, adapting the super- interested in serving as FWEs or clinical site coordinators,
visory approach when needed, and modeling professional or who have staff pursuing these roles. Reading about these
behaviors for students. is a start, but taking it to the next level of learning means
■ Evaluation Competencies: FWEs are responsible for actually completing the SAFECOM based on one’s cur-
evaluating students’ performance during the field- rent knowledge and skills. After completing the 5 sections,
work experience, not only formally at midterms and FWEs should create a professional development plan, which
finals but also informally throughout the fieldwork is the last page of the SAFECOM. They need to identify at
experience. Items in this section include reviewing the least 1 goal related to fieldwork education, remembering to
evaluation tool with students at the start of fieldwork, make this a SMART goal—specific, measurable, achievable,
CHAPTER 43. Management of Fieldwork Education 405
CASE EXAMPLE 43.1. Susan: Beginning Fieldwork Education
Susan is an occupational therapy practitioner who has been working for the past 2 years in an outpatient mental health setting. She has been
approached by the AFWC at a local university to take a Level II fieldwork student 3 months from now. Susan is overwhelmed with the prospect of
taking her first student and does not know where to start. The AFWC suggests to Susan that she take the 2-day AOTA Fieldwork Educator Certificate
Program workshop and consider ordering the book The Essential Guide to Fieldwork Education (Costa, 2015) from AOTA. The information Susan
gains in the course is very helpful, and she knows the book will be the beginning of her fieldwork library.
Susan next approaches Mrs. Jones, the administrator of the agency, to ask who at the agency has the authority to sign the contract, and she
finds out that Mrs. Jones has signatory authority. However, Mrs. Jones wants to know how Susan will be able to handle the increased workload of
having a student and reminds Susan she still needs to maintain the 90% productivity requirement. Susan remembers hearing about an article during
the FWECP workshop that provided objective evidence that productivity did not go down when clinicians had students. She tells Mrs. Jones that she
will send her the article.
Once the MOU has been signed by her agency, Susan starts working on a plan to prepare for her student. She begins to review the curriculum
that the AFWC sent her and the syllabus for the mental health course that students take. Susan checks out AOTA’s website and finds many resources
that will help her in establishing her fieldwork program. One of the resources is for site-specific objectives. She finds that there are sample
objectives for a mental health setting that only need a little modification to make them apply to her site. Susan also finds the recommended content
for a student fieldwork manual and starts collecting documents to put in the manual. The last item she tackles is to write a sample outline for the
12-week fieldwork experience; she finds a sample outline in The Essential Guide to Fieldwork Education that she modifies for her setting. It is now
1 week before her student starts, and Susan feels much less overwhelmed about this process. She is still nervous about taking her first student,
but the AFWC has reassured her that she will be available to talk with her on a weekly basis.
Review Questions
1. What does the AFWC recommend that Susan do to help her prepare to take her first student?
2. Where does Susan find sample site-specific objectives for an outpatient mental health setting?
3. What book contains many resources to help fieldwork educators prepare to take students?
results focused, and time bound. The form lists a variety of American Occupational Therapy Association. (2000). Recommended
learning methods to achieve the established goals. FWEs content for a student fieldwork manual. Retrieved from https://
should check off those goals they feel are most appropriate www.aota.org/Education-Careers/Fieldwork/NewPrograms
for them. Lastly, they should establish a time frame for goal /Content.aspx
American Occupational Therapy Association. (2009). The American
attainment, then date and sign it. The SAFECOM is a dy-
Occupational Therapy Association self-assessment tool for field-
namic rather than static document and should be revisited at
work educator competency. Retrieved from https://www.aota
periodic intervals. ❖ .org/~/media/Corporate/Files/EducationCareers/Educators
/Fieldwork/Supervisor/Forms/Self-Assessment%20Tool%20
FW%20Ed%20Competency%20(2009).pdf
ACOTE STANDARDS American Occupational Therapy Association. (2013). COE guide-
lines for an occupational therapy fieldwork experience—Level II.
This chapter addresses the following ACOTE Standards: Retrieved from https://www.aota.org/~/media/Corporate/Files
■ C.1.1. Fieldwork Program Reflects the Curriculum Design /EducationCareers/Educators/Fieldwork/LevelII/COE%20
■ C.1.11. Qualified Level II Fieldwork Supervisors Guidelines%20for%20an%20Occupational%20Therapy%20
Fieldwork%20Experience%20--%20Level%20II--Final.pdf
■ C.1.12. Evaluating the Effectiveness of Supervision. American Occupational Therapy Association. (2014). Occupational
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
REFERENCES American Occupational Therapy Association. (2015a). Occupa-
Accreditation Council for Occupational Therapy Education. (2018). tional therapy code of ethics (2015). American Journal of Occupa-
2018 Accreditation Council for Occupational Therapy Education tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014
(ACOTE) standards and interpretive guide. American Journal /ajot.2015.696S03
of Occupational Therapy, 72(Suppl. 2). https://doi.org/10.5014 American Occupational Therapy Association. (2015b). Standards of
/ajot.2018.72S217 practice for occupational therapy. American Journal of Occupa-
American Occupational Therapy Association. (n.d.). Site-specific ob- tional Therapy, 69(Suppl. 3), 6913410057. https://doi.org/10.5014
jectives. Retrieved from https://www.aota.org/Education-Careers /ajot.2015.696S06
/Fieldwork/SiteObj.aspx American Occupational Therapy Association. (2018). Fieldwork
American Occupational Therapy Association. (1999). Level I field- Level II and occupational therapy students. American Journal
work. Retrieved from https://www.aota.org/Education-Careers of Occupational Therapy, 72(Suppl. 2), 7212410020. https://doi
/Fieldwork/LevelI.aspx .org/10.5014/ajot.2018.72S205
Americans With Disabilities Act of 1990, Pub. L. 101–336, U.S.C. practitioners: Challenges for health professional education
42 § 12101 (pp. 125–135). Butterworth-Heineman: Boston: MA.
Costa, D. (Ed.). (2015). The essential guide to occupational therapy Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g; 34
fieldwork education: Resources for today’s educators and practi- C.F.R. Part 99.
tioners (2nd ed.). Bethesda, MD: AOTA Press. Health Insurance Portability and Accountability Act of 1996, Pub.
Costa, D., University of North Dakota Occupational Therapy Depart- L. 104–191, 110 Stat. 1963.
ment, Central Nassau Guidance and Counseling Services, & Stony Individuals With Disabilities Education Act of 1990, Pub. L. 101–476,
Brook University. (2015). Sample 12 week assignment outlines for 20 U.S.C., Ch. 33.
Level II fieldwork. In Costa, D. (Ed.), The essential guide to occu- Ozelie, R., Janow, J., Kreutz, C., Mulry, M. K., & Penkala, A. (2014).
pational therapy fieldwork education: Resources for educators and Supervision of occupational therapy Level II fieldwork students:
practitioners (2nd ed., pp. 83–99). Bethesda, MD: AOTA Press. Impact on and predictors of clinician productivity. American
Dwyer, G., & Higgs, J. (1999). Profiling health science stu- Journal of Occupational Therapy, 69, 6901260010. https://doi.org
dents. In J. Higgs & H. Edwards (Eds.), Educating beginning /10.5014/ajot.2015.013532
SECTION VII.
Communication
407
CHAPTER
Communicating Across Generations and Cultures
Melissa A. Plourde, OTR/L 44
LEARNING OBJECTIVES
■ Identify 3 predicted changes in cultural and generational demographics in the United States and 1 potential impact on
occupational therapy management and practice,
■ Define and demonstrate an understanding of the use of cultural effectiveness and critical reflexivity in relation to
occupational therapy practice, and
■ Demonstrate practical application of essential components of culture and communication in relation to occupational
therapy management and practice.

• Active listening • Cultural sensitivity • Organizational culture
• Baby Boomers • Culture • Plurality nation
• Critical reflexivity • Generation X • Storytelling
• Cultural competence • Generation Y • Therapeutic communication
• Cultural effectiveness • Generation Z • Whole-body listening
• Cultural humility • Moral distress
“The fundamentals of good communication don’t that enables effective work in cross-cultural situations” (Cross
change between generations. Listening, remaining et al., 1989, p. 13). Although prominent in the allied health lit-
concise, and including all the important details are as erature, cultural competence has been disapproved or viewed
important as they’ve ever been; the difference now as having a measurable endpoint (Beagan, 2015; Hammell,
is the modes of communication we choose to apply 2013) instead of requiring a lifelong obligation to develop it
those fundamentals” (American Occupational Therapy Association [AOTA], 2013;
Isaacson, 2014).
Larry Alton (2017, para. 11)
Cultural competence has been criticized as an action that
requires a person to respond to others in a specific way (Black,
2016) with a cultural attribute checklist that promotes ste-
reotypes (Beagan, 2015). Dettwyler (2011) proposed that the
OVERVIEW term cultural competence suggests that the U.S. Western cul-
B
ecause it bridges cultures in various contexts and inter- ture is the “norm” and that “we don’t have culture, but they
actions, competency in communication skills is a fun- do” (p. 413), often reducing culture to ethnicity and nation-
damental component of the cross-cultural relationship ality. Other terms used in literature and education include
that occupational therapy practitioners develop with clients cultural tolerance, cultural sensitivity, cultural responsiveness,
and other health care professionals. Cultural competence cultural humility, cultural intelligence, cultural safety, cultural
is “a set of congruent behaviors, attitudes, and policies that congruence, cultural proficiency, and cultural effectiveness
come together in a system, agency, or among professionals (Wells et al., 2016).
https://doi.org/10.7139/2019.978-1-56900-592-7.044
409
410 SECTION VII. Communication
With a plethora of terms used to describe cross-cultural re- dyad, when co-constructing meaningful goals and outcomes
lationships, the most recent and inclusive concept in occupa- in the therapeutic process, and in developing respect of and
tional therapy is cultural effectiveness, which entails “work- trust in the relationship with the practitioner.
ing successfully with people whose cultural background
differs from yours in a manner that embodies respect, sensi- Organizational Culture
tivity, and recognition of difference” (Wells et al., 2016, p. 66).
With the expected rise in the foreign-born population within Organizational culture includes “an organization’s expecta-
the United States, as well as changing age demographics tions, experiences, philosophy, and values. It is based on shared
(Colby & Ortman, 2014), how one experiences culture and en- attitudes, beliefs, customs, and written and unwritten rules
gages in interpersonal communication during the therapeutic that have been developed over time and are considered valid”
process and with other health care professionals is critical in (Organizational Culture, n.d.). Occupational therapy practi-
an evolving health care system. This chapter discusses com- tioners work in a range of organizational cultures within var-
ponents of cultural effectiveness with a focus on how these ious work environments, including hospitals, schools, private
concepts influence communication across cultures and gen- sectors, and community-based programs; they may interact
erations in occupational therapy management and practice. not only at the local level but also be involved in state, national,
and global issues (Braveman, 2016). As important as culture
is to occupational performance in clients served by occupa-
ESSENTIAL CONSIDERATIONS tional therapy practitioners, the fit between practitioners and
the organizations in which they work is essential in providing
Culture and Clients high-quality occupational therapy services (Braveman, 2016).
According to AOTA’s (2014b) Occupational Therapy Practice In a culturally diverse workplace, occupational therapy prac-
Framework: Domain and Process, culture is defined as “customs, titioners often find themselves in circumstances that require
beliefs, activity patterns, behavioral standards, and expectations more consideration of moral and ethical values than clinical
accepted by the society of which a client is a member” (p. S28). knowledge (Wells, 2016), especially in an evolving health care
Each person is rooted in a culture that specifies a particular way organizational culture where productivity and reimbursement
of doing (i.e., action) and thinking (i.e., knowledge; Asad & Kay, often supersede best practice. Penny et al. (2014) conducted a
2015; Zango Martin et al., 2015); that culture in turn influences study of occupational therapy practitioners relative to moral
an individual’s identity (habits, routines, ritual, roles) and occu- distress in the workplace and found that practitioners who ex-
pations within a specific group or population (AOTA, 2014b). perience moral distress are more likely to leave employment.
For example, an occupational therapy practitioner might ex- Moral distress is a discomfort or tension that emerges when a
plore the dietary habits of a Hindu family to design an authentic practitioner is unsure of the best course of action or experiences
cultural and meaningful experience during a cooking activ- ethical conflict and constraints that stop the practitioner from
ity in the clinic with this client. Also, the dismissal of a family doing what is right, which is imposed between the practitioner
member from an initial evaluation process with a client, where and either other practitioners, health care organizations, or cli-
corporate identity supersedes individualism in a client’s culture, ents (AOTA, 2016; Penny et al., 2016). The top factors in eliciting
could greatly diminish the ability to build an authentic thera- moral distress in this study were within the scope of responsibil-
peutic relationship. Asking a clarifying question, such as “Would ity of occupational therapy managers, specifically the constraints
it be helpful for your family to join our evaluation process?” of witnessing “diminished patient care quality due to poor com-
can build trust and further promote client-centered practice. munication” and providing “less than optimal care due to pres-
People identify with more than 1 specific culture, so catego- sures from administrators or insurers to reduce costs” (Penny
rizing people into a single cultural or ethnic group can be lim- et al., 2014, p. 389). For example, overscheduling a therapist’s
iting as occupational therapy practitioners seek to understand work schedule to meet high productivity standards or directing a
a client’s perspective. Because one’s own culture is individually practitioner to discontinue services because of concerns regard-
defined, it includes aspects that are outwardly noticeable (e.g., ing reimbursement based on type of insurance are both work en-
appearance, language, age, gender, race) and also represents un- vironment issues that elicit ethical concerns (Penny et al., 2016).
seen influences (e.g., socioeconomic status, education) and un- The Occupational Therapy Code of Ethics (2015) (AOTA,
derlying attitudes, beliefs, values, and unique personal experi- 2015b) describes the standards of ethical occupational ther-
ences (Carey, 2017). The individuality of a client’s culture makes apy practice and provides an outline for ethical conduct and
effective communication critical within the practitioner–client decision making. Managers can support complications raised
by ethical considerations and moral distress by promoting a
culture of safety where discussions of ethical concerns or con-
For Additional Learning flicts can openly be discussed and steps to improve team com-
munication can be implemented to foster a healthy practice
For additional learning, see environment as a priority (AOTA, 2016; Penny et al., 2014).
■ Chapter 25, “Understanding Client-Centered Practice,” and
Occupational therapy managers and practitioners can
■ Chapter 47, “Practitioner–Client Communication.” advocate for monthly ethical rounds (preferably interpro-
fessional) during which topics ethical in nature can be
CHAPTER 44. Communicating Across Generations and Cultures 411
discussed openly as a means of improving communication Doing this could include asking collaborative questions
and potentially decreasing moral distress (AOTA, 2016). Such such as, “Would you like to involve anyone else in your ther-
topics might include strategies to facilitate interprofessional apy?” or “What resources in your community do you use for
communication and role delineation, review of the organi- support?” Further negotiation of a treatment plan may be
zational vision and mission statements, and communication vital in the cross-cultural interaction, and the discussions
regarding health care models of service delivery. could be promoted by “What parts of this plan do you think
will work best?” or “What parts of the plan are not going to
work for you?” (Clowes, n.d., as cited in Wells et al., 2016).
For Additional Learning It could also include a flexible approach when a manager asks
a practitioner to cover someone’s shift, knowing the coworker
For additional learning, see asked for a day off, secondary to observance of a religious
■ Chapter 57, “Organizational Ethics,” and
holiday.
■ Chapter 66, “Moral Distress.” The term cultural humility encompasses a “critical aware-
ness of one’s own assumptions, beliefs, values, and biases:
an understanding of how one’s own perspective may differ
from those of other people; and an acknowledgment of the
Cultural Effectiveness unearned advantages, privileges, and power that derive from
Cultural effectiveness is working productively in a cross-cul- one’s own particular social position” (Hammell, 2013, p. 231).
tural interaction in a manner that exemplifies sensitivity and It includes an ongoing commitment to developing cultural
respect while recognizing a person’s differences and being re- awareness, shaped by an impartial approach to all interac-
sponsive to their beliefs, practices, and cultural needs (Wells tion with others (Fahlberg et al., 2016; Isaacson, 2014; see
et al., 2016). This applies not only to interactions between a Exhibit 44.1 for a reflective activity). Cultural effectiveness
practitioner and a client but also to interactions with other is inclusive of both cultural sensitivity and cultural humility
health care professionals. Moreover, cultural effectiveness re- because they draw on an open and willing attitude to bet-
quires more than just identifying differences; it is an active ter understand and recognize that the occupational therapy
approach to obtaining cultural knowledge, understanding, practitioner and the client have equally important worldviews
and experience of various cultures and worldviews to more (i.e., ideas and attitudes) that need to be considered (Beagan,
effectively interact with others with a common purpose 2015). Cultural humility is a conscious recognition that cul-
(Wells et al., 2016). Wells et al. (2016) describe a culturally tural differences lie within the practitioner–client dyad, not
effective practitioner as one who develops the skills to under- solely within the client (Hammell, 2013), and that there are
stand and use an array of communication skills to numerous means of viewing the world.
■ Understand of the effects of culture on human develop-

ment and disability, Critical Reflexivity
■ Adapt and create interventions to meet the client and fam- The term critical reflexivity is often connected with the
ily’s specific cultural needs, term cultural humility, both of which point to a heightened
■ Address power disparities that might exist between the self-awareness, a critical component of cultural effectiveness
client and practitioner, and (Beagan, 2015; Black, 2016). Critical reflexivity has been de-
■ Support and address a client’s cultural needs specific to scribed as “holding a mirror” (Paré, 2013, p. 66) to one’s social
the influence on behaviors within the therapeutic process. values in relation to their sociocultural positioning, including
class, gender, race, ethnicity, sexuality, and age (Beagan, 2015;
Hammell, 2015). Culturally effective occupational therapy
Cultural Sensitivity and Humility
Cultural sensitivity is “being aware that cultural differences
and similarities between people exist without assigning them
EXHIBIT 44.1. Reflective Activity: Cultural Awareness
a value—positive or negative, better or worse, right or wrong”
(Dabbah, n.d.). Further, cultural effectiveness encompasses
Developing cultural effectiveness, including sensitivity, humility,
cultural sensitivity to include an “open-mindedness and
and critical reflexivity, begins with identifying one’s own biases and
curiosity into communication—developing and expressing assumptions that have been cultivated by personal experience,
genuine warmth, thoughtfulness, and respect” to strengthen education, and cultural practices (Black, 2016; Hammell, 2013). These
the efficacy of health care delivery and client-centered care biases can be subtle in nature or specific identifiable experiences.
(Clowes, n.d., as cited in Wells et al., 2016, p. 67). Instead
■ At what point in your life did you begin to realize that your specific
of assuming what is most important, practitioners should
cultural practices differed from those around you?
demonstrate sensitivity by asking clarifying questions to find
■ How did you respond to this experience? Did it elicit emotions?
out how the client understands the problem and solution and If so, how did you communicate this to others?
co-constructing a meaningful therapeutic process that is spe- ■ How did this challenge or strengthen your perception of your culture?
cific to the client’s cultural context.
practitioners and managers must be mindful to resolve the to present) will account for 40% of all consumers by 2020
power disparities that might occur with a social or profes- (White, 2017). Given the nation’s projected changes in the age
sional status (Beagan, 2015). structure and shifts in the racial and ethnic configuration of
With a culturally diverse nation on the rise, it is worth re- the population, the likelihood that a client and occupational
membering that by 2025 in the United States, those entering therapy practitioner will come from similar backgrounds is
the profession as occupational therapy practitioners might greatly reduced. Developing cultural effectiveness with inter-
be educated at the doctoral level (AOTA, 2014a) with a mid- generational communication skills is critical for occupational
dle-class status and will most likely be female. It is estimated therapy practitioners (Accreditation Council for Occupa-
that 90.9% of occupational therapy practitioners in the United
States are women (AOTA, 2015a). Managers and practitioners
®
tional Therapy Education [ACOTE], 2018).
should recognize potential disparities that might affect the Generational Differences
therapeutic relationship and the relationships formed with
other health care professionals to more effectively address Chapters, books, and a magnitude of articles and online
them. Consider the following questions: reports regarding generational differences in the workplace
have been exceedingly popular over the past several decades
■ How is a client’s compliance with therapy affected by their (Christopher et al., 2017; Gibson et al., 2009; Hills et al., 2013;
income? Lyons & Kuron, 2013; Wirthman, 2016). Lyons and Kuron’s
■ Does a parent’s need to work affect adherence to their (2013) review of the evidence to support generational differ-
child’s therapy or medical needs? ences in the workplace revealed predominantly descriptive
■ How does urban versus rural living affect access to services? studies, often lacking theoretical constructs and method-
■ How do health care professionals unintentionally enact ological consistencies. However, although not supported
middle class-ness or marginalize clients? empirically, the perception that generational differences exist
■ What assumptions do I make that may not fit for working- is well argued and documented in the literature (Christopher
class clients? et al., 2017; Gibson et al., 2009; Hills et al., 2013; Lyons &
■ Who is most likely to feel welcome within this clinic, and Kuron, 2013; Wirthman, 2016).
why? With changing demographics and the unique position of
■ How might the clinic culture be adjusted to be more inviting 4 generations—specifically, Baby Boomers, Generation X,
for clients and their families? (adapted from Beagan, 2015) Generation Y (Millennials), and Generation Z (iGen or
Centennials)—potentially working in a workforce, a general
Critical reflexivity also involves reflecting on previous ex-
understanding of the characteristics and trends that identify
periences and making changes to promote a successful inter-
each generation is applicable. A defined generation consists of
action within a current situation. This could include asking
an age span of 15–20 years (generally speaking; dates vary in
oneself, “What might I do differently next time?” or “How
the literature), is determined by birth year and geography, and
might I choose my words to communicate more effectively?”
is considered a “predictive clue” in determining how to most
In the context of professional relationships, this could include
effectively connect and communicate with people of various
■ What assumptions do I make about my coworkers that age and stages of life (Center for Generational Kinetics, n.d.).
may affect my ability to develop a professional relation- The generation a person belongs to is not meant to be con-
ship? How might I rethink these assumptions? strued as stereotypical but is another potential indicator of
■ Professionally, who is most likely to feel welcome within one’s individual culture, which is also influenced by personal
this work environment and why? experience, cultural events, parenting, and economic and po-
■ How does my position as a supervisor or manager affect litical influences (Christopher et al., 2017).
my ability to effectively communicate with coworkers who Understanding what shapes a particular generation offers
are younger or older than myself? insight into forming professional and trusting relationships
within the workplace, while providing insight into how to best
support intergenerational communication, improve produc-
A Culturally Diverse Nation
tivity, and boost morale in the workplace (Zelevansky, 2014).
The U.S. Census Current Population Report projects that by Although managers should take care to avoid generalizing
2060, the native-born population will reach 339 million, an about generations, Table 44.1 depicts generational differences
increase of 22% (or 62 million; Colby & Ortman, 2014). Simul- related to communication and technology, as well as cohort
taneously, the foreign-born population is projected to reach characteristics relative to potential occupational values, atti-
78 million, an increase of 85% (or 36 million). By 2044, the tudes, and characteristics. The table should be viewed with
United States is expected to be a plurality nation, meaning no caution, knowing that a person cannot be pigeonholed into
race or ethnic group is projected to have greater than a 50% one specific group or classification, but it does give readers
share of the nation’s total population (Colby & Ortman, 2014). an opportunity to recognize whether they have bought into
Demographics are also changing. The last Baby Boomers generational generalizations that need to be reconsidered.
will turn 65 years old in 2029, and by 2030 the number of older In addition, investigation of trends specific to technology
citizens will jump to 1 in 5 (Colby & Ortman, 2014). Predicted provides additional insight regarding the influence of tech-
to be the last identifiable generation, Generation Z (born 1996 nology in communication. Communication strategies that
TABLE 44.1. Generational Differences
TECHNOLOGY AND OCCUPATIONAL VALUES AND COMMUNICATION STRATEGIES

GENERATION COMMUNICATION PREFERENCES CHARACTERISTICS AND SUPPORTS
Baby Boomers ■ Internet and email created later in ■ Competitive ■ Recognize their titles.
Born: 1946–1964 career ■ Strong work ethic ■ Build rapport with respect.
■ Use of Internet for social connection ■ Strive for recognition ■ Use formal language (e.g., “Mr.”
Parenting:
■ Prefer a telephone call ■ Enjoy group work or “Mrs.”).
Traditional nuclear family
■ “Live to work” ■ Express that they are needed.
■ Loyal to the organization ■ Include them in meetings.
■ Communicate well ■ Address career advancement.
Gen X or latch-key ■ Birth and advance of the Internet ■ Challenge status quo ■ Avoid unnecessary meetings.
Born: 1965–1979 ■ Own personal computers ■ Self-accountability ■ Speak directly; get to the point.
■ 14% think it is appropriate to text ■ “Work to live” ■ Discuss the work–life balance.
Parenting:
or surf the web during work hours ■ Work–life balance ■ Give direct and concise explanations
Divorce
■ Loyal to the profession for changes.
Dual income
■ Entrepreneurial ■ Use instant information (email,
■ Adaptable and pragmatic iMessage).
■ Give ownership in tasks and an
opportunity to do it “their way.”
Gen Y or Millennials ■ Most globalized connection via ■ Need immediate feedback ■ When formulating a plan, allow
Born: 1980–1995 the Internet ■ Goal oriented them to voice their input, goals, and
■ Technology savvy; prefer text ■ Not afraid to ask questions opinions (even if already decided).
Parenting:
and social media over telephone ■ Innovative in the workplace ■ Allow them to discuss work–life
■ Helicopter parenting
calls ■ “Live for today” balance.
■ Overworked
■ 18% think it is appropriate to ■ Shift employment frequently ■ Let them ask questions.
text or surf the web during work (2–3 years) ■ Encourage their collaboration as
hours ■ Expect to be moved to supervisory team players.
or managerial position several ■ Present positive messages.
years out of college ■ Voice clear expectations with
explicit structure.
■ Clearly articulate defined roles.
Gen Z, iGen, or Centennials ■ Instant connection and highly ■ More diverse than Millennials ■ Use face-to-face communication.
Born: 1996–present mobile ■ Self-reliant ■ Be honest and provide validation.
■ Technology native ■ Highly educated ■ Give managerial feedback
Parenting:
■ 57% use messaging apps when ■ 55% believe they will own their frequently.
■ Multi-generational
using their phones (Snapchat, own business one day
households
iMessage, Skype) ■ Independent work style
■ Shared decision making
■ Thrive on video-based learning
■ More than any other generation,
believes social media impacts how
other people see you (perception)
Sources. BrainBoxol (n.d.); Christopher et al. (2017); Gibson et al. (2009); RRD Connect (2018).
managers or supervisors can employ are offered to help im- communication are vital to supporting client outcomes (Bell,
prove the function of multigenerational teams (Gibson et al., 2013), and having a multigenerational team of professionals
2009). can be viewed as a strength to meeting the generational di-
Table 44.1 shows the potential differences that affect com- versity of the consumer (Wirthman, 2016).
munication, technology needs, workplace motivation, pre- Using a mixed-method research design, Hills et al. (2013)
ferred leadership styles, and recognition systems (Hills et al., surveyed a group of managers who supervise Generation Y
2013). When managing a multigenerational team, open con- practitioners. Specifically, Millennial occupational therapy
versations and facilitated team discussions are critical. Em- practitioners were identified by managers as
phasize individual work style preferences, which typically
vary among employees, to avoid referencing age differences, ■ Confident in technology (86% agreed),
which may be deemed discriminatory (Wirthman, 2016). ■ Using Internet as a learning resource (72%),
This avoids assumptions based on a person’s generational ■ Social with emailing or texting family while at work (66%),
category and reduces conflict, which often occurs within ■ Thriving on immediate feedback (66%), and
multigenerational teams. In addition, effective teamwork and ■ Disliking routine tasks (48%).
Directing these positive characteristics through mentoring work hours, face to face, chairperson, and spouse/partner should
and coaching may help retain Millennials in the profession replace biased words such as man-hours, man to man, chair-
through collaborative career planning and entrepreneur- man, and husbands/wives (Carey, 2017). Erler et al. (2018)
ial leadership to support evolving health care needs (Hills suggests that generalizations that can be biased toward any
et al., 2013). specific ethnic group, religion, or gender identity should be
Douglas et al. (2015) suggested managers use 5 strategies avoided in verbal communication and printed materials.
to improve the function of multigenerational teams: Unbiased language should be used in printed materials
for clients and in written documentation and organizational
1. Create a signed team agreement to support account-
policies for employees. Correcting a health care employee or
ability and a safe environmental culture (i.e., written
a client who uses biased language supports culturally effec-
communication),
tive practice by creating a workplace environment that cul-
2. Provide 1:1 coaching to address individual needs
tivates mutual respect. When issues do arise, even potential
and to facilitate real-time feedback (i.e., face-to-face
discrimination by a client toward an occupational therapy
communication),
practitioner, such as a request for or refusal of treatment by
3. Conducting a communication workshop (class or online)
a practitioner based on race or gender, the practitioner has
to support developing effective communication skills
already developed trust in their coworkers. This allows the
(i.e., technology),
practitioner to seek support from the team of health care
4. Probe for conflict by facilitating and providing a safe cul-
professionals while examining potentially complex ethical
ture for debate (i.e., face-to-face communication), and
decisions (Erler et al., 2018).
5. Create a culture of appreciation through recognition
(i.e., formal communication).
Communication
Therapeutic communication is defined as the interaction
Learning Activity
that takes place between the practitioner and client, includ-
With the popularity of instant messaging and texting, developers are ing consideration of the client’s holistic needs and demon-
creating software that allows managers to coach employees with stration of professionalism by the practitioner (Tamparo &
immediate feedback. Targeting the most researched generation, Lindh, 2016). Communication is an essential component to
Generation Y, employee appreciation software allows managers and becoming a culturally effective occupational therapy profes-
coworkers to send a “high-five” message offering praise for a job sional and is an invaluable skill to cultivate. Gurden (2016)
well done (15five, n.d.). Elemeno Health is a privacy law–approved and Luedtke et al. (2012) provide a list of dos and don’ts for
app that targets health care organizations; the app is marketed for health care professional communicating in conversation or
use in elevating quality, empowering teams, and engaging every written forms:
employee around patient care. It can simplify complicated practices
into bite-sized learning, and game-like (i.e., gamification) elements ■ Be honest and straightforward.
are featured to empower team members (Elemeno Health, n.d.). ■ Be appropriate and know your audience.
Reflect on the potential use of apps as a means of coaching and ■ Be concise and clear in providing information.
managing a team of occupational therapy practitioners. What might ■ Be aware of potential barriers (e.g., language, literacy,
be helpful or harmful in respect to team communication? body language, cognitive ability).
■ Do not be judgmental or give personal opinions.
■ Do not use unnecessary jargon.
Review Questions ■ Do not monopolize the discussion.
■ Do not assume you know what the other person is going
1. Identify 3 ways in which communication supports the de- to say.
velopment of cultural effectiveness. ■ Do not interrupt.
2. As a manager, identify 5 ways in which specific commu- ■ Be an active listener.
nication strategies can be employed to support intergen-
erational team collaboration. In a world where technology dependency is substantial
3. See Table 44.1. As a manager, why might better under- for transmitting information, Dua (2015) pointed out that
standing potential generational differences be helpful? “Emojis are doing what the tone of voice did on the tele-
phone and what gestures, tones, and facial expressions did in
interpersonal communication.” Steinbrecher (2016) argued,
PRACTICAL APPLICATIONS IN “You cannot build relationships in soundbites;” meeting face
OCCUPATIONAL THERAPY to face or speaking over the phone avoids misinterpreting
information or a tone that might occur with shortened bits
Unbiased Language
of information in an email. However, Alton (2017) suggested
Creating an inclusive work environment where respectful that although the principles of effective communication do
communication is practiced among health care profession- not change between generations, the mode of delivery may. In
als promotes the use of skillful language when interacting a multigenerational team, the use of email or a privacy law–
with clients. For example, gender-neutral language such as approved app may be essential in coaching and mentoring,
as well as providing a multi-forum for discussion and trans- (Wells et al., 2016). By using active listening and effective
mission of information. verbal and nonverbal communication skills, managers and
practitioners establish authentic relationships with clients,
Active Listening families, and other health care professionals. Nonverbal
communication must be carefully considered, because inter-
Active listening is the process of making a “conscious effort pretation varies significantly across cultures. For example,
to hear not only the words that another person is saying but, if a nonverbal cue is misinterpreted by a client because an
more importantly, try to understand the complete message interpreter was not available, a client may reject the health
being sent” both verbally and nonverbally (Mind Tools, n.d.). care professional before a therapeutic relationship is estab-
Active listening is a skill that takes practice to cultivate. lished (Wells et al., 2016).
Susanne Poulette Truesdale, CCC–SLP, introduced the con- Cherry (2018) suggested that paying closer attention to other
cept of whole-body listening as a means of teaching children people’s unspoken behaviors will improve one’s own ability to
how to best direct their attention for listening in the class- communicate nonverbally. Nonverbal attributes that are essen-
room (Truesdale, 2013). By identifying behaviors associated tial components of communication include the following:
with parts of the body, even a young child can practice and
conceptualize active listening: ■ Pay attention to nonverbal signals: eye contact, gestures,
and body movements.
■ Eyes look at the speaker. ■ Look for incongruent behaviors. When spoken words do
■ Ears listen to what is said. not coincide with behaviors, people tend to dismiss what
■ Mouth is silent. was said.
■ Hands and feet are still. ■ Focus on your tone of voice, which can communicate
■ Brain is processing what is being said. enthusiasm or disinterest.
■ Heart is caring. ■ Balance good eye contact. It should be comfortable for
By adding the heart, empathy, perspective, and respect are both you and the other person.
emphasized (Shapiro, 2016; Truesdale, 2013). ■ Ask questions when clarification is needed regarding
This simplistic model intended for children is a reminder nonverbal signals: “I noticed you turned away when I
to health care practitioners and managers to intentionally mentioned . Is that difficult to talk about?”
think about our behaviors while interacting with a client or ■ Understand body language. A stance or arm placement
another health care professional. In the U.S. workplace with (e.g., crossed, openly extended) can display confidence,
its competing distractions and the pressure of productivity intimidation, or openness.
and time constraints, active listening is critical in delivering ■ Look at signals as a group. A person’s demeanor is more
client-centered care across generations and cultures. It is easy communicative than a single gesture.
to begin to listen to a client and then find oneself drifting ■ Consider the context: Who is your audience? What level of
in thought, maybe already formulating a treatment plan or professionalism is needed?
thinking about how this interaction will be documented for ■ Practice your skills to improve your communication.
billing purposes. A ringing telephone, emails that need to be
answered, or the notification of a new message on a phone
are all competing for our attention. With time constraints, Storytelling
it is easy to formulate a quick rebuttal to a conversation or Cultural traditions, values, and beliefs have long been ex-
interrupt whoever is talking to make sure our input is received. pressed through storytelling as a means of universal commu-
Active listening requires a face-to-face interaction be- nication (Echo, n.d.). Whether in oral, print, or digital form,
tween 2 or more people, requiring self-awareness and prac- storytelling is a dynamic and influential interaction between
tice. To effectively develop one’s active listening skills requires the creator and the listener. Whether strategically orches-
(Steinbrecher, 2016) trated to communicate evidence regarding an intervention
■ Practicing mindfulness by being present in the moment. to a client (Arbesman & Lieberman, 2014), to articulate the
■ Pausing between statements and before answering. distinct value of the practice of occupational therapy, to ed-
■ Observing the person’s responses and striving to create a ucate patients, or to better understand a client’s perspective,
rapport. a well-told story has the potential to communicate powerful
■ Being inquisitive. messages in cross-cultural interactions (Warren, 2017).
■ Asking questions for clarification. Storytelling can be an empowering means of self-
■ Paraphrasing the other person’s statements. expression, often providing a voice to an individual or group
■ Summarizing your understanding of the discussion when of people. For example, for Ethel, a patient diagnosed with
concluding a conversation. moderate Alzheimer’s disease, a story told by her daughter
greatly reduced unnecessary stress and confusion with ADL
tasks in the nursing home. The story incorporated meaning-
Nonverbal Communication
ful activities that were part of her routine in the past. Smelling
The cost of cultural ineffectiveness can be substantial, result- a cup of coffee and feeling a newspaper 15 minutes before the
ing in miscommunication, misinterpretation, and mistrust start of the ADL routine significantly reduced the confusion
and time needed to complete the tasks; the activities also in- changing, the occupational therapy profession must actively
creased Ethel’s participation in the routine. demonstrate its distinct value in the promotion of health,
well-being, and quality of life (Pizzi & Richards, 2017) for the
Review Questions individuals, groups, and populations we serve. Specific to this
discussion, it involves
1. What are 4 means of developing active listening?
2. What are 4 nonverbal strategies that are essential compo- ■ Pursuing a lifelong commitment to developing cultural
nents of communication? effectiveness by cultivating cultural sensitivity, cultural
3. Describe 1 way that storytelling can be an effective form humility, and critical reflexivity;
of communication. ■ Practicing an ongoing commitment to improving
self-awareness and developing active listening, verbal, and
nonverbal communication skills competency; and
SUMMARY ■ Using effective communication skills and strategies that
In her 1961 Eleanor Clarke Slagle Lecture, Reilly asked, “Is support the roles we play as a “direct care provider, consul-
occupational therapy a sufficiently vital and unique service tant, educator, manager, researcher, and advocate for the
for medicine to support and society to reward?” (p. 87). Her profession and the consumer” (ACOTE, 2018, p. 1) specific
question is authentic and timeless. With culture rapidly to communicating across cultures and generations. ❖
CASE EXAMPLE 44.1. Thomas: Generation Z
Thomas was a 15-year-old high school student (Generation Z) who was diagnosed with a rare degenerative neurological and physical disability
that confined him to a wheelchair with fluctuating motor coordination and balance and ataxic speech. Most recently, Thomas consistently refused to
engage in all therapeutic activities, with each of the interdisciplinary team practitioners during his routine sessions. He communicated his refusal,
both verbally and nonverbally, by crossing his legs in his wheelchair, folding his arms across his chest, flexing his body inward and hanging his head,
and stating in a loud ataxic voice, “I won’t do it. I don’t care.” His disengagement was a threat to continuing direct services.
In an effort to address the situation, the occupational therapy practitioner sent Thomas and his mother a simple email empathizing with his
recent expression of frustration, and she included a list of questions to consider for a conversation that would take place during the next therapy
session. A new plan for how occupational therapy could best support Thomas to maintain services was needed. After spending the previous evening
reflecting on the questions and discussing his answers with his parents, Thomas was prepared to discuss his latest version of his personal story.
The next day the practitioner asked Thomas why he was so frustrated and what could be done to change that so the therapeutic process could be
meaningful.
Thomas began by expressing that he was frustrated with the rote therapy exercises that he didn’t care about. He stated that he recently
threw his iPad out of anger and broke the screen. His inability to use his hands well was affecting his ability to use his iPad; he was unable to
interact with others on social media or game with his best friend. Further, he revealed his embarrassment at his inability to do simple tasks
(such as self-feeding, picking up small game pieces, and typing) he once was able to do even in therapeutic sessions.
Acknowledging his fears and frustrations, the practitioner explained in simple terms and with modeling how positioning techniques could
decrease his ataxia and reflex interference; she also reinforced with encouragement that a successful means would be discovered to decrease his
frustration. Thomas took the risk, trusted the practitioner, and was able to isolate his finger for improved use of his iPad within minutes. He was
also given a weighted cuff that could be used at home as well to support refined finger movements.
With a culture of trust and respect, an authentic discussion took place, and culturally meaningful co-constructed goals were reestablished.
The occupational therapy practitioner was able to communicate that therapy services were important not only for school activities but also
for Thomas’s meaningful activities such as gaming and using his iPad for social networking and enjoyment at home. With this understanding,
Thomas’s investment in physical therapy also improved because he better understood the connection between his exercises and maintaining
his skills for meaningful activities such as driving his scooter, texting, and gaming with his friends. Thomas also said that receiving the
email was helpful and asked if he could email the practitioner if other therapy-related questions came up between sessions. Each week, Thomas
sent a message asking what he needed for his therapy session and often included a question about how to adapt or simplify an activity for
increased independence.
Mattingly (1991) articulates a simplistic connection between constructed narration and human motivation, stating, “narratives make sense of
reality by linking the outward world of actions and events to the inner world of human intention and motivation” (p. 999). Thomas’ both verbally
and nonverbally was communicating his lack of motivation and pure defeat with his recent challenges with motor coordination, as well as the lack
of culturally meaningful activities in his treatment sessions. Further, his advocacy against conformity was a reminder that an occupational therapy
practitioner cannot assume that compliance with therapeutic activities equates to client-centered therapy. The need for consistent collaboration
and negotiation is essential in ensuring that the process is culturally meaningful.
Review Questions
1. List 3 ways in which the occupational therapy practitioner used communication to collaborate and negotiate with Thomas.
2. Does compliance with a treatment activity or plan indicate that an intervention is meaningful? If not, why?
3. How was technology instrumental in Thomas’s ability to effectively communicate with the occupational therapy practitioner?
ACOTE STANDARDS Black, R. (2016). The changing language of cross-cultural prac-

tice. In S. A. Wells, R. M. Black, & J. Gupta (Eds.), Culture and
This chapter addresses the following ACOTE Standards: occupation: Effectiveness for occupational therapy practice, edu-
cation, and research (3rd ed., pp. 51–62). Bethesda, MD: AOTA
■ B.1.2. Sociocultural, Socioeconomic, Diversity Factors, Press.
and Lifestyle Choices BrainBoxol. (n.d.). The tech revolution and how we all fit in
■ B.4.0. Referral, screening, evaluation, and intervention [Infographic]. Retrieved from https://blog.brainboxol.com/index
plan .php/2017/08/21/the-tech-evolution-and-how-we-all-fit-in
■ B.4.23. Effective Communication -infographic/
■ B.4.25. Principles of Interprofessional Team Dynamics Braveman, B. (2016). Understanding and working within organi-
■ B.7.1. Ethical Decision Making (moral distress is dis- zations. In B. Braveman (Ed.), Leading and managing occupa-
cussed with reference to code of ethics). tional therapy services: An evidence-based approach (2nd ed.,
pp. 93–125). Philadelphia: F.A. Davis.
Carey, S. (2017). Why you should use gender-neutral language in the
workplace. Retrieved from https://www.totaljobs.com/insidejob
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/ajot.2017.028456 -at-work-improving-intergenerational-communication
CHAPTER
Using Social Media Appropriately
Amanda Nardone, OTS 45
LEARNING OBJECTIVES
■ Define social media and identify different platforms for social networking;
■ Use social media effectively as a tool for promotion, professional connections, and engagement; and
■ Understand the ethical concerns related to using social media.

• Facebook • Social media marketing • Social networking sites
• LinkedIn • Social media platforms • Twitter
• Media sharing sites • Social media policies • Twitter chat
• Social media • Social networking • Virtual context
OVERVIEW This chapter focuses on understanding terms used in so-

cial media, discusses ways that social media can be part of the
S
ocial media has undergone dramatic growth in recent occupational therapy profession, and presents some ethical
years, with millions of users across the globe actively concerns related to the use of these networks. Two case exam-
engaging, communicating, and participating on web- ples support the concepts covered in the chapter.
sites such as Facebook, Twitter, LinkedIn, and YouTube.
Globally, with almost 2.5 billion smartphone users with easy
access to the Internet, social media, and social network- ESSENTIAL CONSIDERATIONS
ing sites provide opportunities for messages to reach large
Defining Social Media and
audiences and creates possibilities for 2-way engagement
Social Media Marketing
(eMarketer, 2016; Kepios, 2017). The use of social media web-
sites and applications to communicate, engage, and interact Social media is defined as websites or applications that allow
with others is called social networking. users to create online communities where they can share in-
The Occupational Therapy Practice Framework: Domain formation, personal messages, and content (e.g., videos, pho-
and Process (OTPF–3) considers a virtual context recognizing tos, events). If you go on the Internet and create a Facebook
that many individuals would consider use of social media as or Twitter account, you have created a social media account.
a meaningful occupation and should be considered in inter- After just a few minutes, you’ll probably find that you already
vention approaches and methods (American Occupational have a number of friends or connections through that web-
Therapy Association [AOTA], 2014). Social media has count- site. When you start to interact with those people through the
less uses, including professional promotion, marketing, so- website, you are engaging in social networking. You might
cial and professional communication, education, health pro- even create a Facebook page specifically for occupational
motion, and even intervention. therapy students or use apps in occupational therapy practice.
https://doi.org/10.7139/2019.978-1-56900-592-7.045
419
CHAPTER
Using Social Media Appropriately
Amanda Nardone, OTS 45
LEARNING OBJECTIVES
■ Define social media and identify different platforms for social networking;
■ Use social media effectively as a tool for promotion, professional connections, and engagement; and
■ Understand the ethical concerns related to using social media.

• Facebook • Social media marketing • Social networking sites
• LinkedIn • Social media platforms • Twitter
• Media sharing sites • Social media policies • Twitter chat
• Social media • Social networking • Virtual context
OVERVIEW This chapter focuses on understanding terms used in so-

cial media, discusses ways that social media can be part of the
S
ocial media has undergone dramatic growth in recent occupational therapy profession, and presents some ethical
years, with millions of users across the globe actively concerns related to the use of these networks. Two case exam-
engaging, communicating, and participating on web- ples support the concepts covered in the chapter.
sites such as Facebook, Twitter, LinkedIn, and YouTube.
Globally, with almost 2.5 billion smartphone users with easy
access to the Internet, social media, and social network- ESSENTIAL CONSIDERATIONS
ing sites provide opportunities for messages to reach large
Defining Social Media and
audiences and creates possibilities for 2-way engagement
Social Media Marketing
(eMarketer, 2016; Kepios, 2017). The use of social media web-
sites and applications to communicate, engage, and interact Social media is defined as websites or applications that allow
with others is called social networking. users to create online communities where they can share in-
The Occupational Therapy Practice Framework: Domain formation, personal messages, and content (e.g., videos, pho-
and Process (OTPF–3) considers a virtual context recognizing tos, events). If you go on the Internet and create a Facebook
that many individuals would consider use of social media as or Twitter account, you have created a social media account.
a meaningful occupation and should be considered in inter- After just a few minutes, you’ll probably find that you already
vention approaches and methods (American Occupational have a number of friends or connections through that web-
Therapy Association [AOTA], 2014). Social media has count- site. When you start to interact with those people through the
less uses, including professional promotion, marketing, so- website, you are engaging in social networking. You might
cial and professional communication, education, health pro- even create a Facebook page specifically for occupational
motion, and even intervention. therapy students or use apps in occupational therapy practice.
https://doi.org/10.7139/2019.978-1-56900-592-7.045
419
TABLE 45.1. Social Media Platforms
FACEBOOK INSTAGRAM LINKEDIN YOUTUBE SNAPCHAT TWITTER

No. of active 2.06 billion 700 million 106 million 1.5 billion 255 million 328 million
monthly users
worldwide*
Key feature and ■ Build a network ■ Share photos ■ Social media for ■ Video viewing ■ Share photos and ■ Share updates
uses of friends. and videos professionals. and sharing. short videos with in tweets of
■ Join groups and with followers. ■ Create an online ■ Create a Snapchat friends. 280 characters
invite people to ■ Follow other résumé. channel so that ■ Live updates or less.
events. accounts that ■ Search for job other users to friends and ■ Follow accounts
■ Share media are interesting opportunities. can follow your communication around the
such as photos, to you. ■ Connect with specific content. through shared world and grow
videos, web ■ Explore employers and ■ Follow other media. a network of
links, and more. interests by coworkers. channels to followers.
handles and ■ Use SlideShare to stay up to date ■ Use hashtags to
hashtags. share presentations on interested find information
publicly. content. on particular
topics or events.
Useful ■ Create a ■ Image content ■ Post a job opening ■ Video content is ■ Allows ■ Communicate
features for business page provides a and search for engaging and engagement with in real time with
managers and for free. personal potential candidate. entertaining. clients through other users to
administrators ■ Create event look at your ■ Use LinkedIn’s ■ Videos can be Snapchat- immediately
pages. business or CE to learn more educational. temporary content address any
■ Advertise and services. about program ■ Managers facilitates a feeling negative
share content. management, can create of more natural content.
■ Inexpensive to problem solving, educational communication. ■ Use trending
“boost” posts marketing, content as well ■ Can create a hashtags or
and share computer programs, as learn from snapcode and create your
content with a leadership, and so other YouTube when users take own hashtag
larger audience. forth. users. a picture of it, it to engage
■ Create an online takes them to a users and track
resume or business particular URL activity.
page. destination.
Note. *As of September 2017. CE = continuing education; URL = uniform resource locator.
If you use a hashtag (e.g., #OTconference) to start sharing Table 45.1 provides a brief summary of different social
photos and videos from an occupational therapy conference media sites. Every site has different privacy settings that users
to your Facebook and Instagram page, you are using social should be aware of, and it is recommended that users explore
media marketing to promote the occupational therapy pro- these options. Occupational therapy students and practi-
fession. Social media marketing is the process and technique tioners should consider why they use social media and who
of gaining attention on social media accounts to promote a they want to be able access personal information. Exhibit 45.1
particular message or product. You may even create a You- provides helpful information and general guidelines for stu-
Tube channel where you share videos that you made in class dents, practitioners, administrators, and managers using
describing interventions or frames of reference. social media sites.
Both social media networking and marketing are import-
ant to occupational therapy managers and administrators.
Social Media Platforms
Networking promotes engagement with potential clients and
can facilitate connections with potential future employees or Each of the many social media platforms can be used dif-
partners. Networking allows managers and administrators to ferently and for different purposes. Social media platforms
share information with an audience as well as learn about the are websites and applications that allow users to create on-
audience’s needs and interests. Marketing spreads awareness line communities and share information, personal messages,
about the occupational therapy profession and available ser- and other content (e.g., videos, photos). Examples of social
vices and supports potential clients in finding providers that media platforms include Facebook, Twitter, LinkedIn, and
are right for them. YouTube. We spend a lot of time being connected on these
CHAPTER 45. Using Social Media Appropriately 421
(e.g., “liking” or commenting on a photo), chat online, stream

EXHIBIT 45.1. Social Media Tips live videos, and create pages (e.g., for groups, events, busi-
nesses, fundraising, or fans). There are Facebook groups for
The following tips should be shared with employees as part of a connecting with all kinds of people and causes: individuals
social media policy: with cancer, moms of children with autism, traumatic brain
■ Remove any posts or photos that other people could interpret as injury (TBI) support groups, occupational therapy student
inappropriate or unprofessional. groups, groups for OTs in mental health, and millions more.
■ For safety, be mindful when sharing personal information, such as With almost 2 billion Facebook users (Fiegerman, 2017), the
location; be careful when you receive requests from people you possibilities for connecting are endless.
don’t know. Use privacy settings on different social media sites. Managers and administrators can use Facebook to con-
■ Connect with professionals in the field and other students on nect with particular groups of clients and learn about differ-
LinkedIn with similar interests. ent communities’s needs. For example, a pediatric wellness
■ Stay in contact with former classmates and colleagues through clinic could connect with groups of mothers of children with
LinkedIn.
disabilities, or local schools. Managers can use Facebook
■ Join online groups or discussion boards related to topics that
to share information about events, services offered, or cli-
interest you.
■ Share information that you think others will find useful.
ent successes (with appropriate permissions). To expand on
■ Create positive, engaging, and educational content. the pediatric wellness center example, the clinic may obtain
■ Use social media to learn about upcoming events, browse permissions to share a before-and-after video of a child who
employment opportunities, stay up to date, and share relevant participated in intensive therapy such as pediatric constraint-
information and resources. induced movement therapy. Or, the clinic may create a post
■ Follow companies and brands of interest. about a particular service that is offered, such as integrated
■ Use hashtags on twitter to highlight events and conferences, and listening systems, and who can benefit from that interven-
participate in Twitter chats. tion. Facebook is also cost-effective. Setting up a Facebook
■ Explore CommunOT or other online communities of interest. Business Page is completely free and allows easy engagement
■ Find legislators or senators on Twitter, Facebook, or LinkedIn and
with potential clients who comment and provides a platform
let them know about occupational therapy’s distinct value.
to share post updates, receive feedback, and share contact or
Avoid being connected on social media with clients, patients, website information.
and their families, AOTA’s (2015) Occupational Therapy Code of
Ethics (2015) Principle 3H reminds practitioners to maintain client LinkedIn. LinkedIn is social media specifically for profes-
confidentiality and privacy. Do not take photos of clients and post,
sional purposes. LinkedIn functions as an online résumé and
which is a violation of privacy.
works similarly to Facebook’s “friend request” feature. To add
a professional connection, you send a request to that person’s
profile. Job seekers can search companies, browse job listings,
connect with old colleagues, and participate in relevant groups.
websites; in fact, approximately 30% of all time spent online Companies and organizations can use LinkedIn to recruit
is on social media websites (Asano, 2017). The average person employees, search for potential candidates, post job openings,
spends almost 2 hours a day on social media, with YouTube and share information about their business. LinkedIn also has
taking up the most time, at an average of 40 minutes a day. a blog feature that users can use to share content and a Slide-
Two hours per day ends up comprising more than 5 years on Share option, where users can upload presentations and share
social media sites in a lifetime (Asano, 2017). It is no won- them with other professionals on LinkedIn.
der that there are entire careers and companies dedicated to LinkedIn is a valuable resource for occupational manag-
social media marketing. ers and administrators. Because LinkedIn functions as an
online résumé and networking site for professionals, it is a
good place to recruit potential candidates for jobs and post
Social network sites
open positions. LinkedIn also has an educational and con-
Social networking sites are used to connect users with other tinuing education (CE) platform that covers topics such as
people, organizations, groups, or brands. They can help a per- problem-solving techniques, interviewer tips, leadership,
son or business by allowing relationship building, increasing project management, marketing, and tutorials for using
awareness, and generate leads for hiring. Some examples of various computer programs and softwares. Managers and
popular social network sites include Facebook, LinkedIn, and administrators can benefit from these tutorials and courses,
Twitter. especially because many occupational therapy practioners
may not have formal education and training in these topics.
Facebook. Many people may have started using Facebook
as a way to keep in touch with friends who live far away; Twitter. Twitter allows users to share an update in 280 char-
today, however, the site is now used in many ways, connecting acters or less. Broadcasting these short messages is called
people around the globe. Facebook allows users to maintain a tweeting. Twitter is a marketing tool, a way for news to be
list of friends, share media, interact with other people’s media shared quickly and efficiently, and a platform to connect with
people across the globe and easily learn about events around Media sharing sites are important for occupational ther-
the globe through another person’s eyes. On Twitter, users apy managers and administrators because they atttact mil-
can build a following of users who are interested in them and lions of users per day and support creating and sharing
the content they share. engaging content. YouTube and Instagram allow personal
AOTA has a Twitter account (@AOTAInc) through which in- profiles in which shared content can be viewed at any time by
formation relevant to the therapy profession is shared. Hashtags other users. These profiles provide ways for current clientele,
can be used to identify tweets on a particular topic. For exam- partners, other professionals, or future clients to learn about
ple, if a user selects the hashtag #OTCentennial, he or she could occupational therapy services and connect more personally
view tweets related to that topic that have used the hashtag. For by viewing photo and video content. A business’s brand or
managers or administrators using Twitter to spread aware- mission can be shared effectively through media sharing site
ness and interact with the community, incorporating a trend- profiles. It is also crucial for managers and administrators to
ing hashtag helps to reach a larger audience because the tweet be aware of media sharing sites because of the inherent pri-
can be found by anyone searching the hashtag. Twitter makes vacy risks if employees use these sites at work.
it easy to target a particular community. In addition to being
a marketing tool, Twitter can also serve a customer support Review Questions
function. If a manager comes across any negative content, it
can be quickly and easily resolved on a public platform because 1. What is social media?
communication on Twitter occurs in real time. a. Websites or apps that allow users to create online com-
munities where they can share information, personal
messages, and content (e.g., videos, photos, events).
Media sharing sites
b. Online communities where individuals can commu-
Media sharing sites are used to share photos, live videos, pre- nicate about shared interests, network with profes-
recorded videos, music, and other media online. sionals, and plan events.
c. Websites that allow individuals to build a network
Instagram. Instagram, an app for sharing pictures and vid- of followers, share brief updates, and explore content
eos, is part of the growing popularity of mobile photography. posted by others around the world.
Similar to other social media sites, every user has his or her d. All of the above.
own profile; users can interact with one another by follow- 2. Students and professionals using social media should do
ing others, being followed, commenting, liking, tagging, and all of the following except:
sending private messages. When an individual posts a video a. Join the AOTA online communities to stay up to date
or photo on Instagram, it is added to that person’s profile and on the profession and network with occupational
shared with his or her followers. therapy practitioners.
b. Build trusting relationships with clients by commu-
YouTube. YouTube is one of the most popular video shar- nicating through social media sites and sharing per-
ing sites, with millions of videos on the website ranging from sonal information.
how to use a goniometer and how to move trailers to cute c. Share information through social media platforms
puppy videos. Anyone with an Internet connection can up- that could be helpful to others (e.g., articles, news,
load and watch videos on YouTube. With such a wide range of tips, videos).
video content, YouTube can be used for leisure, professional, d. Use LinkedIn to develop an online résumé and con-
or educational purposes. YouTube users can create individual nect with coworkers, health care professionals, and
channels for other users to easily find videos posted to that former classmates.
person or organization’s page. AOTA has a YouTube channel, 3. Why is it important to use privacy settings on social
and many colleges and universities have their own YouTube media sites?
channels to share content about students, programs, and
events. Occupational therapy students may create a YouTube
channel to share videos describing different frames of refer- PRACTICAL APPLICATIONS IN
ence or demonstrating intervention techniques. OCCUPATIONAL THERAPY
Social Media, Clients, and the Workplace
Snapchat. Snapchat, one of the newest social media sites, has
really revolutionized the way that friends interact and commu- The OTPF–3 refers to the virtual context as the environment
nicate with one another. It is similar to texting, except that it uses in which communication occurs through computers or air-
short videos and photos. What is different about Snapchat is that waves, such as messaging, chatrooms, and email. It occurs in
the photos and videos disappear, instead of being permanently the absence of physical interaction (AOTA, 2014). For occu-
posted to an online profile or website. This makes it feel more pational therapy practitioners who are concerned with how
like a natural communication, taking place in the present mo- people spend their time, the fact that people spend on average
ment. As with the other social media sites described, Snapchat about 2 hours a day using social media sites is important in-
has both personal uses as well as professional marketing uses. formation (Asano, 2017).
Using social media sites is a way of communicating, that a Facebook group provides an opportunity for discus-
interacting, sharing, and learning. For many individuals, so- sion, questions, and further clarification. Facebook is a
cial media participation is a meaningful occupation. It serves client-centered approach that uses a more natural context
as a tool to engage and develop social networks. Individuals by sharing information through a virtual platform that is al-
may use social media to learn about events, seek support in ready commonly used by individuals and can fit into a daily
an online group, meet new people, and explore interests and routine.
hobbies. Client confidentiality and privacy are very high priorities
For occupational therapy practitioners, it is possible that for health professionals and are protected by laws and regu-
a goal related to building a social network could include in- lations; all privacy and confidentiality policies apply to so-
tervention activities incorporating social media. These sites cial media accounts. More than 40% of nurses reported that
can also be places for clients to share about an illness expe- a coworker has inappropriately posted details about patients
rience and seek advice or support from others with similar or colleagues on social media sites (Larney, 2013). Sharing
illness experiences (Naslund et al., 2016). This search for an anecdote about a client can be a breach of confidentiality,
peer-to-peer support through social media avenues is being even if the client’s name is not used. Communication with
seen particularly frequently for individuals with mental ill- clients through personal social media accounts can be un-
ness and chronic diseases (Greene et al., 2011; Naslund et al., professional and inappropriate. Additionally, managers and
2016). One study evaluating social media use among patients administrators should be aware that public posts can affect
with diabetes found that patients, family members, and their the reputation not only of an individual but also of an en-
friends use Facebook to request guidance and support for tire company, as well as the occupational therapy profession.
disease management and emotional support and to share There are frequently stories in the news about people being
personal clinical information (Greene et al., 2011). There are suspended or fired for inappropriate content on social media
benefits and potential risks to virtual peer support, and it is (AOTA, 2015).
important for health professionals, including occupational Organizations supporting professionals in understanding
therapy practitioners, to be aware of these communities and the appropriate use of social media can develop social media
provide education to clients as needed regarding the possible policies, which provide rules and guidelines for employees to
benefits and risks. follow when using social media. These policies are developed
Aside from supporting clients in developing social net- to keep company information safe and secure, protect clients,
works, social media can also be used as an educational tool and preserve the company’s image and reputation (Cain,
for clients. Inge et al. (2017) conducted a random control 2011). Some recommendations include clearly defining who
study to evaluate the effectiveness of a Facebook group in is permitted to make public statements on behalf of the orga-
enhancing knowledge of evidence-based employment prac- nization; social media postings should never include personal
tices among individuals with TBI. It is well documented in patient information, and there should be clearly defined con-
the literature that individuals with TBI experience chal- sequences for violating policies (Cain, 2011).
lenges obtaining and maintaining employment (Wheeler & However, the potential negative effects of social media
Acord-Vira, 2016). A lot of evidence-based practice informa- should not deter practitioners from using social media in
tion is available, but it is often inaccessible or hard for indi- ways that can improve health care and client outcomes. In
viduals with TBI to understand. fact, a survey of occupational therapy practitioners in Ontario
Inge et al. (2017) proposed that sharing evidence-based revealed that 25% use social media in practice (Larney, 2013).
information through social media could be an effective ap- This can include using YouTube videos for educational pur-
proach. They randomly assigned 67 study participants into poses, connecting with other professionals for advice or in-
2 groups. One group received evidence-based information tervention ideas, or sharing successful techniques with other
through the form of a secret Facebook group, and the other practitioners.
group received information through an email newsletter
brief. Information about state employment resources, assis- Promoting Occupational Therapy Through
tive technology (AT) options, and intervention techniques
Social Media
was developed from research databases and was shared to
participants in a common language to enhance participant Social media is a powerful tool for sharing information about
comprehension. the occupational therapy profession and its distinct value.
Although the study findings did not conclude that Face- Promoting occupational therapy can be as simple as shar-
book is a more effective knowledge translation option for ing a photo on an Instagram account, tweeting a photo with
increasing employment knowledge of individuals with TBI, a caption using an OT hashtag, or sharing an article about
statistical analysis showed that participants did gain knowl- occupational therapy on a personal Facebook page to help
edge from the intervention. The researchers concluded that others learn about the profession. It is especially important to
there are advantages to using Facebook or email newsletters promote occupational therapy because it plays such a unique
to share evidence-based information with individuals with and dynamic role in various settings, which often results in
TBI. One of the benefits is that it allows people to access in- challenges when practitioners need to succinctly and effec-
formation when it is convenient for them. They also found tively explain occupational therapy.
Many readers may have heard phrases such as “OT is the number of visitors at varying times of the day, positive
physical therapy for the upper body,” “OT helps people interactions (e.g., likes), negative interactions (e.g., unliking,
with going to the bathroom and dressing,” or “OT helps unfollowing); comments; post reach; and other informa-
people with disabilities find jobs.” Occupational therapy tion. Twitter provides similar analytic information, includ-
professionals promote meaningful engagement in every- ing the number of engagements with a particular tweet, link
day activities and provide ways for individuals to live life clicks, and retweets. This information can also be viewed
to the fullest. Helping others understand occupational over a 28-day period, allowing users to track changes over
therapy’s role can improve funding and reimbursement, time. Exploring analytics gives important insight that can be
increase physician referrals, prevent encroachment in oc- used to craft better content and optimize the frequency of
cupational therapy’s practice area, and support interpro- distribution.
fessional collaboration. Another option for maximizing social media use is mul-
Promoting occupational therapy and ways that practi- tiplatform management services, such as Hootsuite, which
tioners enhance participation in meaningful activities is pulls multiple social media platforms so users can view all
also promoting health. For example, retweeting an article of them in a single, easy-to-read window. Hootsuite offers
about AOTA’s National School Backpack Awareness Day many features including scheduling posts, content curation,
is a way to share occupational therapy’s impact as well as analytics, and monitoring (Hootsuite, 2018). Scheduling with
important health promotion and safety information. Proj- Hootsuite allows sharing of pre-uploaded content to social
ect Career is a grant-funded program that provides support media accounts at designated times. Users can upload and
to undergraduate students with TBI. Case Example 45.1 schedule hundreds of messages at once. The monitoring fea-
outlines how Project Career has used social media for in- ture finds and filters conversations on social media by key-
formation sharing, program promotion, and participant words, hashtags, or location and provides a stream of content
recruitment. that can be easily shared with colleagues (Hootsuite, 2018).
AOTA is an active participant on several social networks, Hootsuite is an example of a social media management
which provides platforms for students and practitioners to tool and has several plans that can be purchased, depend-
connect, discuss, share timely information, problem solve, ing on whether an individual professional, team, or entire
and advocate. AOTA has an online community for mem- business is using Hootsuite and the site’s various features.
bers called CommunOT, which hosts postings from AOTA Hootsuite can help managers and administrators expand
staff, public discussion forums, forums for asking and an- their social media impact in a way that is cost-effective and
swering questions, and community blogs. It is also a place efficient.
to find AOTA podcasts, occupational therapy events, videos,
event and conference albums, and various ways to connect Review Questions
with other occupational therapy professionals. This is a place
where occupational therapy students can begin having a pro- 1. Aside from Facebook, what other social media platforms
fessional online presence, and administrators and managers might be effective for knowledge translation?
can seek support from other professionals, share knowledge 2. Do you think social media platforms are accessible and
and experiences, or learn about CE opportunities. user friendly for individuals with disabilities? Explain
your answer.
3. If you were a supervisor, what rules or guidelines
Maximizing Social Media would you create to help employees use social media
For individuals or organizations using social media, it can be appropriately?
beneficial to use various features, tools, or social media man-
agers to reach audiences, maximize benefits, and keep track
of data. For example, Twitter has a feature called retweeting,
SUMMARY
which is reposting another Twitter user’s tweet on your own An increasing number of people around the world are access-
profile to show to others you follow. This feature helps to ing social media sites, sharing information, and using the In-
share messages to large audiences. If an occupational ther- ternet to search for health-related information. Occupational
apy practitioner tweets a link about an upcoming webinar, therapy practitioners are trained in a holistic, client-centered
that tweet can be viewed by all of their followers. To in- approach that considers participation in occupation in differ-
form AOTA about the webinar, the practitioner could men- ent contexts and environments, including the virtual context.
tion AOTA in the tweet by using the AOTA Twitter handle Social media can be an effective tool for promoting the occu-
@AOTAInc. If AOTA retweets it, the announcement would pational therapy profession, sharing up-to-date information
then be shared with all of AOTA’s followers, reaching a much relating to the profession, networking with professionals, and
larger audience. Facebook has a similar reposting feature, seeking mentorship.
called sharing. Social media provides great opportunities, and it is crucial
Many social media platforms have free built-in analytics to be mindful of the information and content shared publicly.
tools that give users data. For example, Facebook Analytics When used carefully, it can also be a method for interven-
shows page managers a lot of valuable information, such as tion, particularly for knowledge translation and peer-to-peer
CASE EXAMPLE 45.1. Project Career and Social Media
Project Career demonstrates the use of social media as a tool for promoting grant activities and disseminating information. Project Career is a
5-year, multisite, interprofessional demonstration project funded through the National Institute on Disability, Independent Living, and Rehabilitation
Research (Hendricks et al., 2015; Nardone et al., 2015). The project provides a combination of cognitive support technology (CST) and intensive case
management to improve the employment outcomes of undergraduate students with TBI. The CST provided to all program participants is an iPad and
recommended apps, based on the participants’ specific cognitive challenges.
Knowing that social media is a way to reach a variety of individuals, Project Career has successfully used platforms to disseminate information
about the program and to target particular audiences. Project Career used Twitter and Facebook to share updates about upcoming presentations,
webinars, and articles. Project Career found Twitter accounts and Facebook pages owned by organizations and programs that support adults
with TBI, and interacted with those accounts and pages to engage an appropriate audience. These accounts are also used to connect with other
organizations or programs that are supporting individuals with TBI, using AT, and helping clients to return to work. Facebook can be used for creating
event pages; inviting other Facebook users to events; and sharing photos, videos, and other media. Project Career also hosted a Twitter chat, using
that #ProjectCareer hashtag. A Twitter chat is a public conversation that uses one unique hashtag, allowing other users to follow the conversation
and ask questions to the hosts. Through the Twitter chat, Project Career was able to answer questions and to share information about iPad apps that
are helpful for undergraduate students with TBI, based on program data. Social media has allowed Project Career to share research outcomes in a
way that is more accessible than peer-reviewed journal articles and other academic or scientific literature.
Review Questions
1. What are good topics for hosting a Twitter chat? How would you promote your chat to your target audience?
2. What are some other social media platforms that Project Career could use?
3. Why is it important for a program like Project Career to share information in accessible ways, other than academic journals?
Note. AT = assistive technology; TBI = traumatic brain injury.
support networks. Concerns related to the use of social media Asano, E. (2017). How much time do people spend on social media?
in health care are privacy and confidentiality, usability, the Retrieved from https://www.socialmediatoday.com/marketing
impact on patient–provider communication, and potential /how-much-time-do-people-spend-social-media-infographic
for misinformation. However, despite the challenges, the use Cain, J. (2011). Social media in health care: The case for organi-
zational policy and employee education. American Journal of
of social media is an exciting emerging trend with potential
Health-System Pharmacy, 68, 1036–1040.
for improving patient engagement, social networks, and com-
eMarketer. (2016). Smartphone users and penetration worldwide,
munity engagement. ❖ 2014–2020. Retrieved from http://www.emarketer.com/Chart
/Smartphone-Users-Penetration-Worldwide-2014-2020-billions
-of-mobile-phone-users-change/188679
ACOTE STANDARDS Fiegerman, S. (2017). Facebook is closing in on 2 billion users.
This chapter addresses the following ACOTE Standards: Retrieved from http://money.cnn.com/2017/02/01/technology/face
■ B.5.2. Advocacy book-earnings/index.html
■ B.5.6. Market the Delivery of Services Greene, J. A., Choudhry, N. K., Kilabuk, E., & Shrank, W. H. (2011).
Online social networking by patients with diabetes: A qualitative
■ B.7.1 Ethical Decision Making
evaluation of communication with Facebook. Journal of Gen-
■ B.7.2. Professional Engagement eral Internal Medicine, 26(3), 287–292. https://doi.org/10.1007
■ B.7.3. Promote Occupational Therapy /s11606-010-1526-3
■ B.7.5. Personal and Professional Responsibilities. Hendricks, D. J., Sampson, E., Rumrill, P., Leopold, A., Elias, E.,
Jacobs, K., . . . Stauffer, C. (2015). Activities and interim outcomes
of a multi-site development project to promote cognitive support
REFERENCES technology use and employment success among postsecondary
Accreditation Council for Occupational Therapy Education. (2018). students with traumatic brain injuries. Neurorehabilitation, 37,
2018 Accreditation Council for Occupational Therapy Education 449–458. https://doi.org/10.3233/NRE-151273
(ACOTE) standards and interpretive guide. American Journal of Hootsuite. (2018). Manage social media content. Retrieved from
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org https://hootsuite.com
/10.5014/ajot.2018.72S217 Inge, K. J., Graham, C. W., McLaughlin, J. W., Erickson, D.,
American Occupational Therapy Association. (2014). Occupational Wehman, P., & Seward, H. E. (2017). Evaluating the effectiveness
therapy practice framework: Domain and process (3rd ed.). of Facebook to impact the knowledge of evidence-based em-
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. ployment practices by individuals with traumatic brain injury:
https://doi.org/10.5014/ajot.2014.682006 A knowledge translation random control study. Work, 58, 73–81.
American Occupational Therapy Association. (2015). Occupational https://doi.org/10.3233/WOR-172595
therapy code of ethics (2015). American Journal of Occupational Kepios. (2017). Digital in APAC in 2017 [PowerPoint presentation].
Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot Retrieved from https://www.slideshare.net/kepios/digital-in
.2015.696S06 -apac-in-2017
Larney, E. (2013, June). Social media for occupational therapists: Naslund, J., Aschbrenner, K., Marsch, L., & Bartels, S. (2016). The
Balancing the risks and benefits. Presented at Canadian Occupa- future of mental health care: Peer-to-peer support and social me-
tional Therapy Conference, Victoria, BC. dia. Epidemiology and Psychiatric Sciences, 25, 113–122. https://
Nardone, A., Sampson, E., Stauffer, C., Leopold, A., Jacobs, K., doi.org/10.1017/S2045796015001067
Hendricks, D., . . . Rumrill, P. (2015). Project Career: A qualitative ex- Wheeler, S., & Acord-Vira, A. (2016). Occupational therapy practice
amination of five college students with traumatic brain injuries. Neu- guidelines for adults with traumatic brain injury. Bethesda, MD:
rorehabilitation, 37, 459–489. https://doi.org/10.3233/NRE-151274 AOTA Press.
CHAPTER
Grant Proposal Writing
Jessica J. Bolduc, DrOT, OTR/L, and Regula Robnett, PhD, OTR/L, FAOTA 46
LEARNING OBJECTIVES
■ Describe the role and purpose for grant proposal writing,
■ Describe the grant proposal process and format,
■ Identify funding resources,
■ Use grant-writing resources, and
■ Discuss 11 tips for proposal development.

• Award letter • Grantor • Program officer
• Budget • Indirect costs • Progress report
• Cover letter • Long-term goals • Public funding
• Direct costs • Methods • Short-term goals
• Dissemination • Needs assessment • Statement of the problem
• Evaluation • Objectives • Submission
• Grant • Pilot data • Summary
• Grant proposal • Private funding • Timeline
OVERVIEW ■ To secure funding for opportunities or activities for com-
A
munities, clients, practitioners, or students; and
grant is an award (usually monetary) provided to an
eligible grant proposal writer or group to support
■ To advance their professional careers (Wilson, 2011).
research or non-research-related projects. A grant Applying for grants can be a daunting task; thus, it is im-
proposal is a document used to convince a funding source portant to understand the scope of this endeavor. Securing
to support the writer’s (i.e., applicant’s) idea. Grant proposal funding is a multistep process that includes idea brain-
writing is normally a task undertaken by occupational ther- storming, needs assessment, program development to for-
apy practitioners and managers who aim to develop or grow malize and operationalize the idea, determining budget
a program, to secure resources for a therapeutic program, and funding needs, and undergoing a peer-review process
or to fill a client’s or community’s occupational needs. The (see Exhibit 46.1).
needed resources could involve a simple piece of equipment It can take upward of a year (or longer) to search for the
or software, or it could involve asking for funds to undertake grant that best fits the project’s needs and to follow the ap-
a research project. Other examples of reasons why occupa- plication process and timelines. The best practice is to seek
tional therapy practitioners seek grants include mentorship (e.g., like-minded colleagues, the grants man-
■ To advance scientific occupation-based knowledge through ager for your employer, the granting agency contact person)
research; throughout this process and have at least 1 expert read the ap-
■ To support the training and research agendas of research- plication draft. Some grantors review applications only once
ers or institutions; or a few times a year, which further slows down the process.
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427
CHAPTER
Grant Proposal Writing
Jessica J. Bolduc, DrOT, OTR/L, and Regula Robnett, PhD, OTR/L, FAOTA 46
LEARNING OBJECTIVES
■ Describe the role and purpose for grant proposal writing,
■ Describe the grant proposal process and format,
■ Identify funding resources,
■ Use grant-writing resources, and
■ Discuss 11 tips for proposal development.

• Award letter • Grantor • Program officer
• Budget • Indirect costs • Progress report
• Cover letter • Long-term goals • Public funding
• Direct costs • Methods • Short-term goals
• Dissemination • Needs assessment • Statement of the problem
• Evaluation • Objectives • Submission
• Grant • Pilot data • Summary
• Grant proposal • Private funding • Timeline
OVERVIEW ■ To secure funding for opportunities or activities for com-
A
munities, clients, practitioners, or students; and
grant is an award (usually monetary) provided to an
eligible grant proposal writer or group to support
■ To advance their professional careers (Wilson, 2011).
research or non-research-related projects. A grant Applying for grants can be a daunting task; thus, it is im-
proposal is a document used to convince a funding source portant to understand the scope of this endeavor. Securing
to support the writer’s (i.e., applicant’s) idea. Grant proposal funding is a multistep process that includes idea brain-
writing is normally a task undertaken by occupational ther- storming, needs assessment, program development to for-
apy practitioners and managers who aim to develop or grow malize and operationalize the idea, determining budget
a program, to secure resources for a therapeutic program, and funding needs, and undergoing a peer-review process
or to fill a client’s or community’s occupational needs. The (see Exhibit 46.1).
needed resources could involve a simple piece of equipment It can take upward of a year (or longer) to search for the
or software, or it could involve asking for funds to undertake grant that best fits the project’s needs and to follow the ap-
a research project. Other examples of reasons why occupa- plication process and timelines. The best practice is to seek
tional therapy practitioners seek grants include mentorship (e.g., like-minded colleagues, the grants man-
■ To advance scientific occupation-based knowledge through ager for your employer, the granting agency contact person)
research; throughout this process and have at least 1 expert read the ap-
■ To support the training and research agendas of research- plication draft. Some grantors review applications only once
ers or institutions; or a few times a year, which further slows down the process.
https://doi.org/10.7139/2019.978-1-56900-592-7.046
427
programmatic or community gap in services or other unmet

EXHIBIT 46.1. Steps of Grant Proposal Writing biopsychosocial needs to further provide supporting data for
the proposed grant.
1. Develop an idea that you are passionate about. Moreover, the applicant needs to make a concerted effort
2. Generate data to support your idea. to obtain pilot data to demonstrate preliminary outcomes
3. Find a funding source offering a grant that fits with your idea. of proposed programs, research, or equipment use. This in-
4. Seek mentoring, if you have not already. formation can strengthen the grant application and may be
5. Follow the funding source’s proposal template to the letter.
required. As the applicant, you may be fully confident in your
6. Get feedback on your proposal (and proceed with project or
ability to manage the requested funds for the purpose you
start over).
propose, but why should the granting agency believe you?
Source. Adapted from Cameron and Luvisi (2012). Share convincing evidence (Seeman, 2015).
Hard data in terms of pilot testing with individual clients
or initial research projects can be extremely helpful in clearly
However, if funding is needed, the program or service cannot establishing a need. Rarely will a granting agency fund some-
move forward without it. Much like the process of occupa- one without evidence that the applicant has done due dili-
tional therapy, grant proposal writing is a methodical (and gence to ensure that what he or she proposes has merit (NIH,
perhaps cyclical) endeavor. 2016). The needs assessment and preliminary data should
This chapter describes the skills needed for occupational be finalized prior to looking for potential funding sources
therapy managers and practitioners to fulfill their funding (Cameron & Luvisi, 2012).
needs, including developing an idea, identifying funding
options, grant proposal formatting, and improving their
overall success.
Learning Activity
ESSENTIAL CONSIDERATIONS On a flip chart, writing board, or a piece of paper, brainstorm

ideas for new programs you could provide as an occupational
Depending on the source of the grant, the funds can be ex- therapy practitioner. This may work best in a group setting. At the
tremely competitive to obtain, such as from the National brainstorming stage, there should be no judgment.
Institutes of Health (NIH), or they may be found relatively
easily through an individual philanthropist or foundation,
such as the American Occupational Therapy Foundation
(AOTF). The goal of obtaining grants is to secure funding Needs Assessment
for a specific client, population, or community. Regardless The needs assessment is an informal or formal evaluative pro-
of program or research needs, the client’s or population’s cess to assess an individual, group, or community for gaps in
need should come first. A potential grant recipient should service or other unmet physical, emotional, or psychological
never seek funding solely for individual gain (Cameron & needs. Specifically, the process is undertaken to identify dis-
Luvisi, 2012). crepancies between the resources available and the resources
that are needed. Traditionally, this can be done through chart
Start With an Idea reviews, client or family interviews, or the use of formal as-
sessment tools (Doll, 2010). Community-based needs assess-
Academicians and clinicians alike often develop ideas during
ment may also include demographic data or other convincing
their careers for the development of new programs and
health or societal indicators that can be quantitative or qual-
research projects for which they may require outside fund-
itative. The gathered data, in turn, will help to clearly con-
ing. They may seek support for a program or a direct service
ceptualize the new program or service that requires funding
or other needs for a client (Cameron & Luvisi, 2012). Securing
(see Case Examples 46.1 and 46.2).
grant funding also may help support academic promotion,
The needs assessment may involve any of the following
tenure, or institutional advancement (Liu et al., 2016).
data-gathering techniques:
The initial idea for a grant typically stems from a client
or community need, which may require additional funding ■ Surveys—to gather data online, by mail, or in person from a
beyond the applicant’s or employer’s capability. The idea population of interest
must be well thought out and supported by preliminary data ■ Community meetings—face-to-face meetings with the pop-
for any funding agency to consider funding the grant. The ulation of interest
idea must also match the mission of the granting agency. ■ Focus groups—to gather information on a topic usually
Support from the applicant’s administration or managers not well researched from a select group of stakeholders
can be influential, but data beyond this are also desired. (those for whom this information is pertinent)
At minimum, the applicant should conduct a review of the ■ Interviews with key informants—to gather information
evidence-based literature to support the need for funding. In from the experts, that is, those who are directly affected
addition, the applicant can conduct a needs assessment on a (University of Minnesota, n.d.).
CHAPTER 46. Grant Proposal Writing 429
It falls on the grant applicant (or applicant group) to synthe- sources are government entities that promote their mission
size this gathered information to “make the case” for the need and purpose by partnering with external organizations by
for requested funds. providing funding for research, development, or program-
ming. The U.S. federal government has the largest source of
Program Development funds for grants; the NIH (2017) has access to billions of dol-
lars ($30 billion to date). However, the funds are becoming
Following the completion of a needs assessment, develop a harder to replenish, so NIH grants, along with other federal
program to fill the established needs. The key items for pro- grants, are competitive and becoming increasingly challeng-
gram planning include ing to obtain (Liu et al., 2016).
■ Mission statement—the purpose or the why of the program Commonly sought-after government funding sources
being proposed, which must align with the mission of the include
funding agency; ■ NIH (including National Institute on Aging),
■ Goals and objectives—where you are going and the steps ■ Centers for Disease Control and Prevention,
needed to get there; ■ U.S. Department of Health and Human Services,
■ Implementation plan—the how of reaching the goals and ■ U.S. Department of Transportation,
objectives; ■ National Science Foundation,
■ Program evaluation—the outcome measures, including how ■ U.S. Department of Education, and
you will determine level of success; ■ U.S. Department of Veterans Affairs (Doll, 2010).
■ Grant funding needs—the explicit what you are asking for;
and Information about these agencies’ grants can be found on
■ Cost—the needs assessment, needs to include a clear, con- their individual websites or through search engines such as
cise, and exemplified budget (Doll, 2010). www.gov.org.
Completing these steps will enable a more focused search for

appropriate grant funding and provide a jumpstart to filling
out the grant application. Learning Activity
Search the www.gov.org website, and write down some options

Review Questions to fund your hypothetical new program. Then go to the Foundation
1. Where do initial ideas for a grant typically stem from? Center (www.foundationcenter.org) to see what options there are
2. Which grant ideas have the best chance to be approved available for funding in the private sector.
for funding?
3. What is the purpose of the needs assessment?
Private Funding Sources

PRACTICAL APPLICATIONS IN Grants not administered by government departments often
OCCUPATIONAL THERAPY fall in the private funding source sector, such as organiza-
Grantors or funders are the individuals or agencies that tions (e.g., businesses and foundations) that promote specific
provide grant funds. Grantors can come in many forms. areas of interest by reaching out to provide funds in the com-
Grant money can come from individuals or a group of munities where they operate businesses, provide services, or
investors or donors, organizations (public or private), reli- have special interests. Private funding sources can include
gious institutions, charities, academic institutions, or gov- individuals (philanthropists), groups of investors or donors,
ernment agencies (Cameron & Luvisi, 2012). Grant funding nongovernmental organizations (NGOs), corporations, reli-
may support part or all of the proposal, may cover startup gious institutions, charities, academic institutions, or foun-
costs, or may just support the cause in another way. The dations (Doll, 2010; Reynolds & Lane, 2010).
funding can vary in length of distribution, and there are Examples of nongovernmental funding organizations
always rules about renewals or reapplications. Program include
officers can be a resource when reviewing potential grant ■ Those related to a profession, such as AOTF;
sources; they serve as the contact person for answering ■ Those related to conditions or diseases, such as the
questions about the grant application and requirements Alzheimer’s Association or Juvenile Diabetes Research
(Doll, 2010). Foundation; and
■ Academic institutions, such as a local college or university.
Public Funding Sources
Online directories for private grant funds can be found at
One sector to consider when searching for public funding Foundation Center (www.foundationcenter.org) or GrantSpace
sources is to review federal agencies to assess whether their (www.grantspace.org). Librarians are often invaluable in as-
goals match the needs of the proposed project. Public funding sisting in the grant source quest. Regardless of whether you are
seeking public or private grant funding, the same principles proposed service or program funding to the mission of the
apply for determining which grants are appropriate and the ba- granting agency (Doll, 2010).
sics on how to write a grant proposal.
Objectives
Writing the Grant Proposal Grantors will look intently at the objectives, or goals, of the
A well-written grant proposal unambiguously communicates grant proposal. Objectives should clearly define the intent of
the need for funding, the intended impact of the proposed the program or service and how these intended outcomes will
program or service, and the feasibility of the projected probe achieved (Doll, 2010). Most often, no more than 3 objectives
gram outcomes (Gholipour et al., 2014). The grant proposal are recommended. The process of writing objectives should
needs to be clearly and concisely written and directed to the be familiar to the occupational therapy practitioner because
specific criteria required in the application. Proofreading to goal writing is used regularly in treatment planning. Each
ensure accuracy is an absolute necessity. A simple typo can objective needs to be well defined, concise, and measurable
sway a reviewer to toss aside an otherwise compelling appli- and address the needs of the person, group, or community.
cation. Requirements for grant applications will vary based If granted funding, progress reports written by the grantee
on the grantor. Ensure that you are using the most up-to-date and reviewed by the grantor on the services provided or the
forms available, be exceedingly mindful of deadlines, and use of the products obtained will be measured against these
provide all the requested supporting documentation. objectives. Granting agencies usually require progress re-
ports at specific intervals or at the conclusion of the grant to
ensure their funds are being used as proposed. The grant ap-
Cover letter plication may request hierarchical objectives; much like goal
Much like the cover letter for new employment, the grant pro- writing for client intervention, you may need to include long-
posal cover letter is used to pique the initial interest of the term goals, short-term goals or objectives, and specific aims
reader. The (generally) 1-page letter should aim to succinctly or activities to integrate the goals in addressing the problem
introduce the person or organization applying for the grant; or need (Gholipour et al., 2014).
list the title of the program or service; and state the compel- Long-term goals should address the significance of the
ling need for funding, the intent of the program or service, proposed plan and its long-term impact. The short-term goals
and the purpose of the application with regard to requested or objectives need to include the specific steps to be taken to
funds (Doll, 2010; Liu et al., 2016). Although a cover letter meet the long-term goals. The specific aims and anticipated
is not always required, an easy-to-read, enticing cover letter activities are the means to address both sets of goals. Overall,
may make the difference between further review and the re- the questions that must be answered include “What do you
viewers “deep sixing” the entire application. The cover letter intend to do?” “Why are these intended pursuits are import-
should provide undeniable reasons to invest in you and your ant?” and “How will everything be accomplished?”
plan (see a sample cover letter in Appendix 46.A, “Sample
Cover Letter”).
Learning Activity
Summary Use the SMART method for writing goals:
A summary or abstract is nearly always required in a grant S – Specific
proposal and serves to concisely summarize the literature M – Measurable
review and results of the needs assessment. The summary A – Achievable
may also tie in the theoretical foundations of occupational R – Relevant
therapy to the proposed program or service and highlight T – Time bound
evidence from the literature (Doll, 2010). Assuming that you Hypothetical example: Participation in a 6-week, occupation-based
have properly prepared and preplanned, the information community wellness group for at-risk older adults will decrease
should be readily available for this part of the application. The the risk factor for diabetes by 20% (based on scores on a specific
summary is usually not longer than 1 page, and the grant- measurement tool for risk of diabetes).
ing agency may have guidelines for word or character length Activity: Write at least 1 long-term goal and 2 short-term goals or
(Trujilo, 2013). objectives for your new program idea.
Source. Adapted from Smart Goals Guide (2016).

Statement of the problem or needs
The statement of the problem or needs section of the grant
Timeline
application can come from the needs assessment and should
describe specific unmet needs of an individual, commu- The timeline component of a grant proposal helps to ground
nity, or other entity. The statement should clearly link to the all aspects of the program, service, or device utilization.
service, or device delivery is recommended. Periodic checks

EXHIBIT 46.2. Timeline Template of program effectiveness will help to ensure consistent prog-
ress toward achieving the desired outcomes (Doll, 2010). If
DATE OR RESPONSIBLE necessary, based on these ongoing reviews, changes can be
ACTIVITY TIME FRAME PARTY made to the program, service, or device to keep everything
on track toward reaching the overarching goal and ensuring
proper use of the grant funds.
As determined by the proposed methods, data collection
may involve interviews, observations, questionnaires or sur-
veys, focus groups, or quantitative pre- and post-measures
(Doll, 2010). Not only is an effective evaluation process im-
portant during the granting period, but the use of effective
measures also may be helpful for long-term sustainabil-
It informs the grantor of the steps to be taken as part of the ity even after the initial grant funds have been exhausted.
grant in chronological and dated order (Doll, 2010). Time- Comprehensive, relevant collected data could provide the
lines may be retroactive and reflect relevant steps already needed leverage for continued monetary support from other
taken, such as the completion of the needs assessment, any potential granting sources to address client or community
necessary training, or approval of the research project by the needs.
involved institutional review board. Timelines also need to
succinctly outline the time frame for all the relevant tasks for Budget
the future, possibly including participant recruitment; the
length of the program, service, or device use; and when data Thoughtfulness and accuracy must be given to the budget
collection, data analysis, and dissemination will take place. If section of the grant application. Not requesting enough
funds are granted, the timeline then serves to keep the pro- funding can mean the program or service cannot be prop-
gram on track. See Exhibit 46.2 for a template example. erly implemented or the needed device cannot be obtained,
whereas requesting too much money without establishing
commensurate need can be wasteful and may result in a
Methods rejection of the proposal by the granting agency. Budgeting
The methods section of a grant application can also be thought is a complex art and science, based on expert opinions and
of as the implementation plan. This section needs to address cost estimates that are valid perhaps only today. As an appli-
how the program or service will be carried out or the device cant, confer with experienced grant recipients to make sure
will be used (including the assessment of efficacy); therefore, the budget is as inclusive and relevant as possible.
methods need to be well thought out to be considered wor- Within the budget, direct and indirect costs must be taken
thy of funding (Doll, 2010). Similar to an activity analysis, into consideration so that each dollar of the grant can be
the grant writer needs to break down, step-by-step, the ac- accounted for (Doll, 2010). Direct costs reflect all allowed cost
tions that will be taken to fulfill the delivery of the program, lines, such as personnel, equipment, supplies, training, and
service, or device. travel. Indirect costs reflect “the cost of doing business,” such
Always keeping in mind what is required by the potential as space, utilities, insurance, maintenance, and administra-
funder, the methods section may include other information tive costs (Doll, 2010).
regarding personnel, policies, and procedures; recruitment The funding agency and the applicant’s sponsor (e.g.,
of clients; how a program, service, or device will be used; employer) may both have rules regarding the percentage
data collection; and data analysis. Although the method sec- allowed for indirect costs. Start the budget plan by writing
tion may be complex, it is important to follow the granting a list of all possible resources needed to make the program,
agency’s instructions to precisely and to concisely connect service, or device delivery possible. Then break down each of
the grant activities to the problem statement and the stated these into direct and indirect costs. In general, direct costs
goals and objectives (Wisdom et al., 2015). should be itemized, whereas indirect costs may be a lump
sum or percentage of the requested funds. Each dollar in the
grant proposal should match a direct or indirect cost to be
Evaluation
justifiable.
The evaluation section of the grant application informs grant Be sure to review the criteria of the grant application to
funders the means by which progress on the proposed grant have a crystal-clear understanding of what grant dollars can
activities will be analyzed. The grant writer should articulate be used for, whether the use of certain funds is time sensi-
how data collection will be incorporated into the program, tive, whether (and how much) matching funds are required,
service, or device utilization as a means to record progress and whether unused funds must be returned (Doll, 2010). See
toward the project’s goals and objectives. Incorporating con- Exhibit 46.3 for a sample budget template and, as a relevant
sistent data collection measures throughout the program, activity, try to begin filling in your own.
Submission
EXHIBIT 46.3. Budget Template
Grant proposal applications must meet the stated submis-
BUDGET ITEM COST (NOTE sion deadline in the format of the granting agency’s choos-
(LIST SPECIFICS) DIRECT/INDIRECT) JUSTIFICATION ing. Some grantors ask for emailed submissions, some re-
quest mailed-in hard copies, and others use an online format
Personnel (contract/
salary) through a specific website. Lack of respect for the exact time-
liness may result in automatic rejection, or the proposal may
Training
miss the current review cycle and be held for the next cycle, if
Equipment (itemize) there is one. Be aware of dates and submit accordingly.
Supplies (itemize) In addition to the deadline given by the granting agency,
Space keep in mind that extra time may be needed to go through the
Other (be specific) process required by the applicant’s sponsoring agency. For
example, universities often have grant managers or offices,
Total direct cost:
and these may require several academic administrators (e.g.,
Total indirect cost: deans, provosts, chief operating officers) to sign off on the
proposal before it is submitted. These processes can take
Source. Adapted from Doll (2010).
time; do not assume all the necessary parties will all sign off
on the final day before the deadline.
Once the grant proposal is submitted, be prepared to wait
for weeks to months for an answer. You may contact the pro-
Dissemination gram officer at the funding agency for information, but keep
Dissemination is the process of sharing the outcomes of the in mind that he or she may be hearing from many other appli-
program, service, or device delivery with the larger commu- cants depending on the volume of submissions (Cameron &
nity, either formally or informally (Doll, 2010). Through the Luvisi, 2012). Prior to submitting, even for an in-house review,
mindful dissemination of program details, the program may be sure to have at least 1 peer or mentor review the application.
be able to be replicated, and thus the positive outcomes be- If the application is not accepted, review the feedback
come sustainable to the benefit of future recipients. In a best- offered, or request feedback to improve the next submis-
case scenario, the evidence gathered will provide an overview sion. Many projects are not funded initially. Consider what
of efficacious occupational therapy services as well as valuable changes are needed to strengthen the proposal, and resubmit
information to advance the profession. Occupational therapy if allowed to do so (Cameron & Luvisi, 2012). After editing,
practitioners who aspire to obtain grant funding should con- consider submitting to other grant funders. At times, it may
sider how their intended outcomes will provide supporting be worthwhile to submit to more than 1 grant application at
evidence. a time to increase the odds of being accepted. If accepted by
The outcomes should be shared multiple funders, review the rules of each granting agency to
determine whether multiple awards are permitted. Decline
■ Locally within the community where the program took those awards that would provide duplicate funding.
place (e.g., clinic, community setting, hospital); Be sure to review the award letter to understand any stip-
■ With the broader occupational therapy or interprofes- ulations attached to the award, what further documentation
sional health community locally, nationally, or interna- is required, and the expectations of adherence to the timeline
tionally, as applicable; and and plan. Confirm that the funds are entered into an appro-
■ In a medium that will reach the masses, such as in aca- priate account and that they are used solely for the project
demic lectures, peer-reviewed articles, continuing educa- as intended. Any changes in the plan need to be reported to
tion courses or workshops, or live or recorded webinars. the funding agency and may result in changes to the budget.
The applicant’s intentions for dissemination should high- Expect to account for each dollar spent (Cameron & Luvisi,
light the need to educate others beyond the scope of the initial 2012). Last, but not least, be sure to thank the grantors!
grant project based on the original gap in program, service, or
device delivery. By addressing the stated problem and achiev- Review Questions
ing the ultimate long-term goals through completion of the
grant program, the grantee may also become known as an 1. Which section of the grant application provides the
expert in the realm of intervention related to the project. Suc- grantor with the initial introduction to the idea, support-
cessful grant achievements may lead to academic accolades, ing facts, and needs assessment?
professional development, and career advancement. This sig- 2. Which section of the grant clearly describes all the steps
nificant accomplishment in occupational therapy also may for the project, including personnel needs and data
serve to open the doors to further opportunities for grant analysis?
funding (Doll, 2010). 3. What are direct and indirect costs related to budgeting?
Searching for public or private grants can be done

EXHIBIT 46.4. 11 Key Steps in Grant Writing through various means. A thorough review of the purpose
of the grants available from a grantor will enable an appli-
1. Develop a clear idea for program, service, or device delivery. cant to find the best match for a project. A thorough grant
2. Conduct a needs assessment to reflect the need for the proposal plan includes a statement of the problem or need,
proposed idea. goals, objectives, methods, timeline, evaluation methods,
3. Conduct a literature review and review theoretical foundations budget, and a dissemination or sustainability strategy. En-
to support the idea.
suring that these important components of the grant project
4. Develop a clear plan that includes a statement of problem or
are included and that the grant application is in harmony
need, objectives, methods, timeline, evaluation methods, budget,
and dissemination plan. with the mission of the grantor will improve the odds of
5. Seek out and identify appropriate funding sources. securing funding.
6. Collaborate with others, seek a mentor, and contact the program Extreme fastidiousness in attention to detail is needed for
officer for questions or clarification. successful completion of the application. Be mindful of any
7. Follow the directions and format of the grant application requirements for supporting documents and both in-house
explicitly, tweaking your original plan as needed. and grantor deadlines. Throughout the process, an expert
8. Be aware of timelines and deadlines for submissions (including mentor is invaluable, and asking respected others to proof-
the sponsoring institution’s rules). read the application and give feedback (including on the pro-
9. Proofread, edit, and rewrite until it is right. posed program as well as on accuracy in writing) can make
10. Be patient; this is a time-consuming endeavor.
the difference between a successful and a rejected grant pro-
11. Resubmit as needed; do not give up after 1 rejection.
posal. Learn from any unsuccessful attempts at attaining
Source. Adapted from Wisdom et al. (2015). funding and remember that success, in grant proposal writ-
ing as in most challenging endeavors in life, often takes per-
severance (see Exhibit 46.4). ❖
SUMMARY
Grant proposal writing involves a multifaceted, complex set ACOTE STANDARDS
of tasks; it requires much preplanning and attention to de-
tail. The first step of an astute grant applicant is to come up
with a clear idea of why grant funding is needed. A needs ■ B.5.1. Factors, Policy Issues, and Social Systems
assessment may help put the actual need into perspective ■ B.5.3. Business Aspects of Practice
and assist with finding sustaining theoretical support for the ■ B.6.4. Locating and Securing Grants
funding idea. ■ B.7.3. Promote Occupational Therapy.
CASE EXAMPLE 46.1. Zoey: Prevention and Wellness
Zoey, an occupational therapy practitioner in a rural region, noticed that the hospital patients being admitted recently have many chronic conditions.
She felt that if these patients had more preventive and wellness education and training, this may help improve their quality of life, fend off
exacerbations, and avoid costly hospitalizations. She began to write down her ideas and soon realized that she would need to complete a thorough
literature review to determine what kinds of health and wellness plans exist that are led by occupation therapy practitioners. Interventions and
education could target patients with diabetes, chronic obstructive pulmonary disease, arthritis, and advanced age.
After speaking with an occupational therapy practitioner in another part of the country who had started a practice in primary care
(a nontraditional work setting for occupational therapy), Zoey started to gather information for a needs assessment. She worked with all the
providers of the 9 primary care sites in her health system, educating them on the role of occupational therapy practitioners and reviewing possible
interventions and case scenarios where occupational therapy practitioners could help address health and wellness needs of older adults. With this
information, Zoey wrote a program proposal for an occupational therapy practice in primary care with a thorough grant proposal with all necessary
sections. Grant searches included the NIH and local foundations that favor small community hospitals in rural areas with a focus on improving
primary care. The program was reviewed by the hospital board, which approved this new practice area pending grant funding to support a pilot
program.
Review Questions
1. What are some literature search strategies that can be used in this case to help inform program development?
2. Which other grantors could be potential funders for this program proposal?
3. What will Zoey need to complete for her grantors after funds have been received and the pilot program is under way?
CASE EXAMPLE 46.2. Acquired Brain Injury Community Program
A small group of interprofessional professors (i.e., occupational therapy, physical therapy, social work) noted that their city had few resources for
the long-term needs for adults who had sustained acquired brain injuries (ABIs), although in a city only 1 hour away, a comprehensive commu-
nity day program had been developed. The established day program had been funded by the generosity of someone who had sustained an ABI and
had received a substantial settlement. The professors brainstormed solutions to the situation and decided to try to set up a local program. Through
their literature search, they found that those who have had ABIs are at a high risk for living a sedentary lifestyle; only a small percentage of this
population participate in regular physical activity (Gomez-Pinilla & Sharma, 2016), and only about 40% of working-age adults return to work within
2 years after sustaining an ABI (Van Velzen et al., 2009).
The group decided to do a local needs assessment. The group surveyed those who had sustained an ABI, their family members and
caregivers, and clinicians who worked in the field of neurorehabilitation. The survey results demonstrated a clear need, and a pilot program for
community-dwelling adults with ABI was initially established through university funding. The group wielded positive results, including increased
productivity and increased community involvement of adults who went through the program. The next step was to find funding from a local
foundation to begin a sustainable small-scale community program, to be run primarily by graduate health care students.
With the concrete evidence (including honest and convincing statistics) about the need for such programming, the university was able to convince
a local foundation to fund the program for a 2-year period.
Review Questions
1. Relate each step of the process listed in Exhibit 46.4, “11 Key Steps in Grant Writing.” Were all steps completed?
2. For what national funding sources may this project be eligible?
3. What types of outcomes would you recommend studying? Briefly, how might you set up a research project to assess these outcomes?
REFERENCES National Institutes of Health. (2017). Budget. Retrieved from

https://www.nih.gov/about-nih/what-we-do/budget
Reynolds, S., & Lane, S. J. (2010). Grant writing for occupational
therapy practitioners. OT Practice, 15(5), 7–12.
(ACOTE) standards and interpretive guide. American Journal of
Seeman, E. (2015). The ABC of writing a grant proposal. Osteopo-
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org
ros International, 26, 1665–1666. https://doi.org/10.1007/s00198
/10.5014/ajot.2018.72S217
-3085-2
Cameron, K. A. V., & Luvisi, J. (2012). Grants: Fulfilling dreams and
Smart Goals Guide. (2016). Smart goal setting. Retrieved from
needs for occupational therapy. Special Interest Section Quarterly,
http://www.smart-goals-.com/smart-goal-setting.html
28(1), 1–3.
Trujilo, L. G. (2013). An introduction to grant writing. In. R. V.
Doll, J. (2010). Program development and grant writing in occupa-
Whitney & C. A. Davis (Eds.), A writer’s toolkit for occupational
tional therapy: Making the connection. Sudbury, MA: Jones &
therapy and health care professionals: An insider’s guide to
Bartlett.
writing, communicating, and getting published (pp. 177–194).
Gholipour, A., Lee, E. Y., & Warfield, S. K. (2014). The anatomy and
Bethesda, MD: AOTA Press.
art of writing a successful grant application: A practical step-by-
University of Minnesota. (n.d.). How do you conduct a needs assess-
step approach. Pediatric Radiology, 44, 1512–1517. https://doi.org
ment? Retrieved from https://cyfar.org/ilm_1_9
/10.1007/s00247-014-3051-8
Van Velzen, J. M., Van Bennekom, C. A. M., Edelaar, M. J. A.,
Gomez-Pinilla, F., & Sharma, S. (2016). The therapeutic potential of
Sluiter, J. K., & Frings-Dresen, M. H. W. (2009). How many
diet and exercise on brain repair. In M. J. Ashley (Ed.), Traumatic
people return to work after acquired brain injury? A system-
brain injury: Rehabilitation, treatment, and case management
atic review. Brain Injury, 23, 473–488. https://doi.org/10.1080
(pp. 485–498). Boca Raton, FL: Taylor & Francis.
/02699050902970737
Liu, C. J., Pynnonen, M. A., St John, M., Rosenthal, E. L., Couch, M. E.,
Wilson, L. S. (2011). Proposal and grant writing. In K. Jacobs & G. L.
& Schmalbach, C. E. (2016). Grant-writing pearls and pitfalls: Max-
McCormack (Eds.), The occupational therapy manager (5th ed.,
imizing funding opportunities. Otolaryngology–Head and Neck
pp. 179–191). Bethesda, MD: AOTA Press.
Surgery, 154, 226–232. https://doi.org/10.1177/0194599815620174
Wisdom, J. P., Riley, H., & Meyers, N. (2015). Recommendations
National Institutes of Health. (2016). Write your application. Re-
for writing successful grant proposals: An information synthesis.
trieved from https://grants.nih.gov/grants/how-to-apply-application
Academic Medicine, 90, 1720–1725. https://doi.org/10.1097/ACM
-guide/format-and-write/write-your-application.htm
.0000000000000811
APPENDIX 46.A. SAMPLE COVER LETTER
Maine Health College

Portland, Maine 04103
March 12, 2019
To Whom It May Concern:
It is with great pleasure that I submit this letter of intent for the proposal to the Alfred E. Chase Charity Foundation under the
Bank of America Philanthropic Grants. Project Career: Development of an Interprofessional Demonstration to Support the Tran-
sition of Students With Traumatic Brain Injuries From Postsecondary Education to Employment meets the needs to students who
seek to gain employment after successful transition from higher education. The intent for this grant is to support development
and training of the interprofessional team who are working with students with traumatic brain injuries to prepare them for the
transition out of the structure of higher education.
After carefully reviewing the three focus areas of this grant, I believe that the grant proposal addresses the education priority:
“We fund educational programs for all ages. To that end, we fund academic access, enrichment, and remedial programming
for children, youth, adults, and older adults that focuses on preparing individuals to achieve while in school and beyond.” With
these funds, students can continue their academic success through the transition into gainful employment and beyond.
Thank you for considering the proposal: Project Career: Development of an Interprofessional Demonstration to Support the
Transition of Students With Traumatic Brain Injuries From Postsecondary Education to Employment.
Thank you for your time and consideration,

Sincerely,
Wendy Barton
Wendy Barton, PhD, OTR, FAOTA
Professor, Occupational Therapy Program
Maine Health College
207 Occupation Drive
Portland, Maine 04103
wbarton@mhc.edu
Source. K. Jacobs. Used with permission.
CHAPTER
Practitioner–Client Communication
Tamera Keiter Humbert, DEd, OTR/L 47
LEARNING OBJECTIVES
■ Identify key components and considerations of communication within the practitioner–client relationship,
■ Describe the historical changes in how therapeutic use of self has been conceptualized and how these ideals have
evolved throughout the past decades,
■ Articulate how the Occupational Therapy Code of Ethics (2015) shapes and influences the communication process, and
■ Describe the various ways that occupational therapy practitioners may address the challenges of communication
within the occupational therapy process and describe multiple approaches to further develop communication skills.

• Clinical reasoning • Journeying with clients • Therapeutic relationship
• Conditional reasoning • Narrative reasoning • Therapeutic use of self
• Ethical dilemmas • Occupational Therapy Code of • Veracity
• Intentional Relationship Model Ethics (2015) • Vulnerability
• Interactive reasoning • Practitioner–client communication
• Intuitive reasoning • Reflective practice
OVERVIEW clients and how they actually convey the various messages
T
they offer within the occupational therapy process. Prac-
o best understand practitioner–client interactions, one
titioners include both occupational therapists and occu-
must situate concepts of communication within the
context of therapeutic relationships and within the pational therapy assistants. Clients include individuals or
ideals of clinical reasoning and the American Occupational groups seeking occupational therapy services; family mem-
Therapy Association’s (AOTA) Occupational Therapy Code bers and significant others are often part of the communica-
of Ethics (2015) (hereinafter, the Code; AOTA, 2015) as pro- tion process.
moted by the profession. This chapter first highlights the con- Next, practitioner–client communication is considered
cept of therapeutic relationships, the interpersonal dynamic through the use of clinical reasoning and the ways commu-
between practitioner and client throughout the therapeutic nication is shaped within the occupational therapy process.
process. One particular construct of the therapeutic rela- Clinical reasoning is the comprehensive cognitive process
tionship is therapeutic use of self, which describes the ways
that practitioners use to make decisions about assessment and
in which practitioners use their own self within the therapy
intervention based on the judgments made about the person
process to facilitate collaboration with clients and evoke ther-
apeutic responses. receiving the therapy and the contexts in which intervention
The complexity of practitioner–client communication is is provided (Cronin & Graebe, 2018). Finally, an explana-
emphasized through a historical analysis of how therapeutic tion of the Code, ideals upheld within the profession that
use of self has evolved over the past 7 decades. Practitioner– define and articulate ethical principles based on core values,
client communication entails what practitioners say to is discussed as it relates to practitioner–client interactions.
https://doi.org/10.7139/2019.978-1-56900-592-7.047
437
CHAPTER
Tamera Keiter Humbert, DEd, OTR/L 47
LEARNING OBJECTIVES
■ Identify key components and considerations of communication within the practitioner–client relationship,
■ Describe the historical changes in how therapeutic use of self has been conceptualized and how these ideals have
evolved throughout the past decades,
■ Articulate how the Occupational Therapy Code of Ethics (2015) shapes and influences the communication process, and
■ Describe the various ways that occupational therapy practitioners may address the challenges of communication
within the occupational therapy process and describe multiple approaches to further develop communication skills.

• Clinical reasoning • Journeying with clients • Therapeutic relationship
• Conditional reasoning • Narrative reasoning • Therapeutic use of self
• Ethical dilemmas • Occupational Therapy Code of • Veracity
• Intentional Relationship Model Ethics (2015) • Vulnerability
• Interactive reasoning • Practitioner–client communication
• Intuitive reasoning • Reflective practice
OVERVIEW clients and how they actually convey the various messages
T
they offer within the occupational therapy process. Prac-
o best understand practitioner–client interactions, one
titioners include both occupational therapists and occu-
must situate concepts of communication within the
context of therapeutic relationships and within the pational therapy assistants. Clients include individuals or
ideals of clinical reasoning and the American Occupational groups seeking occupational therapy services; family mem-
Therapy Association’s (AOTA) Occupational Therapy Code bers and significant others are often part of the communica-
of Ethics (2015) (hereinafter, the Code; AOTA, 2015) as pro- tion process.
moted by the profession. This chapter first highlights the con- Next, practitioner–client communication is considered
cept of therapeutic relationships, the interpersonal dynamic through the use of clinical reasoning and the ways commu-
between practitioner and client throughout the therapeutic nication is shaped within the occupational therapy process.
process. One particular construct of the therapeutic rela- Clinical reasoning is the comprehensive cognitive process
tionship is therapeutic use of self, which describes the ways
that practitioners use to make decisions about assessment and
in which practitioners use their own self within the therapy
intervention based on the judgments made about the person
process to facilitate collaboration with clients and evoke ther-
apeutic responses. receiving the therapy and the contexts in which intervention
The complexity of practitioner–client communication is is provided (Cronin & Graebe, 2018). Finally, an explana-
emphasized through a historical analysis of how therapeutic tion of the Code, ideals upheld within the profession that
use of self has evolved over the past 7 decades. Practitioner– define and articulate ethical principles based on core values,
client communication entails what practitioners say to is discussed as it relates to practitioner–client interactions.
https://doi.org/10.7139/2019.978-1-56900-592-7.047
437
ESSENTIAL CONSIDERATIONS relationship from practitioner as expert to practitioner who

learns about and enters the client’s world (Humbert, 2016;
Evolution of Therapeutic Relationship, Humbert et al., 2018). Journeying with the client entails a
Communication, and Therapeutic Use of Self therapeutic relationship wherein the practitioner and the
According to the Occupational Therapy Practice Framework: client mutually share meaning through the therapy pro-
Domain and Process (OTPF–3; AOTA, 2014), therapeutic use cess. The practitioner learns through the lived experiences
of self and the therapeutic relationship are understood as of the client.
parts of the clinical reasoning process in which information This approach requires practitioners to acknowledge
and perspectives about the client become part of the therapy the often unknown course of events that clients experience
dynamic. The OTPF–3 defines therapeutic use of self as “an during major life challenges (e.g., dealing with the aftermath
integral part of the occupational therapy process . . . [that] of a stroke) and to join clients in that unknown. In addi-
allows occupational therapy practitioners to develop and tion, this approach offers the possibility of practitioners de-
manage their therapeutic relationship with clients by using livering more responsive care by allowing daily events and
narrative and clinical reasoning; empathy; and a client- therapeutic responses to them to unfold naturally. More
centered, collaborative approach to service delivery” (AOTA, specifically, practitioners do not establish intervention goals
2014, p. S12). and strategies for clients and then just apply them in therapy
The way a practitioner engages in the therapeutic rela- sessions but instead address what is most important to cli-
tionship is based on how the practitioner conceptualizes ents at any specific moment. The therapy session is directed
and perceives that relationship. The term therapeutic use by clients’ present needs, and the approaches used to ad-
of self was first presented in the occupational therapy liter- dress those needs are discussed and explored collaboratively
ature in the 1950s but has evolved over the past 7 decades. with clients.
Therapeutic use of self was first espoused as a way for ther- Journeying with clients recognizes the personal and
apists to perceive their own skills, abilities, and importance deep meaning that clients bring to major life events and
within the practitioner– client relationship (Frank, 1958; requires practitioners to not only walk alongside clients
Hunting, 1953). The primary focus was on the practitioner, during their journey by engaging in the cocreation of
with little acknowledgment of what the client brought to the occupations and rituals but also live with and learn from
therapy process. Later, therapeutic use of self was further un- clients through their journey (Beagan & Kumas-Tan, 2005;
derstood as what practitioners projected to clients (Walker Collins, 2007; Luboshitzky, 2008; Romanoff & Thompson,
1971); how practitioners demonstrated empathy (Gilfoyle, 2006). This approach has been linked with using spiritu-
1980; Schwartzberg, 1993); and how various practitioner ality within the therapeutic process (Cole & Creek, 2016;
roles, such as teacher, facilitator, or coach, could influence the Humbert, 2016).
practitioner–client relationship and affect therapy outcomes
(Hopkins & Tiffany, 1988). Clinical Reasoning and
Over the past 3 decades, therapeutic use of self has ex-
panded to include practitioners recognizing the significance
of clients’ lived experiences, honoring clients’ perspectives Various types of thinking and “knowing” that practitioners
and desires (Peloquin, 2003; Price, 2009; Romanoff & use to process information within the therapeutic process
Thompson, 2006), and recognizing the complexity and chal- have been identified and described in the literature as clinical
lenges that can be inherent in such relationships (Taylor, reasoning (Boyt Schell & Schell, 2008). Several types of clin-
2013). As the occupational therapy profession has grown ical reasoning are distinctly related to the practitioner–client
and evolved over the past 70 years in considering and ad- relationship and interactions. Narrative reasoning includes
dressing multiple layers of practice that affect the therapeu- story creation and expression to share the client’s story with
tic relationship, such as client and practice environments, others on the intervention team and within supervisory ses-
reimbursement, legislation, health promotion, and quality sions. Narrative reasoning allows practitioners to appreciate
measures and outcomes, therapeutic use of self has also clients’ perspective of their major life events, to make sense of
expanded to include an appreciation for the complexity clients’ lived experiences, to make meaning of what occurred
of practitioner–client communication (see Table 47.1). The within any practitioner–client interactions, to clarify clients’
current understanding of practitioner–client communica- desires and motives, to link clients’ actions with their per-
tion is that both the practitioner and the client bring perceived internal motivation and goals, and to determine how
sonal attributes, attitudes, perspectives, and unique lived to approach clients in therapy (Boyt Schell & Schell, 2008;
experiences to the therapy process and personal commu- Hess & Ramugondo, 2014).
nication aids in the development of therapeutic relation- Interactive reasoning is related to understanding how best
ships, which can ultimately influence therapeutic outcomes to approach clients within the occupational therapy process
(AOTA, 2014). by respecting each client as an individual with unique per-
In addition to these traditional modes of practitioner– spectives about of his or her occupational performance chal-
client interactions, the phrase journeying with clients is lenges and valuing the client’s cultural points of view (Boyt
also being used to represent a change in the therapeutic Schell & Schell, 2008; Cole & Creek, 2016; Muñoz, 2007).
CHAPTER 47. Practitioner–Client Communication 439
TABLE 47.1. Focus of Practitioner–Client Communication as Represented in AJOT, 1950–Present
TIME EXAMPLES OF THERAPEUTIC RELATIONSHIPS AND

FRAME KEY THEMES AND CONTEXTS WITHIN THE DECADE PRACTITIONER–CLIENT COMMUNICATION
1950s Therapeutic relationships, human dignity for all, intrinsic “Make use of self and intuitive feelings in meeting the patient’s needs”
motivation of patients, developing programs and (Hunting, 1953, p. 107).
occupational therapy departments, student education “To use himself effectively, the therapist must also have a clear realization
of his own abilities and limitations” (Frank, 1958, p. 224).
“To get the patient to make an emotional investment in the therapeutic
situation . . . to reduce the patient’s situation . . . to redirect the patient’s
anxiety, or raise his self-confidence . . . to begin again to profit from
new interpersonal experiences” (Frank, 1958, p. 225).
1960s Human nature orientation, differences in class values and “In his new experience with the occupational therapist the patient brings
activity orientation, independence and self-sufficiency, his particular combinations of feelings and he meets the new important
legal aspects of health care, outcome measures, research, and influential people (his therapist) with reactions similar to those he
structured and standardized assessments, performance has practiced and perfected though the years. This basic phenomenon
requirements, clinical thinking, reimbursement and opens several vistas to the occupational therapist” (Conte, 1960, p. 2).
Medicare, occupational therapy assessments, changing “Therapists adjust their attitude to accomplish the most efficient and
concepts of work and function workable interpersonal relationships” (Pishkin et al., 1961, p. 57).
1970s Research in developmental stages, comparison studies and “The more effective therapists believe in what they do. They have a
normative data, health policy, health planning, private practice, purpose in living” (Walker, 1971, p. 523).
professional identity, competence-based education, proficiency “Essential in a therapeutic environment is a therapist who possesses the
examinations, licensure, consultation models, bioethics, basic attitude that he is a worthwhile person, a person who has a purpose
interdisciplinary education, career specialization, inclusiveness, he believes in and a job to do that he feels is important. When the
rural health, productivity, management, supervision, peer therapist believes in himself, he believes in others” (Walker, 1971, p. 524).
review, occupational therapy theory, occupation-focused
theory, child abuse awareness, elder abuse awareness
1980s Leadership, academia, fieldwork issues, student selection and “Occupational therapists are specialists in making caring happen. We know
preparation, private practice, funding, occupational therapy how to enrich all the transactions in the relationship with the patient.
specialization, standards of practice, multidisciplinary These become caring gestures. . . . Personal caring provides the depth of
approaches, outcomes research, quality assurance, tension emotion necessary to make caring in the professional or societal sense
between the science and art of occupational therapy, ethical possible” (Gilfoyle, 1980, p. 526).
reasoning, access to care, productivity and corporate “The roles a therapist assumes may vary. The therapist may legitimately be a
culture in health care teacher or a facilitator who brings knowledge and skills to the client’s unique
situation. The most important prerequisite to being an effective helper is self-
knowledge: the helper needs to be aware of his/her own needs, perceptual
biases, and capabilities” (Hopkins & Tiffany, 1988, p. 108).
“A therapeutic relationship is a developmental process. The therapist needs
to determine how much support and gratification are necessary to sustain
the patient’s health and well-being. This varies depending on the nature
and phase of the therapeutic relationship” (Schwartzberg, 1988, p. 385).
1990s Managed care, evidence-based practice, professional “The therapist’s use of self is critical to engaging the patient in occupational
competence, clinical reasoning, problem-based learning, therapy. Three ingredients are essential to establishing a therapeutic
continuing education, health care reform, consultation relationship: understanding, neutrality, sometimes called empathy, and
and collaborative models, case management, contractual caring” (Schwartzberg, 1993, p. 269).
work, technology, qualitative research (ethnography, “Empathy is valued in occupational therapy as an attitude that affirms
phenomenology, narratives, life histories), meta-analysis, human dignity” (Peloquin, 1996, p. 660).
occupational science academic programs, legitimizing
occupational therapy knowledge, networking, role delineation
and supervision guidelines, fieldwork expectations and
evaluation, costs and benefits of fieldwork, alternative
fieldwork models, service learning, retaining and reactivating
practitioners, recruitment, part-time Level II fieldwork, student
coping, computer literacy and competency of students, Rasch
analysis of functional assessments, Uniform Terminology,
multicultural competencies, reporting physical abuse,
mentoring relationships, faculty careers and development,
professional doctorate, interdisciplinary teams
(Continued)
TABLE 47.1. Focus of Practitioner–Client Communication as Represented in AJOT, 1950–Present (Cont.)
TIME EXAMPLES OF THERAPEUTIC RELATIONSHIPS AND

FRAME KEY THEMES AND CONTEXTS WITHIN THE DECADE PRACTITIONER–CLIENT COMMUNICATION
2000s Autoethnography, children’s voices in research, longitudinal “The art of the profession’s practice, like most art, is a process of
results of intervention, occupational science research, making connections, evoking responses, and finding shared meaning”
quality of life, culture emergent, occupational identity, (Peloquin, 2003, p. 157).
scope of practice, sensory processing disorders, “One who masters the art of practice perceives and responds to the
occupational therapy seeker, student voices, interpretive individual seeking therapy as a whole person, indivisible into parts or
research, research productivity, OTPF, social action, subsystems” (Peloquin, 2003, p. 158).
social justice and health disparities, occupational justice, “Establishing a collaborative relationship requires that clients be willing to
promotion of health, critical pathways, benchmarks, actively engage as partners in the therapy process and that therapists
client choice, academic terminal degrees, ethical decision be willing to offer and finely adjust therapy activities on the basis of the
making, disaster preparedness, community integration, fall client’s priorities and a careful reading of their desires, motives, and
risks, AMPS, life-threatening illnesses, leisure satisfaction, experiences of therapy” (Price, 2009, p. 332).
the retirement process, neonatal care and feeding, “Therapists use themselves as therapeutic agents when they shift their
adult sensory profiles, obesity, integrated supported role such as director, coach, supporter, and follower, fluidly responding
employment, early intervention, dynamic interactional and using multiple strategies” (Price, 2009, p. 336).
model, assistive technology, cognitive aids, COPM, “The ability to be present to a suffering patient, the willingness to simply
adult vestibular rehabilitation listen, is in itself restorative. The goal is not to analyze or change the
story the patient tells. Rather, the goal is to enter into a relationship to
hear and to honor the story the patient tells as many times as the
patient needs to tell it” (Romanoff & Thompson, 2006, p. 311).
2010s Sensory modulation disorder, informal caregivers, “One of the most common terms used to refer to therapist–client
self-management programs, cancer survivorship, anxiety interactions is the therapeutic relationship. Literature and dialogue
reduction with adolescents and children, attachment about the therapeutic relationship commonly address topics such
disorder, trauma, sleep hygiene, community-dwelling as rapport building, communication, conflict resolution, emotional
older adults, hyperactivity, activity limitation, ASPS, adults sharing, collaboration, and partnership between therapists and
with attention deficit hyperactivity disorder, fitness to clients. Therapeutic use of self is a popular term used in occupational
drive, veterans’ needs, young veterans, military combat therapy to refer to the therapist’s deliberate efforts to enhance their
stress, occupational performance coaching, safe-patient interactions with clients” (Taylor, 2013, p. 426).
handling, self-development groups, medication adherence, Empathy is the emotional exchange between occupational therapy
behavioral health, robotics, fall prevention, home safety, practitioners and clients that allows more open communication, ensuring
fatigue management, home modification, social interaction that practitioners connect with clients at an emotional level to assist
measures, work and industry, community mental health, them with their current life situation” (AOTA, 2014, p. S12).
mindfulness, health service delivery, telerehabilitation, “The focus on spirituality within the construct of the therapeutic use of self
telehealth, systematic reviews, effectiveness of implies intentional acknowledgment of the potential connectivity among
interventions, habilitative services, photovoice methodology, all people associated with the therapeutic journey and a desire to be
knowledge translation, health prevention and wellness open to such connectivity” (Humbert, 2016, p. 153).
and healing, clinical trials, ACA, connectivity, intuition and
emotional intelligence, spirituality
Note. ACA = Patient Protection and Affordable Care Act; AJOT = American Journal of Occupational Therapy; AMPS = Assessment of Motor and Process Skills;
AOTA = American Occupational Therapy Association; ASPS = Adult Sensory Processing Scale; COPM = Canadian Occupational Performance Measure;
OTPF = Occupational Therapy Practice Framework: Domain and Process.
Through various communication styles and approaches, of clients (Audet & Everall, 2010). Lastly, practitioners need to
practitioners get to know the client and, at times, the client’s integrate their communication styles and approaches to best
family or significant others (Boyt Schell & Schell, 2008; Cole address clients’ concerns, strengths, values, and needs related
& Creek, 2016). As practitioners use interactional reasoning, to the therapy process (Cole & Creek, 2016; Pooremamali
or connected and shared knowledge, they are then better pre- et al., 2012).
pared to understand what is most valued and important for Conditional reasoning is characterized as a projective
the client in the therapy process. mode in which practitioners perceive the complexity of a cli-
As part of this clinical reasoning process, practitioners ent’s life, including the family, social, and physical contexts
first need to be respectful of how clients perceive their lives that the client is engaged in and with consideration of the oc-
and what they value about the therapy process (Cole & Creek, cupational challenges the client is experiencing. Conditional
2016; Muñoz, 2007). Practitioners then need to also under- reasoning allows practitioners to imagine how the client’s life
stand how the therapy process might further affect the lives could change in the future and then engage the client in the
construction of a new self-image through the therapy process AOTA’s Code and Implications for
(Boyt Schell & Schell, 2008). Practitioners imagine the client Practitioner–Client Communication
in future contexts based on past and current roles and en-
Practitioner–client interaction and communication take into
gage the client to participate in intervention while assisting
account the lived experiences and perspectives of clients,
the client or family members in understanding possibilities
along with the lived experiences and professional disposi-
for the future (Hess & Ramugondo, 2014). Ultimately, the in-
tions of and approaches used by practitioners. The Code fur-
tegration of narrative, conditional, and interactive reasoning
ther guides practitioners in understanding the perimeters in
allows for the development of shared meaning of the therapy
which such communication needs to be considered and con-
process and new life possibilities (Boyt Schell & Schell, 2008). ducted (AOTA, 2015; see Table 47.2).
Intuitive reasoning has been identified as practitioners’ As supported by the concepts of therapeutic use of self
use of multiple ways of knowing to best respond to clients’ and clinical reasoning, an ethos of dignity and respect for cli-
reactions to the therapy process (Chaffey et al., 2010, 2012; ents and honoring collaboration with clients is also reflected
Pretz et al., 2014). Practitioners’ intuitive reasoning (i.e., sen- in the Code. Decision making, based on client choices and
sitivity to their own emotions and those of the clients) enables desires, is valued and integrated into the therapy process
practitioners to integrate what they are seeing and experi- (Scott & Reitz, 2017). Confidentiality is upheld (AOTA, 2015).
encing within the intervention session and to spontaneously Additionally, the Code acknowledges attitudes of fairness,
adjust their communication approaches to better meet cli- honesty, and truth, reinforcing to practitioners that clients
ents’ needs. This type of reasoning, often linked to emotional should have the necessary information to make informed
intelligence, furthers the unspoken communication between choices about therapy (Scott & Reitz, 2017). Conversely, the
client and practitioner (Chaffey et al., 2010, 2012; Pretz et al., Code denounces behaviors that do not support this ethos
2014) and can be used with individuals when verbal commu- of care. Coercion, giving false information, and deceiving
nication is limited (Raber et al., 2016). clients are ethical violations.
TABLE 47.2. Ethical Considerations Related to Practitioner–Client Communication
ETHOS PRINCIPLE
Dignity and respect “Inherent in the practice of occupational therapy is the promotion and preservation of the individuality and Dignity of
the client by treating him or her with respect in all interactions” (p. 2).
“Respect and honor the expressed wishes of recipients of service” (p. 4).
“Respect the client’s right to refuse occupational therapy services temporarily or permanently, even when that refusal has
potential to result in poor outcomes” (p. 4).
Collaboration “Establish a collaborative relationship with recipients of service and relevant stakeholders to promote shared decision
making” (p. 4).
“Facilitate comprehension and address barriers to communication” (p. 5).
Confidentiality “Maintain the confidentiality of all verbal, written, electronic, augmentative, and nonverbal communications” (p. 4).
Ethical behavior “Refrain from threatening, coercing, or deceiving clients to promote compliance with occupational therapy
recommendations” (p. 4).
“Occupational therapy personnel should relate in a respectful, fair, and impartial manner to individuals and groups with
whom they interact” (p. 5).
“Refrain from using or participating in the use of any form of communication that contains false, fraudulent, deceptive,
misleading, or unfair statements or claims” (p. 6).
“Recognize and take appropriate action to remedy personal problems and limitations that might cause harm to recipients
of service, colleagues, students, research participants, or others” (p. 3).
Honesty and integrity “Fully disclose the benefits, risks, and potential outcomes of any intervention; the personnel who will be providing the
intervention; and any reasonable alternatives to the proposed intervention” (p. 4).
“In communicating with others, occupational therapy personnel implicitly promise to be truthful and not deceptive. When
entering into a therapeutic or research relationship, the recipient of service or research participant has a right to
accurate information. In addition, transmission of information is incomplete without also ensuring that the recipient or
participant understands the information provided” (p. 6).
Critical analysis “Concepts of veracity must be carefully balanced with other potentially competing ethical principles, cultural beliefs,
and organizational policies. Veracity ultimately is valued as a means to establish trust and strengthen professional
relationships. Therefore, adherence to the Principle of Veracity also requires thoughtful analysis of how full disclosure
of information may affect outcomes” (p. 6).
Note. Principle descriptions are from the Occupational Therapy Code of Ethics (2015) (AOTA, 2015).
What is noteworthy in the Code is the recognition that and collaborative relationship between practitioner and client
communication is challenging and at times complex. Verac- (Provencher & Keyes, 2011; Steffen, 2013; Young, 2010).
ity encompasses the core values of truth telling, candor, and Clients bring to the occupational therapy process their
honesty. Veracity, or truth, needs to be balanced with other knowledge about their life experiences and their hopes and
ethical principles, cultural beliefs, and organizational policies dreams for the future. They identify and share their needs
(AOTA, 2015). Inherent conflicts do exist at times between the and priorities about engaging and reengaging their roles
principles governing ethical decision making. Understand- and occupations. Occupational therapy practitioners bring
ing the complexities of practitioner–client communication their knowledge about how engagement in occupation affects
means having an appreciation for the conflicts that do arise health, well-being, and participation; they use this informa-
between practitioner and client and the challenging contexts tion, coupled with theoretical perspectives and clinical rea-
or environments in which therapy is provided (Purtilo & soning, to critically observe, analyze, describe, and interpret
Doherty, 2015; Scott & Reitz, 2017). Not only do practitioners human performance (AOTA, 2014).
need to have awareness and appreciation for the conflicts and In addition, the literature related to spirituality and thera-
critical analysis of the issues, but they also need the ability to peutic use of self has shifted even further, considering not only
consider multiple perspectives, develop strategies to address the potential for practitioner and client vulnerability (i.e.,
the conflicts, and develop the professional skills to address shared openness about personal beliefs and perspectives) but
such conflicts (Purtilo & Doherty, 2015; Scott & Reitz, 2017). also reciprocal personal and professional growth between cli-
ent and practitioner within the therapeutic relationship (Gee &
Loewenthal, 2013; Humbert, 2016; Humbert et al., 2018; Kirsh,
Review Questions
2011). Vulnerability reflects an openness to experiencing and
1. How has therapeutic use of self evolved within occupa- sharing one’s own feelings, insecurities, and concerns within
tional therapy practice, and what are the implications for the therapy process. Practitioners need to consider how these
practitioners and clients? communication approaches may at times come into conflict
2. What are the types of clinical reasoning that shape with the desires and needs of clients (see Case Example 47.1).
practitioner–client communication, and when might each Throughout the literature, clients have identified the value
type be used within the occupational therapy process? and significance of helpful therapeutic relationships when
3. How does the Code support practitioner–client commu- these interactions provide alternative viewpoints (Gunnarsson
nication? et al., 2010), offer hope and encouragement (Duff & Bedi,
2010; Wright & Jones, 2012), and honor the client as an ac-
tive contributor to the therapy process (Bachelor, 2013; Cruz
PRACTICAL APPLICATIONS IN et al., 2015; Steffen, 2013). However, clients have identified the
OCCUPATIONAL THERAPY therapeutic relationship as challenging at times when cul-
tural differences and beliefs between client and practitioner
Complexities of Practitioner–Client
are realized (Bellin et al., 2011; Pooremamali et al., 2012) and
Communication when practitioners have not fully developed a realistic image
The complexities of the practitioner–client relationship offer of the client (Cruz et al., 2015; Jeyaraj et al., 2013).
insights into what practitioners must be attentive to in the Additionally, practitioners have identified the challenges
therapy process, including the differences in how clients of developing therapeutic relationships when productivity de-
perceive the practitioner–client relationship and how deci- mands are high (Palmadottir, 2006), when the workplace en-
sions are made about the therapy process, how sensitive top- vironment does not value such relationships (Sweeney et al.,
ics are discussed, and the ongoing development of related 2014), and when theoretical models of practice focus only on
professional communication skills. This section provides narrow aspects of care and dismiss the value of practitioner–
an overview of current literature related to variations of client collaboration (Palmadottir, 2006).
practitioner–client relationships, strategies that may be used
during challenging interactions, and ways to support ongoing Strategies When Engaging in Challenging
professional development in enhancing communication. Practitioner–Client Communication
Specific strategies can be used in practitioner–client commu-
Therapeutic Context Matters
nication, whether the challenge is a pragmatic concern, such
The occupational therapy literature has identified empathy as limited time and resources; constitutes a difference in how
(AOTA, 2014), authentic respect (Pooremamali et al., 2012), ac- the therapeutic relationship is viewed by the client; involves
tive and compassionate listening (Crepeau & Garren, 2011), col- discussing sensitive topics such as sex; or includes direct
laboration and reciprocity (Audet & Everall, 2010; Morrison & verbal communication that is physically or psychosocially
Smith, 2013), and openness and trust (Crepeau & Garren, 2011; impossible (see Table 47.3). Additionally, an interdisciplin-
Holmqvist et al., 2013) as important qualities in the therapeu- ary approach is recommended in the therapy process when
tic relationship. The literature, in and outside the occupational such challenges may not be resolved solely by the occupa-
therapy profession, has also indicated a shift in understand- tional therapy practitioner. Referrals to applicable disciplines
ing therapeutic relationships in support of a more dynamic should be made, such as referrals to chaplains in discussing
TABLE 47.3. Difficult or Challenging Conversations and Suggested Strategies
TOPICS/ CONSIDERATIONS STRATEGIES REFERENCES

Developing health partnerships/ ■ Providing access to health records Rief et al. (2017)
client-driven communication ■ Providing ongoing, online communication prompts to clients
■ Providing information and assessment results prior to practitioner visits
■ Tracking and sharing client’s progress
Relationship building with practitioners ■ Using teaching models that support sharing emotional responses Porter et al. (2015)
with practitioners
Developing collaboration and using ■ Using combined strategies of eHealth interface and face-to-face meetings Beentjes et al. (2016)
eHealth interaction
Practitioner–client shared ■ Assessing effectiveness in long-term vs. short-term decision making Golden et al. (2017)
decision making ■ Choosing information giving vs. eliciting client feelings within decision making Golden et al. (2017)
Person-centered care ■ Understanding and critically assessing various strategies of motivation and Zoffmann et al. (2016)
negotiation depending on the context
Decision making and community ■ Developing a common and shared vision King et al. (2017)
partnership, experts, and persons ■ Building community capacity Nelson et al. (2016)
with experience ■ Developing mutual trust and respect
■ Building bridges between worldviews
■ Opening dialogue
Accuracy and clarity of documented ■ Considering unique perspectives and performance of clients Krüger et al. (2017)
diagnosis do not represent
actual performance
Limited health literacy ■ Using narrative and photo stories Koops Van’t Jagt (2016)
Language and cultural differences ■ Using augmented and computer programs with interactive components Johnson et al. (2006)
Younger patients faced with ■ Providing small amounts of information over time Krüger et al. (2017)
long-term diagnosis ■ Engaging client and significant others
Chronic health care concerns ■ Using interactive information platforms Krüger et al. (2017)
Profound disabilities and limited ■ Providing augmented and alternative technology for communication Mainwaring et al. (2017)
communication ■ Using nonverbal communication, gestures Matthews (2013)
■ Offering respect and dignity Raber et al. (2016).
■ Learning the language; intensive interaction
Suddenly speechless adults ■ Augmented communication Rodriguez et al. (2012)
Family member involvement ■ Clarifying family member involvement Laidsaar-Powell et al. (2016)
■ Actively engaging/affirming family member role
■ Providing psychosocial support of family member and client
Discussing sex ■ Providing clarity in discussing concepts and ideas relative to sexual acts Barnett et al. (2017)
Östlund et al. (2015)
Communicating with family members ■ Building trust, listening, and hearing the client’s and family members’ Warrillow et al. (2015)
of clients in intensive care unit journey
■ Taking time to listen to the emotional concerns of family members
Addressing child abuse ■ Finding common starting points (high-risk behaviors) Weaver et al. (2016)
■ Having a unified approach to injury prevention
■ Normalizing parenting challenges
■ Providing positive parenting strategies
meaning-of-life topics and death (Humbert, 2016) or with a Ethical dilemmas suggest that there are multiple competing
speech pathologist when physical communication is limited values and viewpoints to consider in any given practitioner–
(Mainwaring et al., 2017). client interaction (Purtilo & Doherty, 2015; Scott & Reitz,
2017). For example, it is expected that practitioners be truthful
in the information that is provided to clients (Veracity) and do
Ethical Reasoning and Decision Making
what is best for clients and do no harm. How much information
Practitioner–client communication entails an awareness of the then should a practitioner provide in terms of potential recov-
ethical dilemmas that might arise within the therapeutic rela- ery to be truthful as well as providing hope for the future and
tionship and within the assessment and intervention process. providing a new image for the client (conditional reasoning)?
Ethical dilemmas require practitioners to recognize any to be further developed (Taylor & Van Puymbroeck, 2013).
competing challenges and use reasoning skills to determine Self-awareness cultivates a practice that allows practitioners
the best approach to take when dilemmas exist. In this process, to be present with clients, especially during challenging and
practitioners must first consider the multiple competing val- emotional times (Wilson, 2011), as well as to be aware of one’s
ues that exist within the client scenario, seek out and consider own personal perspectives of pain and suffering (Hayward &
the perspectives and viewpoints of the individuals involved in Taylor, 2011; Luboshitzky, 2008) and ways to attend to adversity
the situation, and then assess and determine personal biases and promote resiliency (Thibeault, 2011; Wilson, 2010, 2011).
and priorities that influence how to proceed through the di- The Intentional Relationship Model (Taylor, 2008) ad-
lemma (Purtilo & Doherty, 2015; Scott & Reitz, 2017). dresses practitioners’ ability to determine what emotional
factors influence or contribute to the therapeutic relationship
(Taylor, 2008). The Intentional Relationship Model is a method
For Additional Learning of thoughtful consideration of how and why practitioners may
respond in distinct ways to clients within the therapeutic rela-
For additional learning about ethics, see Section X, “Ethical and
tionship. As part of practitioner–client communication, prac-
Legal Considerations.”
titioners’ ability to understand clients and support their vary-
ing perspectives and goals may at times become challenged
and result in conflict (Taylor, 2008). Systematically applying
Self-Awareness and Professional Reflection
one of Taylor’s (2008) 6 therapeutic modes to such conflict al-
Improves Practitioner–Client Communication
lows the practitioner to become more emotionally congruent
Practitioner–client communication is enhanced as practi- with clients’ needs (Taylor & Fan, 2013):
tioners actively engage in reflective practice, which includes
1. Advocating for,
assessing personal challenges with conflict (Smith & Taylor,
2. Collaborating with,
2010), establishing and maintaining personal boundaries
3. Empathizing with,
(Humbert et al., 2018), and dealing with complex topics and
4. Encouraging,
issues (Hayward & Taylor, 2011; Luboshitzky, 2008). Reflective
5. Instructing, and
practice provides opportunities for practitioners to compre-
6. Problem-solving with the client.
hend, evaluate, and critique their own thought processes used
and responses offered within the therapeutic relationship. It is believed that practitioners’ ability to be self-aware and
Reflection on and self-awareness of one’s attitudes and the to self-monitor these therapeutic modes increases their abil-
needed skills for effective communication can prompt practi- ity to modify them when needed and intentionally choose to
tioners to take inventory of which aspects of the therapeutic respond to clients in a helpful therapeutic manner (Smith &
relationship need to be emphasized and which aspects need Taylor, 2010).
CASE EXAMPLE 47.1. Stephanie, Jenny, and Mrs. White: Communication and Empathy
Stephanie is an occupational therapy practitioner with 5 years of professional experience working in an acute care hospital setting. She has been
asked to be the fieldwork supervisor for Jenny, a Level II student.
In one of the first client interactions, Jenny is asked to complete an initial evaluation with Mrs. White, who was hospitalized 2 days ago. According to the
chart review, Jenny finds out that Mrs. White is a 76-year-old widow who lives alone in her 2nd-floor apartment. She has a daughter who works full-time
and lives about an hour from Mrs. White. Two days ago, Mrs. White tripped over a piece of furniture and fell, causing her to sustain a fracture of the right hip
and pelvis. Surgery was performed to stabilize the hip. Mrs. White also has a diagnosis of osteoarthritis, mild hypertension, and mild dementia.
Jenny decides that she needs to perform an initial assessment with Mrs. White, including completing an occupational profile. Mrs. White was able
to describe a typical day and articulate what occupations she routinely engages when at home. During the interview, Mrs. White conveys that she
completes all of her own cooking, cleaning, self-care, and laundry and needs assistance from her daughter for financial management.
Jenny then decides to assess Mrs. White’s current ability to complete bed mobility safely. Jenny begins the assessment and determines that
Mrs. White is having trouble following her simple, 1-step directions and that Mrs. White needs moderate assistance to sit at the edge of the bed.
After returning Mrs. White to a supine position, Jenny asks her how she thought she did with the bed mobility task. It is at that moment that
Mrs. White begins to cry and states, “I just want to go home. Promise me that I can go home.” Jenny pauses and then looks at Stephanie for some
guidance in how best to respond to Mrs. White.
Review Questions
1. What initial responses would be applicable to provide to the client in this scenario? Consider the importance of therapeutic use of self, clinical
reasoning, and ethical principles.
2. Identify other individuals who might be part of the client’s life experience and therapeutic scenario, and articulate what information might be
applicable to gather to best know how to respond to the client’s request to return home.
3. What questions may the fieldwork supervisor pose to the student to assist in her reflection of the practitioner–client communication strategies
and how therapeutic use of self was carried out in the therapy session?
Review Questions Kendra N. Beittel, MS, OTR/L; Jennifer N. Brandt, MS, OTR/L;
Katelyn A. Colyer, MS, OTR/L; Emilia P. Costa, MS, OTR/L; Erin
1. What are the challenges that impede or restrict
M. Kelly, MS, OTR/L; Abigail M. Mitchell, MS, OTR/L; Emily
practitioner–client communication?
Schilthuis, MS, OTR/L; and Sarah E. Williams, MS, OTR/L.
2. What are 6 strategies that may be used to enhance
practitioner–client communication?
3. How can professional development may optimize chal- REFERENCES
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SECTION VIII.
Finance and Budgeting
Edited by Nathan B. Herz, OTD, MBA, OTR/L
449
CHAPTER
Understanding Economic and Political Trends
Sabrena McCarley, MBA–SL, OTR/L, CLIPP, RAC–CT, QCP 48
LEARNING OBJECTIVES
■ Describe how the enactment of the Affordable Care Act is affecting the economy and the health care system,
■ Understand how a change in political administration can affect the business of health care, and
■ Describe how the Triple Aim ties into health care reform and the economy.

• American Recovery and • Great Recession • Patient Protection and
Reinvestment Act • Gross domestic Affordable Care Act
• Children’s Health Insurance product • Socioeconomics
Program • Health care reform • Trend
• Economics • Medicaid • Triple Aim
E
conomics, politics, and health care in the United States Understanding Economic and
are tied together in a constantly changing political and Socioeconomic Trends
socioeconomic environment. Americans have long
been faced with the challenges of how to pay for and ac- Economics is the social science behind the production, dis-
cess health care. Rising health care costs are leaving many tribution, and consumption of commodities. Socioeconomics
to rethink how they can pay for their health care coverage. relates to or involves a combination of social and economic
The American people cannot address such challenges alone, factors (e.g., socioeconomic level: lower class, middle class, or
so they rely on elected officials to help solve economic and upper class). A trend is a reflection of what is occurring at
health care issues in the United States. However, each election any given time. To anticipate effects on health care access,
brings a new administration into the political arena, with a consumption, practice, and viability, occupational therapy
new agenda and new priorities. managers should understand the general direction in which
Occupational therapy managers need to understand social and economic trends are moving and why.
how political and economic trends affect day-to-day prac- The federal government operates on a fiscal year (FY) that
tice, financial viability, and clients. This chapter provides an corresponds to the federal budget; it runs from October 1 to
overview of the economic and political trends in the United September 30, regardless of the year. For example, the 2018
States and how together they affect all aspects of health care. FY ran from October 1, 2017 to September 30, 2018. Any ad-
The chapter also explores how these shifting trends affect ministration initiative is faced with the questions “Will this
the role that occupational therapy practitioners and man- affect the budget?” and “If so, what is that effect?”
agers play in the ever-changing political and socioeconomic In 2015, the United States spent 17.8% of the gross domes-
environment. tic product (GDP; i.e., the total value of goods produced and
https://doi.org/10.7139/2019.978-1-56900-592-7.048
451
452 SECTION VIII. Finance and Budgeting
services provided in a country during 1 year) on health care. ■ Unemployment,

This breaks down to $3.2 trillion, or $9,990 per person. Ex- ■ Decline in the stock market,
perts estimate that health care costs will continue to grow at ■ Loss of health insurance, and
an average rate of 5.6% per year from 2016–2025 (Centers for ■ Loss of credit.
Medicare and Medicaid Services [CMS], 2016).
In 2015, the federal government spent $9,990 per person During this time period the unemployment rate increased,
on health care, a sharp increase from the $146 per person in which resulted in a decline in the number of individuals in-
1960 (Amadeo, 2017). Costs associated with health care di- sured by private health insurers (Sheiner, 2015). This caused
rectly affect the economy. However, a simple policy change states to experience an increase in individuals who were el-
from the federal government is not enough to control health igible for Medicaid (i.e., health care insurance program for
care costs and increase access to health care. Any changes low-income individuals) because they had lost their job and
made to the health care system will affect the federal budget, their private health insurance coverage.
individual state budgets, health care providers, health care The recession also affected both state and federal govern-
workers, and taxpayers. ments as they were faced with tighter budgets during the
recession. The loss of revenue due to lower property taxes re-
quired many states to make cuts to their Medicaid programs,
Recent Trends tighten their eligibility requirements for Medicaid programs,
Great Recession reduce their staffing, and reduce their outreach efforts for
both Medicaid and public health programs. The decrease in
In December 2007, the United States was hit with an eco- the number of individuals insured by private insurance (and
nomic crisis that lasted until June 2009. It was the longest subsequent increase in people insured by Medicaid) also
economic decline since World War II and has become known resulted in lower health spending and a lower price in the
as the Great Recession (Rich, 2013). This economic crisis re- average cost of health care services, because Medicaid reim-
sulted from the housing market crash; in December 2007, the bursement is significantly less than private health insurance
mass loss of mortgages, accompanied by a decline in home (Sheiner, 2015).
prices, placed financial institutions and homeowners in such In addition, when unemployment is high and money is
financial straits that the U.S. economy was forced into a tight, households are faced with tough decisions in regard
recession. to where and how to spend available funds, and health care
In an effort to limit the impact on the U.S. economy, the all too often is left as a last priority. This, in turn, furthers
federal government implemented a variety of programs to the gap in access to health care based on an individual’s
assist homeowners and financial institutions. Ultimately, the socioeconomic class. This is a concern because uninsured
Federal Reserve provided unprecedented monetary accom- and underinsured individuals often wait for conditions to
modations to ensure economic recovery in the United States worsen before accessing health care and tend to require more
(Weinberg, 2013). Exhibit 48.1 provides statistics on the ef- expensive procedures.
fects of the Great Recession.
The Great Recession financially affected many individuals
and households through multiple variables: Obama administration
■ Home foreclosures, When Barack Obama was sworn in as the 44th president of
■ Decline in the value of their home, the United States in 2009, the new administration was faced
with many challenges, including the economic effects of the
Great Recession as well as a failing health care system. The
Obama administration’s legislative and policy changes in-
EXHIBIT 48.1. Great Recession Effects cluded progressive tax and spending policies. The admin-
istration also increased health insurance coverage through
■ GDP declined by 4.3% from its peak in the 4th quarter of 2007 to
the Patient Protection and Affordable Care Act (ACA; P. L.
its lowest point in the 2nd quarter of 2009 (Rich, 2013). 111–148) and the extension of the Children’s Health Insur-
■ The unemployment rate increased from 5% in December 2007 to ance Program (CHIP; P. L. 111–3), an insurance program
10% in October 2009 (Rich, 2013). that provides lower cost health insurance coverage for chil-
■ The number of Americans living in poverty totaled 43.6 million in dren when their parents earn too much money to qualify for
2009, an increase of 6.3 million from 2007–2009 (Joint Economic Medicaid but not enough to purchase private health insur-
Committee of U.S. Congress [JEC], 2010). ance coverage.
■ The number of Americans without health insurance Obama’s progressive focus on health care reform allowed
coverage totaled 50.7 million (16.7% of the population) in many Americans to gain access to affordable health care
2009, an increase of 5 million Americans from 2007–2009
across their lifespan. One of the goals of the ACA was to ex-
(JEC, 2010).
pand affordable health care access to all Americans. The ACA
■ The real median household income in 2009 was $49,977, a
decline of $2,188 from 2007–2009 (JEC, 2010). included comprehensive reform of the health insurance mar-
ketplace, which resulted in increased access to care for many
CHAPTER 48. Understanding Economic and Political Trends 453
of those who were already insured because the law required gaining citizenship. They can affect businesses, health care,
private health insurance providers to cover fundamental education, the housing market, and the stock market. These
health care services, such as maternity care, mental health effects depend on the policies and legislation put forth to gov-
and substance use treatments, and preventive services. An- ern us and can be either positive or negative. As voters, we
other component of the ACA allowed individuals to stay on elect state and federal government leaders to work on our be-
their parents’ health insurance plan until age 26 years. This half for the betterment of our state and our nation.
provision was estimated to provide health insurance coverage As shown in the differences between the Obama and
to 2.3 million people in 2010 (Obama, 2016). Trump administrations, each new administration brings
The ACA not only increased access to health care but also change to the current political trends set in motion by the
started the shift in health care delivery from volume-based prior administration. After inauguration of a president or
care to value-based care. Moreover, the act shifted the health a governor, the administration must analyze all aspects of
care industry in the direction of alternative payment models the previous administration, the current overall state of the
and evidence-based practice (Obama, 2016). It is important United States or individual state, and campaign promises to
that managers understand the reimbursement and coverage meet the needs of the people who voted that administration
rules and regulations for the insurance providers they work into office.
with and advocate for occupational therapy services. The 2 main political parties have different views on issues
The ACA left many individuals feeling uncertain. There such as immigration, health care, education, national secu-
were concerns that mandating insurance coverage would re- rity, and tax reform, and a change in policy on any of these
sult in an increase of individuals seeking medical attention, issues can affect Americans and on the economy at both
straining the health care industry. There was also a great deal state and federal levels. The Obama and the Trump admin-
of uncertainty regarding how individual states would handle istrations both ran on campaign platforms of change. This
the costs associated with an increased amount of individu- is significant in several ways: the 2 presidents were from dif-
als qualifying for low-income health insurance through state ferent political parties, both elections are considered to be
Medicaid programs. historical wins, and the presidencies began in very different
economic times.
Trump administration President Obama’s administration made health care re-
form and economic recovery top priorities and wasted no
On January 20, 2017, Donald Trump was sworn in as the 45th time in implementing change after his first inauguration to
president of the United States and was immediately faced stimulate the economy and expand health care coverage. The
with many challenges, including a country divided on issues legislation aimed at tackling these issues included
such as health care and immigration. Health care reform has
been a top priority for this administration. Despite several ■ CHIP extended on February 4, 2009;
failed attempts to repeal and replace the ACA, the Trump ad- ■ American Recovery and Reinvestment Act (ARRA; P. L.
ministration has helped ease the rising health care premium 111–5) signed into law February 17, 2009 (Amadeo, 2018);
costs and broaden access to health care services. These suc- ■ Family Smoking Prevention and Tobacco Control Act
cesses included short-term health care plans that create more (TCA; P. L. 111–31) signed into law on June 22, 2009; and
flexible, cost-effective options for those facing high insurance ■ ACA signed into law on March 23, 2010.
premiums and expanded associated health plan options for
small businesses and self-employed individuals. The legislation that was signed into law under President
The Trump administration’s successes have been met Obama had a significant impact on the U.S. economy. The
with mixed reviews by the American people, who are fearful purpose of the ARRA was to end the Great Recession, create
of losing access to affordable health care services. However, jobs, and increase consumer confidence. Additionally, ARRA
some small businesses and individuals with no health insur- provided monetary support to the health care system to sus-
ance options other than high-premium plans are grateful for tain Medicaid coverage while also investing in the future of
having lower cost options. health care through technology, research, and preventive care
(Obama, 2016).
The Trump administration did not face the same eco-
nomic challenges that the Obama administration did on tak-
ing office, and this administration’s focus has been different
For additional learning, see Chapter 73, “Why Is Policy Important?” than that of the previous administration, including several
attempts to repeal and replace the ACA. Although there are
countless unknowns as to how the health care industry and
occupational therapy practice will be affected by the Trump
Understanding Political Trends
administration, the current trend is on increasing affordable
Political trends at both state and federal levels affect every- health care insurance options and on alternative treatment
one from single individuals to families and from U.S. citizens methods for pain management to reduce opioid use in the
to undocumented immigrants and those in the process of United States.
Occupational therapy is a key health care provider in the The ACA has increased focus on expanding access to
treatment of pain management through education, training, health care services, improving outcomes, and delivering
and individualized plans of care. It is still unknown how the high-quality care, all of which have implications for occu-
current administration will affect future of the U.S. economy, pational therapy.
the socioeconomic economy, the health care industry, immi- Occupational therapy managers need to understand
gration policies, and education. value-based payment incentives because poor outcomes
and performance can have financial penalties. The health
Health care reform care industry has seen an increase in quality of care and
lower health care spending costs under the ACA, as in-
Health care reform is complex but generally focuses on pro- dicated in the following statistics (Council of Economic
viding all Americans with health care coverage and decreas- Advisers, 2017):
ing the costs of care. It has been a high-priority, if controver-
sial, topic in the United States for decades. Rising health care ■ The growth rate in Medicare spending per Medicare
costs have caused many Americans to speak up in support of beneficiary was reduced by 1.3% per year from 2010 to
the need for health care reform. The goals set forth for health 2016.
care reform are simple: increase the number of insured indi- ■ Since 2010, there has been a 21% decline in the rate at
viduals while increasing the overall quality of care and ulti- which beneficiaries were harmed while they were seek-
mately decreasing health care costs. ing hospital care. This translates to an estimated 125,000
The goals of health care reform are in line with the goals avoided deaths from 2010 to 2015.
set forth in the Triple Aim. In 2007, the Institute for Health- ■ An estimated 565,000 hospital readmissions were avoided
care Improvement developed the Triple Aim framework, between April 2010 and May 2015.
an approach to creating better health care in the United
States. The goal of the Triple Aim was to simultaneously
Opioid epidemic
improve the patient care experience, improve the health
of the population, and reduce per capita health care costs The United States is in the middle of an opioid epidemic, and
(Lewis, 2017). the Trump administration declared it a public health emer-
The ACA’s expanded health care coverage has increased gency on October 26, 2017. The Centers for Disease Control
access to health care services, allowing insured individuals and Prevention (CDC) and the U.S. Department of Health
who were previously uninsured a sense of security and a and Human Services have targeted initiatives in place to ad-
higher quality of health as many have gained access to phy- dress the issue. The opioid epidemic is costly to the health
sicians they could not afford previously. Additionally, the care system and weighs heavily on the economy at both the
ACA helped Medicare beneficiaries close the gap that existed state and the federal levels. In 2013, $78.5 billion was spent
under the previous Medicare Part D (i.e., Prescription Drug on prescription drug overdose, abuse, and dependency in the
Program) coverage. The ACA has resulted in a savings of United States (CDC, 2017b).
more than $20 billion for 10 million Medicare beneficiaries During 1999–2014, the number of drug overdoses nearly
(Obama, 2016, p. 527). The ACA has also faced challenges re- tripled. In 2014, there were 28,647 opioid drug overdoses, and
garding state Medicaid expansion. in 2015, the number of opioid drug overdoses increased to
An emphasis of the ACA is preventive care, and occupa- 33,091 (CDC, 2016). Unintentional and nonfatal opioid over-
tional therapists are a perfect fit for wellness and preventive dose cases are being treated in emergency departments and
care. Expanding Americans’ access to health care services are leading to hospitalizations for further medical treatment.
has resulted in higher quality of care. Hospital-acquired con- In 2014, there were an estimated 92,262 emergency depart-
ditions have declined by 17%, breaking down to a decline ment visits and 53,000 hospitalizations as a result of opioid
from 145 per 1,000 discharges in 2010 to 121 per 1,000 dis- use (CDC, 2017a).
charges in 2014. Additionally, the rate of hospital readmis- Both sides of the political aisle have come together for bi-
sion within 30 days of discharge for Medicare patients has partisan support in a series of legislative bills that are aimed
decreased from 19.1% in 2010 to 17.8% in 2015 (Obama, 2016). to combat the opioid epidemic and promote alternative, non-
Occupational therapy interventions to assist in preventing pharmacological pain management interventions. Chronic
hospital readmissions include completing home assessments and acute pain are complex to treat and should not be treated
and modification recommendations and addressing fall by pain medication alone. Instead, pain should be treated
prevention. by a multidisciplinary approach that includes occupational
The expansion of health care coverage allows patients therapy. Skilled occupational therapy treatment interven-
to have better access to occupational therapy services for tions for pain management focus on positioning, body me-
preventive care. However, health care costs continue to chanics, pain control, adaptive equipment, environmental
rise. According to the 2016 data, the national health ex- modifications, and compensatory strategies. The passage of
penditure grew 4.3% to $3.3 trillion in 2016, or $10,348 such legislation will allow for greater access to occupational
per person, and accounted for 17.9% of GDP (CMS, 2016). therapy services.
CHAPTER 48. Understanding Economic and Political Trends 455
Review Questions that the distinct value of occupational therapy is represented

in everything that we do for our clients. We must ensure that
1. How many Americans were without health insurance
coverage in 2009? ■ Clients’ plans of care are comprehensive;
a. 55.7 million ■ Their goals, treatment strategies, and interventions are in-
b. 50.7 million dividualized; and
c. 57.5 million ■ Outcomes tie back to occupational therapy’s distinct value.
d. 60 million
In 2016, an independent study conducted by health pol-
e. 70 million
icy researchers found that occupational therapy is the only
2. In 2015, what percentage of the GDP was spent on health
spending category that results in significantly reduced hospi-
care?
tal readmission rates (Rogers et al., 2017).
a. 18.7%
b. 17.8%
c. 5.6%
d. 10.5%
e. 20.8% For additional learning, see Chapter 33, “Advocating Occupational
3. What are some of the impacts that unemployment can Therapy’s Distinct Value Within Interprofessional Teams.”
have?
4. For what reasons did the ARRA provide monetary sup-
port to the health care system?
Review Questions
1. What direction is health care moving in?
PRACTICAL APPLICATIONS IN a. From value-based care to volume-based care
OCCUPATIONAL THERAPY b. From volume-based care to value-based care
Economic and political events and trends can affect the c. From quality to quantity
health care system. Any change to the health care system can d. From preventive to integrated
have a positive or negative impact on an individual’s ability to 2. The clients occupational therapy practitioners treat can
access the health care services they need. Such changes and be affected either positively or negatively by changes to
trends also affect occupational therapy reimbursement, staff- a. Medicaid
ing, and productivity requirements as organizations attempt b. Medicare
to stay viable during change and various political unknowns. c. Health care
Occupational therapy practitioners treat clients with var- d. All of the above
ious medical diagnoses and disabilities and have the ability 3. A 2016, study found that occupational therapy
to provide habilitation services, as well as rehabilitation ser- a. Increases hospital readmissions
vices to their clients. It is important that practitioners and b. Decreases hospital readmissions
managers understand the economic and political pressures c. Increases the length of hospital stays
on health care organizations, local governments and systems, d. Decreases the length of hospital stays.
and individual clients so they are equipped to ensure that
clients have access to and receive the occupational therapy
services they need.
SUMMARY
Occupational therapy clients are constituents of politi- The economy, the political environment, and the health care
cians; they come from all socioeconomic classes and can be system are all in a state of constant change and affect the day-
directly affected by changes to Medicaid, Medicare, or pri- to-day business of health care, including its financial viabil-
vate insurance regulations. Occupational therapists’ efforts to ity and clients’ access to services. Each new administration
provide high-quality, occupation-based services that provide brings new policies and changes in focus, which can positively
actual value benefit the real clients who need occupational or negatively affect the economy and health care. Americans
therapy as well as the profession itself, regardless of political rely on elected officials to address U.S. economic and health
winds. care issues; occupational therapy practitioners and managers
In response to rising health care costs, the way that health can advocate for their clients to be able to access the health
care services are being delivered is changing. The focus is mov- care services they need (see Case Example 48.1).
ing away from volume-based care to value-based care, with an Implementation of the ACA in 2010 enabled more individ-
increased focus being placed on cutting the cost of health care uals to access health care, but there is still a lot that needs to
while also increasing the quality of services provided. be done to lower health care costs, increase access to health
Occupational therapy practitioners are uniquely posi- care, and increase the quality of care. The Triple Aim has pro-
tioned to help reduce health care costs because we focus on vided the health care system with a foundation to build upon
holistic treatment approaches. It is imperative that we ensure to accomplish these goals. ❖
CASE EXAMPLE 48.1. Maria: Chronic Pain
Maria is a 60-year-old woman who lives alone and has osteoarthritis and chronic pain. In 2008, she worked as the office manager for a local real
estate company. As a result of the housing market crash, the real estate company she worked for was forced to downsize, and she lost her job as
well as her private health insurance. When President Obama was elected, Maria was one of the 50.7 million Americans without health insurance
coverage (JEC, 2010).
Maria has had difficulty finding stable full-time employment and lives on a fixed income. As a result of the ACA, she now has health insurance,
but she struggles to find the money to pay the premiums and the copays for her opioid pain medications. She often goes days or even weeks
without her medication and is forced to live in pain until she can afford to pick up her medications. Maria, like many Americans, is concerned about
the future of health care and about what ACA’s repeal and replace would mean for her and her access to health care services.
Review Questions
1. What treatment interventions could occupational therapy address with Maria?
2. What can Maria do in response to her concerns about the possibility of a change to health care?
3. What should Maria do in response to her struggles to pay her copay for her pain medications?
ACOTE STANDARDS Centers for Medicare and Medicaid Services. (2016). National
health expenditure data: NHE fact sheet. Retrieved from https://
This chapter addresses the following ACOTE Standards: www.cms.gov/research-statistics-data-and-systems/statistics
-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet
■ B.5.0. Context of Service Delivery, Leadership, and Man- .html
agement of Occupational Therapy Services Children’s Health Insurance Program Reauthorization Act of 2009,
■ B.5.1. Factors, Policy Issues, and Social Systems Pub. L. 111–3, 42 U.S.C. §§1305 et seq.
■ B.5.2. Advocacy Council of Economic Advisers. (2017). Economic report of the pres-
■ B.5.7. Quality Management and Improvement ident. Retrieved from https://www.govinfo.gov/content/pkg
■ B.7.3. Promote Occupational Therapy. /ERP-2017/pdf/ERP-2017.pdf
Family Smoking Prevention and Tobacco Control Act of 2009, Pub.
L. 111–31, 21 U.S.C. §§ 301 et seq.
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(ACOTE) standards and interpretive guide. American Journal of .gov/public/_cache/files/845c4b1a-b28e-412f-98fa-9d5968bb0604
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /assessing-the-impact-of-the-great-recession-on-income-poverty
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-rising-healthcare-costs-4064878 -the-triple-aim
Amadeo, K. (2018). ARRA, its details, with pros and cons: What did Obama, B. (2016). United States health care reform: Progress to
ARRA really do? Retrieved from https://www.thebalance.com date and next steps. JAMA, 316, 525–532. https://doi.org/10.1001
/arra-details-3306299 /jama.2016.9797
American Recovery and Reinvestment Act of 2009, Pub. L. 111–5, Patient Protection and Affordable Care Act, Pub. L. 111–148, 42
26 U.S.C. §§1 et seq. U.S.C. §§ 18001–18121 (2010).
Centers for Disease Control and Prevention. (2016). Increases Rich, R. (2013). The Great Recession: December 2007–June 2009. Re-
in drug and opiod-involved overdose deaths—United States, trieved from https://www.federalreservehistory.org/essays/great
2010–2015. Retrieved from https://www.cdc.gov/mmwr/volumes _recession_of_200709
/65/wr/mm655051e1.htm Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher
Centers for Disease Control and Prevention. (2017a). Annual sur- hospital spending on occupational therapy is associated with
veillance report of drug-related risks and outcomes: United States, lower readmission rates. Medical Care Research and Review,
2017. Retrieved from https://www.cdc.gov/drugoverdose/pdf 74(6), 668–686. https://doi.org/10.1177/1077558716666981
/pubs/2017-cdc-drug-surveillance-report.pdf Sheiner, L. (2015). Health spending growth: The effects of the Great
Centers for Disease Control and Prevention. (2017b, March 15). Recession. Washington, DC: Brookings Institution.
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/releases/2017/a0315-Business-Pulse-opioids.html _recession_and_its_aftermath
CHAPTER
Designing a Payment Structure
Ellen Hudgins, OTD, OTR/L, ITOT 49
LEARNING OBJECTIVES
■ Analyze reimbursement terms and best practices associated with designing a payment structure for the provision of
occupational therapy services,
■ Apply concepts for seeking reimbursement for occupational therapy services in a variety of settings,
■ Recognize general rules regarding reimbursement based on the insurance carrier, and
■ Analyze terms associated with alternative payment models and value-based care models.

• Accounts receivable • Cost per visit • Payment structure
• Advanced Alternative Payment • Deductible • Per beneficiary
Model • Fee per service • Per day
• Bundled care • Health Care Common Procedure • Per dollar of charges
• Capitated care Coding System • Per dollar of cost
• Catastrophic health plan • Health maintenance organization • Per episode
• Children’s Health Insurance • ICD–10 Diagnoses Coding • Per time period
Program • Maximum out-of-pocket • Preauthorization
• Claim • Medicaid • Private pay model
• Clearinghouse • Medicare • Quality Payment Program
• CMS 1500 claim form • Merit-based Incentive Payment • Reimbursement
• Commercial insurance companies System • Third party
• Contact capitation • National Provider Identifier • Workers’ compensation
• Copayment/co-insurance
OVERVIEW In the school system, occupational therapy providers may be

an employee of the school district; work for a private company
A
payment structure is the way in which occupational that contracts with the school to provide services; or be an in-
therapy services are graded and reimbursed; they are dependent contractor who receives a contracted rate for the
important for the sustainability of the occupational provision of services. Moreover, home health therapists largely
therapy profession. Setting often dictates the payment struc- bill federal plans for the provision of occupational therapy.
ture for occupational therapy services, but managers must Quinn (2015) lists 8 basic payment methods in health care,
still understand and determine how to bill for services in a which are further discussed in this chapter: Per
sustainable way that best meets clients’ needs. Payments also
vary depending on whether services are provided by occupa- 1. Time period,
tional therapists or occupational therapy assistants. 2. Beneficiary,
Most hospitals and long-term care settings participate with 3. Recipient,
insurance carriers and rely on payment from contracted payers. 4. Episode,
https://doi.org/10.7139/2019.978-1-56900-592-7.049
457
CHAPTER
Designing a Payment Structure
Ellen Hudgins, OTD, OTR/L, ITOT 49
LEARNING OBJECTIVES
■ Analyze reimbursement terms and best practices associated with designing a payment structure for the provision of
occupational therapy services,
■ Apply concepts for seeking reimbursement for occupational therapy services in a variety of settings,
■ Recognize general rules regarding reimbursement based on the insurance carrier, and
■ Analyze terms associated with alternative payment models and value-based care models.

• Accounts receivable • Cost per visit • Payment structure
• Advanced Alternative Payment • Deductible • Per beneficiary
Model • Fee per service • Per day
• Bundled care • Health Care Common Procedure • Per dollar of charges
• Capitated care Coding System • Per dollar of cost
• Catastrophic health plan • Health maintenance organization • Per episode
• Children’s Health Insurance • ICD–10 Diagnoses Coding • Per time period
Program • Maximum out-of-pocket • Preauthorization
• Claim • Medicaid • Private pay model
• Clearinghouse • Medicare • Quality Payment Program
• CMS 1500 claim form • Merit-based Incentive Payment • Reimbursement
• Commercial insurance companies System • Third party
• Contact capitation • National Provider Identifier • Workers’ compensation
• Copayment/co-insurance
OVERVIEW In the school system, occupational therapy providers may be

an employee of the school district; work for a private company
A
payment structure is the way in which occupational that contracts with the school to provide services; or be an in-
therapy services are graded and reimbursed; they are dependent contractor who receives a contracted rate for the
important for the sustainability of the occupational provision of services. Moreover, home health therapists largely
therapy profession. Setting often dictates the payment struc- bill federal plans for the provision of occupational therapy.
ture for occupational therapy services, but managers must Quinn (2015) lists 8 basic payment methods in health care,
still understand and determine how to bill for services in a which are further discussed in this chapter: Per
sustainable way that best meets clients’ needs. Payments also
vary depending on whether services are provided by occupa- 1. Time period,
tional therapists or occupational therapy assistants. 2. Beneficiary,
Most hospitals and long-term care settings participate with 3. Recipient,
insurance carriers and rely on payment from contracted payers. 4. Episode,
https://doi.org/10.7139/2019.978-1-56900-592-7.049
457
5. Day, With the continually changing landscape in health care reim-

6. Service, bursement, occupational therapy managers must remain in-
7. Dollar of cost, and formed of the rules associated with reimbursement and those
8. Dollar of charges. focused on payment structures. Although most occupational
therapy practitioners are altruistic, one still requires compen-
Such payment methods divide the financial risk on the pa-
sation for services provided.
tient versus the provider. While receiving occupational ther-
Since the inception of Patient Protection and Affordable
apy services, patients may have the following to pay:
Care Act (ACA; P. L. 111–148), a shift in reimbursement pat-
■ Maximum out-of-pocket: Total amount paid by the recip- terns has occurred. Between 1975 and 2015, private insurance
ient on an annual basis. After the maximum out-of-pocket reimbursement increased from 25.5%–34.8%; Medicare
expense is met, no more personal funding is required for reimbursement increased from 13.8%–22.3%; Medicaid reim-
the plan year. bursement increased from 11.3%–17.9%; and consumer out-
■ Copayment/co-insurance: Amount a recipient must pay at of-pocket expenses decreased from 32.9%–12.4% (CDC, 2017).
each health care visit. Copays vary depending on the individ- As occupational therapy managers seek to set up a pay-
ual’s insurance policy. Co-insurance is the percentage a recip- ment structure, they must know the setting, options for pay-
ient pays for each visit. For example, Medicare Part B covers ment, demographics of the area, and the practice’s overall
occupational therapy at 80% of the allowed charge. Therefore, budget. If the average income of the area is low, most recipi-
the client’s co-insurance will be 20% of the allowed charge. ents of services will not have the means to pay out of pocket
■ Deductible: Dollar amount the recipient must pay before for services. Therefore, clients rely on providers who accept
insurance funds are paid. Deductibles vary depending on various insurance carriers. In a larger metropolitan area, oc-
the individual’s insurance plan. With the increased cost of cupational therapy managers or practice owners may decide
health insurance, many recipients opt for higher deduct- to not bill for services under an insurance plan; therefore, the
ibles, which reduces monthly premiums. recipient may have to pay out of pocket for services. This is
Ultimately, most care models are based on fee-for-service or commonly referred to as a private pay model versus an insur-
capitated care, which is the total amount allowed for the oc- ance payment model.
cupational therapy case. Once the cap has been met, the case Using a private pay model may be feasible in an area in
must go for medical review. Regardless of the payment model, which the demographics support this payment structure.
emphasis must be placed on quality care and evidence-based Although the client may have health insurance, the provider
care resulting in cost-effective outcomes. Moving to the future, may not be willing to participate in the insurance type, leav-
occupational therapy practitioners may be paid based on qual- ing the client with the option to pay privately. Some practice
itative outcomes versus a fee for service. This chapter explores owners do not want the expenses associated with billing for
the payment models associated with qualitative outcomes. health care services, which include software, billing person-
In 2015, $2.7 trillion was spent on health care resulting nel, clearinghouse fees, and postage. However, the client may
in an average of $8,468 per person. People are living longer, be provided with the appropriate procedure codes, giving
which means more individuals require health care services. them the option of submitting the claim to the insurance
The life expectancy rate is 78.8 years (Centers for Disease claim personally instead of through the practice.
Control and Prevention [CDC], 2017), creating an opportu-
nity for occupational therapy practitioners to serve the aging
population. For practitioners working in hospitals or long- For Additional Learning
term care settings, the payment structure will be aligned with
insurance companies, with the greatest proportion being For additional learning, see
Medicare or Medicaid. ■ Chapter 29, “Federal Health Care Programs and Outcomes,” and
Regardless of the setting, reimbursement for occupational ■ Chapter 30, “Private Health Insurance.”
therapy services is critical for the solvency of the organiza-
tions in which occupational therapy practitioners work. This
chapter discusses the various payment structures when bill- Payment Sources
ing for occupational therapy services, presents options for
payment structures, and offers guidelines for fiscal sound- Providers have 3 main options for payment: (1) private pay,
ness. Unless occupational therapy practitioners work within (2) payment through insurance companies (federal and com-
a reasonable payment structure for the services they provide, mercial carriers), and (3) payment through grants and charity
it is challenging to stay in practice. funding. Based on my experience as a practice owner over
the past 25 years, most occupational therapy clients would
rather have the provider bill the insurance company than pay
ESSENTIAL CONSIDERATIONS out of pocket for the service.
Reimbursement is the payment received for a service provided. When designing payment structures, it is critical to un-
Because of the many aspects of reimbursement in health care, derstand the different payers and the rules associated with the
seeking reimbursement for services can be a daunting task. provision of services. The payment model varies depending
CHAPTER 49. Designing a Payment Structure 459
on the payer, and the rules commonly change; therefore, oc- unfolds, practitioners can design payment structures based
cupational therapy managers must stay abreast of the rules on optimal outcomes. Finally, the provider has the option of
related to the payment structure. being paid for delivering evidence-based care based on client-
centered and occupation-based intervention methods.
Federal Programs
Medicare Medicaid
Medicaid is reimbursed through state and federal funds
Medicare provides federal health insurance coverage to those
and is the largest program providing medical and health-
who are ages 65 years or older. It also provides coverage for
related services to low-income individuals. Medicaid was
those who have long-standing disabilities who are younger
originally available only to individuals receiving state or
than age 65 years. More than 55 million people receive Medi-
federal financial assistance. Historically, this payment
care, with most of those participants receiving Part A and
model is very low compared with other commercial insur-
Part B coverage (CDC, 2017). Part A plans cover inpatient
ance companies; for this reason, some providers may opt
hospital stays, while Part B plans cover outpatient services.
not to participate in Medicaid. However, within my prac-
Medicare C plans are Medicare managed care plans, offering
tice, I choose to serve the entire community. I am willing to
coverage for vision, dental, and prescription drugs. Medicare
receive reduced reimbursement to serve all clients in need
D plans cover prescription drugs. All Medicare claims are
of occupational therapy, regardless of their ability to pay
submitted to the Centers for Medicare and Medicaid Services
for services. When participating with state and federal pro-
(CMS) via a CMS 1500 claim form, which is the official stan-
grams, occupational therapy providers must be willing to
dard Medicare and Medicaid health insurance claim form re-
bill the same fees for all participants of care regardless of the
quired by CMS. For Medicare claims, providers must submit
insurance type. Therefore, the occupational therapy man-
the claim form to the appropriate Medicare contractor, which
agers must ensure the same billing rules apply to all clients
is based on the state in which one provides service. Provid-
receiving services.
ers must include their National Provider Identifier, other-
ACA and the Health Care and Education Reconciliation
wise known as the NPI number, which is a 10-digit number
Act of 2010 (P. L. 111–152) initiated significant changes to
for covered health care providers that is used for submitting
Medicaid; they increased access to health care to individu-
claims for health care services.
als not solely based on income (CDC, 2017): “Within broad
Occupational therapy services billed under Part B were
federal guidelines, each state establishes its own eligibility
formerly subject to a cap of $2,010. After more than 20 years
standards; determines the type, amount, duration, and scope
of advocating to Congress, the cap was repealed, effective
of services; sets the rate of payment for services; and admin-
January 2018. This was huge victory for the occupational
isters its own program” (p. 443). There have been discus-
therapy profession. All services billed under Medicare Part B
sions regarding Medicaid expansion, which is state specific.
remain subject to review for medical necessity. Therefore, the
Although some states did not approve Medicaid expansion,
occupational therapy provider must provide rigorous docu-
some health conditions require Medicaid coverage. In con-
mentation to include outcome measures showing the ongoing
sidering the payment structure for an occupational therapy
need for skilled therapy services. Because the payment mod-
practice, the manager must stay informed about the latest
els may shift to qualitative care models versus fee-for-service
policy changes that affect payment for services.
models, practitioners must focus on reliable and valid out-
come measures to support the need for occupational therapy
services. CHIP
Occupational therapy managers have no control over the Since 1997, the Children’s Health Insurance Program (CHIP)
amount of payment they receive for services under Medicare has provided coverage to eligible low-income, uninsured
plans. The Medicare fee schedules are predetermined by the children who do not qualify for Medicaid. Between 1978 and
federal government and vary based on the practice’s geo- September 2016, the percentage of uninsured children de-
graphic location. Because the provider cannot control the fee creased from 12% to 5% (CDC, 2017). This coverage allows
Medicare sets, the provider must focus on the cost for provid- children who may be ineligible to receive Medicaid coverage
ing care. If the provider’s cost per visit exceeds the Medicare to receive occupational therapy services (CMS, n.d.). See your
payment, the result may be a failed practice. specific state laws regarding CHIP reimbursement for occu-
As CMS implements the Improving Medicare Post-Acute pational therapy services because reimbursement varies from
Care Transformation (IMPACT) Act of 2014 (P. L. 113–185), state to state.
occupational therapy providers have the option of being paid
based on the quality of services (Sandhu et al., 2018). Because
IDEA
occupational therapy practitioners are trained to assess the
whole patient, practitioners can improve resource use, ensur- For an infant–toddler program or a school system, the pay-
ing patient safety, reducing caregiver burden, and enhanc- ment structure is based on the rules established for those
ing the discharge planning for those receiving occupational specific settings. Per the Individuals with Disabilities Educa-
therapy services (Sandhu et al., 2018). As the IMPACT Act tion Act of 1990 (IDEA; P. L. 101–476), children from birth
to age 3 years may receive occupational therapy as part of an and families; National Guard/Reserve and families; survi-
infant intervention program. These services are reimbursed vors; former spouses, Medal of Honor Recipients and families;
through a Part C preschool grant, and the allocation for and others registered in the Defense Enrollment Eligibility
services varies depending on the population demographics Reporting System (Tricare, 2018a). Tricare will pay for oc-
(U.S. Department of Education, 2016). cupational therapy services under the direct supervision of a
Services must be provided in the infant’s natural environ- physician (Tricare, 2018b). Until recently, occupational ther-
ment. Infants who age out of the program may be eligible apy assistants were not authorized to treat Tricare recipients.
to receive services through Head Start programs, followed President Trump signed into law the National Defense Au-
by intervention in the local school system. For students who thorization Act of 2017 (P. L. 114–328), allowing occupational
are Medicaid recipients, the school system can bill Medicaid therapy assistants to treat those with Tricare benefits. This was
for occupational therapy services provided within the public another great victory for the occupational therapy profession
school system. (AOTA, 2017b).
Alternative Payment Models Commercial Carriers

CMS continues the discussion regarding the Advanced Al- Commercial insurance companies are companies that offer
ternative Payment Model (AAPM; AOTA, 2017a), which is insurance plans that are not paid by the government. If oc-
a payment model in which the provider receives an incentive cupational therapy providers plan to design a payment struc-
for quality-based outcomes performed in a cost-effective ture based on commercial insurance carriers, managers must
manner. The Medicare Access and CHIP Reauthorization stay informed about the changing rules associated with vari-
Act of 2015 (P. L. 114–10) established the Quality Payment ous commercial carriers, which include Anthem, Cigna, and
Program for eligible clinicians. Under this program, eligi- United Healthcare.
ble clinicians can participate in 1 of 2 tracks: (1) AAPM or The commercial insurance premium is paid by an indi-
(2) Merit-based Incentive Payment System (MIPS; CMS, vidual or employer, and the reimbursement for occupational
2017b). MIPS payments are based on a predetermined scor- therapy services varies greatly depending on the plan. Within
ing method. The provider may receive an incentive based on commercial plans, one may seek a health maintenance
the predetermined score or outcome. At press time, a great organization (HMO), a type of insurance organization that
deal of discussion is taking place between CMS and AOTA offers fixed fees and co-pays for medical services.
regarding the outcome measures for the scoring system. Other private commercial insurance companies may be
With the evolving health care system, alternative payment offered within individual states. Larger employers may opt
systems will continue to develop, so managers must remain for self-insurance policies. The administrator of the policy
cognizant of the alternative payment models as new ones oversees the coverage for services. Larger companies that
emerge. are self-insured commonly have catastrophic health in-
surance plans that cover catastrophic hospital admissions.
A catastrophic health plan is a higher deductible plan cov-
VA
ering a catastrophe, meaning an emergency department
For occupational therapy practitioners working with veter- visit or hospital admission for a catastrophic event. The
ans, the occupational therapy manager must consider the occupational therapy manager is advised to preauthorize
payment structure related to Department of Veterans Affairs services for all commercial carriers because the coverage
(VA) services. The VA commonly pays for occupational ther- for services varies greatly between individual policies. Ask
apy services to promote independence in ADLs and IADLs if there are specific limitations such as a limit on frequency,
to active and inactive military service members. The facility duration, number of visits, or certain procedure codes;
must be credentialed by the VA to bill for occupational ther- these limitations affect the overall payment structure for
apy services, or the veteran may seek services at a VA hospital. the practice.
The VA often requires preauthorization before providing Occupational therapy practitioners working with injured
services. Preauthorization must be granted by an insur- workers must consider workers’ compensation as a pay-
ance company before occupational therapy services begin ment structure for the practice. Employers provide work-
to ensure payment to the provider; this process can usually ers’ compensation through commercial carriers. In 2016,
be completed on the phone or through an online site. The 2,857,400 injuries were reported in the United States, result-
VA will authorize a certain amount of sessions followed ing in time away from the workplace (U.S. Department of
by a medical review before approving additional sessions Labor, 2017). If a worker is injured while completing occu-
(U.S. Department of Veterans Affairs, n.d.). pational duties, the worker may receive health care benefits
The Civilian Health and Medical Program of the Uni- through a workers’ compensation claim. When an incident
formed Services (CHAMPUS) promotes coverage of occu- occurs in the workplace, the injured worker must report the
pational therapy services. Tricare is a branch of CHAMPUS, incident to their immediate supervisor, and a work injury in-
allowing occupational therapists to treat civilians. Tricare cident report is completed. Typically, the worker is taken to
may be eligible for the following: uniformed service members a medical facility for evaluation and treatment. The incident
report is filed with the state’s industrial commission, which Review Questions
is responsible for monitoring work-related claims within the
1. Typically an occupational therapy may negotiate worker’s
claimant’s state.
compensation payment for occupational services on an
If a worker’s injury results in the need for occupational
annual basis. True or False?
therapy, the primary treating physician refers the injured
2. What are the 3 methods of payment associated with a
worker to an occupational therapist. The injured worker’s
payment structure?
insurance company authorizes visits based on the frequency
3. Most clients will pay privately for services regardless of
and duration prescribed by the physician. Workers’ com-
their insurance coverage. True or False?
pensation reimburses occupational therapists for outpatient
therapy, inpatient therapy, functional capacity evaluations,
impairment ratings, and work conditioning. Ultimately, the
adjuster for the claimant approves the therapy sessions.
In more recent years, occupational therapy providers com- OCCUPATIONAL THERAPY
municate with a third party for workers’ compensation claims. Cost Per Visit
For example, One Call/Align Networks manages therapy ser-
vices for many workers’ compensation carriers. The occupa- As occupational therapy managers address the budget, they
tional therapy provider must have a signed contract with this must consider the cost per visit, which is calculated based
third party, and payment for services is received by the third on the overall expenditures associated with managing the
party. In other words, payment is received through the practice. The reimbursement rate should be higher than the
third party, not the actual worker’s compensation insurance average cost per visit to promote a profitable practice. For
carrier. This is a point of contention for many providers be- example, if the clinic’s fixed monthly costs are $37,197 and
cause the third party receives fees associated with managing the fully loaded labor costs are $80,288, the total monthly
the claims. Also, the third party negotiates with the occupa- expenses are $117,485. If the clinic averages 1,437 visits per
tional therapy provider regarding the payment for services, month, the average cost per visit is approximately $82 per
and the negotiations may occur on an annual basis. Workers’ visit. Although most insurance companies have a predeter-
compensation is one of the few payment models in which pro- mined rate of reimbursement, most workers’ compensation
viders can negotiate the payments for services. carriers will negotiate the terms in a contracted rate for
If the provider opts not to participate with the third party, services.
this may result in limited referrals to the occupational ther- As the occupational therapy management organizes the
apy practice. The occupational therapy manager must main- payment structure, they should work with accountants to es-
tain contracts with carriers, third-party contractors, and tablish budgets and attorneys to establish contracts with dif-
local businesses to receive referrals to the practice. The occu- ferent carriers. Regardless of the payment model, the cost per
pational therapy manager must be willing to negotiate pay- visit must stay below the overall reimbursement per visit for a
ment for services based on the overall cost per visit and the successful and sustainable practice.
type of service provided when designing a payment structure.
Types of Payments
Grants or Charity Funding As previously stated, there are 8 basic payment methods for
As occupational therapy practitioners complete research to health care (per time period, beneficiary, recipient, episode,
provide evidence-based care, occupational therapy managers day, service, dollar of cost, and dollar of charges; Quinn, 2015).
may consider grant funding as a payment structure for ser- The first method of payment, per time period, is based on
vices. Several agencies and organizations offer grants or schol- budget and salary. For example, some government hospitals
arships, including the Agency for Healthcare Research and may pay a provider based on a predetermined annual salary.
Quality, the American Occupational Therapy Foundation, and Payment per beneficiary is commonly referred to as cap-
Patient-Centered Outcomes Research (AOTA, 2018). Manag- itation. Most managed care organizations are paid a prede-
ers may need to acquire grant writing skills in the development termined rate for a service versus an individual provider rate.
of grants, but obtaining a grant is an excellent opportunity for For example, an insurance carrier may only allow 30 occupa-
occupational therapy manager to receive payment for a service tional therapy visits per plan year. Once the recipient receives
not paid via an insurance plan. However, the grant may pay 30 sessions, typically no additional services are covered.
over a limited duration, so managers must consider payment Thirdly, an uncommon form of payment is contact capitation
structures beyond the terms of the grant funding. and is related to physician specialist services. As this mainly
applies to physician specialists, occupational therapy manag-
ers are less concerned about this form of payment.
Some providers may seek payment per episode and per stay.
(Bundled care falls under this form of payment.) The provider
For additional learning, see Chapter 46, “Grant Proposal Writing.” is commonly paid for a service across multiple days (Quinn,
2015). Nursing facilities and ambulatory care centers may be
paid per day at a per diem rate or a day rate. A common pay- either be accepted or denied. The longer it takes to receive
ment method is fee per service, which are separate payments payment, the greater the impact on cash flow for the practice
for multiple services provided in 1 day (Quinn, 2015). (Hudgins, 2016a).
Government-owned providers may be paid on the basis Many factors influence how quickly the claim is paid, in-
of the cost reimbursement associated with the care; there- cluding accuracy of information on the claim form, diagnosis
fore, the provider is paid on the basis of a percentage of cost coding (i.e., ICD–10 Diagnoses Coding [CMS, 2017a]), coding
allowed by the payer (i.e., per dollar of cost; Quinn, 2015). of procedures provided (i.e., Health Care Common Procedure
Finally, any provider may be paid a percentage of charges Coding System), and lack of authorizations. Most providers
(i.e., per dollar of charges). For example, in billing Medicare have benchmarks set for AR. For example, most carriers will
Part B, the participating provider bills for 80% of the allowed pay for services within a 30-day window; yet, workers’ com-
charge for services. pensation may take 90 days to pay for services (Hudgins,
2016a). A healthy metric for a sustainable practice is a 35-day
Bundled care AR benchmark. Receiving payment for services in a timely
manner results in positive cash flow for the occupational
Bundled care is a payment structure in which 1 payment therapy practice. Timely filing is critical to ensure prompt
is made for a group of related services. Medicare often uses reimbursement for services, and electronic medical records
this payment structure. For example, if a patient goes to an promote efficiency in documentation and billing for services.
acute care facility to receive a hip replacement, the payment
will cover the cost of all services, including the hospital, sur-
geon, home health company, and therapy provider. The goal For Additional Learning
is to provide optimal care with improved outcomes in a cost-
effective manner (see Case Example 49.1). For additional learning, see Chapter 52, “Monitoring Cash Flow.”
As the bundled payment system takes effect, health care
providers will be compensated based on functional outcomes
done in a timely manner. Tracking functional outcomes for
Looking to the Future
the insurance carriers will lead to better reimbursement.
Bundled care exists now for occupational therapists treat- Our view of occupational therapy may look vastly different
ing those with joint replacements. The new model provides in 25 years from what we know today. “Because looking into
1 bundled payment for a hip or knee replacement through the proverbial crystal ball to foresee the future isn’t possible,
90 days after discharge, which means acute care hospitals thinking in terms of innovation allows health care admin-
may choose to discharge beneficiaries directly to their home istrators to adapt programs based on forthcoming needs”
to receive rehabilitation services instead of providing services (Hudgins, 2016b, p. 26). Occupational therapy practitioners
in a more traditional inpatient or skilled nursing rehabilita- may provide services through telehealth, or they may develop
tion center (Ray & Parsons, 2016). The participating hospital a niche market centered on women’s health.
will oversee the entire process, including surgery, acute care Numerous opportunities exist around the provision of
stay, and postoperative rehabilitation. care as practitioners seek to promote the participation in oc-
In a study regarding bundled care, those patients who cupations. Moreover, providing alternative delivery methods
opted for bundled care versus traditional reimbursement and different practice methods relates back to designing pay-
for services resulted in a reduction in hospitalization (2.5% ment structures. As one considers the health and well-being
vs. 1.7%, p = .0006), and there was a reduction in emergency of the community, occupational therapy managers and prac-
department visits (11.5% vs. 4.4%, p = .0001; Lawler et al., titioners may consider alternative payment structures for re-
2017). Ultimately, the patient has the choice when seeking imbursement. Given the numerous grants available, one must
bundled care versus traditional fee-for-service care. However, consider grant funding if no other means for payment exist.
as bundled care grows in popularity, patients may not have As a leader for the profession, always consider innovative
the option of choosing one over the other. Further research is delivery methods and innovative methods of payment.
needed to support the effectiveness in bundled payments as a
payment structure for occupational therapy services. Review Questions
1. What is the optimal time period for AR?
Accounts Receivable
a. 60 days
Patient balances for services provided, called accounts b. 120 days
receivable (AR), accrue over a period of days or weeks. These c. 35 days
balances are sent to the patient’s insurance carrier as a claim. 2. Occupational therapy services are not included as part of
The time it takes to submit a claim and receive payment the bundled care payment model. True or false?
is measured in days. The claims are sent through a clearing- 3. Timely and efficient documentation optimizes reim-
house (ClearingHouses.org, 2017), which serves as an aggre- bursement for the occupational therapy provider. True
gator for a variety of software submissions. The claim will or false?
CASE EXAMPLE 49.1. Ms. Jones: Bundled Care
Ms. Jones has severe osteoarthritis in her right knee. She has received diagnostic procedures from her orthopedic surgeon, and a total knee
replacement has been recommended. Ms. Jones has agreed to receive her surgery in a facility that participates in the bundled care program.
The surgeon has met with her and advised that she will be receiving occupational therapy in the hospital immediately after her surgery. The goal
is to return home as soon as possible, where she will receive home health occupational therapy to improve her independence with ADLs. After
she can leave her home safely, she will seek services in an outpatient rehabilitation facility.
Review Questions
1. Acute care stays, surgery, and home health services may be bundled together in 1 payment for this case. True or false?
2. The occupational therapist does not need to use an outcome measure to support the ongoing need for services. True or false?
3. After the client transfers to outpatient therapy, the clinic will more than likely bill with which payment method?

When occupational therapy managers design a payment This chapter addresses the following ACOTE Standards:
structure, they must consider settings in which the services
■ Preamble
are provided; community demographics, options for pay-
■ B.4.29. Reimbursement Systems and Documentation
ment (e.g., federally funded programs, commercial insurance
companies, workers’ compensation carriers), AR, and bud-
■ B.7.3. Promote Occupational Therapy.
gets as related to the cost to provide care. Over time, occu-
pational therapy managers may consider alternative payment
models, which are typically based on the principles of value-
based care. REFERENCES
Although most occupational therapy practitioners are al- Accreditation Council for Occupational Therapy Education. (2018).
truistic, the provider must consider the payment structure 2018 Accreditation Council for Occupational Therapy Education
for fiscal soundness of the practice. It is critical that manag- (ACOTE) standards and interpretive guide. American Journal
ers stay informed regarding the rules associated with pay- of Occupational Therapy, 72(Suppl. 2). https://doi.org/10.5014/ajot
ment because the rules frequently change. Managers must .2018.72S217
learn and understand the rules associated with the payment American Occupational Therapy Association. (2017a). Four ways
structure for occupational therapy services when leading an Medicare final rules affect OT: Coding rates, therapy cap, and
more. Retrieved from https://www.aota.org/Advocacy-Policy
occupational therapy practice. ❖
/Federal-Reg-Affairs/News/2017/Four-Ways-Medicare-Final
-Rules-Affect-OT-Coding-Rates-Therapy-Cap.aspx
American Occupational Therapy Association. (2017b). Tricare reim-
LEARNING ACTIVITIES bursement of occupational therapy assistant services advances in
1. You are completing a billing form for Medicare. Go Congress; policy to be signed into law by end of 2017. Retrieved from
https://www.aota.org/Advocacy-Policy/Congressional-Affairs
to https://go.cms.gov/2FlsTnE, and download the CMS
/Legislative-Issues-Update/2017/tricare-reimbursement-of-ota
1500 billing form. -services-advances-in-congress-policy-to-be-signed-into-law.aspx
Pretend you have a patient with right-hand pain after a American Occupational Therapy Association. (2018). Grants and
carpal tunnel release. Look up the approved ICD–10 code grantsmanship. Retrieved from https://www.aota.org/Practice
(CMS, 2017a) at https://go.cms.gov/2D2vL6s /Researchers/Funding.aspx
Complete the form as if you were going to bill the claim. Centers for Disease Control and Prevention. (2017). Health, United
This provides insight to the type of information that is States, 2016 with Chartbook on Long-term Trends in Health.
submitted for payment. Hyattsville, MD: U.S. Government Printing Office. Retrieved
2. The same above-mentioned patient has been denied. from https://www.cdc.gov/nchs/data/hus/hus16.pdf
Write a letter of medical necessity, indicating why the Centers for Medicare and Medicaid Services. (n.d.). Medicaid and
services are medically necessary based on the patient’s CHIP coverage. Retrieved from https://www.healthcare.gov
/medicaid-chip/getting-medicaid-chip/
condition and diagnosis. The 65-year-old female patient
Centers for Medicare and Medicaid Services. (2017a). Medicare
is unable to complete her ADLs and IADLs and has a nu- National Coverage Determinations (NCD) coding policy manual
meric pain scale of 8/10, a quick DASH score of 80, and and change report (ICD–10–CM). Retrieved from https://www
a grip strength measurement of 20 pounds. She lives at .cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads
home with her 70-year-old husband who had a stroke and /manual201701_ICD10.pdf
requires her assistance for ADLs. No family members live Centers for Medicare and Medicaid Services. (2017b). Medicare Pro-
in the community. gram; CY 2018 Updates to the Quality Payment Program; and
Quality Payment Program: Extreme and Uncontrollable Circum- Quinn, K. (2015). The 8 basic payment methods in health care.
stance Policy for the Transition Year. Federal Register, 82(220), Annals of Internal Medicine, 163(4), 300–306. https://doi
53568–54229. .org/10.7326/M14-2784
ClearingHouses.org. (2017). How to select a good clearinghouse— Ray, J., & Parsons, H. (2016). Capitalizing on occupational therapy’s
7 things you must know. Retrieved from https://clearinghouses.org/ value in the home. Retrieved from https://www.aota.org/Advocacy
Health Care and Education Reconciliation Act of 2010, Pub. L. -Policy/Congressional-Affairs/Legislative-Issues-Update/2016
111–152, 124 Stat. 1029. /Capitalizing-on-Occupational-Therapys-Value-in-the-Home.aspx
Hudgins, E. (2016a). Healthy metrics for a sustainable private prac- Sandhu, S., Furniss, J., & Metzler, C. (2018). Health Policy Perspectives:
tice. SIS Quarterly Practice Connections, 1(3), 25–27. Using the new postacute care quality measures to demonstrate the
Hudgins, E. (2016b). Innovative leadership. SIS Quarterly Practice value of occupational therapy. American Journal of Occupational
Connection, 1(1), 26–27. Therapy, 72, 720209010. https://doi.org/10.5014/ajot.2018.722002
Improving Medicare Post-Acute Care Transformation (IMPACT) Tricare. (2018a). Occupational therapy. Retrieved from https://tricare
Act of 2014, Pub. L. 113–185, 42 U.S.C. 1395. .mil/CoveredServices/IsItCovered/OccupationalTherapy.aspx
Individuals with Disabilities Education Act (IDEA) of 1990, Pub. L. Tricare. (2018b). Eligibility. Retrieved from https://www.tricare.mil
101–476, 104 Stat. 1142. /Plans/Eligibility
Lawler, F., Wilson, F., Smith, K., & Mitchell, L. (2017). Prospective U.S. Department of Education. (2016). Early intervention program
bundled payments in a changing environment: The experience of for infants and toddlers with disabilities. Retrieved from https://
a self-funded, state-sponsored plan. American Health and Drug www2.ed.gov/programs/osepeip/index.html
Benefits, 10, 441–447. U.S. Department of Labor. (2017). Employer-reported workplace
National Defense Authorization Act of 2017, Pub. L. 114–328, injury and illnesses, 2017. Retrieved from https://www.bls.gov
130 Stat. 2442. /news.release/osh.nr0.htm
Medicare Access and CHIP Reauthorization Act of 2015, Pub. L. U.S. Department of Veterans Affairs. (n.d.). How occupational ther-
114–10, 42 U.S.C. 1305. apy works for you. Retrieved from https://www.va.gov/health
Patient Protection and Affordable Care Act, Pub. L. 111–148, 42 /newsfeatures/2015/april/how-occupational-therapy-works
U.S.C. §§ 18001-18121. (2010). -for-you.asp
CHAPTER
Developing a Budget
Nathan B. Herz, OTD, MBA, OTR/L 50
LEARNING OBJECTIVES
■ Understand the meaning of a financial plan;
■ Construct a financial plan for an occupational therapy service;
■ Demonstrate how to delineate the costs of conducting business, including yearly, monthly, weekly, daily, and hourly
rates when given a total cost; and
■ Create a budget justification.

• Advertising • Depreciation • Pro forma
• Benefits • Exempt employees • Profit-and-loss statement
• Billable items • Fiscal year • Rent
• Break-even point • Fixed costs • Repair and maintenance
• Budget • Insurance • Salary expense
• Budget justification • Loan repayments • Supplies
• Capital assets • Non-billable items • Variable costs
• Capital expense • Outside services • Workers’ compensation
• Corporate overhead • Overhead • Zero-based budget
OVERVIEW Occupational therapy managers should have systems in
A
budget is an itemized summary of estimated or place to monitor spending, contracts, and monthly costs. It is
planned expenditures for a set time period along with important to remain aware of where the clinic or business
proposals for financing them. Occupational therapy stands financially, so managers should continuously review
managers must recognize the financial plan (i.e., budget) as its standing and ensure that employees are aware of the or-
a major, guiding document that is considered in all business ganization’s financial obligations and prudent in the use of
decisions and that is regularly monitored. Managers need to equipment and supplies. Many occupational therapy organi-
be aware of all aspects related to the financial plan and what zations have financial staff who do bookkeeping, and that can
their clinic, program, or business is currently spending and provide occupational therapy managers with the information
receiving. they need to create and manage a budget.
In today’s health care economy, a program’s success de- This chapter describes the costs and the budgeting pro-
pends on understanding reimbursement. Managers must bal- cess to guide readers in understanding the differences among
ance the costs of doing business against the reimbursement or what occupational therapy managers need, have, or want.
revenue and determine whether the business is profitable and Capital expenses, fixed vs. variable costs, overhead costs, and
solvent. Managers also need to prioritize spending and maxi- the cost of conducting business are discussed. This chap-
mize resources. A business must be profitable to be viable and ter reminds readers that different situations can influence
provide staff with gainful employment. the management of a budget. Finally, the chapter addresses
https://doi.org/10.7139/2019.978-1-56900-592-7.050
465
CHAPTER
Developing a Budget
LEARNING OBJECTIVES
■ Understand the meaning of a financial plan;
■ Construct a financial plan for an occupational therapy service;
■ Demonstrate how to delineate the costs of conducting business, including yearly, monthly, weekly, daily, and hourly
rates when given a total cost; and
■ Create a budget justification.

• Advertising • Depreciation • Pro forma
• Benefits • Exempt employees • Profit-and-loss statement
• Billable items • Fiscal year • Rent
• Break-even point • Fixed costs • Repair and maintenance
• Budget • Insurance • Salary expense
• Budget justification • Loan repayments • Supplies
• Capital assets • Non-billable items • Variable costs
• Capital expense • Outside services • Workers’ compensation
• Corporate overhead • Overhead • Zero-based budget
OVERVIEW Occupational therapy managers should have systems in
A
budget is an itemized summary of estimated or place to monitor spending, contracts, and monthly costs. It is
planned expenditures for a set time period along with important to remain aware of where the clinic or business
proposals for financing them. Occupational therapy stands financially, so managers should continuously review
managers must recognize the financial plan (i.e., budget) as its standing and ensure that employees are aware of the or-
a major, guiding document that is considered in all business ganization’s financial obligations and prudent in the use of
decisions and that is regularly monitored. Managers need to equipment and supplies. Many occupational therapy organi-
be aware of all aspects related to the financial plan and what zations have financial staff who do bookkeeping, and that can
their clinic, program, or business is currently spending and provide occupational therapy managers with the information
receiving. they need to create and manage a budget.
In today’s health care economy, a program’s success de- This chapter describes the costs and the budgeting pro-
pends on understanding reimbursement. Managers must bal- cess to guide readers in understanding the differences among
ance the costs of doing business against the reimbursement or what occupational therapy managers need, have, or want.
revenue and determine whether the business is profitable and Capital expenses, fixed vs. variable costs, overhead costs, and
solvent. Managers also need to prioritize spending and maxi- the cost of conducting business are discussed. This chap-
mize resources. A business must be profitable to be viable and ter reminds readers that different situations can influence
provide staff with gainful employment. the management of a budget. Finally, the chapter addresses
https://doi.org/10.7139/2019.978-1-56900-592-7.050
465
understanding the context of the business, needs of the com-

CASE EXAMPLE 50.1. Developing a Budget
munity, and need for occupational therapy services.
The manager of an occupational therapy clinic has been asked by
the vice president of the organization for a rehabilitation program
ESSENTIAL CONSIDERATIONS to develop a budget for the next FY for the department. There are
Financial Plan 5 occupational therapy practitioners on staff, including the manager,
whose salaries total $390,000 annually. Two certified occupational
A financial plan, or budget, is basic to evaluating a business therapy assistants and 2 aides earn a total of $127,000 in salary.
and should represent the best estimate of operations. A bud- There is an administrative assistant whose annual salary is $32,000.
get can also serve as an operating plan for the management The total salary for the occupational therapy clinic is $549,000, and
team because many decisions will be based on what it pres- the benefit percentage is 23.5% for $129,015 added to the total
ents, such as number of personnel, equipment, capital items, salaries. New equipment for the next year totals $33,257, including
overhead (both corporate and clinic), billable and non-billable $5,500 for a new copier/printer. Billable supplies are $3,043. Utilities
supplies, office supplies, furniture, rent or mortgage, salaries for the department are $27,052, and administrative needs, including
office supplies and marketing expenses, are $12,345.
and benefits, and so forth.
Finally, a miscellaneous category of $2,500 is for emergency
A budget can be a dynamic variable in a constant state of
funding. There are no capital equipment expenses this FY. A 15%
flux and revised as necessary. However, a budget is not fluid; corporate overhead ($113,431) is added to the total, which
it provides limitations to work within and determines how is $756,206. The total cost for the FY is $869,637. Last year,
much can be spent. Usually a budget is submitted based on reimbursement was 17% over the costs of $817,459, which was
the fiscal year (FY), which is a 12-month period for gathering $138,968. Total revenue for the department was $956,427. If the
the organization’s financial information and can run from revenue stays at that level, there would be a lower percentage
October to September, July to June, or January to December profitability of approximately 10%; however, the company would
(i.e., calendar year). Some organizations choose the dates that like to have 15% profitability.
differ from the calendar year for several reasons. For exam-
Review Questions
ple, October to September can be more convenient because
corporate taxes are due March 15, 1 month earlier than indi- 1. On the basis of the case example, what would the profitability
vidual taxes. FYs can also be arbitrary. For example, the FY of need to be to make the company standard for reimbursement?
an academic program may start in September, when classes 2. How much is the daily expense or amount you need to bring in
begin, and end in May. to break even with and without overhead?
3. What is the profitability level without corporate overhead?
Cost of Doing Business

To illustrate the cost of doing business, take a number that in- repairs or new equipment to be purchased or replaced. Case
cludes all the expenses in total and break it down into monthly, Example 50.1 describes budgeting and the cost of doing busi-
weekly, daily, and hourly expenses to get an idea of the break- ness for an occupational therapy clinic.
even point of this particular business. The break-even point
is when costs are equal to the money brought in for services Review Questions
rendered, leaving no debt or profit.
For example, the total cost to run an occupational therapy 1. What is a FY?
clinic for the FY is $429,512. The monthly cost is the total 2. How do you calculate a break-even point for the business?
divided by 12, which equals $35,792.66. The weekly cost is the 3. An organization’s financial plan is known as a ?
total divided by 52, which equals $8,259.85. The daily cost is It can serve as a for management.
the total divided by 260 working days, which equals $1,651.97.
Finally, the hourly cost is the total divided by 2,080 number of
work hours in a year (based on a 40-hour week), which equals PRACTICAL APPLICATIONS IN
$206.50 an hour. The results are the break-even points at the OCCUPATIONAL THERAPY
different measures of time yearly, monthly, weekly, daily, and Budgets are made up of the various costs associated with pro-
hourly (Exhibit 50.1). viding occupational therapy services.
These figures help occupational therapy managers under
stand the cost of doing business, but there are always un-
anticipated situations that need to be addressed, such as Variable and Fixed Costs
Costs can be variable or fixed. Variable costs vary directly
EXHIBIT 50.1. Occupational Therapy Clinic with output (i.e., productivity), so when output increases,
Cost Breakdown variable costs also increase (e.g., raw materials, electricity;
YEARLY MONTHLY WEEKLY DAILY HOURLY U.S. Small Business Administration, n.d.). Fixed costs do not
change over a period and do not vary with output. Examples
$429,512.00 $35,792.66 $8,259.85 $1,651.97 $206.50
of fixed costs include, rent, taxes, insurance rates, heating,
CHAPTER 50. Developing a Budget 467
and lighting. Fixed costs may vary slightly but usually can taxes and payments needed for the business. They will also
be predicted and must be paid on time even if the company examine and identify the things that are deductible depend-
or business is not producing any goods or services or profits ing on the organizational structure of the business.
(Project Alevel, 2017). An organization will also need a good business attorney to
assist with the application for the organizational status. If the
Variable costs organization chooses to become a not-for-profit, then specific
requirements need to be addressed. Attorneys will serve as a
Outside services. Outside services include costs for con- corporate agent for the business, looking after the business
sultants or subcontractors (e.g., social workers reviewing cli- and the corporate meetings that occur each year.
ents for needs once a month as required by Medicare), overflow
work, and special or 1-time services. This category could in- Fixed costs
clude janitorial services, or it could be included in maintenance.
Salary expenses. Salary expense is base pay plus over-
Supplies. Supplies include services and items purchased time. Some staff are paid hourly rates, including technicians,
for use in the occupational therapy business or practice. The administrative staff, and finance staff who do the billing.
items are usually divided into billable and non-billable items. These individuals often work a 40-hour week and usually
Billable items are items that can be billed for within the ser- do not receive overtime pay, but there may be situations in
vices provided, such as supplies, bandages, adaptive equip- which compensation for overtime needs to be factored into
ment, therapy putty, electrodes, and items that need to be the salary. For example, workloads may vary during the holi-
replaced and not used again and again. Non-billable items days or peak times when more services are rendered.
cannot be billed for and might include hot packs, ice packs, In some settings, professional personnel, including oc-
towels, ultrasound gel, massage cream, and paraffin. cupational therapy practitioners and other professionals
(e.g., physical therapists, speech–language pathologists), are
Utilities. Water, gas, electric, and so forth are always a part paid an annual salary rather than an hourly rate. Exempt
of a clinical environment and budget. To budget for these, employees work until a job is done and do not have a limit of
one should use a business’s history of payments to get an aver- 40 hours; these employees may put in additional hours that
age for the year. Determine the total for the year in payments are not itemized. Their salary is the baseline for their posi-
divided by 12. If an average is unavailable, the utilities com- tion. Managers doing a yearly budget may want to include an
panies will have a history of payments of the facility. annual cost of living raise in salary or financial incentives, so
they may wait and see where the organization is with profit-
Repair and maintenance. Repair and maintenance is ability when the time comes to consider an increase in salary.
work required to fix something that is worn (wear and tear
from use) or broken and includes periodic large expenditures, Payroll expenses and benefits. Federal law requires
including wall painting, furniture, and replacement of equip- that employers provide the following benefits: workers
ment with a short life span, such as computers and items that compensation, time off for jury duty or military service,
need calibration. tax withholding and Federal Insurance Contributions Act
(FICA; P. L. 78–495), state and federal unemployment taxes,
Advertising. Advertising relates to promoting the busi- and compliance with the Family Medical Leave Act of 1993
ness. Advertising may include maintaining a website, desired (P. L. 103–3; U.S. Department of Labor, n.d.).
sales volume, and classified directory expenses. Benefits outside of these items are privileges. Benefits usually
include paid vacations, sick leave, health insurance, holidays, li-
ability insurance, continuing education (this can be a separate
Car and travel. Car and travel benefits include personal
line item in the budget), and long- and short-term disability.
cars used in the business, including parking, mileage, air-
fare, hotel, educational trips, and so forth. These benefits be-
come part of the hiring package in the case of professional For Additional Learning
employees who require some sort of continuing education
travel for retaining licensure For additional learning, see Chapter 64, “Understanding Employment
Laws.”
Accounting and legal. Outside professional services can
be very important. For a new business, a good accountant is
needed to assist with the type of corporation/organization, Unemployment and social security taxes are paid by both
FY choice, and how to structure accounting process- the employer and employee and are legally mandated. Profes-
es. Accountants should go over the business’s pro forma sional and staff packages may be slightly different due to ed-
(Investor Words, n.d.), which is hypothetical balance sheet ucation level and demand, but benefits are considered a part
and income statement based on a set of assumptions. Pro of doing business and in many cases are tax deductible. These
forma statements are used in business plans, loan requests, are usually calculated as a percentage of the base salary, but
and earnings reports. Accountants will give advice about the managers must know the costs to have the correct percentage.
The percentage is calculated on the basis of how an organiza- In some cases, a business can opt for a deferred payment and
tion packages the benefits and what it chooses to offer at the pay only the interest on the loan, and at a certain point begin
time an employee is hired. These hiring packages vary consid- to pay the principal and interest when there is cash flow in
erably. Some occupational therapy practitioners are offered a the business.
sign-on bonus, moving expenses, and other incentives, which
can be used for recruiting staff and as bargaining tools for
both the employer and employee. For Additional Learning
Rent. Rent is the cost associated with the use of a specific For additional learning, see Chapter 52, “Monitoring Cash Flow.”
building or land to carry out services, business, or living. List
only the rent for the real estate used in business. The rent can
also be a mortgage depending on whether the organization Miscellaneous. Miscellaneous are unspecified and small
owns the building. The yearly calculation for rent is the total expenditures without separate accounts, including things that
square footage multiplied by the dollar figure per square may be needed in an emergency, petty cash for items needed,
foot. For example, a 2,400 square foot facility × $9 a square and local purchase items for the facility (e.g., cleaning fluid,
foot = $21,600 per year; $21,600 divided by 12 is $1,800 per mop, paper towels).
month for the building rent.
If starting a new business, consider negotiating for changes Overhead
in the building when figuring a price. Lessee or tenant im-
provements can be either a part of the rent or paid separately. Overhead is the operating expenses of a business, including
For example, clinic space may need to be modified to make the costs of rent, utilities, interior decoration, and taxes, ex-
accommodations for individuals with physical disabilities, or clusive of labor and materials. Overhead includes some of
clinics may need suspension equipment installed. the budget costs that are already mentioned, such as utili-
ties, rent, maintenance, and some equipment. The overhead
is necessary to do business and to provide services to clients.
Depreciation. Depreciation is amortization of capital assets,
Corporate overhead includes the administrative aspects
which are items with a useful lifespan longer than 1 year and
of a business that may be centralized. These include the
not intended for sale during the normal course of business (Ac-
human resources, billing services, medical records, market-
counting Tools, 2017). A certain percentage of the product’s
ing, and executive branch of the business (e.g., chief executive
worth is deductible for tax purposes. Depreciation of capital as-
officer, chief financial officer). A business has a variety of cost
sets include computers; larger therapy equipment, such as elec-
centers, including home health, clinics, and contract therapy
trical stimulation units, fluidotherapy machines, hydrocollators,
sites such as skilled nursing facilities, and usually a percent-
refrigerators, treatment tables, and paraffin machines and other
age is added to the budget. In the case of contract services,
expensive items that may be used for treatment.
overhead is factored into the contract negotiations. The cost
of doing business is important because it contributes to the
Insurance. Insurance is what is used to offset what could
solvency of the overall business when a company can meet
be catastrophic costs associated with business (i.e., liability
overhead and costs while remaining profitable.
on property or products). Important insurance for a business
includes premise liability as well as professional liability
(i.e., malpractice). Premise liability protects a business from any Budget Justification
issue that may affect clients, such as falling on ice, slipping due Budget justification usually consists of a few sentences that
to rain, or falling in the clinic itself. Professional liability offers allow viewers to understand the reasoning and detail be-
protection from any incident that affects clients during treat- hind the expenses associated with the budget. Different
ment. Other insurance may include workers’ compensation, budget items can be categorized and addressed separately.
which protects employees if they are injured on the job. The budget justification will contain what is not able to be
in the budget. Some items have a certain level of expense
and are considered in a separate budget. These items may be
For Additional Learning a specialty piece of equipment or an evaluation that is new
and requires a computer to implement. Money needs to be
earmarked for this specific budget, and in some cases, a loan
■ Chapter 53, “Professional Liability Insurance” and may be needed to cover the expense associated with the item.
■ Chapter 61, “Malpractice.” Sometimes businesses contribute to charitable organi-
zations or budget for petty-cash expenses, such as birthday
celebrations and other events that raise staff morale. Capital
Loan repayments. Loan repayments include interest and expenses (described next) are expensive items and usually
principal payments on outstanding loans, if a business takes will go into a capital budget process, needing both adminis-
out any loans for improvements and for big-ticket items. trative approval and justification for its purchase.
CHAPTER 50. Developing a Budget 469
Capital Expenses Review Questions

A capital expense (H&R Block Tax Glossary, 2009) is an 1. What is corporate overhead?
expenditure made for an asset with a useful life of more than 2. What is a fixed cost?
1 year that increases the value of or extends the asset’s useful 3. What is depreciation?
life. Usually there is a minimum dollar amount set for this
type of purchase as well as a detailed justification. Specific
dollar amounts vary for capital expenses. A smaller business SUMMARY
may have a $2,500 limit, whereas a larger, more established
This chapter examined the structure and composition of a
business may have a $10,000 limit.
budget. The knowledge of the clinic in this case is import-
In many cases, capital expenses are prioritized related to
ant to the process. Budgets may be basic; however, they can
need and return on investment (ROI). Approvals follow an
be complex when truly detailed. Although most budgets in
expense justification that is designed to explain the need
an existing entity are limited by what is allocated, there are
for the equipment, how it will be used, and how it will be fi-
times when other monies can become available in the various
nanced. In the case of a specific piece of equipment, the jus-
implemented cycles of a company, such as capital expenses
tification would include a pro forma or standard form that
for improvement and equipment. Occupational therapy
would demonstrate the ROI or profitability of the item if used
managers must use the monies given in the appropriate man-
to enhance or provide services.
ner. Therefore, prioritization of spending is important. The
Some costs should be capitalized rather than deducted.
company expectation is that managers should spend money
These costs are a part of investment in the business and are
with conservation in mind and in a manner that maximizes
capital expenses. There are 3 types of capitalize expenses:
resources. ❖
1. Going into business (e.g., setting up the infrastructure,
outside services, consultants),
2. Business assets (e.g., equipment, technology), and ACOTE STANDARDS
3. Improvements (e.g., building, infrastructure, technology).
Examples of justification questions could include
■ How much does the item cost? Will it increase revenue to ■ B.5.6. Determination of Programmatic Needs and Service
have a positive ROI (i.e., pay for itself)? Delivery options
■ How will it be paid for (financed through seller, loan, cash)? ■ B.7.5. Personal and Professional Responsibilities.
■ How does the equipment enhance existing services?
■ What is the expected lifespan of the equipment?
■ What maintenance is required? REFERENCES
■ Is there training to be able to use it?
Accounting Tools. (2017). Is depreciation a fixed cost or variable
■ Is there a cost for training? cost? Retrieved from https://www.accountingtools.com/articles
To understand where a business is financially, managers /is-depreciation-a-fixed-cost-or-variable-cost.html
must understand reimbursement patterns and typical costs. Accreditation Council for Occupational Therapy Education. (2018).
A pro forma compares reimbursements to the costs the busi- 2018 Accreditation Council for Occupational Therapy Education
ness currently has. If there are historical data, a manager can
look at that history to compare the data. .org/10.5014/ajot.2018.72S217
Some companies institute a zero-based budget, which Family Medical Leave Act of 1993, Pub. L. 103–3, 29 U.S.C. § 2601.
means any monies allocated for the financial year need to be Federal Insurance Contributions Act of 1945, Pub. L. 78–495, 26
spent by the end of the year (usually 45 days prior to the end of U.S.C. § 21.
the FY), or the funds can be repossessed if needed in another H&R Block Tax Glossary. (2009.) Capital expenses. Retrieved from
place. In this case, there are often accounting associates in the https://financial-dictionary.thefreedictionary.com/Capital
organization that will send out the budget, so managers can +expenses
monitor this monthly. Many times, these individuals will let Investopedia. (n.d.). Profit and Loss Statement. Retrieved from
the business know if it is behind or over the expected spend- https://www.investopedia.com/terms/p/plstatement.asp
ing for that period. Accounting can create a profit-and-loss Investor Words. (n.d.). Pro forma. Retrieved from http://www
.investorwords.com/3889/pro_forma.html
(P&L) statement (Investopedia, n.d.) to show where the busi-
Project Alevel. (n.d.). Business costs. Retrieved from http://project
ness is at any time during the year. A P&L statement shows a alevel.co.uk/business/costs.htm
business’s expenses and reimbursements to see if the business U.S. Department of Labor. (n.d.). Summary of major laws of the De-
is profitable or operating at a loss. Many of the billing pro- partment of Labor. Retrieved from https://www.dol.gov/general
grams provide a printout of reimbursement at a specific pe- /aboutdol/majorlaws
riod and highlight the specific payers, such as Medicare, Blue U.S. Small Business Administration. (n.d.). Build your business
Cross/Blue Shield, workers compensation, and other payers. plan. Retrieved from https://www.sba.gov/tools/business-plan/1
CHAPTER
Determining Costs for New Programs
LEARNING OBJECTIVES
■ Recognize the similarities and differences associated with the costs for new program development and the cost of
doing business related to budgets,
■ Calculate full-time equivalents,
■ Develop a start-up budget for a new program, and
■ Understand and illustrate the proforma.

• Capital expenses • Equipment • Proforma
• Corporate overhead • Full-time equivalent • Quota
• Cost center • Percentage • Subject matter expert
• Cost containment • Precursor and development costs
OVERVIEW Fiscal budgets are similar for new and existing pro-
gram development except for some initial developmental
W
hen starting a new program, there are many things to costs for new programs, and there are no capital expenses
consider when determining its cost. First, there needs (i.e., funds used by a company to acquire, upgrade, and
to be an understanding of the program’s purpose. The maintain physical assets; Investopedia, 2018a) associated
research data derived from the market analysis and program with a start-up. Occupational therapy managers and prac-
development will help occupational therapy managers under- titioners strive for evidenced-based practice to justify what
stand the program’s many facets and determine costs. they do. Likewise, evidence must be presented to support
Managers need to know the costs associated with the a program’s existence and to assist in identifying costs.
program and to be aware of spending as it relates to budgetary Although determining costs can follow a different order,
issues. Cost containment occurs when managers identify and doing so follows a relatively similar budget structure, as
reduce expenses to increase profit. If costs are higher than discussed in Chapter 50.
planned, then some sort of action is needed (e.g., obtaining
more vendor bids to lower costs; Investopedia, 2018c). Cost
containment needs to be implemented during any budgetary For Additional Learning
actions. In the budget, managers search for the lowest prices
that allow them to gain the most value for the dollars they For additional learning, see Chapter 14, “Starting New Programs,”
are spending. In a “start-up” or new program, there is more for an in-depth discussion of developing a new program, which can
be considered in terms of costs in this chapter. For more information
freedom to purchase equipment, develop facilities, and hire
on market analysis, see Chapter 12, “Marketing Strategies
staff that will not be available in the future. There is also more
and Analysis.” For more information on costs, see Chapter 50,
freedom for any work (e.g., construction) that is done before “Developing a Budget.”
the implementation of services.
https://doi.org/10.7139/2019.978-1-56900-592-7.051
471
CHAPTER
Determining Costs for New Programs
LEARNING OBJECTIVES
■ Recognize the similarities and differences associated with the costs for new program development and the cost of
doing business related to budgets,
■ Calculate full-time equivalents,
■ Develop a start-up budget for a new program, and
■ Understand and illustrate the proforma.

• Capital expenses • Equipment • Proforma
• Corporate overhead • Full-time equivalent • Quota
• Cost center • Percentage • Subject matter expert
• Cost containment • Precursor and development costs
OVERVIEW Fiscal budgets are similar for new and existing pro-
gram development except for some initial developmental
W
hen starting a new program, there are many things to costs for new programs, and there are no capital expenses
consider when determining its cost. First, there needs (i.e., funds used by a company to acquire, upgrade, and
to be an understanding of the program’s purpose. The maintain physical assets; Investopedia, 2018a) associated
research data derived from the market analysis and program with a start-up. Occupational therapy managers and prac-
development will help occupational therapy managers under- titioners strive for evidenced-based practice to justify what
stand the program’s many facets and determine costs. they do. Likewise, evidence must be presented to support
Managers need to know the costs associated with the a program’s existence and to assist in identifying costs.
program and to be aware of spending as it relates to budgetary Although determining costs can follow a different order,
issues. Cost containment occurs when managers identify and doing so follows a relatively similar budget structure, as
reduce expenses to increase profit. If costs are higher than discussed in Chapter 50.
planned, then some sort of action is needed (e.g., obtaining
more vendor bids to lower costs; Investopedia, 2018c). Cost
containment needs to be implemented during any budgetary For Additional Learning
actions. In the budget, managers search for the lowest prices
that allow them to gain the most value for the dollars they For additional learning, see Chapter 14, “Starting New Programs,”
are spending. In a “start-up” or new program, there is more for an in-depth discussion of developing a new program, which can
be considered in terms of costs in this chapter. For more information
freedom to purchase equipment, develop facilities, and hire
on market analysis, see Chapter 12, “Marketing Strategies
staff that will not be available in the future. There is also more
and Analysis.” For more information on costs, see Chapter 50,
freedom for any work (e.g., construction) that is done before “Developing a Budget.”
the implementation of services.
https://doi.org/10.7139/2019.978-1-56900-592-7.051
471
ESSENTIAL CONSIDERATIONS EXHIBIT 51.1. Proforma Neurology Start-Up

(First Year)
New Programs
Evaluations ($150 × 15 per week $117,000
Like budgeting, determining costs for new programs requires @ $2,250)
managers to project the number of clients, select a reimburse-
Treatment ($75 × 90 per week $351,000
ment model, and predict the revenue that could be received
@ $6,750)
to the clinic for the services rendered. When considering the
staffing that will be in the cost center, managers also need to Total 1st year revenue $468,000
project the number of potential clients the facility will have to Total 1st year costs $310,947.50
obtain a realistic view of the numbers needed. A cost center −$310,947.50
is a department within an organization that does not directly Subtract costs from revenue = $157,052.50
add to profit but still costs the organization money to oper- gross profit
ate. Cost centers contribute to a company’s profitability only % Gross profit 33.5
indirectly (Investopedia, 2018b). Departments and clinics
can be divided into different cost centers in accounting, re-
flecting the clinic’s diverse clientele and the multiple needs in
the community to be served. The proforma assists managers in determining the program’s
New programs could include pediatric settings, school- staffing and supply needs. There are some calculations that
based practice, upper extremity specialization, neurological need to be done to determine the staffing level (discussed later
treatment, aquatic therapy, vestibular rehabilitation, or sports in this section).
medicine, to name a few. Therefore, the budget is often a con- When managers develop a proforma, they can evaluate
glomerate of programs after start up. Many companies keep the historical reimbursement noted in the existing clinical
track of each program (i.e., cost center) and the department to environment as it relates to the client population. (An organi-
monitor what is and is not going well. zation’s accounting department can supply those figures and
projections.) Managers can then provide a reimbursement
percentage (i.e., a rate or proportion per hundred; “Percent-
Early Development Costs
age,” n.d.) on the basis of historical data for many current
Precursor and development costs represent the work done payers, thereby having an accurate view of the reimbursement
before the implementation of the program, such as a needs pattern for the new program. Managers should keep in mind
assessment, market analysis, and SWOT analysis (strengths, that staffing can be added incrementally to avoid stressing the
weaknesses, opportunities, threats). Other preliminary work initial implementation of the program, but many calculations
includes creating a policy and procedures manual for the pro- are associated with that incremental process. Managers may
gram itself. The person who is the project manager and does need to align with a productivity standard or quota (i.e., a
this research and work is one of the first costs to be deter- proportional part or share of a fixed total amount or quantity;
mined because there is an hourly rate that they are paid—this “Quota,” n.d.) when calculating staffing.
is an example of a precursor cost. There is a related cost for the
time a consultant spends on this project. Usually the person Determining Staffing
is a subject matter expert who has expert knowledge about
what a particular job takes, who assists with the project, and An overall staffing or a monthly number can be calculated for
who is paid contractually (U.S. Office of Personnel Manage- a gradual increase as needed, but when new staff are added,
ment, n.d.). there is a cost that is associated with them (e.g., administra-
The person who does the early analysis has a fixed hourly tive assistants, aides, professional personnel). For example, if
rate that needs to be determined and factored in, which is a we are planning to add a new neurology program to a clinic
financial transaction as a start-up cost for the time that he or to increase revenue, staffing would need to be factored in (e.g.,
she has spent in research and construction of the program. Al- perhaps there is a steady flow of orthopedic clients since the
though the person may be on staff working in the project clinic, clinic opened and not neurology-based clients). When devel-
the time spent in development needs to be shifted to the new oping the proforma, there might be an expectation to have
program cost center. If the person spends 51 hours doing this 105 visits a week after the program is fully implemented.
work at $37.26 per hour, then $1,900.26 needs to be applied to The expectation is that approximately 10% will be the cost
the cost center for the development of the project or program. for evaluations, thus leaving 90% for treatment. This method
gives a dollar figure for reimbursement based on the histor-
ical data. That calculation gives you the total revenue for the
Proforma
program (Exhibit 51.2).
After the program is developed and the client population is To calculate expenses for the potential program that will
determined, there can be the creation of a proforma. A probe a full-time entity, there needs to be a projection of the cli-
forma is a hypothetical balance sheet and income statement entele to be seen that will cover the costs. For example, if we
based on a set of assumptions (Exhibit 51.1; “Proforma,” n.d.). figure 8 hours in the day for individual treatment to include
CHAPTER 51. Determining Costs for New Programs 473
EXHIBIT 51.2. Revenue Calculation EXHIBIT 51.4. Long-Form Calculation
$150 × 15 = $2,250 per week Total work hours per year: 40 × 52 = 2,080
$75 × 90 = $6,750 per week Total PTO days = 29
Total revenue = $9,000 per week 15 vacation, 7 holidays, 7 sick days
PTO = 29 × 8 = 232 hours
Yearly revenue = $9,000 × 52 = $468,000 per year 2,080 – 232 = 1,848
Actual work hours per FTE is 1,848 hours per year
105: 1-hour visits × 52 weeks a year for each FTE = 5,460 visits for
the year
evaluation, then we can use the number 2,080 hours for the 5,460/1,848 = 2.95 or 3.0 FTEs
calculation of full-time equivalent (FTE) employees, which 3.0 FTEs needed for the year
is the number of employees on full-time schedules plus the Short 2.63 vs. Long 3.0 FTEs
number of employees on part-time schedules converted to a
Note. FTE = full-time equivalent; PTO = paid time off.
full-time basis.
On the basis of the clinic’s past history, occupational ther-
apy treatments of neurological clients’ reimbursement average
approximately $74 per treatment. The cost of evaluations is 2. Development costs for a potential new program include
approximately $150 each. These costs are based on an average which assessment before determining the program?
from various reimbursement agencies. Managers can use an a. Rent
arbitrary number as an average for both treatment and eval- b. SWOT analysis
uation reimbursement, so they have an idea of charges and c. Occupational therapy practitioner salaries
the percentage coming back to the clinic or program. They d. Administrative staffing costs
can use the historical information from past reimbursement 3. What is the best information you have if you are a part of
or the information on reimbursement that is expected for the a company that can contribute to a realistic budget and
charges from different payers that have been researched. proforma?
If there is an expectation that there will be 35 client visits
a week for treatment 3 times per week, then there will be
105 treatments per week. To calculate this in the short form,
you take the number of treatments divided by the number of OCCUPATIONAL THERAPY
hours in a week (Exhibit 51.3). If you choose to use the long New program budgets are created in the same way as bud-
form, it demonstrates an accurate assessment to the actual gets for existing programs. More information and examples
number of personnel you need. The calculation includes paid can be found in Chapter 50 (also see Exhibit 51.5 for a budget
time off for holidays and vacation hours (Exhibit 51.4). On the for the neurological clinic example). Managers will need
basis of these calculations, you can now make a judgment about to determine costs for salaries and benefits, space, utilities,
how many FTEs you will need for the program and plan for a marketing, training, corporate overhead, and capital expen-
gradual increase on the basis of the projections for each month ditures.
(Sherman, 2018). If this method is chosen, then you need to plan
and estimate the progression of clients each month. Although
Salaries and Benefits
calculations can work, the long version is more accurate.
Federal law requires that employers provide worker com-
Review Questions pensation benefits, allow time off for jury duty or military
service, withhold taxes and pay FICA tax, pay state and fed-
1. When examining the possibility of a new cost center, a eral unemployment taxes, provide retirement and disability
project manager needs to be aware of the various costs coverage, and comply with Family Medical Leave Act of
that come with beginning a new program. Which is not a 1993 (P. L. 103–3) regulations (Doyle, 2018). Additional
part of the costs associated with the program? benefits (e.g., health insurance, paid medical leave) are a
a. Consultant fees privilege.
b. Space charges For a new program, managers should consider the salaries
c. Project manager salary and benefits package for both the professionals (e.g., occu-
d. Vice-president for rehabilitation pational therapists, occupational therapy assistants [OTAs])
that work in the program and the staff. If staff members (e.g.,
administrative staff, aides) are already working for your
EXHIBIT 51.3. Short-Form Calculation department, then there is an hourly cost associated with their
participation in the new program. Other costs associated
35 × 3 = 105 treatments per week; 105/40 = 2.63 FTEs with benefits may include malpractice insurance; continuing
education (CE) for competency; retirement benefits; life
is $9.50 × 225 sq. ft. = $2,137.50 per year. In addition, the oc-
EXHIBIT 51.5. Neurology Start-up Budget cupational therapy manager may figure $2,137.50/12 = $178
per month for space needs (Kimmons, 2018).
TOTAL COST
CATEGORY COSTS (PER CATEGORY)
Utilities
Staff
3 occupational therapy $180,000 Utilities include water, gas, and electric and need to be
practitioners ($60,000 each) divided by the number of cost centers to determine the ac-
tual dollar amount. An example would be 5 cost center pro-
Benefits @ 25% $45,000
grams in the department, and it is $1,800 per month for the
Administrative assistant $18,750 total utilities: $1,800/5 = $360 per month × 12 = $4,320 for
Benefits @ 25% $4,787.50 the year.
$248,537.50
Space ($178 per month) $2,136 Equipment
Utilities ($360 per month) $4,320 Equipment includes the various modalities used to facili-
$6,456 tate participation in the rehabilitation program (e.g., mats,
Equipment and supplies $6,000 weights, wheelchairs, steps, treadmill). In planning for the
$6,000 new neurology program, there is a need for 3 8 × 10 mats, an
upper-extremity bicycle, and other supplies associated with
Training $2,154
the services provided. These items are usually itemized and
$2,154 justified. In this example, the items would cost approximately
Administrative supplies $1,000 $6,000 for the new program.
$1,000
Corporate overhead $46,800 Marketing
$46,800
The new program will need to have marketing expendi-
Total $310,947.50 tures, which is a reoccurring cost. The cost could include
the occupational therapy practitioners traveling to market
to physicians, unless there is a marketing department in the
facility. Again, there is a cost for the visits as well as for fly-
insurance; health insurance (e.g., medical, dental, vision); ers explaining the program, and this expense needs to be in-
and paid time off for holidays, vacation, and sick time. cluded. Usually, it is the hourly rate for the staff members who
Benefits are usually designated as a percentage of the visit, plus mileage.
person’s base salary; in this example, let’s use 25%. If you Starting out can be a limited number of visits and then
are hiring 3 occupational therapy practitioners, then you expand to a regional area over time. Cost would be arbitrary
are looking at approximately $225,000 with benefits (this on the basis of the number of patients estimated to visit the
includes a base annual salary of $60,000 for each practitioner facility. Approximately $1,000 would be a reasonable amount
plus 25% of benefits = $15,000) and an administrative perfor the marketing visits and publications to potential referrers
son for appointments and paperwork at 3/4 time for a total of and the public.
$23,537.50 ($18,750 salary plus 25% of benefits = $4,787.50).
Therefore, the total for all salaries, including benefits, is Training
$248,537.50. This number could be decreased by hiring an
OTA on staff in the new program, which would lower the cost There may be training costs associated with the new program,
by approximately $25,000 (salary of approximately $40,000 and these costs could be a part of the CE benefits if the facility
and $10,000 for benefits), making the total figure $223,537.50 offers them. It could also be an additional cost for the facility
for annual salary expenses. for any new equipment. Any education is a benefit to an occu-
pational therapy practitioner, but management decides how
the training would be appropriated. For example, training
Space
might occur in the form of a weekend course for which the
If the new program is going to take up space in the organi- staff member would get 2 days off for continuing competency.
zation that is already allocated, then there needs to be a cost In this case, the staff member’s hourly rate would be added to
associated with the use of space. If there is an expansion, then the total for registration, lodging, food, and transportation.
it is easy to consider and come up with a number based on For example, for the occupational therapy practitioner’s sal-
square footage. Improvements are also a part of the budget ary listed in this section’s example, it would be $577 for each
and need to be factored into the overall costs. Therefore, to day, for a total of $1,154. The course, travel, and food total are
have the cost per square foot for a 15 × 15 addition to the clinic $1,000 plus the $1,154 = $2,154 for the person for this training.
CHAPTER 51. Determining Costs for New Programs 475
CASE EXAMPLE 51.1. Calculating Staffing and Space for a Hospital Clinic
The clinic has 26 days off and 213 visits per week. The clinic is a part of the hospital system and has become a cost center associated with the
whole. The human resources, supplies, management, and billing are all centralized. You are developing a budget and staffing. You will need to look at
what the productivity expectations will be and come up with the professional staffing needed to meet the level.
The clinic is planning to add a pediatric addition to the clinic so kids will have a swing and space to play as well as a ball pit and climbing wall.
The addition will require 760 sq. ft. of space. The therapists feel that is enough space needed to have a pediatric area. The price per square foot is
$11.75 and will be added to the rent.
Review Questions
1. Calculate the number of FTEs needed for a clinic that has 213 1-hour visits and 26 days of paid time off (PTO) using the long form.
2. Calculate the number of FTEs needed for a clinic that has 213 1-hour visits and 26 days of PTO using the short form.
3. What is the price per month added to the rent for the pediatric addition?
The occupational therapy manager may need to determine ■ Child care,

how much training is permitted per year, limiting the expense ■ Tuition assistance, and
and, in some cases, determining an as-needed basis for the ■ Disability.
clinic. Benefits for attending CE can be used as a recruitment
incentive for occupational therapy practitioners. When considering these benefits as part of the package for
staff, you must add an additional cost to the percentage of
the package given to the individuals. In the case of profit
Corporate Overhead sharing, your contract should reach a point where the group
Corporate overhead includes the price of administrative ex- or program is successful to expand (approximately 20%
penses that are absorbed as the company is working toward profitability) before giving a portion of the profits.
the program being successful. It includes overhead that is not
necessarily a part of the actual “clinic” cost but is a part of Review Questions
doing business as an organization, if you are a part of a large
company. This expense is usually calculated as a percentage 1. What is corporate overhead, and why does it need to be
of the overall budget. Usually the expense includes the ad- included in the budget?
ministrative or leadership group of the company, centralized 2. How are capital expense items included in a budget for a
departments (e.g., billing, human resources), legal counsel, clinic’s new program?
and accounting. We use 10% for this case study, which is 3. In the area of space costs, how do you calculate the
another $46,800 added to the cost of starting a new program. monthly cost associated with a 871-sq.-ft. area that is
renting for $13.41/sq. ft.?
Capital Expenses
Capital expenses are considered to be part of the budget, but SUMMARY
there is not a separate expenditure for this item when begin- This chapter reviewed budgeting considerations for a new
ning a new program. The capital expenses are included in program. There is little difference between an established fis-
the equipment start-up budget. After the initial budget, the cal budget versus the start-up budget for a new program. The
capital expenses would be visited when the company execu- initial start-up budget allows some flexibility for unknown
tives announce that they want to have the capital budget items expenses and overall purchase power because the program
for the next year for their budget and strategic planning. I does not have a history of cost and expenses like the estab-
would be remiss by not mentioning that the budgetary items lished programs.
that are capital and those that can be deferred over a period This chapter also described the proforma and how to
should be included in a strategic plan, not necessarily the estimate the necessary cost items for a realistic projection of
cost, but the item. a budget. A comparison of the program reimbursement and
costs is included to illustrate the profitability of the program.
Additional Items Remember that this is a hypothetical budget and a best
guess on the basis of historical data. The best guess lies in
If you are not part of a company, consider the following items
one’s ability to gain the knowledge needed to make informed
for a start-up budget:
decisions. In new program, development managers must
■ Profit sharing, illustrate the necessary processes and costs of doing business
■ Licensure, to fully understand what is to be accomplished. ❖
ACOTE STANDARDS Investopedia. (2018b). Cost center. Retrieved from https://www

.investopedia.com/terms/c/cost-center.asp#ixzz57JkJQmnz
This chapter addresses the following ACOTE Standard: Investopedia. (2018c). Cost control. Retrieved from https://www
■ B.5.3. Business Aspects of Practice. .investopedia.com/terms/c/cost-control.asp#ixzz57JjB2uj6
Kimmons, J. (2018). How to calculate commercial rent. Retrieved from
https://www.thebalance.com/commercial-lease-calculations
REFERENCES -tools-2866566
Percentage. (n.d.). In Dictionary.com. Retrieved from http://www
2018 Accreditation Council for Occupational Therapy Education .dictionary.com/browse/percentage
(ACOTE) standards and interpretive guide. American Journal of Proforma. (n.d.). In InvestorWords. Retrieved from http://www
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org .investorwords.com/3889/pro_forma.html
/10.5014/ajot.2018.72S217 Quota. (n.d.). In Dictionary.com. Retrieved from http://www
Doyle, A. (2018, October 29). Types of employee benefits and perks. .dictionary.com/browse/quota
Retrieved from https://www.thebalance.com/types-of-employee Sherman, F. (2018, June 30). How do I calculate FTE? Retrieved from
-benefits-and-perks-2060433 http://smallbusiness.chron.com/calculate-fte-742.html
Family Medical Leave Act of 1993, Pub. L. 103–3, 107 Stat. 6. U.S. Office of Personnel Management. (n.d.). What is a subject matter
Investopedia. (2018a, May 18). Business expenses. Retrieved from expert? Retrieved from https://www.opm.gov/FAQs/QA.aspx?fid
https://w w w.investopedia.com/terms/b/businessexpenses =a6da6c2e-e1cb-4841-b72d-53eb4adf1ab1&pid=c9d6d33b-a98c
.asp#ixzz57JiL2okP -45f5-ad76-497565d58bcf
CHAPTER
Monitoring Cash Flow
Chuck Partridge, CPA 52
LEARNING OBJECTIVES
■ Understand the basics of the statement of cash flows,
■ Understand the framework of generally accepted accounting principles,
■ Interpret the tools available to manage an organization’s cash, and
■ Understand cash flow in the context of occupational therapy.

• Accounts payable • Deferred income • Line of credit
• Accounts receivable • Depreciation • Lockbox
• ACH block • Dividend • Making deposits
• Audited financial statements • Factoring company • Net income
• Automated clearing house • Financial statement • Nexus
• Balance sheet • Financing activities • Operations
• Book value • Fiscal year • Payment card industry (PCI)
• Capital expenditures • Fixed assets standards
• Capital gains • Generally accepted accounting • Positive pay
• Cash flow principles • Prepaid expenses
• Change in investment value • Income statement • Statement of cash flows
• Credit card transactions • Interest • Wire transfer
• Credit sources • Inventory
OVERVIEW govern accounting. This chapter guides readers in under-
I
n today’s health care world, money and flow of money—or standing the statement of cash flows (SoCF), managing cash,
cash flow—sustain the life of any organization. This holds and ultimately securing sufficient cash to sustain the opera-
true for occupational therapy clinics, households, schools, tions of the organization for which you are working.
businesses, agencies, clinics, and Fortune 500 companies. Throughout this chapter, the audited financial statements
Accounting is a subject that many shy away from because its of the American Occupational Therapy Association (AOTA)
terms and concepts seem incomprehensible, but once they are are used as an example (see Appendix 52.A, “AOTA’s Finan-
properly understood, accounting concepts will enable you to cial Statements”). (Audited financial statements have been
better manage the finances of your practice. examined by an independent certified public accountant
To understand and manage cash flow, one needs to look according to professional auditing standards.) The concepts
at how this information is presented in the audited financial and principles that relate to AOTA can be generalized to
statements prepared under generally accepted accounting other organizations and their financials, cash flow, and oper-
principles (GAAPs), which are the underlying rules that ations. AOTA is a not-for-profit entity.
https://doi.org/10.7139/2019.978-1-56900-592-7.052
477
CHAPTER
Monitoring Cash Flow
Chuck Partridge, CPA 52
LEARNING OBJECTIVES
■ Understand the basics of the statement of cash flows,
■ Understand the framework of generally accepted accounting principles,
■ Interpret the tools available to manage an organization’s cash, and
■ Understand cash flow in the context of occupational therapy.

• Accounts payable • Deferred income • Line of credit
• Accounts receivable • Depreciation • Lockbox
• ACH block • Dividend • Making deposits
• Audited financial statements • Factoring company • Net income
• Automated clearing house • Financial statement • Nexus
• Balance sheet • Financing activities • Operations
• Book value • Fiscal year • Payment card industry (PCI)
• Capital expenditures • Fixed assets standards
• Capital gains • Generally accepted accounting • Positive pay
• Cash flow principles • Prepaid expenses
• Change in investment value • Income statement • Statement of cash flows
• Credit card transactions • Interest • Wire transfer
• Credit sources • Inventory
OVERVIEW govern accounting. This chapter guides readers in under-
I
n today’s health care world, money and flow of money—or standing the statement of cash flows (SoCF), managing cash,
cash flow—sustain the life of any organization. This holds and ultimately securing sufficient cash to sustain the opera-
true for occupational therapy clinics, households, schools, tions of the organization for which you are working.
businesses, agencies, clinics, and Fortune 500 companies. Throughout this chapter, the audited financial statements
Accounting is a subject that many shy away from because its of the American Occupational Therapy Association (AOTA)
terms and concepts seem incomprehensible, but once they are are used as an example (see Appendix 52.A, “AOTA’s Finan-
properly understood, accounting concepts will enable you to cial Statements”). (Audited financial statements have been
better manage the finances of your practice. examined by an independent certified public accountant
To understand and manage cash flow, one needs to look according to professional auditing standards.) The concepts
at how this information is presented in the audited financial and principles that relate to AOTA can be generalized to
statements prepared under generally accepted accounting other organizations and their financials, cash flow, and oper-
principles (GAAPs), which are the underlying rules that ations. AOTA is a not-for-profit entity.
https://doi.org/10.7139/2019.978-1-56900-592-7.052
477
ESSENTIAL CONSIDERATIONS you find all the answers by turning to the balance sheet. But
if you continue this dive with me, you can get to the bottom
An organization’s financial statements are composed of of those questions.
3 elements: (1) income statement, (2) balance sheet, and The SoCF is broken into various components and speaks
(3) SoCF. The income statement reports the revenue, ex- to 3 broad categories of important financial activity:
penses, and net income for a given period of time. The bal-
ance sheet reflects the overall position of the organization at 1. Cash flows from operating activities,
a specific date and summarizes the financial history of the 2. Cash flows from investing activities, and
organization. The SoCF integrates these 2 statements, like 3. Cash flows from financing activities.
glue holding together components. More important, the SoCF
removes elements of the accounting terminology that can Cash generated from operations
confuse those outside the accounting profession (e.g., debit, In the operations section of the SoCF, we take a close look
credit, accruals, allowance for bad debt, retained earnings). at the underlying operations of AOTA. Operations are the
normal day-to-day activities of an entity. The net cash flows
from operating activities is $3.4 million for the year. This
SoCF number reflects the cash generated in the normal course of
The SoCF simplifies the financial statements to address these operations. It does not explain all the cash inflows and out-
questions: flows during the year but only those typical and ordinary; the
net cash flows from operations does not account for large,
■ What cash did we receive?
unusual expenditures, which are dealt with in the section on
■ Where did the cash go?
cash flows from investing activities.
■ Did the organization have indebtedness?
Because the balance sheet provides a picture of what
■ How much cash (if any) remains with the organization at
AOTA owns at a point in time, on June 30, 2017, the income
the end of the period?
statement reflects the revenue for memberships, conferences,
If you look at Appendix 52.A, you will see the 3 elements books and publications, accreditation fees, and so forth, and
of the financial statements. Note that in the not-for-profit reflects the cost of providing those goods and services over a
section, these elements have slightly different names: state- period of time. In this case it is for a yearlong period, called a
ment of activities (i.e., income statement) and statement of fiscal year (FY), because it does not coincide with the calendar
financial position (i.e., balance sheet). The SoCF is termed year. A fiscal year is the accounting year an organization
the same. Typically, most readers of financial statements first adopts as the period for annual reporting; AOTA’s FY runs
look at the income statement. News reports might state that from July 1 to June 30. However, financial statements can be
a company reported record profits or that sales increased by prepared for shorter periods of time (e.g., month, quarter),
25% in the previous quarter. Although such statements make which facilitates keeping a closer eye on an organization.
headlines, the income statement does not reveal much about The SoCF is different from the income statement or bal-
the business or its ability to sustain its operations. It’s like ance sheet in that it shows the movement and changes in
eating a Twinkie—it tastes great but contains hollow calories the various components of assets, things owned, liabilities,
that won’t sustain your ADLs. The same is true of the balance things owed, things that are purchased, and money that is
sheet; it will give you the current picture of an organization, borrowed—hence the term cash flow. The SoCF lets you
but only on a single day. So let’s take a deep dive into AOTA’s understand and examine the changes that took place during
SoCF. the year. It can be considered the why statement, whereas
The top line of the SoCF starts with the Change in Net the balance sheet shows what—what an organization owns
Assets. In the not-for-profit world, we speak of the increase or owes. The income statement is the how statement—how
(or decrease) in change in net assets when a more widely used much the organization sold. Therefore, understanding the
term is net income, which results from subtracting incurred SoCF flow allows you to understand the inner workings of an
expenses from an entity’s revenue. On June 30, 2017, you can organization and how operations are financed.
see AOTA’s change in net assets was $1.9 million. Wow! That’s
a lot of money . . . or is it? What does that number tell you? Operating expenses without cash. Some expenses
Do you know whether AOTA has enough cash on hand to use no cash at all. AOTA’s balance sheet shows owned prop-
meet the next payroll or mortgage payment? Does it tell you erty and equipment, usually referred to as fixed assets, of
how much of the reported revenue was collected? Does it tell $9.9 million. Fixed assets doesn’t really mean fixed; rather, it
you whether all expenses were paid? Does it tell you whether refers to items like AOTA’s building; software, such as the as-
AOTA purchased new office equipment or upgraded its soft- sociation management software that tracks membership; or
ware? Do you know whether the mortgage was decreased the desk I sit behind each day at the office.
during the year? Or did AOTA refinance the building to meet Consider my desk, which cost about $2,200. It is the latest
payroll? and greatest, including being fully ergonomically adjust-
The fact is, you do not know the answers to these questions able, so I can sit or stand when working. In FY 2013, AOTA
by looking at the change in the net assets number. Nor will purchased the desk for $2,200, paying cash. My desk will last
CHAPTER 52. Monitoring Cash Flow 479
for several years. Therefore, it makes sense that the desk’s cost so an entry is recorded on the books increasing the value of
should be spread over a longer period than just FY 2013. The the investment portfolio by $5 and increasing income by the
life is estimated to be 5 years, so for the next 5 years, $440 same $5. This is done because we could call our broker and
(i.e., $2,200 divided by 5) will be expensed. Expensed means sell the shares at $15. However, we choose not to sell them, so
that $440 will flow from the balance sheet to the income we continue to own the shares of the power company at the
statement. However, the cash to pay for my desk left AOTA’s end of the year.
checking account in FY 2013; AOTA was cash poorer by If this were the only item on the income statement, we
$2,200 in FY13 but fixed asset richer by $2,200. would have an increase in change in net assets of $5. So where
All that brings us back to the SoCF. If this were the only is the cash? There isn’t any. See AOTA’s statement on the line
item in our financial statement, there would be a Decrease labeled Net (Gain) Loss in Investments in Appendix 52.A. It
in Change in Net Assets of $440 on the top line with an off- reads negative $353,253! But aren’t we $5 richer? Yes, we are.
setting addition of $440 on the line for depreciation (i.e., But do we have any new cash? No. The SoCF begins with the
ratable allocation of the cost of a fixed asset to an FY). This increase in net assets. In this case, it shows an increase of $5.
means that although AOTA “lost money,” there is no change If there were nothing else on the statement, you would see an
in AOTA’s cash position. increase in cash of $5, which is not the case. Therefore, we
Sometimes organizations with which AOTA is doing busi- must subtract the $5 from cash generated from Operations
ness are swimming in debt. As a result, they are unable or because no cash was generated.
unwilling to pay the amount owed or are deemed accounts
receivable; that is, their debt is unpaid at the balance sheet Accounts receivable. You may think accounts receiv-
date. The amounts AOTA is carrying as accounts receivable able always lead to receiving cash. Although this is true, if
must be written off. Does that take or use any cash? No. Writ- you look at individual accounts when taken in totality for
ing off accounts receivable is a bad thing, but it does not take an organization, accounts receivable can in some years con-
any cash. This is why $64,889 is added back as a source of cash sume cash. When AOTA was founded in 1917, we sold our
(Appendix 52.A); although writing off accounts receivable is first membership to Eleanor Clarke Slagle. Because she did
a cost of doing business, it does not require any use of money. not have her checkbook handy, she did not pay immediately.
During the year some companies that owed AOTA money did So AOTA had a receivable of $10. The costs of providing
not pay, so this figure goes into the accounts receivable line. that membership had to be paid. The salary of the person
who prepared her membership card, the cost of mailing the
Investment income. Income can come from the change magazine, and so forth were costs being paid with cash. The
in value of the investments owned. Investments typically can cash that started AOTA was spent to provide the membership
produce 3 types of income: (1) interest and dividends, (2) cap- services, but until Ms. Slagle’s check arrived, the increase in
ital gains, and (3) change in investment value. accounts receivable had used $10 of cash.
Interest is paid on money borrowed or lent; dividends are If this were the only item in the period, AOTA would have
payments made on the basis of owning stock. You may own had a decrease in cash in 1917. In 1918, again if this were the
a certificate of deposit (CD) at your local bank. Each month only transaction, AOTA would have had an increase of $10
the bank sends you a check for the interest paid on the CD. Or when Ms. Slagle’s check cleared the bank. Accounts receiv-
perhaps you inherited shares of stock in a local power com- able in the second year would be a source of cash. The same
pany from your grandparents and the company sends you a account can be either a source or use of cash, depending on
dividend check each quarter. the year’s activity. Being either a source or use of cash applies
The second type of investment income is called capital to other AOTA assets and liabilities accounts, which is why
gains, which are taken into revenue when the investment the SoCF will talk about the sources and uses of cash.
is sold. Your inherited stock shares in the power company On the first line, the section of SoCF for Change in As-
might have cost your grandparents $10 per share when they sets and Liabilities shows an increase in accounts receivable
purchased them, but today they are selling for $15 a share. of $28,445. The number is shown as a negative because
When you sell the power company shares, you have a realized accounts receivable increased during the year, meaning cash
capital gain of $5 a share and $15 in cash. of that amount did not flow into AOTA. The number on the
The third type of investment income, change in investment balance sheet for accounts receivable tells you how much
value, does not produce any cash. It is merely the change in money is owed to AOTA. However, you do not know what
value of the investment. If AOTA purchased the power com- was actually paid to AOTA. When looking at the change in
pany shares at the same time as your grandparents, AOTA accounts receivable during the year, remember the numbers
would have a book value of $10 per share. Book value is the making up accounts receivable come from the difference in
cost of an asset adjusted for depreciation or change in market the accounts receivable on the balance sheet. You can see that
worth. When the purchase is recorded in our accounting AOTA received cash because the change or increase during
system, a value of $10 is entered. At the end of the fiscal year, the year was positive. Knowing whether cash was received is
we must record and adjust the stock’s value as of the balance important. If the Increase in Change in Net Assets is com-
sheet date to $15. (Note: Adjusting book value is required posed exclusively of unpaid accounts receivables, then AOTA
under GAAP.) The power company shares increased in value, would be in a difficult situation. If AOTA is owed money by
members, bookstores, exhibitors, and so forth, it cannot use Cash flow from investing activities
those promises to pay staff. Even its most loyal employees
This section of the SoCF deals with those activities that are
would not wait until Amazon got around to paying AOTA for
not going to occur on a regular basis or are not a central part
its textbooks so AOTA in turn could pay staff.
of the entity’s operation. AOTA’s investment portfolio is not
part of our regular undertakings. Rather, it is like saving for
Prepaid expenses. Immediately after accounts receivable your education. AOTA is saving to be able to deliver future
are prepaid expenses, which are monies paid for events in the member benefits, advocate with insurance companies, and so
future. When you pay your car insurance bill, you send the forth for the future of the profession. The first 2 lines here
company a check for $1,200 for the next 6 months of coverage. reflect the activities of the investment manager of AOTA’s
Your cash has flowed out to the insurance company. But stat- portfolio. The items captured here are for the purchase and
ed another way, the insurance costs $200 per month, and if sale of securities that make up the investment portfolio. This
you sell your car, you could call the insurance company and number is important because it tells you if the organization
get a refund. It is the same for AOTA and other organizations. is increasing its investments or if it needs to sell investments
AOTA can prepay for items related to the next fiscal year or to cover the payroll or make capital purchases. You can’t tell
several years into the future. For example, AOTA has already from the income statement or balance sheet, but hiding in
made payments for the 2023 conference in Kansas City, MO. plain sight you can find investment information here.
The money is gone—it has left AOTA’s bank account—but Capital expenditures are those items purchased that are of
the cost of that conference will not be reflected in the income significant value and have a useful life of greater than 1 year.
statement until 2024. Money has been used, and our cash has As you move deeper into the Cash Flows from Investing
declined, but you will have to wait until FY24 to see it on the Activities, you see a line stating Purchases of Property and
income statement. The cash on the books is no longer avail- Equipment in the amount of $124,312. This figure represents
able for any other use by AOTA. cash spent on long-lived assets. More than $124,000 was spent
on items such as the latest software to make aota.org more user
Inventory. Inventory includes items that are held and friendly and office furniture, such as my desk. Capital expendi-
owned by an entity that can or will be sold. This (printed) tures can consume large amounts of cash. Organizations will
textbook is inventory. Long before you purchased this edition often curtail capital expenditures when business is difficult.
of The Occupational Therapy Manager, AOTA was spending This section of the SoCF lists the large expenditures AOTA
money to create it. Monies were paid to purchase images, de- made during the year. These are items that cost more than
sign the layout, obtain copyrighted permissions, copyedit and $2,000, an amount established by AOTA (this number can
proofread the text, pay the authors, and so forth. Although vary depending on an organization’s size), and have a useful
there is no expense on the income statement, money is life of more than 1 year. Should a purchase not meet those cri-
leaving AOTA to pay for the development of future products. teria, it would show up in the operations section of the SoCF.
In a way, AOTA is making goods to be sold, which is difficult Items that are capitalized can be many types of things. In
to understand. We both know the money is gone as the book addition to my desk, we would capitalize computer software
is being written. You have now purchased the book, and your and equipment needed to operate the national headquarters,
cash will appear in AOTA’s bank account. such as the boiler or garage doors. Capital expenditures can
In FY17, as inventory was sold, AOTA received $84,085 be very large. For example, when AOTA purchased its build-
and has less inventory than the previous year. ing, it was included in this section of the SoCF.
Deferred income. What happens with items that are

Cash flows from financing activities
not income but provide AOTA with cash? Deferred income
is revenue not taken into net income because the event has The final section of the statement is the section on financing
not taken place in the current fiscal period. Consider the activities, which disclose those actions an organization takes
transactions that occur when registering for AOTA’s Annual to supply itself with resources over the long term. Consider
Conference & Expo. You send AOTA your check or we the purchase of a home, which costs $200,000. You go to the
process your credit card for $420 in December. Your money bank and borrow most or all of the money you need to buy
will be put into our bank account, but has AOTA earned the house. The bank expects you to pay on the mortgage each
it? No, because the conference won’t occur until April. The month. Therefore, you have an initial source of cash from the
SoCF will show an increase in cash of $420 while AOTA has a bank loan for $200,000, followed by the use of your cash in
liability or, stated another way, an obligation to you to put on subsequent monthly payments of $1,000.
a conference that is months away; nonetheless we have your AOTA and other organizations have similar transactions.
$420. AOTA does not have increased revenue, but its cash Sometimes organizations will have several of these types
holdings have increased. What you will see on the SoCF is of transactions during the year. For example, when AOTA
an increase in deferred income of $420, which is a source of purchased the headquarters building in 1994, it had a source
cash that AOTA can use to make a deposit on the convention of $8.8 million from the bank to pay for the building and
center or pay the band for the opening ceremony. monthly payments to go along with the loan. You may think
the monthly payment includes both principal and interest, cash advance from AOTA. AOTA borrows from the credit
and you are correct. But where would you find the portion of company to cover staff expenses and leaves its cash in the
the monthly payment that went for interest? It is found in the bank. I can set limits and monitor purchases through the
earlier section on “Cash Flows From Operating Activities”. credit card company’s website. Moreover, I can arrange for a
The interest paid to the bank is taken into account on the payment date that best fits AOTA’s cash flow. I know exactly
income statement and is subtracted from the revenue to arrive which day the money will be taken from AOTA’s account to
at the net income or change in net assets. It makes sense if you make payment in full and avoid any interest or penalty for
think of interest as an expense during the year. However, the late payments. Likewise, when you renew your AOTA mem-
payment of principal on the mortgage is not an expense; it is bership, you can go online and pay AOTA directly without
a reduction in a liability, the mortgage note payable. immediately reducing your bank balance or worrying about
your payment getting lost in the mail.
Cash Management As you need to be careful with your personal credit card,
so must AOTA as we handle yours. Businesses like AOTA
On the SoCF, you see the results of actions AOTA took during must comply with standards established by the credit card
the year and the different types of activities that used or con- industry; these are referred to as payment card industry
sumed cash. You have a broad understanding of what hap- (PCI) standards and must be met as we process credit cards.
pened overall during the year, but what was happening day For example, we can process only part of your credit card
by day? How were inflows and outflows managed? How was number, and should you send in a paper application with
I managing AOTA’s cash flow, and more important, how will your credit card number on it, we must keep that under lock
you manage your organization’s cash flow? The cash manage- and key and destroy it within 30 days. Failure to comply can
ment part of the job is usually referred to as a treasury func- lead to fines and, more important, expose our customers
tion; the person performing the job is a treasurer, but titles to losses.
can vary from one organization to the next. However, the job Businesses that accept credit cards for payment pay a
duties are similar for every organization. fee for doing so. Payments made by credit card are handled
Most days start with checking the activity on AOTA’s bank through a processor, such as TSYS. The amount that is
accounts, which is mundane but nonetheless important. As deposited into the business’s bank account is reduced by pro-
a business, AOTA has only 24 hours to report unauthorized cessor fees and other fees related to credit card payments. The
transactions to the bank. (Different rules apply to you and me costs are complicated and numerous. The amounts charged
as consumers.) Failure to do so can result in losses you might vary, depending on many factors. However, the fees reduce
not be able to recover from the bank. Recent news articles the overall amount of money you receive. As an example, for
have covered frauds perpetrated on businesses that did not $100 of credit cards transactions in a day, the net amount
monitor their bank accounts. credited to AOTA’s bank will be $97.50. In other words, a
I log on to the bank’s website and review the activity that 2.5% processing fee was taken from credit card receipts.
transpired the day before. I can see those amounts coming Keep in mind, you could allow your customers to pay you
into the account and those amounts going out. Although I in 30 days. That could be attractive to some of your customers,
am most interested in the balances in our various accounts, and it would save you the 2.5% processing fee from the credit
I review the activity, looking for things that are unusual or card company. However, this approach will increase the cost
unexpected. Transactions on a typical day would include of your operations. What? How? Just as you get a statement
settlement of credit card transactions, deposits, wire transfers from the credit card company at the end of the month, you
either in or out, automated clearing house (ACH) items, will need to send your customers a statement at the end of the
payroll items, and tax-related transactions. Let’s look at each month reminding them that they owe you money. You also
of these items and see how they are managed. may want someone to call them or send them a text message
if they don’t pay. Sadly, some of your clients will not pay you.
Credit card transactions When they don’t pay you, you will have to write off the receiv-
able. Writing off assets, in this case a receivable, indicates it
Credit card transactions make up the bulk of AOTA’s bank will not be collected and will become an expense to the entity.
activity. Credit card transactions are a short-term loan from
the issuer of the credit card. They have largely replaced cash
Deposits
and checks in terms of how business is transacted. (Today
AOTA receives payments via PayPal and other mobile pay- Making deposits used to mean going to the bank with cash or
ments like Apple Pay. Although different from a technolog- checks. Bank deposits were typically a slip of paper listing the
ical point of view, they are handled in a manner similar to items for the bank to credit to your account. Today AOTA can
credit cards.) An organization that does not accept credit make deposits remotely with scanning equipment provided
cards finds itself with very few customers because individuals by the bank, thus saving the trip to the bank and allowing us
and businesses prefer this means of payment. access to those funds more rapidly. This process is used for
AOTA provides its staff with corporate credit cards. Before those checks that are sent directly to AOTA; usually these are
they leave for a business trip, staff members do not need a from exhibitors, advertisers, or tenants.
However, most of our deposits go to a lockbox. Perhaps you Banks offer another important service called ACH block.
have noticed on the membership renewal form that you send This service allows you to set up with the bank a list of entities
your check to AOTA to a P.O. box in Pittsburgh. A lockbox is that you authorize to draw money from your account.
a post office box that is the mailing address for accounts re-
ceivable. Those payments are processed by the bank without Tax payments
ever coming to the organization to whom the money belongs,
allowing for secure and quick processing of your check. The The last type of transaction that comes through the bank
bank courier stops by the post office several times a day to account is tax payments for sales taxes AOTA collects.
pick up checks as they are delivered. The payments are not AOTA is required to collect sales taxes when we have what
handled by AOTA; the accounting staff logs in to the lockbox lawyers call Nexus, which occurs when you have property
to pick up all the details, while the membership department or employees in a state. This requirement is increasingly
can access this information and update your member record important as states are becoming more sophisticated.
immediately. Scanning deposits and the use of a lockbox For example, AOTA’s headquarters are in Maryland, and
speed up receipt of payment for any organization. we are required to collect sales tax. We send in our sale figures
report on a quarterly basis, and Maryland then takes the money
from our account. Additionally, AOTA is subject to federal
Wire transfers
and state income taxes on our activities that are unrelated to
Wire transfers are the electronic movement of money be- our tax-exempt mission, commonly referred to as UBIT (i.e.,
tween financial institutions. In days gone by, wire transfers unrelated business income taxes). To pay the income taxes due
were used for large transactions when businesses wanted to in Maryland, I call the taxpayer number with the related secu-
handle payments more expeditiously than mailing a check to rity codes and authorize the state to withdraw the amount of
a faraway business. That has changed, and small amounts are the tax due from AOTA’s account on a specific day.
now sent via wire.
As the world shrinks, wire transfer service becomes Accounts Payable
more and more important. Recently, several winners of the
Cordelia Myers Award who live overseas were not able to cash Accounts payable are amounts AOTA owes to other compa-
our checks or found it too expensive and slow to do so. I was nies and people. As you can see from the financial statements,
able to wire them money directly with the option of paying in AOTA spends most of the money that comes in. Those expenses
dollars or their local currency. AOTA also uses wire transfers range from payroll to expense reports, printing, conference
to fund our account at the U.S. Postal Service. That gives the centers, authors, AV companies, and so forth. About 99.99% of
post office money immediately to pay for the mailing of the payments are made via our accounts payable vendor, Anybill.
OT Practice to your doorstep. Many companies provide this type of service. It is a powerful
way to manage our cash position with many related benefits.
First, instead of having a stack of bills show up at AOTA,
ACH
staff, vendors, and service providers can send invoices
Automated clearing house (ACH) items are similar to wires; directly via the internet to Anybill, which scans and routes
the main difference is that the payments are automated and them to the appropriate people at AOTA to review, code for
happen in a routine manner. You may be familiar with direct accounting, and approve for payment. I can log in to Anybill
deposit of a paycheck, which is an ACH transaction. A slight and authorize payment or, more important, not authorize
variation on this is those draws against our account that payment, allowing AOTA to hang on to its cash for a few
happen automatically. To collect the balance owed for the days longer to take advantage of those vendors who offer a
corporate credit cards that we provide to staff, the credit card payment grace period of 30 days or, if we happen to be run-
company draws the amount due from the bank on the 27th ning short of cash, delay a payment to take advantage of those
of each month. By setting up that automatic payment, AOTA vendors who allow a discount for prompt payment. Anybill
avoids paying any interest or late fees on the credit cards. Best then makes the payment on AOTA’s behalf.
of all, I do not have to remember to go online and enter the When you do not pay a vendor, that vendor is extending
transaction. I still check to make sure the amount the credit credit or making you a loan. That becomes a source of cash
company takes from our account agrees with what the state- to you because you can use the cash for another purpose.
ment shows AOTA owes. Sometimes vendors are willing to extend credit voluntarily,
Although AOTA staff enjoy direct deposit, payroll pro- but not every vendor can be flexible on payments terms. In
cessing online is also helpful for AOTA. When I review back those situations, I work with vendors to see if I can stretch
activity, I can see the amount that is going in aggregate to payments, or I explain that money is tight at the moment and
the staff, the amount paid in taxes, and the amounts that cash flow will improve when members buy books or register
are going into staff’s 401(k) accounts. These transactions are for the conference.
important, and a quick glance at the bank’s website tells me This source of cash should not be overlooked; it is available
that staff members have been paid, taxes have been paid, and either from a vendor who wants your business or from those
the money is on the way to their 401(k) accounts. with whom you have a long-term relationship. Be mindful
that it can work the other way around. Those customers who prime lending rate. This rate varies among banks but is usu-
owe you money are using you as a source of funds. ally relatively consistent. What do I mean by 1 or 2 points over
prime? A point is equal to 1%. If the bank’s prime rate is 3.25%
Positive Pay and it charges you 2 points over prime, then the rate is 5.25%.
Remember that sometimes access to money or credit is
Should a business decide to make payments to vendors itself, more important than price. You may run into difficult times
there is another bank service to be considered called positive as most businesses do on occasion. As a good cash flow man-
pay. The bank is informed in advance what checks will be ager, you should have a plan for when things are not going
presented to the bank. You provide the bank with the check smoothly, which means you need to plan for bad times when
number, payee, and dollar amount of checks issued. If a check times are good. For example, you might want to have accounts
is presented to the bank that does not appear on this positive at 2 banks because the first one might be going through a bad
pay listing, the bank will not pay it. This service increasingly time and be unable to extend you credit just when you need
is needed as copying equipment is more readily able to create money.
items that look like normal checks used by businesses. There are other options in the market in addition to banks.
Leasing companies can provide ways of obtaining equipment,
Credit Sources as an example, requiring less cash. If you need to set up your
office, you might need $25,000 of office and lab equipment.
Credit sources are those places a business can draw onto pro- Rather than lay out $25,000, you can lease the equipment and
vide it with cash. You may think of your parents as a source of make monthly payments, which would be similar in amount
credit because they will send you money for things like your to renting the equipment. At the end of the lease, you might
membership to AOTA. The same is true for organizations. have the option to purchase the equipment at a discounted
What if the financial needs of an entity are greater than what price from the leasing company.
can be derived from the operations at the moment? I cannot Although you might not think of your landlord as a source
turn to Eleanor Clark Slagle or past presidents of AOTA for of credit, they are. You could have purchased the apartment
money; I must look elsewhere. you are living in while attending college. It would be similar
I have mentioned the mortgage on the AOTA headquarters to buying a house. You didn’t; instead, the landlord went to
building. Where can one turn for funding long-term financial the bank and borrowed money to buy the building, put in the
needs? The most typical sources of mortgages for small busi- carpeting, and painted it, making it ready for you to move in.
nesses like AOTA are usually banks or insurance companies. That same option is available when you are setting up a clinic.
Again, this is most familiar in the context of a home mort- You can find a landlord who will get your clinic ready for you,
gage. The amount that can be borrowed depends on the value build the counters, put in carpet you choose, and paint. You
of the building and the amount against it the lender is willing will be required to sign a lease, which typically runs for 3 to
to extend; this is referred to as loan-to-value. Usually the bank 5 years. Additionally, the landlord will want to review your
will extend a loan up to 80% of the building’s value. That value financial statements, just like the bank, to determine if you
is determined by an appraiser’s estimate of the building’s value. are creditworthy. Lastly, you will be required to make a se-
It can take a month or more to complete a mortgage loan. curity deposit, usually the equivalent of 1 month’s rent,
However, another source of credit is available to busi- just like for your apartment. The landlord will have laid out
nesses, called a line of credit, which allows you to obtain a the cash to buy the counters and obtain the paint and car-
loan—money—on demand. Sounds nice, does it not? You pet. Remember, your other option would have been to go the
can call your bank and demand money be transferred to your bank and borrow all of the money needed to buy the building,
checking account. But it’s not quite so simple. You must apply build the counters, and carpet the clinic.
for the line of credit. The bank or credit union will look at the There are also factoring companies that will purchase your
financial statements discussed earlier. The banker will closely accounts receivable. Factoring means for $100 of accounts
examine your organization’s SoCF to understand your busi- receivable, you might receive $90 in cash. Your customers will
ness operations. The bank may want you to be a customer of then make payments directly to the factoring company. These
the bank, allowing them to monitor your cash flow day by accounts will no longer belong to you. In addition to providing
day just as you do. They may want some type of security to you cash immediately, the collection efforts and any loss from
support the line of credit. Such security could be provided customers who do not pay will fall on the factoring company.
by pledging your accounts receivable. If you do not repay the
line of credit, the bank could require your customers to pay
Review Questions
the bank instead of you.
After you complete the application, the bank will charge 1. What is a capital expenditure, and where would you find
a commitment fee of, say, a quarter of a percent, 0.25%, on it on the SoCF?
the amount that can be borrowed. For example, AOTA might 2. What types of cash flows arise with corresponding earned
borrow $100,000 for a commitment fee of $250. Typically, revenue?
lines of credit are for a term of 1 year at an interest rate that, 3. Where might you look to see if an organization had good
depending on your credit score, will be 1 or 2 points over the collection procedures?
PRACTICAL APPLICATIONS IN SUMMARY

OCCUPATIONAL THERAPY What a dive! This chapter has covered cash flow and how
Every organization that you work for or practice that you own or to obtain funds and manage an entity’s cash flows. Cash is
establish will have cash to manage. For your organization to be needed to keep a business afloat, and how cash comes and
successful over time, your cash flow will need to be positive and goes is a complex process. The SoCF provides plenty of
sufficient enough to meet your business’s obligations—paying information about an organization’s operation, manage-
salaries, paying suppliers, purchasing equipment, buying insur- ment of resources, financing choices, and cash position.
ance, and so forth. Even the best occupational therapy practice You now know which section of the SoCF to look at to see if
providing high-quality services to clients needs cash flow. an organization has increased its indebtedness, invested in
You can get help to manage your organization’s finances. plant and equipment, and how its assets and liabilities are
You can talk to a neighborhood bank to get a business checking being managed.
account, lockbox, and even a line of credit. The bank helps with With this understanding, you are in a position to know
getting set up to process credit cards and comply with the secu- what is involved in the cash management function of an orga-
rity requirements related to handling them. These are the basic nization and how to approach it. You understand the impor-
financial infrastructure items you need to get up and running. tance of offering credit cards as an option for your customers
Even if you never run your own practice, understanding to speed up your receipt of payment and some of the steps
the SoCF and the ways an organization can fund its oper- that need to be taken to protect their information. Other tools
ations allows you to understand the business environment (e.g., lockbox) can also expedite receipt of cash and provide
your employer operates in and the impact that may have on security in the way those receipts are processed. Moreover,
your continued employment. When the bosses say sales are companies like Anybill can help you manage your payables
up 10% at a staff meeting, you will be able to ask, “What is the and facilitate continued access to that information. You know
cash flow from operations? And is it sufficient to support the that when the organization’s finances are stable you should
new wing that was just built onto the clinic?” establish a line of credit to cover those times when cash flow
turns negative. ❖
Review Questions
1. What are some ways in which cash flow functions in your ACOTE STANDARDS
personal life?
2. How does cash flow affect occupational therapy practi-
tioners, even if they do not own or manage a practice? ■ B.5.3. Business Aspects of Practice
3. If you manage a practice, what options might you con- ■ B.7.2. Professional Engagement
sider to improve your cash position for payroll? ■ B.7.5. Personal and Professional Responsibilities.
APPENDIX 52.A. AOTA’S FINANCIAL STATEMENTS
APPENDIX 52.A. AOTA’S FINANCIAL STATEMENTS (Cont.)
504
SECTION VIII. Finance and Budgeting
CHAPTER
Professional Liability Insurance
Christopher M. Bluhm, CAE, CMA, CPA 53
LEARNING OBJECTIVES
■ Understand the foundations for professional liability,
■ Incorporate the importance of understanding and working within the relevant state scope of practice laws,
■ Discuss the role and responsibilities of supervision as they relate to professional liability,
■ Identify key areas of attention to reduce the possibility and scope of claims for malpractice or inappropriate profes-
sional behavior, and
■ Learn key questions to ask when considering professional liability insurance.

• Accountable • Documentation • Safe environment
• Claims-made policy • Liable • Safety policies and procedures
• Communication • Occurrence policy • Scope of practice
• Conduct • Professional service • Supervision
• Continuing professional • Responsibility • Vicarious liability
development
OVERVIEW and the service delivery process. Occupational therapy

assistants, under the supervision of and in partnership
I
n legal terms, the practice of occupational therapy can be with occupational therapists, are equally responsible for
classified as a professional service, which is defined as “pro- developing a collaborative plan for supervision to ensure
viding a service requiring specialized knowledge and skill proper occupational therapy is being provided. (American
usually of a mental or intellectual nature and usually require a Occupational Therapy Association [AOTA], 2014a, p. S18)
license, certification or other registration” (Merriam-Webster,
n.d.). As with lawyers, doctors, and accountants, states act to In these statements, responsibility can be interpreted as
protect the public through licensure of occupational therapy the duty to control service, and accountable could be inter-
because of their potential impact on their clients and the public. preted as answerable for the services outcomes. Both words
The occupational therapy profession’s official documents have a common synonym—liable.
go even further by stating that As licensed professionals—and those who manage them—
who are responsible and accountable for both the manner
occupational therapists are responsible for all aspects of in which services are planned, supervised and provided, as
occupational therapy service delivery and are accountable for well as their outcomes, occupational therapy practitioners
the safety and effectiveness of occupational therapy services are liable, or legally responsible, to provide a standard of
A portion of this chapter adapted from “Importance of Professional Liability Insurance,” Appendix I, by C. M. Bluhm, 2019, in G. Frolek
Clark, J. E. Rioux, & B. E. Chandler (Eds.), Best Practices for Occupational Therapy in Schools, 2nd Edition, pp. 529–530, Bethesda, MD:
AOTA Press. Copyright © 2019 by the American Occupational Therapy Association. Adapted with permission.
https://doi.org/10.7139/2019.978-1-56900-592-7.053
505
CHAPTER
Professional Liability Insurance
Christopher M. Bluhm, CAE, CMA, CPA 53
LEARNING OBJECTIVES
■ Understand the foundations for professional liability,
■ Incorporate the importance of understanding and working within the relevant state scope of practice laws,
■ Discuss the role and responsibilities of supervision as they relate to professional liability,
■ Identify key areas of attention to reduce the possibility and scope of claims for malpractice or inappropriate profes-
sional behavior, and
■ Learn key questions to ask when considering professional liability insurance.

• Accountable • Documentation • Safe environment
• Claims-made policy • Liable • Safety policies and procedures
• Communication • Occurrence policy • Scope of practice
• Conduct • Professional service • Supervision
• Continuing professional • Responsibility • Vicarious liability
development
OVERVIEW and the service delivery process. Occupational therapy

assistants, under the supervision of and in partnership
I
n legal terms, the practice of occupational therapy can be with occupational therapists, are equally responsible for
classified as a professional service, which is defined as “pro- developing a collaborative plan for supervision to ensure
viding a service requiring specialized knowledge and skill proper occupational therapy is being provided. (American
usually of a mental or intellectual nature and usually require a Occupational Therapy Association [AOTA], 2014a, p. S18)
license, certification or other registration” (Merriam-Webster,
n.d.). As with lawyers, doctors, and accountants, states act to In these statements, responsibility can be interpreted as
protect the public through licensure of occupational therapy the duty to control service, and accountable could be inter-
because of their potential impact on their clients and the public. preted as answerable for the services outcomes. Both words
The occupational therapy profession’s official documents have a common synonym—liable.
go even further by stating that As licensed professionals—and those who manage them—
who are responsible and accountable for both the manner
occupational therapists are responsible for all aspects of in which services are planned, supervised and provided, as
occupational therapy service delivery and are accountable for well as their outcomes, occupational therapy practitioners
the safety and effectiveness of occupational therapy services are liable, or legally responsible, to provide a standard of
A portion of this chapter adapted from “Importance of Professional Liability Insurance,” Appendix I, by C. M. Bluhm, 2019, in G. Frolek
Clark, J. E. Rioux, & B. E. Chandler (Eds.), Best Practices for Occupational Therapy in Schools, 2nd Edition, pp. 529–530, Bethesda, MD:
AOTA Press. Copyright © 2019 by the American Occupational Therapy Association. Adapted with permission.
https://doi.org/10.7139/2019.978-1-56900-592-7.053
505
care and appropriate behavior defined in state licensure laws Scope of practice
and in AOTA’s official documents. One can think of the
Occupational therapy managers and administrators, as well
following: Professional Liability 5 Professional Services 1
as practitioners, must be knowledgeable about the scope of
Responsibility 1 Accountability.
practice defined in the licensure regulations of the state where
services are provided and make certain that their employees
ESSENTIAL CONSIDERATIONS are practicing within those parameters. If work is occurring in
By the nature of working with clients regularly, occupational multiple states, managers and administrators, as well as practi-
therapy practitioners and their managers or administrators tioners, must be familiar with any differences within each state
must recognize the possibility that clients and their families, where services are provided (AOTA, 2014b). It is also import-
as well as a practitioner’s employer or colleagues, can make ant to understand the specific requirements of work in inter-
accusations of improper conduct, inappropriate treatment, professional settings such as joint or physical therapy clinics or
or ethical violations. Complaints can be brought forward in new practice areas such as telehealth (AOTA, 2018b).
to employers, state licensing boards, the National Board for In a corporate or clinical work setting, the occupational
Certification in Occupational Therapy (NBCOT®), AOTA therapy manager or administrator needs to ensure that employ-
(see, e.g., 2015a, 2015b), or in civil court. Regardless of the ees’ job descriptions and all related contracts, policies, and pro-
merit of a complaint, the costs of a defense and compensa- cedures are within the appropriate scope of practice and must
tory damages can be catastrophic to one’s personal finances be comfortable asking about and correcting any discrepancies
as well as the company’s bottom line. Therefore, having an among them (CNA & HPSO, 2017). If a court determines that
awareness of this risk is important. an occupational therapy practitioner is working outside their
relevant scope of practice, the employee and the clinic can be
adjudicated negligent in their care (see Case Example 53.1).
Supervision
Understanding Contributing Factors
Occupational therapy administrators and managers have the
When investigating the causes of accidents in general where institutional knowledge and professional experience to ensure
injury or death has occurred, the final analysis commonly “the safe and effective delivery of occupational therapy ser-
determines that the mishap was a culmination of several vices and fostering a professional competence” (AOTA, 2014a,
small, seemingly inconsequential contributing factors. For p. S16). They are responsible, and again, liable, for staff actions,
automobiles and airplane crashes, weather and equipment including the safety of all served under their supervision. Under
failure are common contributors; for construction and the legal principle of vicarious liability, an employer or super-
domestic falls, environmental clutter is often an issue. Within visor can be found liable for the harm caused by their employees
occupational therapy are several common contributing issues and subordinates. Supervisors must be able to demonstrate and
for injury accidents: document that they took reasonable steps to prevent the inap-
propriate conduct and demonstrated a commitment to prevent-
■ Not working within the appropriate scope of practice, ing inappropriate service (AOTA, 2014a).
■ Not working under or providing appropriate supervision Supervision roles for occupational therapy practitioners
for clients or subordinates,
are defined in the Guidelines for Supervision, Roles, and
■ Not effectively and clearly communicating with the client Responsibilities During the Delivery of Occupational Therapy
and the medical team,
Services (AOTA, 2014a). In addition to role delineation,
■ Failing to providing a safe environment, and 7 general principles cover supervisory methods, frequency,
■ Operating outside organizational policy and procedures. competencies, adherence to treatment plan orders, appropri-
Incomplete or inaccurate documentation can create issues ate interventions, professional conduct, and other important
of risk (CNA & Healthcare Providers Service Organization considerations that need to be followed. It is important for
[HPSO], 2017). occupational therapy practitioners and managers to become
CASE EXAMPLE 53.1. Working Outside the Accepted Scope of Practice
A client receiving both occupational and physical therapy services requested that her OT assist her with her physical therapy exercises by allowing
her to stand at the sink to do them. As the client attempted to demonstrate her ability to reach into a kitchen cupboard, her knees buckled in the
attempt, causing her to fall and suffer 2 leg fractures. The claim against the OT settled for more than $145,000 (CNA & HPSO, 2017).
When working with physical therapists, responsibility for who can do what can become confused. Occupational therapy practitioners need
to balance the clients’ wishes with regulations and proper procedures. In this case, the accident occurred during delivery of physical therapy
services, which are outside the scope of occupational therapy practice. Managers must ensure that client interactions are only during planned and
documented delivery of and within scope of occupational therapy services.
CHAPTER 53. Professional Liability Insurance 507
CASE EXAMPLE 53.2. Unattended Child Falls Off a Swing
A pediatric client with ADHD was prescribed occupational therapy to address sensory difficulties and learn coping techniques for use in school, home, and
other settings. The child attended a regular public kindergarten class and was allowed to play on a supportive swing, which had a calming effect on the
child. While the client was on the swing, the contract OT walked away for a moment, during which time the child fell from the swing and fractured her arm
in 3 places, requiring surgery. The family brought a civil case against both the OT and the contracting company. The company settled separately, leaving
the OT subject to negligence for improper supervision during service delivery. Ultimately, a claim was settled for more than $80,000 (CAN & HPSO, 2017).
familiar with this document, because the type and quality of charges and has been the determining factor in many claims
supervision will be scrutinized during a legal claim. both for and against practitioners.
Occupational therapy practitioners need to remain fo- Write all documentation with the expectation that it will
cused and avoid distractions when supervising and admin- undergo a detailed critique well after the services are pro-
istering client services. Momentary lapses in attention are a vided or the notes seem relevant. Occupational therapy man-
common theme in factors contributing to client injury (see agers and administrators must require and be vigilant that
Case Example 53.2). practitioners are providing complete, detailed, accurate, and
timely documentation of
Communication and professional conduct
■ Screening reports,
Under increasingly urgent time constraints and perhaps ■ Evaluation and re-evaluation reports,
productivity requirements, oral communication and formal ■ Intervention plan, or plan of care,
documentation may suffer. To reduce risk, all conduct and ■ Contact reports, with daily treatment notes,
communication should be professional, courteous, and clear ■ Transition plan, and
with the client, medical care givers, and family. Privacy laws ■ Discharge or discontinuation report (AOTA, 2018a).
and regulations, such as the Health Insurance Portability and
Accountability Act of 1996 (HIPAA; P. L. 104–91) and, for Notes should be dated and include all client discussions
children, the Family Educational Rights Privacy Act (FERPA; and team member communications. The notes should detail
P. L. 93–380) need to be adhered to. Less-than-optimal com- all relevant and necessary information such as medical con-
munication can create misunderstandings and even hard ditions and treatments.
feelings. Occupational therapy practitioners and managers
need to dedicate the time required to ensure full understand- Environment
ing between clients and care team members.
Occupational therapy practitioners should also exhibit cul- Falls, burns, and equipment injuries are the most common
tural competency, including cultural responsiveness, cultural injuries sustained in occupational therapy settings (CNA &
humility, and cultural intelligence. The ability to effectively HPSO, 2017). Occupational therapy administrators and man-
interact and build trust with all clients is fundamental in pro- agers must make certain that practitioners are providing a safe
viding safe and effective care. There are several articles and re- environment that is uncluttered to avoid falls and other injuries.
sources to help build practitioners’ competencies that should be Occupational therapy managers and practitioners need to
included in ongoing professional development, such as Culture ensure that clients are properly using equipment and that all
and Occupation: Effectiveness for Occupational Therapy Prac- equipment is properly maintained. Closed claims typically
tice, Education, and Research (Wells et al., 2016); Chapter 16, reflect a failure to properly test or improper use of equipment
“Promoting and Managing Diversity;” and Chapter 44, “Com- resulting in malfunction and patent injury (CNA & HPSO,
municating Across Generations and Cultures.” 2017).
In their Occupational Therapy Claim Report covering
2006–2015, CNA and HPSO (2017) stated the most frequent
Documentation
allegation was the improper use of a biophysical agent lead-
In a situation where high productivity is a concern, docu- ing to burns and tissue damage. Heat and heat energy must
mentation can be a challenge, but it is one of the first places be used cautiously and with great professional care (see Case
a plaintiff’s legal team will investigate when considering Example 53.3).
CASE EXAMPLE 53.3. Injury During Electrotherapy
A 35-year-old patient with diabetes was prescribed infrared light therapy for diabetic neuropathy ankle and foot pain. On 3 occasions, the patient
received infrared light therapy, but for the 4th treatment the OT used interferential current therapy (IFC). The first treatment of IFC went well. After
the 2nd treatment, however, the patient suffered burns and tissue damage to the inside of both ankles. Due to their comorbidities, the patient had a
complicated healing process and required multiple rounds of antibiotics and surgical debridement. There was no evidence that the OT had notified
the referring practitioner of the change in therapy (CNA & HPSO, 2017).
CASE EXAMPLE 53.4. Student Intern Injured by Equipment
A graduate student intern observing pediatric occupational therapy clients in a hospital outpatient facility was observing a children’s exercise class
conducted by an OT, who was acting as an independent contractor for the children’s hospital. During the class, a hospital volunteer picked up a
balance beam that the OT had been using and placed it vertically against the wall. Shortly after, the beam fell and struck the intern in the head. The
intern experienced a concussion and closed-head injury, causing long-term neurological deficits. The intern sued the insured OT for failure to provide
a safe environment. The claim was settled for more than $325,000 (CNA & HPSO, 2017).
Organizational safety policies and procedures client safety and quality outcomes, enhancing or expanding
professional practice and reaching career goals” (AOTA,
Occupational therapy administrators and managers should
2017, p. 1). CPD includes self-refection, planning, and goal
know their responsibility to ensure that all practitioners are
setting for professional development. At a minimum, state
familiar with and understand organizational safety policies
licenses and required CE credits must be current.
and procedures. Managers should review these annually with
States require ongoing professional CE to ensure that
employees and contractors to make certain they are under-
occupational therapy practitioners hold the appropriate ex-
stood. This should be done with all new employees or can be
perience, current skills, and relevant competencies to work
done through individual meetings on the topic, during annual
within an area of practice. If asked to provide services in
reviews or setting of professional development goals, or with
an area or an intervention without sufficient knowledge or
training sessions. This process should be corporate wide and
supervision, practitioners should refer that client to another
not be limited to only professional services providers but also
provider. In addition to courses on specific interventions or
include administrative, operations, and maintenance staff, as
populations, practitioners should take refresher courses on
well as students and volunteers (see Case Example 53.4).
ethics. It might also be worthwhile to seek out education on
the topic of risk management. Several insurance companies
Managing Risk offer premium discounts for practitioners who have com-
The ability to demonstrate a proactive commitment to best pleted specific risk management coursework.
practice and safety is important in cases in which a claim
is made. As licensed professionals, occupational therapy Professional liability insurance
practitioners—and even students during fieldwork—should
create and maintain a professional portfolio that includes Professional liability insurance protects the policyholder by
providing legal defense resources, as well as paying claims
■ Recent continuing education (CE) demonstrating compe- and compensatory judgments (i.e., damages) up to the lim-
tency in their current area of practice; its of the policy. Other basic policy coverages include HIPAA
■ Checklists that incorporate best practice for evaluation; violations, property damage, medical expenses, assault, and
intervention planning, implementation, and review; and sexual misconduct, but these allegations may have different
evaluating outcomes; coverage limits.
■ A copy of organizational procedural and safety policies; In addition to injury claims, charges of inappropriate
■ A copy of the state practice regulations for the states in behavior or ethics violations that can be submitted to state
which one practices (checking the regulations frequently licensure boards, AOTA, or NBCOT. Defending against these
for updates); and charges, even those determined to be without merit, can be
■ A copy of the current Occupational Therapy Code of Ethics expensive, costing practitioners and employers thousands
(2015b); Guidelines for Supervision, Roles, and Responsibil- of dollars. According to CNA and HPSO (2017), the average
ities During the Delivery of Occupational Therapy Services cost of defense against claims of improper behavior for their
(AOTA 2014a); and Standards of Practice for Occupational policy holders was $47,480 between 2005–2016.
Therapy (AOTA, 2015c). While employees may have the benefit of some coverage
In addition, all should be familiar with AOTA’s Official Doc- through their employers, there have been instances where a
uments in which roles, responsibilities, and guidelines on conflict of interest, or some other circumstance, has created
contemporary evidence-based practice are defined. Occu- a personal financial challenge. Company policies also may
pational therapy managers and administrators can support not cover suits filed after one has left employment, nor do
practitioners in curating this information. they cover services performed outside of the workplace, in-
cluding second jobs, volunteer work, or self-employed activ-
ities. There are also cases in which the employer has brought
Continuing professional development
charges, negating any company group coverage. One example
AOTA defines continuing professional development (CPD), includes an OT who was sued by a former employer; although
in part, as “a self-directed, reflective process of lifelong learn- the practitioner’s defense was successful, the case lasted years
ing aimed at maintaining practitioner competence, ensuring and produced legal expenses exceeding $120,000. In another
CHAPTER 53. Professional Liability Insurance 509
case, even though the practitioner was never charged with SUMMARY
any wrongdoing, they were brought in to testify on a case
where their employer was the defendant and their personal Workplace accidents and accusations of inappropriate
legal expense totaled $1,800 (CNA & HPSO, 2017). behavior can and do happen. Your employer may or may not
provide coverage for mounting a defense. Occupational ther-
apy practitioners have a professional obligation to educate
Evaluation of insurance policies and providers themselves, be very familiar with the most common risk fac-
Policies are written in to 4 employment classifications: tors outlined in this chapter, and remain vigilant to reduce
(1) employees, (2) self-employed, (3) private practice, and client risk. Supervision brings with it additional responsi-
(4) students. In the United States, the 2 largest insurers of bilities, including providing a safe work environment and
occupational therapy practitioners and students currently ensuring company safety and service delivery policies are
have a $1 million per occurrence and $3 million total appropriate and being followed.
liability coverage limits. Policies can also be commonly Each occupational therapy practitioner is personally re-
purchased with higher ($2 million/$4 million) limits when sponsible for their own financial and professional protection
appropriate. and needs to be familiar with the concepts of professional lia-
There are 2 types of policies: (1) occurrence based or bility exposure and ensure they have the right insurance cov-
(2) claims made. An occurrence policy protects any covered erage to protect their career and personal financial assets. ❖
incident during the policy period, even after the policy has
expired or been canceled. A claims-made policy covers only ACOTE STANDARDS
claims made while the policy is in effect. An occurrence
policy is most desirable but may not be available in all states.
A basic insurance policy may not cover everything done ■ B.4.29. Reimbursement Systems and Documentation
in occupational therapy practice. Some treatments and ■ B.5.3. Business Aspects of Practice
interventions, such as hippotherapy, may be deemed experi- ■ B.7.5. Personal and Professional Responsibilities.
mental and thus outside the scope of practice and may not be
covered without a separate policy endorsement. REFERENCES
With the expansion of online purchasing are newer,
smaller, online-only insurance companies offering policies Accreditation Council for Occupational Therapy Education. (2018).
to occupational therapy practitioners. If considering an 2018 Accreditation Council for Occupational Therapy Education
online-only company, be sure to ask about their A.M. Best
rating, a financial rating that compares companies’ ability to .org/10.5014/ajot.2018.72S217
pay out claims. Other important considerations include the American Occupational Therapy Association. (2014a). Guidelines
company’s experience with occupational therapy; number of for supervision, roles, and responsibilities during the delivery
occupational therapy policies in force; customer service; and of occupational therapy services. American Journal of Occupa-
communication formats, including online and in person. tional Therapy, 68(Suppl. 3), S16–S22. https://doi.org/10.5014
When purchasing liability insurance, be prepared to dis- /ajot.2014.686S03
cuss work setting and client population, typical interventions, American Occupational Therapy Association. (2014b). Scope of
the employee–employer relationship, and any special circum- practice. American Journal of Occupational Therapy, 68(Suppl. 3),
stances that may not fall clearly under the scope of practice S34–S40. https://doi.org/10.5014/ajot.2014.686S04
or licensure laws. Pricing for individual and sole practitioner American Occupational Therapy Association. (2015a). Enforce-
ment procedures for the Occupational Therapy Code of Ethics
coverage is competitive; for sole proprietors, pricing will be
(2015). American Journal of Occupational Therapy, 69(Suppl. 3),
based on the size of the practice. A basic policy for an em- 6913410012. https://doi.org/10.5014/ajot.2015.696S19
ployed occupational therapy practitioner is about $100 a year. American Occupational Therapy Association. (2015b). Occupational
therapy code of ethics (2015). American Journal of Occupational
Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot
Review Questions
.2015.696S03
1. Why do occupational therapy practitioners need to un- American Occupational Therapy Association. (2015c). Standards
derstand the foundations for professional liability? of practice for occupational therapy. American Journal of
2. Why is it important to understand and work within state Occupational Therapy, 69(Suppl. 3), 6913410057. https://doi.org
scope of practice laws? /10.5014/ajot.2015.696S06
American Occupational Therapy Association. (2017). Continuing
3. What responsibilities do supervisors have related to pro-
professional development in occupational therapy. American
fessional liability?
Journal of Occupational Therapy, 71(Suppl. 2), 7112410017.
4. What are some key areas where practitioners can focus to https://doi.org/10.5014/ajot.2017.716S13
reduce the possibility and scope of claims for malpractice American Occupational Therapy Association. (2018a). Guidelines
or inappropriate professional behavior? for documentation of occupational therapy. American Journal
5. What should practitioners think about when considering of Occupational Therapy, 72(Suppl. 2), 7212410010. https://doi
professional liability insurance? .org/10.5014/ajot.2018.72S203
American Occupational Therapy Association. (2018b). Telehealth Family Educational Rights and Privacy Act of 1974, Pub. L. 93–380,
in occupational therapy. American Journal of Occupational 20 U.S.C., § 1232g. 34 CFR 79 Stat. 27.
of Therapy, 72(Suppl. 2), 7212410059. https://doi.org/10.5014 Health Insurance Portability and Accountability Act of 1996, Pub.
/ajot.2018.72S219 L. 104-191, 110 Stat. 1936.
CNA & Healthcare Providers Service Organization. (2017). Occupa- Merriam-Webster (n.d.). Professional service. Retrieved from https://
tional therapy claim report: A guide to identifying and addressing www.merriam-webster.com/legal/professional%20service
professional liability exposures. Retrieved from http://www.hpso Wells, S. A., Black, R. M., & Gupta, J. (Eds.). (2016). Culture and
.com/Documents/pdfs/CNA_CLS_OT_032917_CF_PROD occupation: Effectiveness for occupational therapy practice, educa-
_ONLINE_040417_SEC.pdf tion, and research (3rd ed.). Bethesda, MD: AOTA Press.
SECTION IX.
Professional Standards
Edited by Guy L. McCormack, PhD, OTR/L, FAOTA
511
CHAPTER
Continuing Competence
LEARNING OBJECTIVES
■ Describe the importance of continuing competence for stakeholders,
■ Describe a framework for engaging in continuing competence activities, and
■ Describe 2 activities used to support continuing professional development.

• Clinical competencies • Knowledge creation • Professional regulation
• Competence • Knowledge inquiry • Reflection
• Continuing competence • Knowledge tools • Standards for Continuing
• Continuing education • Knowledge translation Competence
• Continuing professional • Knowledge-to-action cycle • Synthesis of knowledge
development • Portfolio
OVERVIEW strong understanding of evidence-based practice that sup-

ports current and future practice and roles as well as ethi-
C
ontinuing competence is an essential component of clin- cal components of practice (Andersen, 2001; AOTA, 2015c;
ical practice to ensure the provision of safe and effective Brown & Elias, 2016; Myers et al., 2017; Vachon et al., 2016).
care and to achieve positive clinical outcomes. Clini-
cians have an obligation to a variety of stakeholders, including
themselves and the client, to pursue opportunities that continue Standards for Continuing Competence
to advance their knowledge and skills using best practices in AOTA (2015c) created Standards for Continuing Competence to
their clinical and procedural decision making. This chapter dis- provide occupational therapy practitioners with expectations for
cusses the purpose and impact of continuing competence for a this process (see Appendix 54.A, “AOTA Standards for Continu-
variety of stakeholders, including managers, practitioners, reg- ing Competence”). The dynamic and complex nature of health
ulatory bodies, employers, the occupational therapy profession, care systems and care delivery affects the continuing compe-
and recipients of occupational therapy services. tence needs of occupational therapy providers. The change in
practice to provide value-based care requires occupational ther-
apy managers and practitioners to ensure that they are using ev-
ESSENTIAL CONSIDERATIONS idence to support clinical decision making to provide safe and
Continuing competence is defined as “a process involving efficient care and to achieve optimal clinical outcomes. This shift
the examination of current competence and the development toward clinical outcomes becoming the primary determinant
of capacity for the future” (American Occupational Therapy for reimbursement and quality care will require occupational
Association [AOTA], 2015c, p. 1). This process involves an therapy practitioners to engage in continuing competence activ-
assessment of clinical knowledge and skills as well as pro- ities with the goal of improving health care service quality and
fessional behaviors and attitudes and the development of a safety (Hall et al., 2016; Myers et al., 2017; Tran et al., 2014).
https://doi.org/10.7139/2019.978-1-56900-592-7.054
513
514 SECTION IX. Professional Standards
Purpose for Continuing Competence (NBCOT®), for entry-level practice may not be relevant and
necessary for an occupational therapy practitioner’s current
Occupational therapy practitioners, like other health care
practice area and setting.
providers, need to develop habits and skills that support self-
Competence is an evolving process that can change over
directed lifelong learning. A variation of the quote “half of
the course of one’s professional journey and requires clini-
what was learned in your formative education will not be true
cians to meet ever-changing demands to provide safe and ef-
in 5 years; the only problem is we don’t know which half”
fective care. Essentially, competence denotes that knowledge
has been heard in many university graduation ceremonies.
translation is occurring over time to ensure best practice and
If this quote is true, the onus is on the individual practi-
is guiding clinical decision making and care provision.
tioner through a commitment to clients and the profession
to take responsibility to maintain competence. Occupational
Knowledge Translation
therapists and occupational therapy assistants are ethically
responsible for the delivery of the service they provide to fa- Knowledge translation is defined by the World Health Or-
cilitate optimal clinical outcomes for clients (Leland et al., ganization (2018, p. 1) as “the synthesis, exchange, and
2014). Facilitating such outcomes is accomplished through application of knowledge by relevant stakeholders to accel-
the consistent use of evidence-based assessments and inter- erate the benefits of global and local innovation in strength-
ventions and remaining current with practice trends. ening health systems and improving people’s health.” When
Competence is a multidimensional concept that involves knowledge translation is used, the gap from knowledge to
acquiring knowledge, interpersonal and performance skills, practice is reduced and a shift from dissemination of knowl-
and ethical and clinical reasoning skills and applying and edge to the application of knowledge is implemented (Straus
maintaining the competencies acquired (AOTA, 2015c). et al., 2013).
Norman et al. (2015) described competence as situational and A conceptual framework called the knowledge-to-action
the competencies assessed by regulatory bodies, such as the cycle provides users with a process to apply knowledge in the
National Board for Certification in Occupational Therapy appropriate practice setting (Straus et al., 2013; Figure 54.1).
FIGURE 54.1. Knowledge translation: What it is and what it isn’t.
Select, Tailor Monitor

Implement Knowledge
Interventions Use
Assess
Barriers/ KNOWLEDGE CREATION
Facilitators to Evaluate
Knowledge Inquiry Outcomes
Knowledge
Tail
ge
Use
d
Knowledge
o
wle
ring
Synthesis
Kno
Kno
ing
Knowledge
wled
or
Tools/
Tail
ge
Adapt Products
Knowledge Sustain
to Local Knowledge
Context Use
Id e n
tify Problem
D eter min e th e
Know/Do Gap
Identify, Review,
S ele ct
Kno wle d ge
ACTION CYCLE
Source. Knowledge translation: What it is and what it isn’t. Straus, S., Tetroe, J., & Graham, I. D. (Eds.). (2013). Knowledge translation in health care: Moving from evidence
to practice. Hoboken, NJ: Wiley. Copyright © 2013 by Wiley. Used with permission.
CHAPTER 54. Continuing Competence 515
The knowledge-to-action framework consists of knowledge as the Navigator® used by NBCOT. Unstructured or unsched-
creation and application. Knowledge creation is composed of uled reflection or self-assessment can occur in the moment
3 phases: (1) knowledge inquiry, (2) synthesis of knowledge, in response to situations and experiences in the clinical
and (3) creation of knowledge tools. Knowledge inquiry in- environment.
volves the completion of primary research. The synthesis of Reflection or self-assessment provides the practitioner
knowledge assesses this research and identifies common pat- with the opportunity to review current knowledge and
terns. As knowledge is filtered through this process, the de- skills, roles and responsibilities, and clinical outcomes
velopment of knowledge tools such as practice guidelines or achieved with clients; identify gaps in practice, knowledge,
algorithms may be developed (Straus et al., 2013). and skills; and contemplate anticipated changes in roles,
The knowledge-to-action cycle consists of 7 phases that responsibilities, or emerging practice areas. Essentially, re-
can occur simultaneously or sequentially and can be influ- flection or self-assessment identifies the practitioner’s learn-
enced by the knowledge phases at any point. The 7 actions ing needs.
include
1. Identifying a problem; Planning
2. Identifying, reviewing, and selecting the knowledge to
implement; Once learning needs have been identified, planning for
3. Adapting knowledge to the current context; short- and long-term goals can be completed. These goals
4. Assessing any barriers to knowledge application; should be created by considering the individual practi-
5. Selecting, adapting, and implementing interventions; tioner’s personal learning style and priorities (Tran et al.,
6. Monitoring knowledge use; and 2014). In addition, strategies should be identified to ensure
7. Evaluating impacts and outcomes of knowledge use and the goals are measurable and achievable. Practitioners may
creating strategies for sustainability (Straus et al., 2013). choose to use a template such as SMART goals (specific,
measurable, attainable, relevant, time-oriented) to develop
As knowledge is updated, its effect on knowledge application a learning plan.
needs to be re-evaluated. Occupational therapy managers
and practitioners can use this framework to identify gaps in
knowledge and practice to ensure they are consistently inte- Learning
grating the best strategies and interventions to achieve opti- Occupational therapists and occupational therapy assistants
mal outcomes with clients and for the profession. may engage in many different learning activities to meet their
continuing professional development goals. Traditionally, oc-
cupational therapists have engaged in continuing education
Continuing Professional Development
(CE)—a structured learning experience designed to commu-
Determining the areas for maintaining or developing com- nicate current and emerging practice areas—as a means to
petence can be identified through continuing professional achieve learning related to knowledge acquisition. CE may be
development. Continuing professional development involves provided in a variety of formats, including live presentations,
identifying and addressing learning needs through reflecting electronic or web-based courses, and self-paced courses or
on current and past practice, developing and implement- other formalized self-study courses. Attendance in or com-
ing a plan to meet these learning needs, and evaluating the pletion of formal CE courses does not ensure competency be-
effectiveness of the plan (Tran et al., 2014). According to Tran cause individual learning needs and application to practice
et al. (2014), continuing professional development includes are not typically assessed as a component of these courses
a 4-stage cycle: (1) reflection, (2) planning, (3) learning, and (Andersen, 2001).
(4) evaluating. The inclusion of simulation labs as a teaching technique
has strengthened the transfer of knowledge to practice in
some cases. Academic coursework, as it relates to the prac-
Reflection
tice of occupational therapy or applies to practitioners’ roles
Reflection, or self-assessment can either be structured or and responsibilities, may also be used to meet learning goals.
unstructured (Brown & Elias, 2016; Myers et al., 2017; Tran Independent learning, mentoring (as a mentor or mentee),
et al., 2014; Vachon et al., 2016). Structured reflection or self- fieldwork supervision and capstone mentoring, professional
assessment can occur on a regular schedule (i.e., annually or writing (e.g., books, chapters, articles), preparation for and
quarterly) and with a prescribed format. Managers may pro- providing presentations (e.g., academic, CE, conferences),
vide the format to occupational therapy practitioners during participation in research, evidence-based or quality im-
performance evaluations to give a context for each practi- provement projects, grant writing, participation in profes-
tioner to identify achievements, gaps in practice, and oppor- sional meetings and activities (e.g., boards, committees), and
tunities for growth. community engagement are additional activities in which
Additional resources are available to facilitate the assess- occupational therapy practitioners may engage to meet their
ment of learning and competency needs and interests such professional development goals.
In recent years, the opportunity to participate in post- Review Questions

professional fellowship programs through AOTA or other
1. A framework for continuing competence involves all of
agencies has provided structured didactic learning and men-
the following except
toring for occupational therapy practitioners to advance their
a. Development and implementation of learning plan.
knowledge and clinical skills and apply them to practice in
b. Development of strategy for use of outcome measures.
specific clinical areas and settings. AOTA-approved fellow-
c. Documentation of learning activity.
ship programs are aligned with the standards of continuing
d. Evaluation of learning outcomes.
competence (knowledge, critical reasoning, interpersonal
2. CE is a structured learning experience that
skills, performance skills, ethical practice) and offer a compo-
a. Consistently assesses individual learning needs as a
nent of scholarly activity. Another opportunity for clinicians
component of the learning experience.
to pursue structured continuing professional development is
b. Ensures competency once completed.
by completing board or specialty certification through AOTA
c. Ensures that knowledge translation occurs from dis-
or other providers, such as the Hand Therapy Certification
semination into practice.
Commission (HTCC).
d. Is designed to communicate current and emerging
AOTA’s board or specialty certification currently provide
practice skills and knowledge.
occupational therapy practitioners with a structure to de-
3. Knowledge translation is an important component of
velop a portfolio that demonstrates how they have met the
continuing competence that
standards of continuing competence through selected activ-
a. Ensures that best practices and evidence are being ap-
ities. The portfolio describes how they have grown clinically
plied in clinical situations.
and professionally and how this growth has affected their
b. Is consistently applied in the same manner in all clin-
clinical outcomes. Practitioners are required to meet appli-
ical situations.
cation criteria for practice hours in the area of certification,
c. Results in a shift from application of knowledge to
complete a self-assessment, and develop a professional devel-
dissemination of knowledge.
opment plan for the next 5 years.
d. When applied in practice, may impede change toward
The mission of the HTCC Certified Hand Therapist pro-
healthier populations.
gram is “to support a high level of competence in hand ther-
apy practice and to advance the specialty through a formal
credentialing process” (HTCC, n.d., p. 1). The commission
requires therapists to meet the application criteria in practice PRACTICAL APPLICATIONS IN
hours and then take a comprehensive examination. OCCUPATIONAL THERAPY
Value of Continuing Competence to
Evaluating External Stakeholders
The last component of the cycle is to evaluate and reflect Regulatory bodies, such as NBCOT, ensure competence
on each stage, which should be completed by the clinician of practitioners at entry into practice. As mentioned previ-
and may be supplemented by peers and supervisors (Tran ously in this chapter, as clinicians move into different areas
et al., 2014). Ideally, occupational therapy practitioners en- of practice or into different roles, the requirement to main-
gage in a reflective learning process that evaluates the quality tain competence in all of these entry-level skills may become
of the learning activity; assesses the relevance of the activity less relevant, and the need to develop and maintain compe-
to the learning plan; and evaluates the impact of the activ- tence in more advanced or specialized skills becomes more
ity on knowledge, skills, and competence and on practice important.
changes (Vachon et al., 2016). The evaluation of learning and Professional regulation through licensure is designed to
its impact on practice can facilitate the practitioner’s transla- increase accountability of the profession to protect public in-
tion of the knowledge into practice by identifying gaps in the terests through the delivery of competent, safe, and effective
knowledge-to-action process (Straus et al., 2013). care. Most states require practitioners to demonstrate pro-
Critical to the success of this cycle is documentation of fessional competence through CE activities with a renewal
the process and subsequent review over time. Documenta- cycle of 1–3 years and with a requirement of 10–40 hours of
tion of activities completed throughout the process provides CE activities (Hall et al., 2016). Approximately half of states
evidence that the professional development activity occurred require that professional development activities be related
and gives clinicians the opportunity to identify practice to care delivery, and to date, only a small number include
changes and improvement in client outcomes (Tran et al., ethical practice as a required topic of CE (Hall et al., 2016).
2014). This documentation may be used as a foundation to Some states require a self-assessment to be completed with
guide future professional development goals and activities to a professional development or learning plan. As states have
maintain competence. Many formats can be used for docu- updated their practice acts, additional professional devel-
mentation, including informal methods such as journaling or opment activities have been included to reflect changes in
formal portfolios. practice.
Employers are another important stakeholder in facil- the learning process, its impact on clinical outcomes and
itating continuing competence for occupational therapy efficiency of care delivery is evaluated. One evaluation tool
practitioners. Occupational therapy leaders and managers is to identify a practitioner’s clinical competencies (i.e., the
are well positioned to create expectations and opportuni- knowledge and skills necessary to provide effective care to
ties for developing and maintaining continuing compe- clients within a defined population) and validate them (see
tence in clinical settings. Many health care organizations Case Example 54.1). Validation may include direct obser-
have structured review processes that require employees vation by a more experienced clinician who has previously
to develop professional goals and to function in accor- demonstrated competence, review of documentation, and
dance with established assessment criteria. Creating the knowledge assessment.
opportunity for clinicians to receive feedback from a va-
riety of sources can provide balanced input to assist them
Reentry Into Clinical Practice
in identifying strengths, opportunities for development,
and gaps between current and future practice. Completion Occupational therapy practitioners who have had a hia-
of a self-assessment that evaluates professional behaviors tus from clinical practice should engage in an assessment
(e.g., attitudes, values, ethical considerations), clinical of their clinical competence as they plan for reentry into
knowledge, and skills and efficiencies in practice provides a practice. Some states have specific requirements for licen-
framework for reflection. sure renewal if the clinician’s license has lapsed. AOTA’s
Given the dynamic nature of health care, occupational Guidelines for Reentry into the Field of Occupational Ther-
therapy practitioners and managers should consider how apy (2015a) recommends that practitioners who have left
their practice area is changing regarding the population the field for more than 24 months will need to identify
they work with, opportunities to leverage technology in areas for development of continuing competence and pro-
their practice environment, work systems and demands, fessional development through a self-assessment and then
service and quality expectations from clients and payers, engage in formal learning and supervised service delivery.
and regulatory requirements. They can then create a learn- After return to practice, clinicians are encouraged to engage
ing plan or professional development goals that align with in structured activities that foster continuing competence
their health care organization’s strategic plan or annual op- (AOTA, 2015a).
erating plan based on the self-assessment and relevant peer,
mentor, or manager feedback. These goals often have spec-
Review Questions
ified strategies and targeted actions in addition to defined
time frames for goal achievement. The leader or manager 1. Professional regulation is designed to protect public in-
can facilitate the employee’s success in achieving these goals terests through the delivery of safe and effective care.
through structured meetings and discussions throughout Occupational therapy practitioners in most states
the review cycle. a. Have requirements for continuing professional
Lack of continuing competence may result in delivery of development.
ineffective and inefficient care by front-line care providers, b. Require CE to include ethical practice.
which can pose significant risk for organizations, including c. Require self-assessment and the development of a
problems with reimbursement, longer lengths of stay for cli- learning plan.
ents, and poor quality of care with the potential for negative d. Require 40 hours of CE units.
clinical outcomes. Additionally, organizations that provide 2. Occupational therapy managers can facilitate continuing
a framework for continuing competence for staff, including competence with employees through
opportunities for advancement through clinical growth, are a. Creating expectations for development and mainte-
likely to be more desirable as employers and therefore attract nance of continuing competence.
high-level clinicians. Occupational therapy leaders can im- b. Facilitating self-assessment with the development of a
plement the framework of reflection, planning, learning, learning plan.
and evaluating as they develop a strategic plan for their team c. Providing opportunities and support for continuing
or department to facilitate the delivery of effective and effi- professional development activities.
cient care. Through this process, an assessment of capacity d. All of the above.
demands, practice shifts, and changes to gaps in knowledge 3. The use of clinical competencies for teams
translation can be identified, creating the opportunity to a. Facilitates the development of foundational compe-
develop a plan to enhance the continuing competence of tence for delivery of care for a specific client popula-
their team. tion or the administration of specific interventions.
The development plan may include a review of the cur- b. May be validated through direct observation, record
rent evidence supporting practice; development of best review, or knowledge assessment.
practice guidelines, including algorithms to support clin- c. Can be used to assess a clinician’s ability to apply new
ical decision making; education of team members; and knowledge to practice.
validation of clinical competence. After implementation of d. All of the above.
CASE EXAMPLE 54.1. Craig: Continuing Competence
Craig is an occupational therapist in a hospital outpatient clinic working with clients with upper-extremity injuries and conditions and is changing
his practice area to work in the burn unit at the same facility. He requests a meeting with his manager, Megan, to determine the necessary steps
to prepare for this new opportunity. Megan asks Craig to reflect on his work with his current client population by identifying his clinical strengths and
then to identify gaps in knowledge and skills necessary to provide safe and efficient care for his new client population through a self-assessment
process. She provides Craig with the hospital’s self-assessment form and a learning style assessment tool. Craig completes the self-assessments
and then meets with Megan to determine the next steps to ensure he is ready to meet the needs of his clients.
Megan reviews the self-assessment with Craig and helps him identify priorities for his learning plan and encourages him to engage in reflection
of how he should best approach the strategies for learning based on the results of his learning style assessment. Because Craig is both a visual
and tactile learner, he decides to develop a mentoring relationship with one of the current occupational therapists in the burn service to meet the
service delivery items on his learning plan. He also decides to create a plan to meet his knowledge needs by taking CE courses, attending American
Burn Association national and regional conferences, and reviewing current literature on burn-related topics. Craig will also work on the validation of
the hospital’s clinical competency assessment for occupational therapists working on the burn service.
Megan reviews the learning strategies with Craig and suggests that he sets time frames for the achievement of his learning goals. Once Craig
finalizes his learning plan, he and Megan set up quarterly meetings to check on his progress toward goal attainment and to evaluate the learning
outcomes to date. Megan provides Craig with a template to document his learning and clinical outcomes.
Review Questions
1. Craig is transitioning to a new clinical area of practice. What are some of the strategies recommended by his manager, Megan?
a. Development of learning goals and strategies
b. Identification of gaps in skills and knowledge
c. Self-assessment of current knowledge and skills
d. All of the above
2. Leadership qualities Megan used to facilitate Craig’s engagement in continuing competence activities include all of the following except
a. Coaching
b. Directing
c. Facilitating
d. Mentoring
3. What action items related to continuing competence are identified in this case example?
a. Completion of a self-assessment or formal reflection on current skills and knowledge to identify opportunities for learning and growth
b. Development of a learning plan with strategies and time frames
c. Plan for evaluation and reflection of the learning activities
d. All of the above

To support the ongoing relevance and impact that the occu- This chapter addresses the following ACOTE Standards:
pational therapy profession has for the “health, well-being
and quality of life for all people, populations, and commu-
■ A.6.2. Professional Development Plans
nities through effective solutions that facilitate participation
■ A.6.3. Program Evaluation
in everyday living,” as stated in Vision 2025 (AOTA, 2017, p. ■ B.1.2. Sociocultural, Socioecomonic, Diversity Factors,
1), occupational therapy practitioners and managers need to and Lifestyle Choices
engage in the process of continuing competence. They need ■ B.1.3. Social Determinants of Health
to facilitate and develop habits and skills that support the ■ B.2.1. Scientific Evidence, Theories, Models of Practice
practice of self-directed lifelong learning. and Frames of Reference
Competence is a multidimensional process that evolves ■ B.3.1. Occupational Therapy History, Philosophical Base,
and changes over the course of one’s professional life and re- Theory, and Sociopolitical Climate
quires practitioners to engage in professional development ■ B.3.4. Balancing Area of Occupation, Role in Promotion
activities to support continuing competence. Continuing of Health, and Prevention
competence involves a process of reflection followed by the ■ B4.20. Care coordination, case management, and transi-
development, implementation, and evaluation of a learning tion services
plan and activities. Engaging in this process supports the ■ B.4.24. Effective Intraprofessional Collaboration
ability of both the practitioner and the profession to meet the ■ B.4.25. Principles of Interprofessional Team Dynamics
ever-changing clinical demands to provide evidence-based ■ B.4.27. Community and Primary Care Programs
care that enhances the quality and safety of care delivery. ❖ ■ B.4.29. Reimbursement Systems and Documentation
■ B.5.0. Context of Service Delivery, Leadership, and Regulation, 7, 43–52. https://doi.org/ https://doi.org/10.1016/S2155
Management -8256(16)31080-8
■ B.6.0. Scholarship Hall, S. R., Crifasi, K. A., Marinelli, C. M., & Yuen, H. K. (2016).
Continuing education requirements among state occupational
■ B.7.0. Professional Ethics, Values, and Responsibilities. therapy regulatory boards in the United States of America.
Journal of Educational Evaluation for Health Professions, 13, 37.
https://doi.org/10.3352/jeehp.2016.13.37
REFERENCES Hand Therapy Certification Commission. (n.d.). Mission, vision, and
Accreditation Council for Occupational Therapy Education. (2018). purpose of HTCC. Retrieved from https://www.htcc.org/consumer
2018 Accreditation Council for Occupational Therapy Education -information/about-htcc/mission-vision-purpose-of-htcc
(ACOTE) standards and interpretive guide. American Journal of Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2014).
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org Advancing the value and quality of occupational therapy in health
/10.5014/ajot.2018.72S217 service delivery. American Journal of Occupational Therapy, 69,
American Occupational Therapy Association. (2014). Occupational 6901090010. https://doi.org/10.5014/ajot.2015.691001
therapy practice framework: Domain and process (3rd ed.). Myers, C. T., Schaefer, N., & Coudron, A. (2017). Continuing com-
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. petence assessment and maintenance in occupational therapy:
https://doi.org/10.5014/ajot.2014.682006 Scoping review with stakeholder consultation. Australian Oc-
American Occupational Therapy Association. (2015a). Guidelines cupational Therapy Journal, 64, 486–500. https://doi.org/10.1111
for reentry into the field of occupational therapy. American Jour- /1440-1630.12398
nal of Occupational Therapy, 69(Suppl. 3), 6913410015. https://doi Norman, K. E., O’Donovan, M. J., & Campbell, F. (2015). Impact
.org/10.5014/ajot.2015.696S15 of college-administered quality practice assessments: A longitu-
American Occupational Therapy Association. (2015b). Occupa- dinal evaluation of repeat peer assessments of continuing com-
tional therapy code of ethics (2015). American Journal of Occupa- petence in physiotherapists. Physiotherapy Canada, 67, 174–183.
tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014 https://doi.org/10.3138/ptc.2014-21
/ajot.2015.696S03 Straus, S., Tetroe, J., & Graham, I. D. (Eds.). (2013). Knowledge trans-
American Occupational Therapy Association. (2015c). Standards lation in health care: Moving from evidence to practice. Hoboken,
for continuing competence. American Journal of Occupational NJ: Wiley.
Therapy, 69(Suppl. 3), 6913410055. https://doi.org/10.5014/ajot Tran, D., Tofade, T., Thakkar, N., & Rouse, M. (2014). U.S. and
.2015.696S16 international health professions’ requirements for continuing
American Occupational Therapy Association. (2017). Vision 2025. professional development. American Journal of Pharmaceutical
American Journal of Occupational Therapy, 71, 7103420010. Education, 78, 129. https://doi.org/10.5688/ajpe786129
https://doi.org/10.5014/ajot.2017.713002 Vachon, B., Rochette, A., Thomas, A., Foucar Desormeaux, W., &
Andersen, L. T. (2001). Occupational therapy practitioners’ percep- Huynh, A. T. (2016). Professional portfolios used by Canadian occu-
tions of the impact of continuing education activities on continu- pational therapists: How can they be improved? Open Journal of Oc-
ing competency. American Journal of Occupational Therapy, 55, cupational Therapy, 4(3), 4. https://doi.org/10.15453/2168-6408.1280
449–454. https://doi.org/10.5014/ajot.55.4.449 World Health Organization. (2018). Knowledge translation.
Brown, S., & Elias, D. (2016). Creating a comprehensive, robust con- Retrieved from https://www.who.int/ageing/projects/knowledge
tinuing competence program in Manitoba. Journal of Nursing _translation/en/
APPENDIX 54.A. AOTA STANDARDS ■ Integration of feedback from clients, supervisors, and
FOR CONTINUING COMPETENCE colleagues to modify one’s professional behavior and
therapeutic use of self;
Standard 1. Knowledge ■ Collaboration with clients, families, significant others, and
Occupational therapists and occupational therapy assistants professionals to attain optimal consumer outcomes; and
shall demonstrate understanding and integration of the in- ■ The ability to develop, sustain, and refine interprofessional
formation required for the multiple roles and responsibilities and team relationships to meet identified outcomes.
they assume. The individual must demonstrate
Standard 4. Performance Skills
■ Mastery of the core of the practice and profession of occu-
pational therapy as it is applied in the multiple responsi- Occupational therapists and occupational therapy assistants
bilities assumed; shall demonstrate the expertise, proficiencies, and abilities to
■ Expertise in client-centered occupational therapy practice competently fulfill their roles and responsibilities by employ-
and related primary responsibilities; ing the art and science of occupational therapy in the delivery
■ Integration of relevant evidence, literature, and epidemi- of services. The individual must demonstrate expertise in
ological data related to primary responsibilities and to the
consumer population(s) served by occupational therapy; ■ Practice grounded in the core of occupational therapy;
■ Integration of current AOTA documents and legislative, ■ The therapeutic use of self, the therapeutic use of client-
legal, and regulatory requirements into occupation- and centered occupations and activities, the consultation
evidence-based practice; and process, and the education process to bring about change
■ The ability to seek new knowledge to meet client needs as (AOTA, 2014);
well as the demands of a dynamic profession. ■ Integrating current evidence-based practice techniques
and technologies;
■ Updating performance based on current evidence-based
Standard 2. Critical Reasoning
literature with consideration given to client interest and
Occupational therapists and occupational therapy assistants practitioner judgment; and
shall use reasoning processes to make sound judgments and ■ Using quality improvement processes that prevent prac-
decisions. The individual must demonstrate tice error and optimize client outcomes.
■ Deductive and inductive reasoning in making decisions
specific to roles and responsibilities; Standard 5. Ethical Practice
■ Problem-solving skills necessary to carry out responsibilities; Occupational therapists and occupational therapy assistants
■ The ability to analyze occupational performance as influ- shall identify, analyze, and clarify ethical issues or dilemmas
enced by client and environmental factors; to make responsible decisions within the changing context of
■ The ability to reflect on one’s own practice of occupational their roles and responsibilities. The individual must demon-
therapy; strate in practice
■ Management and synthesis of information from a variety
of sources in support of making decisions; ■ Understanding and adherence to the Occupational Ther-
■ Application of evidence, research findings, and outcome apy Code of Ethics (2015) (AOTA, 2015b), other relevant
data in making decisions; and codes of ethics, and applicable laws and regulations;
■ The ability to assess previous assumptions against new ev- ■ The use of ethical principles and the profession’s core val-
idence and revise decision-making processes. ues to understand complex situations;
■ The integrity to make and defend decisions based on ethi-
Standard 3. Interpersonal Skills cal reasoning; and
■ Integration of varying perspectives in the ethics of clinical
Occupational therapists and occupational therapy assistants practice.
shall develop and maintain their professional relationships
with others within the context of their roles and responsibili-
ties. The individual must demonstrate
■ Use of effective communication methods that match the Source. From “Standards for Continuing Competence,” by
abilities, personal factors, learning styles, and therapeutic the American Occupational Therapy Association, 2015, Amer-
needs of consumers and others; ican Journal of Occupational Therapy, Vol. 69, Suppl. 3, pp. 1–3.
■ Cultural competence through effective interaction with Copyright © 2015 by the American Occupational Therapy
people from diverse backgrounds; Association. Used with permission.
CHAPTER
Major Accrediting Organizations
LEARNING OBJECTIVES
■ Explain the importance of The Joint Commission and the Commission on the Accreditation of Rehabilitation Facilities
International for occupational therapy practitioners,
■ Describe how occupational therapy practitioners participate in maintaining compliance with current standards for
accreditation,
■ Analyze the influence of accreditation on quality of care,
■ Understand the role of occupational therapy managers and practitioners as participants in the accreditation process, and
■ Distinguish between regulatory requirements and accreditation standards.

• Accreditation • Functions • State regulatory board
• Commission on Accreditation of • National Patient Safety Goals • Surveys
Rehabilitation Facilities • Regulation • The Joint Commission
International • Standards
OVERVIEW Occupational therapy managers need to be aware of the

specific accrediting bodies that are used to denote compliance
A
ccreditation is a process by which an institution or an in their setting. They must also have a basic understanding of
educational organization seeks to demonstrate that it the standards and regulations that are used to provide over-
complies with generally accepted standards. Accredita- sight for patient or client care and safety. Practitioners depend
tion gives official recognition to sanction, authorize to certify, on the occupational therapy manager to learn about currently
or guarantee meeting required standards (Accreditation, 2018). acceptable policies, procedures, regulations, and standards.
Accreditation is used to recognize health care organiza- Accreditation and regulatory standards act as guideposts for
tions, educational institutions, and professional programs the daily operation of the occupational therapy program.
affiliated with those institutions for a level of performance, This chapter introduces occupational therapy practi-
integrity, and high quality, which entitles them to the con- tioners and students to the major accreditation bodies that
fidence of the community and the public they serve. In the govern health care organizations and occupational therapy
United States, the recognition of accreditation is extended services. The Joint Commission and the CARF are priori-
primarily through nongovernmental, voluntary institutional, tized. In addition, each state and local government may have
or professional associations. These groups establish criteria, unique accreditation requirements that often correlate with
arrange site visits, and evaluate those institutions and pro- the The Joint Commission and CARF standards.
fessional programs that desire accredited status. The impor-
tance of establishing client-identified goals is also highlighted
in the accreditation criteria for both the The Joint Commis-
sion and the Commission on Accreditation of Rehabilitation In most countries outside the United States, a central govern-
Facilities (CARF; Phipps & Richardson, 2007). ment bureau is responsible for establishing and maintaining
https://doi.org/10.7139/2019.978-1-56900-592-7.055
521
CHAPTER
Major Accrediting Organizations
LEARNING OBJECTIVES
■ Explain the importance of The Joint Commission and the Commission on the Accreditation of Rehabilitation Facilities
International for occupational therapy practitioners,
■ Describe how occupational therapy practitioners participate in maintaining compliance with current standards for
accreditation,
■ Analyze the influence of accreditation on quality of care,
■ Understand the role of occupational therapy managers and practitioners as participants in the accreditation process, and
■ Distinguish between regulatory requirements and accreditation standards.

• Accreditation • Functions • State regulatory board
• Commission on Accreditation of • National Patient Safety Goals • Surveys
Rehabilitation Facilities • Regulation • The Joint Commission
International • Standards
OVERVIEW Occupational therapy managers need to be aware of the

specific accrediting bodies that are used to denote compliance
A
ccreditation is a process by which an institution or an in their setting. They must also have a basic understanding of
educational organization seeks to demonstrate that it the standards and regulations that are used to provide over-
complies with generally accepted standards. Accredita- sight for patient or client care and safety. Practitioners depend
tion gives official recognition to sanction, authorize to certify, on the occupational therapy manager to learn about currently
or guarantee meeting required standards (Accreditation, 2018). acceptable policies, procedures, regulations, and standards.
Accreditation is used to recognize health care organiza- Accreditation and regulatory standards act as guideposts for
tions, educational institutions, and professional programs the daily operation of the occupational therapy program.
affiliated with those institutions for a level of performance, This chapter introduces occupational therapy practi-
integrity, and high quality, which entitles them to the con- tioners and students to the major accreditation bodies that
fidence of the community and the public they serve. In the govern health care organizations and occupational therapy
United States, the recognition of accreditation is extended services. The Joint Commission and the CARF are priori-
primarily through nongovernmental, voluntary institutional, tized. In addition, each state and local government may have
or professional associations. These groups establish criteria, unique accreditation requirements that often correlate with
arrange site visits, and evaluate those institutions and pro- the The Joint Commission and CARF standards.
fessional programs that desire accredited status. The impor-
tance of establishing client-identified goals is also highlighted
in the accreditation criteria for both the The Joint Commis-
sion and the Commission on Accreditation of Rehabilitation In most countries outside the United States, a central govern-
Facilities (CARF; Phipps & Richardson, 2007). ment bureau is responsible for establishing and maintaining
https://doi.org/10.7139/2019.978-1-56900-592-7.055
521
educational standards. In the United States, public authority and CARF International, provide a voluntary, self-regulatory
in education is constitutionally reserved to individual states. process by which the agencies can grant formal recognition
This system of voluntary nongovernmental evaluation, called that an institution has met quality standards that are relevant
accreditation, has evolved to promote both regional and na- to consumers, employers, and stakeholders. Furthermore, in-
tional approaches to determine educational quality. stitutional accreditation represents some degree of prestige
Although accreditation is a private, voluntary process, and legitimacy that sets the institution apart from those that
accrediting decisions are considered in many formal actions are not accredited.
(The Joint Commission, 2019c). The accrediting process re- SRBs have a more narrow scope of authority on the basis
quires institutions and programs to examine their goals, of law to ensure competency and ethical practice and to pro-
activities, and achievements; to consider the expert criticism tect consumers from unnecessary harm. Because educational
and suggestions of a visiting team; and to determine internal accreditation and state regulation are addressed in other
procedures for action on recommendations from the accred- chapters, this chapter focuses on The Joint Commission and
iting agency. Because accreditation status is reviewed period- CARF accreditation.
ically, recognized institutions and professional programs are
encouraged to maintain continuous self-study and improve-
ment mechanisms. For Additional Learning

Accreditation and Regulation
■ Chapter 56, “Accreditation Related to Education,” and
There is a sharp distinction between accreditation and reg- ■ Chapter 75, “State Regulation of Occupational Therapy.”
ulation. Accreditation is the “recognition of an institution of
learning as maintaining standards requisite for its graduates
to gain admission to other reputable institutions of higher Accreditation standards change frequently due to ad-
learning or to achieve credentials for professional practice” vances in practice. Therefore, this chapter provides the most
(U.S. Department of Education, 2018). When a novice oc- current information as of press time; readers are advised to
cupational therapy practitioner has been educated by an ac- visit an accreditation agency’s website for the most up-to-date
credited program, they have been prepared to practice under information.
accreditation standards in which the program’s institution
is accountable for the student meeting performance stan-
dards for entry-level competencies in occupational therapy. The Joint Commission
Standards define the performance expectations, structures, The Joint Commission, formerly the Joint Commission on
or processes that must be in place in an organization to en- Accreditation of Healthcare Organizations (JCAHO), is a pri-
hance the quality of care. vate sector–based, nonprofit organization. Its mission state-
Accountability shifts to the individual as the student grad- ment is to continuously improve health care for the public, in
uates and becomes certified and licensed under state law. collaboration with other stakeholders, by evaluating health
Jurisdiction falls to the state regulatory board (SRB) to de- care organizations and inspiring them to excel in provid-
termine the scope of practice within state law. Therefore, a ing safe and effective care of the highest quality and value
regulation is a law or rule prescribed by authority to regulate (The Joint Commission, 2019h).
conduct (“Regulation,” 2018). The Joint Commission operates voluntary accreditation
Accrediting agencies are present in educational institu- programs for hospitals and other health care organizations
tions, hospitals, and rehabilitation centers. Both accrediting such as behavioral health care, home health care, laboratory
agencies and SRBs are concerned with protecting the public services, long-term care, office-based surgery, and Medicare
and striving for quality assurance, maintaining the compe- and Medicaid. In the United States, The Joint Commission
tencies of practitioners, and making ethical decisions in daily accredits nearly 18,000 health care organizations and pro-
practice. Because occupational therapy practitioners perform grams. A majority of state governments recognize The Joint
within accredited health care institutions, the accountability Commission accreditation as a condition of licensure and
shifts to the individual to comply with accreditation stan- receipt of Medicare reimbursement.
dards and SRB requirements.
Ultimately, the occupational therapy practitioner is re-
History
sponsible to the practice requirements of state law. State reg-
ulations stem from statutes, which begin as bills. A bill must The Joint Commission is the largest and oldest private agency
be constitutional and go through parliamentary process to involved in voluntary accreditation in health care in the
be debated and approved by the legislature. Regulations are United States. It dates to the 1917 formulation of minimum
formed and adopted to make sure the statute is enforced ac- standards for hospitals by the American College of Surgeons
cording to law. and that group’s initiation of onsite inspections of hospitals
In occupational therapy education, accreditation provides in 1918. In 1951, the American College of Physicians, the
a uniform set of standards and core educational competen- American Hospital Association, the American Medical Asso
cies. Accreditation agencies, such as The Joint Commission ciation, and the Canadian Medical Association joined with
CHAPTER 55. Major Accrediting Organizations 523
the American College of Surgeons to create the Joint Com- office for analysis and review. Professional staff members re-
mission on Accreditation of Hospitals as an independent, view these results, reach an accreditation decision, and define
nonprofit organization to provide voluntary accreditation for any necessary follow-up requirements for improvement. Ap-
hospitals. proximately 45 days after the survey, the organization is sent
The Joint Commission International (JCI) extends its mis- the official accreditation decision and a report detailing the
sion worldwide. Through international consultation and ac- findings. Most accredited organizations receive recommen-
creditation, JCI helps improve the quality of consumer care dations (each of which requires either a visit or a progress
in public and private health care organizations and with local report) based on potential supplemental recommendations,
governments in more than 40 countries. such as unique laws and regulations, patient care models, pa-
tient care–centered communication standards, and cultural
Accreditation process competency (The Joint Commission, 2019d).
After being surveyed, an organization is classified into an
All health care organizations, with laboratories being the ex- accreditation category. As of January 1, 2019, the accredita-
ception, are subject to a Joint Commission 3-year accreditation decision categories were
tion cycle. The accreditation process involves several surveys,
during which an individual or a team visits an organization ■ Accreditation,
seeking accreditation to assess its compliance with standards. ■ Preliminary Accreditation,
The Joint Commission conducts surveys, which are site vis- ■ Accreditation With Follow-up Survey,
its that usually follow published standards. The findings are ■ Preliminary Denial of Accreditation, and
made available to the public in an accreditation quality re- ■ Denial of Accreditation (The Joint Commission, 2019i).
port through The Joint Commission’s Quality Check listings Organizations that are denied accreditation can appeal
(The Joint Commission, 2019e). before a final accreditation decision is made. Hospital orga-
The Joint Commission also conducts unannounced full nizations do not make the details of the survey findings pub-
survey visits as part of the accreditation process. In these vis- lic. However, they do provide the organization’s accreditation
its, the organization does not receive an advance notice of its decision, the date that accreditation was awarded, and any
survey date. Follow-up surveys typically occur 18–39 months standards that were cited for improvement. Hospital orga-
after the organization’s previous unannounced survey. nizations are deemed to be in compliance when all or most
During the accreditation process, surveyors review docu- of the applicable standards are met to the satisfaction of the
ments, interview the organization’s leaders, visit settings that site visitation team. Behavioral, home health, and laboratory
provide care for clients, make observations, perform func- facilities have additional options in that they can request a
tion interviews, review the organization’s processes to assess scheduled meeting, a scheduled onsite review to discuss the
competence, compliance, hold feedback sessions, and con- survey results, and a visit from agents to conduct interviews
duct public information interviews. Because of the nature of about the compliance and noncompliance issues (The Joint
functions (goal-directed, interrelated series of processes such Commission, 2019f).
as consumer assessment or human resource management) The Joint Commission offers a joint survey option to reha-
that occur throughout an organization, surveyors cannot bilitation hospitals that choose to have both The Joint Com-
reach a final score on compliance until they have visited all mission and CARF International accreditation. This optional
the scheduled consumer care settings and have conducted all survey is structured to coordinate many survey activities (i.e.,
the other survey interviews and activities. Anyone who has interviews, document reviews) between both sets of surveyors.
information about an organization’s compliance with the ac-
creditation standards may request a public information inter-
Survey preparation
view (The Joint Commission, 2019d).
A program’s policies and procedures, plans, and other doc- Occupational therapy managers and practitioners should
uments must be updated, approved, and consistent with other continuously be in compliance with The Joint Commission
units or programs within the organization; they should also standards. Continuous improvement and attention to detail
reflect actual practice. For example, an occupational therapy will limit emotional stress that can be experienced when
program does not need separate occupational therapy poli- being surveyed. In addition, continuous readiness will pre-
cies and procedures if sufficient information is contained in pare occupational therapy practitioners for the unannounced
the overall organizational policies and procedures. Surveyors surveys.
will tour an occupational therapy setting, review clinical re- Occupational therapy managers and practitioners should
cords, speak with or observe clients, and meet with some oc- begin formal preparation for a survey 16 months before the
cupational therapy practitioners. These practitioners may be anticipated survey date to be able to demonstrate a 12-month
questioned about their qualifications with specific responsi- track record of compliance with standards. Managers and
bilities, education and training, and continuing competency. practitioners should have access to the standards, the scoring
At the end of the onsite survey, the surveyors enter the guidelines, and the Perspectives newsletter (discussed later).
findings into a laptop, print a draft copy of the report, and To meet the standards, managers and practitioners must col-
present it to the organization. The surveyors then send the laborate with consumers, their families, other disciplines,
findings electronically to The Joint Commission’s central and peers.
Some typical questions the surveyor might ask include the can contribute to the process to meet the requirements for
following: compliance.
In recent years The Joint Commission (2019a) has estab-
■ What mechanisms are used to identify and prioritize indi- lished the National Patient Safety Goals (NPSGs) with the
vidual needs in determining care delivery?
purpose of identifying specific improvements in patient safety.
■ How is education instruction presented for the consumer The NPSGs highlight areas considered to be problematic in
and the family to address the consumer’s health rehabili-
health care and provide evidence- and expert-based solutions
tation needs?
to typical problems. The rationale for the NPSGs is to reinforce
■ How is occupational therapy integrated into the organiza- the premise that a well-coordinated system design is import-
tion (e.g., through strategic planning, budgeting, perfor-
ant to the delivery of safe, high-quality health care.
mance improvement)?
For instance, The Joint Commission established a Univer-
■ What steps have been taken to assess the risks for con- sal Protocol to reduce surgical errors, and it enforces existing
sumer care and the safety of the organization’s buildings,
regulations on medication reconciliation for 2018 on the basis
grounds, equipment, occupants, and physical systems?
of feedback received during onsite surveys. Occupational
■ How have staff participated in the organization’s informa- therapists see patients shortly after surgery in acute care.
tion management needs assessment?
Complications related to surgical errors need to be reported
The survey team looks for a collaborative, interdisci- to the occupational therapy manager and appropriate person-
plinary approach in an intervention to meet client-centered nel. In addition, occupational therapy practitioners should be
care goals and to achieve optimal outcomes. The assessment aware of side effects of major drugs and patient compliance
should include the client’s physical, cognitive, emotional, and with taking medications (e.g., blood pressure medication)
social status, and a written intervention plan should identify in a timely manner as part of the patient’s daily activities
the client’s rehabilitation needs such as objectives related to (The Joint Commission, 2019g).
activities of daily living, learning, and return to work; mea-
sures and time frames for achievement of rehabilitation goals
Collaboration with other agencies
and objectives; and factors that may influence use of services
or goal achievement. Long-term rehabilitation goals should In keeping with its stated mission, The Joint Commission
be stated in functional terms and developed in collaboration (2019h) collaborates with multiple professional and health
with the client and family. care organizations, including the American Occupational
Preparing for a Joint Commission survey can be a chal- Therapy Association (AOTA) and occupational therapy prac-
lenging process for the hospital administration and occu- titioners. The Joint Commission evaluates, accredits, and col-
pational therapy managers and practitioners as well. At a laborates with a range of organizations on the development of
minimum, hospital administrators and staff must be familiar standards and consultation, including mental health and pe-
with the current Joint Commission standards; examine their diatric organizations; rehabilitation hospitals; health care net-
current processes, policies, and procedures relative to those works, such as health maintenance organizations, integrated
standards; and prepare to address any areas that are not in delivery networks, and preferred provider organizations;
compliance. Occupational therapy managers can promote home care organizations; home infusion and other pharmacy
improved standards compliance by reading the standards, services; durable medical equipment services; hospice ser-
attending related seminars and presentations at occupational vices; nursing homes and assisted living facilities; behavioral
therapy conferences, and networking with other occupa- health care organizations; ambulatory care providers; and
tional therapy managers and practitioners. clinical laboratories. In addition, The Joint Commission has a
Accreditation is a continuous improvement process in disease-specific care certification designed to evaluate disease
which all divisions and departments must participate to re- management and chronic care services. The Joint Commis-
main in compliance. For example, a hospital seeking accred- sion also maintains a Professional and Technical Advisory
itation for the first time must be in compliance with the stan- Committee for each field (The Joint Commission, 2019b).
dards for at least 4–6 months before the initial survey. Health Occupational therapy managers who are interested in par-
care organizations seeking recertification must be in compli- ticipating in the development of standards (discussed next),
ance 6–9 months before the site visit (The Joint Commission, the survey process, and strategic initiatives are encouraged
2019b). The hospital should then be in compliance with ap- to communicate with their occupational therapy representa-
plicable standards during the entire period of accreditation, tives at AOTA.
which means the survey team usually looks for a full 3 years of
implementation for several standards-related issues.
Standards
The standards and the survey focus on the processes and
outcomes affecting customer care and organizational per- For occupational therapy managers and practitioners, survey
formance, not on specific disciplines. Occupational ther- preparation begins with knowing the current standards and
apy managers and practitioners who provide care in Joint having access to the standards manual (or manuals) for the
Commission–accredited organizations will be held account- health care field in which they provide services. Manuals are
able for knowledge of the standards and the strategies they available electronically or in print in a comprehensive version
(which contains accreditation policies, standards, intent History, mission, and goals
statements, scoring guidelines, and aggregation rules) and
CARF International, formerly the Commission on Accredi-
a standards version (which contains accreditation policies,
tation of Rehabilitation Facilities, is a private, nonprofit or-
standards, and intent statements).
ganization that accredits human services organizations with
Every accredited organization receives a complimentary
programs and services in the fields of adult day services, as-
copy of the comprehensive standards manual (or manuals)
sisted living, mental or behavioral health, community agen-
that applies to its organization. The standards that most per-
cies, and medical rehabilitation facilities around the world.
tain to occupational therapy are in the areas of disease and
CARF was established in 1966 to assist consumers in iden-
specific care, primary stroke centers, obstructive pulmonary
tifying quality rehabilitation programs and services. CARF
disease, supporting self-management, and performance mea-
also includes a variety of services such as occupational re-
sures. Within these categories, occupational therapy prac-
habilitation programs, respite services, criminal justice pro-
titioners are likely to find specific language that pertains to
grams, adult day care services, and workforce development
measures affecting occupational therapy practice.
programs (CARF International, 2019a).
Many of the standards are focused on performance
CARF’s mission statement is to promote the quality, value,
and structured around functions. Occupational therapy
and optimal outcomes of services through a consultative ac-
managers and practitioners can influence standards either
creditation process that centers on enhancing the lives of the
through their AOTA representatives or on an individual
persons served (CARF International, 2019a). CARF’s primary
basis. Sharing thoughts and suggestions about the standards
purpose is to
with AOTA is important. This can be accomplished by con-
tacting an AOTA representative to The Joint Commission. ■ Develop and maintain current, field-driven standards that
This information might include feedback about the survey improve the value and responsiveness of the programs
experience, in particular whether occupational therapy ser- and services delivered to people in need of rehabilitation
vices were sufficiently included in the survey and whether and other life enhancement services;
the surveyors had adequate knowledge to fairly survey these ■ Recognize organizations that achieve accreditation through
services. Practitioners and managers can direct standards a consultative peer review process and demonstrate their
interpretation questions to the Commission’s Standards In- commitment to the continuous improvement of their pro-
terpretation Group by submitting an online question form at grams and services;
https://bit.ly/2d3vGji. ■ Conduct research on accreditation processes and out-
comes that measure the management, common program
strengths, and areas that need improvement;
Perspectives newsletter
■ Provide consultation, education, training, and publica-
As The Joint Commission standards undergo frequent tions that support organizations in achieving the require-
changes, it publishes Perspectives, a monthly newsletter that ments for accreditation;
reports changes in standards, policies, and procedures and ■ Provide information and education to the public, consum-
also features content to improve understanding of accredi- ers, and other stakeholders on the value of accreditation; and
tation. At the time of the site survey, practitioners are held ■ Seek input through a variety of resources (e.g., national
accountable not only for what is in the current standards leadership panels, focus groups, 1:1 interactions, surveyor
manual but also for the changes, additions, and corrections interactions) for continuous improvement (CARF Interna-
noted in Perspectives. tional, 2019b).
CARF is governed by a board of trustees that represents the
CARF International consumers who receive services, the providers, the payers,
and the regulators. AOTA has been involved in the develop-
During budgetary shortfalls, when the general public demands
ment and revision of CARF standards and its practices for
more accountability, the pressure increases for organizations
more than 30 years (CARF International, 2019c).
to disclose information about their outcomes. Third-party
payers and regulators need many ways to ensure that the or-
ganization has identified its risks and has systems in place to Performance indicators for
reduce risk and exposure to loss. Accredited providers can
rehabilitation programs
evaluate the results of their services and their performance by
using key indicators outlined by CARF International. Because of growing pressure to demonstrate services that are
CARF accreditation standards establish the framework valued and evidence based, CARF conducted focus groups
for business, information, and measurement systems and the with consumers, health administrators, and health profes-
programmatic components of service delivery. Occupational sionals to establish national standards that can be applied
therapists, providing services as part of a team in a health as a measure of quality outcomes. Thus, CARF developed
care, school-based practice, home health, or community performance indicators to more precisely define the desired
wellness programs, need to demonstrate they are in compli- outcome through a common metric that could establish
ance with these standards. benchmarking from pooled data sets.
The CARF board uses the Performance Indicators for 2. An organization conducts a self-study by evaluating the
Rehabilitation Programs, which are qualitative expressions organization’s compliance with the standards.
used to point to program quality within the area of concern 3. The organization implements the CARF standards for at
(Leland et al., 2015). For example, if the area of concern is least 6 months. During this time, the organization can
the client’s living situation, then the performance indicator engage CARF staff members in phone conversations,
may be the degree to which the consumer experiences in- conference calls, emails, and in-person meetings for tech-
creased independence in their living environment. Indica- nical assistance and standards interpretation.
tors are expressed as degrees, rates, ratios, or percentages. 4. The organization requests an application for the accredi-
In many ways, CARF’s policies also reflect the values of oc- tation survey, which it completes and submits a minimum
cupational therapy; people who receive support and services of 3 months before the month in which it is requesting the
in accredited organizations should have the opportunity to site visit.
live fulfilling lives or live life to its fullest (Moyers Cleveland, 5. After reviewing and approving the application, CARF
2008). sends a bill to the organization for the survey fee, which
is based on the number of surveyors and days needed to
Standards evaluate the organization’s programs and services.
6. CARF selects the survey team based on a match of the
CARF develops and maintains relevant and practical stan-
surveyors’ areas of expertise and the organization’s unique
dards of quality for human services organizations. The stan-
needs.
dards address good business practices, measurable outcomes
7. The onsite CARF survey is conducted by a peer sur-
of services, the process of how the services are delivered, and
vey team that evaluates conformance to the standards.
specific standards for particular populations and services
The survey comprises interviews with individuals and
(CARF International, 2019d). The standards are organized
groups, observations of the service delivery, and review
in several categories: financial management, risk manage-
of necessary documentation. People served are always in-
ment, human resources, physical plant, strategic planning,
terviewed and are an integral part of the survey.
corporate compliance, and corporate citizenship. Standards
8. CARF evaluates the survey team’s findings, and the CARF
about information and outcome management focus on per-
board of trustees renders an accreditation decision (see
formance improvement. The site survey is based on a consul-
below). The organization is notified of the decision and re-
tative peer approach that provides feedback on conformance
ceives a written survey report about 8 weeks after the survey.
to the standards. The degree of conformance to the standards
9. The organization is awarded a certificate of accreditation
determines the accreditation outcome.
that lists the programs or services that have been included
CARF develops standards using a field-driven approach.
in the rehabilitation process.
The term field relates to the people served, the providers of
10. Within 90 days after notification, the organization sub-
services, the purchasers of services, and other stakeholders
mits a quality improvement plan to CARF outlining the
(i.e., people who have a vested interest in the organization).
actions that have been taken or will be taken in response
The members of the field or the committee come together
to any recommendations of the report.
with surveyors, board of trustee members, and CARF staff
members to develop a proposed set of standards. The propos- The typical time frame for an organization to prepare for
als then go to the field for review and comment. After careful an initial survey is 12–16 months. Accredited organizations
review and revision, the board of trustees gives the final ap- should maintain compliance to the standards at all times. Pre-
proval for the set of standards. The standards are then applied paring for most resurveys takes approximately 6–9 months.
to specific programs and services, including occupational A quality improvement plan should be submitted within 90
therapy. days after notice of accreditation. Although an organization
may not be in full compliance with every applicable standard,
Accreditation process the accreditation decision will be based on the balance of the
organization’s strengths with those areas in which the orga-
The process of a CARF accreditation is based on an onsite re- nization requires improvement.
view conducted by peer surveyors. The emphasis is always on Accreditation decisions acknowledge compliance out-
those receiving services and how the provider has developed comes in 4 categories: (1) 3-year accreditation, (2) 1-year
an individualized program that has achieved predicted out- accreditation, (3) provisional accreditation, and (4) non
comes. If those outcomes have not been achieved, then per- accreditation (CARF International, 2019e).
formance will be analyzed to develop a plan to accomplish the
goal. The CARF surveyors act as collaborative partners with
3-Year Accreditation. The organization has demonstrated
the organization throughout the process.
that its services and practices are designed and carried out to
The following 10 steps outline the process of accreditation
benefit the people it serves. Services, personnel, and documen-
(CARF, 2019e):
tation indicate that present conditions represent an established
1. An organization contacts the CARF office to verify which pattern of total operation and that these conditions are likely
of the standards manuals it should use for accreditation. to be maintained or improved in the near future.
1-Year Accreditation. Guidelines for l-year accredi- ■ Ensure that occupational therapy services are based on
tation require the organization to meet each of the CARF standards and the latest evidence for occupational therapy
accreditation conditions. Although the organization may effectiveness (Phipps & Roberts, 2012). Data should be pre-
demonstrate noncompliance with respect to the standards, sented demonstrating clear compliance with each standard.
the evidence shows the organization’s capability and com- ■ If there is no evidence of standard compliance, implement
mitment to correct the deficiencies and progress toward a quality improvement plan to ensure compliance for at
their correction. least 6 months.
■ Keep in mind that the onsite survey is conducted by a peer
Provisional accreditation. The organization is given survey team that evaluates conformance to the standards.
provisional accreditation if it meets each of the CARF ac- The survey comprises interviews with patients and staff,
creditation conditions. Although the organization may observations of the service delivery, and review of neces-
demonstrate noncompliance in relation to the standards, sary documentation.
the evidence shows the organization’s capability and com- ■ Within 90 days after notification, submit a quality im-
mitment to correct the deficiencies and progress toward provement plan to the accreditation agencies outlining the
conformance. actions that have been taken or will be taken in response to
any recommendations from the report.
Nonaccreditation. The organization will receive a nonac-
creditation decision when
Review Questions
■ It demonstrates major noncompliance in several areas
of the standards, and serious questions arise as to the 1. What is the importance of The Joint Commission and
benefits of services or the health, welfare, or safety of its CARF International for occupational therapy practitioners?
clientele; 2. How do occupational therapy managers and practitioners
■ The organization has failed over time to bring itself into participate in maintaining compliance with current stan-
substantial compliance with the standards; or dards for accreditation?
■ The organization has failed to meet any 1 of the CARF 3. What is the influence of the accreditation process on
accreditation conditions. quality of care?
Nonaccredited organizations cannot reapply for accredita-

tion for a minimum of 6 months. SUMMARY
The accreditation process is the gatekeeper for high-quality
Review Questions health care. It is a collaborative venture whereby the organi-
1. What are the specific requirements for occupational ther- zations develop standards that are mutually agreed upon by
apy managers and practitioners in preparation for a suc- consumers, stakeholders, and expert health professionals so
cessful survey from The Joint Commission? the standards exemplify best practices. Accrediting agencies
2. What are the specific requirements for occupational ther- such as The Joint Commission and CARF provide a stamp of
apy managers and practitioners in preparation for a suc- approval that informs the health care consumer that the or-
cessful survey from CARF International? ganization strives for quality care, continuous improvement,
3. How can occupational therapy demonstrate its distinct and high standards in business practices.
value during a survey from The Joint Commission and Occupational therapy practitioners are often called on to
CARF International? participate in the self-study process and be interviewed by
the surveyors or site visitors. The hospital or rehabilitation
center will then receive a thorough summary of the self-study
PRACTICAL APPLICATIONS IN document and the site visit findings, which describe the or-
OCCUPATIONAL THERAPY ganization’s strengths and areas that need improvement. The
Specific practical applications for preparing for The Joint occupational therapy manager should view the accreditation
Commission or CARF survey include the following: process as a positive opportunity to improve services for
clients and patients. ❖
■ Verify which of the standards should be focused on for
accreditation. Standards directly related to occupational
therapy practice should be identified. ACOTE STANDARDS
■ Conduct a self-study by evaluating the organization’s This chapter addresses the following ACOTE Standards:
conformance to the standards. Once the standards have
been identified, occupational therapy practitioners and ■ B.5.7. Quality Management and Improvement
managers should determine if the standards are met or if ■ B.7.2. Professional Engagement
a quality improvement plan should be initiated to ensure ■ B.7.3. Promote Occupational Therapy
compliance. ■ B.7.4. Ongoing Professional Development.
CASE EXAMPLE 55.1. Karen: Preparing for an Onsite Survey Visit
Karen is an occupational therapy manager who is preparing for an onsite survey visit from both The Joint Commission and CARF International this
year. One year in advance, she has reviewed the updated standards for both accreditation agencies and begins providing documentation of how her
occupational therapy department meets each of the standards that apply to her department. She is actively engaged with the interprofessional team
to ensure that all leaders and front-line staff are collaborating effectively in meeting each of the standards. She engages her front-line staff to become
a part of prioritized quality improvement projects that demonstrate how occupational therapy is successfully implementing improvement activities
and evidence-based practice to ensure that all patients receive equitable and high-quality care.
Review Questions
1. What is an example of a focus area for quality improvement that occupational therapy managers and practitioners may prioritize in
preparation for an accreditation survey from The Joint Commission and CARF International?
2. How do occupational therapy managers ensure effective communication with members of the interprofessional team?
3. How do Karen and her staff ensure that the distinct value of occupational therapy is highlighted to The Joint Commission and CARF
International?
REFERENCES ®
The Joint Commission. (2019e). Quality check and quality reports . ®
Retrieved from https://www.jointcommission.org/facts_about
Accreditation. (2018). American Heritage Dictionary. London: _quality_check_and_quality_reports/
Williams & Collins. The Joint Commission. (2019f). Field review for long term care
Accreditation Council for Occupational Therapy Education. (2018). reinvention proposed requirements. Retrieved from https://www
2018 Accreditation Council for Occupational Therapy Education .jointcommission.org/standards_information/field_review_ltc
(ACOTE) standards and interpretive guide. American Journal _reinvention_prop_reqs.aspx
of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi The Joint Commission. (2019g). Improve the safety of using medica-
.org/10.5014/ajot.2018.72S217 tions. Retrieved from https://www.jointcommission.org/assets/1
CARF International. (2019a). CARF’s mission, vision, core values, /6/NPSG_Chapter_HAP_Jan2019.pdf
and purposes. Retrieved from http://www.carf.org/AboutCARF The Joint Commission. (2019h). The Joint Commission mission
/MissionPurposes.htm/ statement. Retrieved from https://www.jointcommission.org
CARF International. (2019b). Payers choose CARF to reduce risk /the_joint_commission_mission_statement
and raise accountability. Retrieved from http://www.carf.org The Joint Commission. (2019i). What is “Joint Commission re-
/Payers/?terms=payers+choose+carf+to+reduce+risk quirements?”. Retrieved from https://www.jointcommission.org
CARF International. (2019c). The public says: Accreditation matters! /standards_information/tjc_requirements.aspx
Retrieved from http://www.carf.org/Public/?terms=public+say Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B.
+accreditation+matters (2015). Advancing the value and quality of occupational therapy
CARF International. (2019d). Who we are. Retrieved from http://www in health service delivery. American Journal of Occupational
.carf.org/About/WhoWeAre/ Therapy, 69, 6901090010. https://doi.org/10.5014/ajot.2015.691001
CARF International. (2019e). Why does accreditation matter? Re- Moyers Cleveland, P. (2008). Be unreasonable. Knock on the big doors.
trieved from http://www.carf.org/Accreditation/?terms=why+is Knock loudly! [Presidential address]. American Journal of Occu
+accreditation+important%3f pational Therapy, 62, 737–742. https://doi.org/10.5014/ajot.62.6.737
The Joint Commission. (2019a). 2019 national patient safety goals. Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for
Retrieved from https://www.jointcommission.org/standards clients with traumatic brain injury and stroke using the Canadian
_information/npsgs.aspx Occupational Performance Measure. American Journal of Occu
The Joint Commission. (2019b). Accreditation/certification fact pational Therapy, 61, 328–334. https://doi.org/10.5014/ajot.61.3.328
sheets. Retrieved from https://www.jointcommission.org/about Phipps, S., & Roberts, P. (2012). Predicting the effects of cerebral palsy
_us/accreditation_fact_sheets.aspx severity on self-care, mobility, and social function. American
The Joint Commission. (2019c). Facts about Joint Commission stan- Journal of Occupational Therapy, 66, 422–429. https://doi.org
dards. Retrieved from https://www.jointcommission.org/facts /10.5014/ajot.2012.003921
_about_joint_commission_accreditation_standards/ Regulation. (2018). Webster’s American Dictionary. New York:
The Joint Commission. (2019d). Facts about patient-centered com- Random House.
munications. Retrieved from https://www.jointcommission.org U.S. Department of Education. (2018). Glossary. Retrieved from
/facts_about_patient-centered_communications/ http://ope.ed.gov/accreditation
CHAPTER
Accreditation Related to Education
Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA 56
LEARNING OBJECTIVES
■ Differentiate institutional accreditation compared to external program accreditation,
■ Identify the influence of the institutional mission on the occupational therapy academic program,
■ Understand the management of educational standards in compliance to external accreditation,
■ Differentiate the compliance with external accreditation to strategic planning in academic programs, and
■ Understand strategies to identify unique attributes of the academic program to promote the profession of occupational
therapy.

• Accreditation • Compliance approach • Faculty professional development
• Accreditation Council for • Council of Higher Education plans
Occupational Therapy Accreditation • Internal quality assurance
Education ®
• ACOTE Self-Study document
• Design Thinking
• External accreditation
• Strategic plan
• Student learning outcome
• Aspirational approach • External quality assurance • SWOT analysis
T
his chapter provides an overview of the management Accreditation
required in occupational therapy academic programs
to meet several responsibilities. The institution where Accreditation refers to a process where an official recognition
the academic program is located has expectations, and of status or abilities is awarded (Eaton, 2015). Accreditation
managing these expectations is discussed. Compliance with includes an external review designed to scrutinize the quality
external accreditation agencies is described, along with the of educational institutions and assure the public that quality
goal of external accreditation. The institutional expectations education is provided at the institution awarded accredita-
and accreditation requirements are balanced with a discus- tion (Garfolo & L’Huillier, 2015; Murphy, 2016).
sion of creating and managing an academic program that For academic institutions, such as colleges and univer-
goes beyond meeting basic external standards to developing sities, external accreditation is sought for several reasons.
a program that provides a unique contribution to the profes- External accreditation refers an agency, outside of the institu-
sion of occupational therapy. Identifying the unique contri- tion, reviewing documents for a specific program, degree, or
butions of the academic program requires strategic planning the entire institution to compare these to external standards.
and monitoring outcomes. Accreditation of the entire institution provides the official
https://doi.org/10.7139/2019.978-1-56900-592-7.056
529
CHAPTER
Accreditation Related to Education
Winifred Schultz-Krohn, PhD, OTR/L, BCP, SWC, FAOTA 56
LEARNING OBJECTIVES
■ Differentiate institutional accreditation compared to external program accreditation,
■ Identify the influence of the institutional mission on the occupational therapy academic program,
■ Understand the management of educational standards in compliance to external accreditation,
■ Differentiate the compliance with external accreditation to strategic planning in academic programs, and
■ Understand strategies to identify unique attributes of the academic program to promote the profession of occupational
therapy.

• Accreditation • Compliance approach • Faculty professional development
• Accreditation Council for • Council of Higher Education plans
Occupational Therapy Accreditation • Internal quality assurance
Education ®
• ACOTE Self-Study document
• Design Thinking
• External accreditation
• Strategic plan
• Student learning outcome
• Aspirational approach • External quality assurance • SWOT analysis
T
his chapter provides an overview of the management Accreditation
required in occupational therapy academic programs
to meet several responsibilities. The institution where Accreditation refers to a process where an official recognition
the academic program is located has expectations, and of status or abilities is awarded (Eaton, 2015). Accreditation
managing these expectations is discussed. Compliance with includes an external review designed to scrutinize the quality
external accreditation agencies is described, along with the of educational institutions and assure the public that quality
goal of external accreditation. The institutional expectations education is provided at the institution awarded accredita-
and accreditation requirements are balanced with a discus- tion (Garfolo & L’Huillier, 2015; Murphy, 2016).
sion of creating and managing an academic program that For academic institutions, such as colleges and univer-
goes beyond meeting basic external standards to developing sities, external accreditation is sought for several reasons.
a program that provides a unique contribution to the profes- External accreditation refers an agency, outside of the institu-
sion of occupational therapy. Identifying the unique contri- tion, reviewing documents for a specific program, degree, or
butions of the academic program requires strategic planning the entire institution to compare these to external standards.
and monitoring outcomes. Accreditation of the entire institution provides the official
https://doi.org/10.7139/2019.978-1-56900-592-7.056
529
recognition of meeting specified standards, and this recog- advocates for systematic, cyclical, and rigorous accreditation
nition gives students access to specific funding sources to with a role in informing the public about “accreditation mills”
support educational pursuits. Seeking external accreditation and “degree mills” that undermine educational quality and
most often requires the institution or program to develop a harm the public when individuals misrepresent the level of ed-
self-study document that includes current educational prac- ucation achieved. CHEA recognition is voluntary and informs
tices, faculty credentials, and the mechanism used to meet consumers of the quality of the institution or program they are
the standards set forth by the accrediting agency. attending.
The process of accreditation can be considered an exercise The types of accreditation agencies included in CHEA’s
in compliance with stated standards, but some accrediting association vary substantially. CHEA membership includes
agencies are more focused on using an aspirational model regional accrediting bodies, such as the Western Association
(Cheng, 2015). Cheng (2015) compared 2 accreditation ap- of Schools and Colleges and the New England Association of
proaches revealed a marked contrast in the impact on the Schools and Colleges–Commission on Institutions of Higher
university programs. Accreditation that was focused primar- Education; national faith-based accreditation agencies, such
ily on compliance produced a self-study report that was more as the Commission on Accrediting of the Association of Theo-
retrospective in nature, identifying how all standards had logical Schools; and specific programmatic accrediting orga-
been met during the period under review. nizations, such as the Accreditation Council for Occupational
The compliance approach is focused on accountability ®
Therapy Education (ACOTE; CHEA, 2018).
to external standards. This approach was contrasted with The accreditation of occupational therapy educational
an aspirational approach in which institutions discuss how programs had been a stated function of the American Oc-
standards were being met and what improvements are being cupational Therapy Association (AOTA) since 1923 (AOTA,
planned for in the future. This aspirational approach reflects n.d.). Today, the educational standards for occupational ther-
the institutional engagement to meet the standards along apy academic programs within the United States are the re-
with expressing the uniqueness of the institution and the sponsibility of ACOTE, which is the accrediting agency for
steps taken to improve the institution. occupational therapy education. Ultimately, ACOTE devel-
Both approaches have respective benefits but produce dif- ops educational standards for academic programs that are
ferent results when institutions produce a self-study report proactive in supporting the clients receiving occupational
to meet the accreditation requirements. The compliance ap- therapy services and advancing the profession. The ACOTE
proach is successful at producing programs that meet prede- standards are revised every 5 years by an independent Educa-
termined standards, but the report lacks the expression of tional Standards Review Committee, appointed by ACOTE,
uniqueness of the institution. to conduct a complete evaluation and revision of the Accred-
When compliance is the primary focus of the accreditation itation Standards for a Doctoral-Degree-Level Educational
process, consultation was limited throughout the institution. Program for the Occupational Therapist, Accreditation Stan-
The aspirational accreditation approach provides guidance dards for a Master’s-Degree-Level Educational Program for
to ensure standards are met while allowing institutions to the Occupational Therapist, Accreditation Standards for an
reflect unique characteristics. Included in the aspirational Baccalaureate-Degree-Level Educational Program for the Oc-
model of accreditation is the expectation of “consultation and cupational Therapy Assistant, and Accreditation Standards
progressive stages of examination,” which can be more costly for an Associate-Degree-Level Educational Program for the
(Cheng, 2015, p. 1031). Understanding the external accredi- Occupational Therapy Assistant.
tation agency’s focus is important when completing the self- Regional accreditation of postsecondary institutions
study document for new or continuing accreditation. within the United States occurs with specific agencies that
Under the Higher Education Act (P. L. 89–329), the U.S. are recognized by USDE and/or are members of CHEA.
Department of Education (USDE) provides oversight of the Discipline-specific commissions manage programmatic ac-
agencies that are responsible for accrediting postsecondary in- creditation such as ACOTE’s responsibility for occupational
stitutions and specialized accreditors. It assesses an accreditor’s therapy educational programs. Increasingly, foreign insti-
ability to reliably evaluate the quality of education or training tutions of higher education are seeking international part-
by institutions of higher learning. USDE recognition is import- nerships and recognition from accrediting agencies in the
ant because it gives access to Title IV funds that provide federal United States (Ramirez, 2015). This reflects the globalization
assistance to education. of higher education and the need for consistent quality edu-
The Council of Higher Education Accreditation (CHEA) cation across various institutions of higher education.
promotes postsecondary academic quality through the accred-
itation process. CHEA (2018) provides standards that external
Institutional Expectations
accreditation agencies use to review post-secondary institu-
tions. These standards provide guidance and expectations for Academic institutions that offer occupational therapy pro-
the agencies affiliated with CHEA. The focus of these stan- grams have distinct mission statements that reflect the insti-
dards is to promote academic quality, accountability, and fair tution’s purpose. Examples can be seen by comparing mission
procedures by all accreditation agencies. Additionally, CHEA statements across the variety of institutions such as the mission
provides oversight to the various accreditation agencies and statement of private, nonprofit institutions compared to private,
CHAPTER 56. Accreditation Related to Education 531
for-profit institutions compared to faith-based institutions, or Standard is met. It requires each OT/OTA program to provide
by comparing mission statements of public institutions pri- clear, objective evidence demonstrating how each standard
marily focused on teaching to public institutions primarily fo- is met. This document is generated for the initial OT/OTA
cused on research endeavors. These mission statements direct program accreditation and for the periodic reaccreditation
the efforts of the administrators, faculty, and staff while still process. The Self-Study document includes not only how the
meeting the institutional accreditation requirements. specific ACOTE standard is met but also notes outcomes data
Occupational therapy educational programs are found in when the OT/OTA program pursues renewal. The assessment
all of these types of institutions, and although all institutions of outcomes data is critical to include in the accreditation pro-
are accredited, the mission will influence the focus of the cess. This step provides the ACOTE accreditation reviewers
occupational therapy curriculum. An example can be seen with information about the process of meeting the standards
with a large public institution located in a substantial metro- and how that data is being used by the OT/OTA program.
politan area. The institution meets all regional accreditation The current ACOTE Self-Study document is divided into
standards and, in accordance with its mission, is focused on 3 distinct sections that are required for an OT/OTA program
educational access and community engagement. The occu- to be accredited and then reaccredited to continue to offer the
pational therapy program meets all ACOTE standards and educational program: (1) A Standards, (2) B Standards, and
demonstrates a good fit within the larger institution. (3) C Standards.
To meet the institutional expectations, the occupational
therapy program includes courses where students and faculty
ACOTE A Standards
engage in community outreach and community-built pro-
grams (Elliot et al., 2001; Schindler, 2014; Wittman & Velde, The first section, the A Standards, addresses the administra-
2001). These community-built programs provide congruence tive and institutional support; credentials of the OT/OTA fac-
with the overall institutional mission while meeting specific ulty, program director, academic fieldwork coordinator; and
ACOTE standards (ACOTE, 2018). The outcomes of these ef- informational materials. The OT/OTA program must care-
forts support the profession’s emerging practice areas. Another fully document that the program has sufficient resources and
example can be seen where an occupational therapy program is institutional supports to meet the requirements of educating
located in a small private, nonprofit, faith-based institution. The occupational therapy practitioners.
occupational therapy program developed a Level I fieldwork A strategic plan must be included in this section; it out-
experience where faculty members supervised students with lines the goals and objectives of the OT/OTA program along
underserved populations in the region. This fulfilled both the with faculty professional development plans. The faculty
institution’s mission and ACOTE’s accreditation requirements. professional development plan meets several requirements.
A third example of an innovative approach to meet both This plan identifies the currency of the faculty member to
the institutional mission and ACOTE standards can be seen teach the specific course content, identifies how the faculty
in a public occupational therapy assistant program at Salt member advances professional skills, and describes how the
Lake Community College. This program provides students professional skills support specific objectives in the strategic
an opportunity to engage in telehealth services to support plan.
outreach to rural communities and communities where A strategic plan can take many forms but typically includes
transportation issues limit access to occupational therapy an in-depth analysis of current strengths, weaknesses, oppor-
services. These examples serve to illustrate how various occu- tunities, and perceived threats. This is referred to as the SWOT
pational therapy programs can meet the institution’s mission analysis and provides a systematic approach to consider the
statement while meeting the ACOTE standards. Again, all program’s strengths; weaknesses; opportunities both within
ACOTE standards must be met by the occupational therapy/ the program, institution, and external opportunities; and the
occupational therapy assistant (OT/OTA) program to retain perceived threats to the program. The strategic plan not only
program accreditation, but how those standards are met identifies the future goals of the OT/OTA program but also
reflects the influence of the institution’s mission statement. outlines a systematic approach to reach those goals.
Although the ACOTE A standards are primarily focused
on the ability of the institution and program to document
ACOTE Self-Study Document
how these standards are met, documentation must include
Obtaining and sustaining accreditation require ongoing planning for the continuation of the program through stra-
management and program evaluation. Frequently, the focus tegic planning and individual faculty development plans.
of external accreditation is on accountability (Chen & Hou, This section contains information that has been referred to
2016), which requires the OT/OTA program to provide clear as both external quality assurance (EQA) and internal qual-
evidence of how ACOTE standards are met. The documenta- ity assurance (IQA) elements (Chen & Hou, 2016). EQA is
tion of how these standards are met often includes multiple focused primarily on accountability, whereas IQA is focused
sources such as specific course objectives, assignments, on improvement. The individual faculty professional devel-
student surveys, and external reviews. opment plans support the OT/OTA strategic plan to meet
The ACOTE Self-Study document (ACOTE, n.d.) is what future program goals and objectives. Program evaluation
each program produces to demonstrate how each ACOTE must document that the program is meeting its stated goals.
ACOTE B Standards 3. What are the general differences in the ACOTE A, B, and
C Standards?
The second section of the ACOTE standards, the B Standards,
4. What programs would need to include ACOTE D Stan-
requires evidence that the educational requirements are met
dards in the Self-Study document?
through specific coursework and assignments. The process
of selecting the best evidence requires collaboration and
careful examination of the demands of the standard and the
demands of the specific coursework or assignment. Generally, PRACTICAL APPLICATIONS IN
it is preferable to offer specific learning activities and requi- OCCUPATIONAL THERAPY
site assessments as evidence of meeting the specific B Standard
Management of Accreditation
instead of detailing an entire course. The content covered in
a course is typically wider ranging than is required in a spe- Throughout the ACOTE Self-Study, the OT/OTA program
cific educational B Standard. A single course may meet several provides not only evidence of meeting the standards in the
of the B Standards through different assignments. The OT/ various sections but identifies how these standards are met
OTA program would present each assignment as evidence and in accordance with the institution’s mission. The ACOTE ac-
included in the ACOTE Self-Study document. creditation process does not dictate how the standards are met
in individual programs. It is the responsibility of the OT/OTA
ACOTE C Standards program to provide clear, objective evidence that all standards
are met to fulfill the educational requirements.
The third section of the ACOTE standards is focused on the The management of the accreditation self-study should
fieldwork education for the OT/OTA student. The fieldwork be viewed as part of a larger process where the standards
program should be closely aligned with the curriculum and articulate with the curricular design, state licensure require-
should make clear linkages with the content being covered in ments, onsite visits, annual and interim reports, and institu-
coursework. This section, the C Standards, includes the role of tional expectations such as cyclic program reviews (Young &
the academic fieldwork coordinator, the mechanism used to se- Perrone, 2016). Articulating all the required elements across
cure fieldwork sites, the process of review of fieldwork sites, and all agencies can avoid duplicating data or collecting data that
specific requirements of the OT/OTA program or institution. is not useful. Additionally, data collected can be used to meet
Evidence should include a range of fieldwork opportunities in several different groups’ requirements if the collection in-
sufficient quantity to meet the program enrollment. Although a strument is well designed.
specific number is not stipulated by ACOTE, the evidence pre- Aligning the OT/OTA curriculum with both external
sented must identify that sufficient fieldwork sites are available accreditation and internal review processes can present a
for the number of students enrolled in the academic program. challenge in managing time and resources (Bowker, 2017).
Institutions often require a cyclic program review process
ACOTE D Standards that may not coincide with the external accreditation review
The fourth section of the ACOTE standards is not included in cycle. Additionally, the data elements required for the institu-
every self-study submitted by OT/OTA programs. This section, tional program review and the external accreditation agency
the D Standards, is exclusively designed for programs offering may be quite different. Meeting these different demands can
a baccalaureate OTA degree or programs offering a doctoral present a management issue. An investigation specifically
OT degree—either an occupational therapy doctorate (OTD) looked at the process of balancing these 2 review mechanisms
or doctor of occupational therapy (DrOT). The D Standards (institutional and external agency) and provided concrete
provide specific information addressing the baccalaureate suggestions (Bowker, 2017):
project the OTA student must complete as part of the degree
requirements. This is an in-depth experience for the student
■ Communication within the institution is critical to inform
stakeholders of the timing and requirements of the external
integrated into the curriculum. The baccalaureate project is not
accreditation agency. For an OT/OTA program, this would
a third fieldwork experience.
mean sharing the ACOTE standards and the accreditation
For programs offering a doctoral OT degree, the ACOTE
requirements at least 3 years before the submission of the
D Standards outline the details and differentiates the cap-
ACOTE Self-Study document.
stone project from the capstone experience. Both the doc-
toral capstone project and experience are integrated into the
■ Aligning the institutional program review with the
accreditation process is an important step in the manage-
curriculum but occur after the student has completed the
ment process. Many institutions require student satisfac-
required fieldwork experiences.
tion surveys be included in the program review process
(Neelaveni, 2015); this data can be used as evidence for the
Review Questions
ACOTE Self-Study.
1. What is the purpose of CHEA in relation to OT/OTA ■ Systematically comparing the expectations of the insti-
programs? tution and the ACOTE standards can reveal similarities
2. Why would it be important for an OT/OTA program to manage the data collection process. The alignment
to be located within an institution awarded regional of this process can be done by careful examination and
accreditation? presentation of the benefits of aligning these processes.
A nationwide survey of health care academic deans and client to refine the solutions. DT, applied to strategic planning,
allied health program directors investigated the process of ac- is focused more on examining what goals and outcomes are de-
creditation (Baker et al., 2004). The deans and the program sired and how to reach those goals; the DT approach spends less
directors agreed that the role of external accreditation assured time examining threats (Wrigley & Straker, 2017).
the quality of the educational programs. There was a notable By intention, a strategic plan developed using a DT model
difference between deans and program directors on the process would be revisited and revised on an ongoing basis to meet the
used in the external accreditation. Deans supported the reform needs of students and the preparation of OT/OTA graduates
efforts of the external accreditation agencies but did not sup- to meet community and societal needs (Beaird et al., 2018). A
port the process used, whereas program directors supported strategic plan developed using the DT model provides guid-
the process and reform efforts used by the external accredi- ance and structure but includes flexibility to adjust to chang-
tation agencies. This reflects the need to clearly communicate ing needs. In this manner, an OT/OTA program strategic
the purpose, process, and intended outcomes of the external plan provides a foundation for a curriculum focused on the
accreditation. Specific supports are available from ACOTE to students and the preparation of graduates and not merely on
assist OT/OTA program directors in communicating these reiterating the ACOTE standards in each class.
roles to deans and institutional administrators. Whether an OT/OTA program uses a traditional SWOT
analysis or the more contemporary DT model, the strategic
plan provides guidance and focus for the program. Goals and
Strategic Planning outcome measures are defined with a plan of how to accom-
Strategic planning and the development of the strategic plan plish these goals. The alignment of the OT/OTA program with
accomplish 2 critical parts required for the ACOTE Self-Study. the institution is clear with the intended outcomes and iden-
First, the strategic plan outlines how the program intends to tifies which faculty are working toward meeting specific out-
meet the institution’s mission and vision and the ACOTE Stan- comes. Faculty professional development plans are designed
dards. Second, the strategic plan allows each faculty member to support the strategic plan and to demonstrate coherence
to design an individual faculty development plan to support with the plan and the institutional mission and vision.
the strategic plan. In this process, the strategic plan is a col-
laborative endeavor supported by all faculty. When developing
Data Collection for Self-Study
the strategic plan, the traditional SWOT analysis can be used,
but a more contemporary approach is the Design Thinking At the foundation of the accreditation process is the ability
model (Wrigley & Straker, 2017). of an institution or program to demonstrate that students
The traditional SWOT analysis examines current program learn what they are expected to learn. This requires writing
and institutional strengths and weaknesses as a foundation. clear, objective student learning outcomes (SLOs; Schneider,
The next step is to evaluate opportunities that may be available 2015/2016). Regional accrediting agencies may identify specific
and determine what is needed to access those opportunities. core competencies that should be met, such as written and oral
The analysis includes looking at specific threats to the program. communication. The OT/OTA program would collect data to
These variables are considered when developing the strategic submit as evidence of meeting the ACOTE standards while
plan. Although this approach has been used in the past, it lacks also identifying how the program supports the institutional
the quick responsiveness needed to adjust the curriculum to accreditation requirements.
meet changing community needs. The strategic plan, when written with clear SLOs, directs the
An example can be seen when an OT/OTA program, lo- method of data collection (Schneider, 2015/2016). This allows
cated in a small city, projects a need for graduates to serve the program to systematically and periodically collect data,
children diagnosed with autism spectrum disorders within review data, and make adjustments as needed. These data would
regional school districts and designs substantial curriculum be included in the reaccreditation self-study document. As an
focused on this population. Within a short period of time, example, the program mentioned earlier focused on a curric-
schools are closing because of changing demographics and ulum with substantial information on school-based practice,
an increasing aging population. The curriculum is no longer interventions for school-aged children with autism spectrum
serving the needs of the immediate community and should be disorders, and service models within the public educational
adjusted. Design Thinking, from the outset, is focused on the system. Over the course of 3 years, the demographics changed,
end user (Matthews & Wrigley, 2017), or from an occupational and many young families left the region, which resulted in
therapy perspective, the client, and considers how to meet the the closing of several public schools. Graduates reported that
client’s needs. most local jobs were in skilled nursing facilities and retirement
Design Thinking (DT) is emerging as an approach to develop communities. Additionally, a population shift was noted, with
a strategic plan in educational settings given the rapid advance- many community residents retiring and needing support at
ments and changes in health care (Beaird et al., 2018). The foun- home or in retirement communities. The educational program
dation of DT is rapid prototyping of an immediate solution for a revised the curriculum to provide coursework focused on ser-
specific problem. The prototype, by intention, is expected to be vices to support aging in place. This change in curriculum did
revised several times to meet the client’s needs. This approach not jeopardize the ACOTE accreditation because all standards
does not expect the product to be perfect in this first attempt were met, but the curriculum shifted to meet the needs of an
but uses systematic approximations with feedback from the aging population served by the graduates of the program.
CASE EXAMPLE 56.1. Internal Institutional Review Process
At a large public institution, the occupational therapy faculty, through the process of shared governance, initiated a policy where the internal
institutional review process would be aligned for all programs that are accredited through external agencies. The proposed policy was presented
to the dean and various administrators for feedback. The faculty then submitted the proposed policy to other programs within the institution with
external accreditation requirements and sought feedback. This collaborative approach allowed the policy to be revised and ultimately approved by
the institutional shared governance body and the university president.
All programs accredited by an external accreditation agency were able to submit the self-study as the primary part of the internal institutional
review process. This streamlined the internal review process and reduced the workload for the program director. Although the institutional review
process required additional elements, programs with external accreditation were allowed to submit self-study documents to meet many of the
requirements. This process was completed well in advance of the submission of the ACOTE document to reduce workload demands and streamline
the accountability requirements.
In preparation for the ACOTE Self-Study document, the occupational therapy faculty reviewed the existing strategic plan and found that many
faculty had difficulties aligning their professional development plan with the strategic plan. Outcomes identified in the strategic plan were not clearly
measurable and did not reflect the SLOs.
The occupational therapy faculty identified key program outcomes for every student graduating from the program. This was completed using
a DT model that was less focused on threats and weaknesses and more focused on aspirational outcomes that were then converted into specific
and measureable program outcomes. These program outcomes reflected global skills. Specific SLOs for each required course were aligned to
the program outcomes. Benchmarks were identified for each SLO that provided evidence of meeting the program outcomes. An example of a
benchmark for a specific SLO was all students successfully completed a specific competency or completed a specific assignment with a grade of B
or better. During this process, each course was also aligned with appropriate ACOTE standards. The SLOs were unique to the course content and did
not merely replicate the ACOTE standards.
During this review time, each course was aligned to the ACOTE standards to facilitate data collection. An example can be seen with the program
outcome to understand and value the occupational core of the profession. This program outcome was met through SLOs in several courses. Each
course addressing this outcome was discussed, and a collaborative decision was made regarding the selection of appropriate measurements for
each SLO. The faculty decided it was not sufficient to measure the program outcome using only 1 SLO. Multiple data points increased the strength of
evidence to demonstrate how students accomplished the program outcome.
The institutional review process required a process be developed for systematic data collection. This data collection process was scheduled
by the occupational therapy faculty so all data was collected for both the institutional review and the ACOTE Self-Study document simultaneously
during a 3-year period. In keeping with the DT model, all faculty participated in the data collection process and provided feedback on modifications
that were needed. Incremental adjustments were implemented to collect meaningful data that could be used for both the ACOTE Self-Study
document and the internal institutional review process.
This specific occupational therapy program was located in a large public institution in a substantial metropolitan area and designed SLOs that
met the institutional mission and vision and the ACOTE standards. The DT model used for strategic planning fostered an attitude of “What do we
want for our students and their clients?” in contrast to a mindset of “How can we meet all the ACOTE standards?”
The occupational therapy program submitted the ACOTE Self-Study document with evidence of meeting all standards. The onsite visit confirmed
the evidence, and the program was awarded reaccreditation. The ACOTE Self-Study document required minimal revisions and was then submitted to
the institutional internal review process. The overall planning for the ACOTE Self-Study, the collection of data as evidence of meeting the standards,
and the coordination of the ACOTE accreditation process with the internal institutional review process required time and commitment of all faculty.
The successful outcome of ACOTE reaccreditation and the positive institutional review made the effort worthwhile.
Review Questions
1. What steps can be taken by an OT/OTA program to align the ACOTE accreditation with the institutional review process?
2. What is the relationship of the program outcome to student learning outcomes?
3. What advantages did DT offer in developing the strategic plan?
The outcome of the periodic review and the accreditation several administration levels within the institution. At
process is to improve the quality and relevance of the program a minimum, the program director of the OT/OTA pro-
(Melo, 2016). The specific SLOs with outcome measures program needs to communicate the ACOTE requirements to
vide a systematic approach to review the quality and effec- the dean and potentially the provost or president of the
tiveness of the educational program. institution.
Case Example 56.1 illustrates how the ACOTE accreditation
process was aligned with the internal institutional program re-
Review Questions
view cycle. The strategic plan was developed using a DT model,
and the accreditation self-study document included evidence 1. What is the purpose of a strategic plan?
from several sources. The ACOTE Self-Study was submitted to 2. What is the difference between a SWOT analysis and the
meet the institutional program review with minor additions. DT model?
Aligning the ACOTE accreditation process with the in- 3. What is the purpose of a faculty professional development
stitutional review process requires communication among plan?
SUMMARY Cheng, N. S. (2015). A comparison of compliance and aspirational

accreditation models: Recounting a university’s experience with
The process of completing the ACOTE Self-Study may be both a Taiwanese and an American accreditation body. Higher Ed-
seen as an unwieldy task faced by the program director. Addi- ucation, 70, 1017–1032. http://doi.org/10.1007/s10734-015-9880-z
tionally, many OT/OTA programs are located in institutions Council for Higher Education Accreditation. (2018). Homepage.
that also require cyclic internal reviews. By aligning these Retrieved from http://www.chea.org/4DCGI/index.html?Menu
processes, the workload is more manageable. Strategic plan- Key=home
ning is critical in managing these demands, and use of DT Eaton, J. S. (2015). An overview of U.S. accreditation (revised Novem-
ber 2015). Retrieved from http://search.proquest.com.libaccess
fosters ongoing assessment of the plan’s appropriateness, the
.sjlibrary.org/docview/1871570271?accountid=10361
data collected, and the outcomes achieved in the educational
Elliot, S., O’Neal, S., & Velde, B. P. (2001). Using chaos theory to
program. The process of accreditation is demanding but can understand community-built occupational therapy practice.
be managed with systematic planning and communication Occupational Therapy in Health Care, 13, 101–111. https://doi
across support systems within the institution. ❖ .org/10.1080/J003v13n03_09
Garfolo, B. T., & L’Huillier, B. (2015). Demystifying assessment: The
ACOTE STANDARDS road to accreditation. Journal of College Teaching and& Learning,
12, 151–170. https://doi.org/10.19030/tlc.v12i3.9303
This chapter addresses the following ACOTE Standards: Matthews, J., & Wrigley, C. (2017). Design and design thinking in
business and management higher education. Journal of Learning
■ A.6.0. Strategic Plan and Program Assessment Design, 10, 41–54. https://doi.org/10.5204/jld.v9i3.294
■ A.6.1. Strategic Plan Melo, S. (2016). The impact of accreditation on healthcare quality
■ A.6.2. Professional Development Plans. improvement: A qualitative case study. Journal of Health Organi-
zation and Management, 30, 1242–1258. https://doi.org/10.1108
/JHOM-01-2016-0021
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ACOTE self-study document. Retrieved from https://acote.aota health counseling programs (doctoral dissertation). Available from
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Accreditation Council for Occupational Therapy Education. (2018). Neelaveni, C. (2015). A study on students’ satisfaction based on
2018 Accreditation Council for Occupational Therapy Education quality standards of accreditation in higher education. Educa-
(ACOTE) standards and interpretive guide. American Journal of tional Research and Reviews, 10, 282–289. https://doi.org/10.5897
Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi.org /ERR2014.2045
/10.5014/ajot.2018.72S217 Ramirez, G. B. (2015). Translating quality in higher education: US
American Occupational Therapy Association. (n.d.). Accredita- approaches to accreditation of institutions from around the world.
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Baker, S. S., Marrone, A. S., & Gable, K. E. (2004). Allied health Schindler, V. P. (2014). Community engagement: Outcomes for
deans’ and program directors’ perspectives of specialized occupational therapy students, faculty and clients. Occupational
accreditation effectiveness and reform. Journal of Allied Health, Therapy International, 21, 71–80. https://doi.org/10.1002/oti.1364
33, 247–254. Schneider, C. G. (2015/2016, Fall/Winter). Policy priorities for accredita-
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SECTION X.
Ethical and Legal Considerations
Edited by Lea Brandt, OTD, MA, OTR/L
537
CHAPTER
Organizational Ethics
Deborah Yarett Slater, MS, OT, FAOTA 57
LEARNING OBJECTIVES
■ Identify key issues that managers face in the current health care environment that impact the provision of occupa-
tional therapy services;
■ Recognize the role and impact of state licensure statute and regulations on ethical practice; and
■ Identify strategies managers can use to develop, model, and implement an ethical culture with employees.

• Administrative directive • Compliance • Organizational culture
• Altruism • Ethical dilemma • Organizational ethics
• Beneficence • Moral distress • Procedural justice
• Client-centered care • Nonmaleficence
The time is always right to do what is right. that conforms to ethical and professional standards while also
meeting institutional financial goals to ensure that the orga-
—Martin Luther King, Jr., civil rights leader and minister
nization remains financially viable. Managers may also be
(1929–1968; brainyquote.com, n.d.)
personally incentivized through a bonus system to meet finan-
cial targets. These diverse responsibilities can provoke ethical
conflicts for managers as they seek to be effective leaders in
OVERVIEW the organization while setting appropriate standards for the
M
anagers in the current health care environment face employees they oversee.
personal and professional challenges when fulfilling This chapter addresses the ethical responsibilities and
their responsibility as ethical role models. On the challenges facing occupational therapy managers and pro-
one hand, they are part of the organizational management vides resources to address these challenges in the context of
structure, but on the other, they are often members of a clini- the current health care environment.
cal profession with a background in patient care. This can put
them in a position of conflicting loyalties and responsibility
that can lead to ethical dilemmas (“a situation in which there
is not one clear cut, right answer but two possible courses of Organizational ethics includes not only culture and trust
action that, however, conflict with one another”; Slater, 2016, but also processes, outcomes, and character that perfuse
p. 291) as they seek to balance the business priorities of the an entire organization regarding how one should act with a
organization with the diverse needs of staff and their patients. common sense of purpose and values (Pearson et al., 2003).
Occupational therapy managers must ensure that their Typically, the ethics of an organization is conveyed through
clinical employees understand their ethical obligations as they value-based mission statements, policies, and practices
apply to practice. However, managers also have a dual obliga- (Doherty & Purtilo, 2016). An organization’s philosophy
tion. They should support employees in upholding practice can define its reputation both externally to the public and
https://doi.org/10.7139/2019.978-1-56900-592-7.057
539
540 SECTION X. Ethical and Legal Considerations
internally to employees. Its philosophy should be evident in groups, which increased economic considerations in provid-
the organizational culture of the institution, which should ing care but did not, in the physicians’ opinions, increase
reflect the “beliefs, values, attitudes, ideologies, practices, efficiency; it resulted in instances of over or under provision
customs and language” (Butts, 2008, p. 121). However, there of care that were not based on clinical need (Fassler et al.,
can be a disconnect among the stated mission, related poli- 2015).
cies, and what happens in everyday practice. Issues related to the business orientation of health care or-
ganizations are some of the most frequent concerns brought
Administrative Directives to the American Occupational Therapy Association (AOTA)
by its members; they occur in a variety of practice settings.
Organizational issues that provoke distress related to situa- Administrative decisions about clinical care, sometimes
tions that challenge appropriate ethical conduct or actions made and conveyed by non-clinicians, are often based on
in the current environment often relate to administrative reimbursement and revenue targets and may override the
directives. Administrative directives are policies or mandates clinical judgment of the practitioner. This can undermine
from management affecting patient care that may override the clinician’s ability to make client-centered care decisions
clinical judgment regarding the provision of services. These that uphold the overarching ethical principles of Beneficence
can include pressure to provide intervention beyond the (i.e., client well-being) and Nonmaleficence (i.e., preventing
practitioner’s competency, unrealistic productivity demands, harm), which are central to the therapeutic, moral obligation
violations of the occupational therapy scope of practice, of health care practitioners.
inability to discharge patients when goals have been met,
inadequate supervision, and use of unqualified personnel to
Client-Centered Care
provide skilled services.
It is important to distinguish between facts and myths The concept of client-centered care, incorporating clients as
related to regulations and policies when directives about pa- active partners in their therapy (AOTA, 2014), is a cornerstone
tient care, documentation, or billing are given. For example, of occupational therapy and is at the heart of ethical princi-
a manager might tell an occupational therapy assistant to ples in Occupational Therapy Code of Ethics (2015) (herein-
independently write and sign off on a discharge summary, after, the Code; AOTA, 2015). Yet today’s practitioners may
which is not correct. Therefore, managers themselves must be feel like they’re answering to multiple masters—the client, the
knowledgeable about relevant laws, regulations, and policies employer, and professional organizations—so it may not be
from the primary source (e.g., Medicare) so they can convey clear where the s ervice recipient actually fits (Gupta & Taff,
accurate information to employees and ensure that depart- 2015). Arguably, the conflicting values of the workplace and
mental processes are in compliance, meaning that they con- influence of payers on clinical decision-making are not con-
form to regulations, requirements, or policies. ducive to client-centered practice. Practitioners inevitably
Managers should be aware that illegal activities can be re- have difficulty remaining attentive and client-centered when
ported to the Office of the Inspector General, organizational working with several patients simultaneously, each presum-
ombudsmen, or compliance officers and that ultimately, these ably engaged in different activities with differing responses
may be investigated by the U.S. Department of Justice. There- (Gupta & Taff, 2015). Unrealistically high productivity stan-
fore, fact-based information from primary sources for regu- dards and the more recent pressure of point-of-service doc-
lations, laws, or policies is important to counteract directives umentation, all efforts to maximize billable “treatment” time
that seem questionable and may put one’s license in jeopardy. and minimize required but nonreimbursable activities, may
However, in addition to regulatory compliance, directives make client-centered treatment merely an illusion (Gupta &
can challenge ethical obligations for practitioners and man- Taff, 2015).
agers, causing moral distress and workplace conflict. Society trusts health care professionals to be ethical and
competent, but the current health care environment pres-
Health Care’s Business Environment ents challenges to exhibiting professionalism as expected
by consumers (Nortje & DeJongh, 2017). In addition to
In recent years, organizational ethics has emerged as one of specific training, role modeling and reflection can promote
the most prevalent concerns for occupational therapy prac- professional conduct that instills the need for respect, ethical
titioners because of the business environment in which ther- behavior, competence, interpersonal skills, cultural compe-
apy is often provided (Slater & Brandt, 2009). Brody (2014) tence, and altruism (Nortje & DeJongh, 2017).
cited a recurring theme throughout a conference sponsored
by the Lown Institute in Boston in 2013; the United States
Review Questions
no longer has a health care system but instead has a revenue
extraction system, configured to deliver wealth to corpo- 1. What makes up an organizational culture?
rations instead of care to people. Unfortunately, the same 2. What are 3 organizational issues that can cause distress
economic pressures can be felt outside the United States, as in practitioners?
noted in a survey of Swiss physicians after the implementa- 3. Which ethical principles may be challenged by a
tion of a reimbursement system based on diagnostic-related reimbursement-driven organizational culture?
CHAPTER 57. Organizational Ethics 541
EXHIBIT 57.1. Framework for Ethical Decision Making
Managers can play a significant role in setting policies and Many models for addressing ethical dilemmas exist, and most
procedures that reflect high ethical standards within their address the following key questions:
departments. As noted, they can be valuable and influential
■ What is the nature of the perceived problem (ethical distress,
role models of appropriate professional conduct, not only ethical dilemma) and what is the specific problem? Similar to
through words and writing but also through their actions and clinical reasoning, “name and frame” the problem.
expectations. Individuals in middle management positions ■ Who are the players (not just those immediately involved, but
can face particular challenges in creating this departmental others who may be influenced by the situation and any decision
culture if it is at odds with the culture, behavior, or decisions that is made)?
demonstrated at the highest administrative levels. Therefore, ■ What information is known and what additional information is
occupational therapy managers need to acquire and use tools needed to thoroughly evaluate the situation and formulate options?
and strategies to effectively address organizational ethics is- ■ What resources are available to assist clients?
sues that affect the delivery of clinical services if the organi- ■ What are the options and likely consequences of each option?
■ Am I willing to prioritize moral values (despite potential negative
zation does not have an integrated, systems-level program.
personal repercussions) to act on what I believe is the best
decision? (Good intentions do not always bring about good deeds;
Values Kanny & Slater, 2008.)
■ Can I defend my action?
Managers also have a responsibility to create a workplace cul- ■ Was the outcome what I expected? Would I make a different
ture based on the values of integrity, accountability, fairness, decision if confronted with a similar situation again?
and respect. An ethical work environment empowers and
supports employees to “do the right thing.” This can benefit
employee morale and ultimately productivity and customer
relations. In addition, it is also likely to increase quality of In an organization with an integrated ethics program at the
care by reinforcing altruism, putting the welfare and needs of organizational level, using ethics resources will be easier as sys-
clients before those of oneself (AOTA, 2015). This is the core tems will be designed to support education and transparency,
value that typically led employees to choose occupational with a goal of promoting open communication to address eth-
therapy as a profession and emphasizes the importance of ical challenges at all levels of the institution. In other facilities,
respecting patient autonomy related to care decisions. an ethics committee consisting of knowledgeable and com-
Leadership starts by example and is reinforced when man- petent members can provide valuable assistance in clarifying
agers’ actions mirror their words. Setting aspirational goals issues and potential actions for a patient-specific issue with the
and mirroring exemplary behavioral expectations (e.g., what health care team so there is consensus and consistency.
one should do vs. what one can do) is a good start to develop- An ethics committee may also be able to advise manag-
ing an ethical culture within the department. ers about relevant literature and other educational materials
that can assist them in formulating departmental policies and
procedures that support an ethical culture. Librarians may
Ethical Reasoning
assist with literature searches on aspects of ethics related to
Another way to develop an ethical culture is to promote com- organizational cultures. AOTA also offers a variety of edu-
petency in ethical reasoning through continuing education, cational publications (see Exhibit 57.2), an ethics mailbox
awareness, and promotion of available resources, and perhaps (ethics@aota.org), and individualized consultation to man-
most important, to assist employees in applying a framework agers who want to ensure that they develop systems to sup-
for ethical decision making to analyze clinical situations that port ethical practice operations and staff policies.
may pose ethical dilemmas (Exhibit 57.1).
The framework encourages managers and practitioners
to systematically work through dilemmas to ensure that
they have considered all important information to make an EXHIBIT 57.2. AOTA Ethics Publications
ethically supported decision.
■ American Occupational Therapy Association. (2015). Occupational
therapy code of ethics (2015). American Journal of Occupational
Resources Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot
Just as a framework provides a systematic method of working .2015.696S03
through an ethically challenging situation, the benefits of using ■ Slater, D. Y. (Ed.). (2015). Reference guide to the Occupational
external or additional resources cannot be minimized. It is the Therapy Code of Ethics (2015 edition). Bethesda, MD: AOTA Press.
■ Scott, J., & Reitz, S. M. (Eds.). (2017). Practical applications
responsibility of managers to be aware of available resources
for the Occupational Therapy Code of Ethics (2015). Bethesda,
such as ethics information available through AOTA and specific
MD: AOTA Press.
institutional programs and facilitate access to them by their staff.
Continuing education through a variety of means, related therapy services specific to their needs” (AOTA, 2015, p. 2).
to aspects of clinical practice, is important because each eth- Case Example 57.1 examines pressure to provide services
ical dilemma may be unique. Therefore, developing reason- inconsistent with the clinical needs of the client.
ing skills in this area is more helpful than memorizing rules,
which may not be applicable to every situation. Departmental
Clinical Needs
in-services using case examples for analysis with the Code,
the Framework for Ethical Decision Making, and other rel- Managers have an ethical responsibility to ensure that the
evant ethics literature can promote development of ethical clinical needs and benefit of clients are prioritized and not
reasoning. ultimately compromised. This is explicitly addressed in the
In addition, managers should analyze institutional sys- Code (AOTA, 2015) under Principle 1E (Beneficence), which
tems that seem to cause the most frequent staff concerns. states, “Occupational therapy personnel shall provide occu-
This should be done proactively so that policies, proce- pational therapy services, including education and training,
dures, and educational efforts can focus on addressing that are within each practitioner’s level of competence and
them preventively rather than taking a reactive approach. scope of practice” (p. 3).
An example of institutional procedures that may promote Managers must also support appropriate clinical decision-
unethical behavior could be pressure to schedule patients making by their staff, particularly related to frequency, type,
for 20-minute evaluation slots with the last 10 minutes and duration of services. An effective staffing model requires
being treatment. The rationale behind this procedure may creativity and flexibility in analyzing caseloads, diagnostic case
be an effort to maximize productivity or “efficiency” but mix, staff skill sets, and the setting. It also requires balancing
also to maximize the billing codes that can be charged. sometimes competing priorities among the wishes and needs of
Given the limited time frame, it may not be possible to staff, patients, and senior management. Although the manager
evaluate patients with neurological diagnoses, those who has an important role in ensuring the efficient use of personnel
are elderly, or those who have complex medical issues ad- and delivery of services to move patients through the system,
equately to identify problems needed to develop an ap- it is ethically problematic to base goals on improving profit
propriate plan of care and goals. In addition, a focus on margin and not on providing quality of care or a healthy work
identifying occupational performance deficits, which is environment for employees who are producing those profits.
the philosophical basis of the profession, requires some This can be at odds with public statements from administration
time in discussion with patients or clients to determine about the ethical values of the organization and can put both
meaningful activities with which they are having diffi- managers and employees in a challenging position.
culty. Instead of focusing on a rigid schedule for efficiency, Specifically, one challenge seen in practice results from
managers need to give practitioners some autonomy in de- limitations in insurance coverage for clients who need ongo-
veloping an individualized treatment plan including ap- ing services and have no alternate payment sources. This can
propriate intervention time. also create an ethical dilemma for clinicians who believe the
This type of situation may not lend itself to a cursory eval- client’s needs require additional therapy, beyond the payer’s
uation, followed by a treatment session of routine exercises, allowance for therapy sessions. The following case study
as clearly stated in Principle 1A of the Code: “Occupational demonstrates how financial goals of the organization may in-
therapy personnel shall provide appropriate evaluation fluence or impede provision of needed occupational therapy
and a plan of intervention for recipients of occupational services (Case Example 57.2).
CASE EXAMPLE 57.1. Power Differentials Within the Health Care Team
Mike, an occupational therapist, discharges a patient from occupational therapy services because the patient is no longer making progress toward
goals. The patient complains to the physician, who writes another referral for occupational therapy services 3 times a week for 12 weeks and calls
Laura, the department manager, to complain about Mike’s discontinuation of services, which occurred without the physician’s knowledge.
The physician states that if any of Laura’s employees discharges one of his patients without conferring with him first, he will no longer refer patients
to Laura’s clinic. To complicate the situation, just last week Laura was called into her director’s office as she was concerned about the recent
decline in referrals for therapy services. As a result, a target of increasing outpatient referrals by 3% in the next 6 months has been added to Laura’s
performance goals and her annual raise is dependent on the number of performance goals she meets by the end of the fiscal year.
Review Questions
Use the Framework for Ethical Decision Making and other noted strategies to address the following questions:
1. What are the ethical issues here?
2. What possible actions can be taken?
3. What resources might be available to assist in resolving the ethical conflict?
4. Which is the best option for Laura to take, and why?
CASE EXAMPLE 57.2. Competing Goals
The occupational therapy manager is told by administration that all outpatient pediatric programming will be eliminated because it does not
generate revenue. The manager, who is also an occupational therapy practitioner, feels that this is tantamount to abandoning patients, because
staff provide care in the Intensive Care Nursery and will not be able to follow through with treatment interventions if outpatient programming
is cut. In addition, all outpatient-based pediatric practices in the area have closed because of financial insolvency.
Review Questions
1. What are the issues?
2. Who are the players who may be affected by this decision?
3. What additional information may be helpful in developing potential options?
4. Are there strategies that the manager can take to address or reverse this decision?
5. Which is the best strategy, and why?
Moral Distress avoid disciplinary action from failing to protect the safety
and well-being of clients. Violations of procedural justice put
Because many clinicians pursue a career in occupational ther-
the organization in legal jeopardy and can also result in re-
apy for altruistic purposes, they may experience moral dis-
vocation of licensure for occupational therapy managers and
tress, when one knows the right thing to do but encounters
practitioners. Failure to maintain a license in good standing
a barrier preventing action (Doherty & Purtilo, 2016). When
may impact their ability to work as occupational therapy
practitioners feel constrained in providing clinically indicated
practitioners.
services and notice negative patient outcomes, moral distress
may surface (Slater & Brandt, 2009). It is a manager’s respon-
sibility to attempt to reduce factors contributing to moral dis- Licensure: Intersection of Ethical and
tress. Legal Conduct
One strategy is to be aware of institutional policies related
to reduced fee, free care, or other alternate methods that may A good place for managers to start when laying the ground-
be available to cover needed therapy. The manager should work for an ethical culture is with licensure. Occupational
also work with clinicians to identify alternative approaches therapy is now regulated through licensure in all 50 states,
to enable clients to achieve their goals when therapy sessions the District of Columbia, Puerto Rico, and Guam. Therefore,
may be limited. While not always optimal, this may reduce all occupational therapists (OTs) and occupational ther-
moral distress and support ethical practice within realistic apy assistants (OTAs) must obtain and maintain a current
financial constraints. Perhaps the most pressing ethical issue license, including timely renewal and fulfillment of any con-
in occupational therapy practice today stems from the continuing education requirements. This is a personal responsi-
flict between financial pressure to do more with less, and in bility of the employee, but managers should make it clear that
particular unrealistic productivity demands. there are serious consequences for unlicensed practice. These
Managers need to be vigilant that they are not, even in- include potential disciplinary action by the state licensure
advertently, encouraging or allowing unethical conduct that board or the AOTA Ethics Commission. Medicare require-
could foster moral distress. This can occur in occupational ments for provision and reimbursement of skilled services are
therapy practice when, for example, compensation is tied linked to qualified practitioner status.
to productivity. This is especially problematic when mone-
tary incentives are linked to the quantity of billable services QUALIFIED PROFESSIONAL means a physical therapist,
without implementation of associated quality safeguards. occupational therapist, speech–language pathologist,
These practices create a culture that values output over ethics. physician, nurse practitioner, clinical nurse specialist,
Setting or supporting unrealistic productivity standards pro- or physician’s assistant, who is licensed or certified by
motes practices that are not only unethical but also are illegal. the state to furnish therapy services, and who also may
appropriately furnish therapy services under Medicare
policies. Qualified professional may also include a physical
Procedural Justice
therapist assistant (PTA) or an occupational therapy
Managers and practitioners must be mindful of procedural assistant (OTA) when furnishing services under the
justice considerations, which reinforce that processes are fair supervision of a qualified therapist, who is working within
as they provide occupational therapy services (AOTA, 2015). the state scope of practice in the state in which the services
They must be knowledgeable about and compliant with legal are furnished. (Medicare Benefit Policy Manual, 2018,
considerations in their state practice act and regulations to p. 154, italics added)
Treatment and billing of services by an unlicensed prac- ethical obligations as outlined in Principle 1D (Delegation–
titioner may require a “give back” of money that was re- Beneficence) and 4 H (Supervision–Justice; AOTA, 2015).
imbursed to the organization. This may constitute a legal Financial considerations may lead an organization to
violation of Medicare regulations but, in addition, any pe- pressure managers to hire a high ratio of OTAs to OTs with-
riod of unlicensed practice can put the practitioner’s license out permitting adequate personnel (or staff time) to provide
in jeopardy and result in disciplinary action from the state. appropriate supervision. Again, managers must be familiar
Failure to maintain a current license is illegal because the with state regulations addressing supervision requirements
licensure board is a legal body. It is also an ethical violation; and fulfill their ethical responsibility to comply, ultimately
awareness of licensure laws is addressed as an obligation in ensuring that services are delivered safely and effectively.
the Code under Principle 4 (Justice; AOTA, 2015). Managers This is another example of a situation where organizational
can set up simple procedures to remind their staff about policies or pressure may be incongruent with ethical and
timely renewal and can facilitate continuing education op- legal mandates, requiring strong advocacy by managers in
portunities within and outside the department to meet licen- dealing with senior administrators to avoid compromising
sure requirements as previously mentioned. their licensure status and that of their employees.
Organizational administrative directives that mandate Many state licensure regulations have adopted the Code,
the use of unskilled, unlicensed aides to provide and bill for either through inserting actual language from the document
skilled occupational therapy services also present both ethi- or by reference. In other states, there is a section in a regu-
cal and legal dilemmas that must be addressed. It is the man- lation or a statute that addresses “professional conduct” or
ager’s responsibility to develop a staffing plan with different the licensure board may develop their own code of ethics.
levels of personnel to meet ethical and legal requirements The language in this section is often similar to or reflects the
and to be clear with both employees and senior management key concepts that are found in the Code. The mission of state
about acceptable scopes of practice for each level. Employees licensure boards is protection of the public. Therefore, key
should never be asked to provide services for which they do points related to professional conduct often include but are
not feel competent or that are not within their scope of prac- not limited to competency, sexual misconduct, privacy, right
tice as legally defined in state practice acts. to refuse treatment, causing harm, unlicensed practice, su-
It is critical that all occupational therapy practitioners, pervision expectations, fraudulent documentation/billing,
including managers, protect their licenses (which permit nondiscrimination, and conviction of a crime. Likewise, the
them to practice) by not engaging in illegal or unethical ac- focus of the Code is the well-being of occupational therapy
tions. This is also true for the appropriate use of OTAs who, clients, prevention of harm, professional boundaries, re-
although licensed themselves, must be supervised by an OT. spect for client autonomy in making health care decisions,
The supervising OT ultimately has oversight over the client honesty, and the trust that is owed as part of the therapeutic
and delegates clinical work on the basis of client need, practi- relationship. Case Example 57.3 demonstrates how organi-
tioner competency, and expertise. As with licensure, it is the zational pressures may impede the practitioner’s ability to
responsibility of both the OTA and the supervisor to meet uphold the Code.
CASE EXAMPLE 57.3. Uphold the Code or Comply With the Directive?
An occupational therapist is asked to work with a patient who has been diagnosed with pancreatic cancer and is asking for palliative care.
The patient consistently refuses occupational therapy intervention and has stated that she does not want to work toward goals related to
rehabilitation. The physician and family are pressuring the patient and occupational therapist to work toward goals to increase independence
with ADLs no longer valued by the patient. When the occupational therapist discusses the issues with her clinical supervisor, she is informed that
because the physician and family are both in agreement that the patient should continue to receive occupational therapy services, intervention
must be provided consistent with their wishes.
Although this case study relates specifically to patient care, the scope of the Code is broader, going beyond clients; the principles can be
applied to educators, researchers, and colleagues as well. Compliance with Principles in the Code is an essential individual responsibility, not only
for practitioners but also for managers as they develop and implement policies and procedures in areas for which they have oversight. Managers
also have an additional responsibility to ensure that violations do not occur by their employees and to work with them to resolve conflicts as
they arise.
Review Questions
1. What principles may be violated here?
2. Who are the involved parties?
3. Whose rights should prevail, and why?
4. What actions might be taken to address this situation?
Review Questions ACOTE STANDARDS

1. What negative consequences can result from unlicensed This chapter addresses the following ACOTE Standards:
practice?
2. What must a manager consider when developing a staff- ■ B.4.24. Effective Intraprofessional Collaboration
ing model using different levels of personnel? ■ B.4.25. Principles of Interprofessional Team Dynamics
3. How can the Framework for Ethical Decision Making be ■ B.5.3. Business Aspects of Practice
applied to learning? ■ B.5.8. Supervision of Personnel
■ B.7.1. Ethical Decision Making.
SUMMARY REFERENCES
Occupational therapy managers play a critical role in Accreditation Council for Occupational Therapy Education. (2018).
developing and maintaining an ethical culture in their de- 2018 Accreditation Council for Occupational Therapy Education
partments as well as promoting systems and policies that (ACOTE) standards and interpretive guide. American Journal
support ethical conduct within their organizations. There- of Occupational Therapy, 72, 7212410005. https://doi.org/10.5014
fore, they must be knowledgeable about ethical principles /ajot.2018.72S217
and legal requirements for practice. Managers can also pro- American Occupational Therapy Association. (2014). Occupational
mote the development of ethical reasoning skills, identify
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
resources for ethical practice, and serve as important role
models for their employees and colleagues at all levels. Ef- American Occupational Therapy Association. (2015). Occupational
fective managers need to understand organizational and therapy code of ethics (2015). American Journal of Occupational
environmental forces that affect the provision of services Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot
within institutional systems and how to balance these with .2015.696S03
their ultimate responsibility to oversee high-quality care Brody, H. (2014), Economism and the commercialization of health
that complies with the ethical principles and values of the care. Journal of Law, Medicine and Ethics, 42, 501–508. https://doi
occupational therapy profession. ❖ .org/10.1111/jlme.12171
Butts, J. B. (2008). Ethics in organizations and leadership. Burlington,
MA: Jones & Bartlett.
Everything you do sends a message about who you Doherty, R. F., & Purtilo, R. B. (2016). Ethical dimensions in the
are and what you value health professions (6th ed.). St. Louis: Elsevier.
—Michael Josephson, founder of Character Counts Fassler, M., Wild, V., Clarinval, C., Tschopp, A., Faehnrich, J. A.,
& Biller-Andorno, N. (2015). Impact of the DRG-based reim-
and the Josephson Institute (quotefancy.com, n.d.)
bursement system on patient care and professional practise:
Perspectives of Swiss hospital physicians. Swiss Medical Weekly,
145, w14080. https://doi.org/10.4414/smw.2015.14080
LEARNING ACTIVITIES Gupta, J., & Taff, S. (2015). The illusion of client-centred practice.
Scandinavian Journal of Occupational Therapy, 22, 244–251.
1. Who or what have been the 3 most important influences
https://doi.org/10.3109/11038128.2015.1020866
on your understanding of right and wrong?
Kanny, E. M., & Slater, D. Y. (2008). Ethical reasoning. In B. A. Boyt
2. What 3 things do you value most, and why? Schell & J. W. Schell (Eds.), Clinical and professional reasoning
3. Name 3 qualities or “virtues” that you think are essential in occupational therapy (pp. 188–208). Philadelphia: Wolters
in living a moral life. Kluwer/Lippincott Williams & Wilkins.
4. Think about a situation in fieldwork or in your job Medicare Benefit Policy Manual. (2018). Chapter 15—Covered med-
that created moral distress and how you handled it (if ical and other health services. Retrieved from https://www.cms
at all) and how you would handle it having read this .gov/Regulations-and-Guidance/Guidance/Manuals/Downloads
chapter. /bp102c15.pdf
5. Complete an ethical analysis of either a case or ethical Nortje, N., & DeJongh, J. (2017). Professionalism—A case for med-
issue relevant to occupational therapy practice. Use Advi- ical education to honour the societal contract. South African
Journal of Occupational Therapy, 47(2), 41–44.
sory Opinions in the Reference Guide to the Occupational
Pearson, S. D., Sabin, J. E., & Emanuel, E. J. (2003). No margin,
Therapy Code of Ethics (Slater, 2016) as a framework for
no mission: Health-care organizations and the quest for ethical
paper development. excellence. Oxford, UK: Oxford University Press.
Slater, D. Y. (Ed.). (2016). Reference guide to the Occupational
Therapy Code of Ethics (2015 ed.). Bethesda, MD: AOTA Press.
Slater, D. Y., & Brandt, L. C. (2009). Combating moral distress.
OT Practice, 14(2), 13–18.
CHAPTER
Ethics in Fieldwork
Joanne Phillips Estes, PhD, OTR/L, and Leslie E. Bennett, OTD, OTR/L 58
LEARNING OBJECTIVES
■ Describe internal and external contextual factors that could affect the provision of fieldwork education from an occu-
pational therapy manager’s perspective;
■ Explain an occupational therapy manager’s ethical responsibilities to key stakeholders involved in a fieldwork
education program, including the organization, clients, department, staff, academic institutions, and students; and
■ Discuss ethical issues that may arise as related to overseeing a fieldwork education program from the lens of an
occupational therapy manager and cite principles of the Occupational Therapy Code of Ethics (American Occupational
Therapy Association, 2015) that may facilitate decision-making related to these issues.

• Competency • Ethical responsibilities • Principles
• Confidentiality • External stakeholders • Privacy
• Duties • Fieldwork • Rights
• Ethical issues • Internal stakeholders • Unethical
OVERVIEW occupational therapy managers must critically analyze ethical
O
ne integral and vital aspect of occupational therapy edu- implications stemming from multiple factions to make these
cation is the fieldwork component, which includes work determinations.
done in the field by students to gain practical, hands-on This chapter describes ethical dynamics related to field-
experience. Fieldwork provides students an opportunity to de- work education through the lens of occupational therapy
velop professional competencies in a practice setting under the managers. For managers, decision making related to fieldwork
supervision of qualified fieldwork educators (FWEds). Fieldwork education is influenced by the need to meet duties, that is, pro-
education propels the future of the profession and offers several fessional, moral, and legal responsibilities to multiple internal
potential benefits to health care recipients, students, FWEds, de- and external stakeholders. Internal stakeholders include the
partments, and organizations (American Occupational Therapy employer/organization, department, staff, and perhaps most
Association [AOTA], 2016). Benefits of and challenges to pro- importantly, the care recipients. External stakeholders in-
viding fieldwork education are well documented (Barton et al., clude third-party payers, academic institutions, fieldwork stu-
2013; Evenson et al., 2015; Varland et al., 2017; Zeman & Tickle- dents, and the profession of occupational therapy.
Degnen, 2016). Perhaps the challenges outweigh the benefits, as Managers must meet ethical responsibilities, or obliga-
there is currently a national shortage of fieldwork education sites tions to uphold professional, ethical, and legal standards,
(Stutz-Tanenbaum et al., 2015; Swinth, 2016). to all stakeholders within the context of dynamic and ever-
Occupational therapy managers are uniquely positioned to changing delivery systems. Ethical issues, situations that can
determine the feasibility of providing appropriate fieldwork arise that require decision making leading to morally correct
education opportunities at their organizations. Although courses of action, can arise when duties conflict and managers
their desire to support fieldwork education may be strong, must make difficult decisions.
https://doi.org/10.7139/2019.978-1-56900-592-7.058
547
CHAPTER
Ethics in Fieldwork
Joanne Phillips Estes, PhD, OTR/L, and Leslie E. Bennett, OTD, OTR/L 58
LEARNING OBJECTIVES
■ Describe internal and external contextual factors that could affect the provision of fieldwork education from an occu-
pational therapy manager’s perspective;
■ Explain an occupational therapy manager’s ethical responsibilities to key stakeholders involved in a fieldwork
education program, including the organization, clients, department, staff, academic institutions, and students; and
■ Discuss ethical issues that may arise as related to overseeing a fieldwork education program from the lens of an
occupational therapy manager and cite principles of the Occupational Therapy Code of Ethics (American Occupational
Therapy Association, 2015) that may facilitate decision-making related to these issues.

• Competency • Ethical responsibilities • Principles
• Confidentiality • External stakeholders • Privacy
• Duties • Fieldwork • Rights
• Ethical issues • Internal stakeholders • Unethical
OVERVIEW occupational therapy managers must critically analyze ethical
O
ne integral and vital aspect of occupational therapy edu- implications stemming from multiple factions to make these
cation is the fieldwork component, which includes work determinations.
done in the field by students to gain practical, hands-on This chapter describes ethical dynamics related to field-
experience. Fieldwork provides students an opportunity to de- work education through the lens of occupational therapy
velop professional competencies in a practice setting under the managers. For managers, decision making related to fieldwork
supervision of qualified fieldwork educators (FWEds). Fieldwork education is influenced by the need to meet duties, that is, pro-
education propels the future of the profession and offers several fessional, moral, and legal responsibilities to multiple internal
potential benefits to health care recipients, students, FWEds, de- and external stakeholders. Internal stakeholders include the
partments, and organizations (American Occupational Therapy employer/organization, department, staff, and perhaps most
Association [AOTA], 2016). Benefits of and challenges to pro- importantly, the care recipients. External stakeholders in-
viding fieldwork education are well documented (Barton et al., clude third-party payers, academic institutions, fieldwork stu-
2013; Evenson et al., 2015; Varland et al., 2017; Zeman & Tickle- dents, and the profession of occupational therapy.
Degnen, 2016). Perhaps the challenges outweigh the benefits, as Managers must meet ethical responsibilities, or obliga-
there is currently a national shortage of fieldwork education sites tions to uphold professional, ethical, and legal standards,
(Stutz-Tanenbaum et al., 2015; Swinth, 2016). to all stakeholders within the context of dynamic and ever-
Occupational therapy managers are uniquely positioned to changing delivery systems. Ethical issues, situations that can
determine the feasibility of providing appropriate fieldwork arise that require decision making leading to morally correct
education opportunities at their organizations. Although courses of action, can arise when duties conflict and managers
their desire to support fieldwork education may be strong, must make difficult decisions.
https://doi.org/10.7139/2019.978-1-56900-592-7.058
547
In this chapter, we discuss essential considerations related Frequent turnover, entry-level occupational therapy prac-
to these internal and external contextual realities and ethical titioners, and absences due to maternity leave or other health-
issues occupational therapy managers may face as they navi- related issues can affect the staffing of a department. Because
gate these contextual forces. many fieldwork sites will request that a student be hosted up
to 1 or 2 years from the actual fieldwork placement, making
sure there is adequate staffing at that time is essential.
ESSENTIAL CONSIDERATIONS Beyond having sufficient staffing to host students, other
Occupational therapy managers have a professional and ethi- factors—both positive and negative—affect occupational
cal responsibility to promote and advocate for fieldwork edu- therapy practitioners’ willingness to supervise fieldwork stu-
cation. They play an essential role in promoting career growth dents (Varland et al., 2017). Obtaining continuing education
and development, which includes accepting fieldwork stu- units, quality access to educational resources, job responsi-
dents (Politano, 2013). However, a manager’s role in this pro- bilities and caseload, and the fear of failing a student are all
cess is multidimensional and complex. Occupational therapy considerations. Burnout, workplace stress, and compassion
managers must function as both advocates and mentors. In fatigue can affect staffing and the ability to host fieldwork
addition, they serve as a proxy for the health care organization students. Occupational therapy managers must acknowledge
they work for and the practitioners who work under them. and take these factors into consideration when examining the
Clients being served and the payers reimbursing for ser- impact that having a fieldwork student may have.
vices rendered also have stakes in decisions made by man-
agers. Without support from all dimensions, occupational Department
therapy managers cannot successfully hope to host fieldwork
Occupational therapy managers must also consider the phys-
students in an ethically sound and professional environment
ical space and available resources of their department. Is the
that facilitates a career-oriented culture of work (Politano,
department physically big enough to host students? Manag-
2013). Managers must examine both the internal and exter-
ers need to examine their equipment and the resources avail-
nal contextual factors that affect their work environment that
able to students to decide if they can provide an adequate
can help to foster or hinder fieldwork success.
fieldwork experience. Being able to provide access to office
space and electronic documentation systems are all essential
Internal Factors considerations. Last, is the practice environment a traditional
or nontraditional practice setting? The emergence of specialty
Client
practice areas outside of traditional settings can influence the
Choosing to accept fieldwork students can affect the health ability to take on a fieldwork student. Consideration for the
and safety of the clients for whom an occupational ther- site location as well as the practitioners’ hours at the site must
apy manager has agreed to provide care. Privacy and safety be examined to see if they can meet the requirements of the
are 2 essential considerations when examining fieldwork fieldwork placement.
programs. Ensuring that the individual’s right to privacy is
protected and that all are safe from harm are obligations that Organization and payers
an occupational therapy manager must meet at the organiza-
tional and professional levels. Organizational and systemic constraints also affect fieldwork
Making sure that fieldwork students abide by guidelines of education experiences. Balancing student needs with client
the Health Insurance Portability and Accountability Act of priorities and the requirements of health care organizations
1996 (HIPAA; P. L. 104–191) is critical, especially in a grow- can be difficult. Competing obligations can affect how well a
ing technological world. Maintaining privacy both in the department can handle the additional stress of fieldwork ed-
facility and outside of it is important. In addition, students ucation. Organizational versus professional standards must
must demonstrate sufficient awareness of safety guidelines be considered in the decision-making process. Occupational
when working with clients. therapy managers have as much responsibility to adhere to
HIPAA standards, which protect their clients, as they do to
the Occupational Therapy Code of Ethics (2015) (hereinafter,
Staffing
the Code; AOTA, 2015). Local and national fiscal conditions,
Occupational therapy managers must ensure that the de- business structures, and current and future laws all support
partment they oversee is prepared to handle the addition of or inhibit a department’s ability to participate in fieldwork
fieldwork students. Sufficient staffing to supervise students is education (Politano, 2013).
essential. More importantly, making sure that staff members One of the fastest growing professional issues in oc-
have adequate professional experience must be part of the cupational therapy practice concerns rising productivity
decision-making process. Fieldwork training courses help standards. Excessive workload demands with less time for
prepare occupational therapy practitioners for the role of documentation and other essential job functions can af-
FWEd; however, departmental budgets affect the extent to fect the ability to take on students. Occupational therapy
which a manager can support such training. managers must examine how the addition of supervisory
CHAPTER 58. Ethics in Fieldwork 549
time on an occupational therapy practitioner’s daily sched- AOTA calls for occupational therapy managers and prac-
ule will affect the day’s outcomes and numbers (Wressle & titioners to become career conscious, linking education, re-
Samuelsson, 2014). search, and practice (Burke & Harvison, 2015). Occupational
Changing billing and reimbursement regulations also af- therapy managers need to begin to think creatively about how
fect practice. Each payer source has its own rules and reg- they can use fieldwork students to benefit their organization
ulations. Some third-party payers will not reimburse for as well as the profession. Currently, AOTA is examining its
services provided under a student. Ineffective departmental fieldwork processes and examining how to continue making
and organizational processes can affect fieldwork education fieldwork education an essential part of occupational therapy
as well as resource limitations and lack of services provided education (Burke & Harvison, 2015). Turning to less tradi-
by a site. tional practice settings and grouping students are just some
of the ideas being presented to help make fieldwork experi-
ences a little easier.
External Factors
As the profession continues to evolve in this ever-changing
Academic institution health care climate, occupational therapy managers must re-
flect on fieldwork education and how they can use this expe-
Occupational therapy managers must consider the academic rience to benefit both their practitioners and their students.
programs and institutions that look to them to host students. Management techniques to consider for successful fieldwork
Aligning their facility’s fieldwork program with specific aca- placement should include open communication and trans-
demic program requirements can be challenging. While all parency, as well as boundary setting. Occupational therapy
programs must meet the Accreditation Council for Occupa- managers need to be able to negotiate and advocate for occu-
tional Therapy Education (ACOTE®) accreditation standards pational therapy within their organization while maintaining
(ACOTE, 2018), each program’s curriculum is different, and current policies and regulations. They must be open-minded
goals and assignments will differ from institution to insti- and flexible when looking at fieldwork education. Appendix
tution. Occupational therapy managers stay on top of these 58.A provides a SWOT (strengths, weaknesses, opportunities,
contextual features and how each can affect the day-to-day threats) analysis activity for managers to use to determine their
functions of their departments. Without support from any of organization’s ability to participate in fieldwork education.
these key stakeholders, the ability to host fieldwork students
can be jeopardized.
Review Questions
Students 1. What factors affect an occupational therapy manager’s
decision making when it comes to hosting fieldwork
Students must demonstrate basic-level competencies (i.e.,
students?
skill sets) when they prepare to go into a fieldwork setting.
a. Staffing
Adequate knowledge to handle job duties at various sites is
b. Organizational and payer requirements
essential, which requires close collaboration and communi-
c. Academic institutions
cation with the organization and academic institution. A col-
d. All of the above
laborative effort between the student and the host facility is
2. How can you align your facility’s fieldwork program with
necessary to maximize the learning experience. A facility’s
an academic program that wishes to send a student to you
ability to provide an adequate experiential learning envi-
next year?
ronment, combined with a student’s readiness to learn, is
3. How do organizational ethics influence your ability to
important (Grenier, 2015).
host fieldwork students (positively or negatively)?
Vision 2025 and the Future of Fieldwork

Vision 2025, established by AOTA, states that “Occupational
therapy maximizes health, well-being, and quality of life for
all people, populations, and communities through effective Occupational therapy managers must meet their responsi-
solutions that facilitate participation in everyday living” bilities to all stakeholders in accordance with high ethical
(AOTA, 2017, p. 1). The guideposts for practice include ac- standards. Ultimately, occupational therapy managers must
cessible services that are client centered and collaborative determine whether they can provide a legitimate, hands-on
cost-efficient services that work with clients and the health educational experience for fieldwork students while meeting
care organizations to produce effective outcomes. Effective ethical responsibilities to clients, their employment organi-
occupational therapy services will be “evidence based, client zation, staff, academic institutions, and fieldwork students.
centered, and cost-effective” (AOTA, 2017, p. 1). Last, occu- Managers will face issues and challenges as they strive to si-
pational therapy will be a recognized leader in the health multaneously meet responsibilities to all these stakeholders
care domain, influencing practice and the policies that guide and must effectively resolve tensions and situations that
practice (AOTA, 2017, p. 1). arise as duties to one faction clash with duties to others.
A description of potential issues follows and, where relevant, policies related to reimbursing services provided by fi eldwork
specific Principles of the Code (AOTA, 2015) that offer guid- students will prevent instances of fraudulent billing practices.
ance are identified. Deceptive billing practices are also unethical. Billing charges
must be submitted legally (Principle 4.M) and accurately rep-
Client Level resent actual services provided (Principle 5.B). Billing for ser-
vices provided by students as if those services were provided
An occupational therapy manager’s primary duties are to by staff occupational therapy practitioners is unethical and
clients in the form of protecting their safety (Principle 2.A) illegal.
and advocating for their well-being by respecting their
rights (Principles 3.A, 3.B, 3.H) and promoting high qual- Department and Staff
ity and best practice interventions (Principle 1.C). Ensuring
that fieldwork students receive appropriate levels of super- Staffing management
vision (Principle 4.H) and are determined to be competent
Ethical issues arise for occupational therapy managers as
(Principle 1.D) in skills before they are allowed to provide
they consider the costs and benefits of accepting fieldwork
hands-on interactions with care recipients is of utmost
students in terms of manpower and staff management and re-
importance. Issues may arise when a manager is tempted
source consideration. Although managers may desire to host
to have a Level II fieldwork student fill staffing gaps and
fieldwork students in support of their profession, the decision
meet productivity standards when the student has not yet
to do so includes positive and negative ramifications for staff
adequately demonstrated competencies. One might view
occupational therapy practitioners. Despite the benefits asso-
this scenario as the client benefiting from receiving some
ciated with serving as an FWEd, at times a manager may be
intervention from the student as opposed to receiving no
forced to deny staff opportunities for supervising students to
treatment. However, ethical standards deem this unaccept-
avoid conflicts of commitment (Principle 6.C) when staffing
able when doing so places client safety and well-being at risk
levels are low and the manager determines they are unable
(Principle 2.A).
to provide a legitimate hands-on learning experience for the
Fieldwork students must adhere to the same standards as
students. On the other hand, if staffing levels are such that
staff in protecting client rights such as those related to privacy
a FWEd is allotted time to provide appropriate supervi-
and confidentiality (Principle 3.H). Implementing electronic
sion (Principle 4.H) and able to simultaneously meet other
medical record systems makes accessing any person’s medi-
responsibilities (e.g., realistic productivity expectations,
cal record easy. As with staff, Level II fieldwork students are
documentation standards), then the FWEd and department
allowed to access only those records of individuals on their
may experience the many benefits of providing fieldwork
caseload on that day. And depending on facility policy, Level
education described earlier.
I fieldwork students may or may not be authorized to view
client records. Students who access records without authori-
zation violate HIPAA standards (Principle 3.H). Managers in Resource implications
these cases must respond in accordance with facility policies Occupational therapy managers may need to make decisions
and procedures related to privacy breaches. This may involve related to accepting fieldwork students under circumstances
making difficult decisions related to determining who (i.e., in which the facility lacks resources necessary for providing
FWEd or student) should be held responsible and sanctioned an appropriate educational experience. Lack of resources,
for the violation. such as competent FWEds (Principles 1.D, 1.E), evaluation
and treatment, supplies and equipment, or spaces for private
Organization and Payers supervisory meetings, could negatively affect the quality of a
student’s experience on a continuum ranging from minimally
Ethical issues may arise when organizational values differ to significantly.
from employee values. Occupational therapy managers may Considering the shortage of appropriate fieldwork sites,
want to meet their professional duty to support fieldwork occupational therapy managers must determine whether
education at their facility whereas their employer may not. the benefits of providing fieldwork education opportunities
Conversely, managers may determine that they are unable (e.g., students are able to complete fieldwork education re-
to provide an appropriate fieldwork experience for students quirements) outweigh the costs (e.g., students complete a
but are directed by higher level administrators to accept field- subquality fieldwork educational experience that may affect
work students as a way to deal with staffing shortages or to their ability to pass the National Board for Certification of
increase productivity and revenue. In these situations, man- Occupational Therapy® exam). This decision must be based on
agers should advocate for their profession by working toward critical analysis and sound ethical reasoning (Principle 2.H).
a resolution with their employers (Principle 4.L).
Occupational therapy managers need to be knowledge-
Competent FWEds
able about current laws and regulations related to billing and
collecting fees for services provided by fieldwork students Occupational therapy managers are responsible for ensur-
(Principle 4.E). Knowledge of individual third-party payer ing that staff serving as FWEds are competent to provide
appropriate learning experiences for students and must pro- Students may choose to reveal the presence of a health
mote sound ethical practices (Principles 1.D, 4.G). FWEds condition that qualifies them to receive accommodations
are ethically bound to provide ongoing feedback and fair and during the performance of their duties. For example, a field-
objective appraisals of student performance (Principles 4.H, work student at a rehabilitation facility may present with a
5.G). Failure to do so is especially problematic in instances physical condition that prevents her from lifting over 10 lbs.
where student performance is poor and the student is in dan- and is allotted accommodations under the Americans With
ger of not meeting requirements for successful completion of Disabilities Act of 1990 (ADA; P. L. 101–336). The facility
the fieldwork rotation. manager is legally and ethically (Principle 4.E) bound to pro-
Ethical issues can arise if a student is not provided clear vide the student with a learning experience that incorporates
and objective ongoing feedback and is surprised when in- the accommodations without compromising the quality of
formed that they will fail the rotation. In such an instance, the student’s experience.
an FWEd may be tempted to compensate for lack of feedback
by passing a student who otherwise did not demonstrate Students’ rights
minimum levels of competency. However, doing so is un-
ethical (Principle 5.G) and may allow future practice by an Occupational therapy managers are ethically bound to pro-
incompetent occupational therapy practitioner and place the tect students’ rights the same way they would staff rights.
safety and well-being of clients at risk. Deciding to fail a stu- Issues may arise related to students’ rights concerning con-
dent can be an emotionally difficult one for an FWEd, and fidentiality and receiving an appropriate learning experi-
this decision may be further complicated if a student threat- ence. The Family Educational Rights and Privacy Act of
ens to sue the facility for failure to provide appropriate su- 1974 (FERPA; P. L. 93–380) protects the confidentiality of
pervision. student information, including that related to student field-
work performance. FWEds are ethically bound to share in-
formation about student performance only with those who
Academic Institution and Student have a legitimate need to know (Principle 3.H). That is,
Accepting students venting frustrations related to supervising a student or stu-
dent performance with peers, interdisciplinary team mem-
As noted previously, accepting fieldwork students brings bers, friends, or academic site faculty is illegal and unethical
with it an ethical responsibility to provide a legitimate, (Principles 3.H, 6.G). However, sharing information about a
hands-on educational experience that meets expectations of student’s performance (poor or otherwise) with one’s man-
the academic institution (Principle 5.F). If an occupational ager and the academic fieldwork coordinator to seek assis-
therapy manager determines that circumstances are such tance and support is an ethically responsible action.
that the institution is unable to provide this experience, Students have the right to receive an appropriate and le-
they may be forced to cancel a student rotation. While doing gitimate fieldwork education experience that meets current
so may be in a student’s best interest, canceling a fieldwork ACOTE (2018) Standards and as documented in fieldwork
rotation requires an academic institution to find another contract and site fieldwork manual. As mentioned earlier, po-
rotation that may prove difficult in times of fieldwork site sitioning Level II fieldwork students to replace practitioners
shortages. In these instances, an academic institution may functioning in situations of inadequate staffing or lack of
be willing to send a student to a suboptimal facility so that availability of a competent FWEd is unethical (Principle 1.D).
the student can complete educational requirements and Blurring the lines between student role and staff responsibil-
graduate in a timely manner. Facility managers are ethically ities equates to the exploitation of the student to meet facility
bound to agree to accept students only in circumstances needs (Principle 2.I).
under which the students will be provided a legitimate
experience.
Review Questions
1. Which of the following statutes prohibits an FWEd’s
Students with disabilities
inappropriate sharing of information about student
Occupational therapy managers are expected to adhere to performance?
legal and ethical standards (Principle 4.E) when working a. ADA
with students with disabilities. Academic institution person- b. HIPAA
nel are restricted from disclosing that a student has an oth- c. FERPA
erwise invisible disability without the student’s permission. d. IDEA
And students have the right to choose whether to reveal this 2. An FWEd approaches her facility manager and explains
information or to keep personal health information con- that a current Level II fieldwork student’s poor perfor-
fidential. If a student decides to not reveal personal health mance may be due to a suspected learning disability. Nei-
information, a manager must respect the student’s decision ther the student nor the academic institution informed
and not try to extract further information from the student the facility that this student has a disability. The FWEd
or academic institution personnel. feels she can better support the student if the student
reveals her condition so that accommodations can be im-

plemented and asks the manager for assistance. Which
SUMMARY
of the following represents the manager’s most ethically This chapter examined the internal and external contextual
sound course of action? factors that could affect a facility’s ability to provide adequate
a. Ask the student if she has a learning disability educational experiences for fieldwork programs from the
b. Discuss her concerns with the academic institution, perspective of the occupational therapy manager. As part of
and ask for confirmation of the student’s diagnosis their ethical responsibilities, occupational therapy manag-
c. Instruct the FWEd to implement accommodations to ers must consider the impact on key stakeholders involved
facilitate the student’s successful performance in fieldwork education programs, including the organiza-
d. Do nothing until the student discloses that she has a tion, clients, department, staff, academic institutions, and the
learning disability students that they serve.
3. Samma is a Level II fieldwork student who is 3 weeks away Ethical issues will arise, and the occupational therapy
from successfully completing her first rotation at Happy manager’s ability to negotiate these situations and make
Valley skilled nursing facility. Samma’s performance has sound decisions is essential (see Case Example 58.1 and
been outstanding, and clients and staff alike would like her Appendix 58.B). The ethical principles that guide the occu-
to work at Happy Valley after she becomes licensed to prac- pational therapy profession as written in the Code (AOTA,
tice. Upon arriving at Happy Valley on a Monday, Jalen 2015) must serve as a key resource for managers. Serving
(the occupational therapy manager) approaches Samma as both a proxy for the health care organizations that they
and explains that 2 of the 3 staff occupational therapy prac- work for and the academic institutions they contract with re-
titioners (Blaine and J. P., Samma’s FWEd) have serious quires that managers have knowledge of the issues that affect
cases of flu and are unable to work the rest of the week. fieldwork education. Examining all of the contextual factors
Jalen asks Samma to treat all of her own clients and pick up involved and acknowledging any ethical implications of host-
all of J. P.’s and half of Blaine’s caseload. Jalen’s request is ing a student are essential.
a. Ethically sound because the facility residents will This chapter provided a framework for decision making
receive care. that occupational therapy managers can use when looking at
b. Unethical because Samma is not qualified to meet developing fieldwork education programs. It is important to
staff expectations. consider all of the stakeholders involved. Fieldwork education
c. Ethically sound because Samma has demonstrated comes with a unique set of challenges but can also be very
competence. rewarding. A risk–benefit analysis of hosting fieldwork edu-
d. Unethical because the caseload is too high to provide cation programs is an essential component for occupational
quality treatments for all. therapy managers. ❖
CASE EXAMPLE 58.1. Sally: Level II Fieldwork
Sally has just started her first Level II fieldwork placement at a local outpatient hand center. Although she had taken a physical agent modalities
(PAMs) course during the didactic portion of her education, she has not had any hands-on experience using PAMs for more than a year. She is in
Week 2 of her placement when her supervisor, Randy, asks Sally if she can place hot packs on a patient while he completes a treatment session
with a patient. Sally and Randy have not met to discuss and review protocols or contraindications for safe application of PAMs at this point.
Sally proceeds to set up the hot pack as her supervisor instructed; however, she is unsure about how many towel layers she should add. The
patient, Vera, is an 86-year-old woman with a history of osteoarthritis. She is frail and has very thin skin with poor sensation. Without asking Randy
about the number of layers of towels to provide, Sally applies the hot packs to Vera and walks away to observe Randy as he completes treatment
with the prior patient.
Twenty minutes pass since Sally applied the hot packs, and she has not yet checked Vera’s skin integrity and tolerance for the heat. On removing
the hot packs, Randy instantly notices blistered and reddened skin where the hot packs were placed. Randy asks Sally if she checked Vera during
the course of the treatment, and Sally replied no because Vera did not voice complaints. Randy also noted that Sally applied only 1 layer of towels
between Vera’s hand and the hot pack.
Review Questions
1. List and explain the principles of the Code (AOTA, 2015) relevant to the above scenario.
2. What are the occupational therapy manager’s ethical responsibilities in the above scenario?
3. From an ethical lens, explain what the occupational therapy manager, Randy, and Sally should have done differently to prevent Vera’s injury
from occurring.
ACOTE STANDARDS Burke, J. P., & Harvison, N. (2015). Guest Editorial—Evolution

of a revolution in occupational therapy education. American
This chapter addresses the following ACOTE Standards: Journal of Occupational Therapy, 69(Suppl. 2), 6912170010.
https://doi.org/10.5014/ajot2015.695S01
Evenson, M. E., Roberts, M., Kaldenbert, J., Barnes, M. A., & Ozelie,
■ C.1.3. Fieldwork Objectives R. (2015). National survey of fieldwork educators: Implications
■ C.1.4. Ratio of Fieldwork Educators to Students for occupational therapy education. American Journal of Occupa-
■ C.1.6. Level I and II Fieldwork Memoranda of tional Therapy, 69(Suppl. 2), 6912350020. https://doi.org/10.5014
Understanding /ajot.2015.019265
■ C.1.8. Qualified Level I Fieldwork Supervisors Family Educational Rights and Privacy Act of 1974, Pub. L. 93–380,
■ C.1.9. Level I Fieldwork 20 U.S.C. § 1232g; 34 CFR Part 99.
■ C.1.11. Qualified Level II Fieldwork Supervisors Grenier, M.-L. (2015). Facilitators and barriers to learning in oc-
■ C.1.12. Evaluating the Effectiveness of Supervision cupational therapy fieldwork education: Student perspectives.
■ C.1.13. Level II Fieldwork Supervision American Journal of Occupational Therapy, 69(Suppl. 2),
6912185070. https://doi.org/10.5014/ajot.2015.015180
■ C.1.15. Evaluation of Student Performance on Level II
Health Insurance Portability and Accountability Act of 1996,
Fieldwork.
Pub. L. 104–191, 45 C.F.R. § 264(a)–(b).
Politano, C. (2013). It’s not just a job: Fostering a career-oriented
occupational therapy department. Administration and Manage-
REFERENCES ment Special Interest Section Quarterly, 29, 1–4.
Accreditation Council for Occupational Therapy Education. (2018). 2018 Stutz-Tanenbaum, P., Hanson, D. J., Koski, J., & Greene, D. (2015).
Accreditation Council for Occupational Therapy Education (ACOTE) Exploring the complexity of the academic fieldwork coordinator
standards and interpretive guide. American Journal of Occupational role. Occupational Therapy in Healthcare, 29, 139–152. https://
Therapy, 72, 7212410005. https://doi.org/10.5014/ajot.2018.72S217 doi.org/10.3109/07380577.2015.1017897
American Occupational Therapy Association. (2015). Occupational Swinth, Y. (2016). Why should you take a fieldwork student? Journal of
therapy code of ethics (2015). American Journal of Occupational Occupational Therapy, Schools, and Early Intervention, 9, 223–225.
Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot https://doi.org/10.1080/19411243.2016.1212536
.2015.696S03 Varland, J., Cardell, E., Koski, J., & McFadden, M. (2017). Factors
American Occupational Therapy Association. (2016). Occupational influencing occupational therapists’ decision to supervise field-
therapy fieldwork education: Value and purpose. American Jour- work students. Occupational Therapy in Health Care, 31, 238–254.
nal of Occupational Therapy, 70(Suppl. 2), 7012410060. https:// https://doi.org/10.1080/07380577.2017.1328631
doi.org/10.5014/ajot.2016.706S06 Wressle, E., & Samuelsson, K. (2014). High job demands and lack of
American Occupational Therapy Association. (2017). Vision 2025. time: A future challenge in occupational therapy. Scandinavian
American Journal of Occupational Therapy, 71, 7103420010. Journal of Occupational Therapy, 21, 421–428. https://doi.org/10
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Americans With Disabilities Act of 1990, Pub. L. 101–336, 42 Zeman, E. A., & Tickle-Degnen, L. (2016). Professional quality of
U.S.C.A. § 12101. life in occupational therapists: Navigating the dual role of field-
Barton, R., Corban, A., Herrli-Warner, L., McClain, E., Riehle, D., & work educator and practitioner. American Journal of Occupa-
Tinner, E. (2013). Role strain in occupational therapy fieldwork tional Therapy, 70(Suppl. 1), 7011505148. https://doi.org/10.5014
educators. Work, 44, 317–328. https://doi.org/10.3223/WOR-121508 /ajot.2016.70S1-PO4123
APPENDIX 58.A. SWOT ANALYSIS APPENDIX 58.B. ROLE-PLAY ACTIVITY

TO EXAMINE AN ORGANIZATION’S Break students into groups of 5 or 6 and provide them the fol-
ABILITY TO PARTICIPATE IN lowing role-play scenario. Two students (1 in role of manager,
FIELDWORK EDUCATION 1 in role of fieldwork student) will role play a discussion based
on facts included in the scenario with the other students ob-
Directions: Often health care administrators and managers
serving the discussion. Following the role-play, students will
use SWOT (strengths, weaknesses, opportunities, threats)
reflect by addressing the following questions:
matrix grids to analyze the strengths and weaknesses of
A. Describe the ethical issues that emerged during the
programs within their organization. You will use this SWOT
discussion.
analysis to examine where your organization stands currently
B. Which principles from the Occupational Therapy
on taking on fieldwork students, and where you would like to
Code of Ethics (AOTA, 2015) would support the occu-
see it go for the future. Strengths and weakness are internal to
pational therapy manager’s perspective?
your organization and can be controlled, whereas opportuni-
C. Which principles from the Occupational Therapy
ties and threats are generally uncontrollable external forces
Code of Ethics (AOTA, 2015) would support the stu-
that affect your organization. Use the following questions to
dent’s perspective?
guide you and fill in the SWOT matrix, analyzing your fa-
D. Brainstorm how this issue might have been prevented
cility’s ability to ethically participate in fieldwork education:
from both the occupational therapy manager’s and
Strengths student’s perspective.
■ What does the organization do well? Scenario. At 11 weeks into Kim Lee’s 3rd Level II field-
■ What unique resources can you draw on? work rotation, Isa (his FWEd) informs Kim Lee that it is
■ What do outside providers and educational institutions not possible for him to pass this rotation due to serious con-
see as your strengths? cerns related to safety concerns and to his lack of ability to
complete documentation. Angry, Kim Lee storms into the
Weaknesses
office of Becky, the department manager, and asks to meet
■ What could you improve? with her about the unfair way he has been treated by Isa over
■ What resources are you lacking? the past 11 weeks. Kim Lee goes on to state that he is being
■ What are others likely to see as your weaknesses? terminated unfairly because Isa has failed to provide ade-
Opportunities quate supervision “since Day 1” and he further accused Isa of
■ What opportunities for fieldwork education are open discriminating against him because he is Asian and a male.
to you?
■ What advantages can you take from participating in field-
work education?
■ How can you turn your strengths into opportunities?
Threats
■ What are the threats you perceive from participating in
fieldwork education?
■ What are your competitors doing?
■ What threats do your weaknesses expose you to?
Strengths Weaknesses
Opportunities Threats
CHAPTER
Ethics for OTA Managers
Callie Schwartzkopf, OTD, OT/L, and Melissa Tilton, OTA, BS, COTA, ROH 59
LEARNING OBJECTIVES
■ Understand ethical and moral behaviors unique to occupational therapy assistants (OTAs) serving in the role of
manager,
■ Identify challenges OTA managers may encounter when promoting ethical and moral behavior within the workplace,
■ Specify how ethical principles may come into conflict when working as an OTA manager, and
■ Apply the Occupational Therapy Code of Ethics (AOTA, 2015b) to common ethical situations encountered by OTA
managers.

• Beneficence • Ethics • Moral distress
• Ethical behavior • Ethics rounds • Veracity
• Ethical environment • Fidelity
OVERVIEW in ethical behavior in the health care setting but also to pro-
mote it. Ethical behavior involves actions that are believed to
M
anagers in health care must fulfill many roles, includ- be good. This behavior can be characterized as honesty, integ-
ing figurehead, leader, monitor, disseminator, spokes- rity, and fairness for all people. Employees’ ethical behaviors
person, negotiator, decision maker, and entrepreneur. reflect on an organization’s character and reputation. OTAs
While fulfilling these roles, the manager must do so by acting are required to work clinically under the supervision of an
as a moral agent of the health care organization. Ethical situ- occupational therapist (OT). In contrast, when OTAs serve in
ations are even more at the forefront with the ever-changing the role of manager, their position as a leader affects employee
health care environment and the pressure to work more effi- morale, behavior, and loyalty. Therefore, just like all manag-
ciently to deliver high-quality care. Managers have a respon- ers, OTAs who are functioning in this role must engage in
sibility to adhere to and promote ethical behavior. They must ethical behaviors and express and encourage employees to
create an environment that fosters ethical behavior. This chap- maintain high professional standards.
ter explores the concepts of ethical behaviors within the role
of occupational therapy assistant (OTA) managers and how to
promote high ethical standards in the workplace, while bal- Creating an Ethical and Moral Environment
ancing often divergent roles in practice and administration. Ethical conflicts cannot be prevented in today’s complex prac-
tice environments; therefore, managers must create an ethical
atmosphere. An ethical environment is one where ethical
ESSENTIAL CONSIDERATIONS principles and standards in which a health care team operates
Ethics is “the discipline dealing with what is good and bad and are inherent, demonstrated through acts of fairness, com-
with moral duty” (Merriam-Webster, n.d., para. 1). Occupa- passion, and integrity. Examples of an ethical environment
tional therapy managers have an obligation not only to engage include being accountable, focusing on quality and detail,
https://doi.org/10.7139/2019.978-1-56900-592-7.059
555
CHAPTER
Ethics for OTA Managers
Callie Schwartzkopf, OTD, OT/L, and Melissa Tilton, OTA, BS, COTA, ROH 59
LEARNING OBJECTIVES
■ Understand ethical and moral behaviors unique to occupational therapy assistants (OTAs) serving in the role of
manager,
■ Identify challenges OTA managers may encounter when promoting ethical and moral behavior within the workplace,
■ Specify how ethical principles may come into conflict when working as an OTA manager, and
■ Apply the Occupational Therapy Code of Ethics (AOTA, 2015b) to common ethical situations encountered by OTA
managers.

• Beneficence • Ethics • Moral distress
• Ethical behavior • Ethics rounds • Veracity
• Ethical environment • Fidelity
OVERVIEW in ethical behavior in the health care setting but also to pro-
mote it. Ethical behavior involves actions that are believed to
M
anagers in health care must fulfill many roles, includ- be good. This behavior can be characterized as honesty, integ-
ing figurehead, leader, monitor, disseminator, spokes- rity, and fairness for all people. Employees’ ethical behaviors
person, negotiator, decision maker, and entrepreneur. reflect on an organization’s character and reputation. OTAs
While fulfilling these roles, the manager must do so by acting are required to work clinically under the supervision of an
as a moral agent of the health care organization. Ethical situ- occupational therapist (OT). In contrast, when OTAs serve in
ations are even more at the forefront with the ever-changing the role of manager, their position as a leader affects employee
health care environment and the pressure to work more effi- morale, behavior, and loyalty. Therefore, just like all manag-
ciently to deliver high-quality care. Managers have a respon- ers, OTAs who are functioning in this role must engage in
sibility to adhere to and promote ethical behavior. They must ethical behaviors and express and encourage employees to
create an environment that fosters ethical behavior. This chap- maintain high professional standards.
ter explores the concepts of ethical behaviors within the role
of occupational therapy assistant (OTA) managers and how to
promote high ethical standards in the workplace, while bal- Creating an Ethical and Moral Environment
ancing often divergent roles in practice and administration. Ethical conflicts cannot be prevented in today’s complex prac-
tice environments; therefore, managers must create an ethical
atmosphere. An ethical environment is one where ethical
ESSENTIAL CONSIDERATIONS principles and standards in which a health care team operates
Ethics is “the discipline dealing with what is good and bad and are inherent, demonstrated through acts of fairness, com-
with moral duty” (Merriam-Webster, n.d., para. 1). Occupa- passion, and integrity. Examples of an ethical environment
tional therapy managers have an obligation not only to engage include being accountable, focusing on quality and detail,
https://doi.org/10.7139/2019.978-1-56900-592-7.059
555
being reliable, being honest, persevering, and being diligent. of practitioners. Managers should know how to interview
Building an ethical environment may prevent some issues and find candidates with attitudes and characteristics needed
and remove ethical barriers within the health care setting. for the department. OTA managers should develop ethical
Employees need to feel as though a value is placed on ethical questions and scenarios to present during the interview
standards and communication that supports quality of care. for candidate selection. Hiring someone who already can
To create an ethical environment, managers must first act demonstrate good moral reasoning and ethical behavior is
as role models by displaying the highest professional standards the first step to creating this environment. Consider using
and then communicating these standards and values with behavioral interview questions to identify their experiences
employees. Managers have a unique role in that their charac- and the processes they have used previously. Some sample
ter and their chosen actions can greatly influence employees. questions to help guide the interviewing process include
Understanding how a manager’s ethical behavior affects the
■ What do you believe compromises the ethical workplace?
organization and department as a whole is important to being
■ What value do you place on ethics of care?
able to demonstrate a strong ethical tone for all to follow. Set-
■ Tell me about a time that you were challenged ethically,
ting the right ethical environment and structure of processes
and take me through your decision-making process.
and systems of how to handle ethical situations can help prac-
■ How would you handle working for an OTA (if they are
titioners in their decision making and aid in overall respect for
an OT)? (Then explain your role as both the department
the institution and its members. Examples of how a manager
manager and an occupational therapy practitioner.)
can demonstrate high ethical standards include
Managers are ultimately responsible for the department’s
■ Being knowledgeable on scope of practice,
ability to provide competent and ethical services. Managers
■ Demonstrating a high level of clinical competence,
must be comfortable addressing ethical behaviors to allow
■ Submitting timely and accurate documentation, and
better clinical care delivery. Creating ethical policies that fol-
■ Consistently communicating with their employees on how
low the Occupational Therapy Code of Ethics (2015) (American
to respond to ethical situations.
Occupational Therapy Association [AOTA], 2015b) is an im-
Organizations must have managers who create a culture that portant strategy in establishing an ethical culture. Be explicit
values ethical character. Thus, managers need to be mindful and about what is right and what is wrong in giving ethical care.
intentional regarding the values they want reinforced and pro- Great managers establish professional practices that keep the
vide employees with the necessary tools to uphold those values. ethical conversation at the forefront. Managers can incor-
OTA managers can begin creating an ethical environment porate many practical strategies into their daily routines to
with their employees in recruitment, hiring, and retention foster an intentional ethical environment (see Figure 59.1).
FIGURE 59.1. Tip box.
Include ethical values in strategic planning and departmental goals.
Be visible. Managers have a unique position to assist employees in day-to-day interactions

in which ethical situations may arise.
Set time aside in departmental meetings to discuss ethical situations.
Respond quickly and appropriately to minimize the impact of suspected ethical violations.
Mandatory orientation and training that involves ethics when beginning employment, and
continues during annual trainings, helps set the ethical tone for the department.
Have standards, definitions, and expectations easily accessible, as well as processes for
confidential reporting.
Ensure there is a representative from therapy on ethics review boards or committees within the
organizational structure.
CHAPTER 59. Ethics for OTA Managers 557
Applying the Code of Ethics to Common delivery [and] supervision” (AOTA, 2015b, p. 3). Fidelity
Situations Encountered by OTA Managers “respect(s) the practices, competencies, roles, [and] respon-
sibilities of their own and other professions to promote a col-
Balancing fiscal responsibilities with quality care laborative environment reflective of interprofessional teams”
Managers must be sound, fiscally responsible agents within their (AOTA, 2015b, p. 7).
department. Managers should be involved in budgeting and Regularly scheduled, timely performance evaluations are
forecasting for appropriate equipment and supplies. They also also essential in managing people. Managers cannot pro-
must forecast patient census trends, communicate the budget crastinate with regard to completing this task just because
goals and plans with staff, and make cost-effective decisions in it might be uncomfortable to discuss areas that need im-
order to be fiscally responsible. Fiscal responsibility is related provement with an employee, especially when overseeing
to the ethical Principle of Fidelity, which requires occupational their supervising OT. It is not fair to employees to make
therapy managers to “be diligent stewards of human, financial, them wait or to delay their ability to improve on their per-
and material resources of their employers and refrain from formance. Treating all health care providers with dignity,
exploiting resources for personal gain” (AOTA, 2015b, p. 7). respect, honesty with clear explanation, and fairness is cru-
Managers must advocate for their department, especially cial when managing people. The Principle of Veracity applies
if the facility is prioritizing fiscal sustainability, institutional to the manager’s role: “be honest, fair, accurate, respectful,
efficiency, and competitive positioning instead of quality of and timely in gathering and reporting fact-based information
care. Administrators are accountable for making financial regarding employee performance” (AOTA, 2015b, p. 6).
choices that can affect quality. It can be challenging to balance Supervision is required as an OTA, and according to the
budget requirements with quality and ethics standards. To Guidelines for Supervision, Roles, and Responsibilities During
assist with balancing sometimes competing interests, man- the Delivery of Occupational Therapy Services (AOTA, 2014),
agers should know the rules and regulations that govern oc- OTs and OTAs “are equally responsible for developing a
cupational therapy practice. Understanding these rules and collaborative plan for supervision” (p. 2). Supervision needs
regulations is paramount to ethical practice and can aid in to meet the requirements for state regulatory boards, reim-
advocating for more resources or quality of care for patients. bursement systems, and levels of competency. If a new skill
In addition, state licensure or certification laws specifically set is needed, supervision must be modified to meet the level
regulate OTAs. Both managers and practitioners should be of service competency. For example, an experienced OTA
aware of the state laws and regulations for compliance. This is who has not worked in an outpatient setting will need more
true of other health care professionals the OTA may be man- supervision despite their longevity in the field of occupational
aging. Keep in mind that requirements vary between states therapy as a whole. Best practices recommend that the OT
and professions. providing the clinical supervision not be an OT whom the
Changes in regulation occur frequently. Knowing the laws, OTA is supervising from an administrative position. This
rules, and ethical codes is a must, and not knowing cannot be allows for better transparency, smoother conflict resolution,
an excuse. The federal government and the Federal Register and clearer roles for each party. See Case Example 59.1 for an
publish online changes in rules and regulations that affect example of OTA supervision.
occupational therapy practice. Managers could face Medicare
audits and compliance issues associated with documentation,
coding, and billing. Therefore, providers must ensure that
medical record documentation supports the level of service See Chapter 42, “Occupational Therapy Assistants as Managers,” for
reported to a payer. The Principle of Veracity, ensuring one is more information on OTA roles and supervision.
truthful, is pivotal in all documentation, coding, and billing
of services provided. The Code of Ethics requires all occu-
pational therapy practitioners to “bill and collect fees legally Review Questions
and justly in a manner that is fair, reasonable, and commen-
1. Which of the following is not important for a manager’s
surate with services delivered” (AOTA, 2015b, p. 5).
ethical and moral behavior?
a. Have standards, definitions, and expectations easily
Clinical supervision and scope of practice
accessible in the department
One of the most prevalent concerns for OTA managers is b. Be knowledgeable about scope of practice
working within their scope of practice, which is completed c. Let the therapy staff be independent in all ethical
under the supervision of an OT, while still managing a depart- situations that arise
ment. Case Example 59.1 illustrates how this dual role may d. Provide ethical training and orientation
present ethical conflicts. 2. Which of the following is not a characteristic of ethical
The Code of Ethics would be applied to this case in the and moral behavior?
following ways: The Principle of Beneficence “ensure(s) that a. Actions that are believed to be good
all duties delegated to other occupational therapy personnel b. Integrity and truthfulness
are congruent with credentials, qualifications, experience, c. Loyalty and empathy
competency, and scope of practice with respect to service d. Actions that are positively delivered
CASE EXAMPLE 59.1. Becky and Roshni: Daily Life of an OTA Manager
Becky, an OTA, is the department manager. She partners with Roshni, an OT, who is the clinical supervisor. Roshni writes and builds the plan
of care, which the OTA, Becky, would follow based on practice act and role delineation. The roles are stressful because during the day-to-day
treatment, Roshni is the lead and Becky reports to Roshni, while in nontreatment parts of the day, Becky is the lead and Roshni reports to Becky.
It is imperative for stress management that Becky and Roshni ensure that open, timely, and transparent communication is occurring. Their
communication must be intentional around the plan of care and their roles as OT and OTA.
Becky progressed the goal for the client beyond the plan of care and ultimate long-term goal written by Roshni. As an OTA, she has practiced
out of scope of practice and, depending on the scenario, put the client at risk. Roshni needs to address this practice concern and work with Becky
to ensure that the plan of care is always being followed, while discussing practice acts for their specific location. Roshni may also decide to run the
scenario by another manager to discuss how to address and provide support as appropriate. If there is a need for disciplinary action, it will be key to
involve another manager and human resources staff, if needed. As Roshni addresses the scope of practice issue with Becky, he identifies the areas
of concern, the potential outcome issue for the client, and the recommended course of action. Becky and Roshni decide to develop a performance
improvement plan where Roshni monitors the progress made by Becky clinically and where together they collaborate on the plan and agree on
the plan of action for client outcomes.
Becky, the manager, is open and welcomes this feedback, as she does report clinically to Roshni. She realizes this is an excellent example of
role reversal when one person is the OTA manager and also a treating OTA. As a leader, she sees this as an opportunity to demonstrate the correct
course of action for all teammates. These dynamics are best handled by having honest, transparent, and timely conversations. As part of the plan,
Becky requests that a standing, scheduled time be set each week to ensure that she and Roshni have time for supervision and collaboration. This
also allows Roshni to see the clients more regularly and to modify and change the plan of care where needed.
Review Questions
1. What actions could have been set up before an issue came to light to ensure that the issue of practice outside the scope doesn’t occur?
2. As new employees are hired, what could be done to ensure they are aware of the practice act rules and regulations?
3. What resources could Roshni use to support his conversation with Becky?
PRACTICAL APPLICATIONS IN environment, but because the OT and OTA have not estab-
OCCUPATIONAL THERAPY lished open, transparent, and timely communication, the
OT is nervous to push back. The OT agrees to send the client
Dual Relationship home on the date the center administration picks, and the
client has a fall just 2 days after leaving the center.
OTA managers have a duty to be ethical leaders and to
Ethical leadership requires OTA managers to be confident
demonstrate this in practice, which can be difficult when
and competent to speak to the client’s needs to ensure ethical
functioning in dual roles as clinician and administrator. As
provision of treatment. However, at the same time, they must
an OTA manager, this is a crucial juxtaposition. Although an
not “accept delegated responsibilities that go beyond the scope
OTA must clinically work under the supervision of an OT, an
of an occupational therapy assistant” (AOTA, 2014, p. S19),
OTA manager ensures that the right amount of services at the
such as discharge planning, changing plans of care, and mod-
right time is provided. OTA managers, like all occupational
ifying long-term goals, while they are managing a variety of
therapy personnel, are bound by the Occupational Therapy
practitioners. This can be difficult. See Case Example 59.2 for
Code of Ethics, which requires practitioners to advocate for
an illustration of an OTA manager balancing her clinical and
recipients of service (Stover, 2016).
administrative roles.
However, the dual relationship in which OTA managers
often find themselves can create conflict between the OTA
and OT. When an OTA is acting as both a manager and a
Job Descriptions and Roles
clinical subordinate, conflict can arise. Therefore, OTA man-
agers must intentionally work to mitigate conflicts that could In an ethical department, employees should expect a man-
result in decreased objectivity, competence, or effectiveness ager to provide accurate job descriptions and explain the
in performing their professional roles. The OTA must also expectations of the position. In addition, ethical health care
examine the downstream effects to clients who may be ex- managers need to foster a work environment that uses each
ploited or harmed by the dual relationship of the supervisor employee’s skills, roles, and abilities appropriately. This is es-
and assistant clinician, when not handled well. pecially true when an OTA manages a variety of health care
For example, an OTA manager might push for a client professionals, including OTs. To effectively do this, managers
to be discharged because they are receiving pushback from should have daily contact with their employees and work to-
their administration. The OTA inappropriately states to the gether with them to identify their strengths.
OT that the patient needs to be discharged and the OT does One way for employers to maximize employees’ strengths
not agree with this plan. The OT feels the client needs at is through managers. Decades of Gallup research conclude
least 3 more sessions to be able to safely navigate their home that “people who use their strengths every day are 6 times
CASE EXAMPLE 59.2. Lindee: Articulating the Role of an OTA Manager
Lindee, an OTA, begins her new role as a manager in an outpatient clinic. In this role, she is responsible for the clinic’s day-to-day operations and
the marketing and front-office functions. Lindee quickly notices that documentation is not done on the day of service but sometimes 2 or 3 days
later. This delay in completion of the documentation not only hinders the front office from sending bills in a timely manner but also puts the clinic at
risk for inaccuracies in documentation and missed documentation.
Lindee decides to hold an all-staff meeting to review the workflow processes with the team. As she is reeducating the team members, Lindee
realizes that she also needs to explain her role as a manager and as an OTA. She explains the process for an OTA to be the manager and leader,
while sharing how she receives clinical supervision. In particular, Lindee explains that she guides and leads the overall team in achieving clinical
and operational outcomes like hiring, budgets, customer service, and so on, but she also is a treating practitioner and has the role of OTA, who must
receive supervision per the practice act. Lindee explains that she utilizes resources from professional associations and state practice acts to ensure
that her work roles are balanced and ethical. Lindee sees her staff’s body language shift as they begin to understand her role and the importance
that role delineation, clinical competency, and ethics play in her everyday work.
As Lindee reviews the workflow systems, she provides the reason behind the expectations to ensure buy-in from all teammates. Ensuring each
person understands how their job affects another person’s job helps each practitioner understand where they need to make changes. Additionally,
Lindee shares resources for ethical practice and reviews the consensus statement by AOTA, the American Physical Therapy Association, and
the American Speech-Language-Hearing Association (2014), which demonstrates her commitment to working interprofessionally. Finally, Lindee
offers ideas, like creating agendas for meetings, sharing new resources that can be used in clinical practice, and ensuring breaks and lunches
are taken every day, to help with the difficulties some team members are having with managing their workloads, caring for clients, and caring
for their families.
Lindee begins a monthly journal club in which each person gets to pick an article or book to review as a group and then writes about what they
learned and how they can use it in practice. The team discusses the possibility of ethics rounds to discuss client issues and professional issues that
may or may not occur but would allow them to proactively deal with stressors that may arise.
more likely to be engaged on the job” (Sorenson, 2014, para. insights, and concerns in an open and respectful environ-
1). If employees or managers through daily contact are unable ment. Nelson (2015) proposed a 6-step model for making
to identify their own strengths, managers can utilize Gallup’s ethical decisions specific to health care management:
Strength Based Orientation Index (Sorenson, 2014), Gallup’s 1. Recognize the background (circumstances leading to
Clifton StrengthsFinder assessment (Rath, 2007), or an em- ethical situation).
ployee skills assessment. 2. Identify the specific ethical question that needs clarification.
Once the employee and manager have identified their 3. Consider the related ethical principles and the organiza-
strengths, managers can begin placing employees in positions tion’s values.
and delegating responsibilities that focus on their strengths. 4. Determine the options for response.
For example, a manager might identify a clinician who has 5. Recommend a response.
leadership qualities and decide to give more leadership roles 6. Anticipate the ethical conflict.
to this clinician (e.g., lead therapist who assigns patients to
clinicians). Taking the time to identify clinical strengths This model differs from others in that the last step encour
along with supervisory strengths is important. A manager ages the manager to explore what can be done to stop situ-
might identify a clinician who has proven competency and ations from reoccurring in the future. Re-occurring issues
desires to further enhance their skills in falls mitigation. The threaten quality of care, staff morale, productivity, and the
manager can assign them a quarterly falls clinic, allowing organization’s reputation (Nelson, 2015). To anticipate the
them to plan and coordinate the clinic. ethical conflict, managers should identify and analyze how
To alleviate ethical challenges, managers must distinguish this ethical conflict occurred or can occur in other envi-
between clinical supervision and management of a depart- ronments or situations. Learning from the conflict and
ment. Roles for each practitioner must be clearly defined in documenting the response and consequences can aid in being
job descriptions, and communication needs to be at the fore- proactive for future ethical conflicts.
front (McCracken & Winistorfer, 2017). Using this process as a decision tree when approached with
a situation will provide OTA managers with a more objective
Ethical Decision Making process to follow to identify what may have gone wrong. This
process can be mimicked when differing opinions occur on
After an ethical situation has presented itself, it is import- a client’s progress or when seeing variations in clients’ skills.
ant to have a process in place to review and reflect on a de- These steps are explored further in Case Study 59.3.
cision. Managers have the authority to provide care based
on ethical principles and develop a plan to strengthen pa-
Ethics Rounds
tient care through sound decisions by the entire health care
team. Ethical situations are best decided when everyone In ethics rounds, health care providers can use realistic patient
involved has a chance to discuss their values, observations, cases for reflection and discussion concerning ethical issues.
CASE EXAMPLE 59.3. Going Through the Decision-Making Process
Indar has been an OTA for 7 years and has recently started a new job working in an acute care hospital. Libby, an OT, is Indar’s indirect supervisor.
Indar just completed her first annual review with Libby and their manager, who is a speech therapist. In her review, Libby’s input in the annual review
was favorable and positive regarding Indar’s performance. In fact, she stated that Indar gives invaluable information on initial evaluations.
The following week, Libby has an unexpected emergency and leaves work. The speech therapist, as rehabilitation manager, reassigns all of Libby’s
patients to Indar. Indar is a little overwhelmed because he has to see his own patients, plus Libby’s, and then realizes that several of the patients
are new and an initial evaluation is needed. Indar promptly pulls his manager aside and states that they will have to wait until Libby returns, as she
needs to be directly involved in the initial evaluation. The rehabilitation manager is concerned that Libby may not return in time and states, “Libby
has full confidence in you, as do I, please do the evaluation and bill it. We will just have Libby review everything when she returns.”
Following Nelson’s 6-step process, Indar goes through the following steps:
1. Recognize the background (circumstances leading to ethical situation).
■ Libby is suddenly unable to lead and be involved with initial evaluation.
■ The rehabilitation manager is not in the occupational therapy field.
■ The rehabilitation manager is not fully aware of scope of practice for OTA role.
■ The occupational therapy caseload is heavy.
2. Identify the specific ethical question that needs clarification.
■ What happens if Indar goes against his manager?
■ Are there any other OTs in the department?
■ Will Indar look incompetent?
■ Could Indar get fired for insubordination?
■ Will Indar be reprimanded and not receive a good annual review?
■ Will Indar’s manager be offended that she may not know roles of occupational therapy practitioners?
3. Consider the related ethical principles and the organization’s values.
■ The Principle of Veracity is at the forefront of this situation and therefore, Indar must be accurate with the transmission of information
and true occupational therapy’s roles, responsibilities, and scope of practice.
4. Determine the options for response.
■ Follow the manager’s instructions and do initial evaluations on all new patients.
■ Refuse to do initial evaluations, but see Libby’s other patients.
■ Speak to the manager again and explain that because of occupational therapy’s scope of practice, Indar can participate, but that the
OT needs to be directly involved in the initial evaluation.
5. Recommend a response.
■ Indar decides to speak to his manager again and explain scope of practice. He suggests having another OT available whom Indar can
work with should Libby be unable to return. Indar decides not to do the initial evaluation and wait for an OT to begin the evaluation
but does see Libby’s patients.
6. Anticipate the ethical conflict.
■ Discuss the situation in department meeting to avoid future conflict.
■ Review scope of practice with the rehabilitation manager.
■ Anticipate emergencies and illnesses and have adequate staff for census.
Review Questions
1. What is the correct order to follow in the decision-making process?
a. Recognize background, identify the ethical question, consider ethical principles, determine the options for response, recommend a
response, and anticipate the conflict.
b. Identify the ethical question, recognize background, consider ethical principles, determine the options for response, recommend a response,
and anticipate the conflict.
c. Recognize background, consider ethical principles, determine the options for response, recommend a response, and anticipate the conflict.
2. Why is the last step important in the decision-making process in this scenario?
a. This step is merely a suggestion and not necessary for one to make a final recommendation or decision.
b. Reoccurring issues threaten quality of care, staff morale, productivity, and the organization’s reputation.
c. The last step helps in stopping issues from recurring.
3. Which ethical principle is identified in the above case study?
a. Justice
b. Veracity
c. Autonomy
Erler (2017) describes ethics rounds as “an important medium 2. Implementing ethic rounds is suggested because
for cultivating sensitivity toward anticipatory and emerging a. It helps to cultivate sensitivity toward anticipatory
ethical issues and for preparing practitioners to deal with ac- and emerging ethical issues.
tual ethical problems in practice” (p. 15). Ethics rounds not b. It is easier on managers.
only provide managers and practitioners with a safe outlet to c. Occupational therapy practitioners need assistance in
discuss and address ethical concerns, they also help to address ethical issues.
the issues of moral distress, which Wood (2014) identified. d. All of the above are true.
Moral distress occurs when someone feels they know the right 3. Challenges for managers in creating and promoting ethi-
thing to do; however, other factors, such as institutional con- cal environments include all of the following except:
straints, cause them to feel they may not be able to pursue the a. OTAs managing occupational therapy practitioners
right course of action. who supervise the manager in practice
Individuals who attend the rounds can bring forward a b. Not knowing ethical jurisdiction or procedures asso-
case concern (an actual one or a vignette) to discuss with the ciated with ethical situations
group and identify the ethical issues. The team should discuss c. Making sure to role model ethical and moral behaviors
what occurred and what can be done to resolve the situation on a daily basis
or avoid the situation in the future. d. All of the above
Using ethics rounds provides additional support and
structure when an OTA holds the role of manager and also
reports to the OT. The focus on anticipatory issues can guide SUMMARY
structured conversations between the OTA and the OT to Managing ethical conflict will be a daily requirement for
prevent any potential ethical issues. Additionally, both the OTA managers. Often a manager reports to multiple constit-
OTA and OT may feel moral distress in this dual relationship; uents, all of whom have a desire and need for something else
having a third party during rounds provides support to both, and feel that something else has a higher priority. Managers
which assists with the client outcome. need to be familiar with the language, the reporting struc-
ture, and the institution or employer-specific resources for
Ethical Jurisdiction investigating ethical concerns.
Every day managers are tasked to make decisions that have
Ethical situations are inevitable and expected. Knowing where
ethical implications. The decisions made—or the failure to make
to go and the enforcement procedures are helpful to manag-
decisions—can impact employees, health care organizations,
ers and practitioners. The AOTA Ethics Commission (EC) has
and clients served. In the ever-changing health care setting,
developed the Enforcement Procedures for the Occupational
managers must address diverse values in the workplace to pro-
Therapy Code of Ethics (AOTA, 2015a) to address alleged vio-
mote ethical work environments. Being intentional from the
lations of the Code of Ethics. The EC receives, deliberates, and
beginning of employment may ease some ethical issues from
acts on such complaints when they are filed against AOTA
arising, escalating, and being repeated. Appendix 59.A includes
members or individuals who were AOTA members at the time
resources for OTAs seeking more information on ethics. ❖
of the alleged incident. The EC works to ensure a fair and con-
sistent approach to ethical complaints and also provides an
appeals process. LEARNING ACTIVITIES
OTAs who are managers should fully understand the pro-
cess and be able to speak to it as both an OTA and a manager. 1. Visit the websites suggested in Appendix 59.A and Med-
They need to be able to share this information to empower icaid’s website, and summarize the steps a manager can
other teammates and partnerships. Being knowledgeable take to help prevent ethical lapses.
about the process also supports the OTA in their role as man- 2. Identify 2 ethical situations a manager may experience,
ager and demonstrates competency in practice and an open- and analyze 1 ethical situation.
ness to role delineation and processing. 3. A respected occupational therapy manager should have
self-awareness. Reflect on your personal morality and
how it differs in a role of manager.
Review Questions
a. Where did you get your values from?
1. When establishing a culture of ethical and moral behavior, b. What events in your life or significant people taught
managers must do the following: you standards?
a. Include ethical values in strategic planning and depart- c. How is having personal morality and self-awareness
mental goals different when you are a manager?
b. Be cognizant only of the manager’s own personal 4. Interview a local rehabilitation manager who is an OTA
integrity regarding how they ethically manage their department.
c. Have 1 person appointed and in charge of the ethics in Discuss the ethical training the department receives.
the department 5. Write an essay on how ethical principles may come into
d. All of the above conflict when working as an OTA manager.
ACOTE STANDARDS American Occupational Therapy Association, American Physical

Therapy Association, & American Speech-Language-Hearing
This chapter addresses the following ACOTE Standards: Association. (2014). Consensus statement on clinical judgment in
health care setting. Retrieved from https://www.aota.org/Practice
■ B.4.24. Effective Intraprofessional Collaboration
/Ethics/Consensus-Statement-AOTA-APTA-ASHA.aspx
■ B.4.25. Principles of Interprofessional Team Dynamics Erler, K. M. (2017). Role of occupational therapy ethics rounds in
■ B.5.1. Factors, Policy Issues, and Social Systems practice. OT Practice, 22(13), 15–18.
■ B.5.8. Supervision of Personnel Ethics. (n.d.) In Merriam-Webster online. Retrieved from https://
■ B.7.1. Ethical Decision Making. w w w.merriam-webster.com/dictionary/ethics?src=search
-dict-hed
McCracken, K., & Winistorfer, W. (2017). Ethical considerations for
the occupational therapy assistants in management roles [Ethics
REFERENCES Advisory]. OT Practice, 22(11), 18–21.
Accreditation Council for Occupational Therapy Education. (2018). Nelson, W. A. (2015). Making ethical decisions: A six-step process
2018 Accreditation Council for Occupational Therapy Education should guide ethical decision making in healthcare. Healthcare Ex-
(ACOTE) standards and interpretive guide. American Journal of ecutive, 30, 46–48. Retrieved from https://www.ache.org/-/media
Occupational Therapy, 72, 7212410005. https://doi.org/10.5014 /ache/about-ache/ja15_ethic_reprint.pdf
/ajot.2018.72S217 Rath, T. (2007). StrengthsFinder 2.0. New York: Gallup Press.
American Occupational Therapy Association. (2014). Guidelines for Sorenson, S. (2014, February 20). How employees’ strengths make your
supervision, roles, and responsibilities during the delivery of occu- company stronger. Business Journal. Retrieved from https://news
pational therapy services. American Journal of Occupational Ther- .gallup.com/businessjournal/167462/employees-strengths-company
apy, 68(Suppl. 3), S16–S22. https://doi.org/10.5014/ajot.2014.686S03 -stronger.aspx
American Occupational Therapy Association. (2015a). Enforcement Stover, A. D. (2016). Client-centered advocacy: Every occupa-
procedures for the Occupational Therapy Code of Ethics. Ameri- tional therapy practitioner’s responsibility to understand med-
can Journal of Occupational Therapy, 69(Suppl. 3), 6913410012. ical necessity. American Journal of Occupational Therapy, 70,
https://doi.org/10.5014/ajot.2015.696S19 7005090010. https://doi.org/10.5014/ajot.2016.705003
American Occupational Therapy Association. (2015b). Occupational Wood, D. (2014, March 3). 10 best practices for addressing ethi-
therapy code of ethics (2015). American Journal of Occupational cal issues and moral distress. Healthcare News. Retrieved from
Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014/ajot https://www.amnhealthcare.com/latest-healthcare-news/10
.2015.696S03 -best-practices-addressing-ethical-issues-moral-distress/
APPENDIX 59.A. ETHICS RESOURCES ■ Centers for Medicare and Medicaid Services:
FOR OTA MANAGERS ■ Learn about medication fraud, abuse, prevention de-
tection, and reporting: https://go.cms.gov/VCT5iH
Ethics Documents ■ A reference tool for documentation and billing Medicare:
American Occupational Therapy Association. (2015). Enforcement https://go.cms.gov/2OSvQMv
procedures for the Occupational Therapy Code of Ethics. Amer- ■ U.S. Department of Health and Human Services has re-
ican Journal of Occupational Therapy, 69(Suppl. 3), 6913410012. sources for Medicare fraud tips (https://bit.ly/2EyLtpt),
https://doi.org/10.5014/ajot.2015.696S19 HIPAA rules and regulations (https://www.hhs.gov/hipaa
American Occupational Therapy Association. (2015). Occupational /index.html), and other links for information: www.hhs.gov
Therapy Code of Ethics (2015). American Journal of Occupa- ■ HIPAA Privacy Rule: https://bit.ly/2IC2Nza
tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014 ■ Office of Human Research Protections: https://www
/ajot.2015.696S03 .hhs.gov/ohrp/
American Occupational Therapy Association, American Physical
Therapy Association, & American Speech–Language–Hearing
■ Stop Medicare Fraud: https://bit.ly/2OS6UsM
Association. (2014). Consensus statement on clinical judgment in
■ National Institutes of Health Department of Bioethics is
health care settings. Retrieved from https://www.aota.org/Practice the nation’s preeminent centers for bioethics scholarship
/Ethics/Consensus-Statement-AOTA-APTA-ASHA.aspx and training: https://www.bioethics.nih.gov/home/index
National Board for Certification in Occupational Therapy. (2015). .shtml
Professional conduct. Retrieved from https://nbcot.org/en/Regulators
/Professional-Conduct Where to Report Ethical Concerns
and Resources
Suggested Websites
■ AOTA: https://www.aota.org/Practice/Ethics
■ American Occupational Therapy Association: Provides ■ National Board for Certification in Occupational
resources and articles on ethics: https://www.aota.org T herapy: https://bit.ly/2IGm6qW
/Practice/Ethics. The formal complaint form from the ■ State Regulatory Boards: https://bit.ly/2GNGZyx (AOTA
AOTA Ethics Commission is available at https://bit. members only)
ly/2SZkTjg ■ American Medical Association: https://bit.ly/2NrXiS8
CHAPTER
Understanding the Law
Barbara L. Kornblau, JD, OTR/L, FAOTA, DASPE, CCM, CDMS, CPE 60
LEARNING OBJECTIVES
At the end of this chapter, readers will be able to
■ Explain 3 ways changes in laws and regulations can affect occupational therapy practice;
■ Describe the impact of policy on occupational therapy practice and why occupational therapy managers and practi-
tioners need to familiarize themselves with policy; and
■ Locate resources to stay apprised of changes in laws, regulations, and other policies that affect occupational therapy.

• Case law • Licensure laws • Practice guidelines
• Consensus statements • Local laws • Regulations
• Law • Policy • State regulations
• Legislative bodies
OVERVIEW operationalize laws. It also explains how occupational ther-

apy practitioners can have input into the regulatory process
O
ccupational therapy managers work within a struc- to advocate for the occupational therapy profession and the
ture of seemingly complicated policies, programs, and people it serves. It explains how the courts can interpret laws
rules. Some policies come from laws or regulations. and by doing so, change policy or make new law, or case law,
Some come from court decisions. Other policies, programs, that can directly affect occupational therapy practice or the
and rules stem from reimbursement requirements. Accred- people served by occupational therapy.
iting bodies, such as The Joint Commission or the Commis- In addition, readers will find information about the rules they
sion on Accreditation of Rehabilitation Facilities (known as must follow based on policies that come from consensus state-
CARF), also promulgate policies, programs, and rules that ments and practice guidelines rather than laws and regulations.
affect occupational therapy management and practice. This chapter also looks at how laws that affect occupational ther-
No one expects occupational therapy managers to be at- apy practice, such as licensure laws (or laws that regulate the
torneys. However, like all managers, they need to familiar- practice of occupational therapy), can vary from state to state.
ize themselves with a basic understanding of how the law (“a
binding custom or practice of a community; a rule of conduct
or action prescribed or formally recognized as binding or en- ESSENTIAL CONSIDERATIONS
forced by a controlling authority”1) works so they understand
Sources of Laws and Regulations
how legal issues affect what they do. This is especially import-
ant as health care becomes increasingly more complicated. Legislative bodies (or a group of law makers, such as the
This chapter provides an overview of how the law works. U.S. Senate, the U.S. House of Representatives, and state
It explains where law comes from and how regulations legislatures) at federal, state, and local levels pass laws that
Note. The in-text legal citations in this chapter are abbreviated, rather than Blue Book style, to make the chapter more readable by occu-
pational therapy professionals and students who do not work in the legal profession.
https://doi.org/10.7139/2019.978-1-56900-592-7.060
565
CHAPTER
Understanding the Law
LEARNING OBJECTIVES
At the end of this chapter, readers will be able to
■ Explain 3 ways changes in laws and regulations can affect occupational therapy practice;
■ Describe the impact of policy on occupational therapy practice and why occupational therapy managers and practi-
tioners need to familiarize themselves with policy; and
■ Locate resources to stay apprised of changes in laws, regulations, and other policies that affect occupational therapy.

• Case law • Licensure laws • Practice guidelines
• Consensus statements • Local laws • Regulations
• Law • Policy • State regulations
• Legislative bodies
OVERVIEW operationalize laws. It also explains how occupational ther-

apy practitioners can have input into the regulatory process
O
ccupational therapy managers work within a struc- to advocate for the occupational therapy profession and the
ture of seemingly complicated policies, programs, and people it serves. It explains how the courts can interpret laws
rules. Some policies come from laws or regulations. and by doing so, change policy or make new law, or case law,
Some come from court decisions. Other policies, programs, that can directly affect occupational therapy practice or the
and rules stem from reimbursement requirements. Accred- people served by occupational therapy.
iting bodies, such as The Joint Commission or the Commis- In addition, readers will find information about the rules they
sion on Accreditation of Rehabilitation Facilities (known as must follow based on policies that come from consensus state-
CARF), also promulgate policies, programs, and rules that ments and practice guidelines rather than laws and regulations.
affect occupational therapy management and practice. This chapter also looks at how laws that affect occupational ther-
No one expects occupational therapy managers to be at- apy practice, such as licensure laws (or laws that regulate the
torneys. However, like all managers, they need to familiar- practice of occupational therapy), can vary from state to state.
ize themselves with a basic understanding of how the law (“a
binding custom or practice of a community; a rule of conduct
or action prescribed or formally recognized as binding or en- ESSENTIAL CONSIDERATIONS
forced by a controlling authority”1) works so they understand
Sources of Laws and Regulations
how legal issues affect what they do. This is especially import-
ant as health care becomes increasingly more complicated. Legislative bodies (or a group of law makers, such as the
This chapter provides an overview of how the law works. U.S. Senate, the U.S. House of Representatives, and state
It explains where law comes from and how regulations legislatures) at federal, state, and local levels pass laws that
Note. The in-text legal citations in this chapter are abbreviated, rather than Blue Book style, to make the chapter more readable by occu-
pational therapy professionals and students who do not work in the legal profession.
https://doi.org/10.7139/2019.978-1-56900-592-7.060
565
affect occupational therapy practice. These laws create and into the process and may ask members to provide comments
implement policy (or “whatever governments choose to do on issues of concern to the occupational therapy profession or
or not to do”2; e.g., public policies may regulate behavior, to consumers of occupational therapy services.
organize government agencies, or require licenses or fees), Other legal requirements that impose policies occupa-
hence the name policymakers for elected officials and those tional therapy managers must follow come from a variety of
who work for government agencies to operationalize poli- sources. In addition to federal laws and regulations, such as
cies into programs. Medicare and the Medicare program,12 these legal require-
When policymakers decide to do something, they base ments may take the form of a law passed by a state or local
their decision on how to do it on principles (e.g., governing legislative body. Although federal laws, such as Medicare,
philosophy, evidence-based information, context, environ- apply to everyone across the country, licensure laws are ex-
mental influences) that guide their decision making. These amples of state laws (e.g., see West Virginia Occupational
principles define policy, whereas laws are an established sys- Therapy Practice Act, Article 28 §30-28-16[e], 2009), which
tem of rules passed by a federal, state, or local authoritative vary from state to state.
body and enforced by a controlling authority. For example, in For example, state licensure laws vary from state to state
1965, President Johnson signed into law the Health Insurance in their requirements for supervision of occupational ther-
for the Aged (Medicare) Act.3 This federal law, enacted as apy assistants (OTAs) and continuing education (CE). Some
Title XIX of the Social Security Act4 (Pub. L. 74–271), estab- state licensure laws limit the number of OTAs an OT can
lished as U.S. policy the provision of insurance for the elderly, supervise (e.g., see Cal. Bus. and Prof. Code §2570.3[j][2]).
and it put in place the Medicare program.5 Some not only specify the number of continuing education
Congress periodically passes new laws to change its Medi- units (CEUs) licensees must take, which varies from state to
care policy. For example, it passed the Medicare Prescrip- state, they also specify specific topics of CEU courses they
tion Drug, Improvement, and Modernization Act of 20036 must take. For example, Oregon requires a 1-time mandatory
(P. L. 108-173), which amended Medicare to add policies 7 hours of CE on pain management for new OTs,13 whereas
such as Medicare Part C; Medicare Advantage Plans; and Florida requires licensees take 2 CEUs in preventing medical
Part D, the Medicare prescription drug benefit. As is typical errors and 2 CEUs in Florida laws and rules that govern oc-
in federal health-related laws, Congress delegated to the Sec- cupational therapy.14
retary of Health and Human Services (HHS) the task of op- Local laws (or laws in force in cities, counties, towns, and
erationalizing the programs by developing regulations (e.g., other municipalities that require or proscribe rules or behav-
see the Medicare prescription drug benefit7). The Centers for iors in that municipality), which vary from town to town or
Medicare and Medicaid Services (CMS), under the Secre- city to city, also affect the practice of occupational therapy.
tary of HHS, developed the regulations for both programs, For example, a law that specifies the size of the sign an oc-
including regulations that affect the delivery of occupational cupational therapy practice may post outside its clinic or the
therapy under the Medicare Advantage Program (e.g., see number of parking spaces the clinic must have is probably a
Benefits and beneficiary protections: Rules regarding pro- local law or ordinance.
vider participation8).
Regulations are “rules and administrative codes issued by
Case Law
governmental agencies at all levels, municipal, county, state
and federal” . . . that “have the force of law, since they are ad- Laws and policies also come from case law, or judge-made
opted under authority granted by statutes, and often include law or law based on precedent established in previous judicial
penalties for violations.”9 Developed by federal agencies, such opinions, rather than statutes, regulations, or other sources.15
as CMS, and state agencies, such as state health departments For example, under Medicare, occupational therapy practi-
and licensure boards, regulations impose legal obligations on tioners were forced to discharge clients with chronic condi-
occupational therapy practitioners. The process of developing tions, such as multiple sclerosis, once they reached a plateau
regulations, however, involves soliciting comments from the or were no longer making progress. The case of Jimmo v.
public on proposed regulations. This step gives occupational Sebelius16 changed the way Medicare reimburses occupa-
therapy practitioners and their clients the opportunity to tional therapy services for people with chronic conditions.
provide input into the regulatory development process. Until 2013, Medicare followed an informal published policy
For example, during the development process of the reg- guideline that required Medicare recipients to make progress
ulations for the Americans With Disabilities Act10 (ADA; in order to receive occupational therapy services. If the client
P. L. 101–336), occupational therapists (OTs) made comments plateaued, or the intervention was considered maintenance,
regarding occupational therapy’s role in the reasonable ac- and/or the client did not make improvement, Medicare no
commodations process, resulting in the mention of OTs and longer considered the occupational therapy services “skilled
how they can assist in the reasonable accommodations pro- care” or “medically necessary” and, therefore, would no lon-
cess in the Equal Employment Opportunity Commission’s ger reimburse for occupational therapy services.17 Many re-
ADA technical assistance manual.11 In addition, the Amer- ferred to this as “the improvement standard.”
ican Occupational Therapy Association monitors the regu- In 2011, the Center for Medicare Advocacy filed a class
latory process to ensure that occupational therapy has input action lawsuit against the Secretary of HHS on behalf of
CHAPTER 60. Understanding the Law 567
Mrs. Jimmo, a woman who is legally blind and has a par- anything to do with denial of a FAPE, which would require
tially amputated leg; other patients with chronic medical further proceedings. Thus, the Fry decision—judge-made
conditions; and some patient advocacy groups.18 They chal- case law—changed the way schools address requests for rea-
lenged the improvement standard. They argued to the court sonable accommodations that do not involve issues related to
that HHS did not base the improvement standard on federal a FAPE. Students with disabilities who need a reasonable ac-
Medicare law and regulations.19 commodation not related to a FAPE can now request it under
The judge denied the government’s motion to dismiss the the ADA or Rehab Act. Now, pediatric occupational therapy
case, prompting the parties to enter into a court-approved class practitioners can help families request simple accommoda-
action settlement agreement. CMS agreed to revise the sections tions not related to a FAPE, such as a change in classroom lo-
in its policy manual relevant to occupational and other thera- cation for a child with a genetic condition who cannot climb
pies to clarify that the improvement standard was not a cate- stairs to get to a classroom.
gorical rule and to conduct an education campaign to notify
Medicare beneficiaries and providers of the change in policy.20
Other Sources of Occupational Therapy Policy
Thus, by approving the settlement agreement in a lawsuit
in a federal court, the judge changed Medicare policy. Oc- Regulations, the rules developed to implement laws on a state
cupational therapy practitioners can now continue to treat or national basis, translate policy into programs and the rules
clients with chronic conditions after they plateau, if they can the programs create that occupational therapy managers
document the client still requires skilled care and some other must follow. Occupational therapy policy can also come from
requirements. In response to the court-approved class action the following sources:
settlement, occupational therapy managers need to familiar-
■ Consensus statements, which are practice recommenda-
ize themselves with the changes made in the policy manual,
tions developed by panels of experts who meet to answer
so they meet the documentation requirements for reimburse-
a series of predetermined questions, based on scientific
ment of treatment of clients with chronic conditions.
evidence, and make recommendations for treatment or
Fry v. Napoleon Community Schools21 is a case of interest to
interventions. For example, AOTA, APTA, and ASHA
school-based occupational therapy practice. In Fry, the U.S. Su-
created a consensus statement to provide a evidence-based
preme Court looked at an established policy that required parents
practice recommendations for the 3 rehabilitation pro-
of children with disabilities to exhaust administrative remedies
fessions, titled, “Consensus Statement on Clinical Judg-
or go through all of the required procedures under the Individ-
ment in Health Care Settings: AOTA, APTA, ASHA.”30
uals With Disabilities Education Act22 (IDEA; P. L. 101–476)
Occupational therapy practitioners must follow these
before they could request accommodations under the Re-
recommendation in order to provide the level of clinical
habilitation Act23 (Rehab Act; P. L. 93–112) or Title II of the
judgment dictated by professional standards. Examples
Americans With Disabilities Act24 (ADA; P. L. 101–336). The
of other practice recommendations, some of which may
Fry’s daughter (E.F.) had severe cerebral palsy. When she
apply to occupational therapy, include National Institutes
started kindergarten, the family intended that her trained ser-
of Health (1997),31 the National Health Service Health at
vice dog, Wonder, accompany her to school. The school refused
Work Network (2008),32 and Thigpen et al. (2016).33
to allow Wonder to accompany E.F. to kindergarten to help her
■ Practice guidelines, which are also called clinical prac-
with everyday tasks, preferring an aide.
tice guidelines. According to the Health and Medicine
The parents wanted to request Wonder as an accommoda-
Division of the National Academies of Science, Engineer-
tion for E.F.’s disability under the ADA or the Rehab Act. The
ing, and Medicine (formally the Institute of Medicine)34
school refused and instead required the parents to follow the
“[c]linical practice guidelines are statements that include
national policy declared in a previous Supreme Court deci-
recommendations intended to optimize patient care. They
sion, Smith v. Robinson.25 In Smith, the court ruled IDEA was
are informed by a systematic review of evidence and an
the “exclusive avenue” through which a child with a disability
assessment of the benefits and harms of alternative care
could challenge the adequacy of his or her education. Con-
options.” Examples of occupational therapy practice
gress codified this principle in the Handicapped Children’s
guidelines include Occupational Therapy Practice Guide-
Protection Act of 198626 (P. L. 99–372).
lines for Adults With Stroke35 and Occupational Therapy
However, in Fry,27 the Supreme Court recognized that E.F.’s
Practice Guidelines for Individuals With Autism.36
request to bring her service animal to school was tantamount to
■ State regulations, which often incorporate factors such as
bringing a service animal to any public facility, such as a library
practice guidelines to form standards of care, ethical obli-
or movie theater. It had nothing to do with a quest for a free, ap-
gations, or weight of law.37 Policymakers also may look to
propriate, public education (FAPE), mandated under IDEA.28
research-derived evidence to develop policy.38
Because of this realization, the court held that IDEA’s require-
ment for exhaustion of the administrative procedures was not Policy affects how occupational therapy managers make
necessary when the gravamen of the plaintiff’s suit is something clinical and business decisions. For example, the Jimmo case,39
other than the denial of IDEA’s core guarantee of a FAPE.29 discussed previously, shows how a particular policy determines
The court remanded the case back to the lower court to how OTs treat and document so they can obtain reimbursement
establish whether the gravamen of the Fry’s complaints has through Medicare. Other policies determine the parameters
for Medicaid reimbursement under each state’s Medicaid laws read their state practice acts to familiarize themselves with
and other elements in the federal payment system.40 their legal obligations and review them annually for changes.
Policymakers on the state level, through legislation and Occupational therapy managers need to remember that
licensure requirements, decide scope of practice issues, such their professional obligations do not end at the clinic door.
as those that influence practice and management decisions As professionals, they can play an advocacy role in policy de-
regarding occupational therapy versus physical therapy. The velopment that can benefit their practice, the consumers of
federal government addresses the payment aspect of this their services, and occupational therapy in general. They can
issue through health care financing policy under Medicare advocate by expressing their concerns to their elected officials
laws and regulations. Occupational therapy managers need to pass laws favorable to practice and to protect existing laws
to pay attention to potential policy changes in both Con- favorable to practice. In addition to advocacy for laws, occu-
gress in Washington, DC, and in their own state legislatures. pational therapy managers can participate in the regulatory
Changes to Medicare, Medicaid, and other policies, such as process by making comments on proposed regulations that
the Children’s Health Insurance Plan (CHIP) and the Patient may have an impact on occupational therapy practice or on
Protection and Affordable Care Act41 (P. L. 111–148), directly the consumers served by occupational therapy.
affect both occupational therapy reimbursement and access One of the many benefits of membership in AOTA is
to occupational therapy services and, hence, department or that the association monitors legal challenges that affect
practice revenue, practice policies, and access to services for occupational therapy and keeps its members apprised of
the people occupational therapy serves. changes in law that affect occupational therapy. Member-
A combination of state and federal policy and judicial de- ship in AOTA and individual state occupational therapy
cisions determines who can practice and where they can prac- professional organizations is critical for occupational ther-
tice and establishes legal requirements for supervision.42 For apy managers and practitioners to stay abreast of changes
example, policy determines the degree of training needed to to case law, practice acts, and other national and state laws
treat clients. Policy also determines whom OTs and OTAs may and regulations that affect practice. Membership in AOTA
treat (e.g., adults, children, immigrants) and where they can and state associations helps occupational therapy managers
treat them (e.g., rehabilitation clinic, home, office, hospital and practitioners stay current with their legal obligations
setting). Occupational therapy managers need to monitor the as professionals and their professional obligations to help
policy changes that could affect whom their staff may treat, preserve policies that protect practice and advocate for new
how often they may treat them, and where they may treat them. policies that benefit practice.
Review Questions Review Questions

1. What are 3 ways that laws and regulations can affect 1. Which of the following is true about state licensure laws:
occupational therapy clinical practice? a. All state licensure laws incorporate the AOTA’s Occu-
2. Describe 3 reasons why occupational therapy managers pational Therapy Code of Ethics (2015)43 into their law.
need to familiarize themselves with policy? b. All state licensure laws describe specific requirements
3. Medicare and Medicaid policies that affect occupational for supervision of OTAs.
therapy practice may come from which of the following? c. Licensure laws vary from state to state.
a. Laws d. Once practitioners obtain a license, they need not
b. Regulations worry about their licensure law.
c. Courts’ and judges’ decisions in cases and lawsuits 2. All of the following are benefits of membership in AOTA,
d. All of the above except
a. AOTA keeps watch on policy changes that may affect
PRACTICAL APPLICATIONS IN occupational therapy practice.
b. AOTA tells members who to vote for to promote laws
OCCUPATIONAL THERAPY and policies that benefit occupational therapy.
Licensure sets a basic framework for practice, and managers c. AOTA enables occupational therapy managers to stay
must familiarize themselves with the licensure laws affecting current on policy matters that affect occupational
those whom they manage. State policymakers determine CE therapy.
requirements in licensure laws and detail the specific require- d. AOTA serves as the eyes and ears of its members in
ments in the regulations that implement the state’s licensure Congress to monitor laws that affect practice.
laws, with which occupational therapy practitioners must 3. To fulfill their obligation as professionals, occupational
comply. State regulatory boards determine the proper behav- therapy practitioners should
ior of OTs and OTAs and sanctions for deviating from these a. Participate in advocacy for the profession by familiar-
standards. Because these requirements are determined on a izing themselves with laws that affect practice
state-by-state basis, they often vary from 1 state to another, b. Express their concerns to elected officials about laws
and occupational therapy managers and practitioners should that affect practice
CHAPTER 60. Understanding the Law 569
c. Make comments on proposed regulations that may 4. Find a consensus statement that mentions occupational
affect practice therapy by searching the web for “consensus statement oc-
d. All of the above cupational therapy.” You can use a national or international
statement or a statement from another country. What does
the consensus statement say, and how does it affect occupa-
SUMMARY tional therapy practice, education, and research?
The U.S. health care system becomes more complicated
every day with the many changing laws and regulations
ACOTE STANDARDS
that affect practice. Occupational therapy managers con-
tinually need to familiarize themselves with new laws, This chapter addresses the following ACOTE Standards:
regulations, and policies that may affect occupational ther-
apy practice and consumers. Membership in AOTA and
■ B.5.8. Supervision of Personnel
state occupational therapy associations is critical for stay-
ing current with changing laws, regulations, and policies
■ B.7.4. Ongoing Professional Development
so that occupational therapy managers and occupational
■ B.7.5. Personal and Professional Responsibilities.
therapy professionals at all levels can practice legally and
ethically and fulfill their professional obligation to advo-
cate for the profession and educate themselves regarding REFERENCES
the legal issues that affect occupational therapy practice. ❖ 1. Law [Def. 1]. (n.d.). In Merriam Webster Online, Retrieved
from https://www.merriam-webster.com/dictionary/law
LEARNING ACTIVITIES 2. Dye, T. R. (2005). Understanding public policy (11th ed.). Upper
Saddle River, NJ: Pearson Prentice Hall; p. 1.
1. Locate your state’s licensure law. What are the CE re- 3. Centers for Medicare and Medicaid Services. (2015). Medicare
quirements for your state? Does your state specify su- and Medicaid Services Milestones 1937–2015. Retrieved from
pervision requirements for OTAs? If so, what are those https://w w w.cms.gov/About-CMS/Agency-Information
requirements? Compare your state’s licensure law to an- /History/Downloads/Medicare-and-Medicaid-Milestones
other state’s licensure law, perhaps of 1 of your classmates -1937-2015.pdf
4. Social Security Act of 1935, Pub. L. 74–271, 42 U.S.C. §§
or colleagues from another state. Compare the CE re-
301-1397mm.
quirements and supervision requirements of your state’s 5. Centers for Medicare and Medicaid Services. (2015). Medicare
licensure law with the other state’s requirements. and Medicaid Services Milestones 1937–2015. Retrieved from
2. Go to AOTA’s website. Search for recent legislative suc- https://w w w.cms.gov/About-CMS/Agency-Information
cesses that AOTA describes that affect occupational ther- /History/Downloads/Medicare-and-Medicaid-Milestones
apy practice. How will these changes to law and policy -1937-2015.pdf
affect occupational therapy practice? 6. Medicare Prescription Drug, Improvement, and Moderniza-
3. Go to your U.S. senators’ webpage. Do either of your sen- tion Act of 2003, Pub. L. 108–173, 117 Stat. 2066 (codified in
ators sit on any committees that have to do with health scattered sections of 42 U.S.C. and 26 U.S.C.).
care law and policy that affect occupational therapy? 7. Medicare Prescription Drug, Improvement, and Moderniza-
These could include, for example, tion Act of 2003, Pub. L. 108–173, Title I §101.
8. 42 U.S. Code § 1395w–22[j][3][D]
■ The Senate Finance Committee, which creates laws 9. Hill, G., & Hill, K. (2018). Regulations. Retrieved from https://
and policies on Medicare, Medicaid, and the CHIP dictionary.law.com/Default.aspx?selected=1771
■ The Committee on Health, Education, Labor, and 10. Americans With Disabilities Act of 1990, Pub. L. 101–336, 42
Pension, which deals with issues such as IDEA and U.S.C. §§ 12101–12213 (2000).
a variety of federal agencies that address public 11. Equal Employment Opportunity Commission. (1992). A tech-
health, mental health, health, aging, and health care nical assistance manual on the employment provisions (Title 1)
research of the Americans With Disabilities Act. Retrieved from https://
■ The Armed Services Committee, which deals with askjan.org/publications/ada-specific/Technical-Assistance
health and health research for members of the mili- -Manual-for-Title-I-of-the-ADA.cfm
tary and their families 12. 42 U.S.C. §1395 et seq. (2016).
■ The Committee on Veterans Affairs, which ad- 13. Or. Admin. R, 339-020-0015, 2017.
14. Fla. Admin. Code ch. 64B11, 2017.
dresses medical care and vocational rehabilitation of
15. Cornell University Legal Information Institute. (2018). Case
veterans. law. Retrieved from https://www.law.cornell.edu/wex/case_law
Has either of your senators sponsored any bills that 16. Jimmo v. Sebelius, No. 5:11-cv-17, 2011 WL 5104355 (D. Vt. 2011).
would create policy that affects occupational therapy? 17. Gladieux, J., & Basile, M. (2014). Jimmo and the improvement
Which ones? If not, based on the committees they are on, standard: Implementing Medicare coverage through regulations,
what kind of policy would you suggest that they create to policy manuals and other guidance. American Journal of Law and
promote occupational therapy? Medicine, 40, 7–25. https://doi.org/10.1177/009885881404000101
18. Klein, M. (2014). Update on Jimmo v. Sebelius: Medicare 33. Thigpen, C. A., Shaffer, M. A., Gaunt, B. W., Leggin, B. G.,
standards for skilled nursing care. Bifocal, 36(1), 23–24. Williams, G. R., & Wilcox, R. B., III. (2016). The American
Retrieved from https://www.americanbar.org/content/dam/aba Society of Shoulder and Elbow Therapists’ consensus statement
/publications/bifocal/BIFOCALSeptember-October2014.pdf on rehabilitation following arthroscopic rotator cuff repair.
19. Ibid. Journal of Shoulder and Elbow Surgery, 25, 521–535. https://doi
20. Gladieux, J., & Basile, M. (2014). Jimmo and the improvement .org/10.1016/j.jse.2015.12.018
standard: Implementing Medicare coverage through regulations, 34. Institute of Medicine. (2011). Clinical practice guidelines we can
policy manuals and other guidance. American Journal of Law and trust. Retrieved from http://www.nationalacademies.org/hmd
Medicine, 40, 7–25. https://doi.org/10.1177/009885881404000101 /Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust
21. Fry v. Napoleon Community Schools, 580 U.S. ___ (2017), 137 S. .aspx; p. 1
Ct. 743. 35. Wolf, T. J., & Nilsen, D. M. (2015). Occupational therapy prac-
22. Individuals With Disabilities Education Act of 1990, Pub. tice guidelines for adults with stroke. Bethesda, MD: AOTA
L. 101–476, renamed the Individuals With Disabilities Educa- Press.
tion Improvement Act, codified at 20 U.S.C. §§ 1400-1482. 36. Tomchek, S. D., & Patten Koenig, K. (2016). Occupational
23. Rehabilitation Act of 1973, Pub. L. 93–112, 29 U.S.C. §§ 701-796l. therapy practice guidelines for individuals with autism spec-
24. Americans With Disabilities Act of 1990, Pub. L. 101–336, 42 trum disorder. Bethesda, MD: AOTA Press.
U.S.C. §§ 12101–12213 (2000). 37. Federation of State Medical Boards. (2014). Model policy for
25. Smith v. Robinson, 468 U. S. 992 (1984). the appropriate use of telemedicine technologies in the practice
26. Handicapped Children’s Protection Act of 1986, Pub. L. 99–372. of medicine. Retrieved from https://www.fsmb.org/siteassets
27. Fry v. Napoleon Community Schools, 580 U.S. __ (2017), 137 S. /advocacy/policies/fsmb_telemedicine_policy.pdf
Ct. 743. 38. Hall, A. J., Logan, J. E., Toblin, R. L., Kaplan, J. A., Kraner, J. C.,
28. See 20 U.S.C. §1412(a)(1)(A). Bixler, D . . . & Paulozzi, L. J. (2008). Patterns of abuse among
29. See Fry v. Napoleon Community Schools, 580 U.S. __ (2017), 137 unintentional pharmaceutical overdose fatalities. Journal of the
S. Ct. 758–759. American Medical Association, 300 (22), 2613–2620. https://doi
30. American Occupational Therapy Association (AOTA), American .org/10.1001/jama.2008.802
Speech–Language–Hearing Association (ASHA) & American 39. Jimmo v. Sebelius, No. 5:11-cv-17, 2011 WL 5104355 (D. Vt. 2011).
Physical Therapy Association (APTA). (2014). Consensus statement 40. Medicaid and CHIP Payment and Access Commission. (2016).
on clinical judgment in health care settings: AOTA, APTA, ASHA. State Medicaid payment policies for inpatient hospital services.
Retrieved from https://integrity.apta.org/ConsensusStatement/ Retrieved from https://www.macpac.gov/publication/macpac
31. National Institutes of Health. (1997). Acupuncture: National -inpatient-hospital-payment-landscapes/
Institutes of Health consensus development conference state- 41. Patient Protection and Affordable Care Act, Pub. L. 111–148, 42
ment. Retrieved from https://consensus.nih.gov/1997/1997 U.S.C. §§ 18001-18121 (2010).
Acupuncture107html.htm 42. Florida Administrative Code, Minimum Standards for Home
32. National Health Service Health at Work Network. (2008). Health Agencies, ch. 59A-8.0095[8], 2013.
Healthcare professionals’ consensus statement: Statement of 43. American Occupational Therapy Association. (2015). Occupa-
health and work. Retrieved from https://www.nhshealthatwork. tional therapy code of ethics (2015). American Journal of Oc-
co.uk/images/library/files/Bulletins/Feb_18_hwwb-healthcare cupational Therapy, 69(Suppl. 3), 6913410030. https://doi.org
-professionals-consensus-statement-04-03-2008.pdf /10.5014/ajot.2015.696S03
CHAPTER
Malpractice
LEARNING OBJECTIVES
At the end of this chapter, readers should be able to
■ Discuss steps they can take to avoid malpractice,
■ Explain different kinds of behaviors that constitute malpractice, and
■ Describe the requirements to keep patient information private under the Health Insurance Portability and Accountability
Act (HIPAA).

• Assault • HIPAA Privacy Rule • Negligent supervision
• Battery • HIPAA Security Rule • Privacy
• Compensatory damages • Informed consent • Protected health information
• Confidentiality • Intentional infliction of • Punitive damages
• Disclosure emotional distress • Tort law
• False imprisonment • Malpractice • Vicarious liability
• HIPAA • Negligence

The Joint Commission defines malpractice as Privacy and Confidentiality
improper or unethical conduct or unreasonable lack of Long before the passage of the Health Insurance Portability
skill by a holder of a professional or official position; often and Accountability Act (HIPAA)2 (P. L. 104–191), which cod-
applied to physicians, dentists, lawyers, and public officers ified patient privacy and confidentiality rights, occupational
to denote negligent or unskillful performance of duties therapy practitioners had an obligation to preserve patients’
when professional skills are obligatory.1 privacy and keep patient information confidential.3 This
tradition continues and stands embedded in the American
This chapter introduces future occupational therapy manag- Occupational Therapy Association (AOTA) Occupational
ers to concepts of occupational therapy malpractice, including Therapy Code of Ethics (2015)4 (hereinafter, the Code), which
laws that protect patient privacy. Managers need to recognize mandates that occupational therapy practitioners keep writ-
when legal questions arise and when to ask questions or seek ten communication confidential and maintain the privacy of
advice. Like prevention’s role in health care, prevention plays their clients.
an important role to help people avoid potential malpractice Privacy implies the right of patients “to be left alone,”
and its consequences. free from intrusion, and to choose whether or not to share
Note. The in-text legal citations in this chapter are abbreviated, rather than Blue Book style, to make the chapter more read-
able by occupational therapy professionals and students who do not work in the legal profession.
https://doi.org/10.7139/2019.978-1-56900-592-7.061
571
CHAPTER
Malpractice
LEARNING OBJECTIVES
At the end of this chapter, readers should be able to
■ Discuss steps they can take to avoid malpractice,
■ Explain different kinds of behaviors that constitute malpractice, and
■ Describe the requirements to keep patient information private under the Health Insurance Portability and Accountability
Act (HIPAA).

• Assault • HIPAA Privacy Rule • Negligent supervision
• Battery • HIPAA Security Rule • Privacy
• Compensatory damages • Informed consent • Protected health information
• Confidentiality • Intentional infliction of • Punitive damages
• Disclosure emotional distress • Tort law
• False imprisonment • Malpractice • Vicarious liability
• HIPAA • Negligence

The Joint Commission defines malpractice as Privacy and Confidentiality
improper or unethical conduct or unreasonable lack of Long before the passage of the Health Insurance Portability
skill by a holder of a professional or official position; often and Accountability Act (HIPAA)2 (P. L. 104–191), which cod-
applied to physicians, dentists, lawyers, and public officers ified patient privacy and confidentiality rights, occupational
to denote negligent or unskillful performance of duties therapy practitioners had an obligation to preserve patients’
when professional skills are obligatory.1 privacy and keep patient information confidential.3 This
tradition continues and stands embedded in the American
This chapter introduces future occupational therapy manag- Occupational Therapy Association (AOTA) Occupational
ers to concepts of occupational therapy malpractice, including Therapy Code of Ethics (2015)4 (hereinafter, the Code), which
laws that protect patient privacy. Managers need to recognize mandates that occupational therapy practitioners keep writ-
when legal questions arise and when to ask questions or seek ten communication confidential and maintain the privacy of
advice. Like prevention’s role in health care, prevention plays their clients.
an important role to help people avoid potential malpractice Privacy implies the right of patients “to be left alone,”
and its consequences. free from intrusion, and to choose whether or not to share
https://doi.org/10.7139/2019.978-1-56900-592-7.061
571
one’s self.5 In the health care context, confidentiality refers Since HIPAA’s inception, its regulations have changed from
to information or data about the patient.6 It implies a trust time to time as technology and other circumstances change,
in private communications; when a client makes a disclosure so occupational therapy managers should make sure their
to an occupational therapy practitioner in any form—verbal, staff members maintain current knowledge and practice of
written, and so forth—the practitioner must not disclose the HIPAA requirements to avoid significant penalties to their
information to others.7 Privacy is the right of a patient to con- institution or their own practices.
trol personal information, whereas confidentiality refers to
the promise or obligation not to share information or data
PHI
about the patient.8,9
Some licensure laws specifically incorporate the Code by ref- The purpose of the HIPAA Privacy Rule is to define and
erence, giving its aspirational guidelines for privacy and confi- limit the use and disclosure of individuals’ PHI. The rule sets
dentiality the full weight of law (e.g., the Louisiana Occupational forth 18 identifiers, which if associated with medical infor-
Therapy Practice Act, 201510). Other licensure laws specifically mation or billing, renders that information PHI. Occupa-
mandate client confidentiality and privacy as a legal obligation tional therapy practitioners and other health care providers
without incorporating the Code (e.g., the Pennsylvania Occupa- can de-identify the PHI by removing the 18 identifiers. The
tional Therapy Practice Act, 201411). Occupational therapy prac- 18 identifiers include20,21
titioners need to familiarize themselves with their licensure laws
1. Name
and adjust their behavior accordingly.
2. Address (all geographic subdivisions smaller than state,
HIPAA went a step further than individual state licensure
including street address, city, county, and zip code)
requirements and codified patient privacy and confidential-
3. All elements (except years) of dates related to an individ-
ity requirements into law by attempting to weave together all
ual (including birthdate, admission date, discharge date,
local, state, and federal privacy and confidentiality laws and
date of death, and exact age if over 89)
rules into a single law. HIPAA required the Secretary of Health
4. Telephone numbers
and Human Services (HHS) to establish regulations to pro-
5. Fax number
tect the privacy and “certain health information.”12 HHS met
6. Email address
this requirement by publishing two rules, referred to as the
7. Social Security number
HIPAA Security Rule and the HIPAA Privacy Rule. The final
8. Medical record number
regulations to the HIPAA Security Rule specify a comprehen-
9. Health plan beneficiary number
sive set of security standards to protect electronic-protected
10. Account number
health information, such as information in electronic health
11. Certificate or license number
records and other information transmitted electronically.13,14
12. Any vehicle identifiers, including license plate numbers
The HIPAA Privacy Rule created national privacy standards
13. Device identifiers and serial numbers
to address the circumstances under which private patient
14. Web Universal Resource Locators (URLs)
information (called protected health information, or PHI)
15. Internet Protocol (IP) addresses
may be used and distributed by covered entities.
16. Finger or voice print or other biometric identifiers
Only covered entities, which include providers, clear-
17. Photographic image—not limited to images of the face
inghouses, and health plans, must comply with HIPAA.15,16
18. Any other identifying number or characteristic that
Covered health providers include people, businesses, or agen-
could uniquely identify an individual.
cies that furnish, bill, or receive payment for health care in
the normal course of business and transmit or send any cov- Failure to eliminate any of the 18 identifiers would allow
ered transactions electronically.17 someone to locate or identify the patient and thus violate
Transactions are electronic exchanges of information HIPAA. Under the rules, a covered entity cannot use or dis-
“between two parties to carry out financial or administrative close PHI unless the Privacy Rule allows or requires the dis-
activities related to health care.”18 Electronic transactions closure or the individual or his or her personal representative
relevant to occupational therapy practice include, among authorizes the release in writing.22
others, claims and encounter information, payment and re-
mittance advice, claims status, eligibility, and referrals and
HIPAA enforcement and oversight
authorizations.19 Thus, if an occupational therapy depart-
ment or practice bills electronically or seeks referrals and HHS’ Office for Civil Rights (OCR) oversees enforcement of the
authorizations electronically, HHS will probably consider HIPAA regulations. In 2013, the OCR issued amendments to the
them a “covered health provider” and subject to the HIPAA HIPAA Privacy, Security, Breach Notification, and Enforcement
privacy and security rules. Rules, called the HIPAA Omnibus Final Rule.23 Some of these
Because they are health care providers or work for health changes may affect occupational therapy practitioners directly.
care providers who bill or transmit information electron- For example, the new rules provide additional protection for
ically, occupational therapy practitioners must abide by patients with increased control over the distribution of their
the HIPAA Privacy Rule. Most facilities provide their own PHI.24 Under this rule, when patients pay out of pocket, they
HIPAA training with their own interpretation of the law. can instruct their occupational therapy practitioners not to
CHAPTER 61. Malpractice 573
share information about their treatment with their insurance Not only does disclosure violate legal and ethical require-
company.25 The same sharing restrictions hold true for services ments for confidentiality, privacy, and HIPAA, it may also
paid out of pocket by Medicare recipients.26 threaten the patient in other significant ways. Similarly, some
The 2013 rule also changed the definition of a HIPAA states treat HIV status or testing in a special manner, with
breach. Under the new rule, if a breach occurs, the OCR will specific requirements for privacy and notification in the event
ask for proof that the entity conducted a risk assessment of an exposure (e.g., HIV Testing, 201742). Occupational ther-
to show it had a low probability of compromised PHI.27 apy practitioners who may encounter bloodborne pathogens
Therefore, covered entities should conduct periodic risk should familiarize themselves with their facility’s infection
assessments. The rule also provides that covered entities must control procedures and their state’s requirements.
provide patients with access to their medical record in elec- Some laws create exceptions to the obligation to protect the
tronic format if they prefer an electronic copy.28,29 The federal privacy of medical information. For example, professionals in
government can bring criminal charges against covered enti- all 50 states have a legal obligation to report suspected child
ties and other responsible corporate parties that knowingly abuse and neglect.43 Some states require health professionals
violate HIPAA’s privacy rules.30 Under the 2013 HIPAA rule, to report suspected elder abuse (e.g., Illinois’s Adult Protective
the OCR considers civil money penalties for HIPAA breaches Services Act, 201344). Some of these laws obligate occupational
based on the degree of negligence and mitigating or aggravat- therapy practitioners to report abuse to the proper authorities,
ing factors, and it can assess penalties of up to a maximum of and some waive confidentiality requirements to protect occu-
$1.5 million per breach.31,32,33 pational therapy practitioners who report child abuse.45
Although HIPAA provides for civil and criminal penal- Some states recognize that mental health professionals
ties, it does not create a private cause of action for individuals have a duty to warn potential victims when a patient commu-
whose protected health information is disclosed.34,35 In other nicates a credible threat to another individual to them (e.g.,
words, if an occupational therapy practitioner discloses a pa- Tarasoff v. Regents of University of California, 1976).46 How-
tient’s or client’s protected health information, the patient or ever, few states consider occupational therapy practitioners as
client cannot sue the practitioner or the hospital or employer mental health professionals, and courts have not yet applied
in federal court for violating HIPAA.36 Tarasoff to occupational therapy. Managers may want to seek
However, states have allowed lawsuits where covered enti- legal advice should a client make a credible threat in their
ties violated HIPAA, rejecting the argument that HIPAA, as clinic against another identifiable individual.
a federal law, preempted any state law action for the breach. Some states permit and some may require occupational
This is especially true for state claims of negligence or con- therapists (OTs) to report impaired drivers based on infor-
duct that falls below the standard of care expected of a hos- mation obtained in an occupational therapy assessment. Cir-
pital or health professional.37 Other state courts have viewed cumstances under which OTs may report or shall report vary
unauthorized medical record releases or HIPAA breaches as among the states. States that require reporting impaired driv-
falling under state tort, negligence, or malpractice law (e.g., ers provide immunity from civil lawsuits for reporting.47,48,49
Baum v. Keystone Mercy Health Plan, 2011,38 and Biddle v. Occupational therapy managers should familiarize them-
Warren Gen. Hosp., 199939). Thus, occupational therapy selves with reporting obligations—whether required or per-
practitioners may subject themselves to individual liability mitted—to protect their clients and avoid possible criminal
for breach of confidentiality or invasion of privacy in a civil or civil penalties for failing to report.
lawsuit or to disciplinary action from state licensure boards.
Liability Issues
Disclosure of Medical Information
OTs are responsible for performing accurate assessments,
Disclosure means giving another party access to a patient’s developing sound plans of care, delivering proper clinical in-
or client’s protected health information, without the express terventions, and, above all, doing no harm. Managers must
permission of the patient or client. Disclosure of some catego- understand and try to prevent legal claims against occupa-
ries of medical information can result in drastic consequences tional therapy practitioners or occupational therapy depart-
for patients, whereas special laws provide specific protection ments and practices in cases where OTs or occupational
and others may require disclosure. One law that provides spe- therapy assistants (OTAs) under their supervision fail to
cific protection is the Genetic Information Nondiscrimina- properly perform their duties.
tion Act40 (GINA; P. L. 110–233). GINA specifically prohibits Legal claims fall into 2 main categories: civil and crimi-
discrimination based on the results of genetic tests. Suppose nal. Civil claims, unlike criminal claims or charges, do not
a medical record contains genetic test results for a heart con- threaten practitioners with jail time or a criminal record. Civil
dition. The same test also includes information from the pa- liability or responsibility is concerned with either money dam-
tient’s genetic profile, indicating he is at high risk to develop ages or injunctive relief. When a court issues an injunction, it
Alzheimer’s disease.41 Disclosure of this information to an prevents a person or entity from doing something. In a typi-
employer, for example, may risk job loss or other consequences cal example, a judge issues an injunction to keep an abusive
to the individual, so an occupational therapy practitioner may spouse away from a battered spouse. This section focuses on
not disclose this information without the patient’s permission. the civil aspect of legal actions, and tort actions in particular.
Most lawsuits filed against occupational therapy practi- the task and the role the OTA will play in the task and obtain
tioners for harm fall under the umbrella of tort law.50 Tort law Eric’s consent. If the OTA fails to obtain informed consent,
covers an intentional or negligent harm or wrong against an- courts could consider reaching forward, while communicat-
other that results in damages for which 1 party may be liable. ing the intent to provide assistance, an assault and actually
Torts often form the basis for malpractice.51 Virtually all the touching the client and providing hands-on assistance, bat-
diverse forms of ADLs and other occupations in people’s tery. In some states, failure to obtain informed consent in
lives—driving, working, writing, owning or using real or per- itself may provide its own independent basis for malpractice.
sonal property, or engaging in sexual intercourse—may cause
harm. The harm could be physical harm or emotional harm.
False imprisonment
That harm may lead to a potential civil tort claim or civil law-
suit. Various forms of liability can arise from occupational False imprisonment occurs when someone violates another’s
therapy interventions in ADLs and in other occupations, basic personal right to freedom from wrongful confinement.57
depending on the circumstances. The focus is on the mental harm caused by the knowledge
The legal system categorizes various types of torts, or of confinement. False imprisonment could occur if practi-
wrongs against another. This section addresses some of these tioners confine clients with the intent to confine them within
categories, including battery and assault, false imprisonment, certain boundaries: The “imprisoned” person must know
intentional infliction of emotional distress, negligence, and of no reasonable or safe avenue of escape. Merely blocking
malpractice. someone’s path in one direction or exerting moral or social
pressure does not constitute false imprisonment. The person
must know of the confinement.
Battery and assault
In health care, a patient not lawfully committed to an
Battery and assault are intentional torts or harms, meaning appropriate facility has no obligation to stay, and physi-
the person doing the harm intended to do something that cal or coercive efforts to restrict movement may constitute
results in harm to another.52 Battery occurs when a person false imprisonment. The Nursing Home Reform Act (in
intentionally comes in physical contact with another per- the Omnibus Budget Reconciliation Act, known as OBRA;
son, without that person’s permission, resulting in a harm- P. L. 100–20358), requires nursing homes take certain steps to
ful consequence.53 The person who makes a claim for battery avoid unnecessarily restraining its residents. If the restraint
must prove that a touching occurred, the person who did is not in patients’ care plans, tying nursing home residents
the touching intended to do it, and the touching harmed the to a wheelchair to prevent them from wandering might
person touched. In this context, person includes both one’s constitute false imprisonment. In addition, if patients who
body and the things closely connected to it (e.g., reacher, voluntarily admit themselves to a psychiatric setting decide
wheelchair).54 to leave a few days later, the OT, and nursing staff cannot
Like battery, assault is an intentional tort. An assault oc- coerce them to stay by threatening to have them commit-
curs when a person apprehends a threat that another will en- ted should they leave. A court could determine this threat
gage in an offensive touch or cause them immediate harm.55 meets enough of the basic elements to support a case for false
The court will inquire as to whether a reasonable person imprisonment.59
would apprehend an offensive touching or immediate harm.
It must appear that the threat is imminent, coupled with ob-
Intentional infliction of emotional distress
vious intent to carry out the threat. Words alone, however
strong, do not constitute an assault. There are circumstances Intentional infliction of emotional distress occurs when,
when an act itself may appear innocuous or harmless (e.g., through extreme and outrageous conduct, someone inten-
crossing one’s arms), but the words that accompany it create tionally causes severe emotional or mental distress, such as
the required apprehension. If the court finds that a reasonable grief or anguish, to another person.60,61 The person’s conduct
person would not perceive an immediate danger, the threat- must be “so outrageous in character, and so extreme in degree,
ening gestures probably will not constitute an assault. as to go beyond all possible bounds of decency.”62 Insulting,
Assault and battery in health care settings generally occur profane, abusive, annoying, or even threatening conduct is
because practitioners perform acts or procedures without in- not enough to meet this criterion, unless the offending per-
formed consent. Informed consent implies “a rational and in- son knows of some special sensitivity of the person being sub-
formed decision about undertaking a particular treatment or jected to harm. The person filing a claim must suffer severe
undergoing a particular surgical procedure” based on knowl- emotional damages. A brief episode of unhappiness, humil-
edge of the “significant potential risks involved in the pro- iation, or mild despondence or a few restless nights do not
posed treatment or surgery.”56 Battery may occur if clients do rise to the level of severe emotional distress. If the emotional
not agree to an intervention or would not have agreed had the anguish is great and prolonged, however, it may form the
occupational therapy practitioner informed them about it. basis of a successful claim for intentional infliction of emo-
For example, an OTA wishes to assist Eric, an autistic tional distress.63 Sometimes a bystander who witnesses an-
adult with sensory defensiveness, to put on a shirt. Before as- other’s injury may seek remedies as the party who suffered
sisting him, the OTA should inform him of the objectives of severe emotional distress. The distress to the bystander must
represent a foreseeable consequence of the alleged conduct to Malpractice

constitute intentional infliction of emotional distress.64
The legal system holds health care professionals to a higher
In health care, patients may claim they suffered unneces-
standard than the ordinary care standard expected of a non-
sary severe emotional distress caused by a health care pro-
health professional in most states because of their training
vider. For example, an outpatient clinic provides occupational
and the expectations the public ascribes to health profes-
therapy treatment for a client’s carpal tunnel syndrome. The
sionals. The practitioner–patient relationship creates a legal
client told his OT that he had been undergoing treatment for
duty to the patient. In most cases, the health care provider
depression for the past 6 months, and she noted his antide-
has a duty to obtain informed consent before providing in-
pressant medications in his electronic health record. When
tervention. The provider of occupational therapy services has
the client arrived late to an extremely busy outpatient clinic
a duty to provide those services according to the standard of
for his 3rd visit, the OT screamed and swore at him for show-
care of the profession. When patients enter into a relation-
ing up late. The therapist told the client that he was a “worth-
ship with an OT or OTA, they have an expectation that the
less client” and insisted that he leave the outpatient clinic.
professional will perform using the specialized skills, knowl-
Under these circumstances, the court would probably find a
edge, and abilities of a reasonable and prudent practitioner.
valid claim for intentional infliction of emotional distress, as
This means clients should expect, among other things, accu-
it did in Anderson v. Pease (1982),65 where a physician cursed
rate assessments, sound plans of care, and proper and safe
at a patient who he knew lived with depression and screamed
interventions.
at her to leave his office.
To constitute the tort of malpractice, the client has to show
the occupational therapy practitioner’s action or inaction fell
Negligence below the professional standard of care and injured the client.
In addition to actions for intentional acts of assault, battery, The action or inaction must be contrary to the standards of the
false imprisonment, and intentional infliction of emotional profession.70,71 The occupational therapy practitioner must do
distress, malpractice actions often rest on theories of negli- something or fail to do something—that a reasonable, prudent
gence. Ordinary negligence is the failure to exercise the stan- occupational therapy practitioner in the same situation would
dard of care a reasonable, prudent person would exercise in a do or not do—that causes unnecessary harm to a client.
similar situation.66,67 Negligence does not involve intentional State laws govern damages in malpractice cases. There are
or reckless actions; it involves carelessness. The person’s state generally 2 types of damages: compensatory damages and
of mind is not considered, only his or her actions. punitive damages. Compensatory damages compensate an
Ordinary negligence applies to everyday people in every injured party harmed by the willful or reckless conduct of
day situations. It can result from something a person does a practitioner, usually through monetary relief. Successful
(e.g., rear-ending a car that brakes suddenly to avoid a plaintiffs in medical malpractice cases can usually recover
squirrel) or something a person fails to do (e.g., not placing a out-of-pocket losses, such as medical bills and future med-
“wet floor” sign on a recently washed floor).68 To establish a ical expenses, loss of income and temporary or permanent
claim of negligence, one must prove 4 elements: a duty to act impairment of earning capacity, incidental expenses, and
in a particular way, a breach of that duty, actual harm or dam- money to fairly represent the pain, suffering, and mental dis-
ages, and a causal connection or “proximate cause” between tress experienced.72 Punitive damages are damages meant to
the breach of the duty and the harm or damages.69 punish the party who caused the harm.73 Some states limit
For example, while Mary is driving down the road to do the amount of punitive damages courts may award.
a home evaluation, she drops her cell phone, reaches down In the legal context, OTs and OTAs need not provide supe-
to get it, and crashes into a car stopped at a light. Mary rior care. Rather, they must provide care within the standard
might be found negligent based on each of the 4 elements of care for the profession. Professional malpractice may occur
in negligence (assuming her state does not follow no-fault when an occupational therapy practitioner fails to follow the
insurance laws): standard of care and the failure results in harm or injury to
a client. The following are examples of possible professional
1. Duty to act in a particular way: In exchange for the privi-
malpractice in occupational therapy settings, where the oc-
lege of driving, Mary had a duty to other drivers to drive
cupational therapy practitioner’s conduct falls below the stan-
carefully, keeping her eyes on the road and watching for
dard of care for a reasonable practitioner:
other cars to avoid a collision.
2. Breach of that duty: Mary breached her duty to drive care- ■ Improperly transferring a client, resulting in a fall.
fully when she took her eyes off the road to reach for her ■ Failing to supervise a client during an activity, resulting in
cell phone. an overuse injury.
3. Actual harm or damage: Mary crashed into a car and ■ Forgetting to tell the nurse of the client’s complaints of
caused damage to the car and harm to the passenger. chest pain during occupational therapy intervention, re-
4. Causal connection or proximate cause between the breach sulting in a heart attack and subsequent death.
of the duty and the actual harm: Mary’s failure to drive ■ Improperly maneuvering a wheelchair in preparation for a
carefully by taking her eyes off the road was the proxi- transfer, causing the chair to fall backward and the client’s
mate or direct cause of the car accident. head to hit the floor, resulting in a subdural hematoma.
■ Failing to ensure that a fieldwork student is competent to Review Questions

perform a client transfer before allowing him or her to do
1. The doctrine of respondeat superior refers to
so, causing injury to the client.
a. A supervisor’s responsibility for acts of subordinate
■ Failing to secure sharp instruments properly in the occu-
workers
pational therapy clinic of a locked psychiatric unit.
b. An expert witness
■ Failing to lock the wheelchair during a transfer, resulting
c. A defective product, such as a splint, fabricated by a
in a fall.
superior or a supervisor
■ Causing burns from a hot pack.74
d. The standard of care
■ Engaging in sexual misconduct with a client.75
2. Mrs. Washington has lack of sensation in her right hand
■ Failing to evaluate client safety in bathroom transfers, and
accompanied by stiff joints. José, the treating OT, de-
the client falls.
cides to put a hot pack on Mrs. Washington to alleviate
■ Ignoring seizure precautions for a child during spinning
the stiffness in her joints. Because of the lack of sensation,
activities for a sensory integration intervention, causing a
Mrs. Washington is unable to report pain from the hot
seizure.
pack, and she sustains severe burns on her hand. This in-
■ Improperly instructing a client in the use of a splint or
tervention is not one that any occupational practitioner
other device.
following professional standards of care would use. Since
■ Failing to use a gait belt while ambulating a client with a
José’s conduct falls below the standard of care for occupa-
known risk of falls during a treatment session, resulting in
tional therapy practice, it is called
the client falling and breaking a hip.
a. Negligence
■ Failing to refer the client to another practitioner who is
b. Malpractice
more competent to treat the client.
c. Duty
An OT will testify as an expert witness in malpractice d. Battery
suits against other practitioners, or defendants, to establish 3. An occupational therapy practitioner walks into a room
the standard of care and how a defendant’s actions fell below in a long-term care facility to treat a client and hears the
that standard. The occupational therapy expert witness might certified nursing assistant tell the other patient in the
cite specific textbooks or journal articles to support his or her room that if she doesn’t get out of bed and get dressed im-
position. For example, suppose an OT put a hot pack on a cli- mediately, she will “get her up herself and it won’t be fun.”
ent’s desensate hand for 15 minutes, and the hot pack burned Verbal threats to a patient like this are considered
the client. An occupational therapy expert witness would tes- a. Battery
tify that no reasonable, prudent OT would put a hot pack on b. Assault
a desensate hand for 15 minutes, because it is dangerous and, c. Negligence
therefore, contraindicated, because it might burn the client. d. Malpractice
The expert witness might cite a standard occupational ther-
apy physical disabilities textbook, called a “learned treatise” PRACTICAL APPLICATIONS IN
under the law, to support the position that hot packs are con-
traindicated for a person with a desensate hand.76
OTs, OTAs, and occupational therapy managers may find Victims of malpractice in the therapeutic relationship may suf-
themselves vicariously liable, or responsible for the negli- fer damages in a multitude of areas, physically, mentally, and
gence of others, under the doctrine of respondeat superior, emotionally. Because laws related to medical malpractice vary
Latin for “let the master answer” from the historical master– from state to state, managers must familiarize themselves with
servant relationship. The doctrine of vicarious liability holds the laws that govern malpractice in their own state and take
the employer or supervisor liable or responsible for the ac- steps to prevent malpractice among their staff. Department
tions of employees or subordinates that occur in the course of in-services can keep occupational therapy practitioners current
employment. It implies that the superior may be liable for the in relevant areas of practice. Encouraging and promoting con-
acts of the subordinate, even if the superior is without fault.77 tinuing education opportunities, directly related to practice, can
Another basis for a malpractice action is negligent super help keep people competent. Peer reviewing other practitioners’
vision. Whereas respondeat superior holds employers liable practices can give them insight into their needs, their strengths
for actions of others that were not their fault, under negligent and weaknesses, and ways to improve their interventions.
supervision supervisors are held liable for their own actions Accurate, timely, and detailed documentation can help
in hiring incompetent employees, failing to train them, or protect occupational therapy practitioners from lawsuits.
failing to properly supervise them.78,79 Occupational therapy Conversely, documentation that does not specify what the inter-
practitioners must know and fulfill their professional respon- vention was and how the client responded to it can hurt practi-
sibilities for supervision. In addition to civil lawsuits, negli- tioners. Once something is in a client’s record, the occupational
gent supervision could lead to loss of license or disciplinary therapy practitioner cannot erase or delete it. Similarly, failing
action by the state licensure board (e.g., see Title 24 of the to record something in the medical or health record means it
Delaware Code, 201780). never happened; one cannot add it to the record later.
Simple steps, such as clear communication with clients and LEARNING ACTIVITIES
being nice to clients, helps prevent lawsuits. Research shows
the relationship between actual negligence and the number of 1. An attorney contacts you to serve as an expert witness in
malpractice claims is weak,81 whereas good communication a case in which an occupational therapy client fell during
with clients decreases the incidence of malpractice lawsuits.82 an ADL treatment session while standing in front of a
Managers can play a key role in lowering the risk of malprac- bathroom mirror and shaving. The client’s chart states he
tice by fostering good communication and good customer ser- is at a moderate risk for falls. The OT put a gait belt on
vice with clients and ensuring staff members practice within the client during the session. The attorney wants to know
the boundaries of their practice act and licensure law, standard what the standard of care is under these circumstances.
of practice, and code of ethics.83,84,85 Describe the steps you would take to establish what you
believe is the standard of care.
Review Questions 2. Using the hypothetical situation in Question 1, have 1 person
discuss the reasons to support what the OT did and another
1. Carly’s client, Mrs. Salter, is being discharged from discuss the reasons why the OT’s conduct fell below the stan-
rehab next week. Carly does a home assessment and doc- dard of care.
uments that Mrs. Salter will need training in transferring 3. As a manager of a clinical occupational therapy program,
to a bath bench from her wheelchair with an approach to put together a program of steps you would take to prevent
the left. Carly continues Mrs. Salter’s occupational ther- malpractice in your department.
apy services until discharge. Mrs. Salter is discharged and 4. As a manager of a clinical occupational therapy program,
falls in the bathroom attempting the transfer in her home. describe what you would do to address the need for prac-
Mrs. Salter hires an attorney who requests the medical titioners to obtain informed consent before they provide
record. Upon review of the medical record, no notes are treatment.
found that show that Carly worked on transfers to a bath
bench from a wheelchair with an approach to the left.
Mrs. Salter sues Carly for malpractice. Carly insists she ACOTE STANDARDS
worked with Mrs. Salter on the transfers. This situation
an example of what legal principles? This chapter addresses the following ACOTE Standards:86
a. If you didn’t document it, it didn’t happen. ■ B.3.7. Safety of Self and Others
b. The medical record is a legal document. ■ B.4.10. Provide Interventions and Procedures
c. Documentation can protect you from malpractice if ■ B.4.12. Orthoses and Prosthetic Devices
you document properly. ■ B.4.16. Dysphagia and Feeding Disorders
d. All of the above. ■ B.4.17. Superficial Thermal, Deep Thermal, and Electro-
2. Which of the following are valid ways to prevent therapeutic Agents and Mechanical Devices
malpractice: ■ B.4.22. Need for Continued or Modified Intervention
a. Be nice to patients. ■ B.4.29. Reimbursement Systems and Documentation
b. Document everything. ■ B.5.3. Business Aspects of Practice
c. Never change anything in your documentation after ■ B.5.7. Quality Management and Improvement
the fact. ■ B.5.8. Supervision of Personnel
d. All of the above. ■ B.7.1. Ethical Decision Making
3. Which of the following are simple steps that can help ■ B.7.4. Ongoing Professional Development
avoid malpractice? ■ B.7.5. Personal and Professional Responsibilities.
a. Make sure you have clear communication with your
clients.
b. Stay current with your occupational therapy knowledge. REFERENCES
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23. Modifications to the HIPAA Privacy, Security, Enforcement, and 47. Oregon Driver and Motor Vehicle Services. (2016). At-Risk Driver
Breach Notification Rules Under the Health Information Tech- Program for Medical Professionals. Retrieved from http://www
nology for Economic and Clinical Health Act and the Genetic .oregon.gov/ODOT/DMV/pages/at-risk_program_index.aspx
Information Nondiscrimination Act; Other Modifications to 48. Oregon Driver and Motor Vehicle Services. (n.d.). Driving assess-
the HIPAA Rules. (January 24, 2013). 78 FR 5565 C.F.R. ments; driving training; car adaptations. Retrieved from http://
24. Ibid. www.oregon.gov/otlb/Documents/DRIVINGASSESSMENTS
25. Gamble, M. (Aug. 13, 2013). 15 things to know about the HIPAA -2017.pdf
omnibus final rule before Sept. 23. Becker’s Hospital Review. 49. Virginia Department of Motor Vehicles. (2017). DMV medical
Retrieved from https://www.beckershospitalreview.com/legal review of drivers. Retrieved from https://www.dmv.virginia.gov
-regulatory-issues/15-things-to-know-about-the-hipaa-omnibus /drivers/-medical/review.asp
-final-rule-before-sept-23.html 50. Ranke, B. A., & Moriarty, M. P. (1997). An overview of pro-
26. Ibid. fessional liability in occupational therapy. American Journal
27. Baum, S. (Sept. 23, 2013). 10 things you need to know about HIPAA of Occupational Therapy, 51, 671–680. https://doi.org/10.5014
Omnibus final rule. Medcity News. Retrieved from https://medcity /ajot.51.8.671
news.com/2013/09/10-things-need-know-hipaa-omnibus 51. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser
-final-rule/?rf=1 and Keeton on torts (5th ed). St. Paul, MN: West Group.
52. Ibid. 73. Ibid.

53. Ibid. 74. Ranke, B. A., & Moriarty, M. P. (1997). An overview of professional
54. Ibid. liability in occupational therapy. American Journal of Occupa-
55. Ibid. tional Therapy, 51, 671–680. https://doi.org/10.5014/ajot.51.8.671
56. Johnson v. Kokemoor, 199 Wis.2d 615, 630 (1996). 75. Ibid.
57. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser 76. Learned treatise. (2002). McGraw-Hill Concise Dictionary of
and Keeton on torts (5th ed). St. Paul, MN: West Group. Modern Medicine. Retrieved from https://medical-dictionary
58. Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203. .thefreedictionary.com/learned+treatise
59. Kazin, C. (1989). “Nowhere to go and chose to stay”: Using the 77. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser
tort of false imprisonment to redress involuntary confinement and Keeton on torts (5th ed). St. Paul, MN: West Group.
of the elderly in nursing homes and hospitals. University of 78. Zarin’s Jury Verdict Review and Analysis. (2010). Verdict:
Pennsylvania Law Review, 137, 903–927. Unlicensed physical therapy aide treats plaintiff following rota-
60. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser tor cuff surgery (41805). Retrieved from http://www.juryverdict
and Keeton on torts (5th ed). St. Paul, MN: West Group. review.com/Verdict_Trak/article.aspx?id=41805
61. Prosser, W. L. (1971). Law of torts (4th ed.). St. Paul, MN: 79. Smith, etc. v. Archbishop of St. Louis, 632 S.W. 2d 516 (1982).
West Publishing. 80. 24 Del. C. chap. 20 § 2015 (a)(8) (2017).
62. Metropolitan Life Ins. Co. v. McCarson, 467 So.2d at 279 81. Localio, A., Lawthers, A., Brennan, T., Laird, N., Hebert, L.,
(Fla. 1985). Peterson, L., . . . Hiatt, H. (1991). Relation between malprac-
63. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser tice claims and adverse events due to negligence: Results of the
and Keeton on torts (5th ed). St. Paul, MN: West Group. Harvard Medical Practice Study III. New England Journal of
64. Ibid. Medicine, 325, 245–251.
65. Anderson v. Pease, 445 A.2d, 612 (D.C., 1982) 82. Levinson W. (1997). Physician–patient communication: The
66. Garner, B. A. (2004). Black’s law dictionary (8th ed.). St. Paul, relationship with malpractice claims among primary care
MN: West Publishing. physicians and surgeons. Journal of the American Medical
67. Joint Commission. (Jan. 26, 2006). Sentinel event glossary of Association, 277, 553–559.
terms. Retrieved from http://www.jointcommission.org/Sentinel 83. American Occupational Therapy Association. (2015). Occu-
Events/se_glossary.htm pational therapy code of ethics (2015). American Journal of
68. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser Occupational Therapy, 69(Suppl. 4), 6913410030. https://doi.org
and Keeton on torts (5th ed). St. Paul, MN: West Group. /10.5014/ajot.2015.696S03
69. Ibid. 84. American Occupational Therapy Association. (2015). Stan-
70. American Occupational Therapy Association. (2014). Occupa- dards for continuing competence. American Journal of Oc-
tional therapy practice framework: Domain and process (3rd ed.). cupational Therapy, 66(Suppl. 3), 6913410055. https://doi.org
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48 /10.5014/ajot.2015.696S03
https://doi.org/10.5014/ajot.2014.682006 85. Oklahoma Occupational Therapy Practice Act, Title 59, O.S.
71. American Occupational Therapy Association. (2015). Standards §888.1-888.16 (2015).
for continuing competence. American Journal of Occupational 86. Accreditation Council for Occupational Therapy Education.
Therapy, 66( Suppl. 3), 6913410055. https://doi.org/10.5014/ajot (2018). 2018 Accreditation Council for Occupational Therapy
.2015.696S03 Education (ACOTE) standards and interpretive guide. Ameri-
72. Keeton, W., Dobbs, D., Keeton, R., & Owens, D. (2004). Prosser can Journal of Occupational Therapy, 72(Suppl. 2), 7212410005.
and Keeton on torts (5th ed). St. Paul, MN: West Group. https://doi.org/10.5014/ajot.2018.72S217
CHAPTER
Intellectual Property and Social Media
LEARNING OBJECTIVES
■ Recognize and discuss when occupational therapy practitioners may encounter issues with trade secrets, copyright
issues, and works for hire;
■ Differentiate personal use of social media from professional use of social media; and
■ Identify 3 social media interactions that can interfere with the occupational therapy practitioner–client relationship,
violate HIPAA, or lead to legal or other trouble.

• Copyright • Medium of expression • Trade secrets
• Fair use • Public domain • Work for hire
• Intellectual property
OVERVIEW ownership of intellectual property inherently creates a lim-

ited monopoly in the protected property.”1 Intellectual prop-
T
his chapter explores legal issues that involve occupa- erty traditionally includes the following 4 categories: patent,
tional therapy and intellectual property, such as copy- copyright, trademark, and trade secrets.2
right and trade secrets or using original written material Copyright is a federal law that protects authors of pub-
or ideas created by others. It also looks at the legal challenges lished and unpublished works from infringement by others.
presented by social media within the context of professional Authors of “original works of authorship,” including literary,
occupational therapy practice. With the integral nature of the dramatic, musical, and artistic works, as well as intellectual
Internet in people’s lives today, they may sometimes forget works on occupational therapy (e.g., this book, an occupa-
that someone else may own the photographs and other media tional therapy assessment),3 hold the exclusive right to repro-
on the Internet. Occupational therapy practitioners who want duce and otherwise derive income from their work.4
to use Internet media for their own purposes cannot assume The U.S. Constitution authorizes Congress “to promote
they can do so merely because the materials are on the Inter- the Progress of Science and useful Arts by securing for lim-
net. Using others’ photos on a practice’s website or copying ited Time to Authors and Inventers the exclusive Right to
parts of a written assessment may violate someone’s copyright. their respective Writings and Discoveries.”5 The framers of
the U.S. Constitution included copyright as a fundamental
ESSENTIAL CONSIDERATIONS right because they respected discoveries, writings, and in-
ventions. Pursuant to this mandate, Congress passed The
Understanding Intellectual Property
Copyright Law of the United States 6 to protect authors of
Intellectual property is “any product of the human intellect published and unpublished works from infringement by
that the law protects from unauthorized use by others. The others.
https://doi.org/10.7139/2019.978-1-56900-592-7.062
581
CHAPTER
Intellectual Property and Social Media
LEARNING OBJECTIVES
■ Recognize and discuss when occupational therapy practitioners may encounter issues with trade secrets, copyright
issues, and works for hire;
■ Differentiate personal use of social media from professional use of social media; and
■ Identify 3 social media interactions that can interfere with the occupational therapy practitioner–client relationship,
violate HIPAA, or lead to legal or other trouble.

• Copyright • Medium of expression • Trade secrets
• Fair use • Public domain • Work for hire
• Intellectual property
OVERVIEW ownership of intellectual property inherently creates a lim-

ited monopoly in the protected property.”1 Intellectual prop-
T
his chapter explores legal issues that involve occupa- erty traditionally includes the following 4 categories: patent,
tional therapy and intellectual property, such as copy- copyright, trademark, and trade secrets.2
right and trade secrets or using original written material Copyright is a federal law that protects authors of pub-
or ideas created by others. It also looks at the legal challenges lished and unpublished works from infringement by others.
presented by social media within the context of professional Authors of “original works of authorship,” including literary,
occupational therapy practice. With the integral nature of the dramatic, musical, and artistic works, as well as intellectual
Internet in people’s lives today, they may sometimes forget works on occupational therapy (e.g., this book, an occupa-
that someone else may own the photographs and other media tional therapy assessment),3 hold the exclusive right to repro-
on the Internet. Occupational therapy practitioners who want duce and otherwise derive income from their work.4
to use Internet media for their own purposes cannot assume The U.S. Constitution authorizes Congress “to promote
they can do so merely because the materials are on the Inter- the Progress of Science and useful Arts by securing for lim-
net. Using others’ photos on a practice’s website or copying ited Time to Authors and Inventers the exclusive Right to
parts of a written assessment may violate someone’s copyright. their respective Writings and Discoveries.”5 The framers of
the U.S. Constitution included copyright as a fundamental
ESSENTIAL CONSIDERATIONS right because they respected discoveries, writings, and in-
ventions. Pursuant to this mandate, Congress passed The
Understanding Intellectual Property
Copyright Law of the United States 6 to protect authors of
Intellectual property is “any product of the human intellect published and unpublished works from infringement by
that the law protects from unauthorized use by others. The others.
https://doi.org/10.7139/2019.978-1-56900-592-7.062
581
If a person imitates or copies copyrighted works and Review Questions

presents them to the public without the express consent of
1. Neville is finishing up his Level II fieldwork. During his
the original author, he or she is violating copyright laws and
fieldwork, he used an assessment that was new to him. He
infringing on the owner’s copyright.7 A person can acquire
really likes the assessment and decides to use the field-
copyright for original works only within a concrete medium
work office’s copier to copy the manual and accompanying
of expression, which means a work is tangible. Simply put,
worksheets so he can use them in the future when he gets
in the occupational therapy world, this would include liter-
a real job. What is the problem with Neville’s plan?
ary works, motion pictures or audiovisual works, assessment
2. Shareen is preparing her PowerPoint slides for her first pre-
tools, originally created adaptive equipment, and pictorial
sentation at her state’s annual occupational therapy confer-
and graphic works, among others.8 Express consent or per-
ence, and she wants to use some pictures from a copyrighted
mission to use the copyright-protected material usually
journal article to illustrate her presentation. She remembers
requires verbal or written permission from the author. How-
learning in school there are exceptions to copyright law that
ever, authors can legally transfer ownership of their copy-
would allow her to use the pictures. Which of the following
righted works, such as a chapter in a book, to another entity,
principles allow her to use the copyrighted pictures?
such as the publisher.9 Individuals who seek to use a protected
a. She is using the images for nonprofit educational
work must seek permission from the new or current owner of
purposes.
the copyright, also called the copyright holder.
b. She is using only 1 or 2 images from the copyrighted
article.
Fair Use c. She is using the images in a PowerPoint presentation
Fair use is a limited exception to copyright protection that for a non-profit organization and not in a book.
allows the use of copyrighted materials in limited circum- d. All of the above.
stances, such as teaching, scholarship, research, or book 3. Shareen’s presentation went so well that based on the feed-
reviews in which the use meets certain criteria specified in back she received, she decides to develop and sell a training
the law.10 Under the law, authors or copyright holders hold manual for parents on the same topic. Which of the follow-
the exclusive right to reproduce and otherwise derive income ing principles do not allow her to use the copyrighted pic-
from their work.11 Four factors determine whether copy- tures without the current copyright holder’s permission?
righted material falls under fair use: a. She is using only 1 or 2 images from the copyrighted
article.
1. The purpose and character of the use, including whether b. She is using the images for commercial purposes.
such use is of a commercial nature or is for nonprofit c. She is using the images for educational purposes.
educational purposes d. All of the above.
2. The nature of the copyrighted work
3. The amount and substantiality of the portion used in
relation to the copyrighted work as a whole PRACTICAL APPLICATIONS IN
4. The effect of the use on the potential market for or value OCCUPATIONAL THERAPY
of the copyrighted work.12
Copyrighted Materials in Practice:
Fair use can appear ambiguous and may vary in inter-
Respecting Ownership
pretation. Generally, uses that advance the public interest
in a noncommercial manner, such as criticism, education, Occupational therapy practitioners may encounter a multi
or scholarship, are favored.13 Courts will consider a variety tude of potential copyright concerns or pitfalls. Managers
of factors to determine whether a use constitutes fair use, and directors of facilities work with many different examples
including the quality and quantity of the copyrighted work of intellectual property—the umbrella term for copyright and
used.14 Fair use also means users must credit the original art- other rights such as patents—that neither they nor their staff
ists or authors. created, such as standardized assessments, evaluations, mea-
As indicated above, “fair use” is a limited exception that suring tools, and intervention materials.15 Managers provide
advances the public interest in a non-commercial manner. these materials to staff to enable them to assess their clients,
However, if someone uses a work and generates income from develop occupational profiles, and conduct interventions. If
the use, or interferes with the copyright owner’s income from staff members copy these materials internally, instead of pur-
the work, the law does not consider that fair use but rather chasing additional copies, they infringe on the owner’s copy-
a copyright violation. For example, an occupational therapy right. Practitioners who make copies for later use at another
student who photocopies this chapter instead of purchas- facility also violate copyright law.
ing this book interferes with the income of the copyright If professionals in an occupational therapy practice or fa-
owner and, therefore, is doing something illegal: violating cility create an assessment tool or intervention materials,
the owner’s copyright. Occupational therapy practitioners managers should ensure these items are used in a way that pro-
who photocopy—without permission—another institution’s tects both the employer and the authors of the materials from
assessment materials also violate the owner’s copyright. copyright infringement or trade secret issues. They should also
CHAPTER 62. Intellectual Property and Social Media 583
ensure that their staff does not treat a modified tool as their though José created the protocol and accompanying materials,
own work or distribute work created by someone else. he does not own what he created. Rather, his employer is the
Occupational therapy practitioners must obtain express per- copyright owner.
mission to use materials in all professional capacities, including Even though occupational therapy employees may create
photocopying or scanning. The copyright owner may be the au- materials as part of their job, they cannot use the materials
thor or the publisher; therefore, occupational therapy manag- outside the context of their employment nor can they use the
ers must seek permission to use copyright-protected materials, materials they created if they leave the job where they created
such as an assessment they wish to copy for their staff, through the materials and begin work with a different employer. The
the author or publisher’s website. Generally, occupational law considers such materials the trade secrets of their former
therapy managers can obtain permission for scholarly works employer and a work for hire for the former employer.
through the Copyright Clearance Center (a clearinghouse for Occupational therapy practitioners need to be aware of
many scholarly and professional works; www.copyright.com). their legal responsibility to protect their employers’ trade se-
Unless they guard against illegal and unethical behavior in the crets. Often in the course of employment, practitioners and
copyright arena, managers may find their facilities open to po- other professionals will learn about or use a “a formula, pat-
tential lawsuits for copyright infringement. tern, compilation, program, device, method, technique, or
process” created by and owned by their employer.19 They must
Trade Secrets and Work for Hire understand that this trade secret is meant to stay secret and
Trade secrets are defined under the Uniform Trade Secrets protected for the employer.
Act (UTSA) as adopted by Florida16 as Suppose an OT worked for a practice that developed a
computer program designed to create a home assessment for
information, including a formula, pattern, compilation, people with disabilities and older adults aging in place. Clini-
program, device, method, technique, or process that cians enter information into the program on their laptop or
tablet, which produces a report for the client’s chart with a list
■ Derives independent economic value, actual or potential,
of home modification recommendations in plain English, re-
from not being generally known to, and not being readily
sources to purchase devices and equipment and their prices,
ascertainable by proper means by, other persons who can
and instructions for home use of the devices and equipment.
obtain economic value from its disclosure or use; and
The report also features a list of local contractors who can
■ Is the subject of efforts that are reasonable under the
make the home modifications. This home assessment system
circumstances to maintain its secrecy17
would be considered a trade secret that belongs to the em-
Simply put, trade secrets are confidential business informa- ployer who created it. If the OT who worked for the practice
tion or processes that give a business, or practice or hospital, were to individually, or in conspiracy with others, attempt to
a competitive advantage. sell the information about the program or describe it in detail
Occupational therapy practitioners may acquire knowl- to a subsequent employer, the OT could face significant crim-
edge of trade secrets and intellectual property that belong to inal penalties, including fines of not more than $5 million or
the facilities, programs, departments, or practices in which imprisonment of not more than 15 years or both.20
they work. For example, suppose an occupational therapy
practice put a training program together to teach autistic
Social Media and the Internet
children to dress themselves. The program included a train-
ing manual, a slide presentation, and a methodology with a Social media can also present challenges to company secrets
specific set of procedures for the intervention. The practice and to copyright. Occupational therapy staff, whether cur-
trains Olivia, an occupational therapist (OT), to teach par- rent or former, should not post anything on social media
ents and others to use the program. The law would consider that might divulge any confidential company or employer se-
the methodology and specific set of procedures a trade secret; crets.21 Occupational therapy practitioners must be aware of
therefore, Olivia could use the program only as permitted by potential copyright issues presented by the Internet. They can
her employer, the occupational therapy practice. find a plethora of photographs, videos, graphics, infographics,
If an employee creates materials in his or her role as an em- and the like on the Internet. However, the overabundance of
ployee, those materials are considered a work for hire and is information in various forms on the Internet and the ability
owned by the employer, whether that employer is a practice, to readily and widely share this information or media with so
facility, program, or department.18 For example, suppose an many make it difficult to determine who owns the informa-
occupational therapy employee creates something unique that tion or media occupational therapy practitioners would like
gives his or her employer a competitive advantage. Consider to share with others. Use of photos or other content owned by
José, an OT employed by a private practice, who created mate- others without their permission can subject practitioners to
rials for a specific protocol to address feeding issues in autistic civil or criminal liability if they post the materials on social
children (including evaluation forms, handouts for parents, media sites or websites that belong to the facilities, programs,
and other materials). Because José created the program as an departments, or practices in which they work or to others.22
employee within the scope of his employment, the copyright Occupational therapy practitioners can post photographs,
law considers the materials a work for hire. Therefore, even videos, graphics, infographics, and other creative materials
on the Internet and social media only if they either purchase Social Media, Privacy, and Workplace Rules
a license to use them, or they find such materials in the
public domain, which are not protected by the laws of in- The Internet is not private
tellectual property such as copyright laws.23 Several sites Although there are many good reasons to use the Internet in oc-
(e.g., Flickr.com, unsplash.com, Free-Images.com) include cupational therapy practice, social media is an overlooked source
images and other creative works that are royalty free, available of potential violations of workplace rules, patient and client pri-
under a Creative Commons license, or released into the pub- vacy, and the Health Insurance Portability and Accountability
lic domain as CC0 or Creative Commons zero.24 This means Act (HIPAA; P. L. 104–191).28 Employers, patients, clients, and
occupational therapy practitioners can use these images if others can see what occupational therapy practitioners post,
they give the requested attribution or credit to the creator or threatening the division between one’s personal life and one’s
license holder. The websites that distribute these images will professional life. For example, shortly after the mass shooting at
specify the method for attribution.25 the Pulse Nightclub in Orlando, Florida, Raynard Humphreys,
a pharmacist employed at the Buttonwood Bay Medical Center
The Internet and Occupational Therapy in Belize posted the following on his Facebook page:
The Internet plays a significant role in contemporary society I know people will hate me for this, but I believe the killing of
and a particularly significant role in health care. In their sys- 50 last night in Florida is justified. I’m sure I’m not speaking
tematic review of the uses, benefits, and limitations of social for myself when I say growing up in a moral home where we
media for health communication, Moorhead and colleagues26 know a relationship to be solely between a man and a woman,
identified 7 key uses for social media for health communica- has imprinted that way of life deep into our minds. Seeing
tion for the public, patients, and health professionals, includ- two men kissing irritate the s**t outa me too [** added].
ing providing The only thing that keeps me from acting out is the fact of
1. Health information on a variety of health conditions; punishment our society would give me if I acted upon it.29
2. Answers to medical questions in a variety of formats, He continued to say he was proud that a “moral psychopath”
including, for example, videos instead of text for people took a stand against what he sees as “the REAL evil that’s
with low literacy and visual impairments; plaguing our society now in 2016” and ended by exclaiming,
3. A variety of platforms to facilitate interaction among “Gay rights? What happened to the rights of the straight
patients and between patients and providers; people?”30 A social media firestorm followed; the medical
4. A means to collect data on patient experiences and opin- center distanced itself from Humphreys’ “offensive and in-
ions on provider performance; sensitive” comments; and despite his apology and deactivat-
5. A vehicle for health promotion, health education, and ing his Facebook account, the medical center fired him.31
health intervention; Occupational therapy managers need to caution their staff as
6. The ability to reduce stigma about medical conditions the court did in Ysasi v. Brown: “Only the most ignorant or gull-
(e.g., epilepsy); and ible think what they post on the Internet is or remains private.”32
7. Opportunities for online consultation. In addition, since the advent of the elevator, all health profes-
Social media guru and thought leader, Kevin Pho, MD,27 sionals, including occupational therapy practitioners, have been
with more than 156,000 Twitter and 120,000 Facebook cautioned not to discuss patients in the elevator. Therefore, all
followers, lists 3 ways that doctors can use social media in health professionals should be reminded that “. . . social net-
their practices, which also apply to occupational therapy works may be considered the new millennium’s elevator: a pub-
practitioners: lic forum where you have little to no control over who hears what
you say, even if the material is not intended for the public.”33
1. Filter information and lead clients to reliable information Courts have found when people post something on
and better websites, the Internet, the posts leave their control. For example, in
2. Connect with colleagues with similar interests and U.S. v. Meregildo,34 the court was presented with the issue of
specialties, and whether one’s Facebook posting to a friend was protected by
3. Reach policy makers by having your voice heard. the 4th Amendment to the Constitution—the right against
This author adds 4 more ways for occupational therapy prac- unreasonable search and seizure. The court stressed the fickle
titioners to use social media in their practices: nature of the responsibility of Facebook friends to protect
their friends’ postings. The court found the plaintiff
1. Provide vehicles for patient peer support to help increase
patient engagement. had no justifiable expectation that his “friends” would keep
2. Promote themselves and their practices through social his profile private. . . . And the wider his circle of “friends,” the
media, more likely [his] posts would be viewed by someone he never
3. Provide educational opportunities tailored for their expected to see them. [His] legitimate expectation of privacy
clients, ended when he disseminated posts to his “friends” because
4. Advocate for policies that affect occupational therapy those “friends” were free to use the information however
practice and clients. they wanted—including sharing it with the Government.35
For this reason, regardless of how occupational therapy prac- Facebook account—screen name and password—to contradict
titioners choose to set up their social media accounts, they need that party’s claims for personal injuries.43 Using a work email
to avoid posting unprofessional or potentially objectionable address for Facebook could eliminate one’s expectation of pri-
material that can interfere with the client relationship or de- vacy in a Facebook account under certain circumstances.
stroy their professional reputation. Although this warning may Posting to social media from smartphones can cause prob-
seem obvious, recent studies that examined a variety of medical lems if occupational therapy practitioners have work and per-
specialties showed it is not as obvious as one might think. sonal social media accounts. For example, when tweeting from
Numerous studies of physicians, from a variety of special- a smartphone, users must tweet carefully so they do not confuse
ties, have found that many participate in Facebook and up from which Twitter account they are tweeting. The same holds
to 40% have had unprofessional or potentially objectionable true for posting to Facebook from a smartphone.44 Tweeting
content. Additionally, 13% had profiles that showed blatant from a work account, instead of a personal Twitter account or
unprofessional behavior, such as depictions of intoxication, posting on a work instead of a personal Facebook account could
uncensored profanity, unlawful behavior, and confidential cause an embarrassing problem and may violate workplace rules.
patient information.36,37,38,39 Hiding behind anonymity in social media has proven an
ineffective solution. A Boston pediatrician found that out
HIPAA violations when he blogged anonymously under the name Dr. Flea.45
He thought he covered all of his bases when he blogged about
Innocent social media posts on personal or facility, practice,
his own malpractice trial, which involved the death of a child.
or department social media sites can lead to HIPAA viola-
Writing in his blog as Dr. Flea, he told readers his attorney
tions, destroyed professional reputations, or both. Although
had coached him on how to answer questions to make him
one may be tempted to post information about an unusual
appear more appealing to the jury. The plaintiff’s attorney,
client, HIPAA rules, the American Occupational Therapy
in a “Law and Order” moment, asked the defendant blogger
Association’s (AOTA’s) Occupational Therapy Code of Ethics
doctor, “Are you Dr. Flea?” outing him to the court.
(2015),40 and many state licensure laws forbid it—whether it
is de-identified or not.
Consider the case of Alexander Tran, MD, an emergency Safe use of social media
room physician at a hospital in Rhode Island.41 After she turned Occupational therapy practitioners need to make sure they
to Facebook to unwind after a long day at work, the hospital ter- do not participate in any social media activities that vio-
minated her emergency room physician privileges. Tran posted late HIPAA or other hospital or practice policies or bring
about 1 of her trauma patients without mentioning the patient’s unwanted negative attention to themselves or their employers.
name. However, because she lived in a small community, the Employers terminated all of the following health professionals
hospital and the state medical board viewed the limited infor- from their employment after their behavior on social media,
mation she posted as enough for people in the community to outside of their work setting, violated their employers’ policies
identify the patient. The state medical board reprimanded her. or brought negative media attention upon their employers:
In response to this case, many hospitals in nearby Massachu-
setts quickly developed social media policies. Occupational ■ A hospital nurse, who tweeted racist material accompa-
therapy managers should know whether their employers have nied by her Twitter profile picture.46
social media policies and promote those policies to staff. ■ A rehabilitation center’s activity director, who posted
pictures of himself swimming in the ocean, among other
things, when he was out of work on light duty, awaiting a
For Additional Learning fitness-for-duty exam.47,48
■ A 4th-year neurology resident, who unintentionally starred
For additional learning, see Chapter 45, “Using Social Media in a YouTube video that went viral on Twitter, Facebook,
Appropriately.” and Instagram titled, “Drunk Girl Tries to Hijack an Uber
and Destroys His Car!”49,50
Occupational therapy managers should make sure they
Email and Facebook privacy have a social media policy and that all employees partici-
Email is an important tool in communicating with colleagues pate in training in that policy. The Mayo Clinic proposed its
and others. Occupational therapy practitioners commonly have 12-word social media policy in 2012, which covers most key
a work email address and email access through their employers. points. It reads as follows:
Occupational therapy managers and all occupational therapy Don’t Lie, Don’t Pry,
personnel need to realize they do not have a reasonable expecta- Don’t Cheat, Can’t Delete,
tion of privacy in their work email.42 Their employers can gain Don’t Steal, Don’t Reveal.51
access to their work email accounts, and courts will not protect
the employees from what at first blush looks like an intrusion but Occupational therapy practitioners should maintain personal
legally is not. The same holds true for Facebook pages. Judges Facebook, Twitter, and Instagram accounts for their friends
have allowed a party to a lawsuit access to the other party’s and family and professional accounts for patients, clients, and
CASE EXAMPLE 62.1. Lela: Social Media and Intellectual Property
With the permission of her supervisor, Lela, an occupational therapist, starts a blog for the pediatrics practice where she works to promote the
practice and provide tips for parents and teachers. Lela runs the developmental delay clinic in the practice. She wants to include a section in the
blog with information about herself, including her experience as a pediatric therapist. She decides to use pictures of herself and the children she
treats to make it look like an authentic pediatric clinic webpage.
Review Questions
1. Lela includes a picture of herself from a recent canoe trip on the “About Me” page she created. In the picture, she is wearing a bathing suit top
and shorts. Which of the following is true about Lela’s choice of pictures?
a. Posting the picture may violate the practice’s social media policy.
b. The picture may reveal too much according to the Mayo Clinic’s social media policy.
c. Lela should choose a professional picture to represent herself and the practice.
d. All of the above
2. Lela takes some cute shots of children who participate in occupational therapy sessions. To prepare to upload the images, she arranges them to
layout on the webpage. What is wrong with what Lela is about to do?
a. It may violate the practice’s social media policy.
b. Uploading pictures of children without their parents’ permission violates HIPAA.
c. She may not have permission to take pictures of other staff.
d. a & b
3. Lela wants the blog to include tips for parents and training ideas as well as illustrations of home program ideas from a copyrighted workbook.
Which of the following is true about Lela’s plan to put up the tip sheets and illustrations from the workbook?
a. Putting the tip sheets and illustrations on the website might violate the practice’s social media policy.
b. Putting the tip sheets and illustrations on the website violates copyright laws.
c. Lila’s use of the workbook materials on the website does not qualify as a fair use exception to the copyright law.
d. All of the above
colleagues. Practitioners may want to simply direct patients, cli- c. If you created the treatment protocol and accompanying
ents, and other professional contacts to a LinkedIn account. How- materials while employed by a practice owned by some-
ever, they must also realize that as pointed out in U.S. v. Mere- one else, you cannot use the materials for your new em-
gildo,52 you cannot trust Facebook friends (and probably other ployer without permission from your former employer.
social media contacts) to keep your private information private. d. a & c
Occupational therapy practitioners, clinics, and practices 2. All of the following are important tips to avoid job-related
should Google themselves periodically to see what clients, problems with social media in occupational therapy
patients, and colleagues are saying about them. They can practice except:
also set up a Google Alert (http://www.google.com/alerts) a. Nothing you post on the Internet is truly private.
to automatically search for their name and send daily emails b. Don’t post images that are in the public domain.
with anything Google finds. c. Don’t trust your friends to keep your posts private.
Finally, although many of the situations discussed here d. Make sure your posts pass the Mom Test.
should remind occupational therapy practitioners to assume 3. All of the following uses of social media are valuable in
their employer will see everything they post, this author believes occupational therapy practice except:
the “Mom Test” is equally, if not more, important. Before post- a. Directing patients or clients to better and reliable
ing anything, occupational therapy practitioners should think websites for education
about what their mom would say or do if she saw the post. If the b. Promoting practitioners and their practices
post passes this test, it is probably safe to post on social media. c. Monitoring clients’ social media to ensure they follow
home programs
Review Questions d. Advocating for policies that affect practitioners and
1. Which of the following is/are true about trade secrets and their clients
work for hire?
a. If your former employer created the treatment protocol
and accompanying materials you used at that clinic,
SUMMARY
you cannot use the materials for your new employer Occupational therapy managers need to familiarize them-
without permission from your former employer. selves with the challenges presented by intellectual property
b. As long as you created the treatment protocol and issues and social media. Occupational therapy practitioners
accompanying materials for use in practice, and they need to understand how copyright issues can affect practice
are your original work, you may use them in any fu- and that employers’ trade secrets demand protection. Oc-
ture employment position. cupational therapy managers must ensure they have social
media policies in place that protect clients’ privacy and the www.healthcareitnews.com/news/5-keys-legal-issues-social
reputation of occupational therapy professionals and the -media
practices, clinics, and departments that employ them. ❖ 23. Stanford University Libraries. (2017). Welcome to the public
domain. Retrieved from https://fairuse.stanford.edu/overview
/public-domain/welcome/
ACOTE STANDARDS 24. Best, R. (2015). Using Creative Commons licensed images on
your site with confidence. Retrieved from http://wpandlegalstuff
This chapter addresses the following ACOTE Standards:53 .com/using-creative-commons-images-on-your-site-with-
confidence/
■ B.4.23. Effective Communication
25. Ibid.
■ B.4.15. Technology in Practice
26. Moorhead, S. A., Hazlett, D. E., Harrison, L., Carroll, J. K.,
■ B.5.1. Factors, Policy Issues, and Social Systems Irwin, A., & Hoving, C. (2013). A new dimension of health care:
■ B.5.3. Business Aspects of Practice Systematic review of the uses, benefits, and limitations of social
■ B.5.8. Supervision of Personnel. media for health communication. Journal of Medical Internet
Research, 15, e85. https://doi.org/10.2196/jmir.1933
27. Pho, K. (2015, May 26). 3 ways doctors can use social media
LEARNING ACTIVITIES today. Retrieved from https://www.kevinmd.com/blog/2015/05
1. Write a social media policy for an occupational therapy /3-ways-doctors-can-use-social-media-today.html
department. 28. Health Insurance Portability and Accountability Act of
1996 (HIPAA), Pub. L. 104–191, 42 U.S.C. § 300gg, 29 U.S.C
2. Write a policy for an occupational therapy department
§ 1181-1183, and 42 USC 1320d-1320d9.
that protects the intellectual property that the employees
29. Haggan, M. (2016, June 15). Pharmacist loses job over anti-gay
use, including, for example, assessment materials. Facebook post. Australian Journal of Pharmacy Online Maga-
zine. Retrieved from https://ajp.com.au/news/pharmacist-loses
-job-anti-gay-facebook-post/; p. 1.
REFERENCES 30. Ibid.
1. Cornell Law School Legal Information Institute. (2019). Intel- 31. Ibid.
lectual property. Retrieved from https://www.law.cornell.edu 32. Ysasi v. Brown, 3 F.Supp.3d 1088 (D.N.M. 2014).
/wex/intellectual_property; p. 1. 33. Mostaghimi, A., & Crotty, B. (2011). Professionalism in the dig-
2. Ibid. ital age. Annals of Internal Medicine, 154, 560–563. https://doi
3. 17 U.S.C. § 101. .org/10.7326/0003-4819-154-8-201104190-00008; p. xx.
4. 17 U.S.C. § 106. 34. U.S. v. Meregildo, 883 F.Supp.2d 523 (S.D.N.Y 2012).
5. U.S. Constitution, Article I, Section 8. 35. U.S. v. Meregildo, 883 F.Supp.2d at 526 (S.D.N.Y. 2012).
6. 17 U.S.C § 101 et seq., as amended 2016. 36. Call, T., & Hillock, R. ( 2017). Professionalism, social media,
7. 17 U.S.C. § 510-722; 5501. and the orthopaedic surgeon: What do you have on the Inter-
8. 17 U.S.C. § 5103(a). net? Technology and Health Care, 25, 531–539.
9. 17 U.S.C § 201(d)(1). 37. Kitsis, E. A., Milan, F. B., Cohen, H. W., Myers, D., Herron, P.,
10. 17 U.S.C. § 107. McEvoy, M., . . . Grayson, M. S. (2016). Who’s misbehaving?
11. 17 U.S.C. § 106. Perceptions of unprofessional social media use by medical stu-
12. 17 U.S.C. § 5107. dents and faculty. BMC Medical Education, 16, 67. https://doi
13. 17 U.S.C. §107. .org/10.1186/s12909-016-0572-x
14. U.S. Coyright Office. (2018). More information on fair use. Re- 38. Koo, K., Ficko, Z., & Gormley, E. A. (2017). Unprofessional con-
trieved from https://www.copyright.gov/fair-use/more-info tent on Facebook accounts of US urology residency graduates.
.html BJU International, 119, 955–960.
15. Stanford University Libraries. (2018). Overview of intellectual 39. Langenfeld, S. J., Sudbeck, C., Luers, T., Adamson, P., Cook, G.,
property laws. Retrieved from https://fairuse.stanford.edu & Schenarts, P. J. (2015). The glass houses of attending sur-
/overview/introduction/intellectual-property-laws/ geons: An assessment of unprofessional behavior on Facebook
16. Uniform Trade Secrets Act, 39 Fl. Stat. § 688.001 et seq. (2018). among practicing surgeons. Journal of Surgical Education, 72,
17. Cornell Law School Legal Information Institute. (2019). Trade e280–e285.
secret. Retrieved from https://www.law.cornell.edu/wex/trade 40. American Occupational Therapy Association. (2015). Occu-
_secret pational therapy code of ethics (2015). American Journal of
18. 17 U.S.C. § 101. Occupational Therapy, 69(Suppl. 4), 6913410030. https://doi
19. Cornell Law School Legal Information Institute. (2019). Trade .org/10.5014/ajot.2015.696S03
secret. Retrieved from https://www.law.cornell.edu/wex/trade 41. Conaboy, C. (2011, April 20). For doctors, social media a tricky
_secret case. Boston Globe. Retrieved from http://www.boston.com
20. 18 U.S.C. § 1831 (2013). /lifestyle/health/articles/2011/04/20/for_doctors_social_media
21. McNickle, M. (2012). 5 keys to the legal issues of social me- _a_tricky_case
dia in healthcare. HealthcareITNews. Retrieved from https:// 42. Ontario v. Quon, 560 U.S. 746 (2010).
www.healthcareitnews.com/news/5-keys-legal-issues-social 43. Largent v. Reed, No. 2009-1823, slip op. (Pa. C.P. Franklin Co.
-media Nov. 8, 2011).
22. McNickle, M. (2012). 5 keys to the legal issues of social me- 44. Poppick, S. (2014, September 5). 10 Social media blunders
dia in healthcare. HealthcareITNews. Retrieved from https:// that cost a millennial a job—or worse. Money. Retrieved from
http://time.com/money/3019899/10-facebook-twitter-mistakes- 49. Cinco, J. (Producer). (2016, January 19). Drunk girl tries to hijack
lost-job-millennials-viral/ an Uber and destroys his car! [Video]. Retrieved from https://www
45. Lattman, P. (2007, May 31). Doctor blogs own malpractice .youtube.com/watch?v=Bvq07KBfhnQ&list=RDBvq07KBfhnQ
trial, settles when outed. Wall Street Journal. Retrieved from 50. Rosen, R. (2016). Dr. Anjali Ramkissoon: 5 fast facts you need to
http://blogs.wsj.com/health/2007/05/31/doctor-blogs-own know. Retrieved from https://heavy.com/news/2016/01/dr-anjali
-malpractice-trial-settles-when-outed/ -ramkissoon-drunk-miami-attack-uber-driver-girl/
46. Bongiovnni, D., & Briggs, J. (2017, November 26). Tweet says 51. Mayo Clinic. (n.d.). Social for healthcare certificate from Mayo
white women raise sons to become ‘rapists,’ ‘killers.’ IU Health in- Clinic and Hootsuite. Retrieved from https://socialmedia.mayo
vestigates. Indystar. Retrieved from https://www.usatoday.com/ clinic.org/social-media-basics-certification
story/news/nation-now/2017/11/26/tweet-saying-white-women 52. U.S. v. Meregildo, 883 F.Supp.2d 523 (S.D.N.Y 2012).
-raise-sons-become-rapist-racist-killer-causes-investigation 53. Accreditation Council for Occupational Therapy Education.
-indiana-univers/896170001/ (2018). 2018 Accreditation Council for Occupational Therapy
47. Ibid Education (ACOTE) standards and interpretive guide. Ameri-
48. Jones v. Gulf Coast Health Care of Delaware, LLC, 2016 WL can Journal of Occupational Therapy, 72(Suppl. 2), 7212410005.
659308 (M.D. Fla. Feb. 18, 2016). https://doi.org/10.5014/ajot.2018.72S217
Billing for Occupational Therapy CHAPTER
LEARNING OBJECTIVES
■ Define fraud and abuse and give 2 examples of how fraud and abuse may occur in occupational therapy practice,
■ Explain billing practices that are not allowed under Medicare law and other federal programs, and
■ Discuss the penalties occupational therapy practitioners may face if they participate in fraudulent billing practices.

• Anti-Kickback Statute • Fraud • Relators
• Civil Monetary Penalties Law • Improper retention of overpayments • Remuneration
• Current Procedural Terminology • Medicare abuse • “Stark Law”
• False claim • Medicare fraud • Unbundling
• False Claims Act • Policy • Upcoding
OVERVIEW the penalties they can face should they fail to provide services
according to those policies and fail to properly bill for them.
O
ccupational therapy managers play a role in the pro This chapter examines the legal consequences of not fol
cess of billing for occupational therapy services— lowing the rules or policies for proper billing and delivery of
whether they are teaching new occupational therapy occupational therapy services through Medicare, Medicaid,
staff how to submit their billings for the day or creating pol private insurance, or any other payer. For the purpose of this
icies about how to bill and what to bill for. Managers are ul chapter, a policy is “whatever governments choose to do or
timately responsible for the billing done in their programs, not to do.”1 For example, public policies may regulate behav
departments, and practices. ior, organize government agencies, or require licenses or fees.
Billing is complicated because different payers cover dif
ferent services and have different policies for billing that may
require different billing procedures, different requirements for
documentation, and different processes to obtain authoriza
tion to provide occupational therapy services. Occupational Fraud is defined as making false statements or representa
therapy practitioners tempted to develop creative billing prac tions of material facts to obtain some benefit or payment for
tices or participate in billing schemes, either intentionally or which no entitlement would otherwise exist. These acts may
unknowingly, can face serious legal consequences. Therefore, be committed either for a person’s own benefit or for the ben
occupational therapy managers and practitioners need to un efit of some other party. To prove that fraud has been com
derstand the importance of following the rules for proper ser mitted against the government, for instance under Medicare,
vice delivery and the proper billing policies and procedures it is necessary to prove that fraudulent acts were performed
for the services they provide. They also need to understand knowingly, willfully, and intentionally.2
Note. The in-text legal citations in this chapter are abbreviated, rather than Blue Book style, to make the chapter more read
https://doi.org/10.7139/2019.978-1-56900-592-7.063
589
Billing for Occupational Therapy CHAPTER
LEARNING OBJECTIVES
■ Define fraud and abuse and give 2 examples of how fraud and abuse may occur in occupational therapy practice,
■ Explain billing practices that are not allowed under Medicare law and other federal programs, and
■ Discuss the penalties occupational therapy practitioners may face if they participate in fraudulent billing practices.

• Anti-Kickback Statute • Fraud • Relators
• Civil Monetary Penalties Law • Improper retention of overpayments • Remuneration
• Current Procedural Terminology • Medicare abuse • “Stark Law”
• False claim • Medicare fraud • Unbundling
• False Claims Act • Policy • Upcoding
OVERVIEW the penalties they can face should they fail to provide services
according to those policies and fail to properly bill for them.
O
ccupational therapy managers play a role in the pro This chapter examines the legal consequences of not fol
cess of billing for occupational therapy services— lowing the rules or policies for proper billing and delivery of
whether they are teaching new occupational therapy occupational therapy services through Medicare, Medicaid,
staff how to submit their billings for the day or creating pol private insurance, or any other payer. For the purpose of this
icies about how to bill and what to bill for. Managers are ul chapter, a policy is “whatever governments choose to do or
timately responsible for the billing done in their programs, not to do.”1 For example, public policies may regulate behav
departments, and practices. ior, organize government agencies, or require licenses or fees.
Billing is complicated because different payers cover dif
ferent services and have different policies for billing that may
require different billing procedures, different requirements for
documentation, and different processes to obtain authoriza
tion to provide occupational therapy services. Occupational Fraud is defined as making false statements or representa
therapy practitioners tempted to develop creative billing prac tions of material facts to obtain some benefit or payment for
tices or participate in billing schemes, either intentionally or which no entitlement would otherwise exist. These acts may
unknowingly, can face serious legal consequences. Therefore, be committed either for a person’s own benefit or for the ben
occupational therapy managers and practitioners need to un efit of some other party. To prove that fraud has been com
derstand the importance of following the rules for proper ser mitted against the government, for instance under Medicare,
vice delivery and the proper billing policies and procedures it is necessary to prove that fraudulent acts were performed
for the services they provide. They also need to understand knowingly, willfully, and intentionally.2
Note. The in-text legal citations in this chapter are abbreviated, rather than Blue Book style, to make the chapter more read
https://doi.org/10.7139/2019.978-1-56900-592-7.063
589
Beginning sometime shortly before 2009, concerns for FCA, and compliance programs. Occupational therapy practi
health care fraud evolved and gained prominence. The tioners who violate these laws can lose their licenses, be barred
newly appointed Attorney General and Secretary of Health for life from billing Medicare, incur large fines, or go to jail.
and Human Services (HHS) at the time decided that coor
dinated efforts against health care fraud in the form of pre
Medicare Fraud and Abuse
vention were the best way to address the issue of health care
fraud. Therefore, the Department of Justice (DOJ), HHS, and Medicare fraud typically includes any of the following:
the HHS Office of the Inspector General (OIG) set up the
■ Knowingly submitting, or causing to be submitted, false
Health Care Fraud Prevention and Enforcement Action Team
claims or making misrepresentations of fact to obtain a
(HEAT) in high-fraud cities, such as Miami, Los Angeles, De
federal health care payment for which no entitlement
troit, and Houston, funded by the Omnibus Appropriations
would otherwise exist;
Act3 (P. L. 111–8), which provided an additional $198 million
■ Knowingly soliciting, receiving, offering, and/or paying
for the joint HHS and DOJ health care antifraud programs.4
remuneration to induce or reward referrals for items or
Despite changes in administrations, a heavy emphasis on
services reimbursed by federal health care programs; and
prosecution and enforcement of health care fraud remains a
■ Making prohibited referrals for certain designated health
constant theme through the Offices of the United States At
services.15
torneys, including the DOJ and OIG. For example, in 2018,
the Trump administration proposed a budget increase of Most Medicare fraud stems from false statements or misrep
$19 million to aid in the fight against health care fraud.5 This resentations directly related to Medicare entitlement or payment
budget increase highlights the emphasis the government made by health care providers or their employees; a Medicare
places on combatting health care fraud. beneficiary; or a business entity, such as a rehabilitation agency,
In 2017, the DOJ announced the recovery of more than skilled nursing facility, or home care agency. The most common
$3.7 billion in settlements and judgments for fraud and false examples of fraud in occupational therapy include billing for
claims against the government under the False Claims Act6 occupational therapy services not provided, misrepresenting a
(FCA; P. L. 99-562), which is discussed in detail below.7 The client’s diagnosis to justify occupational therapy services, and
vast majority of that recovery was derived from health care billing for services at a level of complexity higher than services
fraud. For example, the government alleged that an owner actually provided or documented in the file.16
and operator of 220 skilled nursing facilities submitted bills Medicare abuse “describes practices that, either directly
to Medicare and Tricare for rehabilitation therapy services or indirectly, result in unnecessary costs to the Medicare
that were not reasonable, necessary, or skilled. The company program. Abuse includes any practice inconsistent with pro
agreed to pay $145 million to resolve the FCA allegations that viding patients with medically necessary services meeting
it billed for medically unnecessary rehabilitation therapy professionally recognized standards.”17 Many times abuse
services.8 appears to be similar to fraud except that it is not possible to
The federal government has recovered more than $56 bil establish if the abusive acts were committed knowingly, will
lion since 1986, when Congress substantially strengthened fully, and intentionally.18 Whereas Medicare fraud may or
the FCA, with 2017 marking the 8th year in a row that the may not involve the provision of health care services such as
federal government recovered more than $3 billion in FCA occupational therapy, Medicare abuse usually occurs when
settlements and judgments.9 According to Bloomberg News, providers give too much or unnecessary care.19
health care fraud and abuse will remain a paramount issue for Abuse adds unnecessary cost to the Medicare program
the government.10 and may involve improper reimbursement for services not
In light of this prevalence of health care fraud, the federal medically necessary or not within professionally recognized
government set up special fraud and abuse teams in targeted standards of care. Overutilization is the most common form
locations across the country to arrest perpetrators and pros of abuse, and in certain circumstances, a practice initially cat
ecute offenses.11 Occupational therapy practitioners cannot egorized as abuse can develop into fraud.20 Typical examples
ignore the increasing number and complexity of laws, reg of fraud in occupational therapy include performing occupa
ulations, and other rules that govern federal reimburse tional therapy assessments every 2 weeks, charging Medicare
ment and other health care programs. Occupational therapy beneficiaries higher rates than non-Medicare beneficiaries,
practitioners, as well as durable medical equipment (DME) and performing ADL interventions on comatose clients.
vendors, hospitals, clinics, skilled nursing facilities, hospices,
rehabilitation facilities, physician practices, hospices, and
Coding
home health agencies, all face increased scrutiny in what they
do and how they bill for it. The health care industry bills using codes. These codes help
This section samples some of the relevant laws governing insurers determine the amount of reimbursement they will
federal programs that affect occupational therapy reimburse pay for a given service. This billing code system, called Cur-
ment and referrals. It examines Medicare fraud and abuse, the rent Procedural Terminology (CPT), includes numerical
Anti-Kickback Statute12 (AKS), the Stark Law13 (self-referrals codes assigned to each intervention, treatment, or procedure
by physicians), the Civil Monetary Penalty (CMP) Law,14 the and is sometimes referred to as “procedure code.”21 Some
CHAPTER 63. Billing for Occupational Therapy 591
codes pay more than other codes, depending on the level Laws Prohibiting Medicare Fraud and Abuse
of services provided. Payers sometimes require service pro
Several different laws prohibit Medicare fraud and abuse and
viders to bill certain codes individually or separately, or as
impose a variety of penalties for these behaviors. The follow
a group or “bundled” billing codes. Other payers, including
ing sections discuss some representative Medicare-related
Medicare, have included code edits, such as through the Na
statutes and provide examples of what not to do.
tional Correct Coding Initiative, which limit which codes can
be billed together for the same patient on the same day.
AKS
Because reimbursement amounts depend on codes, some
unscrupulous providers, systems, or practices attempt to find The purpose of the Anti-Kickback Statute (AKS) is to limit
ways to increase their reimbursement by misusing codes. the influence of financial incentives on health care. This in
Misusing codes on a claim, such as upcoding or unbundling tentionally broad statute covers any activity that could affect
codes, can fall under fraud or abuse, depending on the cir referrals, and it ascribes criminal and civil liability to par
cumstances.22 Upcoding occurs when occupational therapy ties on both sides of a kickback transaction.32 The AKS, set
practitioners, facilities, or practices bill for interventions forth at §1128B of the Social Security Act33 (P. L. 115–123,
with billing codes that reimburse at higher amounts instead div. E, title III), specifically prohibits kickbacks by making it a
of billing codes for the services that were actually provided, criminal offense to knowingly and willfully offer, pay, solicit,
which reimburse at a lower rate.23,24 Unbundling occurs when or receive any remuneration to induce or reward referrals of
health care practitioners, facilities, or practices bill for codes items or services reimbursable by a federal health care pro
separately instead of as a predetermined group, or “bundled gram. In other words, it is illegal for occupational therapy
code.”25 Medicare abuse or other abuse (e.g., private insur practitioners to pay someone for expectation of a future ben
ance) can subject occupational therapy practitioners and efit, such as future referrals to their clinic or practice.
other providers to criminal and civil liability. Under the AKS, remuneration includes the transfer of
anything of value, directly or indirectly, overtly or covertly,
in cash or in kind. Thus, when individuals purposely pay to
Law enforcement
induce or reward referrals of equipment or services payable
When the Health Insurance Portability and Accountability by a federal health care program, they violate the AKS by
Act26 (HIPAA; P. L. 104–191) became law in 1996, it estab giving someone kickbacks, which is prohibited by the law.34
lished a national Health Care Fraud and Abuse Control Such activity includes bribes and rebates as well as kickbacks.
Program under the auspices and direction of both the U.S. The law provides serious penalties for violating the AKS.
Attorney General and the Secretary of HHS.27 Since then, If found guilty, occupational therapy practitioners face
the Attorney General and the Secretary of HHS created pro criminal felony convictions and fines of up to $100,000, im
grams to coordinate federal, state, and local law enforcement prisonment for up to 10 years, or both, with these penalties
activities regarding health care fraud and abuse. increasing significantly with the passage of the Bipartisan
Several Medicare antifraud and anti-abuse partnerships Budget Act35 (P. L. 115–123). Criminal conviction also means
aim to reduce Medicare costs, combat fraud and abuse, uphold automatic lifetime exclusion from reimbursement from all
Medicare’s integrity, and improve the quality of health care. federally funded health care programs, including Medicare
One example, the Heath Care Fraud Prevention Partnership, and Medicaid. Occupational therapy practitioners who vi
joined the federal government, state agencies, law enforce olate the AKS may also face civil penalties up to $100,000
ment, private health insurance plans, and others to proac and damages 3 times the amount of the kickback, also called
tively detect health care fraud through data sharing.28 treble damages.36,37
Another program within the Centers for Medicare and Violation of the AKS sometimes happens in occupational
Medicaid Services (CMS), the Center for Program Integrity, therapy when someone offers a practitioner or a program an
detects and combats fraud, waste, and abuse of the Medicare inducement. For example, a doctor may offer to refer all of her
and Medicaid programs by ensuring CMS is paying the right patients to an occupational therapy practice if the practice
provider the right amount for services covered under these will pay her 20% of all the Medicare and Medicaid payments
programs, thereby promoting Medicare integrity through it receives. At first blush, this offer might tempt the practice
ongoing monitoring and auditing.29 Pursuant to the Medi with the increase in referrals and new clients. However, this
care Prescription Drug, Improvement, and Modernization plan looks like remuneration for referrals or a kickback and
Act30 (P. L. 108–173), CMS collaborated with 7 contractors is not permissible.38
to cover 7 nationwide zones, called Zone Program Integrity As health care evolves and business structures become
Contractors (ZPICs). The ZPICs prevent, detect, and investi more complicated, remuneration can come in different forms,
gate potential Medicare fraud and abuse. creating business arrangements that appear in the normal
Finally, the DOJ, OIG, and HHS together formed HEAT in se course of business. Yet, in reality, they violate the AKS. In
lect high-fraud cities, as mentioned previously. HEAT strength direct remuneration may come in the form of waiving a fi
ened existing health care fraud and abuse prevention programs nancial obligation, rental payments not within fair market
while investing resources into innovative protocols such as using value, or gifts. Historically, under AKS, investigators tend to
technology to prevent health care fraud and abuse.31 put a greater focus on payers of remuneration, and current
trends show government enforcement equally targets payers of 2018, but other issues may need to see a legislative fix in
and payees, embracing the “it takes 2 to tango” perspective. the future to keep up with changing health care payment and
Occupational therapy programs and practices should delivery systems.44, 45
not pay anyone or accept payment from anyone if they are Occupational therapy practitioners and others who violate
making the payment for the sole purpose of generating more the Stark Law face denial of payment for all DHS claims, refund
Medicare or Medicaid money for their practice, their em of amounts collected for DHS claims, exclusion from partici
ployer, or themselves. For example, Ella, an occupational pation in all federal health care programs, and substantial civil
therapist (OT) in a hand clinic, cannot give Katie, a hospi monetary penalties of up to $100,000 for knowing violations of
tal social worker, money for each client Katie refers to the the prohibition.46 With such harsh potential penalties at stake,
hand clinic for outpatient therapy under Medicare. This rule occupational therapy practitioners who want to collaborate
includes money for both services and goods, such as reim with physicians should seek advice from a competent health
bursable DME. For example, Octavia, an OT, cannot refer care attorney who can advise them on whether their financial
Medicare clients to Donnie’s DME knowing that Donnie will relationship with the physician is legal under the Stark Law.
pay her 10% of each purchase made by the referred clients.
However, there are some exceptions to the AKS law. Be FCA
cause legislators wrote the statute so broadly, health care pro
viders raised concerns that it might prohibit even beneficial The False Claims Act, also called the “Lincoln Law” or the
or innocent transactions, such as free patient transportation “Whistleblower Law,” imposes liability on anyone who know
to and from a hospital or clinic. Congress responded to these ingly submits a false claim to the federal government. The
concerns over time by implementing specific “safe harbors” definition of false claim under the FCA includes knowingly
for various allowable business arrangements that would making a false or fraudulent claim for payment or causing
escape prosecution under the AKS.39 The safe harbor pro others to and knowingly using or causing others to use false
visions are reviewed regularly and updated based on public records or statements, such as false progress notes or false
comments.40 Rather than risk fines, prison, and permanent bills.47 It also includes conspiring with others to do these or
exclusion from federal health program reimbursement, occu similar dishonest actions to get paid for something that was
pational therapy managers should check with a knowledge not done or get paid more than what is entitled based on the
able health care attorney before entering into agreements that services actually provided.48
involve remuneration of any kind. The act defines knowingly to include actual knowledge of
the false claim, action in deliberate ignorance of the truth
or falsity of the claim, or action in reckless disregard of the
Stark Law
truth or falsity of the claim. Anyone who knowingly submits
The Physician Self-Referral Prohibition Statute, commonly false claims to the government is liable for damages up to
referred to as the “Stark Law,” prohibits physicians from 3 times the amount of the erroneous payment plus manda
referring Medicare patients for certain “designated health tory penalties of $5,500–$11,000 or more for each false claim
services” (DHS) to an entity with which the physician (or an submitted. In larger health care settings, where providers
immediate family member) has a financial relationship, un submit thousands of claims annually, damages and penalties
less an exception applies.41 The purpose of the Stark Law is can quickly turn into very large amounts.
to prevent physicians from financially benefitting from their FCA violations occur in occupational therapy when prac
referrals. It also prohibits an entity from submitting claims titioners or their employers bill Medicare for services not
to anyone for provision of DHS that resulted from the pro performed, not covered, unnecessary, or deemed worthless.
hibited referral. Designated health services include, among For example, a rehabilitation department that submits bills
others, occupational therapy services, physical therapy, and to Medicare for recreational therapy services but labels
speech–language pathology services; DME and supplies; them as occupational therapy is filing false claims because
orthotic and prosthetic devices and supplies; home health recreational therapy is not a covered service under Medicare.
services; and inpatient and outpatient hospital services.42 Similarly, a skilled nursing facility that requires that occupa
The complexity of the Stark Law raises several issues, in tional therapy practitioners bill for daily ADL intervention
cluding the nature of the financial arrangement or relationship for all clients who receive occupational therapy, including
among physicians, hospitals, and programs and services and those who do not need ADL intervention, is filing false claims
whether an exception applies to the arrangement. Financial because it is billing for unnecessary services.
relationships arise in different forms and can lead to potential The FCA encourages people who discover a false claim—
Stark Law violations, even when a business arrangement ap called relators—to report the false claim by giving them a share
pears within the normal course of business. Moreover, as the of the proceeds recovered from the action or settlement.49 In
health care system evolves toward value-based payment sys 2009, Congress amended the FCA through the Fraud Enforce
tems and new models of delivery, such as accountable care ment and Recovery Act50 (P. L. 111–21) to make it easier for
organizations, the boundaries of the Stark Law become even relators to bring claims against Medicare and Medicaid pro
more confusing.43 Congress made minor technical changes to viders and other government contractors. It also created a new
the Stark Law with the passage of the Bipartisan Budget Act type of false claim called improper retention of overpayments.
The Affordable Care Act51 (ACA; P. L. 111–148) clarified how ■ Offer or give remuneration to any beneficiary of a federal
improper retention of overpayments would work.52 It required health care program likely to influence the receipt of reim
overpaid providers to report overpayments and return them bursable items or services,
within 60 days of identification. On the 61st day, the retained ■ Arrange for reimbursable services with an entity that is
overpayment becomes a false claim, even if the original error excluded from participation from a federal health care
that resulted in the overpayment was an innocent mistake. program,
Two monumental FCA events in 2015 and 2016 provided ■ Knowingly or willfully solicit or receive remuneration for
more oversight of occupational therapy practitioners. In 2015, a referral of a federal health care program beneficiary, or
the DOJ announced a major policy change that recognized ■ Use a payment intended for a federal health care program
that corporate misconduct is the result of misconduct by indi beneficiary for another use.59
viduals. Thus, the DOJ will pursue financial fraud case pros
ecutions, including those under the FCA, against individuals The CMP authorized the OIG to assess different civil pen
and will punish companies that fail to cooperate in investiga alty amounts, depending on the type of violation at issue,
tions.53 In 2016, CMS issued the final rule regarding the over using the lower civil standard of proof.60 For example, if an
payment reporting and repayment provision of the ACA and, occupational therapist submits or helps an employer submit a
with it, provided clarity and additional burdens to health care false or fraudulent claim, the OIG may seek a penalty of up to
providers, including occupational therapy practitioners, re $20,000 for each item or service improperly claimed and an
garding overpayment obligations using a “reasonable inquiry” assessment of up to 3 times the amount improperly claimed
standard.54 It also defined a self-identified overpayment, rather than seek criminal penalties.61 In an AKS case, the
which occurs when a provider “through the exercise of rea OIG may seek a penalty of up to $100,000 for each improper
sonable diligence, determine[s] that” they received an over act and damages of up to 3 times the amount of remuneration
payment and quantified the amount of the overpayment.”55 at issue, regardless of whether some of the remuneration was
The provider must pay back this overpayment within 60 days. for a lawful purpose.62
Occupational therapy practitioners who discover their The CMP laws function as an additional tool for the
employers’ erroneous billing, such as recreational therapy government to seek financial penalties to deter health care
billed as occupational therapy or ADL interventions billed for fraud and abuse. Occupational therapy practitioners should
clients who do not need them, can act as relators and report be aware of the monetary exposures they face should they
their employer. The employer may face fines and penalties for participate in false or fraudulent claims and understand that
each wrongfully submitted claim, together with any identi CMP laws intertwine with the other aforementioned health
fied overpayments made for the recreational therapy services care fraud and abuse laws.
billed as occupational therapy or the unnecessary ADL inter
ventions. As a relator, under the FCA, the occupational ther Review Questions
apy practitioner may be entitled to a portion of any recovery
for the fraudulent billing. Occupational therapy managers 1. Suppose you get a great job as an occupational therapy
need to know whether their state has enacted its own false practitioner that pays well and your supervisor tells you
claims act (e.g., see Hawaii False Claims Act56 and Massa that you must bill using a specific billing code. In other
chusetts False Claims Act57). Violations of the federal law can words, despite the type of intervention you provide, you
also trigger prosecution under the state’s version of the FCA. must use 1 billing code. You know this billing code re
imburses at a higher rate than other billing codes that
Civil Monetary Penalties match the intervention you are providing. What is the
problem with what the supervisor is asking you to do,
The Civil Monetary Penalties Law (CMP) authorizes the im
and what could happen if you follow the supervisor’s
position of substantial civil money penalties or very large fines
instruction?
against entities that engage in certain prohibited activities. These
2. Suppose you work in an acute care hospital as an OT.
prohibitions are similar to some of the other laws discussed
A representative from a new home health agency takes
herein that impose penalties for various fraudulent activities.
you out to lunch to get to know you. While at lunch, she
However, the “Civil” in CMP changes the standard that prose
explains that she is trying to get more referrals from the
cutors must prove from the highest “beyond a reasonable doubt”
hospital. She realizes that social workers make the refer
criminal standard to a lower civil monetary sanction, mak
rals, but she has an idea. Because the patients ultimately
ing it easier for prosecutors to assess these civil fines (e.g., see
can choose the home health agency they would like to
Plott Nursing Home v. Burwell58) Under the CMP, it is illegal to
use, she thinks that you, as their OT, who spends more
■ Knowingly present or cause to be presented a claim for 1-on-1 time with patients than any other team member,
services not provided as claimed or which is otherwise could steer patients to her home health agency. In return,
false or fraudulent in any way, the agency would give you a $150 bonus for each patient
■ Knowingly give or cause to give false or misleading infor you refer. What is the problem with what the represen
mation reasonably expected to influence the decision to tative is asking you to do, and what could happen if you
discharge a patient, agree to her proposal?
3. Oscar, an OT, was supposed to treat Mrs. Smith on Tues conduct is probably a career-ending choice. Moreover, almost
days and Thursdays. When he went to treat her on Tuesday, all state licensure boards would likely take action against the
Mrs. Smith was not at the facility. She had a doctor’s license of an occupational therapy practitioner excluded from
appointment. Oscar decided he would see Mrs. Smith the federal health programs because of their participation in ille
next day but bill for the visit today, on Tuesday, so his doc gal, fraudulent, or prohibited conduct.
umentation would comply with the treatment plan. Oscar
writes a progress note for Tuesday, but a major power fail Review Questions
ure hits the next day, making him unable to go back to treat
Mrs. Smith. He does not feel so bad missing the treatment An OT is swamped in her practice and hires an OTA to see
session because he really believed Mrs. Smith should have some of the patients and write progress notes. They are so
been discharged 2 weeks earlier when she met her goals. busy that they can’t keep up with client needs. As a result,
Which of the following is true? they both end up writing notes and billing for visits for cli
a. If Medicare is the payer, Oscar has committed Medi ents, who are Medicare beneficiaries, that neither of them
care fraud by billing for visits not made. made, hoping to make up the visits later.
b. If Medicare is the payer, Oscar has committed Medi 1. What are the occupational therapy practitioners doing
care abuse because he has billed for 2 weeks worth of here that is illegal?
therapy Mrs. Smith did not need. 2. What can happen to these practitioners as a result of their
c. Oscar could lose his license to practice occupational illegal practices?
therapy. 3. What should practitioners do if told by a supervisor
d. All of the above to write progress notes for patients he or she has never
seen?
OCCUPATIONAL THERAPY SUMMARY
Fraud and abuse violations can have serious professional Managers are ultimately accountable for the fiscal oversight of
consequences for occupational therapy practitioners. In ad their departments. Those who participate in billing schemes,
dition to imposing civil and criminal penalties, the OIG can even tangentially or unknowingly, could find themselves in
permanently exclude practitioners who have participated volved in serious criminal matters and subject to civil pen
or engaged in certain impermissible, inappropriate, or ille alties or criminal charges. Managers must be diligent with
gal conduct involving federal health care programs from their oversight and make sure their department’s policies
participation in all federal health care programs.63 Federal and procedures ensure that employees bill for actual services
health care programs include Medicare, Medicaid, Tricare provided according to all relevant laws, regulations, policies,
(military health care insurance), CHIP (Children’s Health and rules. ❖
Insurance Program), and all other plans and programs that
provide health benefits funded directly or indirectly by the
U.S. government other than the Federal Employees Health LEARNING ACTIVITIES
Benefits Program.64
1. Do a Google search for “occupational therapist arrested
The government refers to the individuals excluded from
for fraud.” Compile a list of 3 OTs or OTAs and what
participation in these health care programs as debarred
they did that resulted in an accusation of fraud and their
individuals or entities. In addition, entities that participate
arrest.
in or bill a federal health care program generally may not
2. Make a list of 3–5 things to remember never to do to avoid
employ or contract with excluded or debarred individuals
fraudulent billing.
or entities. Federal health care programs may not make any
payments for any items or services furnished, ordered, or
prescribed, directly or indirectly, by an excluded or debarred ACOTE STANDARDS
individual or entity. (The OIG provides information on all
This chapter addresses the following ACOTE Standards:65
individuals and entities currently excluded from participa
tion in federal health care programs at https://oig.hhs.gov ■ B.3.3. Distinct Nature of Occupation
/exclusions/index.asp.) ■ B.3.5. Effects of Disease Processes
In plain English, once barred from participation in Medi ■ B.4.6. Reporting Data
care, Medicaid, and all other federal health care programs ■ B.4.22. Need for Continued or Modified Intervention
because of participation in illegal, fraudulent, or prohibited ■ B.4.24. Effective Intraprofessional Collaboration
conduct, occupational therapy practitioners cannot work ■ B.4.29. Reimbursement Systems and Documentation
for entities that bill these programs nor can they bill these ■ B.5.1. Factors, Policy Issues, and Social Systems
federal programs directly for their services. Because almost ■ B.5.3. Business Aspects of Practice
all employers of occupational therapy practitioners bill these ■ B.5.8. Supervision of Personnel
programs, participation in illegal, fraudulent, or prohibited ■ B.7.1. Ethical Decision Making.
detection, and reporting. Retrieved from https://www.cms.gov

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1351–1356. https://doi.org/10.1377/hlthaff.28.5.1351 CPT® codes for occupational therapy. Retrieved from http://www
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solve False Claims Act allegations relating to the provision of med- /criminal-fraud/health-care-fraud-unit
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https://www.justice.gov/opa/pr/life-care-centers-america-inc Fact sheet: The Health Care Fraud and Abuse Control Program
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act cases in Fiscal Year 2017. Retrieved from https://www.justice -and-taxpayers
.gov/opa/pr/justice-department-recovers-over-37-billion-false 29. Centers for Medicare and Medicaid Services. (2018). Center
-claims-act-cases-fiscal-year-2017 for Program Integrity. Retrieved from https://www.cms.gov
10. Pazanowski, M. A. (2018, Jan. 12). Bloomberg Law health care /About-CMS/Components/CPI/CPI-Landing.html
blog: 2018 outlook is cloudy, health-law experts say. Retrieved 30. Medicare Prescription Drug, Improvement, and Moderniza
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-expands-operations-brooklyn-ny-tampa-fla-and-baton-rouge-la Retrieved from https://www.justice.gov/opa/pr/fact-sheet-health
12. Anti-Kickback Statute, 42 U.S.C. § 1320a-7b. -care-fraud-and-abuse-control-program-protects-conusmers
13. Stark Law, 42 U.S.C. 1395nn. -and-taxpayers
14. Civil Monetary Penalty Law, 42 U.S. Code § 1320a-7a. 32. Medicare and Medicaid Patient Protection Act of 1987, Pub. L
15. Centers for Medicare and Medicaid Services Medicare Learning 100–93, as amended, 42 U.S.C. §1320a-7b, 2009.
Network. (2017, Sept.). Medicare fraud and abuse: Prevention, 33. Pub. L. 115–123, div. E, title III
detection, and reporting. Retrieved from https://www.cms.gov 34. U.S. v. Greber, 760 F.2d 68, 69 (3rd Cir. 1985), cert. denied, 474
/Outreach-and-Education/Medicare-Learning-Network-MLN U.S. 988 (1985).
/MLNProducts/downloads/fraud_and_abuse.pdf 35. Bipartisan Budget Act of 2018, Pub. L. 115–123.
16. Ibid. 36. Fry, T. J., & Barnett, B. W. (2018, March 5). Civil and criminal
17. Ibid. fraud and abuse penalties increase and Stark Law changes.
18. Centers for Medicare and Medicaid Services. (2015b). Medicare Retrieved from https://www.lexology.com/library/detail.aspx?g
general information, eligibility, and entitlement: §20.3.1. Defini- =657194c6-f5be-459b-b8d1-780448dc2ce3
tion and examples of fraud. Retrieved from https://www.cms.gov 37. Civil Monetary Penalty Law, 42 U.S. Code § 1320a-7a(a).
/Regulations-and-Guidance/Guidance/Manuals/Downloads 38. Sabella, T. (n.d.). Anti-Kickback Statute. American Health Law
/ge101c01.pdf yers Association. Retrieved from https://www.healthlawyers.org
19. Becker, D., Kessler, D., & McClellan, M. (2005). Detecting /hlresources/Health Law Wiki/Anti-Kickback Statute.aspx
medicare abuse. Journal of Health Economics, 24(1), 189–210. 39. Office of the Inspector General. (1999). Federal anti-kickback
https://doi.org/10.1016/j.jhealeco.2004.07.002 laws and regulatory safe harbors fact sheet. Retrieved from
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Network. (2017, Sept.). Medicare fraud and abuse: Prevention, .htm
40. Office of the Inspector General. (2009). Proposed rules: Notice 53. U.S. Department of Justice. (2015, Sept. 10). Deputy Attorney
of intent to develop regulations. Retrieved from http://www General Sally Quillian Yates delivers remarks at New York
.thefederalregister.com/d.p/2009-12-29-E9-30560 University School of Law announcing new policy on individual
41. Social Security Act, 42 USC §1395nn, Limitation on certain liability in matters of corporate wrongdoing. Retrieved from
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Physician self-referral. Retrieved from https://www.cms.gov -school
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43. Ellison, A. (2017, Feb. 18). 15 things to know about Stark Law. Medicare reporting and returning of self-identified overpay-
Becker’s Hospital Review. Retrieved from https://www.becker ments: CMS 6037-F Final Rule. Retrieved from https://www.cms
shospitalreview.com/legal-regulatory-issues/15-things-to .gov/newsroom/fact-sheets/medicare-reporting-and-returning
-know-about-stark-law-021717.html -self-identified-overpayments
44. Fry, T. J., & Barnett, B. W. (2018, March 5). Civil and criminal 55. Ibid., p. 1.
fraud and abuse penalties increase and Stark Law changes. 56. Hawaii False Claims Act, Haw. Rev. Stat. §§661-21 et seq.
Retrieved from https://www.lexology.com/library/detail.aspx?g (2001).
=657194c6-f5be-459b-b8d1-780448dc2ce3 57. Massachusetts False Claims Act, Mass. Gen. Laws Ann. ch. 12
45. Morgan, L. B., & D’Emanuele, R. C. (2018). Stark Law reform §§S(A) et seq. (2001).
a focus of recent regulatory and legislative initiatives; 2018 DHS 58. Plott Nursing Home v. Burwell, 779 F3d 975 (9th Cir. 2015).
code list and CPI-U updates. Retrieved from https://dorsey 59. Civil Monetary Penalty Law, 42 U.S.C. § 1320a-7a.
healthlaw.com/stark-law-reform-a-focus-of-recent-regulatory 60. Civil Monetary Penalty Law, 42 CFR § 1003.103.
-and-legislative-initiatives-2018-dhs-code-list-and-cpi-u-updates 61. Civil Monetary Penalty Law, 42 U.S.C. § 1320a-7a(a).
46. Civil Monetary Penalty Law, 42 U.S. Code § 1320a-7a(a). 62. Ibid.
47. False Claims Act, 31 USC §§ 3729(a)(1). 63. Centers for Medicare and Medicaid Services Medicare Learning
48. Ibid. Network. (2009). Medicare fraud & abuse: Prevention, detection,
49. False Claims Act, 31 USC § 3730(b). and reporting. Retrieved from https://www.cms.gov/Outreach
50. Fraud Enforcement and Recovery Act of 2009, Pub. L. 111–21. -and-Education/Medicare-Learning-Network-MLN/MLN
51. Patient Protection and Affordable Care Act, Pub. L. 111–148, 42 Products/downloads/Fraud_and_Abuse.pdf
U.S.C. §§ 18001-18121 (2010). 64. Ibid.
52. Centers for Medicare and Medicaid Services. (2016, Feb. 11). 65. Accreditation Council for Occupational Therapy Education.
Medicare reporting and returning of self-identified overpay- (2018). 2018 Accreditation Council for Occupational Therapy
ments: CMS 6037-F Final Rule. Retrieved from https://www.cms Education (ACOTE) standards and interpretive guide. Ameri-
.gov/newsroom/fact-sheets/medicare-reporting-and-returning can Journal of Occupational Therapy, 72(Suppl. 2), 7212410005.
-self-identified-overpayments https://doi.org/10.5014/ajot.2018.72S217
CHAPTER
Understanding Employment Laws
Veda Collmer, JD, OTR/L 64
LEARNING OBJECTIVES
■ Identify the federal agencies responsible for enforcing employment laws in the United States,
■ Describe the different ways employment law is developed,
■ Discuss strategies for complying with employment laws in the workplace,
■ Identify the role of occupational therapy managers in understanding and enforcing employment law in the workplace,
and
■ Identify the laws prohibiting discrimination and unlawful employment practices.

• Age Discrimination in • Fair Labor Standards Act • Pregnancy Discrimination Act
Employment Act • Family and Medical Leave Act • Protected health information
• Americans With Disabilities Act • Genetic Information • Qualified privilege
• At-will employment Nondiscrimination Act • Regulatory law
• Case law • Harassment • Rehabilitation Act
• Covered entities • Health Insurance Portability and • Right to privacy
• Defamation Accountability Act • Statutory law
• Disability • Lilly Ledbetter Fair Pay Act • Title VII of the Civil Rights Act
• Duty of loyalty • National Labor Relations Act • Tort law
• Employer liability • National Labor Relations Board • U.S. Department of Labor
• Employment law • Negligent hiring • U.S. Equal Opportunity
• Equal Pay Act • Occupational Safety and Employment Commission
• Fair Credit Reporting Act Health Act
OVERVIEW and organizational policies, as well as spot issues and respond
E
mployment law plays an important role in the U.S. appropriately.
workplace by protecting worker safety, prohibiting dis- Employment law touches every area of employment, from
crimination, and preserving employee and employer hiring to performance reviews, compensation, workplace
rights. Recently, employment law issues, such as sexual ha- wellness programs, employee benefits, and termination. Al-
rassment, gender-based compensation disparities, and work- though the occupational therapy manager does not need to
place violence, have come to the forefront in media coverage. understand employment law with the same lens as an attorney
Related news stories underscore the critical part that employ- or a human resources professional, the manager must com-
ment law—and the best practices that follow—play in pro- prehend how the law relates to organizational policies. Occu-
viding a safe and fulfilling workplace. Occupational therapy pational therapy managers must also understand the practical
managers who possess a general understanding of employ- application of employment law in the workplace and adhere to
ment law can proactively prevent problems through training best practices while performing all managerial duties.
Copyright © 2019 by the American Occupational Therapy Association. To reuse this content, contact www.copyright.com.
https://doi.org/10.7139/2019.978-1-56900-592-7.064
597
CHAPTER
Understanding Employment Laws
Veda Collmer, JD, OTR/L 64
LEARNING OBJECTIVES
■ Identify the federal agencies responsible for enforcing employment laws in the United States,
■ Describe the different ways employment law is developed,
■ Discuss strategies for complying with employment laws in the workplace,
■ Identify the role of occupational therapy managers in understanding and enforcing employment law in the workplace,
and
■ Identify the laws prohibiting discrimination and unlawful employment practices.

• Age Discrimination in • Fair Labor Standards Act • Pregnancy Discrimination Act
Employment Act • Family and Medical Leave Act • Protected health information
• Americans With Disabilities Act • Genetic Information • Qualified privilege
• At-will employment Nondiscrimination Act • Regulatory law
• Case law • Harassment • Rehabilitation Act
• Covered entities • Health Insurance Portability and • Right to privacy
• Defamation Accountability Act • Statutory law
• Disability • Lilly Ledbetter Fair Pay Act • Title VII of the Civil Rights Act
• Duty of loyalty • National Labor Relations Act • Tort law
• Employer liability • National Labor Relations Board • U.S. Department of Labor
• Employment law • Negligent hiring • U.S. Equal Opportunity
• Equal Pay Act • Occupational Safety and Employment Commission
• Fair Credit Reporting Act Health Act
OVERVIEW and organizational policies, as well as spot issues and respond
E
mployment law plays an important role in the U.S. appropriately.
workplace by protecting worker safety, prohibiting dis- Employment law touches every area of employment, from
crimination, and preserving employee and employer hiring to performance reviews, compensation, workplace
rights. Recently, employment law issues, such as sexual ha- wellness programs, employee benefits, and termination. Al-
rassment, gender-based compensation disparities, and work- though the occupational therapy manager does not need to
place violence, have come to the forefront in media coverage. understand employment law with the same lens as an attorney
Related news stories underscore the critical part that employ- or a human resources professional, the manager must com-
ment law—and the best practices that follow—play in pro- prehend how the law relates to organizational policies. Occu-
viding a safe and fulfilling workplace. Occupational therapy pational therapy managers must also understand the practical
managers who possess a general understanding of employ- application of employment law in the workplace and adhere to
ment law can proactively prevent problems through training best practices while performing all managerial duties.
https://doi.org/10.7139/2019.978-1-56900-592-7.064
597
ESSENTIAL CONSIDERATIONS Court, who ruled Ms. Ledbetter could not challenge the dis-
criminatory practices of her employer because she filed her
U.S. Employment Law Development claim too late (Ledbetter v. Goodyear Tire & Rubber Co., 2007).
There was a time in the United States when workers had no The Court’s ruling undermined the protections afforded by
rights or protections in the workforce. In the early part of Title VII because employers could conceal, and therefore
the 20th century, U.S. employment law began to take shape continue, unfair discriminatory practices until after the
through the abolishment of child labor, enhanced work- 180-day filing period. Congress responded by passing the Lily
place safety mandates, and collective bargaining (Covington Ledbetter Fair Pay Act to restore the protections of Title VII.
& Seiner, 2017). Since then, employment law has continued
to grow and become a prevalent component of the modern
Defining the Employment Relationship
workplace with such protections as fair pay standards, pro-
hibition on discrimination, and job protection during illness Employers may have different types of relationships with em-
and childbirth (Covington & Seiner, 2017). ployees; each type of relationship establishes different rights
U.S. employment law has developed through different legal between the parties. At-will employment is the presumed
processes (Covington & Seiner, 2017). The federal and state employment status in the United States. The concept of at-
constitutions establish the foundation for employment law will employment is that the employer has no legal obligation
through the preservation of certain inalienable rights. For ex- to retain the employee and the employee has no legal obliga-
ample, the Equal Protection Clause of the 14th Amendment to tion to work for the employer (Covington & Seiner, 2017). In
the U.S. Constitution guarantees the right of all people to pro- the at-will employment relationship, the employer generally
tection under the law (U.S. Constitution Amendment XIV, §1). has no liability for terminating the employee. However, the
Many state constitutions provide for enhanced protection employer may not terminate the employee
from discrimination and the preservation of more expansive
■ In violation of the law,
rights than the U.S. Constitution (Covington & Seiner, 2017).
■ To punish an employee for refusing to violate the law,
Employment law is also developed through statutory and
■ To discipline an employee for performing a duty the em-
regulatory law. Statutory law is created by Congress, at the
ployee is legally obligated to perform, or
federal level, or by the state legislature and signed into law
■ In retaliation for blowing the whistle on the employer’s
by either the U.S. President or the state governor. Regulatory
misconduct (Covington & Seiner, 2017).
law is administrative law, created by state or federal agencies.
Regulations may stem from statutory directives for an ad- On the other end of the employment spectrum is the con-
ministrative agency to address a certain problem. Regulations tracted employee. Employment contracts are formed when
can also be implemented by agencies that have authority to do one person extends an offer that is accepted by the other
so. Regulations are developed through a rulemaking process person and something of value is provided for the contract,
whereby the proposed rule is published and stakeholders are such as compensation or a bonus (Covington & Seiner, 2017).
invited to comment. Contracts can be written or oral and typically establish em-
Federal agencies, such as the U.S. Equal Opportunity Em- ployment for a fixed duration, as well as establish reasons
ployment Commission (EEOC), National Labor Relations and procedures for termination. Failure to abide by the terms
Board (NLRB), and the U.S. Department of Labor (DOL), of the contract can result in liability by either the employer
play an important role in implementing employment regu- or the employee for breach of the contract (Covington &
lations. The EEOC is responsible for enforcing laws making Seiner, 2017).
it illegal to discriminate against job applicants or employees Sometimes an employer will hire an independent contrac-
based on race, color, religion, sex, national origin, disability, tor to fulfill job tasks. Independent contractors may perform
or genetic information. The NLRB enforces employees’ right the same duties as an employee but will not receive the same
to organize and use unions as their bargaining representative. protections as the employee (e.g., overtime protections, ac-
The DOL safeguards employees’ wages, working conditions, cess to employer-provided health insurance, worker’s com-
opportunities for advancement, and work-related benefits. pensation coverage; Internal Revenue Service, 2017). Some
Case law, litigated in both federal and state court, has also states, such as California, may consider such independent
formed the basis for employment law. Litigation can be pur- contractors misclassified employees and will levy steep pen-
sued by federal and state agencies seeking to enforce statutes alties against the employer (Unlawful Actions Regarding
or regulations. Individuals can also litigate cases to enforce Willful Misclassification of Individual as Independent Con-
their rights through the judicial system. The Lilly Ledbetter tractor, California Labor Code §226.8, 2013). Employers may
Fair Pay Act of 2009 (P. L. 111–2, 123) is an example of the be at risk of misclassifying independent contractors if they
interplay between the judicial system and the legislature. are paying the contractor in the same manner as an employee
Lilly Ledbetter filed a complaint with the EEOC, alleging that and having the contractor fulfill the same duties as the em-
her employer discriminated for years against female manag- ployee (Covington & Seiner, 2017).
ers by paying them less than the male managers, in violation Employers generally have a right to terminate employees
of Title VII of the Civil Rights Act of 1964 (42 U.S.C. §2000e- for a variety of reasons. Employers may terminate employ-
16). The case went all the way to the United States Supreme ees for good cause, due to poor performance (Covington &
CHAPTER 64. Understanding Employment Laws 599
Seiner, 2017). Employers may also terminate employees on (Covington & Seiner, 2017). The harm to the employee can
the basis of business decisions, such as economics or busi- be the lost job opportunity or inability to find replacement
ness goals; these types of terminations are often referred to work as a result of the employer’s defamation (Covington &
as layoffs. Businesses with 100 or more employees must pro- Seiner, 2017). This is distinct from the employer’s right, or
vide 60 days notification, in compliance with the Worker Ad- qualified privilege, to communicate employee information if
justment and Retraining Notification Act of 1988 (WARN; it serves legitimate business purposes and the employer be-
P. L. 100–379), for mass layoffs (Notification Required Before lieves the statement to be true (Covington & Seiner, 2017). An
Plant Closings and Mass Layoffs, 29 U.S.C. §2102, 2015). example of the employer’s qualified privilege is illustrated in
Palmisano v. Allina Health Systems, Inc. (190 F 3d. 881, 8th
Cir. 1999), where the court found the employer had a quali-
Employer Liability fied privilege to disclose that its vice president was terminated
Employers can be directly liable for their actions and indi- for allowing serious fraudulent billing practices to occur. The
rectly liable for the actions of their employees. Employer employer’s statement was based on a 3-month internal inves-
liability is based on tort law, which is the wrongdoing or tigation that verified the truth of the statement (Palmisano v.
injury to another person resulting in a civil case seeking re- Allina Health Systems, Inc., 1999).
imbursement (Covington & Seiner, 2017). Employer torts can
include negligent hiring practices and defamation (Coving- Employees’ Duty of Loyalty
ton & Seiner, 2017).
The tort of negligent hiring is based on the employer’s Employees owe the employer a duty of loyalty, which includes
duty to protect the employee or third parties (Covington & an obligation not to steal or disclose the employer’s confiden-
Seiner, 2017). Employers are negligent in hiring if they knew tial or proprietary information (Covington & Seiner, 2017).
or should have known about an employee’s background, Employers may wish to sign a confidentiality agreement with
which may indicate a dangerous or untrustworthy character employees to clarify this duty, define the types of confidential
(Covington & Seiner, 2017). Employers may be liable for neg- information protected, and to preserve certain enforcement
ligent hiring when they fail to check an applicant’s references, remedies if the employee does misuse confidential informa-
fail to perform background checks, and fail to contact for- tion (e.g., a restraining order). Confidential information can
mer employers (Covington & Seiner, 2017). This is especially include the employer’s trade secrets, which are protected by
important in health care, where employees are caring for federal and state law. Trade secrets are valuable information
patients. An occupational therapy manager will be expected that gives the employer a competitive edge and are protected
to perform background checks on prospective employees in with additional safeguards (e.g., password-protected files, ac-
a similar manner to other health care employers in the in- cess for only certain employees; U.S. Patent and Trademark
dustry. Such checks may include verifying the individual’s li- Office, 2017).
cense, performing a background check to determine whether Employer agreements may also restrict the employee’s
the prospective employee has been convicted of a crime, ability to compete with the employer or poach employees.
and searching the U.S. Department of Health and Human Non-compete and non-solicitation agreements are governed
Services (DHHS; n.d.) exclusion database to ensure the indi- by state law. Some states, like California, will not enforce these
vidual has not been excluded from participating in a federal agreements for the general employment relationship and con-
program. sider them a restraint on trade (Void Contracts, California
Employers who refuse, as a rule, to hire candidates with Business and Professional Code §16600, 2017). Other states
past criminal convictions or credit problems risk liability for will uphold the agreement if the terms are reasonable to pro-
unlawful discriminatory practices (Dodge et al., 2013). The tect the employer’s legitimate business interest and reason-
employer must follow the guidelines established by EEOC able in scope (e.g., geography, time limits). Courts will not
(2012) in enforcing federal antidiscrimination laws. The em- generally uphold oppressive restrictive covenants designed
ployer must have a business reason for deciding not to hire to intimidate the employee and keep them from gaining em-
the individual based on the conduct associated with the crime ployment (Covington & Seiner, 2017).
(EEOC, 2012). For example, an employer can decide not to
hire an individual who was convicted of theft and extortion
Employee Right to Privacy
because these types of crimes may indicate the individual is
not trustworthy. A character trait of trustworthiness is im- Employees have a limited right to privacy in the workplace,
portant when caring for and providing services to patients. which are protected by state, federal, and constitutional laws
However, an employer cannot refuse to hire an individual (Covington & Seiner, 2017). The employer can monitor the
solely because the person was convicted of driving while employee’s use of company mail and email and use of com-
under the influence over 20 years ago and has had no other pany equipment (e.g., mobile devices, computers) as long as
convictions since that time. the employee is notified (Interception and Disclosure of Wire,
Another type of employer liability is defamation, in which Oral, or Electronic Communications Prohibited, 18 U.S.C.
the employer tells another individual something false about §2511, 2008). Employers cannot hack into employees’ per-
the employee and the false statement harms the employee sonal emails (Interception and Disclosure of Wire, Oral, or
Electronic Communications Prohibited, 2008). Employers or employees. Genetic information includes information about
can search company lockers and desks; however, the em- employees’ genetic tests or genetic tests of a family member
ployer cannot search the employees’ bags, purses, or vehicles (Employer Practices, 42 U.S.C. §2000ff-1, 2008). The employer
(Covington & Seiner, 2017). is permitted to request genetic information for limited excep-
For various reasons, the employer may create and collect tions, such as if the employer is providing a wellness program;
confidential information about the employee, such as social however, the employer must segregate the information and
security numbers, criminal background history, addresses, treat it as confidential (Employer Practices, 2008).
medical history, information about sick or medical leave,
and credit history. The employer has a duty to protect the FCRA
employee’s confidential information under various state and
federal laws (Covington & Seiner, 2017). The Fair Credit Reporting Act of 2011 (FCRA; 15 U.S.C.
§168) mandates accuracy, fairness, and privacy of the files of
consumer reporting agencies (Fair Credit Reporting Agency,
HIPAA 2011). Consumer reporting agencies must report accurate in-
One federal privacy law, the Health Insurance Portability formation and correct or remove inaccurate, incomplete, or
and Accountability Act of 1996 (HIPAA; P. L. 104–191), has unverifiable information (Permissible Purposes of Consumer
paved the way for the first national privacy standards for Reports, §15 U.S.C. 1681b, 2011). A consumer report includes
health information. Since passage of HIPAA, the DHHS has any information reported by the consumer reporting agency
passed privacy, security, and breach notification regulations bearing on consumers’ credit capacity, which is used or ex-
limiting the use and disclosure of protected health informa- pected to be used or collected (Definitions, Rules of Construc-
tion (PHI), as well as establishing data security safeguards tion, 15 U.S.C. §1681a, 2011). The employee or applicant must
(Notification in the Case of Breach of Unsecured Protected give consent before the employer can request the consumer
Health Information, 45 C.F.R. Subpart D, 2013; Privacy of report (Compliance Procedures, 15 U.S.C. §1681e, 2011).
Individually Identifiable Health Information, 45 C.F.R. Sub- If an employer decides to fire or not hire a person due to a
part E, 2013; Security Standards for Protection of Electronic credit report, the employer must provide the individual with
Protected Health Information, 45 C.F.R. Subpart C, 2013). a copy of the report (Compliance Procedures, 2011). The em-
PHI is defined as individually identifiable health information ployee has a right to dispute the information in the report
created or received by a covered entity, relating to the past, (Identity Theft Prevention; Fraud Alerts and Active Duty
present, or future physical or mental health conditions or the Alerts, 15 U.S.C. §1681c, 2011).
provision of health care or payment (Definitions, 45 C.F.R.
§160.103, 2014). State privacy laws
PHI is information that identifies an individual, such as State privacy laws may also impose restrictions on how em-
social security number, name and address, and the types of ployee information is used and the safeguards required to
services (Definitions, 2014). Covered entities are health care protect the confidential information. For example, Maine
providers, health plans, and health care clearinghouse (Defi- requires the employer to implement adequate measures to
nitions, 2014). Although employers collect and retain con- ensure the confidentiality and integrity of the information
fidential information about employees, that information is (Employee Right to Review Personnel File, 26 M.R.S.A. §631,
not PHI unless the employer is considered a covered entity. 2017). Most states, such as California (Agencies Owning,
Employers that are also health care providers (e.g., hospitals) Licensing, or Maintaining Computerized Data Including
are covered entities. The employer that offers a medical clinic Personal Information, California Civil Code §1798.29, 2017)
for employees is also a HIPAA-covered entity to the extent and Colorado (Notification of Security Breach, C.R.S.A.
that the employer is providing health care. Employers that §6-1-716, 2010), have implemented state breach notification
have self-insured employee health plans, rather than pur- laws to require the employer to notify employees of a breach
chasing coverage from private insurance companies, are of personal information.
also HIPAA-covered entities (Administrative Simplification:
Covered Entity Guidance, n.d.). Employers that are HIPAA-
covered entities must comply with HIPAA’s regulations, in-
Social media
cluding, among other regulatory requirements, establishing Social media can also pose privacy concerns in the workplace
security safeguards to protect PHI, implementing HIPAA (e.g., employees posting images of clients on social media
policies and procedures, and notifying employees in the event platforms) and can interfere with work duties. Employers
PHI is used or disclosed in an unauthorized manner. may restrict employee access to social media during working
hours; however, they generally do not have a right to control
employee activity after hours, and they do not have access
GINA
rights to employee accounts (Coyne et al., 2015). Federal and
The Genetic Information Nondiscrimination Act of 2008 some state laws restrict employer rights to access employees’
(GINA; P. L. 110–233) prohibits employers from requesting, social media accounts (Coyne et al., 2015). Some states have
requiring, or purchasing genetic information about applicants enacted lifestyle discrimination statutes that forbid employer
restrictions on employees’ behavior off duty and off the em- employment practices, such as policies or tests, that dispro-
ployer’s premises (Coyne et al., 2015). portionally affect minorities. In Robinson v. Shell Oil (519 U.S.
337, 1997), the Supreme Court ruled that Title VII prohibits
retaliation against former and current employees. In Fara-
Laws Prohibiting Employment Discrimination gher v. City of Boca Raton (524 U.S. 775, 1998) and Burlington
State and federal laws prohibit discrimination in the work- Industries, Inc. v. Ellerth (524 U.S. 742, 1998), the Court iden-
place. Such laws include constitutional protections against tified circumstances in which an employer can be held liable
discrimination. For example, the 14th Amendment of the for its manager’s sexual harassment of employees.
U.S. Constitution prohibits discrimination based on national
origin, race, or gender by state entities, such as government
officials. Some state constitutions have broader equal pro-
EEOC
tection rights for gender, color, national origin, and religion EEOC enforces federal laws by investigating employee com-
that may apply to public and private entities (Covington & plaints, conducting investigations, and filing lawsuits on
Seiner, 2017). behalf of the employee (Enforcement Provisions, 2009). To
Several federal statutes have been enacted to prohibit file a discrimination suit against an employer, the employee
workplace discrimination based on race, gender, age, preg- must first file charges with the EEOC within 180 days of the
nancy, disability, and genetic information. Title VII of the alleged discrimination (Enforcement Provisions, 42 U.S.C.
Civil Rights Act of 1964 (P. L. 88–352) is a federal law that §2000e-5, 2009). The employee’s ability to file a lawsuit in
prohibits discriminating against employees on the basis of federal court depends on the applicable statute. If the com-
sex, race, color, national origin, and religion. Title VII forbids plaint is filed under Title VII or ADEA, the employee must
discrimination against prospective, present, and former em- wait at least 180 days after filing to allow EEOC to resolve
ployees in all aspects of employment (Unlawful Employment the case (Enforcement Provisions, 2009). If the case is not re-
Practices, 42 U.S.C. §2000e-2, 1991). This includes hiring solved within this time frame, the employee can then can re-
and firing; transfers, promotions, and layoffs; job postings; quest a Notice of Right to Sue from the EEOC (Enforcement
recruitment; testing; job training; fringe benefits; retirement Provisions, 2009). If the complaint is filed under the Equal
plans; and disability leave. Pay Act, the employee can file a lawsuit in federal court up
The Age Discrimination in Employment Act of 1967 to 2 years after the complaint, and a Notice of Right to Sue is
(ADEA; P. L. 90–202) prohibits discriminatory employment not required (Minimum Wage, 2016). The employer must re-
practices based on age (Prohibition of Age Discrimination, spond to the complaint within 20 days. EEOC can issue a sub-
29 U.S.C. §623, 2016). The Pregnancy Discrimination Act poena for documents and testimony to compel cooperation
of 1978 (P. L. 95–555) forbids discrimination based on preg- (Enforcement Provisions, 2009).
nancy for any aspect of employment (Definitions, 42 U.S.C. The EEOC has sued many employers for discrimination
§2000e, 2016). The Americans With Disabilities Act (ADA; for unlawful practices, including refusing to consider a male
P. L. 101–336) and ADA Amendments Act 2008 (P. L. 110–325) applicant for a management position in a maternity program
prohibit discrimination against a qualified individual with a (EEOC, 2017b) and threatening to fire pregnant employees
disability relative to job application procedures, hiring, ad- (EEOC, 2017a). The EEOC has sued and settled many ADA
vancement, discharge, employee compensation, job training, cases when the employer discriminated against an employee
or other privileges of employment. The Rehabilitation Act of on the basis of a disability by failing to provide reasonable
1973 (P. L. 93–112) prohibits discrimination based on disabil- accommodations when refusing to allow short breaks to at-
ity for recipients of federal funds. The Equal Pay Act of 1963 tend to medical needs (EEOC, 2017c), refusing to modify the
(P. L. 88–38) prohibits sex-based wage discrimination between company absenteeism policy to accommodate an employee’s
men and women who perform jobs that require equal skills, chronic condition (EEOC, 2017e), and refusing to transfer an
effort, and responsibility under similar working conditions employee with lifting restrictions to another qualified po-
(Minimum Wage, 29 U.S.C. §206, 2016). GINA prohibits dis- sition (EEOC, 2017d). ADA requires employers to provide
crimination against employee or applicants because of genetic reasonable accommodations for employees with disabilities,
information (Employer Practices, 2008). The National Labor unless the accommodation would be an undue hardship
Relations Act of 1974 (29 U.S.C. §§ 151-169, Chapter 7) bans to an employer (Discrimination, 42 U.S.C. §12112, 2009).
discrimination on the basis of union membership. Additionally, the ADA defines disability as a physical or men-
tal impairment that substantially limits one or more major life
activities (Definition of Disability, 42 U.S.C. §12102, 2009).
Supreme Court decisions
Employers are permitted to implement medical exams to
A series of U.S. Supreme Court decisions have helped shaped test ability to perform job duties; however, they cannot use
federal discrimination laws. In Phillips v. Martin Marietta these tools as a disguise for discriminating against employees.
Corp. (400 U.S. 524, 1971), the Court ruled that an employer ADA restricts the employer’s release of medical testing results
policy of using a special hiring practice for women with chil- to limited circumstances, such as informing other manag-
dren is a form of sex discrimination. Griggs v. Duke Power ers who need information to provide reasonable accommo-
Co. (401 U.S. 424, 1971), allowed employees to challenge dations (Discrimination, 2009). In one case, a federal court
ruled that an employer violated the ADA when it refused to with occupational safety and health standards, and report
hire an employer because he had a prior carpal tunnel sur- and maintain records of injuries. Employees may question
gery. The court found the employer was arbitrarily ruling out unsafe conditions, assist with inspection, and bring an ac-
potential applicants based on a nerve conduction study rather tion to compel the Secretary of Labor to stop the unsafe
than individual assessment of the applicant’s present ability condition causing imminent danger to employees. Retalia-
to perform the job (Amsted Rail Co. v. Defendant, 169 F. Supp. tion and harassment for filing complaints with OSHA are
3d 877, 2016). prohibited (OSHA, 1970). For example, in one OSHA en-
Employers may implement workplace wellness programs forcement action, a U.S. Postal Service employee who filed a
to reduce health care insurance premiums; however, the complaint and questioned unsafe workplace conditions was
employer may not use the programs to discriminate against harassed and demoted. As a result of the retaliation, the em-
employees. Wellness programs may include such activities as ployer was ordered to pay the employee $229,000 in damages
participating in a walking program, requesting completion (DOL, 2015).
of medical screenings, providing rewards for participation Among the workplace hazards affecting health care pro-
in smoking cessation programs, or joining a gym. Employ- viders, workplace violence has been recognized by DOL as
ers may not mandate participation in wellness programs one of the more serious risks. Workplace violence is defined
and may not discriminate against employees for refusing to as “violent acts, including physical assaults and threats of
participate (Collmer et al., 2013). Although employers can assaults, directed at persons at work or on duty” (OSHA,
offer rewards for participation, GINA prohibits offering an 2015). Health care workers face higher rates of workplace vi-
employee financial inducements for providing genetic infor- olence than other workers in the private sector, and patients
mation (Employer Practices, 2008). are often the source of workplace violence (Curtis, 2017).
Title VII, the ADEA, and the ADA (Discrimination, 2009) Health care providers may work alone or with patients who
forbid harassment in the workplace. Harassment is unwel- are under the influence of drugs or alcohol. Many workplace
come behavior based on race, color, religion, sex, pregnancy, violence incidences are underreported because providers
national origin, age (40 years or older), disability, or genetic feel a professional duty to help the patient, placing their per-
information (Harassment, n.d.). Sexual harassment can in- sonal safety at risk. OSHA has published a request for infor-
clude unwelcome sexual advances, requests for sexual favors, mation in support of a new standard on workplace violence
or verbal or physical harassment of a sexual nature (Sexual in health care with the goal of regulations mandating orga-
Harassment, n.d.). Harassment is unlawful when (1) enduring nizational policies and procedures addressing these issues
offensive conduct becomes a condition of continued employ- (Curtis, 2017).
ment or (2) harassing conduct is severe and pervasive enough OSHA (1970) authorized states to develop their own
to create a work environment that a reasonable person would OSHA plans. Twenty-two states, including Alaska, Arizona,
consider intimidating, hostile, or abusive (Harris v. Forklift California, and New Mexico, have state OSHA plans that ex-
Systems, 510 U.S. 17, 1993). Employers are not only prohibited tend to private, state, and local government employers. When
from harassing their employees and creating a hostile work states develop their own OSHA plans, the state assumes
environment but also prohibited from retaliating against an responsibility for enforcement of the statute (OSHA, 1970).
employee for filing a charge, testifying, or participating in an
investigation or proceeding. Employers who fail to prevent Laws Protecting Employee Compensation
or correct harassing behavior can be liable for the harassing
and Job Security
conduct of their managers.
The Fair Labor Standards Act of 1938 (FLSA; P. L.75–718)
imposes minimum wage and overtime standards on most
Laws Protecting Employee Safety
employers (Minimum Wage, 2016). FLSA requires overtime-
The federal Occupational Safety and Health Act of 1970 eligible employees to be compensated for overtime pay for
(OSHA; P. L. 91–596) is designed to prevent injury and disease hours worked over 40 hours (Minimum Wage, 2016). FLSA
among workers. OSHA applies to public and private-sector has a white-collar exemption for administrative, executive,
employers. Employer is broadly defined in the statute as any and professional employees from FLSA’s wage and hour
person engaged in commerce (Definitions, 29 U.S.C. §652, restrictions (Exemptions, 29 U.S.C. §213, 2014). The DOL,
1970). OSHA is enforced by the DOL and the Secretary of the federal agency responsible for administration and en-
Labor is responsible for administration of OSHA, includ- forcement of FLSA, proposed rules in early 2016 to double
ing the development and implementation of occupational the minimum salaries necessary to satisfy the white-collar
safety and health standards. DOL’s enforcement authority exemption. The proposed regulations were stopped by a pre-
includes physical inspection, issuance of citations requiring liminary injunction, and DOL is reconsidering new over-
remediation of safety hazards, and imposition of penalties time rules (State of Nevada v. U.S. Department of Labor, 218
(Inspections, Investigations, and Recordkeeping, 29 U.S.C. F. Supp. 3d 520, 2016).
§657, 1970). Pregnant and nursing mothers may have additional rights
Under OSHA (1970), the employer must provide a work- under FLSA. FLSA requires employers to provide nursing
place free from known health and safety hazards, comply mothers a reasonable amount of time to express milk as
frequently as needed. Employers must also provide a func- 4. Tim has a specialized occupational therapy practice in
tional space for nursing. Although the space does not have which he uses several proprietary techniques to treat mu-
to be dedicated to nursing, it cannot be a bathroom and sicians with hand injuries. He hires an employee to pro-
has to be available and private (Maximum Hours, 29 U.S.C. vide occupational therapy services. A court would most
§207, 2010). Many states, such as California, have enacted likely uphold Tim’s confidentiality and non- compete
laws with additional protections for nursing mothers (e.g., agreement with his employee, if (select all that apply)
providing compensated breaks or breaks beyond 1 year after a. It contains a non-compete provision restricting the
a child’s birth). employee from working as an occupational therapy
The Family and Medical Leave Act of 1993 (FMLA; practitioner anywhere in the United States for 5
P. L. 103–3) protects job security for employee leave. Eligible years after termination of employment.
employees can take up to 12 weeks of unpaid leave per year b. It contains a provision requiring the employee to
to address serious health conditions, care for a newborn, or not use or disclose Tim’s confidential information
care for a sick family member. FMLA also guarantees group for purposes outside the job duties.
health insurance coverage and the ability to return to the c. It contains a provision restricting the employee from
same or equivalent job. Employees must work for employers opening an occupational therapy practice treating mu-
for over 1,250 hours for 12 months to qualify. Employers with sician hand injuries within 5 miles of Tim’s practice.
less than 50 employees are not covered by the law. d. It allows Tim to seek a restraining order if the em-
ployee is misusing confidential information.
5. If an employer offers an in-house medical clinic for em-
Review Questions
ployees, the employer may be a HIPAA-covered entity,
1. Emma has just returned to work after maternity leave. required to
She explains to her supervisor, Lisa, that she needs a pri- a. Notify employees of unauthorized use and disclo-
vate room to pump breastmilk during the workday. Lisa sure of PHI
shakes her head and says, “You can’t pump at work. You b. Implement security safeguards to protect PHI
are expected to perform at 90% productivity, and exces- c. Comply with HIPAA privacy, security, and breach
sive breaks for pumping will interfere with your work notification rules
duties. Besides, we don’t have a private location for you.” d. All of the above
Lisa’s response may have violated which laws: 6. Desert Outpatient Facility has decided to implement a
a. Title VII of the Civil Rights Act of 1964 workplace wellness program to reduce health insurance
b. ADA premiums. Which of the following programs is permis-
c. Pregnancy Discrimination Act sible under the ADA?
d. All of the above a. All employees are required to participate in a walk-
2. John hired Linda to provide occupational therapy ser- ing program or their premiums will be increased by
vices for 90 days in his practice. John and Linda agreed to 20% from the previous year.
the terms of the employment in writing, including a clause b. Employees have the option to complete a health
that allows John to terminate Linda only for cause. John screening or join the facility gym at a discounted fee
and Linda’s employment relationship can be described as as participation in the program.
a. At-will employment c. Employees are paid $50 to complete DNA testing to
b. An independent contractor relationship identify early-onset dementia.
c. A contractual relationship d. Desert Outpatient will not pay health insurance pre-
d. A partnership miums for employees who are overweight unless the
3. Mercy Hospital terminated Sam, an occupational employees joins a weight management program.
therapy practitioner, for billing in a fraudulent man- 7. Which federal law prohibits discrimination against em-
ner. Mercy had conducted an extensive investigation ployees on the basis of genetic information?
and confirmed Sam was billing for services he did not a. ADA
perform. Sam’s prospective employer contacted Mercy b. GINA
Hospital for references and verification of Sam’s employ- c. Equal Pay Act
ment. Which of the following statements are true? d. HIPAA
a. Mercy Hospital has a qualified privilege to allow dis- 8. If an employee wishes to file a lawsuit against his employer
closure of the reason for Sam’s termination. for discrimination under Title VII, the employee must
b. Mercy Hospital may be vicariously liable for Sam’s a. File a complaint in federal court
conduct because his acts were performed in the b. Retain an attorney
course of his employment. c. File a complaint with EEOC within 180 days after
c. If Mercy Hospital discloses the reason for the termi- the alleged discrimination, wait for EEOC to resolve
nation to the prospective employer, it may be liable the case, and request a Notice of Right to Sue
for defamation. d. Publish his intent to file a lawsuit in the local
d. Both a and b newspaper
9. The occupational therapy manager at West Hospi- Occupational therapy managers must also understand im-
tal has received several complaints of sexual harass- proper reasons for disciplining employees with disabilities
ment among the staff. The manager should implement and partner with human resources to identify reasonable
which of the following to reduce occurrences of sexual accommodations.
harassment: Nearly every person has a social media account, and
a. Employee training about sexual harassment and posting pictures or comments to social media has become
ways to report it a part of daily life. Employees may not understand the
b. An anonymous reporting hotline privacy implications of posting images of their clients or
c. A zero tolerance policy prohibiting all forms of sex- discussing clients on social media. A well-written social
ual harassment media policy provides guidance on acceptable use of so-
d. All of the above cial media in the workplace. Social media policies should
10. Lucy has rheumatoid arthritis. Most days, she can per- be narrowly written to restrict social media use during
form her job duties; however, on occasion, she needs working hours and prohibit employee disclosure of patient
reasonable accommodations, such as rest breaks and information. The policy should establish a disciplinary
lighter duty. Which law requires her employer to pro- procedure to address noncompliance. The occupational
vide reasonable accommodations? therapy manager can enforce the policy for work-related
a. ADA conduct only.
b. FLSA
c. EEOC
Vetting and Verifying Applicants
d. OSHA
11. Which of the following is not mandated by OSHA? (se- Occupational therapy managers should perform extensive
lect all that apply) reference and criminal background checks to assess an ap-
a. The employer must provide a workplace free from plicant’s fitness for the job. The manager should confirm the
known health and safety hazards. prospective employee’s state license is active and no pending
b. The DOL can enforce the law through court action. actions against the individual exist. The health care setting
c. Employers must pay employees overtime for hours requires qualities of trustworthiness and ethical behavior.
worked over 40 hours. The occupational therapy manager should not hire individ-
d. Employees may question unsafe working conditions uals who have been convicted on crimes that would affect
and employers are prohibited from retaliation. their fitness for a job in health care, such as theft, fraud, or
assault.
Alternatively, the occupational therapy manager has a
PRACTICAL APPLICATIONS IN qualified privilege to disclose true statements about the em-
OCCUPATIONAL THERAPY ployee to future employers. Statements that inform the other
The occupational therapy manager’s role in understanding employer of the employee’s character and job performance
employment law is to apply the principles in the workplace are important in making a hiring decision. Examples of such
in a manner that creates a safe, fair, and productive environ- statements include employees’ documented noncompliance
ment. Developing and implementing strategies to comply with company policies that threaten the safety of patients or
with employment laws aids the manager in decision mak- expose the employer to liability and inappropriate employee
ing and developing an effective partnership with human conduct toward patients and other employees. The manager
resources professionals. Employees will respond well to a should base the statements on documented performance de-
managerial style that applies a fair and consistent approach ficiencies and internal investigations and avoid making state-
to addressing workplace concerns. ment not supported by facts.
Understanding and Incorporating Employee Training

Organizational Policies
Workplace sexual harassment has become prominent in the
Occupational therapy managers should become familiar media, illustrating the importance of employee training and
with organizational policies and procedures or employee reporting mechanisms to prevent harassment. Occupational
handbooks defining company policies. These documents therapy managers can be liable if they do not implement pre-
provide important guidance for addressing employment ventive measures and intervene when sexual harassment is
matters in compliance with the law. A manager’s incor- reported. The occupational therapy manager should become
poration of organizational policies and procedures aids familiar with organizational sexual harassment policies. A
in decision making and creates a productive relationship strong organizational policy will establish zero tolerance
with employees. Policies and procedures must be the foun- of sexual harassment and identify an effective complaint or
dation for employee discipline and supported by docu- grievance process (e.g., anonymous hotlines or other report-
mented facts. Consistent application of organizational ing mechanisms). Occupational therapy managers should
policies and procedures reduces the risk of discrimination. train employees about sexual harassment and take immediate
action on all reports of sexual harassment, which may include 4. Which of the following is not required by the FMLA?
partnering with human resources or employment counsel to a. Paid time away from the job
conduct internal investigations. b. The employee can return to the job or an equivalent
Health care providers face higher risks of workplace vio- job
lence. Employees should receive safety and health training c. The employee may take 12 weeks of time from the job
to educate them about workplace hazards. Some occupa- to care a sick family member or personal medical needs
tional therapy practice settings may pose higher safety risks d. Employer must continue group health insurance
to employees (e.g., providing services in the home, com- 5. Employment law is developed through
munity services, delivering services in isolated locations). a. Regulations and statutes
Occupational therapy managers should develop policies b. Constitutional law
and procedures for responding to and reporting workplace c. Case law
hazards. The occupational therapy manager may consider d. All of the above
performing a worksite analysis to identify and remediate 6. Which of the following does not describe at-will
potential hazards. For example, an occupational therapy employment?
manager can implement preventive safeguards for employ- a. The employer has no legal obligation to retain the
ees providing services in unsafe neighborhoods (e.g., no employee.
appointments after a certain hour, employees must travel b. The employee may resign at any time for any reason.
in pairs). c. The employer and employee have agreed on a fixed
employment term.
d. At-will employment is the presumed employment sta-
Review Questions
tus in the United States.
1. Which of the following strategies can an occupational 7. An employer who refuses to hire an applicant with a
therapy manager implement to protect employee safety in criminal conviction is not in violation of antidiscrimina-
a home health setting? tion laws when
a. Employee training on safety risks and prevention a. The employer implements a blanket rule not to hire
when providing services in the patient’s home any applicant with a criminal conviction of any kind,
b. A policy that employees must immediately report no matter how remote.
workplace violence and management must investi- b. The employer refuses to hire an applicant who has
gate reports within 24 hours convicted of driving under the influence, even though
c. A requirement that the manager must assess risks the conviction is unrelated to the job duties.
of different working environments and implement c. The employer does not feel safe around individuals
appropriate preventative measures with criminal convictions.
d. All of the above d. The applicant was convicted of extortion and theft,
2. Eligible employees may take 12 weeks of unpaid time to and the job involves providing services in clients’
care for a newborn or sick family member while guar- homes, where employees must be trustworthy and
anteed job security and health insurance benefits, as ethical.
mandated by which law? 8. Joseph is an occupational therapy practitioner working
a. FLSA at an outpatient clinic. Joseph applied for a job opening at
b. ADA the hospital, was interviewed, and provided employment
c. FMLA references. The hospital contacted Joseph and explained
d. OSHA they could not hire him because his current employer
3. Stan, an occupational therapy practitioner in a pediatric disclosed that he abuses alcohol and has been intoxicated
setting, was excited when his client was able to climb the on the job. The employer’s statements were not true. The
jungle gym independently. He snapped a picture of his employer may be liable for
client and posted it to his social media site with a cap- a. Nothing, since the employer has a qualified privilege
tion “Jimmy conquers the playground!” Which of the fol- to disclose information about Joseph
lowing would be helpful in guiding Stan on use of social b. Negligent hiring
media at work? c. Defamation
a. Immediate termination because posting pictures of d. Vicarious liability
clients is not acceptable 9. Harassment in the workplace is unlawful when
b. Scolding Stan during a staff meeting about his a. It occurs once.
conduct b. Enduring offensive conduct becomes a condition of
c. A social media policy explaining appropriate use continued employment.
of personal accounts and employee training on the c. Harassing conduct is severe and pervasive enough to
policy create a work environment that a reasonable person
d. The manager should have access to all employee would consider intimidating, hostile, or abusive.
accounts to be able to edit posts d. Both b and c
CASE EXAMPLE 64.1. Understanding Employment Laws
Scenario 1. Protecting Employee Safety

An OTA works in the client’s home, providing habilitation services to a child. The OTA reports to her manager that the child’s father recently attended
a session wearing only his boxer shorts. He made several inappropriate comments about the OTA during the visit. The OTA does not feel safe
returning to the home.
Review Questions
1. What law is implicated in this scenario?
2. What duty does the manager have to protect the employee?
3. What action can the manager take to protect the employee’s safety?
Scenario 2. Safeguarding Confidential Business Information

An occupational therapy practitioner opened a new clinic providing low vision services. The practitioner developed a strong relationship with
referring physicians, as well as a competitive client list. The physician and client list produce significant revenue for the clinic, and the practitioner
maintains the list in an unprotected file on the company server. The practitioner hires an employee who later resigns and uses the physician and
client list to open a competing clinic 5 miles away.
Review Questions
1. What agreements could the occupational therapy practitioner implement to protect his specialized practice?
2. What duty does the employee owe the employer regarding the physician and client list?
Scenario 3. Protecting Employee Confidential Information

An outpatient rehabilitation center provides an in-house health clinic for employees to receive checkups and minor medical care. The rehabilitation
center stores all employee information on a company laptop, including employee protected health information, criminal background checks, and
payroll information. One afternoon, the laptop, containing the sensitive information, disappeared.
Review Questions
1. What laws or legal principles apply to require the rehabilitation center to protect the employee information?
2. What measures could the rehabilitation center implement to protect the employee information?
3. What actions should the rehabilitation center take now that the information has been stolen?
Scenario 4. Employer Discrimination

An occupational therapy practitioner is employed at an inpatient rehabilitation hospital. Her client caseload consists of patients requiring varying
levels of transfer assistance. She notified her employer that she is 13 weeks pregnant and her physician has restricted her from lifting more than
20 pounds. The employer terminated the practitioner, stating she cannot perform her job duties as a result of the lifting restrictions.
Review Questions
1. What laws has the employer violated by firing the occupational therapy practitioner?
2. What reasonable accommodations could the employer implement to allow the practitioner to perform her job?
3. What actions can the practitioner take as a result of the wrongful termination?
SUMMARY when the employer is also a HIPAA-covered entity; and em-

ployer discrimination based on pregnancy. ❖
Employment law plays an important role in the modern
workplace. Occupational therapy managers are a critical
component of providing a fair and safe work setting. Basic
LEARNING ACTIVITIES
knowledge of the law, a partnership with human resources, 1. Describe recent media references to workplace discrim-
and practical application of employment law principles ination and sexual harassment and how you perceive
are important for creating a safe and effective workplace. the employer– employee relationships for the involved
Case Example 64.1 examines laws protecting employee safety, organizations.
as well as the occupational therapy manager’s role in reduc- 2. Interview 3 employers about their workplace wellness
ing workplace hazards; an employee’s duty of loyalty to the programs, including the goals of the program and how
employer, as well as the employer’s options to protect confi- the employers encourage participation.
dential and proprietary business information; the employer’s 3. Review an employee handbook and identify policies
duty to protect confidential employee information, especially addressing social media use, employee disciplinary
procedures, anti-retaliation policy, and background Employee Right to Review Personnel File, 26 M.R.S.A. §631 (2017).
check policies. What requirements do these policies place Employer Practices, 42 U.S.C. §2000ff-1 (2008).
on the employee and the employer? Enforcement Provisions, 42 U.S.C. §2000e-5 (2009).
4. Review your state’s laws to preserve the nursing mother’s Equal Pay Act of 1963, Pub. L. 88–38, 29 U.S.C. §206(d).
Exemptions, 29 U.S.C. §213 (2014).
right to breastfeed or pump breast milk in the workplace?
Fair Credit Reporting Act of 2011, 15 U.S.C. §168.
How does your law differ from the federal requirements
Fair Labor Standards Act of 1938, Pub. L. 75–718, 29 U.S.C. § 203
(e.g., paid breaks, longer break time)? Family Medical Leave Act of 1993, Pub. L. 103–3, 107 Stat. 6.
Faragher v. City of Boca Raton, 524 U.S. 775 (1998).
ACOTE STANDARDS Genetic Information Nondiscrimination Act of 2008, Pub. L.
110–233, 122 Stat. 881.
This chapter addresses the following ACOTE Standards: Griggs v. Duke Power Co., 401 U.S. 424 (1971).
Harassment. (n.d.). U.S. Equal Employment Opportunity Commission.
■ B.5.3. Business Aspects of Practice Retrieved from https://www.eeoc.gov/laws/types/harassment.cfm
■ B.5.8. Supervision of Personnel. Harris v. Forklift Systems, Inc., 510 U.S. 17 (1993).
Health Insurance Portability and Accountability Act of 1996,
Pub. L. 104–191, 110 Stat. 1936.
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(ACOTE) standards and interpretive guide. American Journal employed) or employee? Retrieved from https://www.irs.gov
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.org/10.5014/ajot.2018.72S217 -contractor-self-employed-or-employee
ADA Amendments Act of 2008, Pub. L. 110–325, 42 USCA § 12101. Inspections, Investigations, and Recordkeeping, 29 U.S.C. §657
Administrative Simplification: Covered Entity Guidance. (n.d.). Re- (1970).
trieved from https://www.cms.gov/Regulations-and-Guidance Interception and Disclosure of Wire, Oral, or Electronic Communi-
/Administrative-Simplification/HIPAA-ACA/Downloads cations Prohibited, 18 U.S.C. §2511 (2008).
/CoveredEntitiesChart20160617.pdf Ledbetter v. Goodyear Tire & Rubber Co., 550 U.S. 618 (2007).
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29 U.S.C. § 621 to 29 U.S.C. § 634. (2009), 42 U.S.C. §2000e-16.
Agencies Owning, Licensing, or Maintaining Computerized Maximum Hours, 29 U.S.C. §207 (2010).
Data Including Personal Information, California Civil Code Minimum Wage, 29 U.S.C. §206 (2016).
§1798.29 (2017). National Labor Relations Act of 1974, 29 U.S.C. §§ 151–169,
Americans With Disabilities Act of 1990, Pub. L. 101–336, 104 Chapter 7.
Stat. 327. Notification in the Case of Breach of Unsecured Protected Health
Amsted Rail Co. v. Defendant, 169 F. Supp. 3d 877 (S.D. Illinois, 2016). Information, 45 C.F.R. Subpart D (2013).
Burlington Industries, Inc. v. Ellerth, 524 U.S. 742 (1998). Notification of Security Breach, C.R.S.A. §6-1-716 (2010, August 11).
California Business and Professional Code §16600 (2017). Notification Required Before Plant Closings and Mass Layoffs,
Civil Rights Act of 1964, Pub. L. 88–352, 78 Stat. 241. 29 U.S.C. §2102 (2015).
Collmer, V., Millea, C., & Wearne, N. (2013). Guidelines for improv- Occupational Safety and Health Act of 1970, Pub. L. 91–596,
ing workplace wellness. Health Lawyer, 25(6), 44–46. 29 U.S.C. §Chapter 15.
Compliance Procedures, 15 U.S.C.§1681e (2011). Occupational Safety and Health Administration. (2015). Workplace
Coyne, J., Dretler, J., Foster, J., & Grimaldi, J. (2015). Adverse em- violence in healthcare. Retrieved from https://www.osha.gov
ployment actions and off-duty conduct [Power Point slides]. Re- /Publications/OSHA3826.pdf
trieved from http://webcasts.acc.com/handouts/PPT_258_7E69 Palmisano v. Allina Health Systems, Inc., 190 F 3d. 881 (8th Cir.
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Covington, R., & Seiner. (2017). Employment law in a nutshell Phillips v. Martin Marietta Corp., 400 U.S. 524 (1971).
(4th ed.). St. Paul, MN: West. Pregnancy Discrimination Act of 1978, Pub. L. 95–555, 92 Stat.
Curtis, J. (2017, February 8). OSHA considers workplace violence for 2096.
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www.securityinfowatch.com/article/12303659/osha-considers Subpart E (2013).
-workplace-violence-standard-for-healthcare-industry Prohibition of Age Discrimination, 29 U.S.C. §623 (2016).
Definition of Disability, 42 U.S.C. §12102 (2009). Rehabilitation Act of 1973, Pub. L. 93–112, 87 Stat. 394.
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CHAPTER
Addressing Health Disparities
M. Beth Merryman, PhD, OTR/L, FAOTA 65
LEARNING OBJECTIVES
■ Define terms relative to health disparity and occupational therapy,
■ Identify causes and impacts of health disparity,
■ Explore and review explanatory models of health disparity,
■ Apply the Occupational Therapy Code of Ethics (AOTA, 2015a) to address health disparity, and
■ Develop and create interventions to reduce health disparity.

• Distributive justice • Health literacy • Socioeconomic status
• Fundamental cause theory • Healthy People 2020 • Stress process model
• Health disparities • Occupational justice • Transactional perspective
• Health inequality • Social–cognitive theory
OVERVIEW perspective of the professional Code. First, the chapter pro-

vides foundational information such as terminology and
H
ealth disparities are “differences in the incidence, definitions. Then, models that are used to understand health
prevalence, mortality, and burden of diseases and other inequality and disparity are presented. Specific ways that
adverse health conditions that exist among specific health disparity and inequality may be seen in practice are
population groups in the United States” (U.S. Department identified, with an emphasis on the role of the manager to
of Health and Human Services [DHHS], National Institutes establish an environment in which the core values, principles,
of Health, National Health, Lung, and Blood Institute, 2017, and standards of conduct of the profession are upheld.
para. 1; also see Institute of Medicine, 2002). Broad health-
related research has identified the importance of social fac-
tors such as socioeconomic status (SES; i.e., factors affecting ESSENTIAL CONSIDERATIONS
resources to engage and participate in meaningful occupa-
Health Initiatives
tions of daily life; Madsen et al., 2015) and marginalization
due to discrimination in measures of health and well-being Health inequalities are “avoidable inequalities in health
(American Occupational Therapy Association [AOTA], 2013; between groups of people within countries and between
Bass-Haugen, 2009). countries” (World Health Organization [WHO], 2018,
Occupational therapy managers are responsible for up- para. 1). Health disparity refers to the metric to measure
holding the professional Occupational Therapy Code of Ethics health equity and is a descriptive term for a specific popula-
(2015) (hereinafter, the Code; AOTA, 2015a). Among the tion group difference in access to health care or health status
challenges for all health care providers is ensuring access (Gamble & Stone, 2006). An example is a population group
to services. This chapter explores the role of occupational that demonstrates reduced health access after controlling
therapy managers to address health care disparity from the for insurance coverage (Braveman, 2014).
https://doi.org/10.7139/2019.978-1-56900-592-7.065
609
CHAPTER
Addressing Health Disparities
M. Beth Merryman, PhD, OTR/L, FAOTA 65
LEARNING OBJECTIVES
■ Define terms relative to health disparity and occupational therapy,
■ Identify causes and impacts of health disparity,
■ Explore and review explanatory models of health disparity,
■ Apply the Occupational Therapy Code of Ethics (AOTA, 2015a) to address health disparity, and
■ Develop and create interventions to reduce health disparity.

• Distributive justice • Health literacy • Socioeconomic status
• Fundamental cause theory • Healthy People 2020 • Stress process model
• Health disparities • Occupational justice • Transactional perspective
• Health inequality • Social–cognitive theory
OVERVIEW perspective of the professional Code. First, the chapter pro-

vides foundational information such as terminology and
H
ealth disparities are “differences in the incidence, definitions. Then, models that are used to understand health
prevalence, mortality, and burden of diseases and other inequality and disparity are presented. Specific ways that
adverse health conditions that exist among specific health disparity and inequality may be seen in practice are
population groups in the United States” (U.S. Department identified, with an emphasis on the role of the manager to
of Health and Human Services [DHHS], National Institutes establish an environment in which the core values, principles,
of Health, National Health, Lung, and Blood Institute, 2017, and standards of conduct of the profession are upheld.
para. 1; also see Institute of Medicine, 2002). Broad health-
related research has identified the importance of social fac-
tors such as socioeconomic status (SES; i.e., factors affecting ESSENTIAL CONSIDERATIONS
resources to engage and participate in meaningful occupa-
Health Initiatives
tions of daily life; Madsen et al., 2015) and marginalization
due to discrimination in measures of health and well-being Health inequalities are “avoidable inequalities in health
(American Occupational Therapy Association [AOTA], 2013; between groups of people within countries and between
Bass-Haugen, 2009). countries” (World Health Organization [WHO], 2018,
Occupational therapy managers are responsible for up- para. 1). Health disparity refers to the metric to measure
holding the professional Occupational Therapy Code of Ethics health equity and is a descriptive term for a specific popula-
(2015) (hereinafter, the Code; AOTA, 2015a). Among the tion group difference in access to health care or health status
challenges for all health care providers is ensuring access (Gamble & Stone, 2006). An example is a population group
to services. This chapter explores the role of occupational that demonstrates reduced health access after controlling
therapy managers to address health care disparity from the for insurance coverage (Braveman, 2014).
https://doi.org/10.7139/2019.978-1-56900-592-7.065
609
A concern that affects health status is the concept of health status limits their resources relative to healthy food and reli-
literacy, which refers to a person’s “capacity to obtain, com- able transportation. The theory has 4 aspects:
municate, process and understand basic health information
1. Multiple illnesses are potentially affected.
and services in order to make appropriate health decisions”
2. Multiple risks are present.
(Centers for Disease Control and Prevention [CDC], 2015,
3. Access and resources can decrease risk and consequence
para.1). This is a concern because health literacy has been
if disease occurs.
demonstrated to influence health outcomes (AOTA, 2017;
4. Risk and consequence can be reduced through methods
Schnitzer et al., 2011).
that improve health outcomes.
The federal government has established priorities through
overarching goals identified in Healthy People 2020, which fo-
cuses on improving the health of all groups through elimina- Stress process model
tion of disparities and inequities (DHHS, 2016). This document The stress process model (Pearlin, 1989) explores the person–
reflects many of the core values and principles of occupational environment interactions relative to individual exposure, re-
therapy by emphasizing health status by improving activity sponse, and recurrence of stress. Pearlin (1989) addressed the
participation, emphasizing improved natural and built envi- structural and contextual elements in which behavior occurs
ronments, and promoting participation in everyday activities. and reoccurs in the form of a habit and the challenges of change.
The Agency for Healthcare Research and Quality’s Na- The theory is relevant because it addresses both stressful life
tional Healthcare Quality and Disparities Report, an annual events, such as an acute medical crisis, and chronic strain, such
report on quality of health care in the United States, iden- as that produced from caregiving over time. The basic premise
tified improvements in rate of insurance among adults ages is that stressors are embedded in the transaction between peo-
18–64 years, specifically among Black and Hispanic adults, ple and their contexts. This person–environment or ecological
and rates of childhood immunization across racial and eth- model is congruent with the tenets of occupational therapy.
nic groups (DHHS, 2014). However, some areas reflected in-
creased disparity, including hospice care and chronic disease
management. Both areas reflect core aspects of occupational Social–cognitive theory
therapy practice. Social–cognitive theory (Bandura, 2001) posits that learning
occurs most effectively through observation of the choices and
Models and Theories to Address consequences of others. This theory supports that learning oc-
Health Disparity curs in a social context and that the person and environment
influence and are influenced by each other in a bidirectional
Several social sciences and occupation-based models inform manner. Personal factors include cognitive, affective, and bio-
understanding about the impact of social factors, such as the logical aspects of behavior, whereas environmental influences
environment, on client health. In each model described in this include social and contextual factors of health.
section, the role of the environment as part of the relation-
ship between the client and occupational therapy practitioner
is emphasized as key to influencing health. Occupational
Transactional perspective
therapy is invested in client health and thus uses models to The transactional perspective is occupation based and argues
understand challenges to client behavior change. that health-promoting theories emphasizing only individual
Potential occupational therapy interventions include ad- behavior or a systems approach are limiting, because health be-
dressing both the person and the environment. For example, havior is more complex (Cutchin & Dickie, 2013; Madsen et al.,
an occupational therapy manager committing to an inclusive 2015). This perspective, based on John Dewey’s pragmatism and
work environment might research and require staff training theory of action, argues that the person and context are embed-
on cultural competence and implicit bias, so that staff might ded and of one piece—person, behavior, and occupations cannot
more clearly use communication strategies and styles likely be separated from the context in which they will be enacted or
to result in client understanding and adoption of import- performed. The social and cultural aspects of engagement and
ant safety considerations (AOTA, 2013). Another example participation are addressed in this perspective and are crucial
might include institutional efforts to hire occupational ther- in understanding and addressing health behavior and disparity.
apy practitioners and staff whose sociocultural backgrounds
reflect the client population. Review Questions
For Questions 1–3, identify the best fit from the following:
Fundamental cause theory
a. Fundamental cause theory
The fundamental cause theory was developed by Link and b. Social–cognitive theory
Phelan (1995) to explain why the association between SES c. Stress process model
and mortality has persisted despite radical changes in dis- d. Transactional perspective
eases, and risk factors are presumed to explain it. The theory 1. As a new manager, you are concerned at the high percent-
posits that those with lower SES continue to have higher rates age of no-show outpatient rehab appointments at the urban
of cancer and cardiovascular disease because their economic clinic setting that serves many low-income clients. You want
CHAPTER 65. Addressing Health Disparities 611
to explore ways to modify the treatment culture so that it 3. Autonomy, or respect for client self-determination, pri-
is congruent with the challenges of the population. Among vacy, confidentiality, and consent;
the suggested changes are to expand evening hours to ac- 4. Justice, or the promotion of fairness and objectivity;
commodate the number of hourly workers who cannot take 5. Veracity, or full, accurate, and nonbiased information;
off to attend therapy and to provide signs, brochures, and and
handouts in the native language of the population. 6. Fidelity, or to treat with fairness, respect, discretion, and
2. The pediatric therapy clinic has experienced a most dra- integrity.
matic no-show rate. An administrative meeting reveals
The Code also espouses Core Values, including equality in the
that many of the youth live with a single grandmother
treatment of all people free of discrimination and adherence
who must juggle the school and medical schedule and
to justice, so that the manager establishes and works toward a
appointments; often occupational therapy is simply not
climate where all staff, clients, and family members can effec-
attended. To address the challenges of the grandmother’s
tively function and flourish.
stressful daily routine, you coordinate occupational
For occupational therapy managers, embracing models
therapy appointments with other disciplines so that the
that reflect the beliefs of occupational therapy—that engage-
family only needs to attend once weekly, and you offer
ment in occupation promotes and sustains health—is critical.
free WiFi, light snacks, comfortable chairs, and reading
Establishing an environment that is truly inclusive and sup-
materials in the native language in the waiting area.
ports the positive health of all is the objective of occupational
3. One concern is that the demographics of your therapy
therapy managers. Recognizing social and structural barriers
staff do not reflect the community you serve. You are
to individual engagement and participation and positive
considering engaging with community leaders to sponsor
health is a critical, ethical role of managers.
a health fair in which you will staff on common issues of
aging such as preventing fall risks, healthy child develop- Occupational justice
ment, and managing daily stress.
4. You overhear staff making disparaging comments about Awareness of social inequities led to the term and model of
potential clients who would be served as a result of ex- occupational justice, which articulates the unique beliefs
panding bariatric surgery. You are concerned that there and contributions of the profession to individual and popu-
may be bias in treating this population. Choose the best lation health and quality of life (Wilcock & Townsend, 2000).
strategy: This is done through attention to ways in which occupation
a. Send offending staff to a workshop on bariatric surgery. is thwarted—by disease, environment, and even society
b. Pull offending staff from serving any clients on this (Townsend & Wilcock, 2004; Wilcock & Townsend, 2000).
service. Among the roots of this contribution were explorations of
c. Verbally reprimand staff publicly so people know you theories of justice. In turn, this focus on justice led to edu-
mean business. cating occupational therapy practitioners on ways of right-
d. Require and model routine staff training on identifying wrongs, including distributive justice and learning and
ing and addressing implicit bias. attending to advocating policies and practices that support
5. One aspect of health disparity occurs when clients do not engagement and participation in communities of choice—
understand instructions, handouts, or worksheets during and inclusion—of all members of society. Distributive justice
discharge planning. When they do not speak up, they generally refers to the just distribution of income, wealth, and
may not benefit from therapy or risk readmission because opportunities (Sandel, 2009).
they did not receive culturally competent care. The inter- Attention to power dynamics and injustice relative to race,
vention that needs to occur would address: gender, and class, such as that espoused by Young (1990) be-
a. Health inequivalence yond distributive policies, has also been incorporated by
b. Health literacy occupational scientists. This knowledge has influenced global
c. Translational research occupational therapy interest in improving access to resources
d. Health inequality and necessities of marginalized populations through policy
improvements such as better mental health environments
(Townsend et al., 2003) and access to HIV care (Braveman &
PRACTICAL APPLICATIONS IN Suarez-Balcazar, 2009). Canadian occupational scientists in-
OCCUPATIONAL THERAPY troduced the notion of occupational possibilities (Gerlach, 2015;
Rudman, 2012) by applying critical theory and intersectional
Code, Disparity, and Implications for analysis to understand historical challenges to health and re-
Occupational Therapy Practice source access by less powerful, marginalized populations.
Occupational therapy researchers in the areas of pub-
The Code (AOTA, 2015a) identifies 6 Principles:
lic health have used a social justice lens and qualitative
1. Beneficence, or concern for the well-being and safety of research methods to bring to light the lived experiences of
clients; marginalized persons with disabilities to influence policy
2. Nonmaleficence, or refraining from actions that cause (Magasi & Hammel, 2009). The past decade has seen occupa-
harm; tional therapy and science argue not only for justice through
individual access to needed therapy but also for global popu- to treatment. Such disparities have been revealed at the sys-
lation health in pursuit of occupational justice through atten- tem and individual levels (Smedley et al., 2003). An example
tion to occupational possibilities (Rudman & Aldrich, 2017). of an individual-level disparity might be at the practitioner–
client level and involve an occupational therapy practitioner’s
Health policy cultural insensitivity to social role or norms that may poten-
tially prevent follow-up, thus limiting the client’s access to
ACA. In the United States, several health and social policy occupational therapy services. An example of a system-level
changes designed specifically to improve access have im- disparity might be a policy that prevents participation be-
proved access to occupational therapy services. For example, cause of religious or ethnic practices, such as a clinic requir-
the enactment of the Patient Protection and Affordable Care ing follow-up on Friday afternoons, which prevents some
Act of 2010 (ACA; P. L. 111–148) enabled access for many peo- with religious beliefs from either attending or staffing roles.
ple who were shut out of the private health insurance market According to Laveist and Nuru-Jeter (2002), client satisfac-
for structural or social reasons. This included those with pre- tion increased among those whose care was race concordant
existing medical conditions and those with complicated and with their provider, implying that attention to sociocultural
costly conditions who could now access care due to the re- aspects of care was important to recipients. Client satisfaction
moval of annual and lifetime caps on essential health benefits. may lead to better adherence to treatment, and in this case,
In addition, plans had to accept all applicants without regard a feeling that the provider understands them. Adherence
to their age, sex, or preexisting medical history. Certain plans enables the client to receive maximal benefit of therapies,
needed to meet a minimum threshold and cover essential the main objective of a rehabilitation department. Other re-
health care benefits, including mental health and substance searchers suggest providing training in cultural competence
abuse treatment and habilitative care. to improve client perceptions of quality, compliance, and
satisfaction (Holden et al., 2014; Saha et al., 1999).
MHPAEA. The Paul Wellstone and Pete Domenici Mental Specific recommendations have been offered relative to
Health Parity and Addiction Equity Act of 2008 (MHPAEA; system changes, such as allocation of resources to enable
P. L. 110–343) was designed to ensure equal coverage and training all staff who come in contact with patients and fam-
treatment for those seeking mental health and substance use ilies (Betancourt et al., 2003). The occupational therapy man-
disorder services relative to services for medical conditions ager, therefore, can address a lack of diverse staff resources
(Buchmueller et al., 2007; Ettner et al., 2016; Centers for Medi- by focusing on staff recruitment to ensure that a broad and
care and Medicaid Services, n.d.). In addition, some states diverse pool is obtained, and to provide and reinforce on-
opted to broaden access to health care for those at income going training to assist staff in providing culturally compe-
levels traditionally higher than poverty levels through an tent care. The manager can also advocate for staff to receive
expansion of Medicaid. Many of these individuals have dis- training to identify and address implicit bias that might be
abilities and were able to work without fear of losing critical reflected in hours of operation, treatment approach, or types
health coverage through Medicaid (Hall et al., 2017). of intervention.
The ACA also enabled young people with preexisting In some settings, reimbursement policies may preclude
mental health conditions or substance abuse challenges to redirect service to some populations. The occupational therapy
ceive care until age 26 years on their parents’ health policies. manager can work to promote outreach and educational in-
Lifetime and annual expense limits were removed, protect- volvement on the part of the rehabilitation staff. Literature
ing those with devastating conditions that carried exorbitant shows that some person-level strategies such as education
costs, such as spinal cord injury or complex NICU condi- are effective in health promotion. Participation in health
tions, from potential bankruptcy or suffering from lack of fairs, equipment loan programs, and screenings can be a
needed care. ACA and MHPAEA were designed to emphasize mechanism to provide important health promotion infor-
improved access to needed care. Medicaid waiver programs mation for those in the community with chronic condi-
enable states to increase access and expand care to particu- tions who would otherwise not have access. Knowledge and
lar populations, such as children and youth with autism, or awareness of the community influences can guide the health
adults with serious mental illness (Bilaver & Jordan, 2013). promotion efforts, such as training the community leaders
and offering outreach at the local community center, school,
Disparity Issues and Ethical Concept of or church.
Unrealistic productivity demands can sap staff energy to
Social Justice
participate in voluntary, off-the-clock, nonrevenue-producing
The literature on health disparity focuses on social factors activities. An institutional commitment to the community
that prevent best practice. The Code requires occupational during work hours demonstrates that fairness regardless
therapy practitioners to promote fairness in providing ser- of ability to pay is valued. Collaborating with a university
vices. For the occupational therapy manager, how can fair- occupational therapy program and involving students in
ness be assured in the clinic? both formal fieldwork and outreach can be an effective mech-
Unconscious bias may lead to subtle differences in health anism to provide important information that would not be
care delivery that can negatively affect client adherence available otherwise.
Client Demographics for respondents to identify race and ethnicity, and more are
identifying as multi-racial (Association of American Medical
Negative health outcomes can result from social factors, such
Colleges [AAMC], 2014).
as lower SES; historic marginalization, such as persons of
Data for 2015 reveal that the percentage of medical school
color; and prejudice against those with illnesses or conditions
graduates identifying as Black/African American (6%) and
in which there is a history of stigma, such as HIV/AIDS, se-
Hispanic/Latino (5%) has remained stable since 2011. Full-
rious mental illness, and addictions. There is an increase in
time faculty in medical schools has become more diverse in
people living with complex chronic conditions that likely meet
gender, with 39% women, but only 4% of full-time faculty are
the need for occupational therapy services (Leland et al., 2017).
faculty of color (non-Asian; AAMC, 2016). Data collected
According to the U.S. Census, approximately 56% of the popu-
between 2005 and 2015 on percentage of medical school
lation with health insurance receives it through their employer,
graduates planning to work with an underserved popula-
with another 19.4% through Medicaid, 17% through Medicare,
tion reveal the highest percentage (greater than 50%) re-
16% through individual coverage, and 4.6% through military
ported by Black/African American graduates, and a growth
coverage (Barnett & Berchick, 2017). There is a reported 18.6%
in Hispanic/Latino graduates during this time from 33% to
increase in Medicaid enrollment from 2013 to 2015, with Med-
39% (AAMC, 2016). The data for American Indian/Alaskan
icaid and Children’s Health Insurance Program now covering
Native (37%) and White and Asian (23%) graduates planning
1 in 5 people in the United States (Leonard, 2015). This infor-
to work with underserved populations remained the same
mation reveals that even for those with insurance, 20% meet
during this time period.
income and/or disability requirements to receive Medicaid.
The AOTA Salary and Workforce Survey (AOTA, 2015b)
Despite attempts to improve access to insurance, there is no
indicated that the median age of responding occupational
universal safety net for all citizens, leading to differences in
therapy practitioners was 39 years, down from 41 five years
access to occupational therapy services based on health insur-
earlier. Other demographic data addressed practice area but
ance as well as due to lack of insurance.
not gender, race, or geographic distribution of practitioners.
Managers can advocate for occupational therapy’s role
The DHHS Health Resources and Services Administration
in the primary care setting, particularly for clients with
(2017) revealed that female workers were the majority of 25
chronic, complex conditions (AOTA, 2014). Occupational
of the 30 top U.S. health occupations. All minority groups
therapy practitioners can assist in supporting clients’ self-
except Asians were underrepresented in health professions
management through problem-solving aspects of daily life
identified as diagnostic and treatment occupations, the cate-
affected by their conditions (Coleman & Newton, 2005). An
gory that also includes occupational therapy. Demographics
example of an effective program offered by occupational
are shown in Table 65.1.
therapy practitioners in Australia details the relatively minor
Of the total number of occupational therapy practitioners
investment in a 6-week program that yielded improved par-
(N = 108,412) in the United States, 90.3% are women, and
ticipation, self-efficacy, and perceived quality of life (O’Toole
9.7% are men. The data indicate that most occupational ther-
et al., 2013). A retrospective study conducted in Canada re-
apy practitioners are White women. The data also reveal an
vealed the personal value and cost-savings of home-based
underrepresentation of occupational therapy practitioners
versus no care for those with chronic conditions requiring
relative to men and persons of color (DHHS Health Re-
daily management (Health Quality Ontario, 2013). The study
sources and Services Administration, 2017). With the knowl-
also reported fewer emergency room visits and improved
edge about the impact of social factors on accessing care
ability to perform personal ADLs (e.g., dressing).
and following through with treatment recommendations, it
is imperative that recruitment and retention strategies em-
Provider Demographics
phasize cultural competence. The recommended managerial
A health care workforce that reflects the population served is interventions identified earlier—focused recruitment and
a desired goal for several reasons. Studies of client satisfaction mandating ongoing training in cultural competence—can
have indicated higher satisfaction when provider and client assist departments to meet clinical standards of excellence
are race concordant. Moreover, attention to sociocultural regardless of staff composition.
factors can promote adherence to treatment. According to a
health care workforce report (Castillo-Page, 2010), between
the years 1978 and 2008, 75% of all U.S. medical school grad- TABLE 65.1. Occupational Therapy Provider
uates practicing medicine were White, 13% were Asian, and Demographics
6% were Black/African American. The 2008 data set revealed RACE/ETHNICITY % U.S. WORKFORCE % OT WORKFORCE
that, among practicing physicians, 60% were men and 40% White 64.4 83.0
were women among the White, Asian, and Hispanic popu-
Hispanic 16.1 4.0
lations, whereas for Black people/African Americans, 45%
were men and 55% were women. In the interest of increasing African American 11.6 4.4
diversity, U.S. medical schools collect applicant and graduate Asian 5.3 6.6
data on an annual basis. Self-reported race and ethnicity Note. OT = occupational therapy. Data from DHHS Health Resources and Services
may not be linear, because there are opportunities over time Administration (2017).
CASE EXAMPLE 65.1. Addressing Health Disparities
Scenario 1
Stating cultural preferences, a male family member of a client with a cognitive impairment admitted to the skilled nursing facility in which you
are the manager insists that the client be treated by the only male occupational therapy practitioner on the team. You are concerned because this
practitioner is the least experienced with the clinical care needs of this client and he is already at full caseload.
Review Questions
1. How you might address the request, using the stress process model in part to guide your reasoning.
2. How could you address the health literacy of the client and family to ensure best practice?
3. Explore your decision regarding how to assign the therapist to this client, applying the Code of Ethics as your guide.
Scenario 2
A homeless client on the acute rehabilitation unit that you manage must be discharged, and staff are concerned that she has not received full
benefit of the rehabilitation treatment for her traumatic brain injury suffered when she fell while intoxicated and was hit by a car. She does not have
outpatient coverage, and her life is quite chaotic. Several attempts have been made to have her family attend training sessions to assist her safety
and follow-up to prevent readmission, and all have resulted in no-shows. Staff are concerned about safe discharge, but the social worker insists
this must occur today.
Review Questions
1. Consider the case from the perspective of the fundamental cause theory, emphasizing benefit of ongoing treatment and coordination with the
shelter. How would you advocate for additional treatment?
2. Consider the case from the perspective of the stress process model, recognizing that the client may have exhausted family members’ support.
Explore outreach options based on the Code. How would you advocate for additional time to train shelter staff?
3. As a manager, how can you focus staff recruitment to emphasize interest in social aspects of complex medical conditions?
Review Questions policies and frame them as promoting fairness and pro-
viding access regardless of work status. This is most re-
1. As a manager, you are responsible to establish an environ-
flective of which Principle in the Code?
ment that promotes fairness and reduces bias. Identify the
a. Veracity
Code of Ethics Principle that this most clearly addresses:
b. Beneficence
a. Autonomy
c. Nonmaleficence
b. Veracity
d. Justice
c. Justice
d. Beneficence
2. Occupational therapy practitioners and scientists have
SUMMARY
studied power relationships as a means to influence pol-
icy to benefit marginalized populations. A framework for This chapter identified and explored health disparities from
exploring this phenomenon is the perspective of the Occupational Therapy Code of Ethics and
a. Occupational justice the role of the occupational therapy manager to address them.
b. Occupational empowerment As the population changes, the workforce must also change to
c. Occupational science most competently deliver care. The overarching goal of creat-
d. Occupational perspective ing an environment that fully supports inclusion is desired.
3. A recent series of communication errors on the part of A 2-pronged approach includes (1) health care workforce im-
the rehabilitation staff relative to misunderstanding so- plications relative to recruitment, training, and support and
cial norms and customs of the client population and de- (2) treatment environment implications relative to cultural
cision making lead you to design a recruitment strategy competence and acknowledgment of the sociocultural aspects
to hire staff that reflect the population participating in of best practice. Case Example 65.1 gives 2 scenarios to ex-
treatment. This solution best addresses which Principle plore how managers can address health disparities. ❖
in the Code of Ethics?
a. Beneficence
b. Nonmaleficence ACOTE STANDARDS
c. Autonomy
This chapter address the following ACOTE Standards:
d. Fidelity
4. Several health-related policies in the recent past (e.g., ACA, ■ B.1.3. Social Determinants of Health
MHPAEA, Medicaid 1915 waivers) have expanded ac- ■ B.4.21. Teaching-Learning Process and Health Literacy
cess to occupational therapy services. You present these ■ B.4.23. Effective Communication.
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treatment: Confronting racial and ethnic disparities in health care. Young, I. M. (1990). Justice and the politics of difference. Princeton,
Washington, DC: National Academies Press. NJ: Princeton University Press.
CHAPTER
Moral Distress
Kimberly S. Erler, PhD, OTR/L 66
LEARNING OBJECTIVES
■ Understand the background of moral distress in occupational therapy and the factors that contribute to it,
■ Identify potential consequences of moral distress in occupational therapy, and
■ Apply evidence-based strategies to recognize and combat moral distress in occupational therapy.

• Autonomy • Justice • Nonmaleficence
• Beneficence • Moral agent • Occupational therapy ethics
• Burnout • Moral courage rounds
• Fidelity • Moral distress • Veracity
H
ealth care is an evolving, dynamic environment that Background
is often filled with uncertainties and challenges. For
Occupational therapy practitioners commit to providing
health care professionals, including occupational
evidence-based, comprehensive, ethical care to clients. The
therapy practitioners who rely on rapport building and thera-
Occupational Therapy Code of Ethics (2015) (American Occu-
peutic use of self as integral parts of practice, these complexi-
pational Therapy Association [AOTA], 2015) outlines princi-
ties can sometimes lead to ethical tensions. Moral distress is a
ples and standards of conduct to guide ethical practice while
type of ethical tension that occurs when a practitioner knows
acknowledging that ethical action extends beyond rote com-
the right course of action but experiences constraints or bar-
pliance. It is imperative to understand the ethical Principles
riers that prevent them from acting accordingly (Doherty &
of Beneficence (to do or promote good), Nonmaleficence (to
Purtilo, 2016; Jameton, 1984). Moral distress creates a dis-
do no harm), Autonomy (self-determination), Justice (fair-
comfort that arises from discord between ethical action and
ness), Veracity (honesty), and Fidelity (faithfulness); yet,
practical limitations.
judgment and moral character are also essential for ethical
This chapter describes the background of moral distress
decision making (Beauchamp & Childress, 2013).
and the related literature, including factors that contribute to
Because of the complexities of health care and the messy
its rise. It also explores the potential negative consequences of
elements of human nature, situations arise that cause ethi-
unidentified or unaddressed moral distress in occupational
cal tension or conflict. When these ethical concerns sur-
therapy. Finally, the chapter outlines evidence-based strat-
face, health care professionals must recognize their role as a
egies for preventing moral distress, recognizing it when it
moral agent, that is, a person who can differentiate between
occurs, and taking steps to combat it.
right and wrong. Although moral agents strive to maintain
https://doi.org/10.7139/2019.978-1-56900-592-7.066
617
CHAPTER
Moral Distress
Kimberly S. Erler, PhD, OTR/L 66
LEARNING OBJECTIVES
■ Understand the background of moral distress in occupational therapy and the factors that contribute to it,
■ Identify potential consequences of moral distress in occupational therapy, and
■ Apply evidence-based strategies to recognize and combat moral distress in occupational therapy.

• Autonomy • Justice • Nonmaleficence
• Beneficence • Moral agent • Occupational therapy ethics
• Burnout • Moral courage rounds
• Fidelity • Moral distress • Veracity
H
ealth care is an evolving, dynamic environment that Background
is often filled with uncertainties and challenges. For
Occupational therapy practitioners commit to providing
health care professionals, including occupational
evidence-based, comprehensive, ethical care to clients. The
therapy practitioners who rely on rapport building and thera-
Occupational Therapy Code of Ethics (2015) (American Occu-
peutic use of self as integral parts of practice, these complexi-
pational Therapy Association [AOTA], 2015) outlines princi-
ties can sometimes lead to ethical tensions. Moral distress is a
ples and standards of conduct to guide ethical practice while
type of ethical tension that occurs when a practitioner knows
acknowledging that ethical action extends beyond rote com-
the right course of action but experiences constraints or bar-
pliance. It is imperative to understand the ethical Principles
riers that prevent them from acting accordingly (Doherty &
of Beneficence (to do or promote good), Nonmaleficence (to
Purtilo, 2016; Jameton, 1984). Moral distress creates a dis-
do no harm), Autonomy (self-determination), Justice (fair-
comfort that arises from discord between ethical action and
ness), Veracity (honesty), and Fidelity (faithfulness); yet,
practical limitations.
judgment and moral character are also essential for ethical
This chapter describes the background of moral distress
decision making (Beauchamp & Childress, 2013).
and the related literature, including factors that contribute to
Because of the complexities of health care and the messy
its rise. It also explores the potential negative consequences of
elements of human nature, situations arise that cause ethi-
unidentified or unaddressed moral distress in occupational
cal tension or conflict. When these ethical concerns sur-
therapy. Finally, the chapter outlines evidence-based strat-
face, health care professionals must recognize their role as a
egies for preventing moral distress, recognizing it when it
moral agent, that is, a person who can differentiate between
occurs, and taking steps to combat it.
right and wrong. Although moral agents strive to maintain
https://doi.org/10.7139/2019.978-1-56900-592-7.066
617
the highest standards of integrity while providing empathic Clear overlaps exist between the ethical tensions that
care, obstacles often appear. The lack of clarity during ethical occupational therapy practitioners experience and the reported
tensions or conflict in conjunction with the impetus to be a categories of moral distress. Slater and Brandt (2009) found
moral agent can result in moral distress. that external factors, which are typically market driven, were
Jameton (1984) is credited with coining the term moral dis- major contributors to moral distress in occupational therapy
tress, referring to the feeling or experience that occurs when a practitioners and suggest that this is related to service delivery
moral agent knows the right thing to do but encounters con- models in which occupational therapy services are a source of
straints that prevent them from acting in such a way. Moral revenue. Practitioners are being asked to do more in less time
distress was originally identified and has been extensively and with fewer resources. Although nurses may feel financial
investigated in the field of nursing. The research has shown that or budget constraints indirectly, health professionals like occu-
moral distress in nursing has negative consequences on the pational therapists, physical therapists, speech therapists, and
clinician’s well-being, patient care, and the entire health sys- physicians are more likely to experience the economic pressure
tem (Burston & Tuckett, 2013; Henrich et al., 2017). In today’s directly from current practice and reimbursement models; this
health care climate, the construct of moral distress extends pressure, in turn, contributes to moral distress. Although early
beyond the field of nursing and is recognized as a growing research demonstrates that occupational therapy practitioners
problem for all health care professionals (Ulrich et al., 2010). experience moral distress, there are no indicators that prac-
Although studies have confirmed that moral distress exists tice setting, degree earned, age, or years of practice increase a
in occupational therapy (Brazil et al., 2010; Mukherjee et al., practitioner’s risk for moral distress (Penny et al., 2014). These
2009; Penny et al., 2014; Slater & Brandt, 2009), research on findings indicate that no practitioner is immune to moral dis-
moral distress specific to occupational therapy is in its infancy tress, and further research is needed to understand the extent
compared to the field of nursing. Slater and Brandt (2009) sug- of moral distress in occupational therapy to create effective in-
gest that occupational therapy practitioners are at high risk of terventions and, more importantly, prevention strategies.
moral distress, and until further research specific to occupa-
tion therapy is completed, the similarities to moral distress
in nursing should be considered. Penny et al. (2016) describe
Implications
the development of a moral distress scale for occupational Moral distress in occupational therapy can have a negative
therapists that has the potential to expand the understand- impact on the emotional and physical well-being of the prac-
ing of moral distress in occupational therapy through further titioner, the culture of the workplace, the care of clients, job
research with a valid and reliable instrument. satisfaction, and staff retention (Burston & Tuckett, 2013;
Penny et al., 2014; Whitehead et al., 2015). Moral distress is
Contributing Factors a type of stress that can lead to burnout, which is the state of
emotional and physical exhaustion from chronic stress that
Moral distress typically occurs when there are ethical concerns, results in frustration, inability to meet the demands of the
tensions, or conflicts. In occupational therapy, practitioners job, and disengagement from others (Lydon, 2015).
experience a broad range of ethical tensions. Some of these are Research has shown that occupational and physical therapy
unique to occupational therapy, while others are overarching practitioners experience emotional exhaustion and negative
across health care professions. Bushby et al. (2015) reviewed feelings about their work, clients, and personal accomplish-
the current peer review literature on ethical tensions in occu- ments at concerning rates (Balogun et al., 2002). Some research
pational therapy practice and found 7 themes, including suggests that the lack of professional identity among occupa-
1. Resource and system issues, tional therapy practitioners is associated with burnout and that
2. Ethical principles and values, practitioners are at risk for all aspects of burnout including de-
3. Safety, personalization (Edwards & Dirette, 2010).
4. Vulnerable clients, Vision 2025 (AOTA, 2017) states “Occupational therapy
5. Interpersonal conflicts, maximizes health, well-being, and quality of life for all peo-
6. Professional standards, and ple, populations, and communities through effective solu-
7. Practice management. tions that facilitate participation in everyday living” (p. 1). To
enact this vision, the occupational therapy workforce needs
Another study (Mukherjee et al., 2009) explored moral to be healthy, motivated, and satisfied. Addressing moral dis-
distress among rehabilitation professionals, including occu- tress is crucial to the continued excellence and expansion of
pational therapy practitioners, and found 3 broad categories occupational therapy.
of moral distress, including
1. Institutional ethics (e.g., health care environment, reim-
Review Questions
bursement pressure),
2. Professional practice (e.g., codes of conduct or behavior, 1. What is moral distress?
professionalism), and 2. What contributes to moral distress in occupational therapy?
3. Clinical decision making (e.g., goal setting, discharge 3. Why is it important to consider moral distress in occupa-
planning). tional therapy?
CHAPTER 66. Moral Distress 619
PRACTICAL APPLICATIONS IN Improving Communication

OCCUPATIONAL THERAPY Communication continues to be one of the biggest chal-
There are 2 categories of approaches to combat moral distress lenges in health care today. Fostering an environment where
in occupational therapy: (1) prevention and (2) intervention. all individuals feel comfortable expressing their opinions in
All occupational therapy practitioners, or moral agents, a professional manner is central to mitigating moral dis-
should be empowered to have moral courage and advocate for tress. Managers must create a safe space for open dialogue
what they perceive to be right and ethical. Moral courage is around difficult topics. Although individuals may have dif-
the courage to overcome the fear of adverse consequences and ferent values and opinions, respectful communication al-
act in accordance with ethical standards and values (Doherty lows for necessary discourse and often leads to actionable
& Purtilo, 2016). solutions.
Occupational therapy managers are uniquely situated
to influence a culture of moral courage and ethical action. Creating a Healthy Work Environment
Occupational managers should implement processes and
supports that aim to both prevent and reduce moral dis- Many of the strategies already discussed contribute to the
tress (Penny et al., 2014). Slater and Brandt (2009) proposed creation of a healthy work environment. Communica-
6 strategies: tion among health care leaders, managers, and front line
clinicians is crucial. If all practitioners see themselves as
1. Recognizing moral distress, moral agents with moral courage, the health of a practice
2. Implementing educational strategies, environment will be strengthened. Occupational therapy
3. Facilitating interdisciplinary research, managers must emphasize respect for all individuals, both
4. Improving communication, clients and staff.
5. Creating healthy organizational work environments, and
6. Promoting ethical leadership.
Promoting Ethical Leadership
Recognizing Moral Distress Ethics and leadership are inextricably intertwined. A leader
cannot be effective without careful consideration of ethics.
Identifying and naming moral distress in occupational ther-
Even in challenging situations, an ethical leader will advocate
apy practice is a powerful strategy for mitigating the distress.
for optimal solutions and processes that adhere to the profes-
If a practitioner has the knowledge to recognize and the abil-
sional and ethical standards. A strong ethical leader will set
ity to describe their feelings of powerlessness in an ethical
the example for all staff members and create an environment
situation, they can seek support or resources, (e.g., societal
that upholds the highest expectations.
statements, ethics advisory opinions, ethics committees).
By recognizing the ethical tension as moral distress, a prac-
titioner can identify sources or patterns of the distress and Occupational Therapy Ethics Rounds
create a starting point for intervention.
Occupational therapy ethics rounds are forums that bring
together practitioners and create an opportunity to discuss
Implementing Educational Strategies emerging ethical issues and honestly reflect on practice (Erler,
Continuing education on ethical matters related to health 2017). These rounds allow practitioners to practice communi-
care and occupational therapy is a crucial component to com- cation skills on difficult topics, demonstrate a commitment
bating moral distress. Engaging in or creating opportunities to education and ethics by leadership, and strengthen the
for professional growth strengthens one’s professional iden- ability to recognize an ethical issue. These rounds may be
tity and enhances one’s ability to engage in dialogue around initiated by managers or practitioners and be held at a spe-
ethical tensions. Managers can support both formal and cific frequency (e.g., quarterly) or on an as-needed basis when
informal forums for education on ethics and moral support. challenging cases arise. Not only do ethics rounds enhance a
practitioner’s ability to recognize moral distress, the rounds
also act as a support system and strategy for preventing and
Facilitating Interdisciplinary Research mitigating the moral distress.
Further research is required to understand moral distress
in occupational therapy, but because occupational therapy
Review Questions
practitioners function as part of a health care team, inter-
disciplinary moral distress research is also essential. As dis- 1. What is moral courage, and how does it relate to moral
cussed previously, many members of the interdisciplinary distress?
team experience moral distress. Understanding how team 2. What are 3 strategies for combating moral distress in
dynamics negatively or positively affect moral distress will your practice setting?
lead to more-effective interventions and elevation of the team 3. What role could ethics rounds play in your practice set-
effectiveness. ting to reduce or prevent moral distress?
CASE EXAMPLE 66.1. Moral Distress in Inpatient Acute Care
Sun is an occupational therapy manager overseeing a department of 15 practitioners in an inpatient acute care setting. Sun overheard an
occupational therapist expressing frustration and feelings of powerlessness about a recent situation with a client. Sun decided to meet with
the therapist to learn more about the case.
The therapist explained that she first met the client, Jorge, a few days ago on the neurological intensive care unit. Jorge had flown from Mexico,
where he lives, to the United States to attend his niece’s college graduation. Upon landing, Jorge was noted to have right-side weakness and speech
difficulties. He was immediately taken to the closest emergency room and was found to have a left middle cerebral artery stroke. The neurology
team treated him with IV tissue plasminogen activator (tPA), a clot-busting medication.
During the initial evaluation, which occurred approximately 30 hours after Jorge was admitted, the therapist noted that Jorge had already
demonstrated improved motor strength in his right leg but his right arm did not have any active movement, and he continued to have some expressive
communication impairments. Over the next few days, Jorge made steady progress but remained below his baseline. Occupational therapy, physical
therapy, and speech therapy all recommended that he be transferred to an inpatient acute rehabilitation facility for intense neurorehabilitation.
Despite the entire interprofessional team recognizing that Jorge had excellent rehabilitation potential, the case manager informed everyone during
rounds that he was not eligible for transfer to inpatient rehabilitation because he did not have health insurance in the United States or the personal
financial resources to cover the cost. Sun identified that the therapist was experiencing moral distress because she knew that the most client-
centered, evidence-based, ethical course should include rehabilitation for the client but felt frustrated and powerless because of an external constraint.
Review Questions
1. What is contributing to moral distress in this case example?
2. What steps could Sun take to combat moral distress in this situation and future situations that may arise?
3. What are the potential consequences of not addressing the moral distress?
SUMMARY REFERENCES
Moral distress exists in occupational therapy and can have Accreditation Council for Occupational Therapy Education. (2018).
serious negative consequences to the practitioner, the client, 2018 Accreditation Council for Occupational Therapy Education
and the health care system. Understanding the Occupational (ACOTE) standards and interpretive guide. American Journal of
Therapy Code of Ethics (2015) and ethical principles provides Occupational Therapy, 72, 7212410005. https://doi.org/10.5014
/ajot.2018.72S217
occupational therapy practitioners the foundational knowl-
American Occupational Therapy Association. (2015). Occupational
edge and professional standards that must be upheld in chal- therapy code of ethics (2015). American Journal of Occupa-
lenging ethical scenarios. All practitioners should recognize tional Therapy, 69(Suppl. 3), 6913410030. https://doi.org/10.5014
their role as a moral agent, and managers should strive to /ajot.2015.696S03
facilitate an environment that emphasizes moral courage. An American Occupational Therapy Association. (2017). Vision 2025.
occupational therapy manager can implement strategies such American Journal of Occupational Therapy, 71(3), 7103420010.
as occupational therapy ethics rounds and recognition pro- https://doi.org/10.5014/ajot.2017.713002
grams that emphasize ethics, communication, culture, pro- Balogun, J. A., Titiloye, V., Balogun, A., Oyeyemi, A., & Katz, J. (2002).
cesses, and supports aimed at preventing and reducing moral Prevalence and determinants of burnout among physical and oc-
distress. ❖ cupational therapists. Journal of Allied Health, 31(3),131–139.
Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical
ethics (7th ed.). New York: Oxford University Press.
LEARNING ACTIVITY Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral
distress experienced by health care professionals who provide
Reflect on a time when you felt a sense of frustration and home-based palliative care. Social Science and Medicine, 71(9),
powerlessness. 1687–1691. https://doi.org/10.1016/j.socscimed.2010.07.032
■ What do you think was contributing to your moral dis- Burston, A., & Tuckett, A. G. (2013). Moral distress: Contributing fac-
tors, outcomes and interventions. Nursing Ethics, 20(3), 312–324.
tress in this situation?
https://doi.org/10.1177/0969733012462049
■ How did you proceed? Bushby, K., Chan, J., Druif, S., Ho, K., & Kinsella, E. A. (2015). Eth-
■ Would you do anything different if a similar situation ical tensions in occupational therapy practice: A scoping review.
occurred today? British Journal of Occupational Therapy, 78(4), 212–221. https://
■ What strategies can you implement to prevent moral dis- doi.org/10.1177/0308022614564770
tress in your current practice setting? Doherty, R. F., & Purtilo, R. D. (2016). Ethical dimensions in the
health professions (6th ed.). St. Louis: Elsevier.
Edwards, H., & Dirette, D. (2010). The relationship between pro-
ACOTE STANDARDS fessional identity and burnout among occupational therapists.
This chapter addresses the following ACOTE Standards: Occupational Therapy in Health Care, 24(2), 119–129. https://
doi.org/10.3109/07380570903329610
■ B.7.0. Professional Ethics, Values, and Responsibilities Erler, K. (2017). The role of occupational therapy ethics rounds in
■ B.7.1. Ethical Decision Making. practice. OT Practice, 22(13), 15–18.
CHAPTER 66. Moral Distress 621
Henrich, N. J., Dodek, P. M., Gladstone, E., Alden, L., Keenan, S. P., of Occupational Therapy, 70(4), 1–8. https://doi.org/10.5014/ajot
Reynolds, S., & Rodney, P. (2017). Consequences of moral distress .2015.018358
in the intensive care unit: A qualitative study. American Journal of Penny, N. H., Ewing, T. L., Hamid, R. C., Shutt, K. A., & Walter,
Critical Care, 26(4), e48–e57. https://doi.org/10.4037/ajcc2017786 A. S. (2014). An investigation of moral distress experienced
Jameton, A. (1984). Nursing practice: The ethical issues. Englewood by occupational therapists. Occupational Therapy in Health
Cliffs, NJ: Prentice Hall. Care, 28(4), 382–393. https://doi.org/10.3109/07380577.2014
Lydon, A. (2015). Burnout among health professionals and its effect on .933380
patient safety. Retrieved from https://psnet.ahrq.gov/perspectives Slater, D. Y., & Brandt, L. C. (2009). Combating moral distress. OT
/perspective/190/burnout-among-health-professionals-and-its Practice, 14(2), 13–18.
-effect-on-patient-safety Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress:
Mukherjee, D., Brashler, R., Savage, T. A., & Kirschner, K. L. (2009). A growing problem in the health professions? Hastings Center
Moral distress in rehabilitation professionals: Results from a Report, 40(1), 20–22. https://doi.org/10.1353/hcr.0.0222
hospital ethics survey. PM&R, 1(5), 450–458. https://doi.org Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G.,
/10.1016/j.pmrj.2009.03.004 & Fisher, J. M. (2015). Moral distress among healthcare pro-
Penny, N. H., Bires, S. J., Bonn, E. A., Dockery, A. N., & Pettit, N. fessionals: Report of an institution-wide survey. Journal of
L. (2016). Moral distress scale for occupational therapists: Part 1. Nursing Scholarship, 47(2), 117–125. https://doi.org/10.1111
Instrument development and content validity. American Journal /jnu.12115
SECTION XI.
Managing Your Career
Edited by Karen Duddy, OTD, MHA, OTR/L
623
CHAPTER
Succeeding as a New Leader or Manager
Mandyleigh Smoot, MOT, OTR/L 67
LEARNING OBJECTIVES
■ Identify the value of participating in formal and informal leadership assessments as a new leader,
■ Create a personal leadership vision statement and understand its purpose,
■ Understand principled negotiation and identify its 4 principles,
■ Identify core components of leadership when in a new leadership role, and
■ Describe the 3 phases of the journey to authentic leadership.

• 360 degree • Informal expectations • Leadership vision statement
• Authentic leadership • Job description • Principled negotiation
• Expectations • Leadership mission statement • Success
• Formal expectations
O
ccupational therapy practitioners are uniquely quali- Foundations
fied for leadership positions. They are poised to move
into leadership and management roles because of the You began training to be a rehabilitation manager or leader
specialized nature of their training and experiences related the moment you entered an occupational therapy program.
to task analysis and performance. These unique qualities are Occupational therapy practitioners are trained with skills
enhanced by the ability to develop a plan and execute it. that are unique to the profession. These skills provide dis-
Becoming a successful new leader involves preparation for tinct value in leadership because of the holistic and per-
the role, participation in activities that allow you to practice son-centered perspective embedded in the occupational
and hone your skills, and constant learning and growth. In therapy curriculum and daily practice. The profession’s foun-
the context of this chapter, success is defined as becoming a dational theories have equipped you to understand the whole
quality leader who is trusted by the team and the organiza- person in context and the way purposeful activity drives
tion to lead the team to efficient and effective practices while performance.
enhancing the profession and individuals. The hours you have spent breaking down tasks to under-
This chapter stresses the importance of understand- stand how dysfunction affects performance have honed the
ing occupational therapy foundations, knowing yourself as same skills needed to develop professional competencies. To
an occupational therapy practitioner and as a person, and develop competencies, you must assess areas of need, break
understanding what is expected of you. These 3 keys can set the skills into the smallest steps, and make an action plan for
you on a path to becoming a successful new leader. the outcome with short- and long-term graded goals. Client
https://doi.org/10.7139/2019.978-1-56900-592-7.067
625
626 SECTION XI. Managing Your Career
treatment plans and goals, written and rewritten to meet the ■ Treatment outcomes or client satisfaction scores that are
highest levels of independence, are similar to employee pro- not favorable, and
fessional development plans written to meet the highest levels ■ Staffing methodology and appropriate levels of staffing.
of success.
The Occupational Therapy Practice Framework: Domain The questions in the right column of Table 67.1 may help
and Process (OTPF–3; American Occupational Therapy Asso- managers learn more about a presented challenge to priori-
ciation [AOTA], 2014) “describes the central concepts that tize opportunities for improvement, much as an occupational
ground occupational therapy practice and builds a common therapy practitioner would approach client care.
understanding of the basic tenets and vision of the profes- After considering the leadership focus domains, as an
sion.” (p. S3). Occupational therapy practitioners consider occupational therapy practitioner would typically do with
occupation, client factors, performance skills and patterns, client domains, and determining need for further evalu-
and contexts and environments in every interaction with ation, leaders can make a plan. When treating a client, the
clients. They identify a client’s areas of occupation; consider occupational therapy practitioner makes a plan for further
client factors, performance skills, performance patterns, and client evaluation, determination of treatment modalities, or
context and activity demands; and then design a plan. They designation of short- and long-term goals that capitalize on
then execute, review, and modify that plan on the basis of the client’s strongest factors and compensate for their areas
the client’s response. Finally, the plan is considered complete of improvement. When making a leadership focus plan,
when the goals are met. in contrast, leaders might identify champions for activity
Many leadership opportunities and challenges can be demands, develop processes that facilitate performance pat-
approached with similar principles and strategies. For exam- terns, consider the project plan, and start providing leader-
ple, a new leader who is presented with a challenge to increase ship interventions.
the efficiency of staffing can assess their areas of knowledge,
make plans to educate themselves, use tools and resources to Know Your Strengths and Weaknesses
solve problems, draw on the assistance of others, and then
Strong leaders understand their own strengths and oppor-
create and enact their action plan. The first time the leader is
tunities for improvement and create a plan for professional
asked to work on efficiencies, they may need moderate assis-
development (Cashman, 2017). Just as occupational thera-
tance, but with the skills they learn, they get closer to inde-
pists can develop a treatment plan for patients, new leaders
pendence with each short-term goal met.
can develop an equally important treatment plan for leader-
The OTPF–3 provides domains of practice that guide
ship challenges and for themselves in this new role.
assessment and intervention. Occupational therapy prac-
When gathering the data to create the leadership treatment
titioners typically think of ADLS, work, play, and social
plan, new leaders have multiple “evaluations” available for use.
participation, for example, as the areas of occupation they
Selecting screens and evaluations for client treatment plan-
are addressing. When addressing leadership challenges, oc-
ning is comparable to surveying the field for appropriate lead-
cupational therapy practitioners can think of physical re-
ership and personality screens or evaluations. A wide variety
sources, personnel, information management, performance
of options can be found in the literature for learning about
improvement, education, and so forth as the areas of occu-
personality or leadership styles and traits, ranging from quick
pation for which intervention is needed.
self-assessments to comprehensive reviews by colleagues.
Leadership challenges range from task specific to per-
An example of a popular colleague-initiated assessment is
sonnel specific, all of which can be benefited by the use of a
the 360 degree. This type of leadership assessment is often
framework; the occupational therapy practice framework is
used for senior leadership and is intended to measure a va-
ideal for understanding and responding to leadership chal-
riety of characteristics from a broader viewpoint, such as
lenges as well as for responding to clients. Consider using
other colleagues or employees, instead of just the leader’s
the following steps based on the practice framework when a
boss (Taylor, 2011). Other assessments focus on identifying
management or leadership opportunity arises.
strengths and matching personality types.
Self-assessments help managers gain information about
Learn to Turn Leadership Challenges Into themselves as emerging leaders and identify past or poten-
Treatment Plans tial performance and leadership traits (Horton-Deutsh et al.,
2010; Lyubovnikova et al., 2017). The information can be used
Using the OTPF–3 with a leadership problem focus (see
to create a full picture of leadership strengths and areas of
Table 67.1) assists new managers to identify problem areas
opportunity for skill development. Continuing education in
by asking leadership focus questions as if they are asking
health care management is helpful, and new leaders may con-
questions about occupational therapy domains for a cli-
sider applying to programs such as AOTA’s Emerging Leaders
ent to develop a treatment plan. Some common leadership
Development Program.
challenges that may be presented to new leaders are
Being open to feedback and looking at it as an opportunity
■ Productivity concerns, for improvement and goal development is key to the success of
■ Billable hours of service and coding inefficiencies, new leaders (Dalakoura, 2010; Horton-Deutsch et al., 2010).
CHAPTER 67. Succeeding as a New Leader or Manager 627
TABLE 67.1. Turning Leadership Challenges Into Treatment Plans
CLIENT FOCUS: OTPF–3 LANGUAGE LEADERSHIP FOCUS: OCCUPATIONAL THERAPY LEADER LANGUAGE QUESTIONS
Identify the client factors or the task factors at play. ■ Who created this goal or this project?
■ What is the value of the scenario?
■ What are the beliefs that surround the situation, and who are the stakeholders?
■ Do the stakeholders have different values or beliefs regarding the situation?
■ Who needs to be engaged in the process?
■ What functions of the organization or the team need to be considered?
■ Are there written and unwritten cultures and rules that are intermingled with the
situation and challenge?
Identify the performance skills required and optimal team ■ What skills are required for this project?
members. ■ What personalities will be helpful and harmful to the process?
■ What type of cognitive skills are required for this project?
■ Do you have a range of feelers and thinkers on your team?
■ What communication skills are required?
■ Who will champion this project and the results?
Identify the performance patterns that will need adjustment ■ What are the routines built inherently in the processes or current practice that are
or those that are, in effect, contributing to the problem. affecting this scenario or challenge?
■ What are the roles of those who are involved?
■ What is the role of the leader?
■ What habits are the team or the organization participating in that might have
contributed to this scenario?
■ What processes are in place currently, and are they official or unofficial?
Identify the context and the environment surrounding the ■ Where does this scenario occur?
scenario. ■ What factors surrounding time and space influence the scenario?
■ What is the workplace culture that may influence the challenge?
■ What factors in the physical space and resources are affecting the situation?
Identify the activity demands for success. ■ What objects or equipment are used in this scenario?
■ What are the process steps, and what is required for each step?
■ What are the implications for clients or coworkers?
■ How does the process work?
■ What must be done, and where are the limitations?
Note. OTPF–3 = Occupational Therapy Practice Framework: Domain and Process, 3rd Edition.
Being aware of their own responses and approaches under What are the characteristics you find in leaders you look up
ideal circumstances as well as when dealing with problematic to? Which of your own traits do you want to shine through?
situations can help new leaders identify areas for growth and Emerging leaders should develop a written personal lead-
development. After all, staff under direction of the leader will ership vision statement and leadership mission statement
inevitably see the leader in both sets of circumstances over time. early in their leadership journey to guide treatment plans and
shape the outcomes. A personal leadership vision statement
Develop Your Personal Leadership Mission should include core values, what the leader wants to achieve
and Vision Statement or contribute, and what characteristics are important to them
in their leadership (Gonzalez, 2017).
Knowing one’s self as a leader also means having a vision for The leadership vision statement is the leader’s personal
one’s self as a leader (Braveman, 2016). When an occupational statement that encompasses their individual goals and aspi-
therapist completes a treatment plan for a client, they con- rations. Others should be able to read it and recognize the
sider their roles, habits, and routines to create the plan and statement in the leader’s actions and as their purpose. The
the goals. When the practitioner does not understand the cli- personal leadership mission statement is similar to an orga-
ent’s roles, responsibilities, and passions, it becomes difficult nization’s mission statement in that it should
to plan goals or establish purposeful outcomes.
Similarly, when developing leadership skills, knowing the ■ Inspire;
kind of leader one wants to be is important. Know the core ■ Provide a compass for decision making; and
values of leaders whom you find admirable. What are the ■ Describe supporting organizational goals, team goals, and
things you would want stated about you and your leadership? how the leader plans action.
Leadership vision statements may feel vulnerable, open, Doing the following can create a strong foundation for
and transparent, but successful leadership:
the only way we grow as leaders is by stretching the ■ Assume a goal-oriented approach to work tasks.
limits of who we are—doing new things that make us ■ Be respectful of associates and employees.
uncomfortable but that teach us through direct experience ■ Communicate effectively.
who we want to become. Such growth doesn’t require a ■ Develop planning skills, including time management, pri-
radical personality makeover. Small changes—in the way oritization of work, and establishment of goals for work
we carry ourselves, the way we communicate, the way teams.
we interact—often make a world of difference in how ■ Demonstrate a full range of leadership styles.
effectively we lead. (Ibarra, 2015, p. 59) ■ Exhibit key leadership practices, including challenging the
process, inspiring a shared vision, enabling others to act,
modeling the way, and encouraging the heart (Snodgrass,
Know Expectations 2011).
Successful leaders know what is expected of them, and they rise
■ Recognize the need to continue your own professional de-
velopment and help improve your role in leadership.
to those occasions. Expectations are the standards that define
a leader’s roles and responsibilities from multiple stakeholders
that define the success of leaders may be written and unwritten, Gather Pertinent Data
formal and informal. Learning the written and unwritten ex- Leaders should know
pectations of a new leader can be challenging.
Written expectations are often in the form of a job de- ■ How to gather pertinent information;
scription, which typically focuses on skills and performance ■ What information exists in their organization;
tasks that are required of the role and is straightforward. For- ■ How to interpret the data; and
mal expectations may look like performance plans and goals, ■ How to create, track, and maintain critical information
reviewed at periodic intervals to assess overall performance in dashboards to illustrate compliance with performance
and progress toward goals. Formal expectations, such as per- measures (Braveman, 2016).
formance plans and yearly goals, may have ratings attached In addition to being able to report performance with the use
that link to pay or status in positions. For additional infor- of dashboards, leaders should be able to anticipate the needs
mation, leaders can look at the organization’s written goals of their team and the management actions required to meet
and strategic plans to understand what drives this organiza- relevant critical performance measures. Critical performance
tion forward and to understand their place in the bigger plan measures may be defined by the organization or defined by
(Strickland, 2011). Becoming familiar with the particular set- the leader as information points necessary to make sound de-
ting’s requirements is essential for success. cisions. Typical performance measures demonstrate the effi-
ciency and effectiveness of a department.
For Additional Learning Readily available health care leadership education pro-
grams often focus on increasing students’ knowledge of
For additional learning, see Chapter 9, “Strategic Planning.” health care data analytics. Leaders should be prepared to
share their team’s story through data with high-level leaders
and to prove the worth of the team through this information.
Informal expectations are particular to a specific orga-
nization and are unwritten and cultural. They are similar
Update Communication and Negotiation Skills
to a patient assessment when the practitioner is striving to
understand the context and the environment surrounding Successfully competing for resources and advocating for
the patient’s goals. The leader may start exploring the culture the team’s needs depends on the leader’s ability to speak
through their mentors in the organization and being obser- a business language (Braveman, 2016). New leaders may
vant in leadership meetings. They can begin to pay attention to want to consider learning these skills if they are not natural
the language spoken in the organization by getting involved, strengths. Opportunities to learn these skills exist in many
saying yes, and being mindful of their personal learning goals. formats, such as working with a mentor and taking courses.
Staff expectations of the new leader are less clear but are For example, leaders can begin to seek out those in the orga-
just as important as any other performance expectation. It is nization who can assist them and whose role is to support the
important to ask the team about its expectations of a leader. information systems. In addition, emerging leaders may con-
Allow the team to express what it needs and desires in a suc- sider enrolling in business or health care leadership courses
cessful leader. Facilitate conversations about leadership and to become more business savvy and learn to speak a language
goals for the department. Although each team has its own that relates to health care management. Organizations make
needs, the most effective leaders have a particular set of de- decisions on the basis of data; a team or department can be
fined qualities and behaviors or leadership characteristics under-resourced if their leadership’s business plan and staff-
(Snodgrass, 2011). ing requests are not data driven.
Review Questions
1. What is the value of participating in formal and informal
For additional learning, see Chapter 10, “Using Data to Guide leadership assessments?
Business Decisions,” for more information on uses of data in 2. How can the OTPF–3 help you approach a leadership
management positions. challenge?
3. What is the intent of using principled negotiation as a
new manager?
Negotiating is another skill that benefits new and estab-
lished leaders alike. Leaders can use principled negotiation
to provide a strategy for negotiation (McCarthy & Hay, 2015). PRACTICAL APPLICATIONS IN
Principled negotiation is a strategy developed by Fisher and OCCUPATIONAL THERAPY
Ury (2011) that describes finding a mutually satisfying out-
come. This strategy focuses on the interests of the parties Authentic leadership reflects self-awareness and genuine-
and emphasizes conflict management and conflict resolu- ness, transparency and fairness, and a focus on the results
tion. For those who are uncomfortable in negotiations, prin- and the long term. The leadership treatment plan to this point
cipled negotiation gives some guidance on the “how to” of consists of evaluation, individual assessments, areas of focus,
negotiations. and short-term goals. However, occupational therapy man-
The 4 principles of principled negotiation, described in the agers and practitioners know that both short-term and long-
Harvard Negotiation Project (Fisher & Ury, 2011), include the term goals are always considerations in the treatment plan. It
following: is important for occupational therapy practitioners to con-
sider long-term goals when creating a plan and starting a role
1. People: Separate the people from the problem. The issue as a leader. Although long-term goals may not be read and
likely is related to a process or policy, not the people evaluated on a daily basis, the occupational therapy practi-
themselves. Focusing on the problem decreases the like- tioner always has them in mind.
lihood that anyone will become defensive. The parties All accomplished short-term goals lead to a success-
should attack the problem, not each other. ful leadership journey. Many people picture leadership as a
2. Interests: Focus on the interests, not the positions. Taking straight-line process: a climb and a direct ascension. Occu-
a position on a particular issue informs others where you pational therapy practitioners know that is rarely the way a
stand but can also lead to conflict and impede negotia- treatment plan plays out. The path to authentic leadership is
tions. When people engage in positional bargaining, they a “marathon journey that progresses through many stages
pay more attention to the position and less to the under- until you reach your peak” (George, 2015, p. 25). George de-
lying issue and potential resolution. Focusing on shared scribed the process in 3 phases:
interests helps people collaborate and compromise.
3. Options: Invent multiple options looking for mutual gains 1. Preparing for leadership,
before deciding what to do. Presenting only 1 or 2 solu- 2. Leading, and
tions may limit cooperative problem solving if none of the 3. Generativity.
solutions is seen as beneficial. Brainstorming mutually
beneficial solutions can help parties reach an agreement Phase I. Preparing for Leadership
sooner.
Preparing for leadership consists of forming character, learn-
4. Criteria: Insist that the result be based on some objective
ing and studying, and growing. This is the preparatory phase,
standard. Basing the outcome on a fair standard, such as
a time for learning about strengths, areas for opportunity,
best practice, number of patients seen per day, or time-
and the expectations. Formal and informal assessments of
liness of documentation, can help parties defer to a fair
personality and leadership are completed in this phase. Take
solution rather than what either party is willing or wants
time to learn and truly understand your areas of strength and
to do.
improvement and how they might affect those you lead.
Occupational therapy practitioners negotiate with clients Preparation also consists of practicing leadership skills
for every session to meet the client’s goals. The principled in safe settings or trying out the skills in simulated environ-
negotiation methodology matches how most practitioners ments. This may include role playing, running your thoughts
negotiate in those instances. New leaders can make adjust- by a trusted mentor, or trialing some strategies for manage-
ments to the verbiage to negotiate for the team’s needs, for the ment in case studies before implementing them in the clinic
resources, or for the position taken in a leadership scenario. setting. This preparation enables new leaders to gather the
Leaders will likely learn to be more comfortable with negoti- tools they need to begin leading successfully.
ating over time, but in the beginning a framework can help
them develop confidence and skills. Using the principled ne-
Phase II. Leading
gotiation framework to practice these skills can yield benefits
and help one meet strategic goals while concurrently learning Leading consists of taking opportunities to lead, devel-
to speak the business language and create change for teams. oping leadership and management skills, and taking on
increasing responsibility for oneself and one’s team. In this build, the leading phase results in confident leaders who
phase, leaders begin the real work of leading. Successes and are involved in leadership decisions and projects.
failures will occur, and it is up to the leader to use both to
learn, grow, and develop. Leaders in this phase have the
Phase III. Generativity
critical conversations with staff and others, drive them-
selves and others toward excellence, remain self-aware, and The final phase of leadership development, which George
foster confidence. As experience increases and successes (2015) describes as the ultimate goal of leadership, can be
CASE EXAMPLE 67.1. Adele’s Leadership Journey
Adele, a newly appointed occupational therapy manager, has been hired for a department that is quickly growing and changing in a dynamic
workplace. The rehabilitation department needs to be competitive for resources against large services that are money generators for the facility.
The department currently has limited access to information systems and decision-making support. The new leader is asked to determine what the
department’s needs are in the midst of the growth to advocate for those needs and justify the department’s value.
Background
■ Adele was promoted from within the health care system and has worked with the therapists as peers for about 5 years.
■ Adele has knowledge of the department, a newly completed certificate in health care administration, and a strong desire to do a good job sup-
porting the department.
■ The caseload and demand for productivity have increased each year without an associated increase in administrative support.
■ Facility leaders are making data-driven decisions. Consequently, therapy departments without the relevant data will be less competitive for
resources and needs.
■ Adele has a strong desire to advocate for her team but is unsure where to start.
■ Adele is unable to determine how decisions were made in the past for staffing, coverage planning, productivity, performance measures, and
general allocation of resources.
Solution
Adele’s first step is to understand what the department needs and wants in a leader. After learning that the department wanted and needed
recognition and to feel supported, Adele held a focus group with staff on what that means to them. She asked them such questions as, “How will
you know you have done a good job?” “What do you feel you should be measured on?” and “How will you and others know the department is
successful?”
After gathering more information, Adele began to determine the organization’s criteria for a successful therapy department and what the
department needed to compete for resources with other areas in the hospital. A series of questions defined how Adele would structure the
department:
■ What is the best staffing ratio?
■ How many people need to be cross-trained, in what areas, to meet the needs of the clients served?
■ How fast is the department providing access to services in the facility?
■ Is the answer different across different teams?
■ How does one know a therapist is meeting their goals?
■ How does one know a department is meeting its goals, and, at the most basic level, what are these goals, and who sets them?
Adele knew what she wanted to accomplish but didn’t know how to get there or where to start. To begin her journey, she explored options within
the facility for who could help her. She found partners with knowledge she, as a manager, did not have. She reached out and completed additional
continuing education in the areas of data management and health care data analytics. Adele spent countless hours using newly learned skills to
create and use Excel systems and data management pulls to make rough dashboards for key metrics.
For staff, Adele created games from the newly developed systems, orchestrated races and competitions, and showed everyone how to use the
systems. She planned monthly meetings to review all the information that was shareable with all involved and empowered the group to talk about
why things were the way they were. She encouraged and facilitated discussions about the information, what might be contributing to challenges,
and possible solutions.
The team took the newly accessible information and created process changes and new work practices. Adele’s role as the leader was to support
them in their endeavors and remove boundaries along the way. Over time, the information translated into stories about the department and stories
about needs.
Adele started to learn how to tell those stories to advocate for the service across the facility at large and begin to make change and gather resources.
Review Questions
1. What questions would help Adele define the leadership problem?
2. Are there written and unwritten cultures and rules that are intermingled with the situation and challenge?
3. What leadership skills discussed in this chapter are demonstrated by Adele in this scenario?
considered the occupation-based practice. The preparatory the position? How might you have used the principles in
work has been done (i.e., preparing for leadership), the prac- your negotiation? Could that have changed your outcome?
tice in purposeful activity has occurred (i.e., leading), and 5. Consider the creation of your personal leadership vision
now the leader is experiencing the flow of leadership (i.e., statement. Write down those things that you see as your pur-
generativity). In this stage, leaders are continually growing, pose, as your values, and as how you want your leadership to
experiencing, learning, and participating, but they are also be experienced by others. Does the statement feel authentic?
looking for opportunities to share their knowledge, strengths,
and gifts with others.
ACOTE STANDARDS
Review Questions This chapter addresses the following ACOTE (2018) Standards:
1. How is a leadership journey process similar to a treat- ■ B.5.0. Context of Service Delivery, Leadership, and Man-
ment-planning process for an occupational therapy client? agement of Occupational Therapy Services
2. What are the 3 phases George (2015) defined as part of the ■ B.5.2. Business Aspects of Practice
leadership development journey? ■ B.5.8. Supervision of Personnel
3. According to George (2015), what is the ultimate goal of ■ B.7.2. Professional Engagement.
leadership?
REFERENCES
SUMMARY Accreditation Council for Occupational Therapy Education. (2018).
Occupational therapy practitioners are uniquely qualified (ACOTE) standards and interpretive guide. American Journal
for leadership positions by virtue of their occupational ther- of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
apy training and experiences. Moreover, occupational therapy .org/10.5014/ajot.2018.72S217
practitioners' ability to design and execute a plan and optimize American Occupational Therapy Association. (2014). Occupational
their strengths to develop new skills adds to their predisposi- therapy practice framework: Domain and process (3rd ed.)
tion for leadership. New leaders and managers can benefit from American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
remembering the foundations of occupational therapy, assessing https://doi.org/10.5014/ajot.2014.682006
and knowing themselves, and understanding expectations. Braveman, B. H. (2016). Leading and managing occupational therapy ser-
vices: An evidence-based approach (2nd ed.). Philadelphia: F. A. Davis.
Identifying resources and learning opportunities that
Cashman, K. (2017). Leadership from the inside out: Becoming a
allow you to develop skills and authentic leadership qualities leader for life (3rd ed.). Oakland, CA: Berrett–Koehler.
contributes to your success as a leader. Although understand- Dalakoura, A. (2010). Differentiating leader and leadership develop-
ing the principles of business and health care administra- ment. Journal of Management Development, 29, 432–441. https://
tion is important in the competitive and fast-paced health doi.org/10.1108/02621711011039204
care field, occupational therapy managers should be sure to Fisher, R., & Ury, W. (2011). Getting to yes: Negotiating agreement
remember their unique approach to problems and situations without giving in. New York: Penguin.
and trust that this approach will support and enhance their George, B. (2015). Discover your True North: Becoming an authentic
abilities to be successful. ❖ leader. Hoboken, NJ: Wiley.
Gonzalez, B. Y. N. (2017). Build a leadership vision. Strategic Finance,
99(5), 22–24.
LEARNING ACTIVITIES Horton-Deutsch, S., Young, P. K., & Nelson, K. A. (2010). Becoming a
nurse faculty leader: Facing challenges through reflecting, perse-
vering and relating in new ways. Journal of Nursing Management,
1. Discuss with others how occupational practitioners are 18, 487–493. https://doi.org/10.1111/j.1365-2834.2010.01075.x
uniquely prepared for leadership roles. What surprises you? Ibarra, H. (2015). The authenticity paradox. Retrieved from https://
2. Consider Case Example 67.1 and discuss the following hbr.org/2015/01/the-authenticity-paradox
questions in a small group: Lyubovnikova, J., Legood, A., Turner, N., & Mamakouka, A. (2017).
■ What client factors are at play? How authentic leadership influences team performance: The
■ What considerations are there for the context and the mediating role of team reflexivity. Journal of Business Ethics, 141,
environment in this scenario? 59–70. https://doi.org/10.1007/s10551-015-2692-3
■ What are the activity demands to be successful? McCarthy, A., & Hay, S. (2015). Advanced negotiation techniques.
■ How would Adele go about identifying the perfor- New York: Apress.
mance skills required, and who on the team is best Snodgrass, J. (2011). Leadership development. In K. Jacobs & G.
McCormack (Eds.), The occupational therapy manager (5th ed.,
suited to meet those needs?
pp. 265–280). Bethesda, MD: AOTA Press.
■ What performance patterns will need adjustment? Strickland, R. (2011). Strategic planning. In K. Jacobs & G. L.
3. Consider your own personal strengths and areas of op- McCormack (Eds.), The occupational therapy manager (5th ed.,
portunity. What areas would you spend your time focus- pp. 103–112). Bethesda, MD: AOTA Press.
ing on first when you become a leader? Taylor, S. (2011). Assess pros and cons of 360-degree performance ap-
4. Discuss the concept of principled negotiation. Think back to praisal. Retrieved from https://www.shrm.org/resourcesandtools
your last “negotiation.” Were you separating the person from /hr-topics/employee-relations/pages/360degreeperformance.aspx
CHAPTER
Returning to the Occupational Therapy Workforce
Catherine C. Haines, OTR/L, and Stephanie Johnston, OTD, OTR, FAOTA 68
LEARNING OBJECTIVES
■ Explain the value of occupational therapy practitioners’ reentry to the profession;
■ Appreciate why a practitioner might leave and then return to practice at a later date;
■ Define the individual’s role in successfully reentering the profession;
■ Describe how ethical practice and continuing competence relate to reentry; and
■ Understand issues relating to licensure, career breaks, reentry, and future directions for the profession.

• Continuing competence • Formal learning • Reentry programs
• Continuing professional • Inactive status • Relaunchers
development • Licensure by endorsement • Self-assessment
• Experiential learning or reciprocity
OVERVIEW The impact has been felt acutely in the field of nursing, lead-
O
f all the chapters in this book, if you turned to this ing to identification and implementation of solutions that
one first, chances are you are an occupational ther- could also work for occupational therapy.
apy practitioner who is looking to reenter the field. In In an article titled “Exploring Incentives for RNs to Re-
these pages is practical guidance for your journey. We discuss turn to Practice,” a team of researchers asked “What type of
licensure and the importance of knowing your state’s reg- work environment and resources are necessary to encourage
ulations. We address ethical issues in reentry, suggest ways unemployed RNs to return to practice?” (Langan et al., 2007,
to maintain and develop your occupational therapy identity p. 14). Nurses who had left the workforce indicated that re-
while on a break, and explain how to incorporate reflection fresher courses, good salaries and benefits, and flexible hours
into practice. were some of the things that could entice them to return.
Students or new graduates will learn how to plan for a There are now many refresher courses for nurses. These may
career break and discover why this is important. If you are be hospital or college based or available online, and they may
a practitioner looking to change your area of practice, you be offered as a hiring incentive (Childers, n.d.).
will find relevant information here. If you are an educator, In the field of occupational therapy, Powell et al. (2008)
manager, or senior-level practitioner, you will learn how to suggested that refresher and reentry courses, mentorships,
support reentering colleagues and how doing so benefits the and peer supervision can be powerful incentives for return-
profession as a whole. ing practitioners. Unfortunately, those resources are limited,
The health care shortage is here. Across multiple fields, the and occupational therapy practitioners are largely on their
supply of health care professionals is inadequate to meet ex- own when it comes to finding a way back into practice.
isting needs, and the shortage is projected to worsen in the Occupational therapy practitioners who have taken a
coming years (Derksen & Whelan, 2009; Lin et al., 2015). leave from the field may find themselves faced with obstacles
https://doi.org/10.7139/2019.978-1-56900-592-7.068
633
CHAPTER
Returning to the Occupational Therapy Workforce
Catherine C. Haines, OTR/L, and Stephanie Johnston, OTD, OTR, FAOTA 68
LEARNING OBJECTIVES
■ Explain the value of occupational therapy practitioners’ reentry to the profession;
■ Appreciate why a practitioner might leave and then return to practice at a later date;
■ Define the individual’s role in successfully reentering the profession;
■ Describe how ethical practice and continuing competence relate to reentry; and
■ Understand issues relating to licensure, career breaks, reentry, and future directions for the profession.

• Continuing competence • Formal learning • Reentry programs
• Continuing professional • Inactive status • Relaunchers
development • Licensure by endorsement • Self-assessment
• Experiential learning or reciprocity
OVERVIEW The impact has been felt acutely in the field of nursing, lead-
O
f all the chapters in this book, if you turned to this ing to identification and implementation of solutions that
one first, chances are you are an occupational ther- could also work for occupational therapy.
apy practitioner who is looking to reenter the field. In In an article titled “Exploring Incentives for RNs to Re-
these pages is practical guidance for your journey. We discuss turn to Practice,” a team of researchers asked “What type of
licensure and the importance of knowing your state’s reg- work environment and resources are necessary to encourage
ulations. We address ethical issues in reentry, suggest ways unemployed RNs to return to practice?” (Langan et al., 2007,
to maintain and develop your occupational therapy identity p. 14). Nurses who had left the workforce indicated that re-
while on a break, and explain how to incorporate reflection fresher courses, good salaries and benefits, and flexible hours
into practice. were some of the things that could entice them to return.
Students or new graduates will learn how to plan for a There are now many refresher courses for nurses. These may
career break and discover why this is important. If you are be hospital or college based or available online, and they may
a practitioner looking to change your area of practice, you be offered as a hiring incentive (Childers, n.d.).
will find relevant information here. If you are an educator, In the field of occupational therapy, Powell et al. (2008)
manager, or senior-level practitioner, you will learn how to suggested that refresher and reentry courses, mentorships,
support reentering colleagues and how doing so benefits the and peer supervision can be powerful incentives for return-
profession as a whole. ing practitioners. Unfortunately, those resources are limited,
The health care shortage is here. Across multiple fields, the and occupational therapy practitioners are largely on their
supply of health care professionals is inadequate to meet ex- own when it comes to finding a way back into practice.
isting needs, and the shortage is projected to worsen in the Occupational therapy practitioners who have taken a
coming years (Derksen & Whelan, 2009; Lin et al., 2015). leave from the field may find themselves faced with obstacles
https://doi.org/10.7139/2019.978-1-56900-592-7.068
633
be needed more than ever. They may represent an untapped

EXHIBIT 68.1. The Value of Returning Practitioners resource in helping the profession meet society’s needs
(Powell et al., 2008).
Carol Fishman Cohen’s (2015) TED Talk How to Get Back to Work After
a Career Break has garnered more than 1.5 million views and has been
translated into 30 languages. In her talk, Fishman Cohen said,
Why We Pause
A proliferation of books, websites, and articles address the
I believe relaunchers are a gem of the workforce, and here’s needs and aspirations of “relaunchers,” a term coined by
why. Think about our life stage: For those of us who took career
Carol Fishman Cohen, CEO and cofounder of iRelaunch, and
breaks for childcare reasons, we have fewer or no maternity
author, speaker, and consultant in the career reentry move-
leaves. We did that already. We have fewer spousal or partner job
relocations. We’re in a more settled time of life. We have great ment. Relaunchers are college-educated professional women
work experience. We have a more mature perspective. We’re who take time away from the workforce (typically for family
not trying to find ourselves at an employer’s expense. Plus, we caregiving) and then want to return to work (Fishman Cohen,
have an energy, an enthusiasm about returning to work precisely 2015). The occupational therapy workforce is 92% female, so
because we’ve been away from it for a while. occupational therapy practitioners who take a career break
are part of this group (Beers, 2010). The information in this
chapter is useful to all occupational therapy practitioners, but
such as rusty skills, decreased confidence, and loss of con- because career reentry issues mostly affect women, reentry in
tacts. That said, time spent engaging in life roles and partic- occupational therapy is likely to be most pertinent to female
ipating in other work or meaningful occupations during the practitioners.
absence from the field can be considered valuable experience. A 2017 survey titled Reentry Into the Occupational Therapy
Occupational therapy managers should recognize that prac- Workforce investigated motives and other issues associated
titioners with this experience are an asset to the profession with taking a career break (see Exhibit 68.2). Sixty-two percent
(see Exhibit 68.1). of respondents selected child-bearing as their top reason for
pausing their career. Career needs of a spouse, caregiving re-
sponsibilities for elderly parents, family obligations, personal
ESSENTIAL CONSIDERATIONS health issues, burnout, and desire to pursue an alternative ca-
Occupational Therapy Workforce: reer path were also identified as reasons for leaving.
Present and Future
Occupational therapy is on the rise. The field is evolving
Review Questions
as it becomes more evidence based, recognized, and in 1. What factors are linked to the predicted growth of occu-
demand. Occupational therapy consistently ranks high in pational therapy jobs into the next decade?
media reports of “top jobs,” attracting students to the field 2. What assets can a reentering practitioner bring to the job?
with promises of a fulfilling career, good earning potential, Might they have something to teach a new graduate?
and opportunities for advancement (U.S. News & World 3. Discuss the economics of training occupational therapy
Report, 2018). The U.S. Department of Labor’s Bureau of practitioners. Compare the time and money required
Labor Statistics (2017) projected that jobs in occupational to educate a new practitioner vs. refreshing or retrain-
therapy would increase by nearly 30% between 2014 and ing an experienced practitioner returning from a career
2024, “much faster than average in comparison with all break.
occupations” (para. 5).
Lin et al. (2015) found that the current demand for oc-
cupational therapy practitioners exceeds the supply in sev- EXHIBIT 68.2. Survey: Reentry Into the Occupational
eral states. The insufficiency of the occupational therapy Therapy Workforce
workforce is predicted to continue as the U.S. population A 13-question survey titled Re-Entry into the Occupational Therapy
ages. Demographic predictions indicate that 20% of the U.S. Workforce was drafted to generate data for use in this chapter.
population will be older than age 65 years by 2030. Baby Occupational therapy practitioners were invited to share their
Boomers, who make up 40% of the health care workforce, experiences surrounding reentry. Questions focused on work history,
will shift from being caregivers to being in need of care length and reasons for pausing, reentry activities, and obstacles
themselves. to reentry.
This so-called “silver tsunami” will inundate the health Email addresses were collected, and participants were given
care system with medical problems and health care needs. the option to be informed of “opportunities or topics of interest to
Demand for occupational therapy practitioners working OT practitioners seeking reentry to the OT workforce.” Forty-seven
participants from the United States and elsewhere responded to
with older adults will be especially strong over the next de-
the survey link posted to Facebook occupational therapy forums
cade and beyond, and there may not be enough occupational and in AOTA OTConnections (now CommunOT; see Appendix 68.A
therapy practitioners to fill the gap (Lin et al., 2015). Practi- for survey questions).
tioners who have left the field and are willing to return will
CHAPTER 68. Returning to the Occupational Therapy Workforce 635
PRACTICAL APPLICATIONS IN An important professional consideration is whether you

OCCUPATIONAL THERAPY have established sufficient levels of skills or proficiencies be-
fore taking a career break. There is no substitution for time
Life is what happens to us while we are spent working in the field and experience gained on the job.
busy making other plans. This is how new graduates develop a baseline of competence
—Allen Saunders (1957) and confidence.
Coworkers tend to remember colleagues as they were be-
Ideally, every career break would be voluntary and planned, fore a career break, even after many years have passed since
but life can be unpredictable. Events such as illnesses, family they worked together. In her TED Talk, Fishman Cohen
crises, or the birth or adoption of a child may necessitate an (2015) said, “They only remember you as you were, and it’s a
unplanned or sudden departure from the workforce. Accord- great confidence boost to be back in touch with these people
ing to the Reentry Into the Occupational Therapy Workforce and hear their enthusiasm about your interest in returning
survey, 53% of occupational therapy practitioners planned to work.” Their “frozen-in-time” viewpoint can be advanta-
their career break in advance. However, 68% expressed an in- geous when you contact former coworkers.
tention to eventually return to the workforce, whether their Practitioners who have taken a career break before gaining
leave was planned or unplanned. Plans for the timing of a experience are likely to have more challenges because they
return may change while one is on a career break, but most lack these experiences and professional networks. Respon-
occupational therapy practitioners value their career and do dents from the Reentry Into the Occupational Therapy Work-
want to return. force Survey with little work experience before their hiatus
reported feelings of isolation, lack of support, and difficulties
with confidence:
Preparing to Pause: What to Know ■ “I don’t feel my rehab experience was strong before my
Before You Go hiatus.”
Occupational therapy practitioners can take steps to safe- ■ “It’s really hard to go into a setting that I haven’t worked in
guard reentry options before taking a career hiatus, which before.”
can ease their eventual return. While one’s career is paused, ■ “Not being able to find a mentor as they often already have
taking the time to periodically make deliberate, thoughtful commitments to new students and don’t have the time for
choices will help to preserve options, allowing more control a returner.”
over reentry when the time is right. ■ “Decreased confidence due to extended time off and hard
In a field where job openings may exceed job applicants, to find supervision for reentry.”
practitioners may feel empowered to move in and out of the ■ “I was a new grad when I left, so didn’t have a base of expe-
workforce, to request job flexibility, or to opt for part-time rience. It was very difficult, and I had no mentoring.”
or per diem work. Practitioners can avoid many of the bar- ■ “I found nothing in online searches to find support or
riers to reentry by maintaining some level of clinical activity network with others going through this process.”
(American Academy of Pediatrics [AAP], 2014). The Fed- ■ “I have had to be very self-directed in my learning, not an
eration of State Boards of Physical Therapy (2016) included obstacle in itself, but more support, say from university/
occupational therapy in its review of health care professions’ health board for returnees would have been invaluable.”
models on reentry. In medicine, nursing, occupational ther- When practitioners who are in this situation are ready to
apy, and other health care fields, it is recognized that provid- return to the workforce, they should carefully consider their
ers must possess up-to-date skills and knowledge to practice first job placement when reentering. They are most likely to
competently after time away. find success in a supportive work environment with reason-
A decision to step away from the workforce deserves able caseloads, continuing education (CE) opportunities, and
thoughtful investigation and intentional preparation. An ele- coworkers who are willing to take on a mentoring role.
ment of planning is to consider the next 5–10 years and reflect
on questions related to career, family, finances, and personal
The License: A Golden Ticket
or emotional factors (AAP, 2014). Is it realistic or feasible to
take a career break in that time? Weigh the financial impact of Occupational therapy is regulated by licensure in all 50 states
lost wages and benefits, such as health insurance and retire- and the District of Columbia. The license is a precious career
ment contributions. Calculate whether the reduced income asset. It represents years of education, sacrifice, hard work,
will allow you to meet financial commitments and goals, such and expense, and one cannot practice without it.
as loan payments, college tuition, and retirement. Maintaining a license while away from the workforce can
It is also important to weigh the potential social and emo- be expensive and may seem unnecessary or optional, espe-
tional impact of leaving the workforce. Consider questions cially during a time of reduced income. This may tempt a
such as whether loved ones support the decision to take a ca- practitioner to allow the license to lapse. A better alterna-
reer break or how changes to your roles and routines might tive, however, may be to convert the license to an inactive
affect your professional identity and self-esteem. status. Converting a license from active to inactive suspends
requirements for CE while maintaining a license in good Volunteering at a homeless shelter or soup kitchen will pro-
standing and preserving the ability for reactivation later. vide access to an underserved population with complex
In addition, seeking licensure by endorsement or reci- needs who might not otherwise have access to occupational
procity may be appropriate in some circumstances. This pro- therapy services.
cess allows a practitioner who already holds an active license LinkedIn Volunteer Marketplace, VolunteerMatch (www
in one state to become licensed in another state or jurisdic- .volunteermatch.org/) and the Points of Light’s HandsOn
tion. It is based on verification of credentials from one state’s Network (www.pointsoflight.org/handsonnetwork) aim
licensing authority to another. Specific requirements vary to connect professionals with opportunities to share their
from state to state, and some states do not participate. skills in the community. Joining a board can also be a ca-
Being aware of state-specific licensure regulations may reer booster, providing opportunities to grow profession-
help inform decisions, preserve options, and avoid unex- ally (Gelbard, 2017). In a recent survey on LinkedIn, 42% of
pected barriers to reentry later. The American Occupational hiring managers stated that they consider volunteer work
Therapy Association (AOTA) has contact information for all equivalent to full-time work experience, and 20% said they
state occupational therapy regulatory agencies. For the most had hired someone because of their volunteer experience
reliable and current state licensure requirements, always refer (Hoffman, 2014).
directly to that state’s occupational therapy regulatory agency.
Continuing Competence in Reentry:
Sustaining Professional Identity Guidelines for Success
It is wise to revisit personal reentry timelines on a regular Nothing is permanent but change.
basis (AAP, 2014). If you have not scheduled an endpoint to
the career break, periodically review your feelings about re- — Elbert Hubbard (1922)
turning to work. It may be helpful to pick a time of year as-
sociated with milestones or new beginnings—perhaps at the Continuing competence among providers is a vital issue in all
start of the new year or at back-to-school time. Keep in mind of health care and is a fundamental concern in career reen-
that returning from a short hiatus will be easier than reenter- try. This is the process by which practitioners keep their skills
ing after a longer break. and knowledge current and take steps to remain effective and
Be mindful about the need to nurture your professional proficient going forward. It is an important aspect of continu-
identity. Take deliberate steps to stay engaged and to find sup- ing professional development.
port. Membership in AOTA and state occupational therapy Potential employers may be apprehensive that a practi-
associations can foster professional social connections. Par- tioner who has been out of the workforce might lack the nec-
ticipate in AOTA online discussion forums and on social essary skills and knowledge for the job and therefore might
media groups to keep informed of current issues in the field. not be competent. Practitioners who have taken a career
Facebook has numerous occupational therapy groups, in- break should become familiar with the AOTA (2015a) Guide-
cluding one called Reentry4OT (www.facebook.com/groups lines for Reentry Into the Field of Occupational Therapy. This
/108614389856017) created specifically “to bring occupational official document provides a template for regaining compe-
therapy practitioners together for support and ideas around tence, with the recognition that the longer one has been out of
the topic of reentry.” the workforce, the longer the road to reentry will be.
Reach out to former classmates and to your alma mater, and Other AOTA official documents, including the Occu-
take advantage of programs or opportunities for alumni. Con- pational Therapy Practice Framework: Domain and Pro-
tact colleges and universities in your area with occupational cess (AOTA, 2014b); Occupational Therapy Code of Ethics
therapy or occupational therapy assistant programs. Many (2015) (AOTA, 2015b); Standards for Continuing Competence
programs have community ties, and they may welcome local (AOTA, 2015c); Standards of Practice (AOTA, 2015d); and
occupational therapy practitioners as role models for their Guidelines for Supervision, Roles, and Responsibilities During
students. Networking with academic colleagues can lead to the Delivery of Occupational Therapy (AOTA, 2014a), will
invitations to student research presentations, weekend work- provide further guidance. While becoming familiar with
shops, or other events on campus (Haines & McGee, 2012). these documents, it is important to identify core knowledge
Consider strategic volunteering (Barrett-Newman, n.d.). deficits and make a plan for their remediation (Haines &
This involves thinking of the area in which your relaunch McGee, 2012).
may take place and researching organizations that will allow Continuing professional development (CPD) is the means
volunteer exposure to that population. Besides benefiting the by which clinicians advance professionally. CPD is a self-
organization, volunteering provides recent work experience directed, reflective process of lifelong learning aimed at
for a résumé. maintaining practitioner competence, ensuring client safety
Are you interested in geriatrics? Many nursing homes and and quality outcomes, enhancing or expanding professional
adult day programs actively seek volunteers. Are you tran- practice, and reaching career goals. CPD allows occupational
sitioning to pediatrics? Become a Big Sister or Big Brother, therapy practitioners to develop measurable skills, explore
or help to develop an inclusive Sunday school curriculum. new ideas, become reflective in their thinking, and integrate
evidence-based and outcome-focused concepts into their EXHIBIT 68.3. AOTA’s Guidelines for Reentry Into the
knowledge base (AOTA, 2017a). Field of Occupational Therapy
CPD mandates that practitioners “actively engage in activ-
ities to assure each other and society that we are effective and The Guidelines for Reentry (AOTA, 2015a) recommend the following
proficient” (Hinojosa et al., 2000, p. CE1). Each individual steps for lapsed practitioners:
must internalize this responsibility and take the necessary ■ Engaging in formalized self-assessment;
steps to ensure that they are up to speed. CPD is an essential ■ Attending at least 10 hours of formal learning activities for each
component of ethical practice, which requires occupational year out of practice;
therapy practitioners to ■ Attaining relevant updates to the core of occupational therapy
practice; and
■ Practice mindful reflection, ■ Engaging in at least 30 hours of documented supervised
■ Take steps to ensure proficiency, service delivery, for practitioners who have been out of practice
■ Maintain competency by ongoing participation in rele- for 3 years or more.
vant CE, and
After successful reentry, maintain continuing competence by
■ Represent credentials, qualifications, education, experi-
ence, training, roles, duties, competence, contributions, ■ Seeking mentoring or supervision, especially during the 1st year
and findings accurately (AOTA, 2015b). of return to practice;
■ Participating in AOTA Special Interest Section forums;
The process of restoring professional competence should ■ Pursuing AOTA board and specialty certifications; and
begin with a systematic self-assessment. Self-assessment in- ■ Joining and becoming active in AOTA and your state occupational
volves evaluation of oneself or one’s actions and attitudes, therapy association.
review of one’s own level of skills or knowledge, or appraisal
of one’s performance at a job or learning task in comparison
with an objective or measurable standard. It can be used to
identify areas of strength or weakness and measure improve- Relaunching Your Career
ment over time. Used in conjunction with self-reflection, When I orbited Earth in the spaceship, I saw for the first
self-assessment allows a practitioner to develop insight and time how beautiful our planet is.
learn new behaviors.
The National Board for Certification in Occupational —Yuri Gagarin, on his reentry from outer space
Therapy (NBCOT®; n.d.) offers free self-assessments in gen- (New Mexico Museum of Space History, n.d.)
eral practice and specialty areas. The AOTA Professional
Development Tool (PDT; AOTA, 2003) is available to AOTA Engaging in meaningful occupations is a prime goal of oc-
members; it guides the process of evaluating learning needs cupational therapy. Practitioners can apply the occupational
and interests, formulating a professional development plan, therapy process of evaluation, treatment planning, and goal
and recording professional development activities. The PDT setting to their own personal reentry situation. After you as-
advocates self-reflection and journaling. sess your knowledge deficits through self-reflection, devising
Formal learning experiences are available in many formats. short-term objectives and identifying associated activities
These activities are designed to increase one’s knowledge and can lead to achievement of the long-term goal of being hired
skills, with measurable goals and objectives. Conferences, self- for a job (Haines & McGee, 2012).
study courses, and online learning modules are examples of In today’s fast-paced and dynamic health care environ-
formal learning activities. ment, the prospect of refreshing skills and knowledge that
Much of this learning can be done online, and although may be years out of date can feel overwhelming. This is a
this is convenient, it is best to incorporate some experiential process that will take time, patience, and determination.
learning activities into a plan for CPD. Experiential learning For practitioners who have taken an extended break and
consists of hands-on activities in which a person learns by for those with little or no on-the-job experience beyond
doing and then reflects on the experience. Workshops, su- fieldwork, reentry and refresher courses may be a good
pervised work, and role-playing are activities with an expe- option.
riential learning component. In addition, attendance at con- Reentry programs are specifically designed to assist oc-
ventions, conferences, Special Interest Section meetings, and cupational therapists or occupational therapy assistants to
workshops can help combat isolation, maintain professional return to practice. Participation in these programs may be
identity, and provide opportunities to network while gaining a means or requirement for reentry into the workforce when
skills and information (see Exhibit 68.3). one’s licensure, registration, or certification has lapsed.
They can provide the boost returning practitioners need
to obtain current information in a comprehensive format,
with the added benefit of peer support. Practitioners who
have been out of the workforce for 20 years or more have
For additional learning, see Chapter 71, “Professional Development.” successfully reentered after completing such programs
(see Exhibit 68.4).
EXHIBIT 68.4. Reentry and Refresher Courses EXHIBIT 68.5. Self-Care and Stress Management
In 2011, AOTA identified reentry as an emerging niche in occupational Returning to the workforce represents a major change in familiar roles,
therapy education. However, growth in the area of reentry has routines, and habits. Practicing good self-care is critical for ensuring
been minimal to date. Practitioners can choose from the following that you have the physical and emotional reserves for your patients,
U.S. programs: clients, and others in your life, as well as for yourself. Set limits, say
“no,” and try to maintain a healthy balance between your personal
■ The University of Minnesota Hybrid Refresher Course combines
and professional life. Integrate self-care activities, such as exercising,
online learning modules completed individually, followed by
eating healthy foods, and getting enough sleep (Barnett, 2014).
face-to-face, hands-on learning on campus in Minneapolis.
Lack of confidence and low self-esteem are common pitfalls for
Instruction includes lab experiences, case-based learning, ethics,
relaunchers (Fishman Cohen, 2015). Recognize negative self-talk
documentation review and the electronic medical record, and
if it appears, and take steps to replace insecurity with confidence.
résumé writing.
Positive self-affirmations can be reassuring while you are in the midst
■ Lone Star College, in Tomball, Texas, includes a fieldwork component
of stressful interactions. To bolster self-assurance and resilience, try
in its reentry program for OTs and OTAs. Eight weeks of online
memorizing a phrase such as “It’s okay if I don’t have all the answers
instruction are followed by 4 weeks of supervised clinical practice.
right away, because I know how to find them. I am a good therapist
Successful participants are eligible for re-licensure in Texas.
who has the best intentions for my patients” (Tietz, 2017, p. 49).
Interviews Visions for Our Future

Regaining confidence for interviewing is an important At the time of printing, the occupational therapy profession is
milestone in returning to the workforce. Be prepared to grappling over whether to advance entry-level degree require-
highlight attributes, skills, and talents for a potential em- ments to the doctoral level for occupational therapists and to
ployer. Anticipate questions about “strengths and weak- the baccalaureate level for occupational therapy assistants.
nesses,” and answer them truthfully but strategically. Although it is too early to predict how these changes might
Discuss life skills that may be useful in overcoming any affect the future occupational therapy workforce, demand for
perceived deficits. occupational therapy practitioners will continue to grow.
If lack of work experience or time away from the work- Assisting and supporting returning practitioners with their
force is raised, acknowledge this concern and describe a reentry can address workforce shortages while strengthening
plan for addressing it professionally. Identify real-life sit- the profession. Professionals can facilitate their colleagues’
uations that highlight job-relevant skill sets. Maintain the return by fostering a warm, welcoming, and inclusive work
focus on abilities and work ethic, and promote yourself as culture where pauses and relaunches are considered a normal
eager to jump in and work hard (Fishman Cohen, 2016; part of a professional’s career trajectory and where practi-
Williams, n.d.). tioners who want to return have the options and support they
need to do so (AAP, 2014). Guidance is available from pro-
grams such as Canada’s Supporting (Re)Entry to Professional
Beyond the paycheck: Quality of life at work Practice Project, which addresses workforce issues and helps
Never get so busy making a living that you bring occupational therapists and physical therapists together
forget to make a life. through “facilitating mentoring relationships linked to prac-
tice opportunities” (Baptiste et al., 2010, p. 145).
—Anonymous Powell et al. (2008) suggested ways to bolster the occupa-
tional therapy workforce. They noted that
While contemplating a return to the workforce, take time
to reflect on your personal values. Consider factors beyond efforts to add workers also could include bringing back
salary, company policies, and work environment. These are therapists who have left the field. In this area, CE refresher
important, and when they fail to meet expectations, job discourses targeted for people interested in returning in either
satisfaction is likely. However, most people feel unfulfilled by the same or different practice arenas could be helpful. (p. 103)
work that meets only their financial needs.
Other factors contribute to feelings of success and enrich- The profession can expand to meet the needs of its mem-
ment. A gratifying work experience includes having good re- bership by reaching out to occupational therapy practitioners
lationships with coworkers and supervisors, feeling respected whose licenses have lapsed and attracting them back into the
and valued, feeling intellectually challenged, and knowing field with mentorship, reentry and refresher programs, online
that one is making a difference. Additionally, ask about oppor- learning modules, and specialty conferences.
tunities to co-treat, to gradually assume a full caseload, and to
Review Questions
participate in regular staff development activities. Before ac-
cepting a job offer, try to gauge the work culture and determine 1. What are 3 things a practitioner can do while on a career
whether this place would be a good fit (Chanmugham, 2016; break to keep their professional identity intact? Why is
see Exhibit 68.5). this important?
2. Imagine yourself taking time off for an extended period. If your career has been on the back burner, know that re-
Identify how you would maintain your professional li- turning to clinical practice requires that you reflect truthfully
cense in your state. on what you see in the mirror. It is your responsibility to take
3. What are some ethical issues that might arise for a person the necessary steps to refresh your knowledge and skills. You
who has been out of the field for a number of years? will know you are ready for work when you see a competent
Which of the Occupational Therapy Code of Ethics practitioner staring back at you.
(AOTA, 2015b) Core Values, Principles, and Standards of AOTA’s (2015b) Code of Ethics inspires practice as
Conduct are most applicable to a reentering practitioner? “a manifestation of moral character and mindful reflection, a
commitment to benefit others, to virtuous practice of artistry
and science, to genuinely good behaviors, and to noble acts
SUMMARY of courage” (p. 1). Ethical practice includes identifying one’s
deficits and taking appropriate steps to remediate them. Eth-
There is a crack in everything, that’s how the light gets in. ical practice also includes mentoring, offering support, and
—Leonard Cohen (1992) sharing expertise and knowledge with a reentering colleague.
Reentering practitioners are an asset to the field. Invest-
If you take away only 1 piece of information from this chapter, let ing in them can help address workforce shortages and, in
it be this: Know your state’s occupational therapy practice regu- turn, strengthen the occupational therapy profession. Such
lations and what the requirements are for licensure. Knowledge measures can advance our profession toward the aspirations
is power. If you educate yourself and plan carefully in advance of AOTA’s (2017b) Vision 2025: “Occupational therapy max-
of a career break, you will be in the driver’s seat when you are imizes health, well-being, and quality of life for all people,
ready to step back in. Case Example 68.1 provides 2 scenarios of populations, and communities through effective solutions
occupational therapy practitioners returning to the workforce. that facilitate participation in everyday living” (p. 1). ❖
CASE EXAMPLE 68.1. Returning to the Occupational Therapy Workforce
Scenario 1. Annette: Reentering After an Extended Pause

After graduating from occupational therapy school in Texas, Annette took her first full-time job in a rehabilitation facility. She worked there for several
years, then transitioned to skilled nursing, outpatient care, and home health care. She met her husband, and they started their family. His military career
required them to move frequently, away from other family and supports. Annette was often on her own during her husband’s overseas deployments,
and she found it increasingly difficult to care for their young children and manage the household while maintaining her own career. After working for
8 years, Annette and her husband decided that she would stay home full time.
Several years passed, and Annette and her family eventually settled back in Texas. When her youngest child entered kindergarten, Annette’s
thoughts turned to her occupational therapy career. She had been out of practice for 9 years and was disappointed to discover that to restore her
lapsed Texas occupational therapy license, she had to retake the NBCOT certification exam. This was not feasible, and she reluctantly put her
dreams on hold.
The milestone of her youngest child graduating from high school and planning for college prompted Annette to contemplate her own dormant
occupational therapy career. Although she had been out of practice for 20 years, she felt ready for the challenge of regaining her career. Her dreams
became reality when she discovered that Texas had a successful reentry program for people like her, whose license had lapsed and who had not
practiced in many years.
At first, Annette was reluctant to admit how long she had been out of the occupational therapy workforce and worried about what others would
think of her. She read, studied, and overworked every assignment, trying to prove to herself and to her instructors that she could still function as an
occupational therapist (OT). She started the fieldwork experience and worried that she would make so many mistakes. Her supervisor was young
enough to be her daughter! With time, however, Annette started to regain confidence in herself and began to “feel like an OT again.” She completed
the required courses and the fieldwork and regained her Texas occupational therapy license.
Annette is now successfully employed. She was apprehensive about the 20-year employment gap, but, to her relief, that has not been a problem.
She has a great position in a busy rehab department with supportive colleagues. She is still studying diligently and reflecting on her practice using
the latest evidence, and loving every minute of it!
Scenario 2. Gillian: Seeking Work–Life Balance

Gillian is an OT from Florida. She has 10 years of combined work experience in pediatrics and home health care for children and adults. Gillian
admits she was feeling some career burnout when she took her career break after the birth of her child. She had originally planned to take 1 year off
but ended up staying home for 4 years. When her child entered preschool, Gillian felt ready to reenter the workforce.
Gillian described how activities during the hiatus facilitated her return. She maintained her license and participated in CPD activities. She used
networks and contacts to stay professionally engaged, saying, “I have been reaching out to former colleagues about available positions. I also held a
couple of volunteer positions with my state’s OT association. Those positions required that I write articles for our newsletter and present at an annual
conference.”
(Continued)
CASE EXAMPLE 68.1. Returning to the Occupational Therapy Workforce (Cont.)
Gillian’s priorities were flexibility with scheduling and working in a setting with coworkers. Gillian joined the Facebook group Reentry4OT, and
at the beginning of October, she shared her happy news with the group: “Started per diem work last week after a 4-year break. First day was tough
(working with children who were profoundly disabled, and I had little prior experience with that population); but every day has gotten a bit easier.
I feel like I’m slowly getting my groove back and it is quite nice to be around other rehab colleagues as well.”
Gillian is enjoying her new job. “The therapists I am working with have been very patient and supportive with me as I settle into work again,”
she told the Facebook group. “Occasionally, I have felt my skills were ‘rusty’— like forgetting the proper names of hand grasp patterns and taking
forever to write up evaluations; but overall, I feel like this is the perfect reentry position for me and am so happy that I took the time to analyze what
exactly I wanted/needed in a job and was able to ask for, and receive it.” Gillian offered these words of advice about the road to reentry: “It’s such
a personal journey—do what you need to do to feel happy.”
Review Questions
1. Determine whether Annette or Gillian felt stigmatized about their career break. What was Annette most concerned about? What were
Gillian’s major concerns?
2. Discuss how Annette’s and Gillian’s supervision needs might be different and how they might differ from a new graduate’s needs.
3. For a reentering practitioner, what are the advantages of having daily contact with colleagues?
ACOTE STANDARDS American Occupational Therapy Association. (2015d). Standards

of practice for occupational therapy. American Journal of Oc-
This chapter addresses the following ACOTE Standards: cupational Therapy, 69, 6913410057. https://doi.org/10.5014/ajot
■ B.5.5. Requirements for Credentialing and Licensure .2015.696S06
American Occupational Therapy Association. (2017a). Continuing
professional development in occupational therapy. American
■ B.7.2. Professional Engagement
Journal of Occupational Therapy, 71, 7412410017. https://doi
■ B.7.4. Ongoing Professional Development. .org/10.5014/ajot.2017.716S13
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APPENDIX 68.A. REENTRY INTO 7. Was your hiatus from the OT workforce planned?
THE OCCUPATIONAL THERAPY 8. What prompted your hiatus from the OT workforce?
9. What was your area of practice before and after your
WORKFORCE hiatus?
Survey Questions: 10. Describe activities during your hiatus that may have
facilitated your return to the OT workforce.
1. Where do you live?
11. Please describe any barriers or obstacles you have en-
2. Please describe your status as an occupational therapy
countered in your efforts to reenter the OT workforce.
practitioner.
12. Do you agree or disagree with the following statement:
3. Do you agree or disagree with the following statement:
“Reentry to the workforce is an important issue for our
“OT practitioners returning to the field are a valuable
profession”?
resource for the profession”?
13. Would you like to be informed of opportunities or top-
4. Are you currently employed?
ics of interest to OT practitioners seeking reentry to the
5. How long did you work as an OT practitioner before your
OT workforce?
hiatus?
6. How long was your hiatus from the OT workforce?
CHAPTER
Transitioning to New Practice Areas
Tracy L. Witty, OTD, OTR/L, Reg.(OT), CLCP 69
LEARNING OBJECTIVES
■ Explain why occupational therapy practitioners may want to change their practice area,
■ Describe the steps involved in the transition to a new practice area, and
■ Discuss ways that occupational therapy practitioners can best engage with their new practice area.

• Adaptive work environments • Formal mentorships • Professional networking
• Contemplation • Informal mentorships • Provisional license
• Context • Internal factors • Soft skills
• Engagement • Mentor • Transition
• External factors • Planning • Work
• Flexibility
OVERVIEW (American Occupational Therapy Association [AOTA], 2014).

The Occupational Therapy Practice Framework: Domain and
A
transition is “a passage, evolution, development, or Process (OTPF–3) defines work as “Labor or exertion; to make,
abrupt change that leads to movement from one . . . construct, manufacture, form, fashion, or shape objects; to
state, stage, or place to another” (Orentlicher & Gibson, organize, plan, or evaluate services or processes of living or
2015, p. 22). Occupational therapy practitioners often transi- governing; committed occupations that are performed with
tion to new areas of practice for a variety of reasons, including or without financial reward” (p. S20). For many, being an oc-
professional growth, family considerations, and financial de- cupational therapy practitioner is a valued role and occupa-
mands, just to name a few. The field of occupational therapy tion and contributes to their self-identity. Practice area is an
allows such lateral movement, and transitioning is often both important context to an occupational therapy practitioner’s
a challenging and rewarding experience. role as an employee. Transitioning to a new practice area is
This chapter examines important aspects of transitioning no small matter.
to a new practice area, which range from an initial impetus to Why change practice areas? Various internal and external
change, to the adjustments that need to be made. The chapter factors can contribute to this decision. Occupational therapy
then addresses personal and professional assessments made by practitioners work in dynamic systems. New and stronger
practitioners after they have begun practicing in their new areas. research is constantly being produced, which causes rec-
ommendations to change accordingly; team compositions
change over time; and changing technology can affect what
ESSENTIAL CONSIDERATIONS might benefit clients.
Occupational therapy practitioners understand the impor- Management changes might cause an occupational ther-
tance of engagement and work, which ranges from paid em- apy practitioner to question their place in the current team or
ployment to volunteerism. The term occupation includes work work environment; changes or differences in reimbursement
https://doi.org/10.7139/2019.978-1-56900-592-7.069
643
CHAPTER
Transitioning to New Practice Areas
Tracy L. Witty, OTD, OTR/L, Reg.(OT), CLCP 69
LEARNING OBJECTIVES
■ Explain why occupational therapy practitioners may want to change their practice area,
■ Describe the steps involved in the transition to a new practice area, and
■ Discuss ways that occupational therapy practitioners can best engage with their new practice area.

• Adaptive work environments • Formal mentorships • Professional networking
• Contemplation • Informal mentorships • Provisional license
• Context • Internal factors • Soft skills
• Engagement • Mentor • Transition
• External factors • Planning • Work
• Flexibility
OVERVIEW (American Occupational Therapy Association [AOTA], 2014).

The Occupational Therapy Practice Framework: Domain and
A
transition is “a passage, evolution, development, or Process (OTPF–3) defines work as “Labor or exertion; to make,
abrupt change that leads to movement from one . . . construct, manufacture, form, fashion, or shape objects; to
state, stage, or place to another” (Orentlicher & Gibson, organize, plan, or evaluate services or processes of living or
2015, p. 22). Occupational therapy practitioners often transi- governing; committed occupations that are performed with
tion to new areas of practice for a variety of reasons, including or without financial reward” (p. S20). For many, being an oc-
professional growth, family considerations, and financial de- cupational therapy practitioner is a valued role and occupa-
mands, just to name a few. The field of occupational therapy tion and contributes to their self-identity. Practice area is an
allows such lateral movement, and transitioning is often both important context to an occupational therapy practitioner’s
a challenging and rewarding experience. role as an employee. Transitioning to a new practice area is
This chapter examines important aspects of transitioning no small matter.
to a new practice area, which range from an initial impetus to Why change practice areas? Various internal and external
change, to the adjustments that need to be made. The chapter factors can contribute to this decision. Occupational therapy
then addresses personal and professional assessments made by practitioners work in dynamic systems. New and stronger
practitioners after they have begun practicing in their new areas. research is constantly being produced, which causes rec-
ommendations to change accordingly; team compositions
change over time; and changing technology can affect what
ESSENTIAL CONSIDERATIONS might benefit clients.
Occupational therapy practitioners understand the impor- Management changes might cause an occupational ther-
tance of engagement and work, which ranges from paid em- apy practitioner to question their place in the current team or
ployment to volunteerism. The term occupation includes work work environment; changes or differences in reimbursement
https://doi.org/10.7139/2019.978-1-56900-592-7.069
643
policies and the limits of one’s occupational therapy role in EXHIBIT 69.1. Internal and External Factors Leading to
treating clients can affect a practitioner’s job satisfaction. For Overall Retention
example, some systems reimburse only for consultation and not
treatment, such as being directed to communicate to a teacher Quality of work life
or parent what activities or strategies would be helpful for the ■ Balance of work life and home life
client, but nothing further. Some clinical practices limit the ■ Work design
types of services that can be provided despite what the practi- ■ Work context
tioner may determine as necessary (e.g., when the occupational
therapist can assess only for home safety but not psychological Overall satisfaction
distress). Other systems reimburse with flat fees for services; ■ Personal growth
if the practitioner can’t perform the services in the window of ■ Salary package
time allotted, which can happen for legitimate reasons such as ■ Professional support
the health of the client, they may not receive payment for their
work. These different approaches mean that an occupational
therapy practitioner should consider what working context
might best suit their strengths and goals in the profession. Contemplation involves considering or imagining the
idea of working in a different practice area. In this stage, the
Internal Factors occupational therapy practitioner has identified some rea-
Internal factors relate to ideas or thoughts within the mind. sons for change. Planning involves more than just submit-
After being in a position for a prolonged period of time, oc- ting a résumé; a practitioner must consider various tasks that
cupational therapy practitioners may desire a new challenge will make this part of the transition more rewarding for them
or want to explore other professional interests. Practitioners and their potential employer. Engagement occurs when the
grow and evolve, and exposure to various practice areas can transition to a new job has been accomplished and the prac-
unearth new passions. An emerging practice area might titioner is looking at ways to make the first months and years
pique or bring together one’s professional interests. in a new role more effective and satisfying.
Or, after a long career in a single area, an occupational
therapy practitioner may feel they are no longer growing pro- Review Questions
fessionally. At this level, practitioners have often provided
mentorship, training, and management for newer practitioners. 1. What are additional examples of internal and external
Although this might be engaging and fulfilling for some, others factors that might influence an occupational therapy
might find such work repetitive and uninteresting. Seeking new practitioner’s decision to change their practice area?
challenges can help to satisfy personal and professional growth 2. What are the 3 stages of transition?
needs and might include shifting to another area of practice. 3. When does engagement occur within the transition
process?
External Factors
External factors are those things that happen in one’s environ- PRACTICAL APPLICATIONS IN
ment which are largely dictated by the actions of others and OCCUPATIONAL THERAPY
must be accounted for on the basis of their importance to the
Context
individual. In other words, they relate to ideas or actions occur-
ring outside the mind. Such factors may include family changes Context can be defined as the collection of interrelated con-
or family demands whereby an occupational therapy practi- ditions and variables that make up a person’s environment
tioner needs more flexibility but wants to maintain a similar (AOTA, 2014). Context also includes working conditions
income. They are seeking a lateral move, versus a “start over” and the worker’s personal condition. Workplace conditions
experience, to a position in which they can use their current include the physical environment’s adaptability, design, and
clinical skills and gain new expertise; at the same time, they operation and also support mechanisms to help manage in-
continue to earn a similar or even higher wage with enough terpersonal work relationships. Working conditions can in-
flexibility to balance family and work demands. Exhibit 69.1 clude the physical environment, work culture and attitudes,
highlights some internal and external factors considered when processes, and employee supports.
transitioning to a new practice area (Parveen et al., 2016). An important consideration, which institutions do not
always consider, is a person’s physical condition and how
3 Transition Stages the stresses and physical and mental demands of an occu
pational therapy practice might better be handled over
The process of transitioning to a new practice area can be cat-
the course of a career, especially when a change in practice
egorized into 3 general stages:
is being undertaken. For instance, a study of health work-
1. Contemplation, ers in Australia found that participants “had a desire to in-
2. Planning, and crease their physical activity levels; had different perspectives
3. Engagement. of physical health from those recommended by government
CHAPTER 69. Transitioning to New Practice Areas 645
guidelines; and viewed physical health as important to job process begins. Practitioners should have an updated résumé
satisfaction, yet related to stress and fatigue” (Rice et al., 2014, that highlights relevant occupational therapy skills; courses
p. 155). With this in mind, and given that physical health is di- completed; and experience and that includes transferrable
rectly connected to overall mental and emotional well-being, soft skills, such as establishing client rapport, time manage-
during a career transition, occupational therapy practitioners ment, and reliability. The résumé allows practitioners to high-
should give themselves space for maintaining their health light the goals of their practice change and note how their
and pay particular attention to their exercise and rest needs. previous experience will add to the new practice environment.
The transitioning occupational therapy practitioner must
reflect on the relevance and importance of particular working
Job search
conditions to determine their fit with a potential employer.
Assessing the work environment is important for many rea- With an updated résumé and cover letter, occupational
sons, such as potential long-term job satisfaction and profes- therapy practitioners are ready to begin a formal job search
sional compatibility. How well a potential employer maintains through targeted networking or using online job search plat-
the workspace reveals the degree to which the employer cares forms. In some practice areas, employers hire professional
about safe and adaptive work environments for its employees. recruitment services to find qualified candidates. This often
Adaptive work environments consider how employees’ needs indicates high occupational therapy demand with the em-
can be met. The design and operation of a work facility can ployer having difficulty finding people, such as is sometimes
affect the way a person feels about both their job and their the case in rural areas (Lannin & Longland, 2003; Lin et al.,
commitment to it (Sadatsafavi et al., 2015). 2015). In more urban locations, a greater number of positions
may be available in a variety of practice areas; however, com-
petition for these positions may also be increased. Whether
Initiating a Change in Practice Area
interviewing for a position in a small rural practice or a fast-
Occupational therapy practitioners may benefit from listing paced rehabilitation center, practitioners must prepare for
at least 3 goals, personal or professional, they hope to achieve the interview.
by practicing in the new area. A recent study on the transition
from occupational therapy student to practitioner, and one
Interviewing
that may inform goal setting, found that several factors con-
tributed to a positive transition, including In preparation for an interview, practitioners should learn
about the employer or organization’s mission, services, and
■ Having clearly defined roles and responsibilities, population served. They should also try to determine the
■ Realistic caseloads, employer’s needs, goals, and what specific role they want the
■ Opportunities for establishing strong professional successful candidate to perform. This allows practitioners
relationships,
to identify their current skill set and the skills they need
■ Good clinical skills, and to have.
■ Presence of a supportive mentor (McCombie & Antanavage, Examining relevant information about the facility and
2017, p. 140).
staff and pertinent clinical information assists practitioners
These factors are aspects of the stages in the transition process. in making a more informed decision; this could involve en-
In the initial stage of the transition contemplation process, suring the employer’s public philosophies are similar to an
the occupational therapy practitioner may casually speak occupational therapy practitioner’s professional philoso-
to occupational therapy colleagues to learn about the current phies, reviewing the occupational therapy or rehabilitation
occupational therapy market, areas of demand, and other team and their skill sets, and thinking about how occupa-
work cultures. Specific questions may include tional therapy practice skills can complement that team, fill
in any gaps, or identify learning needs.
■ How are occupational therapy services reimbursed? For example, in Case Example 69.1, Diane was proficient
■ How are practitioners reimbursed? in working with children who had experienced a traumatic
■ Is there a high demand for occupational therapy in this brain injury (TBI), but she was required to engage in con-
practice area?
tinuing education regarding the assessment and treatment of
■ Is the practice area secure? adults with TBI. Although many of her existing skills were
These discussions may lead to learning about local work- transferrable, she needed additional training to ensure that
shops or training courses in a potential area of interest. Taking where her experience did not account for a given aspect of
a short course in a new area of practice provides exposure to care, her recent training would. In Case Example 69.2, when
a potential area and an opportunity to network with relevant Robert reviewed a potential employer’s website, he saw the
professionals during the informal information-gathering pro- company was focused on providing expert-level care. When
cess. Information gathered may provide details on reimburse- examining the occupational therapy team skill set, he saw
ment policies, core occupational therapy skills required, any that he had similar mental health and trauma experience but
special courses recommended, job contacts, and more. with a different client population. He knew he had to engage
After sufficient information is collected to ensure the new in training for this specific client population to be considered
practice area is a good fit, the job search and application a viable candidate.
CASE EXAMPLE 69.1. Diane: Exploring Mental Health
Diane is an occupational therapist who has worked in hospitals for more than 10 years, but she wants a change in focus that would allow her
to explore some of her other professional interests related to working with individuals with mental health conditions. With the support of her
self-employed husband, she ventures away from the security of the hospital environment and finds work with a private, community-based
rehabilitation clinic.
During this transition, Diane receives support from her personal and professional network, including physicians, business mentors, and other
occupational therapists in private practice. All have supported her by directing her to relevant training courses, guiding her on how to set up her
home office, providing referrals for professionals who provided business strategies, and offering shadowing experiences.
After a few months in her new role, Diane discovers that the work was even better than she expected, noting the schedule flexibility and
independence that came with the private practice setting. This flexibility allows her to become more involved in her children’s lives by attending
school events and other important activities, and she is not limited to doing housework on weekends. Diane also finds a direct therapy model more
professionally satisfying because the interventions had a greater individual impact compared to those in the consultation model she was
accustomed to in the hospital system.
Review Questions
1. What aspect of Diane’s career was at risk by moving from a government-funded hospital environment to a private-clinic setting?
2. How did Diane’s social network help with her transition to a new practice area?
3. What was the most satisfying outcome of the transition for Diane?
All of the knowledge discovered during the preparation suggested responses, which can be found under the “Education
phase is useful when answering interview questions regarding & Careers” tab on the AOTA website, www.aota.org.
why you want to work with an organization and will show the If looking for work in a different state or country, occu-
potential employer that you have done your research. Many pational therapy practitioners should familiarize themselves
employers use performance-based interviewing, which is also with the relevant licensing requirements because the process
referred to as competency-based or behavioral interviewing. may take longer than expected; furthermore, the employer
The U.S. Department of Veterans Affairs uses performance- will need a practitioner who meets basic licensing require-
based interviewing methods in part because “[r]esearch find- ments by the start date. In the case of practitioners working
ings show that the best predictor of future behavior is past with a provisional license (i.e., restricted occupational
behavior. The job-related questions help the interviewer bet- therapy license that requires the holder to be supervised by
ter evaluate applicants fairly and improve the match between a fully licensed occupational therapy practitioner), the em-
people and jobs.” (U.S. Department of Veterans Affairs, n.d.) ployer needs to ensure an occupational therapist is on staff to
AOTA provides a variety of resources on interviewing and provide the appropriate level of supervision to reduce risk of
lists common performance-based interview questions and ethical violations.
CASE EXAMPLE 69.2. Robert: Public Health to Private Practice
Robert is an occupational therapist who has provided occupational therapy for 15 years to individuals with mental health and substance abuse
issues in the public health system. He puts together functional, substance use, cognitive, vocational/educational, and rehabilitation readiness
assessments. In his off-work hours, he teaches at a local college, presents at conferences, and volunteers with an occupational therapy
regulatory body.
Professionally, Robert has set a goal to work 2 days in the public health field each week and 3 days in community-based private practice. He
is seeking more rigor, intensity, and challenging clinical work while keeping the benefits of public health employment and maintaining a flexible
schedule for his family. He has found such work in private practice and was provided with a mentor. He then familiarized himself with the practice’s
reimbursement schedule, software, and documentation requirements. He also signed up for relevant courses that would enhance his skill set in his
new role.
Robert is reinvigorated as an occupational therapist because he was able to apply his previous expertise and clinical reasoning skills in the new
practice area. After his transition, he acquired new skills, experienced a new client population, gained more job flexibility, and continued to have
secure benefits.
Occupational therapy practitioners commonly report job satisfaction in their facilitation of client improvement (Moore et al., 2006) and in Robert’s
case this dovetailed with the renewed sense of purpose he felt in his new role, along with the personal satisfaction of successfully making the
change. The various specializations within occupational therapy make it possible for practitioners who want to transition to a new practice area
to do so with a little preparation and planning. Also, personal life is an important consideration. Finding work that enhances the quality of life for
practitioners and their families is a variable they should weigh as they go through the transitioning process.
In addition to highlighting one’s professional skills and Gradual Transitions: Part-Time Options
achievements, demonstrate how your soft skills (i.e., those
If an occupational therapy practitioner is unsure whether
attributes that allow you to successfully interact with others,
to make a transition, perhaps because they do not want to
such as taking initiative, understanding how your behavior
lose seniority in their current position, transitioning slowly
affects others, accepting criticism, responding appropriately,
might be an option. This could take the form of dropping
ethical problem solving and decision making; Summers et al.,
1 position from full-time to part-time and seeking a 2nd po-
2015) contribute to your effectiveness as an occupational
sition on a part-time basis. Before making this change, the
therapy practitioner in any practice area.
practitioner must understand how reducing to part-time
status affects benefits. Managing 2 positions, long term,
Mentorship may prove challenging, but in the short term it often reduces
During the interview, ask about the orientation period the stress associated with leaving a well-known and secure
and whether you will have an opportunity to learn from a position for a new practice area.
mentor (that is, a more experienced occupational therapy After working in the new practice area for a period of time,
practitioner). Mentorship has been found to be beneficial for the practitioner can decide which position is more desirable.
both the mentor and mentee (Gilfoyle et al., 2011; Milner & However, professional courtesy should be given to both em-
Bossers, 2005; Owens et al., 1998). This professional relation- ployers regarding professional intentions. For instance, in Case
ship is created on either an informal or formal basis. Informal Example 69.3, Kate provided 30 days’ notice that she would be
mentorships tend to be spontaneous connections between a quitting her long-term position, giving her employer time to
longtime occupational therapy practitioner and someone be- find and train a replacement. Robert, in Case Example 69.2,
ginning their practice in the area, while formal mentorships gave notice to his employer of his intentions and accepted a
are prearranged, “such as a preceptorship, or [they] can be an .4 full-time equivalent (FTE) position that enabled him to ex-
assigned relationship as part of an institutional endeavor to plore a new practice area as a .6 FTE. Robert will take the next
develop clinical, research, or leadership skills” (Owens et al., year to determine if he wants to maintain 2 positions to have
1998, p. 83). variety, benefits, and flexibility or whether he wants to transi-
Benefits of being mentored typically include “greater ex- tion full-time to the new practice area.
pertise, enhanced commitment and dedication to the profes-
sion, improved critical thinking skills, and mutual support” Critical Reflection
(Owens et al., 1998, p. 80). Mentees are often promoted faster,
experience greater professional success and satisfaction, re- Once the transition takes place, the orientation is completed,
ceive higher salaries at a younger age, and are better able and the occupational therapy practitioner is fully engaged in
to turn failures into learning experiences (Jowers & Herr, the new practice area, the practitioner should spend some
1990, as cited in Milner & Bossers, 2005; Ortega et al., 2018). time reflecting on the transition. The following reflection
Mentees tend to follow a career plan, be happier with their questions can help identify whether the transition has been
careers, and derive greater pleasure from their work. It was successful thus far and determine any additional needs.
also observed that “[f]or the mentor, the relationship can ■ Has the transition fulfilled the intended personal and pro-
yield gratification, stimulation and a feeling of giving back to fessional goals?
future professionals,” as noted by Jowers and Herr (as cited in ■ Are more action steps required to fully meet each goal? If
Milner & Bossers, 2005, p. 206). so, evaluate and determine what still needs to be done to
Because formal mentorship programs are not found ev- meet each goal.
erywhere in occupational therapy, new or transitioning oc- ■ Are personal or professional boundaries needed to enable
cupational therapy practitioners should look for a mentor the optimal work–family balance at this life stage?
who will share a genuine and mutual connection and po- ■ Are a mentor or more educational opportunities required?
tentially benefit their careers in the above-mentioned ways. ■ Is engagement in professional networking opportunities
In addition, occupational therapy students should consider through social events of a business nature or with relevant
mentorship programs hosted by their institution because professional organizations needed?
“even with five or six mentees to each mentor, most par-
ticipants find this relationship rewarding and derive some Occupational therapy practitioners must develop and make
benefits consistent with mentoring (e.g., professional exper- note of their own personal and professional goals and create
tise and commitment to the profession)” (Milner & Bossers, their own action plan for a satisfactory career and home life so
2005, p. 211). they can provide optimal occupational therapy services to the
When an occupational therapy practitioner transitions clients they serve. When a practitioner remains in an unsatis-
to a new practice area, they are often again considered a fying practice area for too long, it may affect the quality of their
novice practitioner. Being supported is 1 key to a successful service delivery. Practitioners must find a career path in which
transition. Acquiring new skills and seeking supervision are their personal and professional interests match their actual
essential for practicing occupational therapy competently, practice. Transitioning in occupational therapy is a major un-
safely, and ethically in the context of a new client population. dertaking, but with proper planning, it can be done successfully.
CASE EXAMPLE 69.3. Kate: Seeking Direct Treatment Opportunities
Kate is a new graduate with an interest in pediatrics who had thought that working in a school system was an attractive first placement. The school
system did not provide services during the summer, which gave her the ability to work on an on-call basis at the local hospital to gain clinical
experience. The school-based practice used a consultative model, which limited direct treatment time.
After 2 years in the school setting, Kate wanted to be in a practice area where she could develop more direct treatment skills. She found a
private-practice occupational therapy firm with an orientation program, ongoing mentorship, and flexible working hours. She was required to
learn a new billing system and documentation protocol, but she was already familiar with assessments and treatment planning. She engaged in
professional training to gain skills in direct treatments for children with physical, cognitive, and emotional impairments, which improved their daily
functioning at school, home, and in their communities. In Kate’s new occupational therapy work, she felt more effective delivering services through
direct and regular contact with the children’s parents, who followed through with reinforcing therapeutic strategies. This transition gave her a deeper
sense of satisfaction in her work because of the positive impact she was able to see firsthand.
Review Questions
1. Kate’s previous work focused on consultation. What aspect of occupational therapy practice was she missing out on prior to transitioning to a
new practice area?
2. What areas of continuing education would be appropriate for Kate?
3. What factors likely contributed to Kate’s sense of satisfaction in her new practice area?
Review Questions for their own personal situation and professional goals. Men-
torship in the newly sought practice area is also important,
1. What are 3 relevant questions to ask colleagues when
and it comes with the benefits of greater professional exper-
seeking to acquire information on a new practice area?
tise, commitment to the profession, faster promotion pros-
2. What questions could an occupational therapy practi-
pects, and a higher salary at a younger age. Practitioners
tioner ask a potential employer during an interview that
who are mentored also tend to follow a career plan and are
would help them decide if the new practice area will meet
generally happier with their careers than those who are not
their goals? Choose a relevant goal, and then provide 2 or
mentored. ❖
3 questions.
3. What skills does an occupational therapist working in
acute care in a hospital context have that would be rele- ACOTE STANDARDS
vant and transferrable to a skilled nursing facility?
4. Given the nature of occupational therapy, what are 2 or
3 traits or skills an employer would like to see in a poten- ■ Preamble
tial employee? ■ B.7.2. Professional Engagement
5. If a potential employer does not offer a formal mentor ■ B.7.3. Promote Occupational Therapy
program, how can a practitioner find a mentor? ■ B.7.4. Ongoing Professional Development.
SUMMARY REFERENCES
This chapter discussed some important reasons why occupa- 2018 Accreditation Council for Occupational Therapy Education
tional therapy practitioners change their practice area, and (ACOTE) standards and interpretive guide. American Journal
this involves both internal and external factors. Internal fac- of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
tors can include interest in a different specialization, need for .org/10.5014/ajot.2018.72S217
professional growth, or lack of sufficient professional mento- American Occupational Therapy Association. (2014). Occupational
ring in one’s current practice area. External factors affect the therapy practice framework: Domain and process (3rd ed.).
lives of practitioners, such as family considerations, financial American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
needs, or an unexpected relocation. https://doi.org/10.5014/ajot.2014.682006
Before applying for a position, occupational therapy prac- Gilfoyle, E., Grady, A., & Nielson, C. (2011). Mentoring leaders: The
power of storytelling for building leadership in health care and
titioners should consider the facility, the staff and their vari-
education. Bethesda, MD: AOTA Press.
ous skill sets, clinical requirements to ensure competency, the Jowers, L. T., & Herr, K. (1990). A review of literature on mentor–
organization’s mission statement, and how their own skills protégé relationships. NLN Publications, 15, 49–77.
might complement the team or fill any current gaps. The Lannin, N., & Longland, S. (2003). Critical shortage of occupational
chapter examined the importance of physical health, work therapists in rural Australia: Changing our long-held beliefs pro-
environment, and professional support available, all of which vides a solution. Australian Occupational Therapy Journal, 50(3),
can be used to assist practitioners in making the best decision 184–87. https://doi.org/10.1046/j.1440-1630.2003.00394.x
Lin, V., Zhang, X., & Dixon, P. (2015). Occupational therapy work- Owens, B. H., Herrick, C. A., & Kelley, J. A. (1998). A prearranged
force in the United States: Forecasting nationwide shortages. mentorship program: Can it work long distance? Journal of
PM&R. https://doi.org/10.1016/j.pmrj.2015.02.012 Professional Nursing, 14(2), 78–84. https://doi.org/10.1016/S8755
McCombie, R. P., & Antanavage, M. E. (2017). Transitioning from -7223(98)80034-3
occupational therapy student to practicing occupational therapist: Parveen, M., Maimani, K., & Kassim, N. M. (2016). Quality of work
First year of employment. Occupational Therapy in Health Care, life: The determinants of job satisfaction and job retention among
31(2), 126–142. https://doi.org/10.1080/07380577.2017.1307480 RNs and OHPs. International Journal for Quality Research, 11(1),
Milner, T., & Bossers, A. (2005). Evaluation of an occupational 173–194. https://doi.org/10.4172/1522-4821.1000327
therapy mentorship program. Canadian Journal of Occupational Rice, V., Glass, N., Ogle, K. R., & Parsian, N. (2014). Exploring phys-
Therapy, 72(4), 205–211. https://doi.org/10.2182%2Fcjot.05.0003 ical health perceptions, fatigue and stress among health care pro-
Moore, K., Cruickshank, M., & Haas, M. (2006). Job satisfaction fessionals. Journal of Multidisciplinary Healthcare, 7, 155–161.
in occupational therapy: A qualitative investigation in urban https://doi.org/10.2147/JMDH.S59462
Australia. Australian Occupational Therapy Journal, 53(1), Sadatsafavi, H., Walewski, J., & Shepley, M. M. (2015). The influence
18–26. https://doi.org/10.1111/j.1440-1630.2006.00539.x of facility design and human resource management on health
Orentlicher, M. L., & Gibson, R. (2015). Foundations of transition. care professionals. Health Care Management Review, 40(2),
In M. L. Orentlicher, S. Schefkind, & R. Gibson (Eds.), Transitions 126–138. https://doi.org/10.1097/HMR.0000000000000012
across the lifespan: An occupational therapy approach (pp. 21–30). Summers, K., Fisher, T. F., Marshall, A., Pierce, D., & Thompson, M.
Bethesda, MD: AOTA Press. (2015). Transition and work. In M. L. Orentlicher, S. Schefkind, &
Ortega, G., Smith, C., Pichardo, M. S., Ramirez, A., Soto-Greene, R. Gibson (Eds.), Transitions across the lifespan: An occupational
M., & Sánchez, J. P. (2018). Preparing for an academic career: therapy approach (pp. 127–144). Bethesda, MD: AOTA Press.
The significance of mentoring. MedEdPORTAL, https://doi.org U.S. Department of Veterans Affairs (n.d.). Performance based
/10.15766/mep_2374-8265.10690 interviewing (PBI). Retrieved from https://www.va.gov/pbi
CHAPTER
Becoming a Successful Contractor
Shelley Margow, OTD, OTR/L 70
LEARNING OBJECTIVES
■ Describe independent contractor status,
■ Define W-2 employee status,
■ Understand the IRS terms for contractor vs. employee status, and
■ Understand how to ensure best practices as a contractor.

• Behavioral control • Independent contractor • Scope of work
• Contract • IRS 20 Factor Test • Terms of payment
• Exempt positions • Nonexempt positions • W-2 employee
• Financial control • Relationship between the parties
OVERVIEW step is to learn the applicable Internal Revenue Service (IRS)

regulations if they will be working in the United States or the
A
n independent contractor is an autonomous service relevant governing principles if practicing in another country.
provider who delivers therapy for a predetermined A contractor can be an entrepreneur, someone who has
contractual rate. Given that job seekers may have sev- to plan and assess how to make a living while providing ex-
eral opportunities in a variety of settings to choose from, how cellent service to the client. This chapter provides the tools
do new occupational therapy practitioners find the career needed to maneuver successfully through the potentially
that will give them what they have worked so hard to achieve? confusing world of contract work.
Searching the Internet and navigating through job boards
may lead to an ideal job, or perhaps the thought of starting off
as a contractor and exploring multiple settings is intriguing.
Experienced practitioners also may want to explore making
a career shift from being an employee to being self-employed Being prepared and asking the right questions can help to en-
as a contractor. sure a successful career. The most important question, which
Being a contractor may seem exciting to some and unap- only practitioners can answer for themselves, is, “Do I want
pealing to others. Contractors are responsible for all facets of to be a contractor?” It is important to keep in mind several
their own business. Whether the practitioner is a new grad- considerations when formulating an answer.
uate or has many years of experience, the responsibilities First, occupational therapy practitioners must understand
and considerations of being self-employed are the same—a the nature of being self-employed versus working for an em-
contractor has to be aware of all areas of their own business. ployer. As a contractor, the practitioner controls their own
Once the practitioner has decided to be a contractor, the next hours, liability, and expenses. Conversely, when working as
https://doi.org/10.7139/2019.978-1-56900-592-7.070
651
CHAPTER
Becoming a Successful Contractor
Shelley Margow, OTD, OTR/L 70
LEARNING OBJECTIVES
■ Describe independent contractor status,
■ Define W-2 employee status,
■ Understand the IRS terms for contractor vs. employee status, and
■ Understand how to ensure best practices as a contractor.

• Behavioral control • Independent contractor • Scope of work
• Contract • IRS 20 Factor Test • Terms of payment
• Exempt positions • Nonexempt positions • W-2 employee
• Financial control • Relationship between the parties
OVERVIEW step is to learn the applicable Internal Revenue Service (IRS)

regulations if they will be working in the United States or the
A
n independent contractor is an autonomous service relevant governing principles if practicing in another country.
provider who delivers therapy for a predetermined A contractor can be an entrepreneur, someone who has
contractual rate. Given that job seekers may have sev- to plan and assess how to make a living while providing ex-
eral opportunities in a variety of settings to choose from, how cellent service to the client. This chapter provides the tools
do new occupational therapy practitioners find the career needed to maneuver successfully through the potentially
that will give them what they have worked so hard to achieve? confusing world of contract work.
Searching the Internet and navigating through job boards
may lead to an ideal job, or perhaps the thought of starting off
as a contractor and exploring multiple settings is intriguing.
Experienced practitioners also may want to explore making
a career shift from being an employee to being self-employed Being prepared and asking the right questions can help to en-
as a contractor. sure a successful career. The most important question, which
Being a contractor may seem exciting to some and unap- only practitioners can answer for themselves, is, “Do I want
pealing to others. Contractors are responsible for all facets of to be a contractor?” It is important to keep in mind several
their own business. Whether the practitioner is a new grad- considerations when formulating an answer.
uate or has many years of experience, the responsibilities First, occupational therapy practitioners must understand
and considerations of being self-employed are the same—a the nature of being self-employed versus working for an em-
contractor has to be aware of all areas of their own business. ployer. As a contractor, the practitioner controls their own
Once the practitioner has decided to be a contractor, the next hours, liability, and expenses. Conversely, when working as
https://doi.org/10.7139/2019.978-1-56900-592-7.070
651
an employee, the practitioner has less control over the work EXHIBIT 70.1. Reflective Questions to Ask When
being done, and many of their business expenses are funded by Considering Working as a Contractor
the employer. Employees also are covered by their employer’s
liability insurance. ■ Do I enjoy working in a team or solo?
■ Can I work independently in challenging situations?
■ Do I need supervision in building treatment plans, writing goals,
For Additional Learning and performing higher level treatments?
■ Do I want to know what my paycheck will be in advance
For additional information, see Chapter 53, “Professional Liability every month?
Insurance,” and Chapter 72, “Entrepreneurship.” ■ Do I need my paycheck to be the same each month, or am I okay
with fluctuations?
■ What’s more important to me—time, money, or work–life balance?
In addition to workplace factors, the differences in tax ■ What financial responsibilities do I have? How much financial
obligations are a crucial part of the decision to either pur- risk can I afford to take on?
sue contract work or become an employee. Contractor versus
employee status is an IRS and legal classification that is deter-
mined by characteristics of the employer–employee relation- workloads can be much higher. Additionally, larger institu-
ship (Maranjian, 2015). The manner in which one is paid for tions may offer more in-house training. The potential for ad-
the service provided and how taxes are filed entirely depends vancement tends to be slower in an environment with a larger
on this relationship. The IRS mandates how a worker will pay bureaucracy. However, these settings provide job stability
their taxes according to whether the worker is an employee or and consistency and most likely offer a salary.
a contractor. The specific factors that define contractor status If a practitioner is a risk taker and financially savvy, being
are discussed in detail later in this chapter. an independent contractor may be the right fit. Exhibit 70.1
lists questions practitioners can ask themselves as they con-
Self-Reflection sider whether working as a contractor is a good fit.
Occupational therapy practitioners have many opportunities

IRS Control
in the job market, from hospitals to home health care, from
schools to outpatient private-clinic environments, from re- A contractor’s predetermined contractual rate is usually
habilitation to pediatrics. When considering employment higher than a salaried position; however, the contractor is re-
options, the decision to become a contractor or an employee sponsible for all scheduling, taxes, expenses, and time man-
may depend on how much responsibility is desired. Being a agement. A contractor determination is based on the legal
contractor may be a good fit for an autonomous person who terms defined by the IRS as to the relationship between the
prefers to go into an environment to provide therapy and likes worker and employer (IRS, 2018). To evaluate this relationship
managing their schedule. Practitioners looking for benefits, adequately, the IRS uses the IRS 20 Factor Test (IRS, n.d.),
mentorship, supervision, and teamwork most likely will find a checklist that can be used as a guideline for determining
them in an employee situation. whether a worker is an employee or an independent contrac-
When applying for a job in any setting, occupational ther- tor. The IRS considers 3 aspects of control when defining con-
apy practitioners should ensure that the job description and all tractor eligibility:
expectations and job realities are made clear. When interview-
1. Behavioral control,
ing for a small business, a practitioner will meet the owner,
2. Financial control, and
who is likely a therapist and entrepreneur. Most small business
3. The parties’ relationship (IRS, n.d.).
owners depend on their team’s professionalism and talent to
manage the company’s reputation and financial viability. Behavioral control refers to how much control the em-
A small business offering a worker an employee position ployer has over a worker’s behaviors and work results. The
with benefits indicates that the business owners want to re- more control a company has over how, when, where, and by
tain their employees. Maintaining salaried employees adds a whom the work is done, the more likely the person is to be
significant cost to a small business, placing a heavy burden an employee. If a person is told to come to work and leave at
on the finances of the company (Root, n.d.). Occupational a specific time and to provide therapy in a specific manner,
therapy practitioners who are considering becoming part of a then that person is considered to be an employee rather than
small business should be aware that this ever-changing orga- a contractor.
nization may be more like a family than just a workplace. This Financial control refers to how much control the employer
environment also typically offers growth and opportunity. has over a worker’s finances. A contractor gets paid on com-
For occupational therapy practitioners who prefer more pletion of a job or on the basis of commission for a specific
structure, a hospital or school setting may be more comfort- job. If a person is paid hourly, weekly, or monthly, they are
able. These environments potentially provide higher salaries more likely to be considered an employee.
and more benefits, but they can be less personal. Business The relationship between the parties (i.e., company/
is driven by productivity and practitioner billing, and the contractor) is determined by factors such as the permanence
CHAPTER 70. Becoming a Successful Contractor 653
EXHIBIT 70.2. IRS Multifactor Test: Employee or Independent Contractor?
Whether someone who works for you is an employee or an independent contractor is an important question. The answer determines your liability to
pay and withhold federal income tax, Social Security and Medicare taxes, and federal unemployment tax.
In general, someone who performs services for you is your employee if you can control what will be done and how it will be done. The courts have
considered many factors in deciding whether a worker is an independent contractor or an employee. These factors fall into 3 main categories:
1. Behavioral control: Facts that show whether the business has a right to direct and control, including:
■ Instructions. An employee is generally told
■ When, where, and how to work;
■ What tools or equipment to use;
■ What workers to hire or to assist with the work;
■ Where to purchase supplies and services;
■ What work must be performed by a specified individual; and
■ What order or sequence to follow.
■ Training. An employee may be trained to perform services in a particular manner.
2. Financial control: Facts that show whether the business has a right to control the business aspects of the worker’s job include:
■ The extent to which the worker has unreimbursed expenses
■ The extent of the worker’s investment
■ The extent to which the worker makes services available to the relevant market
■ How the business pays the worker
■ The extent to which the worker can realize a profit or loss
3. Type of relationship: Facts that show the type of relationship include
■ Written contracts describing the relationship the parties intended to create
■ Whether the worker is provided with employee-type benefits
■ The permanency of the relationship
■ How integral the services are to the principal activity.
Source. Adapted from IRS 20 Factor Test—Independent Contractor or Employee? Retrieved from https://www.oregon.gov/ODA/shared/Documents/Publications/Natural
Resources/20FactorTestforIndependentContractors.pdf. In the public domain.
of the connection and the benefits provided. If there is a writ- An alternative is to pay for professional accounting services
ten contract that outlines the expectations of the job and how to manage the daily expenses against income.
the relationship will continue once the job is complete, the Contractors pay 3 types of taxes 4 times per year:
worker is most likely a contractor. 1. Federal income tax,
Exhibit 70.2 illustrates the specific elements considered as 2. Federal self-employment tax, and
part of the multifactor test that the IRS offers (IRS, n.d.). 3. State tax and local income tax (not all states require a
state tax).
Employer Considerations Economists recommend putting aside 30% of income for tax
Why might an employer want to hire contractors? First and obligations (see, e.g., Grant, 2016). For example, if you are of-
most important, contractors are less costly for the company fered $100,000 for a contract job, you should set aside $30,000
overall. The business does not have to pay payroll taxes, for taxes. However, contractors should consider estimating
provide health benefits, or offer training for contractors (al- the taxed net income (total dollar amount less expenses) after
though some do), nor is the company responsible for workers’ various expenses have been written off.
compensation insurance or overtime pay. Moreover, a com- The IRS allows independent contractors to take deductions
pany may require contractors to supply their own materials, that are legitimate, thereby decreasing the amount of income
evaluations, and therapy tools. taxed. A good accountant or experienced business owner will
understand how to deduct the costs, which then reduces the
contractor’s overall tax burden (see Case Example 70.1). It is im-
Financial Considerations
portant to note that these deductions may change from year to
One major benefit of being a contractor is having the poten- year subsequent to federal tax legislation (TurboTax, 2017). The
tial to earn more money up front and control the amount of Tax Cuts and Jobs Act of 2017 (P. L. 115–97) provides detailed
taxes paid, write off expenses, and create one’s own schedule, information about deductions for qualified business expenses.
but this arrangement increases financial risk for the contrac- There are many benefits to being an independent contrac-
tor. An entrepreneur running a business must track expenses tor. However, to safely reduce tax liability and ensure com-
meticulously, often by using specific software or spreadsheets. pliance with applicable tax codes, contractors should make
It is important to understand how to write off various ex- sure that a professional can help organize and manage the
penses when filing taxes and tracking time spent on the job. business’s financials.
CASE EXAMPLE 70.1. Jane: Working as a Contractor
Jane accepts a position with ABC Rehab for a 12-month contract. The contract pays an hourly rate of $70 for a 30-hour workweek. Jane earns an
annual gross income of approximately $93,600.
Jane uses her car to travel to the various hospitals and deducts those expenses for the year. She purchases a new computer, evaluation materials,
and equipment to perform her treatments ($10,400 annual expenses). At the end of the year, Jane pays $12,729.60 in taxes, and her take-home
pay is $70,470.40 (Hurdlr, 2016). The benefit to Jane, however, is that all of these expenses are tax deductible. Instead of paying tax on her $93,600
gross annual income, she is taxed on her $83,200 net income after deductions.
Review Questions
1. Jane has planned her budget around a 30-billed-hour work week. However, she finds herself working a 45-hour week due to an increase in
evaluations for that month. Does Jane get paid for all the paperwork time that she is putting in?
2. Is paperwork time billable to ABC Rehab?
3. Can Jane get reimbursed for travel time if she is working at different locations?
Note. Each state has different pay grades and state taxes, which practitioners must consider when calculating a contract. Consult a tax professional to ensure that the
contract is accurate and all laws are followed.
A Contract’s Key Elements are used to determine whether a worker is an employee or an

independent contractor.
A contract is a document that governs the relationship be-
tween the parties. A contract generated by the organization
might have been written by attorneys and could be compli- Duties, contract terms, and acknowledgments
cated and difficult to understand. In this instance, it is im-
The duties and services the contractor agrees to provide are
portant to have a professional read the contract to ensure
outlined in this section of the contract. This is also referred to
that one’s professional interests are represented. Whether
as a scope of work. Duration of the contract, specific projects,
authored by the contractor or the organization defines the
and associated completion dates are typically specified in the
terms of agreement, the contract should clearly state
terms of the contract.
■ Duties or responsibilities of the contractor; Occupational therapists may have contracts for consulting,
■ Services to be performed; for therapy with clients, or even for evaluation services only.
■ Specific licensure, certifications, professional develop- In all cases, the definition of the work should address when
ment, and other qualifications necessary to fulfill the the work will be done, included documentation, and any ad-
contract; ditional services (e.g., contributing to individualized educa-
■ Billing timelines (e.g., a 30-day period of time within tion programs [IEPs]). Additional information in the section
which to pay the bill), where the bill should be delivered, can include where the work will take place and options to ex-
and any interest that can be accrued if the bill is not paid tend the contract if both parties are in agreement.
on time; and
■ Notice and termination or modification of the contract Payment and expenses reimbursement
elements.
For each type of service or work element that is specified,
An independent contractor agreement is there should be associated amounts and terms of payment.
Terms of payment should indicate whether pay is hourly or
critical for defining the legal role of the independent
per treatment and whether there is a different rate for eval-
contractor, including the specific work she agrees to
uations versus follow-up treatment. It is important to note
perform; it also should detail the terms of the agreement.
whether documentation is included in the payment rate.
While the independent contractor agreement is not usually
If so, the contractor must account for the time required to
a legal requirement, it’s preferable over an oral agreement
complete site-specific documentation. Similarly, if the em-
as both parties can refer to it if any questions arise. The
ployer requests participation in IEP or other meetings, the
key elements in the agreement provide clarity and legal
contractor should specify how these types of duties will be
protection for all parties. (Sessoms, n.d., para. 1)
reimbursed. Usually employees are expected to participate in
meetings and similar activities in addition to patient care, so
Define the relationship
it is important to specify payment terms for such tasks.
Defining the relationship between the employer and the con- Sometimes the scope of work for consulting projects can be
tractor within the body of the contract helps clarify roles and organized and completed in portions. In these cases, the con-
specify that the parties are not entering into an employer– tract should indicate when payment for each portion of the
employee relationship. It is advisable to refer to the IRS defi- work will be provided to the contractor, such as half up front
nition of independent contractor and common law rules that and the other half on completion of the project. Additionally,
details should be included regarding who is responsible for for a medical hour (50 minutes of contact time, 5 minutes
providing any required materials and supplies to perform talking to the parent, and 5 minutes to write notes). A reason-
the work or any expenses the hiring company is expected to able expectation is to schedule 7 hours of treatment per day,
reimburse. It is common for therapists contracting in home which takes into account cancellation rates and reschedules.
health to provide their own blood pressure monitors, gait Ultimately, most employers expect productivity at
belts, gloves, and similar items. 70%–75% of the practitioner’s working hours. This equates to
treating 30 hours out of a 40-hour workweek. It is important
Protections and enforceability to remember that if you are an exempt employee, regardless
of the total number of hours you spend treating clients, you
Often contracts include patient privacy and confidentiality must complete all paperwork, evaluations, and treatment
elements as well as conflict of interest clauses. According to within the workweek.
Sessoms (n.d.), Part of a good employee’s responsibilities is managing
their time efficiently. If, for some reason, caseloads are low,
an independent contractor agreement generally includes it is also the employee’s responsibility to be a strong team
key elements that provide legal protections and guarantees, player and find out what other functions the employer has
usually for the hiring company. Provisions typically prohibit for them to do during that time. This may mean helping with
conflict of interest and assignment of rights pertaining to the organization and clean-up or redoing templates for the team;
contractor without the consent of the payer. The agreement there is always work to be done in a company. If you are a
generally requires the contractor to maintain confidentiality W-2 employee, your time essentially belongs to your employer
and comply with provisions for arbitration and for amending while you are at work.
or terminating the agreement. An enforceability provision
can state that if any part of the agreement is for any reason
W-2 nonexempt status
unenforceable, the remaining parts of the agreement remain
in “full force and effect.” (para. 5) Nonexempt positions must be paid at least the federal mini-
mum wage for each hour worked and paid overtime for any
W-2 Employee Considerations hours worked the exceed 40 hours a week at time-and-a-half
(Barada, n.d.). These positions are not exempt from FLSA
Workers who are not independent contractors have W-2 requirements.
employment status. A W-2 employee is an individual who According to Barada (n.d.), being paid as a nonexempt em-
performs services that are subject to the will and control of the ployee is unusual for a professional position. Position status
employer—both what must be done and how it must be done. typically is classified according to a job’s salary and educa-
The employer can allow the employee considerable discretion tion requirements. Practitioners also are expected to make
and freedom of action, as long as the employer has the legal independent decisions for their patients on the basis of pro-
right to control both the method and the result of the work. fessional standards and knowledge, which is also a factor in
The most significant benefit of being an employee is that position status. Employees who are able to make independent
the employer covers benefits, equipment, and work expenses. decisions for 51% of their work time are classified as exempt
There is also comfort in knowing that one’s paycheck stays (Green, 2013).
the same with each pay period. During interviews, it is essential to understand the details
There are two types of W-2 employees: (1) exempt from of the employee classification. It is the employee’s responsibil-
overtime and (2) nonexempt from overtime. The significant ity to ask the right questions and understand the expectations
difference, particularly in the therapy world, is whether the of employment. This information should be available in the
employee is paid per hour or per week. employee manual provided by the company. Misunderstand-
ings and lack of knowledge can have negative consequences if
W-2 exempt status an employee is misclassified as a contractor. Employees and
contractors should know their rights and obligations and
Exempt positions do not adhere to minimum wage overtime
should be aware of relevant employment laws.
regulations and other rights and protections that nonexempt
workers receive (Barada, n.d.); they are called “exempt” be-
Pros of being a W-2 employee
cause they are exempt from the Fair Labor Standards Act
(FLSA) requirements. Employers must pay a salary rather The most notable advantage of being a W-2 employee is that
than an hourly wage for a position to be exempt. Typically, paychecks are predictable. Taxes are withheld from every
only executive, supervisory, professional, and outside sales payment; the employer pays half the taxes, thereby lowering
positions are exempt. This means that as professionals, oc- the employee’s tax burden. Additionally, the cost of benefits is
cupational therapy practitioners are expected to get the job lower than one would find as an individual (e.g., health insur-
done in a reasonable amount of time. ance, 401[k] plan, long-term and short-term disability, paid
Typically, practitioners are expected to see a certain num- time off). It is in the best interest of employers to have happy,
ber of patients per day, as required by a facility. For example, engaged employees, which is why employment benefits his-
in an outpatient pediatric setting, practitioners see patients torically have been offered.
Cons of being a W-2 employee are revised, so be sure to consult an accountant or other fi-
nancial planner to ensure all taxes are paid in full. See Case
For W-2 employees, their company determines work hours,
Example 70.3 for an example of determining whether to
dress code, equipment use, and overall policy and procedural
change W-2 status.
functions, which can be perceived as negative by some. In addi-
tion, annual compensation typically is less than a contractor’s
Considerations When Interviewing
rate on the surface. However, all taxes, benefits, and similar
expenses are paid before an employee receives their net pay- As occupational therapists consider the options, they need
ment; therefore, the entire paycheck is true spendable income. to know the questions to ask during the interview process.
Miscommunication during initial conversations can lead to
Review Questions problems later. Therefore, understanding the needs and ex-
pectations of prospective employers is a critical part of ensur-
1. Can employees set their own schedule?
ing that this potential business opportunity falls within the
2. How do employees know whether they are eligible for
therapist’s mission and vision.
overtime?
For example, some caseloads might result in high cancella-
3. Do employees need to provide their own equipment on
tion rates, and others might have high volume and complex-
the job?
ity and little supervision available. Knowing what to expect
and how to handle these types of circumstances is a critical
PRACTICAL APPLICATIONS IN part of being able to do the job efficiently. Unspoken expecta-
OCCUPATIONAL THERAPY tions also might be a factor if the position involves driving. It
is important to clarify expectations such as gas mileage, ve-
Depending on their passion and choice of environment, oc-
hicle maintenance, and driving radius. Adding 3–4 hours of
cupational therapy practitioners have myriad opportunities
driving into the workday reduces potential revenue and thus
available to them. The profession has tremendous consulting
affects overall income potential.
opportunities in the workforce and, of course, telehealth. With
so many prospects, it is crucial that therapists are well informed,
not just in their practice but also in terms of business savvy. Review Questions
1. When considering work opportunities, what should a
therapist consider before accepting a position?
a. Passion for the setting
For additional information on working in telehealth, see Chapter 32, b. Passion for the population that you will be working with
“Delivering Services Through Telehealth.” c. Financial opportunity
d. All of the above
2. Why is initial communication so important during the
Time management and organization are two essential ele- interview process?
ments of being a successful contractor. Many practitioners are a. Getting a job is really exciting, so it doesn’t matter
excited to take that leap into working for themselves, only to what is offered during the interview.
find that they are not meeting their financial needs. Contrac- b. As a contractor, I have a right to fully understand all
tors must consider how to market their services, who will need components of the job.
those services, and who will pay for the services. Will they need c. Good communication between parties encourages a
to use a billing service, be a cash provider, or join a network with healthy work environment.
third-party payers? It is important that independent contrac- d. b and c
tors manage their cash flow even if they are sole practitioners. 3. Taxes are different for contractors because
Another common mistake contractors make is under- a. Everyone has to pay taxes.
estimating their tax burden and not having a savings plan b. Taxes are due only on March 15 every year.
(see Case Example 70.2). Remember that a contractor makes c. Contractors are responsible for their taxes; therefore,
quarterly tax payments at a rate of 15.3%. That is, for every they should have a clear plan of how to manage taxes
$100 a contractor makes, $15.3 goes to the IRS (IRS, 2018). throughout the year.
It is important to note that this changes when laws and taxes d. Contractors don’t need to worry about taxes.
CASE EXAMPLE 70.2. Jenny: Calculating Take-Home Pay
Jenny has developed a fantastic method of ergonomic therapy that she offers to local businesses. She has diligently worked out her marketing
costs, ongoing business expenses, and profit margins. Jenny calculates that if she charges $120 per hour and can gain 20 billable hours per
week consistently, she can make $9,600 gross per month. Her monthly expenses are $3,500. Jenny calculates that $9,600 − $3,500 = $6,100
of taxable income (she will need to save $933.30 to pay taxes at the end of the quarter). This leaves Jenny $5,166.70 to take home. In reality,
Jenny is making $64.58 per hour.
CASE EXAMPLE 70.3. Tom: Changing W-2 Status
Tom has 20 years of experience as a rehabilitation OT in a local hospital. He has an opportunity to manage the occupational therapy department as
a W-2 employee. The company has offered him an $80,000 annual salary with full benefits.
In addition, a contracting company has offered Tom a traveling home health position at $90 per treatable hour. He calculates that if he sees
6 clients per day, he has the potential to make $540 per day. If he works 5 days per week, he can make $10,800 per month.
Then Tom realizes that he might have a cancellation rate and that he has to add drive time into his day. This reduces his earning potential.
In addition, as a contractor, he would not necessarily have the stability or the benefits of the hospital job. Tom decides that he prefers the stability
and benefits of the hospital job because he is the sole provider for his family.
SUMMARY REFERENCES
There are 2 ways to get paid for services: as a W-2 employee Accreditation Council for Occupational Therapy Education. (2018). 2018
(usually exempt) or as a 1099 contractor. Many employers Accreditation Council for Occupational Therapy Education (ACOTE)
offer a range of benefits to their employees and pay 50% of the standards and interpretive guide. American Journal of Occupational
taxes required by the IRS. Employees must follow company- Therapy, 72, 7212410005. https://doi.org/10.5014/ajot.2018.72S217
Barada, P. W. (n.d.). What’s the difference between exempt and
specific practices that are explained in an employee manual
nonexempt workers? Retrieved from http://www.monster.com
(which one must read). Policies and procedures provide the /career-advice/article/whats-the-difference-between-exempt
framework within which to work. Grant, M. (2016, February 25). How much of my paycheck should I
A contractor is typically self-employed and pays self- save for taxes? Here’s a good guideline for 1099-ers. Retrieved from
employment taxes but can write off specific expenses to lower https://www.bustle.com/articles/144004-how-much-of-my-pay
their tax burden. Contractors have the potential to make more check-should-i-save-for-taxes-heres-a-good-guideline-for-1099-ers
money and the ability to manage their time independently, Green, A. (2013, May 3). Can salaried employees be required to fill
which allows for flexibility in their schedule. However, if a out a timesheet? [Blog post]. Retrieved from http://www.aska
contractor does not work, they do not get paid. manager.org/2013/05/can-salaried-employees-be-required-to
Finding new employment opportunities is exciting. Doing -fill-out-a-timesheet.html
research on potential companies is important in today’s en- Hurdlr. (2016, July 21). Self-employed 1099 tax calculator [Web
tool]. Retrieved from https://hurdlr.com/freelancer-income-tax
vironment, regardless of employment status. It is easy to
-calculator#.Wd5nBdOGNp8
find information on both customer and employee experi- Internal Revenue Service. (n.d.). Independent contractor (self-
ences online—a nd just as easy for employers to learn about employed) or employee? Retrieved from https://www.irs.gov
potential hires or contractors. Regardless of experience, ex- /businesses/small-businesses-self-employed/independent
ploring new opportunities involves change and growth. Oc- -contractor-self-employed-or-employee
cupational therapy practitioners are versatile change agents Internal Revenue Service. (2018, December 20). Employers’ supple-
who choose to make a difference in the lives of their clients mental tax guide (Pub. 15-A, Cat. No. 21453T). Retrieved from
every day. ❖ https://www.irs.gov/pub/irs-pdf/p15a.pdf
IRS 20 Factor Test—independent contractor or employee? (n.d.). Retrieved
from http://www.oregon.gov/ODA/shared/Documents/Publications
/NaturalResources/20FactorTestforIndependentContractors.pdf
ACOTE STANDARDS Maranjian, S. (2015, May 20). 1099 vs W2: Which is preferable for
employers and employees? Retrieved from https://www.fool.com
This chapter addresses the following ACOTE Standards: /investing/general/2015/05/20/1099-vs-w2-which-is-preferable
■ B.5.0. Context of Service Delivery, Leadership, and Man- -for-employers-and-e.aspx
agement of Occupational Therapy Services Root, G. N. (n.d.). What are the struggles of small business owners?
■ B.5.3. Business Aspects of Practice [Blog post]. Retrieved from http://smallbusiness.chron.com
/struggles-small-business-owners-313.html
■ B.5.6. Market the Delivery of Services Sessoms, G. (n.d.). What are the key elements of an agreement with an
■ B.5.7. Quality Management and Improvement independent contractor? [Blog post]. Retrieved from http://work.chron
■ B.7.0. Professional Ethics, Values, and Responsibilities .com/key-elements-agreement-independent-contractor-11313.html
■ B.7.1. Ethical Decision Making Tax Cuts and Jobs Act of 2017, Pub. L. 115–97.
■ B.7.2. Professional Engagement TurboTax. (2017). 9 things you didn’t know were tax deductions.
■ B.7.3. Promote Occupational Therapy Retrieved from https://turbotax.intuit.com/tax-tips/fun-facts/9
■ B.7.5. Personal and Professional Responsibilities. -things-you-didnt-know-were-tax-deductions/L6M1dynSH
CHAPTER
Professional Development
Shain Davis, OTD, OTR/L 71
LEARNING OBJECTIVES
■ Describe the role that professional development plays in advancing the field of occupational therapy,
■ Identify the various avenues of pursuing professional development,
■ Identify potential barriers and supports for professional development in the workplace,
■ Identify resources for tracking and obtaining continuing education and professional development units, and
■ Describe how evidence-based practice contributes to professional development.

• Authentic occupational • Continuing professional • Journal clubs
therapy practice development • Practice scholar communities
• Communities of • Evidence-based practice • Professional development
practice • External evidence • Professional support
• Continuing competency • Internal evidence
OVERVIEW Continuing professional development (CPD) is a constant
T
commitment to maintaining, updating, and modifying one’s
his chapter explores the importance of professional de- knowledge and skill base (Recker-Hughes et al., 2010). CPD
velopment in occupational therapy, including unique is needed to ensure that health care practitioners, admin-
considerations affecting occupational therapy practi- istrators, managers, and organizations engage in or support
tioners, managers, administrators, educators, and scholars. the process of life-long learning, targeting the improvement
The chapter begins by defining professional development and of patient care and population health (Cuff & Forstag 2018).
discusses integral aspects of maintained professional devel- Professional development focuses on the pursuit of learning
opment, including continuing competency. The chapter ex- to achieve future career goals, including becoming an expert
plores the value of professional development as a means for clinician, administrator, educator, researcher, or consultant
promoting, empowering, and progressing the field of occu- (Moyers, 2009). Occupational therapy practitioners use pro-
pational therapy. Finally, different avenues for pursuing professional development to stay up to date with techniques and
fessional development activities are examined along with approaches in their areas of practice to provide the most ef-
summarizing professional development governing agencies. fective treatment as well as navigate career paths and refine
leadership skills.
ESSENTIAL CONSIDERATIONS Continuing competence involves the examination of cur-
rent competence and the capacity for future professional
What Is Professional Development?
development (AOTA, 2015). It is one aspect of professional
Professional development is a multi-modal and personal com- development’s multi-modal approach to lifelong learning.
mitment to life-long career learning to drive growth and stay Continuing competence is a fluid process with the goal of
current with relevant aspects of a profession (Cooper, 2009). developing and maintaining knowledge, performance skills,
https://doi.org/10.7139/2019.978-1-56900-592-7.071
659
CHAPTER
Professional Development
Shain Davis, OTD, OTR/L 71
LEARNING OBJECTIVES
■ Describe the role that professional development plays in advancing the field of occupational therapy,
■ Identify the various avenues of pursuing professional development,
■ Identify potential barriers and supports for professional development in the workplace,
■ Identify resources for tracking and obtaining continuing education and professional development units, and
■ Describe how evidence-based practice contributes to professional development.

• Authentic occupational • Continuing professional • Journal clubs
therapy practice development • Practice scholar communities
• Communities of • Evidence-based practice • Professional development
practice • External evidence • Professional support
• Continuing competency • Internal evidence
OVERVIEW Continuing professional development (CPD) is a constant
T
commitment to maintaining, updating, and modifying one’s
his chapter explores the importance of professional de- knowledge and skill base (Recker-Hughes et al., 2010). CPD
velopment in occupational therapy, including unique is needed to ensure that health care practitioners, admin-
considerations affecting occupational therapy practi- istrators, managers, and organizations engage in or support
tioners, managers, administrators, educators, and scholars. the process of life-long learning, targeting the improvement
The chapter begins by defining professional development and of patient care and population health (Cuff & Forstag 2018).
discusses integral aspects of maintained professional devel- Professional development focuses on the pursuit of learning
opment, including continuing competency. The chapter ex- to achieve future career goals, including becoming an expert
plores the value of professional development as a means for clinician, administrator, educator, researcher, or consultant
promoting, empowering, and progressing the field of occu- (Moyers, 2009). Occupational therapy practitioners use pro-
pational therapy. Finally, different avenues for pursuing professional development to stay up to date with techniques and
fessional development activities are examined along with approaches in their areas of practice to provide the most ef-
summarizing professional development governing agencies. fective treatment as well as navigate career paths and refine
leadership skills.
ESSENTIAL CONSIDERATIONS Continuing competence involves the examination of cur-
rent competence and the capacity for future professional
What Is Professional Development?
development (AOTA, 2015). It is one aspect of professional
Professional development is a multi-modal and personal com- development’s multi-modal approach to lifelong learning.
mitment to life-long career learning to drive growth and stay Continuing competence is a fluid process with the goal of
current with relevant aspects of a profession (Cooper, 2009). developing and maintaining knowledge, performance skills,
https://doi.org/10.7139/2019.978-1-56900-592-7.071
659
interpersonal abilities, critical reasoning, and ethical reason- Why Is Professional Development Important?
ing to perform current and future roles within the profes-
Given that practitioner performance can be context depen-
sion (AOTA, 2015). Continuing competency focuses on one’s
dent, practitioners need to continuously acquire new knowl-
capacity to perform job-specific professional responsibilities
edge and skills throughout their professional career (Hinojosa,
within a particular situation (Moyers, 2009). To work toward
2012). Managers should be supportive of and structure an
professional development, continuing competency must be
environment that promotes professional development. This
established and maintained. To be competent, an occupa-
can include a more inclusive managerial style that promotes
tional therapy practitioner must be able to analyze assess-
career development, provides leadership projects, invests in
ment tools, intervention strategies, and outcome measures
career path planning, and implements technology-forward
(with an evidence-based lens) to provide appropriate services
options (Hills et al., 2013).
and to meet the client’s needs (Moyers, 2009).
However, supporting and acquiring new knowledge and
Core competencies reflect the philosophy and objectives
skills can be met with barriers, such as the following chal-
of an organization or profession (Miller et al., 2001). The
lenges (Moyers, 2009):
American Occupational Therapy Association (AOTA; 2015)
cites 5 standards to assess, maintain, and document con- ■ Skills and abilities fade when they are not continuously
tinuing competence—all revolving around the core values of sharpened through practice, feedback, or administrative
“therapeutic use of occupations with the purpose of enhanc- or system support;
ing or enabling participation in roles, habits, and routines in ■ The constant inundation of knowledge makes it difficult to
home, school, workplace, community, and other settings” maintain and focus learning; and
(AOTA, 2014, p. S1; Figure 71.1). ■ Translating the accumulation of knowledge to practice,
given that a client-centered approach should be used at
all times, requires maneuvering through a confluence of
For Additional Learning cultures.
Constant accumulation of knowledge can be executed in
For additional learning on continuing competence, see AOTA (2015)
and Chapter 54, “Continuing Competence.” many different ways. Traditional continuing education (CE)
methods are only a part of the puzzle; knowledge is more
FIGURE 71.1. Standards for continuing competence.
Standard 1:
Knowledge
Standard 2:
Standard 5: Crical
Ethical reasoning
pracce Assess,
Maintain, and
Document
Connuing
Competence Standard 3:
Standard 4:
Performance Interpersonal
skills skills
Note. Standards from AOTA (2015).
CHAPTER 71. Professional Development 661
useful if it is used appropriately in the right context (Boud ■ Power: Having a seat at the decision-making table is crucial
& Hager, 2012). Emerging CE methods, such as video-based to the growth of any profession. Professional development
coaching, have given rise to a dynamic approach to profes- allows the practitioner’s voice to be heard and respected
sional development. For example, the current generation of among other health care professionals, administrators,
practitioners is fully invested in the use of technology (Hills and even patients. No profession outside of occupational
et al., 2013). If used appropriately and within ethical bound- therapy harnesses the power of meaningful activity and
aries, social networking can be used to facilitate professional therapeutic use of self to promote recovery, function, and
development. adaptation. Occupational therapy practitioners have a
Hills et al. (2013) identified the use of social networking to unique perspective on client-centered care, a mindset that
create communities of practice, groups of people informally can lead to innovative and even cost-effective protocols.
bound together by a shared expertise and passion for a joint ■ Knowledge: Professional development deepens the practi-
enterprise that focus on a shared domain of practice to fa- tioner’s knowledge about professional issues and guides EBP.
cilitate collective learning. Managers should recognize that Being able to apply your knowledge appropriately is just as
mobile technologies and social networking can provide both important as acquiring it. Professional development is a
service and professional development, maximizing creativity. balance between absorbing information and putting it into
Similar to communities of practice, practice scholar com- practice within the correct context (Boud & Hager, 2012).
munities, which are groups of people who assist each another ■ Presence: Maintained professional development is the
to learn about the practice they have in common through responsibility of every practitioner for the profession to
social learning (Wilding et al., 2012). Through collaborative have a known and respected presence in the health care
discussion, the group allows individual members to focus on community. A dedication to professional development has
professional development, decision making, and reasoning. played a key role in the pursuit of occupational therapy’s
Critically diverse and novel ways of thinking, reflecting, and Vision 2025: “Occupational therapy maximizes health,
discussing resulted in participants being able to update their well-being, and quality of life for all people, populations,
knowledge and skills and improve their understanding of and communities through effective solutions that facili-
occupational therapy, philosophy, and theory. tate participation in everyday living” (AOTA, 2017, p. 1).
These practice scholar communities provided “a means ■ Authenticity: Occupational therapy has a genuine out-
through which occupational therapy may better realize its look on the human essence of “being” and the biological,
social contribution, and as a means by which its practitioners anatomical, developmental, and psychological intricacies
can develop wise and prudent judgment, thus moving from that come with it. Authentic occupational therapy facil-
practice to praxis,” enabling participants to engage in “a full itates participation and engagement in the meaningful,
range of intellectual and creative activities that may include necessary, and familiar activities of everyday life (Lamb,
the generation, validation, synthesis or application of knowl- 2016). The future of occupational therapy is secured by its
edge” to their practice (Wilding et al., 2012 p. 313). Communal authenticity. Maintained professional development can
professional development environments may further foster nourish that authenticity.
maintained interest in one’s profession and contribute to per-
sonal reflection and career progression.
Occupational therapy practitioners have a universal respon- Review Questions
sibility to contribute to generational knowledge that advances 1. What are the defining characteristics of CPD vs. continu-
occupational therapy practice, regardless of their assigned roles ing competency?
as academics, practitioners, managers, or researchers (Wilding 2. What topic or practice area would you like to see as the
et al., 2012). Taking ownership of the future of one’s profession focus of a practice scholar community or community of
is a powerful professional development catalyst. When using practice? How might you start one?
a broader lens to develop professionals’ view of the future, not 3. What barriers have you experienced in acquiring and
only do practitioners tend to use more learning strategies to ad- applying new knowledge and skills?
vance their own professional development but their own per-
sonal identities begin to become integrated with that personal
approach to their discipline (Hayward et al., 2013). PRACTICAL APPLICATIONS IN
Managers should consider the following benefits of profes- OCCUPATIONAL THERAPY
sional development:
Pursuing professional development can be difficult because
■ Advancement: Professional development gives practi- new challenges emerge over time, such as changes in policy;
tioners a way of moving the profession forward. By staying new protocols, technology, or clients; or change in special-
up to date with the profession’s legislative, practice, and ization. In some cases, competence can be short lived; practi-
research domains, occupational therapy practitioners can tioners can be competent today and incompetent tomorrow.
have a direct role in ensuring the advancement of the pro- The field of occupational therapy is fluid because it can change
fession. Pursuing continuing competence advances both rapidly according to up-to-date information, new knowledge,
the practitioner and the profession (AOTA, 2015). and modern technologies (Moyers, 2009).
There is not always a linear relationship between learning finding a school, jobs and careers, fieldwork, maintain-
and improved performance. There may be times when there is ing your license, and National Board of Certification in
either limited improvement or even no immediate improve- Occupational Therapy (NBCOT®; https://www.aota.org
ment at all (Moyers, 2009). To translate new knowledge into /Education-Careers.aspx).
practice, managers and practitioners sometimes must move ■ Conferences and Events: Stay up to date with conferences,
away from previously held ideas and incorporate new ways conclaves, expos, Capitol Hill days, and summits. You will
of thinking. A willingness to reorganize established practice also find links for paper submissions and access to your CE
trends can be difficult, but it is often part of the path to CPD transcripts (https://www.aota.org/Conference-Events.aspx).
(Boud & Hager, 2012). ■ Publications and News: Get access to the American Journal
Establishing professional development opportunities in an of Occupational Therapy, OT Practice magazine, Special
organization or business or maintaining professional devel- Interest Sections, AOTA press releases, and E-newsletters
opment as a practitioner can seem daunting. Managers and (https://www.aota.org/Publications-News.aspx).
administrators may not have the same professional cre- ■ About Occupational Therapy: Find resources for patients
dentials as their employees. For example, a manager with and clients as well as prospective occupational ther-
a business or administration degree may not instinctually apy practitioners and professionals (https://www.aota.org
recognize the professional development needs of their health /About-Occupational-Therapy.aspx).
care staff and as a result may not provide resources or oppor-
tunities for continuing education.
Implementing CPD from an organizational or business EBP
standpoint can improve efficiency, resulting in lower oper- Evidence-based practice (EBP) has its roots in the concept
ation costs, employee retention, and quality of patient care. of evidence-based medicine, a term first coined in the 1980s
It can also lead to recognition from professional organiza- and 1990s by researchers and doctors. It is defined as a bot-
tions and increase customer acquisition (Cuff & Forstag, tom-up approach that integrates high-quality evidence with
2018). CPD is a holistic approach that requires implement- clinical expertise and patient preference (Marr, 2017). Since
ing several learning methods and theories. Managers pro- then, the term evidenced-based medicine has morphed into
moting CPD should analyze the organization’s core values a variety of synonymous terms, including evidenced-based
and ask: practice, evidence-based decision making, evidenced-based
■ Why is there a need for action? policy, and evidenced-based education (Marr, 2017).
■ What are the business objectives? Research illustrates the difficulties practitioners have
■ What are the costs of providing employee CPD opportu- with obtaining and implementing EBP, including not al-
nities? (Cuff & Forstag, 2018) ways feeling they have the tools required to fully implement
EBP (Marr, 2017). Lack of confidence in analyzing statis-
tics or rigor of research and in searching through databases
Associations have also been shown to deter not just implementation of
EBP but even the mere discussion of it (Marr, 2017). Al-
Access to both national and state associations is an important
though empirical research to support the practice is growing
resource for fostering and pursing professional development.
(Somers, 2017), occupational therapy’s core value of individ-
For example, AOTA’s website (www.aota.org) is strategically
ualized, client-centered care can also make EBP hard to come
organized to provide a robust database of information: Case
by (Marr, 2017). However, EBP does not have to be a daunting
Example 71.1 shows how to use AOTA website resources.
roadblock for professional development. EBP is not just
■ Practice: Explore all major arenas of occupational ther- about research; it also includes clinical experience and client
apy from children and youth to work and industry. You perspective.
will find information regarding occupational therapy’s Modern EBP literature is beginning to expand its defini-
role in mental health, productive aging, and rehabilita- tions of EBP, describing it as a combination of external and
tion and disability. Managing your practice and occupa- internal evidence (Marr, 2017). External evidence includes
tional therapy assistants are covered. Links to ethics and empirical research but also encompasses “lower quality”
EBP resources are also included (https://www.aota.org studies, including qualitative studies and professional opin-
/Practice.aspx). ion pieces. Internal evidence is the clinical outcomes that a
■ Advocacy and Policy: Stay updated on congressional professional has observed, collected, and reflected on over
affairs, learn how to get involved with the American time—challenges that are contextual by nature and client
Occupational Therapy Political Action Committee, follow specific (Marr, 2017).
health care reform updates, and access health policy Limited access or knowledge of how to gain access to liter-
webinars. You can also find state policy information as well ature can be perceived as a major barrier to “everyday” profes-
as current coding, billing, and documentation mandates sional development. University library networks may no lon-
(https://www.aota.org/Advocacy-Policy.aspx). ger be available to new practitioners after graduation, and not
■ Education and Careers: Catered to both students and all work sites provide employees access to peer-reviewed lit-
current practitioners, you can find information on CE, erature. Although not as extensive, public access to literature
does exist through various media. Two resourceful databases ■ Produce better outcomes with clients, and
include Google Scholar and the U.S. National Library of Med- ■ Experience heighted camaraderie and accountability with
icine, National Institutes of Health (http://www.ncbi.nlm colleagues.
.nih.gov/pmc/). AOTA has also recently revised its EBP col-
The toolkit can be found through the AOTA website or di-
lection and has made it available in a user-friendly manner.
rectly at https://www.aota.org/Practice/Researchers/Journal-
Members are encouraged to access the “Evidence-Based Prac-
Club-Toolkit.aspx.
tice & Research” section of the website (https://www.aota.org
Because learning also occurs through practice in the work
/Practice/Researchers.aspx) to learn more about the Evidence
setting, most learning is not structured around formalized
Exchange, the Journal Club Toolkit, summaries of published
activities but through everyday interactions at work, drawing
literature (critically appraised topics and papers), Practice
on the toolbox of experiences to respond to the need (Mann
Guidelines, as well as special issues of the American Journal
et al., 2009). Consequently, the ability to learn from one’s
of Occupational Therapy featuring systematic reviews and
experience is important in maintaining competence across a
much more.
practice lifetime (Mann et al., 2009). Everyday work situations
provide the context for learning in that occupational therapy
Workplace managers and practitioners can find themselves working in
Professional development begins with a professional re- highly contextual biological, psychological, and personal
sponsibility in the workplace. Managers should support environments (Boud & Hager, 2012). The more adept man-
their employees with policies that encourage and promote agers and practitioners are at contextualizing learning expe-
professional development. Evidence points to improved riences, the stronger professional identities become, further
clinical practice, better client outcomes, enhanced work- validating the cultures of both academia and clinical settings
place satisfaction, increased workplace moral and better (Hayward et al., 2013).
clinical governance within organization when professional Managers should consider capacity-building policies
support is available (Bell et al., 2014). Professional support that value knowledge as constructed by and with practi-
is described as facilitating clinical governance of organiza- tioners, thus promoting contextualized learning experiences.
tions and enhancing the professional development of indi- (Darling-Hammond & Mclaughlin, 2011). These types of pol-
vidual clinicians (Bell et al., 2014). This means managers icies may warrant a transition from the traditional inservice
should promote policies that offer professional support, model to a participant-driven model that promotes collabo-
such as mentoring, peer support programs, clinical su- ration, shared knowledge, experimentation, reflection, and
pervision, appropriate training opportunities, and clearly modeling (Darling-Hammond & Mclaughlin 2011), which is
communicated managerial commitment to the process. Es- a more participatory approach to learning.
tablishing such policies may require strong organizational Ultimately, the ability to connect with patients and their
leadership not only to promote the value of professional meaningful occupations as a form of client-centered prac-
support but to ensure its integration into the regular work tice is what separates occupational therapy practitioners
load (Bell et al., 2014). from other health care professionals. These working re-
There are also collaborative options for promoting pro- lationships are important to the success of the profession
fessional development, including starting a journal club, (Hinojosa, 2012). Strengthening these working relation-
presenting an evidence-based case study to colleagues, or ships promotes professional development. Because of the
making a presentation on updated standardized assessments. unique outlook on health and well-being, occupational
Journal clubs are an informal yet powerful tool for promoting therapy practitioners can catalyze their professional de-
professional development and best practice. Journal clubs are velopment with everyday interactions: “Our everyday
a well established supplement to didactic learning and consist actions— what we do—can promote occupational ther-
of the review of peer-reviewed literature and the interactive apy and help create new opportunities for the profession”
discussion of study strengths, limitations, and potential im- (Jacobs, 2012, p. 653).
plementation in practice (Vadaparampil et al., 2014). A jour-
nal club’s aim is to facilitate the critical appraisal of literature Clinical Instruction
to implement EBP. Journal clubs also encourage a sense of
Clinical instructors play a crucial role in the development
community learning among colleagues. Journal clubs have
of future practitioners. Opportunities to become involved
been shown to be effective in keeping health care practitioners
in fieldwork education come soon after certification. There
current with relevant literature (Lizarondo et al., 2010).
are professional development opportunities to be gained
AOTA has developed a Journal Club Toolkit to inspire
from taking on a clinical instructor role in that a fieldwork
evidence-based discussions among occupational therapy stu-
educator’s own professional development is enhanced by the
dents, educators, and practitioners. The toolkit aims to help
students they are supervising via exposure to current trends,
practitioners
EBP, and research (AOTA, 2016). Besides opportunities to
■ Keep current on trends in literature, earn professional development units, clinical instructors
■ Invest in lifelong learning, must be certain that their own practices are aligned with cur-
■ Provide the best possible EBP, rent theories, evidence, and models as outlined by academic
curriculum and peer-reviewed literature (AOTA, 2016). Self-Assessing Competence

Having to not only be aware of one’s own practice tenden-
AOTA mandates that occupational therapists self-assess their
cies but to be able to effectively explain why one chooses to
strengths and weaknesses regarding knowledge, skills, and
implement a particular set of treatment strategies is a great
attributes for quality service delivery (AOTA, 2015). As part of
catalyst for professional development. The clinical instructor
life-long learning, self-assessment contributes to understand-
experience at any stage (Level I or II) can provide managers
ing inherent learning needs in order to shape effective and
and practitioners with opportunities to fuel their professional
reflective practice (Musolino, 2006). The ability to accurately
development.
self-assess is an important skill for health care professionals.
Fieldwork education can be seen as a bridge not just be-
In contrast, poor self-assessment skills can create a false sense
tween academic education and authentic occupational
of confidence in the learners’ own appraisal of knowledge and
therapy practice (i.e., ensuring participation in the mean-
performance (Musolino, 2006).
ingful activities of everyday life; AOTA, 2016) but between
NBCOT Navigator is an online tool that provides certi-
the practitioner and continued professional development. By
fied occupational therapists with continuing competence
having professional support policies in place that promote
assessments and professional activities (NBCOT, 2015). The
a culture of contextualized learning, managers can effec-
purpose of the platform is to engage participants in assess-
tively support their clinical instruction staff. Organizations
ment of client-centered and EBP knowledge and skills target-
seeking to promote fieldwork education may consider estab-
ing specific practice areas identified through a self-reflection
lishing concrete protocol expectations for hosting a fieldwork
questionnaire (Myers, 2019). PDUs can also be earned by
student, including setting up contracts with academic insti-
completing Navigator activities. Platforms such as these may
tutions to allow for routine fieldwork opportunities. The po-
help guide professional development plans by identifying
tential recruitment of qualified occupational staff is another
clinical and professional competence needs.
benefit of establishing a fieldwork program (AOTA, 2016).
Self-assessment tools need not be limited to online plat-
forms. Self-assessment strategies can be implemented within
Governing Agencies the workplace both on an individual level and at a company-
The National Board of Occupational Therapy (NBCOT®) is wide level. Both managers and practitioners should consider
the national certification body for occupational therapy pro- the facilitation of self-assessment programming. Recommen-
fessionals in the United States, including occupational ther- dations may include videotaping, using workbooks, learning
apy assistants. NBCOT is also a member of the Institute for style and personality inventories, allocating time to complete
Credentialing Excellence. Currently 50 states, Guam, Puerto self-assessment activities, and practice sessions with immedi-
Rico, and the District of Columbia require NBCOT initial ate feedback (Musolino, 2006).
certification for state licensing. Although not all state govern-
ing agencies require NBCOT renewal, Registered Occupa- Review Questions
tional Therapist (OTR®) and Certified Occupational Therapy
Assistant (COTA®) credentials cannot be used if certification 1. What is the aim of a Journal Club, and how can man-
is not renewed during the renewal year. NBCOT maintains agers use it as a form of professional support for their
certification standards based on current and valid compe- employees?
tence indicators of occupational therapy practice. 2. Wilding et al. (2012) described as “a
State licensure identifies to the public individuals who means through which occupational therapy may better
have demonstrated some level of competence to provide realize its social contribution, and as a means by which
professional services within a specified scope of practice its practitioners can develop wise and prudent judgment,
(Moyers, 2009). Levels, amount, and frequency of required thus moving from practice to praxis”:
competence varies by state. Required CE hours can range a. Social justice
from no contact hours required to up to 30 contact hours b. Social networks
required every 2 years. Renewal terms range from annual c. Practice scholar communities
to biennial. State agencies also vary in the documentation d. Advocacy agencies
required to submit with your renewal application. AOTA’s 3. What is an example of external and internal evidence as
website has a full breakdown of each state’s requirement for used to describe expanding EBP definitions?
license renewal.
NBCOT provides a concrete list of learning activities that
occupational therapy professionals can complete to renew
SUMMARY
their NBCOT certification: Competency Assessment Units Analyzing the culture of workplaces, communities, patients,
(CAUs) and Professional Development Units (PDUs). Certifi- and health care agencies can help identify potential for the
cants must accrue at least 36 units within their 3-year renewal growth and fostering of professional development. Learn-
period. State licensure CEU requirements may be converted ing something new does not necessarily translate directly to
to NBCOT-qualifying PDUs according to the NBCOT con- improved performance. Although there is value in acquir-
version chart. ing knowledge, that knowledge becomes muted in its power
CASE EXAMPLE 71.1. Luke: New Practitioner Professional Development
Luke was a recent occupational therapy graduate and had just begun his first full-time job at an outpatient pediatric clinic. He was eager to
implement the things he had learned during his graduate school studies. He believed he would “fit right in” because he had been hired by his most
recent Level II fieldwork site. However, even after a thorough orientation process, after a few days he began to feel overwhelmed. He felt like he
was already behind in staying up to date with EBP. He was so focused on the administrative aspects of the position—such as daily notations, report
writing, and billing—that he did not feel the treatment sessions were as client-centered as they should be.
His first approach was to read up on some pediatric professional development literature in the evenings at home after work. However, often times
he would feel the need to de-stress from the day after coming home, and he would start his readings later, thus keeping him up too late at night.
He began to feel stuck—stuck between being a productive professional, providing client-centered care, and maintaining his own occupational life
balance. He wanted to give all 3 aspects their due attention.
Luke brought up his challenges with his site’s clinical manager, who was also an occupational therapy practitioner. The director commended
him on his awareness and for bringing up the issue. He appreciated that Luke had concerned himself with seeking to address those issues. He also
reminded Luke of the benefits of a multi-modal approach to professional development. Luke had initially focused solely on professional development
experiences outside the workplace, when in fact, there were many opportunities for professional development within his own work site.
The director encouraged Luke to visit AOTA’s website for professional development recommendations and see which could be applied in the
workplace. The director also offered Luke the opportunity to supervise a Level I fieldwork student who was set to start at the clinic the following
month, which was another opportunity to engage in professional development activities.
One month later Luke had established a work flow routine that he was comfortable with. He now feels competent with his daily responsibilities
and has implemented some on-site professional development opportunities. With the help of his coworkers, he organized a weekly “lunch and learn”
using journal club principles that he found on the AOTA website. Once a week he and his coworkers either discuss a peer-reviewed article they
had read over the past week or brainstorm difficult cases and treatment strategies. Luke was now even more comfortable with taking on a Level I
fieldwork student. After he had mastered his on-the-job responsibilities, he would venture out and seek more traditional professional development
opportunities (e.g., workshops, conferences, courses). By integrating professional development opportunities in the workplace, Luke was able to
contextualize his learning experiences and promote a community of practice while achieving a sustainable work–life balance.
Review Questions
1. What other types of support might a manager implement to better support new hires with their professional development?
2. Luke’s manager would like to start exploring professional development options that don’t use the traditional inservice model. What should he
consider to achieve this?
3. What are some of the workplace benefits of establishing professional support policies?
and effectiveness without contextual applications. The path American Occupational Therapy Association. (2014). Occupational
to professional development is both an individual endeavor therapy practice framework: Domain and process (3rd ed.).
and a collaborative undertaking that should be supported by American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
managers. Students, practitioners, educators, and scholars all https//doi.org/10.5014/ajot.2014.682006
American Occupational Therapy Association. (2015). Standards
have a contributing role in the pursuit of authentic occupa-
for continuing competence. American Journal of Occupational
tional therapy practice. Professional development is a critical
Therapy, 69(Suppl. 3), 6913410055. https://doi.org/10.5014/ajot
part of that authenticity. ❖ .2015.696S16
American Occupational Therapy Association. (2016). Occupational
therapy fieldwork education: Value and purpose. American Jour-
ACOTE STANDARDS nal of Occupational Therapy, 70(Suppl. 2), 7012410060. https://
doi.org/10.5014/ajot.2016.706S06
This chapter addresses the following ACOTE standards: American Occupational Therapy Association. (2017). Vision 2025.
■ B.7.4. Ongoing Professional Development
■ B.5.7. Quality Management and Improvement Bell, K., Hall, F., Pager, S., Kuipers, P., Farry, H. (2014). Developing
■ B.5.8. Supervision of Personnel allied health professional support policy in Queensland: A case
■ B.1.4. Quantitative Statistics and Qualitative Analysis. study. Human Resources for Health, 12. https://doi.org/10.1186
/1478-4491-12-57
Boud, D., & Hager, P. (2012). Re-thinking continuing professional
development through changing metaphors and location in pro-
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CHAPTER
Entrepreneurship
Jayne Knowlton, OTD, OTR/L 72
LEARNING OBJECTIVES
■ Identify strategies to participate in entrepreneurship,
■ Describe the characteristics of entrepreneurs, and
■ Apply principles of entrepreneurship to occupational therapy.

• Bootstrapping • Intrapreneur • Risk
• Business plan • Nondisclosure agreement • Scaffolding
• Entrepreneur • Patent • Social entrepreneur
• Entrepreneurship • Professional isolation • Start-up
• Incubator
OVERVIEW purchase by a customer. Like inventors and entrepreneurs,
C
reating new treatment interventions for our clients occupational therapy practitioners tend to be innovators,
is what we do as occupational therapy practitioners. because questioning how we might find new ways to help our
We conduct therapy using the available products until clients can assist them in achieving better outcomes.
we introduce a new product or method of use. The avail- As health care and service delivery evolve, reflecting on
ability of therapeutic options is continually expanding. For how we can continue to meet the needs of our clients and
practitioners who wish to participate in the creation of new society and continuing to evolve as clinicians to ensure we
products and methods of intervention for a larger client ap- are delivering relevant services and best practice requires us
plication, having the characteristics of an entrepreneur can to incorporate novel methods into our practice. It is critical
be very advantageous. to the profession that occupational therapy practitioners
An entrepreneur is an individual who sells a product or identify gaps in care to meet the changing demands of the
service to others in hope of a profit but often at consider- world in which we work and to best serve our clients. Finding
able risk (“Entrepreneur,” n.d.). A successful entrepreneur solutions to fill the gap between the current technologies and
is seen as creating profit in an environment of significant equipment and what is needed to solve a clinical dilemma is
challenges. characteristic of an entrepreneur.
Occupational therapy practitioners are skilled and trained Entrepreneurs often create or bring these innovations to
to administer high-quality interventions that allow clients others to solve problems on a large scale. This chapter explores
to function at a higher level of independence (American the dynamic concept of entrepreneurship in the context of
Occupational Therapy Association [AOTA], 2014). The inter- occupational therapy and discusses a case example. Readers
ventions and products we routinely use were created by an should keep an open mind regarding how entrepreneurship
inventor and brought to the market by an entrepreneur for can fit in their personal and professional lives.
https://doi.org/10.7139/2019.978-1-56900-592-7.072
667
CHAPTER
Entrepreneurship
Jayne Knowlton, OTD, OTR/L 72
LEARNING OBJECTIVES
■ Identify strategies to participate in entrepreneurship,
■ Describe the characteristics of entrepreneurs, and
■ Apply principles of entrepreneurship to occupational therapy.

• Bootstrapping • Intrapreneur • Risk
• Business plan • Nondisclosure agreement • Scaffolding
• Entrepreneur • Patent • Social entrepreneur
• Entrepreneurship • Professional isolation • Start-up
• Incubator
OVERVIEW purchase by a customer. Like inventors and entrepreneurs,
C
reating new treatment interventions for our clients occupational therapy practitioners tend to be innovators,
is what we do as occupational therapy practitioners. because questioning how we might find new ways to help our
We conduct therapy using the available products until clients can assist them in achieving better outcomes.
we introduce a new product or method of use. The avail- As health care and service delivery evolve, reflecting on
ability of therapeutic options is continually expanding. For how we can continue to meet the needs of our clients and
practitioners who wish to participate in the creation of new society and continuing to evolve as clinicians to ensure we
products and methods of intervention for a larger client ap- are delivering relevant services and best practice requires us
plication, having the characteristics of an entrepreneur can to incorporate novel methods into our practice. It is critical
be very advantageous. to the profession that occupational therapy practitioners
An entrepreneur is an individual who sells a product or identify gaps in care to meet the changing demands of the
service to others in hope of a profit but often at consider- world in which we work and to best serve our clients. Finding
able risk (“Entrepreneur,” n.d.). A successful entrepreneur solutions to fill the gap between the current technologies and
is seen as creating profit in an environment of significant equipment and what is needed to solve a clinical dilemma is
challenges. characteristic of an entrepreneur.
Occupational therapy practitioners are skilled and trained Entrepreneurs often create or bring these innovations to
to administer high-quality interventions that allow clients others to solve problems on a large scale. This chapter explores
to function at a higher level of independence (American the dynamic concept of entrepreneurship in the context of
Occupational Therapy Association [AOTA], 2014). The inter- occupational therapy and discusses a case example. Readers
ventions and products we routinely use were created by an should keep an open mind regarding how entrepreneurship
inventor and brought to the market by an entrepreneur for can fit in their personal and professional lives.
https://doi.org/10.7139/2019.978-1-56900-592-7.072
667
ESSENTIAL CONSIDERATIONS Intrapreneur

Who Is an Entrepreneur? The term intrapreneur describes an entrepreneur who starts
an innovative process within a larger organization that brings
Entrepreneurship includes the activities associated with new products and programs to market. This individual
participation in the creation of a business structure that has has the financial and system support of the organization
a goal of taking a new idea to market, usually for a profit. (“Intrapreneur,” n.d.; Kenton, 2018). Occupational therapy
The idea of entrepreneurship includes a high degree of risk, practitioners and managers may find creating a new program
given the unproven novelty of the idea or product. The term or product within the context of their current employment to
entrepreneur has historically been used to describe an in- be a sound method for intrapreneurial activities. The advan-
dividual who runs a business that brings innovation to the tage is that risk to the employee is mitigated, yet new products
market. An additional definition describes an entrepreneur and interventions can be created. It is then the employing
as “one who organizes, manages, and assumes the risks of a organization’s responsibility to finance the implementation
business or enterprise” (“Entrepreneur,” n.d., para. 1). This of the product or service.
definition points out the 2 factors that make an entrepreneur:
(1) risk and (2) business.
Risk is “a probability or threat of damage, injury, liabil- Social entrepreneurs
ity, loss, or any other negative occurrence that is caused by Entrepreneurs also have developed a unique role in nonprofit
external or internal vulnerabilities, and that may be avoided organizations. In these settings, the entrepreneur is a social
through preemptive action” (BusinessDictonary, n.d.-a, entrepreneur—a type of entrepreneur whose focus is social
para. 1). The element of risk indicates that when initiating a equity rather than financial profit. A social entrepreneur is
new endeavor, the outcome is unknown and therefore could driven by the desire to improve the living situation for groups
be negative and have a detrimental effect. The element of risk of individuals. “Social entrepreneurs engage in a variety of
also indicates that negative consequences can be mitigated activities, but always with the intention of solving social
through preemptive action. To mitigate risk, and structure problems. Social entrepreneurs are not merely people who
actions, an entrepreneur will form a new business, com- perform acts of charity; they have an evident desire to improve
monly referred to as a start-up, which is a “company in social well-being and develop projects with long-term vision”
the early stage in the life cycle of an enterprise where the en- (Sastre-Castillo et al., 2015, p. 349). Therefore, to achieve a
trepreneur moves from the idea stage to securing financing, long-term vision of improving social well-being, social entre-
laying down the basis structure of the business, and initiat- preneurs must consider business factors that are consistent
ing operations” (BusinessDictionary, n.d.-b, para. 1). with the principles of entrepreneurship. Even though a social
An enterprise is a business or a company (BusinessDictio- entrepreneur’s outcome desire is social well-being, a business
nary, n.d.-c). According to Drucker (1993), a business must structure is needed to support delivering a program.
initially be defined beyond the business itself—by its purpose. Social entrepreneurs use their entrepreneurial character-
“There is only one valid definition of business purpose: to cre- istics to provide interventions that promote social outcomes.
ate a customer. . . . It is the customer who determines what a In a study of social entrepreneurs, Sastre-Castillo et al.
business is. For it is the customer, and he alone, who through (2015) found that for half of the 400 participants, their en-
being willing to pay for a good or . . . service, converts eco- trepreneurial frame of mind stemmed from their values of
nomic resources into wealth, things into goods” (p. 37, italics self-
enhancement, self-transcendence, and conservation.
added). Similarly, occupational therapy practitioners who create
All entrepreneurs take a novel idea and translate this new novel programs that improve the social participation of their
idea into a tangible reality by launching a business that will clients and who ensure the long-term sustainability of their
bring it to the world. They can found a new business or work work through sound business practices can be considered so-
within a larger business. The goal can be purely financial or cial entrepreneurs.
also have a social intent. The entrepreneur does not have to A blending of traditional and social entrepreneurship
create the idea but is the one who leads the business to have a traits is occurring as businesses are increasingly embracing
real impact. Converting an idea into an enterprise that leads social causes along with generating profits to sustain their
to value requires the dedicated application of the character- business (Sastre-Castillo et al., 2015). Any endeavor in which
istics of an entrepreneur, yet the potential reward can make an occupational therapy practitioner is involved will likely
it all worthwhile. have a significant component of social entrepreneurship.
Entrepreneurs can be business owners; chief executive
officers; inventors; craftsmen; professionals, such as occu-
Taking Responsibility for Risk
pational therapy practitioners and managers; or other in-
dividuals. More recently, the concept of entrepreneurship Initiating or expanding a business or project is often associ-
has expanded to include the different roles and contexts in ated with some degree of financial risk. Identifying what facts
which innovators can be found. In these new contexts, entre- are known and unknown about getting the idea to market
preneurs are sometimes considered intrapreneurs and social and determining the odds of success is a first step in under-
entrepreneurs. standing risk. Even after market analysis, many aspects of the
CHAPTER 72. Entrepreneurship 669
market are unknown or can be unpredictable. For example, Knowledge model to bringing a novel product to customers
even though potential customers may have common con- who could use that product for improved function.
ditions and would benefit from the product, many of these The potential rewards of entrepreneurship—including
individuals may not be interested in purchasing it. profits and the creation of social change—are motivating. The
In addition, uncertainty about whether consumers will enormity of such goals can be managed with a sound model
pay the price required to cover the cost of production con- as a guide.
tributes to market risk. To anticipate and account for these
factors, entrepreneurs can apply a product failure rate of Business Planning
approximately 40% (Castellion & Markham, 2012). Addition-
ally, according to a study by Statistic Brain, the failure rate Plans are worthless; planning is everything.
of all U.S. companies after 5 years was more than 50%, —Dwight D. Eisenhower
and more than 70% after 10 years (Henry, 2017). Therefore, (Quote Investigator, n.d.).
launching a new product is risky, but following evidence-
based strategies of business development and networking can It is necessary to create a business plan to bring your innova-
be methods of taking responsibility for risk. tive idea to clients and customers. A business plan includes
Entrepreneurs can reduce the risk inherent in a business finances, partners, timelines, cost and profit, customers, and
start-up in several ways. For example, it may be wise to start price points. This is a place to begin. When you are scaling an
a business alongside traditional employment, much as you idea from a small application to a much greater one, success is
might dedicate resources (e.g., financial, time) to a hobby. more likely if you follow a plan, which is similar to a roadmap.
However, a business start-up requires a significant amount of Occupational therapy practitioners and managers are aware
time, so business growth will be slower if full-time devotion of the importance of having a strategy or intervention plan to
is not possible. If and when there are signs of the business achieve client goals. The same is true for an entrepreneurial en-
taking off, such as customer demand, then a decision to leave deavor, with the added complexity of designing a strategy for
traditional employment must be made. Forming a partner- uncharted territory. Although developing a plan is necessary, it
ship with someone who complements the entrepreneur’s skill is also important to recognize that the resultant plan can be con-
and knowledge base could also reduce risk. Having in-depth stantly in flux. The plan is created by applying as much knowl-
knowledge of the characteristics of an entrepreneur and edge as is known at the time. As the business develops, new
developing the characteristics of an entrepreneur can also information can be incorporated into the plan. For example, a
increase the likelihood of a sustainable business. plan could start with a product to assist women urinating in bed
and calling it a female urinal, although men also may be able to
use it. The plan could remain to focus on women or be expanded
For Additional Learning to include men. However, if the urinal is perceived as useful to
men and women, women might think that it will not work for
For additional learning, see Chapter 11, “Risk Management and
Contingency Planning.”
them specifically. Accepting and responding to the changing
nature of the business plan allows for learning and adapting.
A successful plan evolves in response to new information
from new experiences. Some social entrepreneurs tend not to
Using a Framework
focus on creating profit; however, the business will be unable
Becoming an entrepreneur can be exciting and daunting. to deliver social outcomes if there is not a method to provide
The path from product or service concept to market can be the innovation. Thus, a business plan is essential for all types
demanding in terms of resources and fraught with barriers to of entrepreneurs and innovations.
success. By following a framework that has been thoughtfully There are many resources available specific to developing
and carefully cultivated and procured, entrepreneurs can a business plan. For small entrepreneurs starting their own
enhance the odds of success. business, The Startup Owner’s Manual (Blank & Dorf, 2012)
For example, in the case of rehabilitation products, occu- and Business Model Generation (Osterwalder & Pigneur,
pational therapy practitioners and managers can use a model 2010) have streamlined the startup process and give spe-
developed by the Center for Knowledge Translation for Tech- cific instructions. Another resource is the Small Business
nology Transfer (KT4TT) at the University at Buffalo, State Administration (SBA), a federal agency for small businesses
University of New York. The coinvestigators at KT4TT devel- whose website contains a significant amount of information,
oped a model based on product development industry stan- including business plan templates that can be useful to the
dards, with more than 200 references to guide individual and entrepreneur (SBA, n.d.) in developing a plan that fits the en-
university grant-recipient inventors and entrepreneurs. The trepreneur’s situation.
Need to Know Knowledge model’s aim is to help entrepre- In addition, most major U.S. cities have a small-business
neurs transfer their innovations to industry manufacturers incubator, an organization that aims to accelerate the growth
and distributors and on to the customer in need (KT4TT, and success of entrepreneurial companies. Incubators can
2017). The KT4TT website includes a step-by-step inventor be supported by a mix of public and private funds that can
and entrepreneur guide that applies the Need to Know come from local universities and state and federal funding
(Global Business Incubation, 2018). Incubators can have a va- who can participate in your project or have influence to help
riety of structures, many offer payment strategies for services you negotiate barriers can enable your success.
used, or services can be provided for a share of ownership of the Although entrepreneurs are often revered for their indi-
entrepreneur’s company and therefore potential future profits. vidual accomplishments, an examination of their journey
A business incubator is usually a shared physical space will always show examples of networking and collaborations
that provides the amenities that a start-up enterprise needs along the way. Consider asking for assistance when needed;
for survival but could not easily or affordably procure on their occasionally a mutually beneficial relationship can develop.
own. Business incubators offer shared resources that can po- Also consider that in entrepreneurship, one has to be cautious
tentially lower startup costs (Andre, 2017). This could include of sharing ideas, because someone else could use the idea as
meeting rooms, mentors and coaching, networking connec- their own and potentially block you from using it.
tions, and machinery (Business Incubator, 2018). Funding If you have an idea that you want to protect, it may be
for these incubators can come from a consortium of public helpful to have a nondisclosure agreement in place with the
and private investors, including state economic development other party. A nondisclosure agreement is a contract that
entities and local universities. Small-business incubators are binds the parties to keep shared information secret. Such an
regionally based and seen as economic growth stimulators. agreement allows the creator to discuss their idea with others
with less fear that it will be stolen. Samples are widely avail-
able on the Internet; however, an attorney could also be a
For Additional Learning source of sound advice (Knowlton, 2017).
Tina Seelig, a professor in Stanford University’s Depart-
For additional learning, see Chapter 9, “Strategic Planning.”
ment of Management Science and Engineering and a faculty
director of the Stanford Technology Ventures Program,
Characteristics of an Entrepreneur proposed a framework to teach individuals how to become
entrepreneurs. She teaches entrepreneurship by scaffolding
The characteristics of successful entrepreneurs are the focus skills, a method of teaching that provides progressively less
of much inquiry, because they can guide a budding entrepre- support as the learner gains skills and competence (Seelig,
neur. Strength in specific skills, knowledge, perseverance, 2017). She has conceptualized the progression to entrepre-
and the ability to develop positive relationships are hall- neurial thinking as follows:
marks of entrepreneurs (Seelig, 2017). Fostering imagination,
creativity, and innovation can contribute to the development ■ “Imagination is envisioning things that don’t exist.
of an entrepreneur. ■ Creativity is applying imagination to address a challenge.
Several qualities that entrepreneurs embody are knowledge ■ Innovation is applying creativity to generate unique solu-
in their chosen discipline, creative problem-solving skills, tions” (Seelig, 2017, para. 5).
leadership abilities, experience working on effective teams, and Seelig (2017) regards becoming an entrepreneur as occur-
adaptability in an ever-changing environment (Seelig, 2017). ring through a process of applying innovations, then scaling
Because entrepreneurs are treading into uncharted territory, the ideas by inspiring others’ imagination. This indicates that
critical thinking is essential. Having extensive knowledge in imagination and creativity contribute to innovation, and
a field gives the potential entrepreneur an understanding of inspiring others is part of the business aspect of entrepre-
how the industry works and the experience to identify poten- neurship. Seelig and her students created a novel transition
tial barriers. Starting an enterprise from the ground up takes program for prisoners and therefore can be considered social
strong leadership skills and effective team management. entrepreneurs. Coordinating the efforts of all the stakehold-
Successful entrepreneurs develop dedication, confidence, ers, determining the root cause of poor transitions, and un-
and fortitude, because the usual path for new products, derstanding the desired outcomes are demanding tasks that
innovations, and services to get to market takes several years. require the characteristics of an entrepreneur.
Entrepreneurs can reinforce their perseverance by keeping
their values and goals in mind. For example, a social entre-
preneur might maintain their motivation by focusing on
Review Questions
the potential positive impact of their business and the many 1. What are 2 ways for a start-up business to reduce risk?
individuals who might increase their participation in daily 2. Describe 2 characteristics of an entrepreneur.
activities because of the product or service. Although dedi- 3. What is a social entrepreneur?
cation and perseverance are important characteristics, being
receptive to new ideas and open to change will make the inev-
itable barriers more negotiable. Along the path to successful PRACTICAL APPLICATIONS IN
entrepreneurship, there are opportunities to learn new and OCCUPATIONAL THERAPY
better methods to fine tune the idea or process.
Problems as Opportunities for Innovation
Developing relationships can be critical in the success of
an entrepreneur. Networking is a valuable way to establish Entrepreneurship can be applied to occupational therapy prac-
contacts and foster opportunities. Having trusted individuals tice. Occupational therapy practitioners are adept at noticing
problems with the current methods and equipment available create (Dobson et al., 2016). Sammons grew up on a farm,
and can often envision a different solution. People with dis- where he solved mechanical problems while working with
abilities or their friends and family have created several widely farm equipment (University of Wisconsin–Milwaukee, 2015),
used adaptive products, such as the OXO vegetable peeler. which likely contributed to his product design abilities.
OXO was founded by John and Betsey Farber and their son Sammons exemplifies the characteristics of an extraordi-
John in response to Mrs. Farber’s continued frustration with nary occupational therapy entrepreneur. His career has had a
their vegetable peeler. Mrs. Farber had arthritis and found it significant impact on the course of assistive technology (AT)
very painful to peel apples when making apple pies. Mr. Far- and the field of occupational therapy (Dobson et al., 2016).
ber was familiar with housewares, because he had founded His contributions began early in his occupational therapy
a cast-iron cookware company. The Farbers imagined that career, as he became an inventor designing and fashioning
other people were experiencing the same problem with un- AT for his clients. Other occupational therapy practitioners
comfortable kitchen utensils. The couple worked with Smart heard of the success of his clients and wanted Sammons’s
Design, a New York industrial design company, and created products for their clients. The demand grew to the point that
the OXO line of kitchen tools (Smart Design, n.d.). The mo- he started selling his creations by mail-order catalog, and thus
ment of exasperation in a situation is often the time to take he became an entrepreneur. His company ultimately grew to
the search for a solution a step further. Clearly identifying a become a multimillion-dollar business (Dobson et al., 2016).
problem is where an innovator can have an impact. The University of Western Michigan holds an archive of
Occupational therapy practitioners do task analysis and documents about Sammons, which is vast resource for budding
problem solve solutions to provide a product or intervention entrepreneurs (University of Wisconsin–Milwaukee, 2015).
that assists clients to be successful (AOTA, 2014). If no such Like Sammons, occupational therapy practitioners have expe-
solution exists, then an innovator creates one. Then the en- rience with creating and adapting products, programs, services,
trepreneur establishes a business pathway to advance the in- and policies, so we have the opportunity to create businesses
novation—a comfortable vegetable peeler, in this case—and around these novel concepts and become entrepreneurs.
creates a product that can be offered for sale, potentially for
a profit. Professional Isolation
Professional isolation is a risk inherent in entrepreneurship
Patent Protection
endeavors, because the entrepreneur is involved in a new area
To protect your idea, it is a good idea to complete a patent of discovery. When in a new area, there will not be many oth-
application (U.S. Patent and Trademark Office [PTO], 2015). ers doing similar activities. It may take substantial effort to
If your idea is found to be new and useful and follows the find someone else in the same area of focus. For example, as a
extensive rules of the PTO, then you may be issued a patent, clinical therapist, I focused outside of my skill set less on clin-
which provides the holder exclusive property rights to the use ical practice while designing a urinal for women restricted to
of the idea for a term of 20 years (PTO, 2015). The decision bed and starting a business to bring it to market. I felt that by
to apply for a patent has significant monetary and property not participating in clinical tasks, I was not working within
rights implications, so it is wise to consult a patent attorney the scope of the profession of occupational therapy. My per-
or agent before applying. spective changed while I was teaching as an adjunct in a local
occupational therapy assistant program, where the program
Supporting Entrepreneurship director embraced the product and concept of the occupa-
tional therapist as entrepreneur.
Being passionate about their work will greatly add to the en- Connecting to the community of occupational therapy
trepreneur’s enjoyment and ability to create novel innovations practitioners can lead to relationships with others with similar
and will improve their ability to persevere through challenges. interests and a wider array of knowledge, skills, and talent. Ac-
Another way to enable the entrepreneurial journey is to begin ademia, professional organizations, blogs, and online groups
working on the product or innovation while remaining em- often are welcoming and supportive of innovative ideas. After
ployed. For example, Suzanne Rappaport, OTD, OTR/L, is all, occupational therapy practitioners are most likely in-
the founder and owner of Circus for Survivors. She drew on volved in these groups to learn about the latest trends in oc-
her love of the circus to found a company that promotes heal- cupational therapy and spark their professional development
ing through circus activities (Esgro, n.d.). She has remained while connecting with colleagues and sharing skills as well.
employed in her primary occupational therapy position while
developing Circus for Survivors over time.
Review Questions
Past experiences and skills can also be very beneficial in
entrepreneurship. Fred Sammons, PhD(Hon.), OT, FAOTA, 1. List 2 characteristics of occupational therapy practi-
worked as an industrial arts teacher, including mechanical tioners that are aligned with what it takes to become an
drawing, before he become an occupational therapy practi- entrepreneur.
tioner. This background is evident in his numerous product 2. Describe a benefit to an entrepreneur of connecting to the
designs, including the adaptive bike seats he continues to occupational therapy community.
CASE EXAMPLE 72.1. AquaEve
My journey as an entrepreneur started with the idea that there could be a better way for women confined to a hospital bed to urinate than waiting
for a nurse and being rolled onto a bedpan. Lack of an effective urinal option for women indicates a gender gap in health care. This case example
describes the development of the AquaEve female urinal, illustrating social entrepreneurship in occupational therapy.
Responsibility for Risk

Inherent in the unknown is risk, and this situation was not an exception. The limited urinal options in the acute care setting have been criticized by
the experts in the field (Cottenden et al., 2013) and something I frequently observed. Despite the stated need for such a product, entrepreneurs and
innovators cannot know in advance whether the product will be accepted by consumers, which creates risk.
A significant amount of time and money were invested in achieving the goal of widespread use of the AquaEve urinal. I created Eve-n-Sol, Inc.,
as the business to support the development of AquaEve. The investment of money came from bootstrapping, when the financial investment in a
start-up business comes from the entrepreneur only. The term indicates that entrepreneurs are pulling themselves up by their bootstraps, launching
their business on their own without outside assistance.
Overcoming Challenges and Seizing Opportunities

Overcoming challenges is a constant occupation of an entrepreneur. For example, I received negative feedback about the fit of the AquaEve cap
on the first sales on Amazon. This was disappointing and led to lowered sales. To recover, I gathered information, considered the options and their
potential impact, and am designing a new cap. Being open to change and being flexible are critical. By keeping the goal in mind, persisting, and
working through glitches, I was able to stay optimistic, which resulted in a solid product and solid business structure.
Characteristics of an Entrepreneur
Occupational therapy practitioners have developed specialized knowledge in the health care field and in task analysis. It takes skill in problem solving to
complete task analysis and strong team and leadership skills to work in outpatient clinics, hospitals, and home care. These skills have served me well
during work on improvised teams in a business incubator workshop and led the team to pitch our plan to the panel of judges. One of the strongest gifts
of being a seasoned occupational therapist is being able to stand up to powerful individuals for what is in the client’s best interest.
Perseverance
There have been many times along the journey to bring AquaEve to market that I thought about quitting. For example, it was discouraging to find
out that nurses in the local hospital would not buy the AquaEve urinal unless there was evidence of effectiveness. Realizing the extent and cost of
tooling and manufacturing involved was another difficult moment.
Focusing on the goal or the impact of the innovation helps. For example, I remember talking with the daughter of a client about her experience
trying to roll her mother onto a bedpan. As she spoke through tears, she said it was the most painful thing her mother endured as she died of cancer.
The knowledge that the AquaEve has the potential to bring a higher quality of life to those who use it increases my drive to continue on the path to
bring the product to a wide market.
Developing Relationships
Developing relationships is an extremely important factor in entrepreneurship. Entrepreneurs need to support each other, especially because
successful entrepreneurs are relatively rare in the health care field. For example, I met my business associate in an incubator workshop. He has
advised on product development and manages the supply chain and manufacturing. Occupational therapy practitioners wear many hats, but not
typically supply chain and manufacturing. Relationships can be very important for connecting to potential investors in the business as well.
Connecting to Passion and Past Experiences

For me, connecting to passion is connecting to compassion. As midlife approached, the desire to have a greater impact on the world became more
acute. The drive that attracted me to becoming an occupational therapist still burned inside, but a yearning grew for something more impactful.
A central question was how to take what I had learned by assisting clients to achieve more independence over the years and do more for them.
Moreover, when this I was 14, I had hip surgery, which required pins being placed through my femoral growth plate. With these pins freshly
placed, I was rolled onto a bedpan; I found the experience painful and mortifying. This event solidified my desire to become an occupational
therapist and help people become more independent.
Innovation
Once the commitment was made to improving the experience for women urinating in bed, the first step had to be determined. Initially, I lacked
the confidence to design a marketable product, so I worked with engineering students to create the first urinal design. After this experience, other
urinals and water bottles were purchased, cut off, turned over, and altered with modeling clay and thermoplastic material. More than 7 design
iterations were completed, and the 8th resulted in success. The AquaEve urinal was created. Task analysis, problem solving, and creativity—for
which occupational therapy practitioners are known—were the tools I used to create the design for the AquaEve urinal.
Review Questions
1. What is an occupational therapy skill that is also useful for innovation?
2. What are 2 ways to mitigate risk?
3. What are 2 ways to overcome barriers to successful entrepreneurship?
SUMMARY Center on Knowledge Translation for Technology Transfer, Uni-

versity at Buffalo, State University of New York. (2017). The need
Participation in entrepreneurship provides dynamic oppor- to knowledge model. Retrieved from http://sphhp.buffalo.edu/cat
tunities for occupational therapy practitioners. With an un- /kt4tt/best-practices/need-to-knowledge-ntk-model.html
derstanding of the characteristics of entrepreneurs, strategies Cottenden, A., Bliss, D. Z., Buckley, B., Fader, M., Gartley, C., Hayder,
for how to participate in entrepreneurship, and how entrepre- D., . . . Wilde, M. (2013). Management using continence products. In
neurship applies to occupational therapy, more occupational P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence:
therapy practitioners have the potential to become entrepre- 5th international consultation on incontinence (pp. 1651–1786).
Arnheim, The Netherlands: International Consultation on Uro-
neurs. As illustrated by the examples in this chapter, occupa-
logical Diseases–European Association of Urology.
tional therapy practitioners who learn the skills and methods
Dobson, C., Koch, R., & Smith, R. (2016). Documenting assistive
of entrepreneurship will promote the advancement of the technology history: The Fred Sammons Archive Project Re-
profession of occupational therapy with new innovations. source. Retrieved from https://www.resna.org/sites/default/files
By following the tenets of entrepreneurship, we can con- /conference/2016/other/dobson.html
tinue to evolve as clinicians, leaders, and agents of change Drucker, P. F. (1993). The practice of management. New York:
to ensure that we are delivering relevant services and best HarperBusiness.
emerging practice to meet the unique needs of the individ- Entrepreneur. (n.d.). In Merriam-Webster’s online dictionary
uals and populations we serve with ever-evolving and ex- (11th ed.). Retrieved from https://www.merriam-webster.com
panding innovations. Occupational therapy practitioners are /dictionary/entrepreneur
poised to advance our participation in the design and imple- Esgro, S. (n.d.). Breaking ground in new practice areas: OT and the
circus. Retrieved from https://www.aota.org/Education-Careers
mentation of the next generation of new ideas by becoming
/Students/Pulse/Archive/career-advice/circus.aspx
entrepreneurs. ❖
Global Business Incubation. (2018, February, 9). Business
incubators —Legal organizational structures. Retrieved from
http://globalbusinessincubation.com/business-incubators-legal
ACOTE STANDARDS -organizational-structures/
This chapter addresses the following ACOTE Standards: Henry, P. (2017, February, 18). Why some startups succeed (and
why most fail). Retrieved from https://www.entrepreneur.com
■ B.3.2. Interaction of Occupation and Activity /article/288769
■ B.3.3. Distinct Nature of Occupation Intrapreneur. (n.d.). Retrieved from http://www.dictionary.com
■ B.3.6. Activity Analysis /browse/intrapreneur
■ B.5.3. Business Aspects of Practice Kenton, W. (2018, March 24). Intrapreneur. Retrieved from http://
■ B.5.6. Market the Delivery of Services www.investopedia.com/terms/i/intrapreneur.asp
■ B.7.3. Promote Occupational Therapy. Knowlton, J. (2017). Conducting a competing product search.
Retrieved from https://sphhp.buffalo.edu/cat/kt4tt/technical
-assistance-and-resources/nidilrr-grantee-technical-assistance
/conducting-a-competing-product-search.html
REFERENCES Osterwalder, A., & Pigneur, Y. (2010). Business model generation:
Accreditation Council for Occupational Therapy Education. (2018). A handbook for visionaries, game changers, and challengers.
2018 Accreditation Council for Occupational Therapy Education Hoboken, NJ: John Wiley & Sons.
(ACOTE) standards and interpretive guide. American Journal of Quote Investigator. (n.d.). Plans are worthless, but planning is everything.
Occupational Therapy, 72, 7212410005. https://doi.org/10.5014 Retrieved from https://quoteinvestigator.com/2017/11/18/planning/
/ajot.2018.72S217 Sastre-Castillo, M., Peris-Ortiz, M., & Danvila-Del Valle, I. (2015).
American Occupational Therapy Association. (2014). Occupational What is different about the profile of the social entrepreneur?
therapy practice framework: Domain and process (3rd ed.). Nonprofit Management and Leadership, 25(4), 349–369. https://
American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. doi.org/10.1002/nml.21138
https://doi.org/10.5014/ajot.2014.682006 Seelig, T. (2017, June 29). Why schools should teach entrepreneur-
Andre, B. (2017, February, 17). 7 incubators that can help your startup. ship. Retrieved from https://www.aspeninstitute.org/blog-posts
Retrieved from https://www.entrepreneur.com/article/287026 /schools-teach-entrepreneurship/
Blank, S., & Dorf, B. (2012). The startup owner’s manual: The step by Smart Design. (n.d.). Getting a grip: A longtime partnership that
step guide for building a great company. Pescadero, CA: K&S Ranch. changed kitchens everywhere. Retrieved from https://smartdesign
Business incubator. (n.d.) Retrieved from https://www.entrepreneur worldwide.com/projects/oxo-partnership/
.com/encyclopedia/business-incubator University of Wisconsin–Milwaukee. (2015, December 15). Re-
BusinessDictionary. (n.d.-a). Risk. Retrieved from http://www nowned OT pioneer Fred Sammons donates collection to UW—
.businessdictionary.com/definition/risk.html Milwaukee Archives. Retrieved from http://uwm.edu/health
BusinessDictionary. (n.d.-b). Startup. Retrieved from http://www sciences/news/renowned-ot-pioneer-fred-sammons-donates
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Castellion, G., & Markham, S. (2012). Perspective: New product fail- -getting-started/general-information-concerning-patents
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Journal of Prod Innovation Management, 30, 976–979. https:// plan. Retrieved from https://www.sba.gov/business-guide/plan
onlinelibrary.wiley.com/doi/abs/10.1111/j.1540-5885.2012.01009.x -your-business/write-your-business-plan
SECTION XII.
Public Policy
Edited by Sarah McKinnon, OT, OTR, OTD, BCPR, MPA
675
CHAPTER
Why Is Policy Important?
Diane L. Smith, PhD, OTR/L, FAOTA, and Melanie Concordia, OTD, OTR/L 73
LEARNING OBJECTIVES
■ Understand the importance of health and non-health–related policies on facilitating or preventing client participation;
■ Discuss how policy influences occupational therapy in practice as well as the need for increased education and re-
search on these policy influences;
■ Describe how occupational therapy practitioners affect policy at the individual, group, organizational, and commu-
nity levels; and
■ Articulate the resources provided at the professional level for occupational therapy practitioners to improve their
policy and advocacy knowledge.

• Health advocacy • Policy competence • Power
• Health policy • Policy influence • Social determinants of health
• Occupational justice • Policy literacy • Triple Aim
• Policy acumen • Political influence
OVERVIEW According to the Occupational Therapy Practice Frame-
H
ealth policy is made up of the decisions, plans, and work: Domain and Process (3rd ed.; American Occupational
actions that are undertaken to achieve specific health Therapy Association [AOTA], 2014a), “achieving health,
care goals within a society. It outlines priorities and well-being, and participation in life through engagement in
the expected roles of different groups, and it builds consensus occupation is the overarching statement that describes the
and informs people (World Health Organization [WHO], domain and process of occupational therapy in its full sense”
n.d.-a). Why is health policy important? Despite medical ad- (p. S4). Occupational therapy practitioners, therefore, focus
vances and health expenditures higher than most developed on creating or facilitating opportunities to engage in occu-
countries, many Americans are unable to achieve their full pations that lead to participation in desired life situations
health potential. This disparity affects not only the quality (AOTA, 2014a).
and duration of their lives but also reduces their ability to To assist occupational therapy practitioners in achieving
participate as well as to be engaged and productive members this purpose, policy and advocacy are mentioned both in the
of society (National Research Council, Committee on Health domain and the process of occupational therapy. Specifically,
Impact Assessment, 2011). Various stakeholders—such as in the domain, it is noted that “occupational therapy prac-
scientists, communities, and policymakers—are recogniz- titioners may recognize areas of occupational injustice and
ing that health is affected by several factors at multiple lev- work to support policies, actions, and laws that allow people
els that occur throughout a person’s lifetime. Many of these to engage in occupations that provide purpose and mean-
factors can be addressed by occupational therapy (Adler & ing in their lives” (AOTA, 2014a, p. S9). With regard to pro-
Stewart, 2010). cess, occupational therapy practitioners and managers are
https://doi.org/10.7139/2019.978-1-56900-592-7.073
677
678 SECTION XII. Public Policy
encouraged to “indirectly affect the lives of clients through literacy. According to Hewison (2008), 1 way is referring to
advocacy” (AOTA, 2014a, p. S11). policy documents and asking the following questions:
Participation in policy efforts by occupational therapy
■ What is the problem that the policy addresses?
managers and practitioners can, therefore, provide an im-
■ When was the process begun?
portant piece of empowering clients to participate in the
■ How many are affected by the policy?
meaningful and purposeful occupations that will allow them
■ Who are the stakeholders?
to achieve health and well-being in the broadest sense.
Another way is to educate oneself through formal or infor-
mal policy courses (Antroubus & Kitson, 1999; Byrd et al.,
ESSENTIAL CONSIDERATIONS 2004), such as participating in continuing education courses
Health advocacy refers to actions taken by health care pro- on relevant policy, webinars, or more formalized additional
fessionals to promote social, economic, educational, and education such as an educational or research doctorate in
political changes that ease the suffering or address threats public policy.
to individual or public health identified through the health
care professional’s work and expertise (Advisory Com- Policy acumen
mittee on Training in Primary Care Medicine and Den- The next stage of the policy influence process, policy acumen,
tistry [ACTPCMD], 2016). It requires developing political is the ability to analyze policies. After occupational therapy
influence, cultivating a professional commitment to pol- managers and practitioners acquire policy acumen, they can
icy, and understanding the connection between policy and actively analyze organizational processes and health care
practice. services, such as new referral or discharge policies to deter-
mine the effect on intervention. This step is especially im-
Development of Political Influence portant for occupational therapy managers because they are
often in decision-making roles and are actively engaged in
To effect change, occupational therapy practitioners must be organizational processes.
knowledgeable about how to influence legislators who can de-
velop and support policies that are favorable to the profession
Policy competence
and clients served. According to Arabi et al. (2014), political
influence is a developmental process that begins with policy Policy competence is related to management in health care.
literacy, moves forward to policy acumen, and then con- Occupational therapy managers who have acquired policy
tinues to policy competence and finally to policy influence. competence can direct their organizations in response to the
Figure 73.1 displays these 4 steps of the policy process. challenges and opportunities related to political situations
(e.g., changes in reimbursement) and advocate for policies
that positively affect their organizations.
Policy literacy
The final stage of policy influence refers to consultation
Policy literacy is the ability to identify and understand a pol- that occupational therapy practitioners can provide to poli-
icy on the basis of policy information and knowledge (Jung, cymakers, establishing an important role in the development,
2008). Malone (2005) described 2 ways to improve policy implementation, and evaluation of government policies about
FIGURE 73.1. Steps of the policy process.
Policy Policy Policy Policy

Literacy Acumen Competence Influence
• Understanding • Analyzing • Health care • Policy

and questioning current policies management consulting that
current policies and their that responds helps shape
• Participating in effects to current or future policies
policy changing • Advocating for
coursework policies change in
• Making policies current policies
that positively
influence the
organization
Note. Steps from Arabi et al. (2014).
CHAPTER 73. Why Is Policy Important? 679
health care (Hewison, 2008). Another important aspect that In addition to the lobbying efforts by AOTA, the Amer-
affects all these stages of policy influence is power, or the abil- ican Occupational Therapy Political Action Committee
ity or authority to have control or influence over others, often (AOTPAC) furthers the legislative goals of the association by
necessary to effect change. influencing or attempting to influence the selection, nomi-
Occupational therapy practitioners need power to protect nation, election, or appointment of any person to any federal
the quality of care and to change organizations (Sullivan & public office with a platform supportive of the profession
Garland, 2010). A final attribute of policy influence is advo- and clients served. AOTPAC also supports any occupational
cacy. Occupational therapy practitioners often serve as client therapy practitioner, occupational therapy assistant, or occu-
advocates. Without involvement in policy, advocacy is inef- pational therapy student member of AOTA seeking election
fective (Boswell et al., 2005). to public office at any level. AOTPAC was authorized by the
AOTA Representative Assembly in 1976 and has been opera-
tional since the spring of 1978 (for more information, see the
Professional Commitment to Policy
AOTPAC home page: https://www.aota.org/Advocacy-Policy
AOTA’s policy-related resources reflect the importance of a /AOTPAC.aspx).
professional commitment to policy issues. Table 73.1 provides Involvement in policy by occupational therapy practi-
suggested resources that AOTA offers to further develop tioners is important to achieve the Triple Aim (Berwick et al.,
members’ professional commitment to policy. Advocacy and 2008, p. 760), which is defined as (1) improving the individual
policy issues are prominent pillars of the organization (see experience of care, (2) improving the health of populations,
AOTA’s Advocacy & Policy home page: https://www.aota.org and (3) reducing the per capita cost of care for populations.
/Advocacy-Policy.aspx). In addition to recent webinars—as Close examination of what policymakers and the system
broad as health care reform and as narrow as understand- view as important demonstrates a need to address relevant
ing the new Current Procedural Terminology (CPT ) codes ® issues related to the Triple Aim, such as hospital readmis-
for reimbursement—t his AOTA service provides information sions, lack of care coordination, and chronic conditions (see
on the latest legislative updates and advocacy efforts by the examples in the “Research” section). Occupational therapy
profession. practitioners need to demonstrate, through research and
Opportunities are provided to members to participate in practice, the effect of solutions to these and other pressing
the policy process through contact with appropriate legisla- problems.
tors to support legislation that supports the clients who are Hildenbrand and Lamb (2013) described how occupa-
served by occupational therapy. AOTA lobbyists are active tional therapy professionals can play a key role in improving
nationally and at the state level to advocate for the profes- the health of a population by reaching out to communities
sion and clients. AOTA Hill Day is an activity sponsored and organizations and by working with clients in managing
by the professional organization in which practitioners, ed- chronic conditions. The authors argued that policymakers
ucators, and occupational therapy students participate by want to hear about evidence-based strategies that are cost ef-
advocating to their congressional representatives for legis- fective and that efficiently use intervention resources. They
lation supportive of occupational therapy, most recently the further explained that absence from the policy table equates
Home Health Flexibility Act (H.R. 3820). This legislation to absence from the policy itself (e.g., direct access to home
would allow occupational therapy practitioners to open a health). Finally, the authors concluded that occupational
home health case without referral from another health care therapy must be more visible and vocal in policy overall
professional (such as a physical therapist or speech–language to ensure inclusion of occupational therapy by name and
pathologist). function.
TABLE 73.1. AOTA Policy Resources
RESOURCE DESCRIPTION LINK

Advocacy & Policy home page A site containing occupational therapy resources and updates https://www.aota.org/Advocacy-Policy.aspx
pertaining to advocacy and policy.
Hill Day An AOTA-sponsored event where educators, students, and clinicians https://www.aota.org/conference-events
advocate for issues important to the profession on Capitol Hill. /hill-day.aspx
AOTPAC A voluntary, nonprofit, nonpartisan, unincorporated committee of https://www.aota.org/Advocacy-Policy

AOTA members furthering the legislative aims of the association. /AOTPAC.aspx
Federal Regulatory Affairs AOTA department that advocates for fair insurance coverage and https://www.aota.org/Advocacy-Policy
payment policies. /Federal-Reg-Affairs.aspx
Note. AOTA = American Occupational Therapy Association; AOTPAC = American Occupational Therapy Political Action Committee.
Policy and Practice the needs of underserved populations in this primary care
setting. FQHCs serve as primary care for underserved areas
Many policies have direct or indirect relationships to occu-
or underserved populations (Centers for Medicare and Med-
pational therapy practice. For example, emerging areas such
icaid Services [CMS], Medicare Learning Network, 2017a).
as health promotion require addressing a much broader set
To support this endeavor, AOTA (2014b) published a position
of factors and policies that shape health-related behaviors
paper that advocated for and highlighted how occupational
than those specifically related to the treatment of health
therapy practitioners could bring a unique perspective to a
conditions. Those factors and their implications for health
primary care team.
have been highlighted in several reports (e.g., Robert Wood
Occupational therapy practitioners work within policies
Johnson Foundation, 2009; WHO, 2002).
and structures that set boundaries on their engagement with
In addition, a broad array of social and economic policies,
clients (Hammell, 2008; Townsend et al., 2003) who are often,
although less frequently investigated in empirical studies,
because of their stigmatized status (Goffman, 1968), in situ-
have measurable health impacts that can be addressed by oc-
ations of inequity, such as those clients with mental health
cupational therapy. Table 73.2 summarizes these broad topics
or substance use diagnoses. In these types of cases, it has
and how they can affect occupational therapy practice and
been argued that occupational therapy practitioners should
the populations accessing these services. For example, pol-
act for social and political changes on the basis of the princi-
icies related to taxation, income supplementation, or access
ples of occupational justice (Pollard et al., 2008), which is a
to education clearly determine a person’s economic resources
subset of social justice concerned with the forms of enabling,
and educational attainment, which have been shown to affect
mediating, or advocating that are needed to create a doing
the occupation of work (Dow et al., 2010). Examples of poli-
environment that is both just and health promoting for all,
cies that can affect participation in ADLs and IADLs as well
recognizing the need to empower people regardless of their
as social participation in general include (1) policies related to
differences (Wilcock & Whiteford, 2003). Social differences
the location of food stores, farmers markets, and other food
realized through occupational injustices require the profes-
services; (2) policies that promote safety and social interac-
sion to develop a transformative and critical position around
tions among neighbors, such as those related to community
the conception of client-centered practice from the perspec-
policing, lighting, organization, and design of attractive pub-
tive of citizenship.
lic spaces; and (3) policies related to economic development
and zoning.
In one example, Murphy et al. (2017) described admin- Political Action Examples Influencing
istrative and policy considerations for occupational therapy Occupational Therapy
services within a federally qualified health center (FQHC)
Several examples of legislation that have influenced occupa-
and how occupational therapy practitioners could address
tional therapy practice include the Individuals with Disabili-
ties Education Act of 1990 (IDEA; P. L. 101–476); the Mental
TABLE 73.2. Types of Policies and Overlap With Areas Health Parity and Addiction Equity Act of 2008 (MHPAEA;
of Occupation P. L. 104–204); components of the Patient Protection and
Affordable Care Act of 2010 (ACA; P. L. 111–148), such as
AREA OF OCCUPATION Medicaid expansion; and the repeal of the Medicare Part B
AFFECTED POLICY AREA Therapy Cap.
ADLs, IADLs ■ Quality, variety, and location of public
transportation IDEA
■ Location of grocery stores, farmers
markets, and other food services IDEA provides access to a free appropriate public education
to eligible children with disabilities and ensures special ed-
Work ■ Taxation
ucation and related services to those children. In addition,
■ Location and price of housing
■ Economic development and zoning
services to children ages 0–2 and 3–5 years are also guaran-
■ Income supplementation teed under IDEA (U.S. Department of Education, Office of
■ Job variety, quality, and environment Special Education and Rehabilitative Services, n.d.). Passage
of IDEA (originally the Education for All Handicapped Chil-
Play, leisure ■ Location and availability of public spaces, dren Act of 1975; P. L. 94–142) was important because oc-
parks, and recreational activities cupational therapy is recognized as a primary service, with
Social participation ■ Physical and social environment schools being one of the largest employer of occupational
structure, support, and safety therapy practitioners.
■ Organization and design of public spaces
Education ■ Access to and quality of educational ACA

services
In another example, the ACA expanded Medicaid eligi-
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living. bility in 2010 to include 138% of the federal poverty level.
However, because of a 2012 U.S. Supreme Court ruling, the and leadership in public policy issues that affect their pro-
expansion is optional for states (Antonisse et al., 2017). As of fessions and the health of the communities they serve (Allan
2014, about half the states elected to expand Medicaid eligi- et al., 2004; Hewison, 2008; McFarlane & Gordon, 1992;
bility. Because states had different eligibility criteria before Patel et al., 2011).
expansion, the demographic characteristics of newly eligi- Specific to occupational therapy, the Accreditation Coun-
ble people varies from state to state. Many clients, especially ®
cil for Occupational Therapy Education (ACOTE ), the ac-
children, receive occupational therapy services through crediting body for occupational therapy education programs
Medicaid, and expansion of eligibility increases the oppor- at the entry level, supports the importance of policy in occu-
tunity for clients to access occupational therapy services. pational therapy through development of standards address-
ing competence in health policy at all levels of education.
ACOTE standards require that graduates of accredited edu-
MHPAEA cational programs “be prepared to advocate as a professional
The MHPAEA is a federal law that generally prevents group for the occupational therapy services offered and for the re-
health plans and health insurance issuers that provide men- cipients of those services” (ACOTE, 2018, p. 3).
tal health or substance use disorder (MH/SUD) benefits from More specifically, at the curriculum level, programs are
imposing less favorable benefit limitations on those benefits required to provide courses in which the student will learn to
than on medical and surgical benefits (CMS, n.d.). Although
the law requires a general equivalence in the way MH/SUD
■ Identify, analyze, and evaluate the contextual factors;
current policy issues; and socioeconomic, political,
and medical and surgical benefits are treated with respect to
geographic, and demographic factors on the delivery of
annual and lifetime dollar limits, financial requirements and
occupational therapy services for persons, groups, and
treatment limitations, MHPAEA does not require large group
populations to promote policy development and social
health plans or health insurance issuers to cover MH/SUD
systems as they relate to the practice of occupational
benefits. However, the ACA builds on MHPAEA and requires
therapy (B.5.1);
coverage of MH/SUD services as 1 of 10 essential health ben-
efit categories in non-grandfathered individual and small
■ Identify, analyze, and advocate for existing and future
service delivery models and policies, and their potential
group plans. This requirement is important because many
effect on the practice of occupational therapy and oppor-
occupational therapy practitioners work in settings serving
tunities to address societal needs (B.5.2); and
people with MH/SUD issues; therefore, parity in reimburse-
ment increases access to these services.
■ Identify and evaluate the systems and structures that cre-
ate federal and state legislation and regulations and their
implications and effects on persons, groups, and popula-
Medicare Part B Therapy Cap tions, as well as practice and policy (B.5.4).
One recent example of effective advocacy called attention to The latest proposed draft of the accreditation standards in-
the negative effects that the Medicare Part B Therapy Cap had cludes these same standards, more specifically addressing
on occupational therapy practice and resulted in repeal of the access to services.
legislation in early 2018 (CMS, Medicare Learning Network, In a comprehensive review of literature related to health
2017b). The “therapy cap” was first adopted in the Balanced policy training (Heiman et al., 2016), barriers to health pol-
Budget Act of 1997 (P. L. 105–33). Under this policy, Medicare icy training included the lack of perceived relevance, the
beneficiaries who exceed the cap cannot receive outpatient lack of resources (or concerns regarding competition for
occupational therapy, physical therapy and speech–language finite resources), and lack of faculty expertise and interest
pathology services, regardless of medical need. (Mou et al., 2011). Barriers also included scheduling and
Since its adoption in 1997, Congress has only allowed the time constraints—specifically, concerns that policy train-
cap on therapy services without exceptions to take effect ing would compete with and dilute and distract from core
4 times. At all other times, they either put in place moratoria clinical training (Cohen & Milone-Nuzzo, 2001). There
on the policy or implemented an exceptions process that al- was also concern about lack of research to inform imple-
lowed access to needed services beyond the amount provided mentation of health policy curricula (Patel et al., 2011).
by the cap. However, thanks to concerted advocacy at the na- Recommendations to address these concerns included en-
tional, state, and grassroots levels, the cap was repealed on gaging necessary interdisciplinary and community and
February 9, 2018. This repeal facilitates access to services for agency-based partners and experts to support health policy
clients receiving therapy paid for by Medicare Part B without training needs (Frenk et al., 2010). On the basis of this re-
the restriction imposed by the cap. view (Heiman et al., 2016), there is a compelling need for
more rigorous research and evaluation to inform health
policy training.
Education
One policy area targeted for occupational therapy and
Health professional leaders and educators from various health other health care profession education is that of the influence
professions, including occupational therapy, have recognized of social determinants of health (SDHs), which are nonmed-
the need for health policy training to support engagement ical circumstances related to how people live, grow, and work
(e.g., housing, education, income) that affect health outcomes Review Questions
(WHO, n.d.-b). In the report Addressing the Social Deter-
1. Discuss how occupational therapy practice helps to achieve
minants of Health: The Role of Health Professions Education
the Triple Aim.
(ACTPCMD, 2016), the authors recommended that in addi-
2. What is 1 example of a policy that has a direct and 1 that
tion to learning about how social factors affect health, health
has an indirect impact on occupational therapy practice?
profession students need opportunities to learn about health
3. How does AOTA directly support education of students
policy and health advocacy. Most especially, the authors rec-
and occupational therapy practitioners with regard to
ommended training to assist faculty and students to advocate
health policy?
for change to reduce health disparities related to SDHs. With
regard to advocacy, the authors recommended that health
care professionals need training on SDHs and issues that af- PRACTICAL APPLICATIONS IN
fect client health outside of the traditional health care setting
as well as interprofessional training in population health,
leadership, social and organizational change, communica- Occupational therapy practitioners can adopt practical
tions, and health policy. applications that can occur at the individual, group, orga-
nizational, and community levels. These examples of policy
participation and advocacy are important because they can
Research often lead to changes that benefit access to occupational ther-
Systematic assessment of the health consequences of policy, apy services for clients.
program, project, and planning decisions is of major impor-
tance for protecting and promoting health because it allows
Individual
the people who are involved in the decision-making process
to consider the health impacts of various policies and their Occupational therapy practitioners have the ability to affect
implementation. Policy decisions can then be modified to health policies on an individual level; however, this effect is
minimize adverse health consequences or to maximize difficult without the required knowledge of the health care
health benefits. Failure to consider health consequences can system as a whole. Occupational therapy practitioners need
result in untended harm or in lost opportunities for health to be aware of policy agendas, policymakers, and political
improvement and disease prevention. backgrounds (Hewitt, 2002). A combination of expertise,
For example, the ACA provided incentives to expand judgment, and policy influence can help them to achieve their
Medicaid coverage (Medicaid.gov, n.d.) for adults with low goals and to facilitate the professional process and the efficacy
income (Murphy et al., 2017). As a result, in states that chose of the health care system.
to expand Medicaid, many people who previously lacked For health care professionals to become successful advo-
access to occupational therapy services because of financial cates, they must dedicate time to training and participating
limitations or lack of insurance now have the means to access in organizations (e.g., AOTA) and initiatives (e.g., Hill Day,
occupational therapy through Medicaid reimbursements. local, state and federal advocacy efforts) to incite change. One
Assessing the health consequence of policies, programs, example would be for occupational therapy practitioners and
projects, and plans is a challenge that requires an interdisci- other health care providers to engage in advocacy by identi-
plinary approach involving disciplines—such as health, so- fying local health problems, working with local partners, and
cial sciences, economics, and policy—and the collaboration developing and communicating plans for a solution.
of scientists, policymakers, and communities. Systematic
processes for rigorously assessing health consequences are
Group
needed.
A review of literature by Heiman et al. (2016) from There has been a significant amount of nursing literature
1983–2013 identified a compelling need for more rigorous and limited occupational therapy literature looking at
research and evaluation to inform health policy training. group participation in the political process that can be ap-
Specific to occupational therapy, Lamb and Metzler (2014) plied to occupational therapy. Suggestions by Arabi et al.
stressed the importance of identifying, protecting, and rec- (2014) to nursing professionals, applicable for occupational
ognizing the specific contribution of occupational therapy therapy, for increasing a clinician’s political influence are
to facility or system outcomes, which can be demonstrated to strengthen political knowledge as a group through ed-
through research. For example, Roberts and Robinson (2014) ucational programs for practitioners and students. These
discussed the important role that occupational therapy prac- can be presented as part of formal educational experiences,
titioners can play in addressing readmissions and hospital- workshops, and active learning sessions (Royal College of
acquired conditions to improve provider performance on Nursing, 2005).
these outcome measures, specifically in the area of accidental In addition, because policy-making requires teamwork
falls. The results of this research can be used to advocate for and needs support and hard work, education on effective
policies supporting occupational therapy services for older decision making by and communication within groups for
adults who may be at risk for falls. occupational therapy practitioners within and outside of the
profession is necessary (Boswell et al., 2005). Finally, educa- ■ Join a school board to advocate for improved nutrition
tion on strategies to strengthen the public mental image of and exercise options in schools to address childhood
occupational therapy as part of a team is imperative because obesity,
policy is related to perceptions and images. Occupational ■ Work with social services agencies to improve client ac-
therapy practitioners’ ability to influence policies depends cess to services needed to address SDHs, and
on others’ images of occupational therapy and also their own ■ Apply for community grants to build programs address-
images of themselves (Fyffe, 2009). ing the needs of the community.
Organizational
Review Questions
Organizational influence, through membership and lead-
ership in organizations such as professional (e.g., AOTA) 1. What are 3 examples of strategies to influence policy at
and community, is imperative to influence policy. Within the individual level?
the description of the policy-making process, Kingdon 2. What are 3 examples related to occupational therapy
(1995) believed that in spite of the dominant effect of gov- strategies to influence policy at the group level?
ernment agents in progression of agenda setting, some 3. Describe how occupational therapy can be involved at the
interest groups, such as AOTA and AOTPAC, have a key community level, not discussed in the text.
role in acceptance or obstruction of an agenda through for-
mation of a coalition. Kingdon further stated that a united
and constant coalition increases the chance for victory in SUMMARY
policy streams by influencing agenda setting and policy Health systems are rapidly developing and changing. As
formation. a result, occupational therapy managers and practitioners
need to influence the formation of health policies rather than
Community just the implementation of them. Then they need to be ac-
tive in the development of health policies to be better able
Van Bruggen (2014) discussed occupational therapy’s role
to control their practice (Toofany, 2005). They need to ac-
in contributing to social and educational reform and chal-
quire policy-making skills to address professional challenges
lenged occupational therapy practitioners to advocate for
(Ferguson, 2001).
policies outside the health sector focused on treating people.
Occupational therapy practitioners should understand
Issues that cannot be addressed by individual solutions in-
the levels of power and know who controls the resources
clude poverty, social inclusiveness, and occupational justice.
of health services and their organizations; they should also
Occupational therapy practitioners can accomplish this
be knowledgeable about policies that affect clients, fam-
goal by working with government and systems-level poli
ilies, the profession, and the health care system (Taft &
cies, otherwise there is a risk that others will fill the gaps in
Nanna, 2008). Occupational therapy managers’ and prac-
society.
titioners’ influence in health policies protects client safety,
ACTPCMD (2016) provided the following examples of
increases quality of care, facilitates the client’s access to
how health care providers can make a positive impact in their
required resources, and promotes quality health care
community through advocacy work:
(Ferguson, 2001; Nembhard & Edmondson, 2006). Case
■ Volunteer on a statewide health board or coalition to Example 73.1 gives an example of why policy and advocacy
advocate for state health care reform to help the uninsured, are important. ❖
CASE EXAMPLE 73.1. Alice: Home Health Advocacy
Alice is an occupational therapy graduate who works part-time in an inpatient rehabilitation facility and part-time for a home health agency in rural
Illinois. Often, the clients that Alice sees at the inpatient facility, such as those with complex health needs (e.g., cerebrovascular accident), will
require continued occupational therapy services by the home health agency. Alice is frustrated because of Medicare regulations; as an occupational
therapy practitioner, she cannot open these home health cases. Because she lives in a rural area, there is often a significant wait time until another
health care professional can complete the initial evaluation and refer the clients for occupational therapy, resulting in a gap in services for the
client, which can affect his or her ability to participate in meaningful and purposeful occupations. Alice’s clients are generally low income and often
unemployed, and therefore, they depend on public insurance to assist with health care.
Review Questions
1. Identify the issues that Alice is facing and what legislative strategies or policies could address these issues.
2. What are examples of strategies that Alice could incorporate at the individual, group, organizational, and community levels to advocate for
her clients?
3. How could Alice, who is an AOTA member, use professional resources to advocate for her clients and her profession?
ACOTE STANDARDS Centers for Medicare and Medicaid Services, Medicare Learning
Network. (2017a). Federally qualified health center. Retrieved
This chapter addresses the following ACOTE Standards: from https://www.cms.gov/Outreach-and-Education/Medicare
-Learning-Network-MLN/MLNProducts/downloads/fqhcfact
■ B.5.1. Factors, Policy Issues, and Social Systems sheet.pdf
■ B.5.2. Advocacy Centers for Medicare and Medicaid Services, Medicare Learning
■ B.5.4. Systems and Structures That Create Legislation. Network. (2017b). MLN matters: Therapy cap values for calendar
year (CY) 2018. Retrieved from https://www.cms.gov/Outreach
-and-Education/Medicare-Learning-Network-MLN/MLN
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CHAPTER
Regulatory and Payment Issues
Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA 74
LEARNING OBJECTIVES
■ Describe the critical relationships that exist among provision of services, documentation, coding, billing, and
reimbursement;
■ Understand the role of occupational therapy practitioners in terms of knowing introduction to coding and resources
to select proper ICD–10 and CPT codes for reimbursement;
■ Explain the importance of knowing who the payer is prior to beginning an occupational therapy evaluation;
■ Describe the difference between a fee-for-service and a prospective payment system; and
■ Explain ongoing system changes in payment systems.

• Billing • Documentation • Occupational therapy services
• Billing agents • HCPCS codes • Patient-driven payment model
• Coding • ICD–10 codes • Reimbursement
• Co-pays • Medical necessity • Skilled services
• CPT codes • Medical reviewer • Third-party payers
• Deductible • Occupational therapists in
• Direct access private practice
OVERVIEW resources within a state and the decisions made through voter
referendum or state legislation determine payment policies
R
egulatory and payment issues are complex and constantly and program eligibility for various populations. In addition
changing. This chapter provides guidelines and describes to federal and state regulations for reimbursement of services,
basic principles related to these issues. The payment pro- private insurance companies set their own policies for reim-
cess, from providing services to receiving payment, is similar for bursement. This chapter gives an overview of reimbursement
all third-party payers, which refers to the insurance company or through service provision, documentation, coding, and billing.
other entity that is paying for service (the patient is the first party
and the provider the second). Learning the importance of who is ESSENTIAL CONSIDERATIONS
paying and understanding the how of billing and what of third
party regulations informs the why of documentation guidelines. Reimbursement is financial remuneration for services pro-
Readers must investigate how regulatory and payment is- vided. The payment process involves
sues apply to specific settings and to specific geographical areas • Provision of occupational therapy services,
because federal health care reimbursement rules vary by setting • Documentation of services,
and rates vary by geographical location, and state programs • Coding of services,
have their own rules and regulations. States develop health • Billing of claims, and
care programs according to their residents’ specific needs; • Reimbursement for services (Figure 74.1).
https://doi.org/10.7139/2019.978-1-56900-592-7.074
687
CHAPTER
Regulatory and Payment Issues
Mary Jo McGuire, MS, OTR/L, OTPP, FAOTA 74
LEARNING OBJECTIVES
■ Describe the critical relationships that exist among provision of services, documentation, coding, billing, and
reimbursement;
■ Understand the role of occupational therapy practitioners in terms of knowing introduction to coding and resources
to select proper ICD–10 and CPT codes for reimbursement;
■ Explain the importance of knowing who the payer is prior to beginning an occupational therapy evaluation;
■ Describe the difference between a fee-for-service and a prospective payment system; and
■ Explain ongoing system changes in payment systems.

• Billing • Documentation • Occupational therapy services
• Billing agents • HCPCS codes • Patient-driven payment model
• Coding • ICD–10 codes • Reimbursement
• Co-pays • Medical necessity • Skilled services
• CPT codes • Medical reviewer • Third-party payers
• Deductible • Occupational therapists in
• Direct access private practice
OVERVIEW resources within a state and the decisions made through voter
referendum or state legislation determine payment policies
R
egulatory and payment issues are complex and constantly and program eligibility for various populations. In addition
changing. This chapter provides guidelines and describes to federal and state regulations for reimbursement of services,
basic principles related to these issues. The payment pro- private insurance companies set their own policies for reim-
cess, from providing services to receiving payment, is similar for bursement. This chapter gives an overview of reimbursement
all third-party payers, which refers to the insurance company or through service provision, documentation, coding, and billing.
other entity that is paying for service (the patient is the first party
and the provider the second). Learning the importance of who is ESSENTIAL CONSIDERATIONS
paying and understanding the how of billing and what of third
party regulations informs the why of documentation guidelines. Reimbursement is financial remuneration for services pro-
Readers must investigate how regulatory and payment is- vided. The payment process involves
sues apply to specific settings and to specific geographical areas • Provision of occupational therapy services,
because federal health care reimbursement rules vary by setting • Documentation of services,
and rates vary by geographical location, and state programs • Coding of services,
have their own rules and regulations. States develop health • Billing of claims, and
care programs according to their residents’ specific needs; • Reimbursement for services (Figure 74.1).
https://doi.org/10.7139/2019.978-1-56900-592-7.074
687
FIGURE 74.1. The service-payment cycle: Provision of OT services to reimbursement.
OT Services
Reimbursement Documentation
Billing Coding
Note. OT = occupational therapy.
It is critical for occupational therapy practitioners and in which they practice; they should contact the state-specific
managers to understand the important relationships and flow licensing board to find out whether their state permits direct
among these components. There are guidelines, regulations access to occupational therapy practitioners.
and policies set by professional organizations, institutions, In addition to receiving a referral or a request to provide
accrediting bodies, and payers for each component of this occupational therapy services, occupational therapy prac-
cycle. Practitioners must identify what set of guidelines or titioners should also know who the payer is prior to begin-
regulations apply to their particular settings and cases and ning an occupational therapy evaluation. Knowing the payer
learn the rules. source, whether self-paying or through a third-party payer,
This section further defines the components of the reim- is necessary before submitting for reimbursement. Although
bursement process and focuses on the federal rules that apply a state may permit direct access, a third-party payer may re-
in all states. Practitioners and managers should explore the quire a physician to determine need for therapy to reimburse
American Occupational Therapy Association’s (AOTA) web- for services. Each third-party payer has different language
site (www.aota.org) and their state associations for informa- and specific requirements for services; some require a phy-
tion regarding specific settings and programs. sician’s order while others may authorize an evaluation and
require preauthorization of intervention. Medicare permits
Occupational Therapy Services a therapist to perform an evaluation and begin intervention
so long as a qualified health care practitioner certifies the
Occupational therapy services are the skilled actions pro- need for services within 30 days of the occupational therapy
vided by an occupational therapy practitioner. These services evaluation.
include, but are not limited to, evaluations and intervention
sessions. Services are provided in a wide variety of settings
Documentation
and contexts, and vary in duration given the settings’ stan-
dards and the client’s needs. Documentation is the official written record that details or
Most frequently, occupational therapy practitioners re- summarizes the provision of occupational therapy services.
quire a referral from a physician to initiate occupational After occupational therapy practitioners determine who is
therapy services; however, some states have direct access laws paying for services and understand what services or codes
that permit the provision of occupational therapy services are covered and the guidelines for coverage, if there is a third
without a physician or other qualified provider’s prescrip- party-payer, they must properly document to fulfill those
tion or referral. The term direct access refers to a health care requirements.
professional’s legal right to provide services without a doc- AOTA’s (2013) Documentation Guidelines for Occupa-
tor’s referral. Managers and practitioners should be aware of tional Therapy provide general and specific documentation
how occupational therapy services are regulated by the state recommendations. In addition, AOTA’s website has excellent
CHAPTER 74. Regulatory and Payment Issues 689
resources, including the AOTA Occupational Profile Tem- be reasonable and necessary. Although defined by CMS, these
plate (AOTA, 2017), and guidelines for collecting data in terms are often still subject to interpretation by a medical re-
accordance with the language and structure of the Occu- viewer, who is someone hired by an insurance company to
pational Therapy Practice Framework: Domain and Process review documentation and determine whether the services
(AOTA, 2014). are covered by the insurance policy. The Medicare Benefits
Policy Manual defines medical necessity as follows:
For Additional Learning Services are medically necessary if the documentation

indicates they meet the requirements for medical
For additional learning, see Chapter 28, “Guidelines for Effective necessity including that they are skilled, rehabilitative
Documentation and Quality Reporting.” services, provided by clinicians (or qualified professionals
when appropriate) with the approval of a physician/
NPP [nonphysician practitioner], safe, and effective (i.e.,
The Centers for Medicare and Medicaid Services (CMS)
progress indicates that the care is effective in rehabilitation
provide extensive, specific guidelines for documentation of
of function). (CMS, 2017, 220.3)
services covered under Medicare. These guidelines are found
in Section 220.3 of the Medicare Benefit Policy Manual, titled The Medicare Benefit Policy Manual includes an extensive
“Documentation Requirements for Therapy Services” (CMS, section, “Reasonable and Necessary Outpatient Rehabil-
2017). CMS defines skilled services as “those services requir- itation Therapy Services,” that provides details to consider
ing the skills of physical therapists, speech–language pathol- when documenting to defend the necessity of occupational
ogists, or occupational therapists” (220.3.A). therapy services (CMS, 2017). Some of the critical points
Documentation of skilled services covered by Medicare in that section that support medical necessity are listed in
must describe the medical necessity of the services and must Exhibit 74.1.
EXHIBIT 74.1. Critical CMS Excerpts Related to What Constitutes Reasonable and Necessary Skilled Therapy
If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable,
of a therapist, the service cannot be regarded as a skilled therapy service. (220.2.A)
Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow
further deterioration of the patient’s condition. (220.2.A)
The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition.
This includes Guidelines and literature of the professions of . . . occupational therapy. (220.2.B)
The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and
effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. (220.2.B)
While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or
prognosis cannot be the sole factor in deciding that a service is or is not skilled. (220.2.B)
The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local
professionals or the state or national therapy associations in the development of any utilization guidelines. (220.2.B)
If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such
potential, rehabilitative therapy is not reasonable and necessary. (220.2.C)
Rehabilitative therapy may be needed, and improvement in a patient’s condition may occur, even when a chronic, progressive, degenerative, or terminal
condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services.
The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient’s condition or
to maximize his/her functional abilities. The deciding factors are always whether the services are considered reasonable, effective treatments for the
patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by non-skilled personnel. (220.2.C)
Rehabilitative therapy is not required to effect improvement or restoration of function when a patient suffers a transient and easily reversible loss
or reduction of function (e.g., temporary and generalized weakness, which may follow a brief period of bed rest following surgery) that could
reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations is not
considered reasonable and necessary for the treatment of the individual’s illness or injury and the services are not covered. (220.2.C)
Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under
a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further
deterioration in function. (220.2.D)
Note. Adapted from CMS (2017). In the public domain.
Medicare is the largest third-party payer in the country WHO

and most insurance companies apply the same guidelines re-
WHO (2016) created a set of codes, ICD–10 codes, that are
garding standards for documentation. Detailed documenta-
used in health care to identify specific diagnoses for clients
tion requirements established by Medicare and other payers
served. Although WHO has published the ICD–11, at the time
are outside the scope of this chapter, but occupational therapy
of publication, the medical community is still using ICD–10
managers and practitioners should be very well acquainted
codes to describe the medical and treatment diagnoses being
with the specific documentation requirements set by CMS.
treated by health care professionals. Occupational therapists
One major change in terms of coverage and documentation
must choose which diagnoses align with the purpose of the
of services has to do with the provision of skilled services for
occupational therapy evaluation and intervention provided
those clients who need functional maintenance programs. In the
and code those diagnoses into the claim.
past, it was generally understood that skilled services were cov-
Practitioners should request that the physician, optome-
ered only if a client could make progress; the case of Jimmo vs.
trist, or nurse practitioner responsible for referring the client
Sebelius (2013) challenged this misinterpretation (CMS, 2014).
for occupational therapy services provide the ICD–10 codes
Skilled services are sometimes needed to ensure maintenance of
that were used in their medical records. In additional to a
function or to prevent or slow deterioration of function. Gener-
medical diagnosis code, therapists can also add a “therapy
ally, practitioners should include evidence that the services are
diagnosis” that relates to specific behavioral or client factors
indeed skilled, safe, necessary, and effective. This chapter aims
that are addressed in therapy.
to guide practitioners to the CMS (2017) manual where the de-
For example, a client may be referred to an occupational
tails are published; these guidelines are the standards by which
therapist with the medical diagnoses of a transient cerebral
CMS payment of services can be denied or appealed.
ischemic attack, unspecified; the ICD–10 diagnosis code is
Medicaid rules vary by state and are published online for
G45.9. The occupational therapist who evaluates the client
practitioners to reference. State Medicaid programs and pri-
may identify an “attention and concentration deficit”; the
vate insurance policies set the amount and type of services
treatment diagnosis could be coded R41.840.
that are covered and provide directives regarding referral and
payment policies. Some regulations include seeking prior au-
thorization before an evaluation is done, after an evaluation AMA
is submitted, or prior to treatment beginning. Other regula- AMA publishes Current Procedural Terminology every year
tions can include type and number of codes and units that and updates the codes used for submitting claims (AMA,
can be submitted per day and within a set range of time. 2018). AMA owns the copyright for the CPT codes used by
Documentation of services must also properly align with the health care professionals. In January 2017, 3 new occupational
codes that are submitted for reimbursement. therapy evaluation codes were published with specific criteria
to guide therapists to code if an evaluation was of low, mod-
erate, or high complexity. Currently, Medicare reimburses
practitioners at the same rate for these 3 codes; however, this is
For additional learning, see Chapter 30, “Private Health Insurance.” subject to change. Some insurance companies reimburse these
3 codes at different rates; it is up to the third-party payer to de-
cide whether the evaluation codes will be paid at a single or dif-
Coding ferent rates. The evaluation code is a service code, which means
it can only be billed for 1 unit; it is not a timed code. Although
The Health Insurance Portability and Accountability Act of
the CPT manual lists typical times associated with each of the
1996 (HIPAA; P. L. 104–191) established rules regarding the
3 codes, time is not a factor to be used to determine the com-
electronic submission of data related to health care that re-
plexity of the evaluation. Information regarding the specifics
quire using various code sets. Three organizations provide
about these evaluation codes developed by AMA is available
essential information for coding:
from AOTA (see http://www.tinyurl.com/OTM-CPThelp).
1. World Health Organization (WHO; ICD–10 codes), The majority of CPT codes used by occupational therapy
2. American Medical Association (AMA; Current Proce- practitioners are found in the “Physical Medicine and Reha-
dural Terminology [CPT] codes), and bilitation” section of CPT manual; this section is referred to
3. CMS (G–codes for types of therapy and L–codes for du- as the “97000” series of codes. Occupational therapy practi-
rable medical equipment and orthotics). tioners also use codes from other sections of the CPT manual
(e.g., codes in the 96000 series related to central nervous sys-
It is important for occupational therapy managers and practi-
tem assessments and tests).
tioners to understand the constantly changing world of cod-
AMA is constantly reviewing, editing, deleting and add-
ing to ensure payment of services. Coding is used to
ing codes. AMA has a CPT editorial panel that makes de-
■ Describe the diagnoses of clients served, cisions about changes; they meet 3 times a year and have a
■ Identify the complexity of the occupational therapy large advisory group made up of representatives from phy-
evaluation, and sician and non-physician professional organizations. AOTA
■ Describe the type and amount of intervention provided. has a representative on the Healthcare Professional Advisory
Committee who participates in this process, advocating for coverage, it is responsible for a larger portion of the claim.
the occupational therapy profession. AOTA’s website has ad- Clients are often unaware of this information.
ditional information on commonly used CPT codes. Occupational therapy practitioners and managers should be
aware that the insurance industry has varied levels of responsi-
bility regarding covering claims and that the rules of the primary
CMS provider typically determine coverage and reimbursement. Bill-
CMS uses what is termed their Healthcare Common Pro- ing agents become proficient in entering the electronic portals
cedure Coding Set, commonly referred to as HCPCS codes. of various insurance companies and exploring the rules and re-
There are 2 levels of HCPCS codes: quirements of each company; sometimes the various ”products”
offered by the same insurance company can have different rules.
■ Level 1 codes are the 5-digit AMA CPT codes and Managers and practitioners must understand the rules of the
■ Level 2 codes are owned by CMS and can be recognized by primary provider to reduce the risk of denial of payment.
their alpha-numeric format. In addition, billing agents are aware of the rules and lan-
The most widely used Level 2 HCPCS codes are L–codes, guage set by specific providers related to submitting electronic
which identify specific types of orthotics provided to beneficia- claims and understanding the explanation of benefits that are
ries by durable medical equipment companies, and G–codes, returned to providers. Claims can be denied for small techni-
which are used on claims forms to identify the type of provider. cal details that billing specialists can identify; resubmission of
claims is a common reality in the billing process. Billing spe-
cialists are an essential part of the administrative team for effi-
Billing cient and just payment of services; they work with occupational
Medical billing and coding is a growing industry. Several therapy practitioners and managers to properly code the skilled
professional associations support and train individuals in the services provided and submit claims for reimbursement. CMS
work of medical billing and coding, including the American has details about the definitions and proper use of modifiers
Medical Billing Association, the American Academy of Pro- available, but most successful businesses use billing agents with
fessional Coders, and the Professional Association of Health- coding expertise to navigate the reimbursement system.
care Coding Specialists. Although occupational therapy prac- Many insurance companies have deductibles that benefi-
titioners must have the skills to select the code that describes ciaries must pay out before coverage begins. A deductible is an
the occupational therapy services provided and documented, established amount of money that a client must pay before the
the actual billing of those services is typically executed by insurance company begins covering services. The amount of the
a professional coder. Professional coders work closely with deductible varies and often is set at a lower level as the premium
occupational therapists to be sure that the proper codes and for the product (i.e., insurance program) increases. Some, but
modifiers are used when billing claims. not all, insurances also include co-pays that beneficiaries must
Billing of services involves the addition of modifiers (e.g., pay per visit; the co-pay can be a flat fee or a percentage of the fee.
−59, −25, KX, GO) that give payers specific information that Clients who are on Medicare have an annual deductible,
permits payment of services that may otherwise not be paid. and must pay 20% of the cost of outpatient services. Some
Placing these modifiers at the right time and in the right Medicare Advantage programs offer beneficiaries full cover-
place on the claim form supports reimbursement. For exam- age for occupational therapy outpatient services provided in
ple, the −59 modifier indicates that a service was a “distinct the home by private practice therapists.
procedural service,” which is used when a provider wants Those private practice therapists who are enrolled as Medi-
to indicate that there were 2 different services provided. It care providers can serve clients in their homes even if they
communicates to the payer that the same service is not being are not homebound and without any other qualifying service.
billed twice—2 codes cannot be billed for the same service, so Whereas occupational therapy is not a “qualifying service”
the −59 modifier is needed when 2 codes that are considered under Part A Home Health Care benefits at this time, Part B
“bundled” are actually provided at different times during the practitioners may enter a case and provide outpatient therapy in
same session. the home without any other skilled service but the service still
For example, 97535 (i.e., self-care/home management) has to be certified by a physician and travel is not covered. Occu-
and 97530 (i.e., therapeutic activities) are bundled. If services pational therapists can enroll with CMS to become independent
were provided separately, the −59 modifier is applied to indi- providers of services to Medicare beneficiaries; CMS refers to
cate this. No matter how medically necessary a service is, or these clinicians as occupational therapists in private practice.
how professionally it was provided, if it is not properly coded,
it will not be paid. Coding requires billing agents to know not
Reimbursement
only what code to use but also when to use it.
Billing agents also must be aware of whether an insur- When occupational therapy services are provided, coded
ance company is providing primary, secondary, or tertiary properly, covered by an insurance carrier, and billed in the
coverage in a case. An insurance company may be providing proper sequence, it is likely that the provider will be paid.
primary coverage for a client but secondary coverage for an- However, policies set by CMS are national policies; there are
other client. When an insurance company provides primary also local coverage determinations (LCDs) that managers
must research for their region. Occupational therapy manag- reduce costs. It is critical for the profession of occupational ther-
ers should check with the Medicare Administrative Contrac- apy to participate in the process of developing APMs to clearly
tor in their region of the country to see if there are any LCDs communicate the distinct value of occupational therapy services
that need to be reviewed. to those who are developing these systems so that clients receiv-
Payment for occupational therapy services may or may not ing “bundled care” can receive the skilled services they need.
require the following:
■ Preauthorization of services: Some insurance companies Review Questions
require practitioners to request permission to do an eval- 1. What are the differences among codes developed by
uation and then to submit the findings to receive a spec- WHO, AMA, and CMS, in terms of coding?
ified number of visits. Frequently, there are special forms 2. Briefly describe how coding may be used related to occu-
created by the insurance company that must be completed pational therapy documentation.
and submitted. Practitioners must communicate with the 3. Describe the role of a billing agent.
third-party payer to identify these specific rules.
■ Order from a referring physician: Most but not all insur-
ance companies require a prescription or a physician PRACTICAL APPLICATIONS IN
signature on a plan of care that supports the provision of OCCUPATIONAL THERAPY
occupational therapy services. Medicare does not require
a prescription but will accept one, particularly when a When an occupational therapy practitioner accepts a refer-
therapist provides only an evaluation. This crucial point ral for a client, it is critical for the practitioner to know who
is often misunderstood and can delay the provision of an the payer is and their requirements for documentation and
evaluation. If a client has a qualified health care profes- coding of services. Payers vary in their requirements; skilled
sional willing to certify the need for services, occupational services must be authorized, documented, and coded in a
therapists can provide the evaluation and obtain a signa- manner that is consistent with the rules and regulations of
ture within 30 days from a qualified health care profes- the third-party payer, or there may not be any reimbursement
sional to certify the need for these services (CMS, 2017). for the services provided. Moreover, practitioners and man-
■ Certification of the plan of care: Medicare requires the signa- agers must also learn and understand the differences between
ture of a physician, optometrist, or nurse practitioner on the timed codes and service codes, and avoid any external pres-
plan of care certifying the need of services within 30 days of sures to upcode or to overcode.
the occupational therapy evaluation. Every state Medicaid
program and insurance company sets its own rules. For Additional Learning
Traditionally, occupational therapy services were reim-
For additional learning, see Chapter 63, “Billing for Occupational
bursed on a fee-for-service basis, meaning that a fee was paid Therapy.”
for each service provided. In 1983, the federal government
began a different model of payment in the acute care setting;
a prospective payment system (PPS) was designed whereby a Occupational therapy practitioners are motivated to focus
pre-determined amount of money was reimbursed to the hos- on client-centered care and to provide skilled services that
pital based on diagnostic related groups. In the PPS model, a support the accomplishment of client goals. However, they
hospital was reimbursed a set fee based on the patient’s diag- must also be aware of the external contextual factors related
nosis; the length of stay (and the quantity and type of therapy to payment of services, and document and code the services
provided) was not a determining factor in the payment model. in a professional, honest manner to ensure reimbursement of
The federal government then developed a PPS for skilled services. Case Example 74.1 describes a scenario in which an
nursing facilities and home health agencies on the basis of occupational therapist must seek preauthorization of services
other factors. Currently, Medicare uses separate PPSs for based on their knowledge of coding.
reimbursement to acute inpatient hospitals, home health In addition to understanding payer, codes, and documen-
agencies, hospice, hospital outpatient, inpatient psychiatric tation needs for reimbursement, it is also important to under-
facilities, inpatient rehabilitation facilities, long-term care stand the current regulatory and payment issues that exist to
hospitals, and skilled nursing facilities (CMS, 2018). Therapy demonstrate quality of services. Beginning in October 2019,
is not reimbursed on a fee-for-service basis when provided the CMS will transition to a patient-driven payment model
in a setting where payment for therapy is bundled in a PPS. (PDPM) to recognize clinically relevant factors, such as qual-
In those settings, management may collect information about ity outcomes, rather than specific codes for diagnoses and
the number of minutes or units of therapy in order to analyze patient characteristics for reimbursement in skilled nursing
patterns of use and determine productivity levels. facilities (SNFs; CMS, 2019).
Health care leaders are working to develop alternative pay- Under the current payment system in SNFs, reimburse-
ment models (APMs) to improve the effectiveness and quality ment is often tied to the amount of therapy a client receives
of services while reducing the cost of care. Health maintenance rather than on the basis of the quality of services provided.
organizations, preferred provider organizations, accountable With PDPM, it will be essential for occupational therapy
care organizations, and others are all efforts to improve care and practitioners to demonstrate client-centered outcomes tied
CASE EXAMPLE 74.1. Preauthorization
A 63-year-old man was referred for outpatient occupational therapy services after being diagnosed as being in the early stages of Parkinson’s
disease (PD). The OT identified that the third-party payer was a private insurance company that required preauthorization of services after
the evaluation was completed and before intervention was provided. The OT evaluation was completed and included an occupational profile,
assessment of performance deficits, clinical reasoning, and a plan of care. The plan of care included long-term and short-term goals, therapeutic
plans, and details regarding the expected frequency and duration of therapy.
The ICD–10 code for PD was coded, and the CPT code for a moderate-level occupational therapy evaluation was also coded. All of this information
was submitted, along with a copy of the doctor’s order that certified the medical necessity for the evaluation, to the insurance company. The therapist
informed the client that he would be contacted to schedule an appointment for treatment as soon as the insurance company authorized services.
Review Questions
1. Why is it important for a therapist to know who the payer is for occupational therapy services?
2. What is the difference between ICD–10 and CPT codes?
3. True or False. If an occupational therapy practitioner has an order for an evaluation or treatment, it will be covered by insurance.
specifically to occupational therapy services provided to REFERENCES

demonstrate the value of occupational therapy required for
reimbursement.
Review Questions of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
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1. What does PDPM stand for and how does it affect occu- American Medical Association. (2018). CPT 2019 professional.
pational therapy? Chicago, IL: Author.
2. What key resource is helpful in understanding codes, American Occupational Therapy Association. (2013). Guidelines
specifically CPT codes? for documentation of occupational therapy. American Journal of
Occupational Therapy, 67, S32–S38. https://doi.org/10.5014/ajot
.2013.67S32
SUMMARY American Occupational Therapy Association. (2014). Occupational
Rules set by federal, state, and third-party payers constantly therapy practice framework: Domain and process (3rd ed.).
change and affect reimbursement. Third-party payers often American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
set limits on services and requirements for documentation https://doi.org/10.5014/ajot.2014.682006
and coding of services that must be understood at the onset American Occupational Therapy Association. (2017). AOTA oc-
cupational profile template. American Journal of Occupational
of providing services. Occupational therapy practitioners,
managers, and their office administrators must know who Centers for Medicare and Medicaid Services. (2014). Manual up-
the payer will be prior to initiating services; indeed, in some dates to clarify skilled nursing facility (SNF), inpatient rehabilita-
cases, pre-authorization requests must precede the evaluation tion facility (IRF), home health (HH), and outpatient (OPT) cov-
for reimbursement to occur. Although administrative assis- erage pursuant to Jimmo vs. Sebelius. Retrieved from https://www
tants can be used to help collect this important information, .cms.gov/Out reach-a nd-Educat ion/Med ica re-L ea r ni ng
as well as to do the clerical work, practitioners are primarily -Network-MLN/MLNMattersArticles/downloads/MM8458.pdf
responsible for the appropriate selection of codes Centers for Medicare and Medicaid Services. (2017). Covered med-
Occupational therapy practitioners and managers must ical and other health services. In Medicare benefit policy manual.
be comfortable with ICD–10 codes, CPT codes, and G–codes Retrieved from https://www.cms.gov/Regulations-and-Guidance
so they properly document information about clients’ diag- /Guidance/Manuals/Downloads/bp102c15.pdf
Centers for Medicare and Medicaid Services. (2018). Prospective
noses, evaluation and intervention services, and functional
payment systems: General information. Retrieved from https://
limitations. They must not only provide and document the www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment
provision of skilled services but also must ensure that docu- /ProspMedicareFeeSvcPmtGen/index.html
mentation is consistent with the codes selected for billing the Centers for Medicare and Medicaid Services. (2019). SNF PPS pay-
services. Information about coding is complex, and private ment model research: patient driven payment model. Retrieved
practices benefit from hiring coding experts who can support from https://www.cms.gov/Medicare/Medicare-Fee-for-Service
the addition of the appropriate modifiers on claims. ❖ -Payment/SNFPPS/therapyresearch.html
Health Insurance Portability and Accountability Act of 1996, Pub.
L. 104–191, 110, Stat. 1936.
ACOTE STANDARDS Jimmo v. Sebelius, 2013. U.S. District Court, District of Vermont,
This chapter addresses the following ACOTE Standards: Case No. 5:11-cv-17.
World Health Organization. (2016). International statistical clas-
■ B.4.29. Reimbursement Systems and Documentation sification of diseases and related health problems (10th rev.).
■ B.5.5. Requirements for Credentialing and Licensure. Retrieved from https://icd.who.int/browse10/2016/en
CHAPTER
State Regulation of Occupational Therapy
Kristen Neville, MA, and Chuck Willmarth, CAE 75
LEARNING OBJECTIVES
■ Explain the importance of state regulation for occupational therapists (OTs) and occupational therapy assistants (OTAs);
■ Identify key licensure requirements to practice as an OT or OTA;
■ Distinguish between the legal requirements of state law regulating occupational therapy and the requirements of
certification organizations, such as the National Board for Certification in Occupational Therapy (NBCOT ); ®
■ Understand the legislative and regulatory process;
■ Describe the difference between statutes and regulations or rules; and
■ Identify the consequences of failure to comply with the licensure requirements, laws, and regulations or rules.

• Administrative agency • Legislation • Scope of practice
• Certification by NBCOT • Licensure • Statutes
• Credentialing • Practice acts • Sunrise laws
• Interstate compact • Regulations • Sunset laws
OVERVIEW reimbursement for occupational therapy services, funding
O
for higher education, the awarding of research grants, and
ccupational therapy is regulated in all 50 American establishment of licensing procedures.
states, the District of Columbia, Puerto Rico, and
In the United States, the earliest evidence of state regu-
Guam. The major purpose of state regulation is to
lation of professions was the Virginia Medical Practice Act
protect consumers in a state or jurisdiction from unqualified
of 1639 (Federation of State Medical Boards, 2015). State
or unscrupulous practitioners. State regulation also ensures a
licensure activity (i.e., the process by which a governmental
high level of professional conduct on the part of occupational
therapists (OTs) and occupational therapy assistants (OTAs). agency grants permission to a person to engage in a given
State laws and regulations (or rules, as termed in some occupation) did not begin in earnest, however, until the late
states) greatly affect the practice of occupational therapy. 1800s. Action by the U.S. Supreme Court had an impact on
Laws or statutes (i.e., a written law passed by a legislative state licensure: “The most far-reaching action of the federal
body) are enacted by legislators, who are elected public of- government related to state regulation of the health profes-
ficials. Regulations specifically describe how the intent of sions was the affirmation by the U.S. Supreme Court of the
laws will be carried out. These regulations are developed constitutional right of state licensing boards to require a
by regulators, who are appointed public officials of various specific educational credential in the late 19th century (Dent
departments in state government. Both kinds of officials v. West Virginia [1888])” (Morrison, 1996, State Regulation
make decisions that directly and indirectly affect occupa- and the Federal Government section, para. 2). “By 1900 most
tional therapy managers and practitioners. These decisions states had licensed attorneys, dentists, pharmacists, physi-
may include the setting of certain standards, coverage and cians, and teachers. Between 1900 and 1960, most states also
https://doi.org/10.7139/2019.978-1-56900-592-7.075
695
CHAPTER
State Regulation of Occupational Therapy
Kristen Neville, MA, and Chuck Willmarth, CAE 75
LEARNING OBJECTIVES
■ Explain the importance of state regulation for occupational therapists (OTs) and occupational therapy assistants (OTAs);
■ Identify key licensure requirements to practice as an OT or OTA;
■ Distinguish between the legal requirements of state law regulating occupational therapy and the requirements of
certification organizations, such as the National Board for Certification in Occupational Therapy (NBCOT ); ®
■ Understand the legislative and regulatory process;
■ Describe the difference between statutes and regulations or rules; and
■ Identify the consequences of failure to comply with the licensure requirements, laws, and regulations or rules.

• Administrative agency • Legislation • Scope of practice
• Certification by NBCOT • Licensure • Statutes
• Credentialing • Practice acts • Sunrise laws
• Interstate compact • Regulations • Sunset laws
OVERVIEW reimbursement for occupational therapy services, funding
O
for higher education, the awarding of research grants, and
ccupational therapy is regulated in all 50 American establishment of licensing procedures.
states, the District of Columbia, Puerto Rico, and
In the United States, the earliest evidence of state regu-
Guam. The major purpose of state regulation is to
lation of professions was the Virginia Medical Practice Act
protect consumers in a state or jurisdiction from unqualified
of 1639 (Federation of State Medical Boards, 2015). State
or unscrupulous practitioners. State regulation also ensures a
licensure activity (i.e., the process by which a governmental
high level of professional conduct on the part of occupational
therapists (OTs) and occupational therapy assistants (OTAs). agency grants permission to a person to engage in a given
State laws and regulations (or rules, as termed in some occupation) did not begin in earnest, however, until the late
states) greatly affect the practice of occupational therapy. 1800s. Action by the U.S. Supreme Court had an impact on
Laws or statutes (i.e., a written law passed by a legislative state licensure: “The most far-reaching action of the federal
body) are enacted by legislators, who are elected public of- government related to state regulation of the health profes-
ficials. Regulations specifically describe how the intent of sions was the affirmation by the U.S. Supreme Court of the
laws will be carried out. These regulations are developed constitutional right of state licensing boards to require a
by regulators, who are appointed public officials of various specific educational credential in the late 19th century (Dent
departments in state government. Both kinds of officials v. West Virginia [1888])” (Morrison, 1996, State Regulation
make decisions that directly and indirectly affect occupa- and the Federal Government section, para. 2). “By 1900 most
tional therapy managers and practitioners. These decisions states had licensed attorneys, dentists, pharmacists, physi-
may include the setting of certain standards, coverage and cians, and teachers. Between 1900 and 1960, most states also
https://doi.org/10.7139/2019.978-1-56900-592-7.075
695
granted licensure to 20 additional groups, including accoun- Each state’s legislature has a regular legislative session
tants, nurses, real estate brokers, barbers, chiropractors, and during which legislative proposals are introduced. Most state
funeral directors” (Shimberg & Roederer, 1994, pp. 1–2). legislatures meet for annual sessions of varying duration,
The American Occupational Therapy Association (AOTA) except for Montana, Nevada, North Dakota, and Texas, which
and state occupational therapy associations have successfully only meet in odd-numbered years (LexisNexis, 2017). A bill,
advocated for the state regulation of occupational therapy for or legislative proposal, once drafted, must be introduced into
more than 40 years. New York and Florida were the first states one or both of the legislative chambers by a sponsor or mem-
to enact occupational therapy licensure legislation (i.e., the ber of the chamber. Depending on the state, a bill can be sup-
preparing and enacting of laws by local, state, or national leg- ported by 1 or more of the following sponsors:
islatures) in 1975. When New York enacted a bill to license
■ Legislator,
OTAs in 2015 and Hawaii did the same in 2014 to license
■ Legislative committee,
occupational therapy practitioners, the profession of occupa-
■ State regulatory board (SRB), and
tional therapy became licensed in all 50 states as well as the
■ State executive agency or department.
District of Columbia, Guam, and Puerto Rico.
The most significant development in recent years as it The state’s political environment can help determine the
relates to occupational licensure is the 2015 Supreme Court best method of introduction, whether into the House, Senate,
decision in North Carolina State Board of Dental Examiners or both, and by which of the potential sponsors most appro-
v. FTC, which subjects all occupational licensure boards to priate to an individual state. Once introduced into a legisla-
scrutiny for potential anti-trust violations, in particular as tive chamber by a sponsor, the bill enters its “first reading,”
related to scope of practice considerations. Additionally, gov- receiving a hearing in an assigned legislative committee. If the
ernors and state legislatures around the country have sought committee votes on the bill favorably, it goes to the floor of the
to reduce the regulatory burden on licensed professionals by corresponding chamber for a vote by the full membership of
issuing executive orders and passing legislation implementing the chamber. Typically, the chamber will vote on the bill twice.
sunset laws (i.e., the process by which a profession wishing The first time is referred to as the “second reading,” during
to receive certification or licensure must propose the compo- which the full chamber is able to make amendments to the
nents of the legislation) and sunrise laws (i.e., laws requiring bill. The second time is referred to as the “third reading”
the legislature, after a periodic review, to reauthorize a board’s and is the final vote in that chamber. If the bill is voted on
existence). Advocates of smaller government have pushed for favorably, it moves to the other legislative chamber, where the
fewer professions to be regulated and by the least restrictive reading process is repeated. If both chambers pass the bill, it
means. Interest groups have advocated for the revisions of li- goes before the governor, who will either approve the bill by
censure laws to facilitate licensure for people with criminal signing it or disapprove the bill, or veto it, by not signing it.
records, and the military has supported laws and regula- Some states allow bills to go into effect without the governor’s
tions—including a national licensure interstate compact (i.e., signature of approval.
contracts between 2 or more states creating an agreement on a
particular policy issue or adopting a certain standard) for OTs
Regulatory Process
and OTAs—to expedite licensure for military personnel and
their families who frequently have to move from state to state. Generally, once legislation is signed into law, regulations or
rules must also be adopted to enforce or implement the law.
A regulation cannot be created without a statute in place to
ESSENTIAL CONSIDERATIONS authorize its creation, and a regulation cannot conflict with
the statute that authorized it.
Legislative Process Although the regulatory process varies widely among the
The legislative process is the process elected state legislators states, in most states, the state agency with jurisdiction drafts
undertake in the 50 states to change state law. AOTA and the regulations, which are then approved and published to
state occupational therapy associations frequently collaborate solicit public comment. After public comments are received
to write and advocate for legislation that would benefit occu- and considered, the proposed regulation is finalized by the
pational therapy practitioners and the occupational therapy state licensing department or another department. If changes
profession through changes to scope of practice, licensure to the original proposal are made because of public feedback,
requirements, disciplinary procedures, or requirements to the proposal is reapproved and republished for more public
perform certain practice interventions such as telehealth or comment. In 41 states, a legislative review committee must
physical agent modalities (PAMs). give the final approval of regulations.
In 49 states, the legislative process takes place in a bicam-
eral (i.e., 2 chambers, a Senate and House of Representatives Regulatory or Advisory Boards for
or House of Delegates) system. Nebraska’s legislature has
Regulated Jurisdictions
1 chamber. The District of Columbia is governed by a coun-
cil that passes laws that are subject to approval by the U.S. In the health care professions, the agency of government that
Congress. is responsible for regulating the profession of occupational
CHAPTER 75. State Regulation of Occupational Therapy 697
therapy is typically the state department of health, but it could relationships that state associations can develop with the SRB
also be a separate agency devoted to all professional licensing. or council members will enhance the work of both entities and
Under a licensure system, that department usually delegates help ensure competent practice by OTs and OTAs as well as
its authority to administer regulations to a board that consists laws and regulations that accurately reflect the occupational
of members of the profession (who are regulated), consum- therapy profession. In states where practitioners are regulated
ers or public members, and—in some cases—representatives by a state agency or a medical board, occupational therapy
of related professions. SRBs operate on a continuum from practitioners and especially occupational therapy managers
full autonomy to a strictly advisory role to no board at all should follow medical board activities and meetings as well
but only a centralized agency responsible for administration as regulations proposed by the administrative agency (i.e.,
(Shimberg & Roederer, 1994). Most SRBs have the authority a government entity that administers a legal framework that
to establish the procedures for licensure, investigate viola- governs the implementation and delivery of a public program)
tions of the practice act, and promulgate rules to regulate the with jurisdiction over health professions. State legislatures are
profession. In some states, the SRB does not promulgate the generally the most active from January through May. Activity
licensing regulations. Instead, promulgation may be carried levels of boards and agencies do not follow this trend; they
out by the department that oversees licensing. make important policy decisions year round.
In some states, appointed practitioners serve as part of an
occupational therapy advisory council. Councils perform Components of an Occupational Therapy
many of the same tasks as an occupational therapy SRB but Practice Act
are less autonomous and serve to advise the administration’s
staff or another licensure board of which the council is part Practice acts (or licensure laws) refer to laws passed by state
on the regulation of OTs and OTAs. Some states combine legislators that establish regulation for health care profes-
occupational therapy SRBs or advisory councils with other sions. The purpose of regulating the occupational therapy
professions such as physical therapy or athletic training. A profession is to
handful of states have no occupational therapy SRB or advi- ■ Safeguard the public health, safety, and welfare;
sory council and rely on administrative officials to promul- ■ Protect the public from incompetent, unethical, or unau-
gate and enforce regulations for the profession. Several states thorized people;
have placed regulation of OTs and OTAs under the state’s ■ Ensure a high level of professional conduct on the part of
medical board and in the hands of an occupational therapy OTs and OTAs; and
advisory council. In these states, a group made up of occu- ■ Ensure the availability of high-quality occupational ther-
pational therapy practitioners advises the medical board on apy services to people in need of those services (AOTA,
occupational therapy regulatory issues, but this group has far 2007).
less power and autonomy than a board.
Occupational therapy managers, practitioners, entrepre- The practice act provides consumers and others with im-
neurs, and consultants as well as state occupational therapy portant information about minimum qualifications for prac-
association leaders need to monitor the activities of the occu- titioners, protects the titles of practitioners, and defines an
pational therapy SRB, medical board, or administrative offi- appropriate scope of practice. Most practice acts have similar
cials who are responsible for regulating occupational therapy components, including requirements for licensure, renewal,
and to maintain an ongoing dialogue on professional issues. supervision, and referral as well as a defined scope of practice,
Occupational therapy SRBs may discuss the need to amend code of ethics, and disciplinary provisions. With the prolifer-
state occupational therapy practice acts or regulations to ation of telehealth technology as a treatment modality, states
keep them up-to-date with current practice. This updating are incorporating provisions authorizing the use of telehealth
process may entail making additions or revisions to scope of into their practice acts for occupational therapy practitioners.
practice, continuing competence, supervision, reentry to the Telehealth practice requirements may also be spelled out in
profession, or references to certification bodies or education state Medicaid requirements, or third-party payers may have
program accreditation institutions. their own requirements.
OTs and OTAs can give input into these processes in a
variety of ways. State occupational therapy associations or
members can propose changes in the practice act or statutes For Additional Learning
through legislative amendments. They also can attend hear-
For additional learning, see Chapter 32, “Delivering Services Through
ings and comment on amendments to regulations that are
Telehealth.”
proposed by the SRB or advisory council and work with them
to initiate needed changes.
State association leaders should be on the mailing list of the
Scope of Practice
occupational therapy SRB or the advisory council to receive
meeting announcements and minutes, and 1 or more repre- All state occupational therapy practice acts include a defi-
sentatives of the associations should regularly attend public nition of occupational therapy or occupational therapy
occupational therapy SRB or council meetings. The positive practice in their practice acts. Defining a scope of practice
(i.e., the range of responsibilities and accountabilities that PRACTICAL APPLICATIONS IN

define a profession’s practice) legally articulates the domain OCCUPATIONAL THERAPY
of occupational therapy practice and provides guidance to
facilities, providers, consumers, and major public and private Requirements for Licensure or
health and education facilities on the appropriate use of occu- Other Forms of Regulation
pational therapy services and practitioners. Most practice acts
Requirements for licensure generally include demonstration
have specific language that prohibits the unauthorized prac-
by the applicant that they have successfully completed the aca-
tice of occupational therapy by people who are not qualified
demic and fieldwork requirements of an educational program
OTs or OTAs and that allows for prosecution of those people.
for OTs or OTAs that is accredited by AOTA’s Accreditation
A profession’s scope of practice should be directly related to
the standards for education, training, and clinical application
Council for Occupational Therapy Education (ACOTE ) and ®
has passed an examination approved by the occupational
within that profession. Some elements of the scopes of practice
therapy board (typically, the National Board for Certification
for different professions may appropriately overlap, but a prac-
tice act should also delineate unique aspects of that scope. For ®
in Occupational Therapy [NBCOT ] entry-level certification
examination). States may have additional requirements, such
example, although both the occupational therapy and physical
as completion of a criminal background check or passing an
therapy practice acts in a given state may authorize the use of
exam on the state’s occupational therapy practice act and reg-
PAMs, the occupational therapy practice act might use the word-
ulations. States may have less complicated requirements for
ing, adapted from the AOTA position paper on PAMs, “Physical
licensure by endorsement for practitioners who are currently
agent modalities may be used by occupational therapists and oc-
licensed or regulated in another state or jurisdiction. Increas-
cupational therapy assistants as an adjunct to or in preparation
ingly, states are implementing expedited licensure processes
for intervention that ultimately enhances engagement in occu-
for OTs and OTAs who are serving in the military or their
pation” to distinguish the unique focus of occupational therapy
spouses who are OTs or OTAs and who move from state to-
on occupation, not on the modality (AOTA, 2003, p. 691).
state frequently so these people are able to practice while their
Exhibit 75.1 presents AOTA’s (2011) definition of occupa-
application for licensure in a new state is being processed.
tional therapy practice for state regulation. States often adopt
Internationally trained OTs may have to follow require-
this model language related to scope of practice because it re-
ments to ensure that their education and training are equiva-
flects the current appropriate scope of practice as articulated
lent to the standards in the United States and that their English
by the standard-setting body of the profession. All managers,
proficiency is adequate. It is important to note that internation-
private practice owners, and practitioners need to be aware of
ally trained therapists must have an education that is consid-
their state’s or their jurisdiction’s scope of practice and need to
ered to be comparable with an entry-level post-baccalaureate
ensure that practitioners under their supervision are not per-
degree in occupational therapy from an ACOTE-accredited
forming services that are outside their legal scope of practice.
program to sit for the NBCOT exam. NBCOT’s Occupational
Review Questions
®
Therapist Eligibility Determination (OTED ) will determine
whether someone’s completed education, including fieldwork,
1. The purpose of state regulation of occupational therapy meets the eligibility requirements to apply for the OTR certi-
practice is to fication exam (NBCOT, 2018a, 2018b).
a. Safeguard the public health, safety, and welfare.
b. Protect the public from incompetent, unethical, or Additional Requirements for
unauthorized people.
Certain Interventions and Settings
c. Ensure a high level of professional conduct on the
part of OTs and OTAs. Occupational therapy practitioners should be aware that
d. All of the above. several states have created additional education and experi-
2. Which of the following is not a typical component of an ence requirements to provide certain interventions or work
occupational therapy practice act? in certain settings. For example, several states have estab-
a. Licensure requirements. lished requirements for practitioners to use PAMs. Other
b. Definition of occupational therapy practice. states have created requirements for other interventions. For
c. Reimbursement rates for occupational therapy services. example, the California Occupational Therapy Practice Act
d. Disciplinary procedures. requires “occupational therapists offering services in hand
3. A key feature of an occupational therapy licensure law is therapy, physical agent modalities, and/or swallowing assess-
that it ment, evaluation or intervention to demonstrate, through
a. Creates a legally defined scope of practice. post-professional education and training, that they are com-
b. Allows occupational therapy practitioners to perform petent to do so” (California Board of Occupational Therapy,
surgery. 2010, para. 1).
c. Mandates insurance coverage for occupational therapy. Several states have created additional requirements for
d. Allows occupational therapy practitioners to practice occupational therapy practitioners to be credentialed to
in multiple states. provide services through state early intervention programs.
EXHIBIT 75.1. AOTA’s Model Practice Act’s Definition of Occupational Therapy
The practice of occupational therapy means the therapeutic use of occupations, including everyday life activities with people, groups,
populations, or organizations to support participation, performance, and function in roles and situations in home, school, workplace, community,
and other settings. Occupational therapy services are provided for habilitation, rehabilitation, and the promotion of health and wellness to those
who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation
restriction. Occupational therapy addresses the physical, cognitive, psychosocial, sensory–perceptual, and other aspects of performance in
a variety of contexts and environments to support engagement in occupations that affect physical and mental health, well-being, and quality
of life.
The practice of occupational therapy includes the following:
A. Evaluation of factors affecting ADLs, IADLs, rest and sleep, education, work, play, leisure, and social participation, including the following:
1. Client factors, including body functions (such as neuromusculoskeletal, sensory–perceptual, visual, mental, cognitive, and pain factors)
and body structures (such as cardiovascular, digestive, nervous, integumentary, genitourinary systems, and structures related to
movement), values, beliefs, and spirituality.
2. Habits, routines, roles, rituals, and behavior patterns.
3. Physical and social environments as well as cultural, personal, temporal, and virtual contexts and activity demands that affect performance.
4. Performance skills, including motor and praxis, sensory–perceptual, emotional regulation, cognitive, communication, and social skills.
B. Methods or approaches selected to direct the process of interventions such as the following:
1. Establishment, remediation, or restoration of a skill or ability that has not yet developed, is impaired, or is in decline.
2. Compensation, modification, or adaptation of activity or environment to enhance performance, or to prevent injuries, disorders, or
other conditions.
3. Retention and enhancement of skills or abilities without which performance in everyday life activities would decline.
4. Promotion of health and wellness, including the use of self-management strategies, to enable or enhance performance in everyday life
activities.
5. Prevention of barriers to performance and participation, including injury and disability prevention.
C. Interventions and procedures to promote or enhance safety and performance in ADLs, IADLs, rest and sleep, education, work, play, leisure,
and social participation, including the following:
1. Therapeutic use of occupations, exercises, and activities.
2. Training in self-care, self-management, health management and maintenance, home management, community and work
reintegration, and school activities and work performance.
3. Development, remediation, or compensation of neuromusculoskeletal, sensory–perceptual, visual, mental, and cognitive functions;
pain tolerance and management; and behavioral skills.
4. Therapeutic use of self, including one’s personality, insights, perceptions, and judgments, as part of the therapeutic process.
5. Education and training of people, including family members, caregivers, groups, populations, and others.
6. Care coordination, case management, and transition services.
7. Consultative services to groups, programs, organizations, or communities.
8. Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic
principles.
9. Assessment, design, fabrication, application, fitting, and training in seating and positioning, assistive technology, adaptive devices, and
orthotic devices, and training in the use of prosthetic devices.
10. Assessment, recommendation, and training in techniques to enhance functional mobility, including management of wheelchairs and
other mobility devices.
11. Low vision rehabilitation.
12. Driver rehabilitation and community mobility.
13. Management of feeding, eating, and swallowing to enable eating and feeding performance.
14. Application of physical agent modalities, and use of a range of specific therapeutic procedures (such as wound care management,
interventions to enhance sensory–perceptual and cognitive processing, and manual therapy) to enhance performance skills.
15. Facilitating the occupational performance of groups, populations, or organizations through the modification of environments and the
adaptation of processes.
Source. Reprinted from “Association Policies,” by the American Occupational Therapy Association, 2011, American Journal of Occupational Therapy, 65, S81–S82.
https://doi.org/10.5014/ajot.2011.65S80. Copyright © 2011 by the American Occupational Therapy Association. Used with permission.
For example, practitioners in Illinois must fulfill extensive 30 CEUs in several core content areas. These areas include the
requirements in addition to licensure, including a back- development of typical and atypical young children, working
ground check, early intervention system training, and doc- with families of young children with disabilities, intervention
umentation of the completion of educational experience that strategies for young children with special needs, and assess-
includes at least 2 college semester hours or the equivalent of ing young children with special needs (Kohl, 2008).
States may also implement requirements beyond what is

needed for licensure for an OT or OTA to practice in certain EXHIBIT 75.2. State Regulation Online Resources
settings, such as requiring an OT or OTA seeking to work in
a public school to obtain additional CE or meet other require- ■ Directory of State Licensure Boards: https://www1.aota.org/reglist/
ments specified by the department. ■ How to Get a License: https://bit.ly/2TyckLM
■ State Continuing Competence Requirements: https://bit.ly/2H4YsD0
Licensure Renewal Requirements

States also require renewal of licensure at specific intervals. their knowledge or skills need improvement. The number of
For most states, this renewal is required every 1 or 2 years. In required points or contact hours of CE activity also varies
New York, the renewal period is 3 years. Increasingly, states widely from state to state, ranging from an average of 6 hours
are requiring not only a fee and completion of the renewal per year to 20 hours per year. Additionally, states have been
application but also completion of a specific amount of con- implementing requirements for all health care practitioners
tinuing competence activities. to take CE courses that focus on various public health issues,
An important role of SRBs is to protect the public from such as suicide prevention, substance abuse prevention, and
incompetent practitioners. State regulators are mandating cultural competency. AOTA maintains a compilation of
continuing competence requirements in an attempt to ensure state requirements on the State Policy page of its website (see
that practitioners who are licensed or regulated in their state Exhibit 75.2 for a list of suggested Internet resources). For the
maintain competence. Some SRBs limit acceptable continu- most up-to-date information on specific state requirements,
ing competence activities to those activities directly related contact the individual SRB or agency.
to clinical practice. Others recognize the importance of a Failure to understand and follow the requirements for re-
person maintaining competence in the varied roles and re- newing of a license can have serious consequences. An OT
sponsibilities related to occupational therapy throughout his or OTA cannot practice after a license is expired, and many
or her career and the important ways that these roles directly boards have the authority to impose harsh penalties on people
and indirectly affect competent practice. who are found to be practicing on an expired license. Waiting
As of 2016, only Hawaii, Maine, Massachusetts, and New to renew a license until just before the deadline to do so may
Jersey did not have continuing competence or CE require- not allow sufficient time to complete the renewal application
ments for licensure renewal (AOTA, State Affairs Group, or for the board to process the renewal. Do not hesitate to
2016). Forces both internal and external to the profession contact your state licensing board if you have any questions
are encouraging states to adopt continuing competence re- about how and when to renew a license.
quirements, and the expectation is that the number of states
with these requirements will continue to grow. Accrediting
organizations, such as the Commission on Accreditation of Profession Reentry
Rehabilitation Facilities (CARF) International and The Joint Occupational therapy practitioners who leave the profession
Commission, address competence-related activities in their for a period of time also need to understand provisions in their
standards. In their accreditation reviews, The Joint Commis- state’s practice act and regulations that establish requirements
sion and CARF International look to see that organizations to reenter the profession. States have several requirements to
develop competencies needed by their staff members to per- regain licensure, from requiring the completion of continu-
form their duties, that a mechanism is in place to measure the ing competence activities to requiring applicants to retake the
level of competency, and that the required competencies are NBCOT examination (AOTA, 2012). Some states include a
assessed annually. In addition, the organizations must make provision that requires that the applicant complete a period
opportunities available to improve the competencies of staff of supervised work experience. In many states, the number of
members. years that the person has been out of practice dictates the spe-
cific requirements that must be met to reenter the profession.
Although intended to keep consumers safe, these require-
For Additional Learning ments can discourage practitioners from returning to prac-
tice. Not only are the provisions daunting but compliance
For additional learning, see Chapter 55, “Major Accrediting could involve a significant amount of time and money. Occu-
Organizations.” pational therapy managers should be aware of such provisions
to be sure that any supervised work experience at their place
of employment complies with state and federal laws. AOTA
Acceptable activities vary in states or jurisdictions and offers several resources to practitioners seeking to reenter the
range from attending or presenting courses to supervising profession, including its official document Guidelines for Re-
fieldwork students or participating in research. More and entry Into the Field of Occupational Therapy (AOTA, 2015a).
more states are including competency assessment or skills To address this concern, some states have included inac-
assessment activities that, instead of educating an occupa- tive status stipulations in either statute or regulation. In many
tional therapy practitioner about a certain topic or a new instances, inactive status allows a practitioner to leave active
treatment modality, allow the practitioner to discover where practice without losing their license. States that offer inactive
status provide practitioners with a much smoother transition OTAs and aides that a therapist may supervise. New Hamp-
back to active licensure. More than 15 states currently allow shire has included a provision in its practice act that prohibits
this option (Kohl, 2007). The provisions regarding inactive coercing OTs or OTAs into compromising patient safety by
status typically require the practitioner to complete continu- requiring them to delegate treatment inappropriately.
ing competence activities during the period of inactive status. Many SRBs also address supervision of unregulated sup-
port personnel such as aides. Aides who provide supportive
services to OTs or OTAs are considered nonlicensed or unreg-
For Additional Learning ulated personnel. Many states do not mention this level of per-
sonnel in their statutes or regulations. However, some states
For additional learning, see Chapter 68, “Returning to the Occupational have incorporated regulations about the use and supervision
Therapy Workforce.” of nonlicensed personnel or aides under rules or regulations
that outline the responsibilities of OTs or OTAs who supervise
these people. The regulations also may list types of activities
that aides can and cannot do under the supervision of OTs and
Referral Requirements OTAs. This list is often consistent with AOTA’s (2014) Guide-
Several state occupational therapy practice acts include refer- lines for Supervision, Roles, and Responsibilities During the
ral requirements, which state that for occupational therapy Delivery of Occupational Therapy Services, which states that
practitioners to evaluate or treat a client, they must first re-
ceive an order from another health professional, typically a An aide, as used in occupational therapy practice, is
physician. Most state referral requirements include a broad an individual who provides supportive services to the
range of referral sources, such as physicians, physician as- occupational therapist and the occupational therapy
sistants, nurse practitioners, podiatrists, optometrists, and assistant. Aides do not provide skilled occupational
others. The laws also include exemptions from the referral therapy services. An aide is trained by an occupational
requirements for occupational therapy services that are pro- therapist or an occupational therapy assistant to perform
vided in nonmedical settings or for prevention, education, or specifically delegated tasks. The occupational therapist
wellness. It is important for occupational therapy managers to is responsible for the overall use and actions of the aide.
note that payers may have their own referral requirements for An aide first must demonstrate competency to be able
reimbursement purposes. AOTA also maintains a listing of to perform the assigned, delegated client and non-client
these requirements on the “State Policy” section of its website. tasks. (pp. S20–S21)
As of January 1, 2019, 32 states have no referral require- Managers, consultants, entrepreneurs, and practitioners
ments (AOTA, State Affairs Group, 2018). AOTA interprets who supervise OTAs and aides must be familiar with their
the lack of a requirement to mean that an OT may initiate individual state’s or jurisdiction’s requirements for supervi-
treatment with a client without a prescription from another sion because they do vary. Some states may require docu-
health care practitioner. However, third-party payers, Medi- mentation of supervisory sessions in a supervision log or may
care, and state Medicaid requirements should always be con- limit the number of personnel that an OT may supervise. The
sulted first in the event that they have established their own amount and type of supervision also varies from jurisdiction
referral requirement in the absence of a state law or regulation. to jurisdiction. Many OTs are not fully aware of an important
concept: They are legally responsible for the patient care ren-
Supervision and Role Delineation of dered by OTAs and aides under their supervision.
OTAs and Aides
Disciplinary Action
SRBs address supervision and role delineation of OTAs and
aides in different ways. Supervision requirements may be in- Boards protect the public by providing consumer information,
cluded in the definitions of OTA or in the definitions of types monitoring regulated practitioners, and investigating com-
or levels of supervision allowed in that state. In many states or plaints. They have the power to discipline practitioners through
jurisdictions, specific subsections in the regulations address a variety of sanctions that range from reprimand to revocation
the role and supervision of OTAs and aides. Most states look of license. Revocation removes the practitioner’s right to prac-
to AOTA’s professional standards on supervision—such as the tice in that state and, thus, is used only in extreme cases. Less
Guidelines for Supervision, Roles, and Responsibilities During harsh actions may require peer review of records, educational
the Delivery of Occupational Therapy Services (AOTA, 2014) meetings, supervision with or without a mentor, CE, payment
as well as the Model State Regulations for Supervision, Roles, of a fine, treatment for addiction or mental health issues, and
and Responsibilities During the Delivery of Occupational suspension of a license (Jacobs & McCormack, 2011).
Therapy Services (AOTA, 2005)—to reflect current best prac- Reports of disciplinary actions taken by SRBs, NBCOT’s
tice in the profession. Disciplinary Action Committee, or AOTA’s Ethics Commis-
When promulgating state regulations, SRBs consider prob- sion are frequently shared among those bodies and also may
lems or issues that arise in their state with respect to the su- be reported to the National Practitioner Data Bank (see http://
pervision of OTAs in specific settings and address workplace www.npdb.hrsa.gov). It is important to note that many SRBs
issues. Some states have established ratios for the number of have laws that outline how disciplinary proceedings should
be conducted. These laws often guarantee to those under in- other professions in their states. Both of these initiatives were
vestigation certain rights, such as the right to have a lawyer defeated because the occupational therapy practitioners in
present for proceedings or to receive due process in the form those states, led by their state associations, strongly objected
of a hearing in which the person under investigation provides to the proposed deregulation. They were able to provide in-
the board with information in their defense. Occupational formation that countered the state’s rationale for deregula-
therapy practitioners should consider obtaining legal counsel tion and made a strong case for licensure as a way to protect
and consult their state’s laws and regulations to know their consumers from unqualified practitioners.
rights if ever investigated. Besides political pressure to shrink the size and regulatory
Boards also may adopt a code of ethics that articulates the ex- scope of government and legal rulings in the courts on an-
pected behaviors of those who are regulated by the board. They ti-trust, SRBs are encouraged by advocacy organizations to
often adopt AOTA’s (2015b) Occupational Therapy Code of Eth- make their requirements for certain demographic groups less
ics (2015) in whole or in part. AOTA’s Code is a public statement stringent so as to enable people to get a license that would
of the common set of values and principles used to promote and lead to a job. Many SRBs have implemented a criminal back-
maintain high standards of behavior in occupational therapy. ground check requirement to ensure that people who receive
The Code is a set of principles that applies to occupational ther- a license are not likely to commit a crime while providing
apy personnel at all levels. These principles to which OTs and services under their license. As a result, a debate has emerged
OTAs aspire are part of a lifelong effort to act in an ethical man- over whether this requirement unfairly prevents people with
ner. The various roles of practitioner (OT and OTA), educator, a criminal record, minorities, or impoverished people from
fieldwork educator, clinical supervisor, manager, administrator, reentering society and being able to get a job. As a result,
consultant, fieldwork coordinator, faculty program director, some states (e.g., Delaware) list in their statutes or regulations
researcher–scholar, private practice owner, entrepreneur, and specific crimes that will automatically disqualify an applicant
student are included in the Code’s scope (AOTA, 2015b). from eligibility for a license. Other states require an SRB to
consider certain factors related to the crime that was commit-
ted, such as how much time has elapsed since the conviction
For Additional Learning and employment references, before deciding whether to issue
a license.
For additional information on ethics, see Section X, “Ethical and States have also implemented processes that require, when
Legal Considerations.”
a regulatory board proposes a new or amended regulation,
that the board consider the fiscal impact on businesses in the
state or on people. In 2011, Ohio’s Governor John R. Kasich
Future of State Regulation started the Common Sense Initiative, which is intended “to
Some have viewed state regulation of health care professionals create a regulatory framework that promotes economic de-
critically, believing that more can be done to strengthen the velopment, is transparent and responsive to regulated busi-
state regulatory framework. Reform has occurred through nesses, makes compliance as easy as possible, and provides
the appointment of public members to licensing boards, the predictability for businesses” (Kasich, n.d., para. 1).
creation of umbrella agencies to oversee licensing boards, the As a result of such interest in the value of occupational li-
passing of sunrise and sunset laws, and rulings by the Federal censing, the National Conference of State Legislatures (NCSL),
Trade Commission on the anticompetitive aspects of some li- the Council of State Governments, and the National Gover-
censing laws (Young, 1987). Some critics have proposed a sys- nor’s Association obtained a grant from the U.S. Department
tem that would encourage consumers to rely on information of Labor to start the Occupational Licensing Project (for more
and on their own judgment with respect to the preparation of information, see the NCSL website at https://bit.ly/2Afs6Ru).
health care professionals. This project not only studies trends in occupational licensing
According to a White House report issued in July 2015, but also provides states with grants to conduct their own study
“the percentage of the workforce covered by State licensing of their state’s occupational licensing climate. The project has
laws grew from less than 5 percent in the early 1950s to 25 also compiled an occupational licensing database that com-
percent by 2008, meaning that the State licensing rate grew pares licensure requirements for select professions, including
roughly five-fold during this period.” (U.S. Department of the OTAs, across all 50 states. Occupational therapy practitioners
Treasury Office of Economic Policy, Council of Economic Ad- and advocates should be aware of this project because it could
visers, and Department of Labor, 2015, p. 17). As regulators of provide an informational resource to state policymakers look-
a profession, SRBs are often targeted by elected government ing to restructure their state’s occupational licensing scheme
officials as part of efforts to shrink the size of government. in a way that harms the occupational therapy profession and
These efforts are often supported by research and advocacy the public.
done by nonpartisan think tanks that feel that government in
general is too intrusive in citizens’ everyday lives.
Nongovernmental Certification
In 2000, the governors of Minnesota and Florida proposed
budget cuts to streamline government. These cuts included Nongovernmental credentialing (i.e., the process of assessing
deregulation of occupational therapy along with several and validating the qualifications of a practitioner according
to a predetermined set of standards) organizations such as The ultimate goal of a practice analysis study is to ensure
NBCOT recognize through the mechanism of certification that there is a representative linkage of examination con-
those people who have attained entry-level competence in tent to practice. The periodic performance of practice anal-
broad areas of responsibility within their profession. A per- ysis studies assists NBCOT with evaluating the validity of
son completing this nongovernmental certification process is the test specifications that guide content distribution of the
granted a certificate and is entitled to use a special designa- credentialing examinations (NBCOT, 2018a). The examina-
tion such as “certified” or “registered” with his or her name. tions consist of the following: OTR has 3 clinical simulation
test items and 170 multiple-choice items with a single an-
swer, and COTA has 200 multiple-choice items with a single
For Additional Learning answer and 6 multiple-choice items with multiple answers
(NBCOT, 2018b).
For information on advanced certification, which is a different Eligibility requirements for NBCOT certification ex-
type of nongovernmental certification that recognizes advanced aminations vary depending on the candidate’s educational
training or experience in specific areas, see Chapter 54, “Continuing background and the type of certification sought. The re-
Competence.”
quirements must be met before a candidate can take an
examination. Certification candidates should obtain the
latest Certification Examination Handbook from NBCOT at
Entry-level certification http://www.nbcot.org.
In the mid-1930s, AOTA initiated a program of nongovern-
mental certification for occupational therapy practitioners, NBCOT certification renewal
which it then administered for more than 50 years. In the
early years, AOTA called the program for occupational ther- NBCOT created a certification renewal program in 1997
apy practitioners registration and granted the designation and added Phase II to the program in 2002, which includes a
registered to applicants who successfully completed the edu- professional development requirement (Smith & Willmarth,
cation, fieldwork, and examination requirements. The associ- 2003, p. 452). Maintaining NBCOT certification entitles peo-
ation introduced a similar program for OTAs in the 1960s. In ple to the continued use of NBCOT’s registered certification
1986, AOTA created an independent organization, the Amer- marks OTR® or COTA®. People who choose not to renew this
ican Occupational Therapy Certification Board (AOTCB), certification are required by NBCOT to no longer use its cer-
and transferred the certification program from AOTA to tification marks.
AOTCB. In 1996, AOTCB changed its name to the National State licensure or jurisdiction laws (or other forms of state
Board for Certification in Occupational Therapy, or NBCOT regulation) generally authorize practitioners who meet their
(AOTA & Johnson, 1996). licensure requirements to use a wide variety of professional
NBCOT is a not-for-profit credentialing organization that designations, including OT (occupational therapist), OTA
oversees and administers the entry-level certification exam- (occupational therapy assistant), OT/L (occupational thera-
ination for OTs and OTAs. This examination is what the SRBs pist/licensed), and OTA/L (occupational therapy assistant/
use as one of the criteria for licensure (or other forms of reg- licensed), among others. Certification renewal candidates
ulation). NBCOT uses the examination as one of the criteria should obtain the latest Certification Renewal Handbook
for initial NBCOT certification (NBCOT, 2018a). Initial cer- from NBCOT at http://www.nbcot.org.
tification from NBCOT is a requirement for licensure as an
occupational therapy practitioner in all 50 states, Washing- Relationship of Nongovernmental Certification to
ton, DC, Guam, and Puerto Rico (NBCOT, 2018d). State Regulation, Private or Public Employment,
NBCOT certifies eligible people as Occupational Thera- and Third-Party Reimbursement
pist Registered (OTR®) or Certified Occupational Therapy
Assistant (COTA®). The OTR and COTA credentials are reg- States or jurisdictions commonly require OTs and OTAs to
istered certification marks owned by NBCOT. Certification be initially certified (i.e., pass the NBCOT entry-level certifi-
by NBCOT indicates to the public that the OTR or the COTA cation exam) before they can qualify for a license. Most states
has met all of NBCOT’s educational, fieldwork, and examina- or jurisdictions, however, do not require practitioners to
tion requirements (NBCOT, 2018c). renew this certification to maintain their licenses to practice.
NBCOT recertification is not a legal requirement to prac-
tice occupational therapy unless a state mandates it as a con-
Entry-level certification examination
dition of licensure. In some states, proof of current certifi-
NBCOT certifies occupational therapy practitioners on the cation satisfies CE requirements. Certification renewal status
basis of separate examinations for OTs and OTAs. The OTR does not affect the ability to be reimbursed by Medicare,
and COTA examinations are constructed on the basis of the Medicaid, or other third-party payers. Additionally, The Joint
results of practice analysis studies. The studies identify the Commission and CARF International do not independently
domains, tasks, knowledge, and skills required for occupa- require in their standards that OTs and OTAs employed by
tional therapy practice relative to the respective credential. facilities renew their certification with NBCOT.
Disciplinary Action by NBCOT 3. Disciplinary action may be taken against occupational

therapy practitioners by which entity?
NBCOT undertakes disciplinary action against OTRs, COTAs,
a. AOTA Ethics Commission
and examination candidates who are incompetent, unethical,
b. NBCOT
or impaired (e.g., by substance abuse). The disciplinary action
c. Occupational therapy SRB
program makes it possible to identify, discipline, and require
d. All of the above
improvements of those who demonstrate incompetent, un-
4. State occupational therapy practice acts and regulations
ethical, or impaired behavior. People who are not exam can-
recognize the entry-level examination for OTs and OTAs
didates or who are not currently certified by NBCOT would
that is administered by
not be subject to discipline by NBCOT. However, all OTs and
a. AOTA.
OTAs who are regulated by a state are subject to discipline by
b. NBCOT.
their state regulatory body, and all members of AOTA are sub-
c. ACOTE.
ject to discipline by AOTA’s Ethics Commission.
d. The Joint Commission.
5. Occupational therapy practitioners should become famil-
Review Questions
iar with which aspects of the state’s occupational therapy
1. Licensure renewal requirements for occupational therapy practice act and regulations?
practitioners often require a. Definition of occupational therapy practice
a. Retaking the NBCOT examination. b. Supervision requirements for OTAs
b. Completion of acceptable continuing competence c. Continuing competence requirements
activities. d. All of the above
c. Demonstration of completing fieldwork education. 6. Which of the following is not a typical state licensure
d. Graduation from a postprofessional occupational requirement for occupational therapy practitioners?
therapy education program. a. Pass the entry-level examination administered by
2. NBCOT owns which of the following registered marks? NBCOT
a. OTR and COTA b. Graduation from an accredited OT or OTA school
b. OT and OTA c. Complete fieldwork requirements
c. OT/L and OTA/L d. Certification as an orthotist by American Board for
d. LOT and LOTA Certification in Orthotics, Prosthetics, and Pedorthics
CASE EXAMPLE 75.1. How Do I Obtain a License?
Step 1. Graduate from an ACOTE-accredited academic program.

The first step in obtaining a license to practice occupational therapy is completing the academic requirements. ACOTE currently requires that an OT
obtain, at a minimum, a master’s degree in occupational therapy from an academic program that is accredited by ACOTE. For OTAs, the minimum
degree is an associate’s degree from an ACOTE-accredited program for OTAs.
Step 2. Complete the required fieldwork.

The second step is to complete the minimum number of hours of fieldwork required by ACOTE to graduate from the ACOTE-accredited program.
The 2 types of fieldwork are Level I and Level II. Level I fieldwork is designed to acclimate the occupational therapy student to the fieldwork
experience and to be comfortable and understand the needs of clients. AOTA does not have a requirement for the number of hours needed to
complete Level I fieldwork. Level II fieldwork should be designed to promote clinical reasoning and reflective practice as well as understanding of
ethical and professional occupational therapy practice; it may require a student to be exposed to a variety of practice settings (AOTA, 2013). The
required number of hours for Level II fieldwork is 24 weeks for an OT student and 16 weeks for an OTA student.
Step 3. Apply to take and pass the NBCOT exam.

After graduating from the appropriate academic program and completing the required fieldwork, the next step is applying to take the NBCOT
exam. Application is made to NBCOT; if an applicant’s credentials meets NBCOT’s standards, they are then issued permission to take the exam.
An applicant must then pass the exam.
Step 4. Obtain a license from the state in which you intend to practice.
After an applicant has passed the exam, they must then apply for a license in the state in which they intend to practice. The application can
be lengthy and often involves filling out an application, paying a fee, and having NBCOT exam scores sent directly to the board; sometimes the
applicant also needs to complete a criminal background check and pass a state test on the state’s laws and regulations related to occupational
therapy. Only after a license is obtained can a person practice occupational therapy.
SUMMARY ■ B.7.3. Promote Occupational Therapy

■ B.7.4. Ongoing Professional Development.
Occupational therapy is regulated in all 50 states, the District
of Columbia, Puerto Rico, and Guam. The purpose of state
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American Occupational Therapy Association. (2014). Guidelines
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CHAPTER
Becoming an Advocate
Elizabeth C. Hart, MS, OTR/L 76
LEARNING OBJECTIVES
■ Identify opportunities to advocate at the daily practice, professional, and systems levels;
■ Communicate effectively with elected representatives to help shape policies that affect the practice of occupational
therapy; and
■ Develop an action plan to make advocacy at all levels a daily part of one’s professional practice.

• Advocacy • Policy • Systems-level advocacy
• Coalitions • Political action committees • Therapeutic use of self
• Daily practice-level advocacy • Professional-level advocacy • Third-party payers
• Lobbyists • Stakeholders
OVERVIEW daily practice, within their professional organizations, and

within governments and systems.
O
ccupational therapy practitioners and managers
must continuously defend occupational therapy’s role
within dynamic health, education, and social systems ESSENTIAL CONSIDERATIONS
that are rife with competition, competing demands, political
contexts, and limited resources. Occupational therapy prac-
What Is Advocacy?
titioners can be advocates for the profession in many ways at Advocacy is the act of speaking up or working on behalf of the
the federal, state, and local government levels. interests of another person, group, or cause. An occupational
Advocacy is an important tool that all practitioners can therapy practitioner advocates on behalf of a client or the
use to promote clients’ well-being, advance the profession, profession, and professional organizations like the American
and ensure that individuals who would benefit from occupa- Occupational Therapy Association (AOTA) or state occupa-
tional therapy have access to services. Here are some import- tional therapy associations advocate for causes important to
ant questions to ask oneself to develop advocacy skills: the membership they serve. Advocacy around public policy
issues is important to the profession of occupational therapy
■ Who are my key stakeholders?
because it ensures that the profession is included at tables
■ What are my stakeholders’ biggest strengths and challenges?
where decisions are made about who has access to occupa-
■ How can occupational therapy help meet those challenges?
tional therapy services, including but not limited to regula-
■ How do my stakeholders’ interests align with mine as an
tion of scope, licensure, reimbursement, and coverage.
occupational therapy practitioner?
Advocacy activities can educate key stakeholders (i.e., indi-
This chapter describes ways that all occupational therapy viduals or groups with a vested interest in occupational ther-
practitioners and managers can advocate effectively in their apy services) in policy discussions on the distinct value that
https://doi.org/10.7139/2019.978-1-56900-592-7.076
707
CHAPTER
Becoming an Advocate
Elizabeth C. Hart, MS, OTR/L 76
LEARNING OBJECTIVES
■ Identify opportunities to advocate at the daily practice, professional, and systems levels;
■ Communicate effectively with elected representatives to help shape policies that affect the practice of occupational
therapy; and
■ Develop an action plan to make advocacy at all levels a daily part of one’s professional practice.

• Advocacy • Policy • Systems-level advocacy
• Coalitions • Political action committees • Therapeutic use of self
• Daily practice-level advocacy • Professional-level advocacy • Third-party payers
• Lobbyists • Stakeholders
OVERVIEW daily practice, within their professional organizations, and

within governments and systems.
O
ccupational therapy practitioners and managers
must continuously defend occupational therapy’s role
within dynamic health, education, and social systems ESSENTIAL CONSIDERATIONS
that are rife with competition, competing demands, political
contexts, and limited resources. Occupational therapy prac-
What Is Advocacy?
titioners can be advocates for the profession in many ways at Advocacy is the act of speaking up or working on behalf of the
the federal, state, and local government levels. interests of another person, group, or cause. An occupational
Advocacy is an important tool that all practitioners can therapy practitioner advocates on behalf of a client or the
use to promote clients’ well-being, advance the profession, profession, and professional organizations like the American
and ensure that individuals who would benefit from occupa- Occupational Therapy Association (AOTA) or state occupa-
tional therapy have access to services. Here are some import- tional therapy associations advocate for causes important to
ant questions to ask oneself to develop advocacy skills: the membership they serve. Advocacy around public policy
issues is important to the profession of occupational therapy
■ Who are my key stakeholders?
because it ensures that the profession is included at tables
■ What are my stakeholders’ biggest strengths and challenges?
where decisions are made about who has access to occupa-
■ How can occupational therapy help meet those challenges?
tional therapy services, including but not limited to regula-
■ How do my stakeholders’ interests align with mine as an
tion of scope, licensure, reimbursement, and coverage.
occupational therapy practitioner?
Advocacy activities can educate key stakeholders (i.e., indi-
This chapter describes ways that all occupational therapy viduals or groups with a vested interest in occupational ther-
practitioners and managers can advocate effectively in their apy services) in policy discussions on the distinct value that
https://doi.org/10.7139/2019.978-1-56900-592-7.076
707
occupational therapy brings in meeting society’s needs. The EXHIBIT 76.1. Examples of Advocacy at the Daily
primary task of an occupational therapy advocate is to help Practice Level
stakeholders understand the role that occupational therapy
can play in meeting their goals. Key stakeholders may include ■ Providing evidence-based, occupation-centered interventions
occupational therapy clients, employers, third-party payers, ■ Documenting the distinct value of occupational therapy
elected officials, and government policymakers. Each of these interventions
stakeholders has their own unique challenges and priorities ■ Ensuring that clients have the supports they need to be successful
after discharge
that affect how an occupational therapy advocate should ap-
■ Communicating clients’ needs to other members of the health care
proach them. The principles of therapeutic use of self that oc-
team
cupational therapy practitioners apply in day-to-day practice ■ Explaining to clients how occupational therapy can help them
(e.g., understanding the values and priorities of another and es- achieve their goals
tablishing rapport; Taylor et al., 2009) can also be used to build
positive working relationships with other key stakeholders.
Advocacy Levels Professional-level advocacy

Occupational therapy practitioners have the opportunity to Professional-level advocacy includes the settings in which
communicate the value of occupational therapy to key stake- practitioners use occupational therapy knowledge and skills
holders at the levels of daily practice, professional, and systems to ensure client access to services and promote best practices
(Hart & Lamb, 2018). Advocacy at each of these levels pro- and appropriate use of services. It serves to link daily occu-
motes our clients’ well-being and ensures that all of those who pational therapy practice and the profession’s recognition at
might benefit have access to occupational therapy services. the systems level. Advocacy at this level begins when occu-
pational therapy practitioners identify opportunities to use
Daily practice-level advocacy their occupational therapy lens to address challenges and
areas of unmet need within their work setting or outside of
Daily practice-level advocacy includes the clinical, education,
their organizations. This often entails building strategic al-
community-based, and research settings where practitioners
liances with other disciplines, administrators, management,
put occupational therapy knowledge and skills to use on a
and outside coalitions (individuals or groups that work
daily basis. Advocacy at this level serves as the foundation for
together toward a common cause).
advocacy efforts at the professional and systems levels.
When occupational therapy practitioners use their exper-
Before occupational therapy practitioners can articulate
tise to help address the challenges of other disciplines, profes-
the profession’s value to external stakeholders, they must first
sionals, and groups, we build powerful alliances and highlight
demonstrate it to clients by being client centered and using
the distinct value of occupational therapy in an ever-changing
occupation-based interventions to meet clients’ needs and
health care system. Exhibit 76.2 lists examples of advocacy at
improve their well-being. Every client served helps to shape
the professional level.
the public perception of occupational therapy; even the most
well-coordinated advocacy campaign cannot contradict a
person’s negative experience with the profession. Conversely,
the most powerful way to advocate for the profession is to EXHIBIT 76.2. Examples of Advocacy at the
demonstrate occupational therapy’s distinct value by improv- Professional Level
ing the lives of those receiving our services.
Daily documentation is the primary window through ■ A practitioner requests a referral for a client she believes would
which many stakeholders and most payers view occupational benefit from occupational therapy services.
■ A practitioner works with management to revise the occupational
therapy. As the health care system strives to reduce costs, im-
therapy evaluation template so it more closely aligns with the new
prove the quality of care, and promote a healthier population,
occupational therapy evaluation CPT codes.
practitioners must demonstrate how occupational therapy is ■ After noticing occupational therapy colleagues using non-
part of the solution to America’s changing health care needs evidence-based interventions, a practitioner establishes a
(Hildenbrand & Lamb, 2013). Occupational therapy practi- biweekly journal club to promote best practices.
tioners must therefore document clinical reasoning, accurately ■ After receiving a denial letter from an insurer, a practitioner
describe services, and demonstrate the efficacy of interven- appeals with objective data that demonstrate how occupational
tions while explicitly linking those outcomes to the interests therapy intervention is improving the client’s health and preventing
of our key stakeholders and third-party payers (i.e., organiza- costlier health care expenditures.
tions that pay health expenses on behalf of beneficiaries). ■ A school-based practitioner develops a lunch program to improve
Exhibit 76.1 provides some practical examples of advocacy social skills in students with autism spectrum disorder while
reducing bullying.
at the daily practice level. These practices demonstrate occu-
■ A practitioner serves on their town’s Council on Aging, contributing
pational therapy’s value to clients while ensuring that ser-
their expertise on matters related to accessibility and aging in
vices continue to be valued by third-party payers in a rapidly place.
evolving health care environment.
CHAPTER 76. Becoming an Advocate 709
Systems-level advocacy guidance on how practitioners can ensure that their voices are
heard at tables where policy is being shaped.
Systems-level advocacy happens where policy (i.e., princi-
Political action committees (PACs) are groups formed by
ples or rules meant to guide decisions and achieve certain
an industry or an issue-oriented organization to raise and
outcomes, including laws and regulations) is introduced,
contribute money to the campaigns of candidates likely to ad-
debated, and passed. This can be at the local, state, or fed-
vance the group’s interests. The American Occupational Ther-
eral level. The policy-making process can be lengthy and
apy Political Action Committee (AOTPAC) works to advance
unpredictable, so many occupational therapy practitioners
the profession’s policy agenda and complement the work of
may be deterred from advocating to policymakers. However,
its lobbyists by providing financial support to elected officials
government policymakers depend on the expertise of occu-
who support occupational therapy. AOTPAC and state PACs
pational therapy practitioners and other health professionals
are funded entirely through donations from individual prac-
to develop good policy. Health, education, and social policy
titioners because AOTA and state associations are legally pro-
determine where occupational therapy services are provided,
hibited from donating to candidates running for public office.
who provides them, who receives them, and how they are re-
Although lobbyists and PACs are critical to ensuring that
imbursed. If occupational therapy practitioners do not make
occupational therapy is represented in important public pol-
their voices heard in these discussions, they risk losing jobs,
icy discussions, policymakers place a higher value on input
limiting the profession’s scope of practice, and restricting the
from their constituents (Congressional Management Foun-
ability to practice in the manner that best meets clients’ needs.
dation, 2011). They recognize that a lobbyist is paid to repre-
Some occupational therapy practitioners may be famil-
sent a certain policy position, but when a constituent takes
iar with the federal legislative process through the iconic
the time to communicate with a representative on a particu-
Schoolhouse Rock video (Frishberg, 1975), but the legislative
lar issue, it sends a powerful signal to that legislator about the
process does not end once a bill is passed, nor do the oppor-
importance of that issue. Congressional and state legislative
tunities to advocate for the profession end at that point. Prac-
offices keep close track of the number of calls, letters, elec-
titioners can advocate at every stage of the legislative process
tronic messages, and social media posts they receive about
by highlighting the need for new policy, by helping to for-
different issues, and this has a significant impact on each leg-
mulate policies that are advantageous to the profession and
islator’s agenda as well as how they cast their votes.
clients, by assisting regulatory agencies in determining how
Anyone can make an appointment to meet with their
an adopted law should be implemented, and by helping policy
elected representatives either on Capitol Hill or in the legisla-
makers evaluate whether an established policy is working as
tor’s district office; elected representatives frequently host town
it was intended. Practitioners can also advocate at the sys-
hall–style meetings in their districts that are open to the pub-
tems level by supporting the work of the profession’s lobbyists
lic. Individual practitioners are most effective at advocating at
(individuals who seek to influence public officials on an
the systems level when they communicate a shared message,
issue on behalf of a group or cause) and by building posi-
which is why AOTA’s lobbyists provide numerous resources on
tive working relationships with their elected representatives.
its website that practitioners can use in communicating with
Exhibit 76.3 provides practical examples of how occupational
their elected representatives (AOTA, 2018a). Exhibits 76.4– 76.6
therapy practitioners can advocate at the systems level.
provide practical advice for communicating with policymakers
Occupational therapy practitioners can support the work
in writing, by phone, and in face-to-face meetings.
of the profession’s lobbyists by maintaining their state associ-
ation and AOTA memberships. These organizations have paid
staff members, including lobbyists, who monitor and influence Review Questions
policy initiatives that affect the practice of occupational ther-
1. Which of these statements does not reflect effective
apy by meeting with regulators and elected representatives on
advocacy?
Capitol Hill. These lobbyists also keep practitioners informed
a. Its primary goal is to convince others to see an issue
about the issues affecting the profession and provide critical
from your point of view as an occupational therapy
practitioner.
b. It incorporates the principles of therapeutic use of self
EXHIBIT 76.3. Examples of Advocacy at the and involves relationship building.
Systems Level c. It educates key stakeholders on the distinct value of
■ Becoming a member of AOTA and state occupational therapy 2. Which of these statements represents an example of occu-
associations to support these organizations’ lobbying efforts. pational therapy advocacy at the professional level?
■ Writing to members of Congress about an issue affecting the a. Including objective outcome measures in your doc-
profession. umentation to demonstrate the efficacy of your
■ Replying to regulatory agencies’ requests for comments about
interventions.
proposed rule changes.
b. Collaborating with other disciplines and administrators
■ Meeting with legislators 1:1 in their offices or at public events.
■ Contributing to AOTPAC and state political action committees.
in your facility to develop a fall prevention program.
c. Attending your state association’s advocacy day.
3. What is the relationship between AOTA’s lobbyists and EXHIBIT 76.5. Sample Phone Call to a Member
the political action committee AOTPAC? of Congress
a. AOTPAC is the political action arm of AOTA that
complements AOTA’s public policy agenda and sup- Phone calls are an important way of sharing feedback with your
ports its lobbying efforts by funding candidates who members of Congress, and they need not be anxiety inducing or time
support occupational therapy. consuming. Here’s an example of an effective call to a member of
b. AOTPAC raises funds to hire lobbyists for AOTA. Congress about an issue important to the profession:
c. AOTPAC is the lobbying arm of AOTA. Hello, Representative Smith’s office.
Hi, this is [Your Name], and I live in [City]. I would like to talk to the
staffer who works on health care policy.
Hold please while I check if that person is available. (pause) I’m
EXHIBIT 76.4. Writing to Elected Representatives sorry, our legislative aide who works on health care issues is not
available right now. Can I take a message?
Although form letters like those provided on AOTA’s website
Yes, I’m calling about [bill number]. I know Representative
(AOTA, 2018b) can be an effective advocacy tool, personalized
Smith is involved in House budget negotiations this week. As an
letters are often more effective. Here are some guidelines to
occupational therapist working with older adults in her district, I
help you write or personalize an email or letter to an elected
would like her support in ensuring that occupational therapists
representative:
be able to establish eligibility for home health services. Current
■ If mailing a letter, use personal stationery or business letterhead if Medicare regulations create an imbalance among skilled therapy
part of a private practice. Do not use an employer’s letterhead. services by limiting occupational therapists’ ability to conduct the
■ Use the correct honorific in addressing a letter or email: required initial assessment under Medicare and to complete the
Senator Last Name for members of the U.S. Senate; comprehensive assessment. Occupational therapy is a critical
Representative Last Name for members of the U.S. House of element of home health with our focus on functional abilities
Representatives. and home safety. I hope that Representative Smith will vote to
■ State the reason for writing. If requesting a meeting or co-sponsor H.R. [resolution number], a bill to give home health
extending an invitation to an event, be sure to include times and agencies the flexibility to use the most appropriate skilled service
dates, the anticipated length of time you would like with the to conduct the initial assessment visit and to complete the
legislator, and the purpose of the meeting or event. comprehensive assessments.
■ Be concise and address only one issue per email or letter.
Thanks for your message. Can I get your full name, address, and
■ Be specific and include the bill title and number if you are
telephone number?
addressing a particular piece of legislation. Don’t assume that
they are familiar with your issue or occupational therapy. Avoid Sure. [Name], [Address], [Phone Number]
using language that is inaccessible to those outside of the
profession. Thank you. I will pass your message along to the Representative.
■ Know the target audience. Familiarize yourself with your elected Thank you for your time.
officials and learn what committees they serve on as well as
what issues are important to them. This will allow you to tailor a
message that aligns with their platform.
■ Personalize the issue. Explain how the issue affects you, your
profession, and your clients and how it affects the legislator’s PRACTICAL APPLICATIONS IN
constituents and their state. Use stories from your practice to
personalize your message and demonstrate your professional OCCUPATIONAL THERAPY
expertise. How to Advocate Effectively at the Daily
■ Request specific action. Be explicit about what you want
your legislator to do about the issue. Use AOTA’s or your state
Practice Level
association’s talking points to help guide you. Be constructive and In day-to-day occupational therapy practice, all practi-
offer proposed solutions if you feel that your representative isn’t tioners have the opportunity to demonstrate occupational
currently taking the best approach. therapy’s distinct value to their clients, colleagues, and
■ Be courteous and respectful. Avoid threatening or hostile
third-party payers. Without the everyday advocacy of oc-
language. Be sure to thank your representative for their time and
attention to your concerns and ask how you can assist them in
cupational therapy practitioners in their respective practice
their efforts. settings, professional and systems-level advocacy is not pos-
■ Follow up. You can follow up your letter or an email with a phone sible (Lamb, 2017). Effective advocates at the daily practice
call to further emphasize the importance of the issue. If you level should
receive a reply from your representative, you can also provide
additional resources or information as appropriate by visiting
■ Treat every client encounter like an opportunity to shape
AOTA’s Advocacy & Policy page (https://www.aota.org/Advocacy-
public perception of the profession.
Policy.aspx). ■ Ensure that their clients and colleagues understand and
can articulate what occupational therapy is.
EXHIBIT 76.6. Dos and Don’ts When Meeting With EXHIBIT 76.7. Tips for Building Relationships With
Elected Officials Elected Officials
DO ■ Visit your members of Congress at their offices in Washington, DC,

or in your district.
■ Familiarize yourself with your legislator before the meeting, and
■ Maintain regular contact with your representatives by phone,
learn what issues are important to them so you can tailor your
email, and regular mail.
message to align with their interests.
■ Attend district events, and introduce yourself as an occupational
■ Respect the official’s time by limiting your conversation to 1–2 key
therapy practitioner.
issues.
■ Share your experience and expertise on issues relevant to your
■ Know your facts and communicate a consistent message. Use
area of practice.
talking points from AOTA to guide your discussion and bring copies
■ Share AOTA resources on occupational therapy’s role in promoting
of AOTA Fact Sheets to leave with your legislator’s office.
health and well-being.
■ Personalize the issue by sharing a brief story about how it affects
■ Invite elected officials to visit your practice setting to witness
the people you serve.
firsthand the value of occupational therapy.
■ Be specific and ask for what you want them to do in regard to your
■ Take time to thank your elected officials when they support issues
issue(s). If you don’t ask, the answer will always be no.
that are important to you.
■ Follow up in writing, thanking them for their time and public
■ Send congratulatory notes to your elected officials when they win
service, providing additional information or documentation as
elections or take on new leadership roles.
requested, and offering to assist them in their efforts.
■ Get to know your elected officials’ legislative staff members and
DON’T build positive working relationships with them.
■ Assume that they are familiar with the profession of occupational
therapy or your issue(s).
■ Overload your legislator with too much written material or too
many issues. How to Advocate Effectively at the
■ Bluff if you don’t know the answer to a question. Offer to follow up
Systems Level
with them after the meeting.
■ Be argumentative or threatening. Occupational therapy practitioners do not need to be pub-
lic policy experts to advocate effectively at the systems level.
Source. Adaption from “Procedure for Conducting an Effective Congressional Visit,”
by the American Occupational Therapy Association. Copyright © 2018 by the AOTA and state association lobbyists provide a wealth of
American Occupational Therapy Association. Used with permission. information to keep practitioners informed about policy de-
velopments affecting the profession as well as resources for
communicating effectively with elected representatives. But
■ Be client-centered, evidence-based, and occupation-focused you do not need to wait until your legislators are considering
in their practice. important legislation to contact them. In fact, occupational
■ Use objective outcome measures in documenting the effi- therapy practitioners can be even more effective advocates
cacy of their interventions. at the systems level if they build relationships with their
■ Describe how their interventions help address third-party elected representatives over time. This means cultivating a
payers’ biggest concerns in their daily documentation. positive relationship with your legislators before you need
to approach them for support on an issue (see Exhibit 76.7).
How to Advocate Effectively at the By using the same principles of therapeutic use of self with
legislators that we use with our clients, occupational therapy
Professional Level
practitioners can help shape public policy to support and
Occupational therapy practitioners advocate at the profes- advance the profession. Effective advocates at the systems
sional level every time they use their expertise to address an level should
unmet need wherever they may find it. By seeking out oppor-
tunities to demonstrate occupational therapy’s distinct value ■ Maintain state association and AOTA membership;
to key stakeholders and outside coalitions, practitioners help ■ Stay informed about legislative developments affecting the
create new opportunities to advance the profession. Effective profession;
advocates at the professional level should ■ Maintain regular correspondence with their elected rep-
resentatives about issues important to the practice of oc-
■ Treat every professional interaction as an opportunity to cupational therapy; and
create a new ally for occupational therapy. ■ Vote in every election, and ensure your clients have the
■ Seek out and seize opportunities to use their occupational accommodations they need to vote.
therapy knowledge and skill set to address someone else’s
challenges. Case Example 76.1 illustrates how an occupational therapy
■ Identify opportunities to contribute their occupational practitioner can advocate at the daily level, professional, and
therapy knowledge to valued causes and groups. systems levels.
CASE EXAMPLE 76.1. Camille: Advocating for Occupational Therapy
Camille is an occupational therapist in a state psychiatric hospital. In this setting, she provides one-on-one intervention to patients living with a
variety of mental health and substance abuse disorders; she also runs 2 groups, one focused on living skills development and the other on creating
a Wellness Recovery Action Plan (WRAP), a mental health wellness and prevention tool. Advocacy is central to her practice both inside and outside of
her work setting.
Daily Practice Level

Camille frequently advocates on behalf of the patients she serves. When a woman lost privileges due to noncompliance with her group treatment
schedule, Camille pointed out to the team that the woman’s low vision might be interfering with her ability to read her daily schedule. She provided
her with a large-print version that immediately improved the patient’s attendance at groups.
Camille considers fostering self-advocacy in her patients one of her most important interventions. When a participant in her WRAP group
expressed frustration with the side effects of his medications, Camille worked with him to develop a list of questions for his next doctor visit. When
she noticed that one doctor frequently recommended that participants in her living skills group be discharged to a group home, she contacted the
physician to determine what skills she should focus on to better prepare her patients for more-independent living situations.
Recognizing that most of her colleagues are familiar with what she does only by what she documents in the electronic health record, Camille
takes great care to write good daily notes that demonstrate how she is preparing her patients to live healthier, more productive lives.
Professional Level
Recognizing a variety of unmet needs in her practice setting, Camille is also a powerful professional advocate. She advocated to create her living
skills group after noticing that doctors frequently ordered living skills assessments just before discharge without giving patients the opportunity
to develop the skills necessary to live independently. She also advocated to change internal referral practices and assessments. When she noted
that members of the interdisciplinary care team were relying on cognitive screens to determine discharge supports, she used research evidence
to advocate to the psychosocial rehabilitation department directors that occupational therapy practitioners conduct more informative functional
cognitive assessments instead. Camille has also sought out opportunities to apply her occupational therapy expertise to improving mental health
services in her community by serving on the board of directors of a psychosocial club house.
Systems Level
After growing frustrated with the lack of community supports available to her patients after discharge, Camille has become a systems-level
advocate. After Congress passed a law creating a demonstration program to improve community mental health services by establishing federally
certified community behavioral health clinics (CCBHCs), Camille submitted testimony to the U.S. Department of Health and Human Services (DHHS)
and the Substance Abuse and Mental Health Administration to advocate for occupational therapy’s inclusion in their staffing criteria; she cited
the profession’s critical role in helping individuals with mental health conditions develop the skills needed to live successfully in the community
(AOTA, 2015).
Camille reached out to her state’s planning group to volunteer to help put together an application for 1 of the 8 demonstration grants, ensuring
that occupational therapy was included in the state’s staffing plan. Although the state’s application was ultimately unsuccessful, Camille gained
valuable insight into the barriers facing occupational therapy practitioners in her state. She became mental health Special Interest Section chair of
her state association and created a mental health advocacy group. The group met with officials from DHHS in an effort to obtain qualified mental
health professionals status for occupational therapy practitioners working in mental health. They also worked with support from AOTA to organize an
advocacy campaign that encouraged occupational therapists in the state to contact their members in Congress to support the Occupational Therapy
in Mental Health Act.
Review Questions
1. How does Camille use advocacy as a form of occupational therapy intervention in her daily practice?
a. By fostering self-advocacy skills in her patients.
b. By advocating on behalf of her patients’ interests to other members of the care team.
c. Both a and b.
2. Which of these is an example of Camille’s advocacy at the professional level?
a. Using daily documentation to demonstrate the distinct value of occupational therapy.
b. Advocating to the interdisciplinary care team that functional cognitive assessments be used in lieu of cognitive screens in determining
appropriate discharge supports.
c. Advocating to the interdisciplinary care team that a patient be provided with the large-print reading material she needs for her low vision.
3. Camille is working to help shape policies to advance occupational therapy practice in mental health by advocating to which of the following key
stakeholders:
a. The U.S. Department of Health and Human Services
b. Her Congressional representatives
c. Her state occupational therapy association
Review Questions systems levels to further the strength of the profession. Creat-
ing a work environment where these activities are valued and
1. Why is daily documentation an important form of advo-
encouraged will support these initiatives. ❖
cacy for the profession?
a. Because it demonstrates why occupational therapy is
more valuable than other disciplines. ACOTE STANDARDS
b. Because regulators use daily documentation to help
determine which providers are reimbursed for what This chapter addresses the following ACOTE Standards:
services and the rate at which those services are ■ B.5.1. Factors, Policy Issues, and Social Systems
reimbursed. ■ B.5.2. Advocacy
c. Because occupational therapy’s claims can be denied ■ B.5.4. Systems and Structures That Create Legislation.
if practitioners are not thorough and objective.
2. Which of the following represent potential occupational
therapy allies and advocates? REFERENCES
a. Occupational therapy clients and family members, Accreditation Council for Occupational Therapy Education. (2018).
interdisciplinary colleagues, administrators. 2018 Accreditation Council for Occupational Therapy Education
b. Local school board, mental health nonprofit organi- (ACOTE) standards and interpretive guide. American Journal
zation, music therapists. of Occupational Therapy, 72(Suppl. 2), 7212410005. https://doi
c. All of the above. .org/10.5014/ajot.2018.72S217
3. Effective advocacy at the systems level is similar to occu- American Occupational Therapy Association. (2015). Occupational
pational therapy practice in that it entails therapists listed in new criteria for federal behavioral health program.
Retrieved from https://www.aota.org/Publications-News/ForThe
a. Relationship building using therapeutic use of self.
Media/PressReleases/2015/052212-CCBHC.aspx
b. Convincing someone else to do what you want them
American Occupational Therapy Association. (2018a). Procedures for
to do. conducting an effective Congressional visit. Retrieved from https://
c. Working collaboratively toward a shared goal. www.aota.org/Conference-Events/Hill-Day/visit-congress-agenda
American Occupational Therapy Association. (2018b). Tips for
writing a letter to your member of Congress. Retrieved from
SUMMARY https://www.aota.org/Advocacy-Policy/Congressional-Affairs
/Take-Action/Write-Member-Of-Congress.aspx
Occupational therapy faces numerous threats and opportu-
Congressional Management Foundation. (2011). Communicating with
nities in an ever-changing health care environment where
Congress: Perceptions of citizen advocacy on Capitol Hill. Retrieved
resources are limited and competition is fierce. With health from http://www.congressfoundation.org/storage/documents/CMF
care costs soaring, policymakers are constantly reforming _Pubs/cwc-perceptions-of-citizen-advocacy.pdf
the payment systems that clients depend on to access occu- Frishberg, D. (1975). I’m just a bill [Schoolhouse Rock video].
pational therapy services and that practitioners depend on Retrieved from https://www.youtube.com/watch?v=tyeJ55o3El0
to be reimbursed. Meanwhile, other professions attempt to Hart, E. C., & Lamb, A. J. (2018). Mindful Path to Leadership Mod-
encroach upon occupational therapy’s scope of practice. Ad- ule 4: A mindful path to advocacy. Bethesda, MD: AOTA Press.
vocacy is not a skill to be exercised only on Capitol Hill and Hildenbrand, W. C., & Lamb, A. J. (2013). Occupational therapy
in state legislatures; it is a critical tool that all practitioners in prevention and wellness: Retaining relevance in a new health
can use in many ways and in many venues to promote clients’ care world. American Journal of Occupational Therapy, 67(3),
266–271. https://doi.org/10.5014/ajot.2013.673001
well-being and to advance the profession.
Lamb, A. J. (2017). Unlocking the potential of everyday opportuni-
It is up to each individual practitioner and manager to
ties. American Journal of Occupational Therapy, 71, 1–8. http://
demonstrate occupational therapy’s distinct value to ensure doi.org/10.5014/ajot.2017.716001
that the individuals, groups, and populations who might ben- Taylor, R., Lee, S., Kielhofner, G., & Ketkar, M. (2009). Therapeutic
efit have access to our services. Managers in particular can use of self: A Nationwide survey of practitioners’ attitudes and
support practitioners in developing these skills and engaging experiences. American Journal of Occupational Therapy, 63(2),
in opportunities in daily practice and at the professional and 198–207. https://doi.org/10.5014/ajot.63.2.198.
APPENDIX A
Answers to Review Questions
715
APPENDIX A
Answers to Review Questions
715
Foundations of Occupational Therapy SECTION
Leadership and Management:
Answers to Review Questions I
CHAPTER 1. THEORIES OF LEADERSHIP environment, and complex systems to meet the diverse
needs of society in a collaborative and inclusive manner.
Chapter 1—Essential Considerations (p. 5) 3. Responses to this question should reflect the relevant is-
1. Values are central to the development of leaders. Leaders sues that might connect with readers’ values and tap into
act based on their core values, which shape how leaders strengths they feel are relevant and fit with their com-
carry out their leadership role. In turn, their leadership mitments. They likely will look at campus or community
actions strengthen their values. organizations, state occupational therapy and health-
2. Servant leaders give away their power so that they can related organizations, and assuming roles that might be
best serve the organization. This builds capacity in them- available to them or creating new roles that would be
selves, others, and the organization, so all share power meaningful to them.
and increase their leadership influence. The goal of
servant leader is not control, but rather to increase the Chapter 1—Case Example 1.1 (p. 7)
capacity of the organization to be effective and flexible in
meeting its goals and achieving its desired outcomes. 1. Sister Genevieve and Sally Ryan were faculty members at
3. As a means to coherently lead in concert with their core St. Catherine’s who were role models and mentors while
values, servant leaders sustain themselves through habits Ginny was a student. They were active in leadership of
that keep them at their best physically, emotionally, in- AOTA and the Minnesota Occupational Therapy Asso-
tellectually, socially, and spiritually. They create space for ciation, as well as on campus and in the local commu-
clarity and explore multiple perspectives. They celebrate nity. They encouraged and supported Ginny’s efforts to
successes, especially those that were challenging and step into leadership roles within the occupational therapy
strengthened their commitment. program, on campus, and as an AOTA student leader.
They continued to be available to her for her first decade
Chapter 1—Practical Applications in as an occupational therapist, and helped her connect with
other occupational therapy national leaders.
Occupational Therapy (p. 6)
2. Readers might read Ginny’s 2013 Presidential Address
1. Readers will highlight the key words based on their own and find specific attributes, skills, and values that are
strengths and aspirations for their development. They linked to servant leadership. Other characteristics of the
might highlight what they will do to influence health, servant leader include authenticity, engaging with others,
well-being, and quality of life for varied populations finding ways to learn from others, and showing active
or reflect on how they will contribute to everyday life empathy and compassion towards others. Adopting a
in specific communities that offer inclusion and offer calm demeanor, being sensitive to the needs of others,
effective solutions to barriers to participation. They and welcoming others to leadership roles were also evi-
could focus on health promotion, prevention, or inter- dent in Ginny’s case reflections.
vention or sustaining inclusive community supports 3. Readers are invited to explore their own possibilities with
and practices. leadership opportunities within occupational therapy and
2. Vision 2025 guideposts emphasize accessibility and cul- in their communities. Depending on what sphere of influ-
turally responsive leadership that is central to meeting ence they value (for example, Ginny got involved in organi-
the needs of diverse persons, populations, and commu- zations that supported mental health as well as occupational
nities. Collaboration is another guidepost that empha- therapy education), each reader can target his or her area
sizes the therapeutic relationship as one where mutual of commitment. Considering local, state, national, and in-
respect and client-centered perspectives guide the pro- ternational opportunities would also map consistently with
cess. The guidepost of effectiveness emphasizes strong the case presented in this chapter. Assuming greater re-
evidence-informed practices that use resources care- sponsibilities over time as well as building sustainable paths
fully and efficiently to offer the greatest value. The final toward leadership was clearly articulated through Ginny’s
guidepost emphasizes leaders influencing policies, the vision of “every member a leader . . . a member for life.”
717
718 APPENDIX A. Answers to Review Questions
CHAPTER 2. PERSPECTIVES ON process of initiating intervention first in trial format

MANAGEMENT and then in a more formal and sustained manner; and
(4) program evaluation, which the ongoing process of
Chapter 2—Essential Considerations (p. 21) assessing the impact and quality of program processes
and outcomes and making continuous improvements in
1. Middle managers oversee a department or group of ser-
efficiency and effectiveness.
vices and coordinate subordinates or employees and
5. CQI is both a management philosophy and a manage-
report up the chain of command to a superior who may
ment method. As a management philosophy, CQI takes
be a top leader in the organization. These managers are
an organizational perspective: setting direction and pro-
in the middle of the organization and are accountable to
moting strategically aligned improvement initiatives
those above and below them in the organizational chart.
through leadership support, organizational learning, and
2. Key outcomes include the creation of an organizational
resource allocation. As a management method, CQI pro-
code of standards and ethics that enables individuals to
vides a framework for identifying improvement oppor-
make independent decisions aligned to the organization’s
tunities and managing CQI teams tasked with analyzing
values and the ability to shape the behaviors and actions
problems so that solutions can be identified and imple-
of members of the organization.
mented; in this way, desired results are achieved.
3. Planning, organizing (and sometimes staffing), controlling,
and directing.
Chapter 2—Case Example 2.1 (p. 24)
Chapter 2—Practical Applications in
1. The PDSA process (Plan, Do, Study, Act) is a continuous
Occupational Therapy (p. 23) quality improvement cyclical process commonly used
1. Competency statements or checks serve as “explicit mea- in health care. The PDSA process helps managers iden-
sures, indicators, or statements that define specific areas tify opportunities for improvement, plan, and conduct a
of knowledge, skills, and abilities related to essential data-driven analysis of the problem and potential solu-
functions and assigned duties” (Bravemen, 2016, p. 298). tions and implement chosen solutions. Robin was able
They are used to assure that staff are competent in per- to use the PDSA process to identify multiple contribut-
forming the essential functions of a job. ing causes to the problem of the lengthy time to receive
2. Financial management is both a planning and a con- and schedule initial evaluations and to move toward
trolling function because managers must project (plan) identifying possible solutions to implement to improve
revenue and expenses and act to control spending and efficiency.
other activities to operate within the budget. 2. Value-based leadership is a model of leadership where
3. The 4 components of the marketing process are (1) orga- the values of all stakeholders create an organizational
nizational assessment, which involves examining what code of standards and ethics that enables individuals
will influence the development and promotion of a new to make independent decisions aligned to the organiza-
product or service and identifying strengths and weak- tion’s values. It can guide Robin’s decisions and actions
nesses through a SWOT (strengths, weaknesses, oppor- by ensuring that they are ethical and are in line with
tunities, threats) analysis; (2) environmental assessment, her organization’s expectations for behavior. Robin can
which involves examining the needs of target populations also use value-based leadership to concentrate on the
that guide the development and promotion of a new prod- core values of the organization and ensure that her ac-
uct or service; (3) Market analysis, which involves vali- tions and decisions prove desirable and beneficial for all
dation of the perceptions of the wants and needs of the stakeholders.
target populations that will receive a new product or ser- 3. Competencies are statements of an employee’s expected
vice; and (4) marketing communications, which involves performance in particular situations. Robin can use com-
packaging and promoting a product so the target popula- petencies to define the specific areas of knowledge, skills,
tions and other key stakeholders have a clear understand- and abilities required for each position in her depart-
ing of what the product or service is and how it may be ment, allowing her to more effectively plan and deliver
accessed occupational therapy services.
4. The 4 steps of the program development process include
(1) needs assessment, which is the process of describing
the target population, naming perceived and felt needs, CHAPTER 3. LEADERSHIP VS.
and analyzing available resources and constraints both MANAGEMENT
internal and external to the organization or context in
Chapter 3—Essential Considerations (p. 29)
which the program is being planned; (2) program plan-
ning, which is the process of identifying the steps and 1. B
sequence of actions to be taken to plan for initiation of 2. C
the program; (3) program implementation, which is the 3. B
SECTION I. Foundations of Occupational Therapy Leadership and Management: Answers 719
Chapter 3—Practical Applications in point of service plans, where the individual selects either
Occupational Therapy (p. 31) an HMO or PPO for each episode of care (NLM, n.d.). In
this situation, individuals need to know about occupational
1. C therapy and the value it would add to their health care ex-
2. D perience and need to be able to self-advocate for this service
3. D or choose an HMO or PPO specifically to address antici-
pated needs.
1. D Chapter 4—Practical Applications in
2. C Occupational Therapy (p. 44)
3. D
1. Hospitals, schools, and long-term care account for the
majority (68.7%) of present occupational therapy prac-
CHAPTER 4. EVOLUTION AND FUTURE tice. There is a need for occupational therapy practitioners
OF OCCUPATIONAL THERAPY to serve individuals in emerging niches for occupational
SERVICE DELIVERY therapy within the areas of children and youth, health
and wellness, mental health, productive aging, rehabilita-
tion, disability and participation, work and industry, and
1. Legislative actions are created in response to the visibil- education (Yamkovenko, n.d). The Healthy People 2020
ity of population needs. This is evident in the Vocational report describes several needs in relationship to preven-
Rehab Act amendments that were developed in response tion and access, community health, and wellness, sug-
to the needs of a large number of World War I and World gesting a need to move beyond extensive focus on work
War II veterans. Later amendments were made to address within the medical setting.
the needs of individuals with disabilities, the elderly, Growth in population diversity suggests that occu-
children and others. pational therapy practitioners need to be able to provide
2. Private health insurance covered 67.5% of the population culturally sensitive care to people with varying “customs,
of the United States in 2016. Without insurance, clients beliefs, activity patterns, behavioral standards, and ex-
may be unable to pay for occupational therapy services, pectations” (AOTA, 2014b, p. S9). In addition, practi-
and therefore have limited access. tioners need to provide care to diverse populations within
3. The four types of managed care insurance plans are: the community.
■ Exclusive provider organizations, 2. Occupational therapy practitioners might help promote
■ Health maintenance organizations (HMOs), health and prevent complications of chronic conditions
■ Preferred provider organizations (PPOs), and by addressing mental and behavioral health management
■ Point of service plans (CMS, n.d.-c.,n.d.-d; U.S. Na- situations that exacerbate co-existing conditions. The
tional Library of Medicine [NLM], n.d.). practitioner might accomplish this by helping the client
Exclusive provider organizations require that individu- create healthy routines that support health, such as med-
als see only specific health care professionals in a specified ication management, blood sugar checks, healthy eating,
network to receive coverage (CMS, n.d.-c). If there are not and physical and social activity.
occupational therapy practitioners working within a given 3. Millennials will require additional care in addressing
network with specific skills to address client needs, the cli- behavioral health needs, such as stress management and
ent may not see an occupational therapy practitioner. In anxiety. Prevention and wellness will be the focus of ser-
HMOs, the individual is assigned to a primary care physi- vices for baby boomers, and will require more emphasis
cian who is responsible for care coordination (i.e., the cli- of occupational therapy services on issues of prevention,
ent needs a referral to access other services; CMS, n.d.-d.; such as safety and falls prevention; moreover, an in-
NLM, n.d.). If occupational therapy is not a visible service creased emphasis on prevention will result in more em-
for that physician, the client may not be referred for occu- phasis on community-based rather than hospital-based
pational therapy services. occupational therapy services.
Individuals covered through PPOs have lower copays,
and health care services are reimbursed at a higher rate
if they remain inside the predetermined network instead
of seeking care outside of the network (NLM, n.d.). How- 1. What are the healthcare needs of the immigrant popu-
ever, if occupational therapy services are available within lation and of the existing population; where do they co-
the network are not visible, or the particular occupational incide; and where are they unique, requiring a specific
therapy expertise needed is not available, occupational culturally sensitive health care approach?
therapy may not be provided to the client. Visibility and 2. Consider legislation regarding refugee immigration status,
marketing of services becomes an even more acute issue in government supports available for immigrant populations,
health care legislation supporting coverage for immigrant families related to victims of Hurricane Maria, and
needs, and legislative support for addressing opioid abuse posttraumatic stress disorder management. For exam-
and reverberating effects across the lifespan and within the ple, after a May 2018 tornado in Connecticut, school-
family system as well as in the rural community. based occupational therapists in the area addressed
3. Consider expanding existing partnerships with the student anxiety during a September 2018 thunderstorm
school, hospital, and nursing home, with a focus on using grounding sensory strategies.
prevention and health care education regarding opioid
use, pain management, and substance abuse prevention.
Work with community agencies not directly focused on Chapter 5—Case Example 5.1 (p. 54)
health care, such as daycare centers, churches, youth 1. Answers will vary based on country chosen.
development organization associated with clubs such as
Boy and Girls Scouts, 4-H, and farm bureau and Farm-
ers Union programs to promote health, educate, and pro- Case Example 5.2 (p. 55)
mote prevention.
1. B
4. Program development may be hampered by lack of reim-
2. A
bursement for services, so there will be a need to identify
available grants, fee-for-service opportunities, and part-
nerships with community initiatives to promote the value Case Example 5.3 (p. 55)
of occupational therapy services for cost containment
and health maintenance over time. 1. Religious prohibition, discomfort with other gender per-
forming personal care tasks, cultural expectations that
parents care for their children with a disability.
CHAPTER 5. GLOBAL PERSPECTIVES 2. “Yes” explanations may include details of looking for cul-
ON OCCUPATIONAL THERAPY tural support and using medical releases appropriately.
PRACTICE “No” explanations may include fidelity to traditional
therapy and billing processes.
Chapter 5—Essential Considerations (p. 51) 3. Language barrier, religious barrier, inexperience work-
1. Local community groups, churches, synagogues, ing with patrimonial dominated decision makers. Other
mosques, and cultural clubs may be examples of where to remedies may have been respecting the family’s deci-
find local people to provide information on the identified sion to provide care in this way and using same-gender
group. videos trainings for the father to help train his son
2. D privately.
3. D

CHAPTER 6. LEADING AND
Occupational Therapy (p. 53) MANAGING WITHIN HEALTHCARE
SYSTEMS
1. Answers may vary, for example, fulfilling the role of “use
of everyday occupations to facilitate recovery” may feel Chapter 6—Essential Considerations (p. 62)
like a familiar skill, but “training of volunteers to carry 1. D
out ‘quick mental health assessment’ and counselling, 2. D
and to facilitate activities and social connectivity, thus 3. A
providing more immediate services for greater num-
bers” may feel like a skill that is not in a practitioners
wheelhouse. Chapter 6—Practical Applications in
2. D Occupational Therapy (p. 64)
3. Recent national disasters (natural and manmade) in-
clude the California wildfires, Las Vegas shooting, and 1. E
Hawaiian volcano eruption. Recent international disas- 2. C
ters include the Syrian civil war and subsequent refugee 3. D
crisis, the floods in Bangladesh, and Hurricane Maria
in Puerto Rico. Disasters can influence occupational
therapy practice in multiple ways, such as an increasing
number of physical dysfunction caseloads or school- 1. D
based services for refugees, more demand for mental 2. D
health occupational therapy services for U.S.-based 3. B
SECTION I. Foundations of Occupational Therapy Leadership and Management: Answers 721
CHAPTER 7. CREATING A BUSINESS ■ Understanding the importance of health and wellness

IN AN EMERGING PRACTICE AREA to children with disabilities and how swimming and
other recreational activities can benefit children in the
Chapter 7—Essential Considerations (p. 72) program
1. B, C, E ■ Being able to observe the children during the swim-
2. B ming activity and modify the swimming experience
3. D to meet the ongoing needs of the child
3. Possible answers may include:
Chapter 7—Practical Applications in ■ Local community groups that support families and
Occupational Therapy (p. 75) children with disabilities
■ Local community businesses that could become spon-
1. A sors for different swimming and sports activities held
2. D at the recreation center
3. C ■ Regional or national sports associations that support
sports activities that she is adapting to be more inclusive.
Chapter 7—Case Example 7.1. (p. 74)
1. Possible answers can include
■ Understanding of the needs of senior travels CHAPTER 8—MANAGEMENT FOR
■ Having an understanding of medical conditions that OCCUPATION-CENTERED PRACTICE
might require adaptation during travel Chapter 8—Essential Considerations (p. 84)
■ Understanding the benefits of travel to seniors health
and wellness 1. Occupation-centered practice is the perspective that occu-
■ Being able to do activity analysis on tour experiences pation is the central organizing lens or framework that
to benefit her senior clients grounds practice, education, and research (Nielson, 1998;
2. Possible answers may include: Yerxa, 1998).
■ Seniors she already knows 2. Occupation-focused practice leaves room for the use of
■ Senior centers that provide recreation opportunities interventions that are not considered occupations but are
■ Travel clients from her parents’ business more preparatory in nature (AOTA, 2014). Focus refers to
■ Outpatient clinics the relative distance of actual participation from the inter-
■ Churches and church groups (especially if there is a vention. In other words, does the intervention, whether an
service component to the travel) occupation, activity, or preparatory method or task, closely
■ Organizations that promote multi-generational resemble or directly lead to the actual goal of intervention?
engagement If so, the intervention is proximally focused on occupa-
tion. However, if the intervention—which could conceiv-
3. Possible answers may include ably be an unrelated occupation, activity, or task—does
■ Create information brochures that can be shared with not immediately or directly impact the target occupation,
the customer segment it is not considered proximal. Therefore, the intervention
■ Create a presentation that can be presented at different can lose the occupation-focused perspective (Fisher, 2013).
community settings, including churches, community 3. “Achieving health, well-being, and participation in life
centers, and other places where seniors might gather through engagement in occupation.” Occupation-centered
for regular meetings practice is the means by which occupational therapy helps
■ Create small videos of trip experiences with customer clients achieve health, well-being, and the ability to partici-
interviews highlighting the benefits of traveling with pate fully in life through the consistent use of engagement in
her company. This could be shared in meetings, on so- occupation as both the means and the end to intervention.”
cial media, and on the company’s website.
Chapter 7—Case Example 7.2. (p. 74) Chapter 8—Practical Applications in

1. Possible answers may include:
■ Families of children with disabilities in the community 1. Be a good communicator, establish trust, and promote a
■ Outpatient therapy clinics learning culture.
■ Early childhood inclusive programs 2. Differentiation of the past from the future can be accom-
■ School and after-school programs plished through discussions and by sharing current prac-
2. Possible answers may include: tice beliefs and those of occupation-centered thinking.
■ Understanding of the impact of different medical con- 3. Leaders must provide resources that practitioners can
ditions on exercises (e.g., issues of fatigue, focus; need use in their own learning and share with each other. For
of additional supports to succeed) example, a leader should work with upper management to
provide AOTA membership for those who are not mem- open communication, knowledge sharing, learning, and a
bers. Attendance at conferences and workshops and partic- shared vision for change.
ipation in continuing education programs that support the 2. Occupation-based practice is an evidence-based and cli-
new paradigm should be funded or strongly encouraged. ent-focused way of working with clients that can improve
participation in therapy and lead to outcomes that make a
difference in clients’ lives.
3. The change may take place but may not be sustained be-
1. The steps listed provide opportunities to establish trust cause there is no champion or passion within the group to
between the leader and staff as well as create a culture of continue to work in a new way.
SECTION
Organizational Planning and Culture:
Answers to Review Questions II
CHAPTER 9. STRATEGIC PLANNING collectively with other occupational therapists and assis-
tants can lead to the identification of outreach strategies.
Chapter 9—Essential Considerations (p. 93) Reviewing AOTA, state association, and state regulatory
1. The home page of the organization’s web site typically de- priorities can assist in the planning a course of action.
scribes a service delivery organization providing therapy Lastly, actively volunteering both in occupational therapy
or health-related services. The mission and aspirational vi- organizations and other community organizations can pro-
sion of your organization is related to a more specific pur- vide an entry point to become a part of the change process.
pose on a local or regional level. As a professional organi- 2. Before presenting the program idea to the council, it
zation, AOTA’s mission and vision is a membership-driven would be useful to review the hospital’s strategic plan.
entity with a broader societal direction promoting the Particular emphasis should be placed on determining
profession. the link between the program idea and the mission and
2. The strengths and weaknesses are factors that exist vision of the hospital. It is important to determine the or-
within the internal environment of the organization; op- ganization’s goals and strategies for the next several years
portunities and threats are factors or conditions that are and to determine the possible fit with the new program
external environmental influences possibly affecting the idea. Finally, prior to the presentation it is important to
organization. thoughtfully consider all program costs and the benefits
3. Key steps in successful strategic planning include: to the hospital. It may be useful to discuss your presenta-
1. Obtaining broad stakeholder input tion in greater detail with your supervisor prior to meet-
2. Conducting a needs assessment, including a SWOT ing with the administrative council.
analysis 3. An example of a personal vision statement might be: “In
3. Creating possible scenarios and selecting the most the next 3–5 years, I plan to become a certified hand ther-
likely one apist (CHT) working in the outpatient clinic in my current
4. Developing plan goals and strategies place of employment. Over the next several years, I plan to
5. Developing a plan for evaluation. successfully complete the CHT credentialing program and
4. Reviewing an organization’s annual report, website, or seek mentorship from my supervisor who is a CHT.”
social media outreach may provide direction for both
current activities and future planning. Additionally, pro- Chapter 9—Case Example 9.1 (p. 97)
gram evaluation data such as satisfaction surveys, exter-
nal accreditation reviews, or regulatory audits may pro- 1. The current occupational therapy operations are focused
vide critical insight into the organization’s effectiveness. on the skilled nursing facility (SNF) setting. The availabil-
5. Seeking and using stakeholder input is essential for plan ity of occupational therapy staff is a strength. A critical
development. Consideration of varied internal and ex- question is whether an outpatient setting matches either
ternal perspectives enriches the process, leading to a the current or potential skill set of the occupational ther-
greater likelihood of plan success. Input may be obtained apy staff. Additionally, does the hospital have a plan to
in multiple ways, such as surveys, group input meetings, ensure a flow of rehabilitation (particularly occupational
and focus groups. Using a broad cross section of different therapy) outpatient referrals?
groups and views (of both internal and external stake- 2. All 4 goals require an integrated and comprehensive ap-
holders) is highly desired in creating a sense of trust, co- proach. While the rehabilitation disciplines and other
hesion, and a shared vision. clinical areas are essential, the goals require allocation
of new resources (financial, space, human resources) and
the development of a new product brand. Rehabilitation
goals must include a focus to ensure the development of
evidence-based protocols and the further development
1. It is useful to for members of their state occupational ther- of competent staff. Additionally, rehabilitation staff re-
apy associations to become actively involved in committees lationships with referral sources will be key to program
such as legislative affairs or community outreach. Working success.
723
3. Assuming that all staff have made an active choice to join and issues surrounding what researchers are allowed to
the program, there is the immediate task to ensure that do with that data once it is collected without consent.
each team member is clinically competent. Furthermore,
added professional development needs to be included for Chapter 10—Case Example 10.1 (p. 104)
all staff. But perhaps the largest challenge is the daunting
task of beginning a new program. Building a program is 1. Options for handling missing data and outliers include
time-consuming, especially with staff transitioning from keeping the data as they are, deleting the entire entry,
the SNF and the high stakes attention (from hospital lead- or entering a mean or aggregate data point. Researchers
ership) centered on the new outpatient program. have several reasons for choosing a particular approach
4. A key strategy that supports contribution is active partic- to handling missing data. Because there were only 10 in-
ipation in the organization. Delivering services or doing stances of missing data, she chose to keep it in. This small
volunteer tasks is important, but it is also important to amount of missing data likely wouldn’t influence the
become environmentally attuned from both an internal overall outcome of her research.
and external perspective. Networking with others across 2. Reporting in multiple ways can help the audience under-
a wide array of settings and perspectives supports on- stand the whole picture of the data. There are instances
going engagement in the needs assessment process and when the reader or audience cannot consume all the data
provides the basis for helping to establish new goals and in a table, and an accompanying graph is helpful to dis-
strategies. Becoming a rehabilitation advocate for the or- play the information visually in a summary format.
ganization’s mission and vison supports the development 3. Oftentimes, descriptive statistics are used in a first step
and achievement of the strategic plan’s goals and provides when analyzing data and can be the basis for predictive
a valuable occupational therapy perspective. modeling. Her model would likely contain the variables
she presented, such as socioeconomic status, gender, age,
race, or ethnicity and how they predict usage and support
CHAPTER 10. USING DATA TO GUIDE the various child services and outcomes provided.
BUSINESS DECISIONS
Chapter 10—Essential Considerations (p. 103) CHAPTER 11. RISK MANAGEMENT
1. Identify the problem or research question. This step is im- AND CONTINGENCY PLANNING
portant because it will frame your work moving forward.
You could include a team of colleagues, mentors in the
field, or hire a data scientist. 1. The 5 risk management strategies are (1) plan, (2) assess-
2. A measurable goal drives the planning process by ensur- ment, (3) analysis, (4) response, and (5) reporting and
ing information is based on available data. It separates the monitoring.
dreams of “it would be nice to know this if we had all the 2. Risk management teams use risk matrixes and incident
access, money and time in the world” from the realities reports in risk assessment. A risk matrix is used to map
“we can gauge this with our available resources.” the most critical risks to an organization. Incident reports
3. A dashboard is a summary report that contains data are used to document objective information after unex-
points to measure performance success in various areas. pected events occur. Teams use a root cause analysis to
You can display quantitative data point on it. determine all system factors directly associated with an
unexpected event and plan the best response. Quality im-
Chapter 10—Practical Applications in provement specialists use a PDSA model to test possible
solutions to risks.
3. An organization’s risk management program includes
1. Answers may include discussion of recent news reports development of contingency plans that will guide the or-
that highlighted data tracking and sharing without con- ganization to resume normal operation when a risk actu-
sent using common social media platforms. ally occurs.
2. Information on cybertechnology standards can be found
when reviewing the Health Insurance Portability and Ac- Chapter 11—Practical Applications in
countability Act of 1996 (HIPAA; P. L. 104–191) privacy and
security rules regularly (U.S. Department of Health and
Human Services, 2013), and the U.S. Department of Health 1. Occupational therapy practitioners can successfully
and Human Services (2018) website (https://bit.ly/2uJAcjr) manage risks in practice and leadership roles by using
that lists HIPAA-covered entities that are subject to follow- their understanding of systems-oriented approach, ac-
ing cybersecurity rules. tivity analysis, performance patterns, clinical reasoning
3. Collecting data on clients without their consent can result and therapeutic use of self, and adaptation. These skills,
in mistrust if this information is discovered. Addition- which are important to the practice of occupational ther-
ally, there are also rights issues with who owns what data, apy, help practitioners to assess risks to an organization’s
SECTION II. Organizational Planning and Culture: Answers 725
outcomes, analyze root causes, embed best practices into 3. Julia must plan how the business will continue to operate
the routine of an organization, foster a culture of safety, if risks become reality. Such risks could include equip-
and create and implement effective contingency plans. ment failure, staffing issues, and natural disasters that
2. Occupational therapy practitioners must monitor for legal threaten the business’ ability to provide occupational
risks and clinical and patient safety risks, such as client falls, therapy services for clients. Julia should develop clear
injuries, and adverse reactions to treatment. Clinicians may contingency plans at a policy level, share these plans with
also need to prepare for hazards, such as weather-related all employees, and test the plans routinely to be sure that
situations, and manage technology risks, including risk they can be effectively implemented.
related to protected health information and the use of social
media. Occupational therapy practitioners who supervise Chapter 11—Case Example 11.3 (p. 117)
and manage others must consider these risks in addition to
financial, strategic, operations, and human capital risks. 1. The steps of risk management included:
3. Examples of risks that occupational therapy managers ■ Risk plan: All employees are responsible for a safe and
and organizational leaders encounter include risks ineffective learning environment. Teachers communi-
volved with adverse events, strategic partnerships, bill- cate with the team and principal and track aggressive
ing for services, compliance with regulatory standards, student behaviors.
hiring and terminating staff, and planning for potential ■ Risk assessment: Aggressive student behaviors present a
threats to operation. likely risk based on recent trends and incident reporting.
■ Risk analysis: The team performed a root cause anal-
ysis following an adverse event in order to determine
Chapter 11—Case Example 11.1 (p. 115) underlying system factors, which included limited
1. The agency completed an annual risk matrix to determine planning for daily schedule, decreased staff commu-
which risks were most critical, based on the frequency nication, and limited time to complete assessments.
and severity of impact on the agency’s ability to fulfill its ■ Risk response: The action plan included ways to miti-
mission. gate these issues, including completion of sensory as-
2. When the group members shared their perspectives and sessment, process for communication and education
experiences without judgement, they were able to identify about the behavior plan, development of a new policy
system causes for the patient’s fall, including staffing is- regarding planning for schoolwide events, and educa-
sues, communication issues, and lack of training related tion for all staff.
to reporting unexpected events. The risk officer and ad- ■ Risk reporting and monitoring: The risk was monitored
ministrators were able to respond by mitigating staffing through weekly team meetings and monthly report-
issues and eliminating breakdowns in team communica- ing on classroom management assessments.
tion and reporting processes. 2. Although the setting and team members may be different
3. The risk officer communicated with stakeholders (i.e., in this school-based example compared to the health care
managers, team members, clients) about how the risk example, the strategies for risk management are the same
of client injury related to falls was being addressed. The (risk plan, assessment, analysis, response, and reporting
quality improvement team audited charts and tracked the and monitoring).
rate of client injury related to fall. Due to the severity of
impact associated with this risk, the agency continued to
rate client injury related to falls as a priority in the next CHAPTER 12. MARKETING STRATEGIES
annual risk matrix. AND ANALYSIS
1. The 7 Ps of marketing are:
1. Risks that are evident in this example include patient 1. Product, the good-and-services combination the
safety risk, strategic risk, operational risk, and financial company offers to the target market.
risk. As Julia builds this practice, she will likely need to 2. Price, the amount of money charged for a product or
monitor human capital risks related to staff, legal and service that consumers exchange for the benefit of
regulatory risks, and hazards that may interrupt normal having or consuming that product.
operations. 3. Place, the physical or virtual location of where the
2. Julia has assessed competition in the area, consulted with a goods and services are provided.
financial advisor, and considered credential processes, fair 4. Promotion, which details how to reach new clients
employee practices, and financial liability insurance. Julia and referral sources.
can obtain information on industry standards related to 5. People, the essential element to occupational therapy
her business through resources from AOTA and pertinent services because clients make judgments about the
regulatory standards. Ongoing communication with stake- organization’s services based on the people represent-
holders will also help her to monitor and respond to risks. ing the organization.
6. Process, how the service is delivered. company or stand out in comparison to competitors’ of-
7. Physical evidence or environment, the physical ele- ferings. The website clearly identify a need the visitor is
ments that convey an organization’s brand and affects experiencing and specifically address how the company
how clients experience its services. can help fulfill that need and show the benefits of choos-
2. The 2 approaches to conduct market analysis are (1) ing its services.
organizational assessment and (2) environmental as-
sessment. An organizational assessment is a self- Chapter 12—Case Example 12.1 (p. 130)
assessment of the organization’s strengths, weakness,
available opportunities, and potential threats (see Case 1. The acronym is SWOT, which stands for strengths, weak-
Example 12.1, “Conducting an Organizational Assess- nesses, opportunities, and threats. It is a framework to
ment”). An environmental assessment identifies the analyze the components of a business when creating a
greater forces, changes, and trends in the environment marketing plan.
(local, national, international) that may affect occupa- 2. Emily determined whether the unit had the resources,
tional therapy practitioners’ business relationships with budget, staffing, and potential opportunities to support
the target market and overall marketing strategy. An a new patient program. She conducted a market analysis
environmental assessment also examines sociocultural for the current patients who would be appropriate for this
trends, economic issues, political issues, legal issues, and group program by conducting a survey of potential par-
trends in technology. By anticipating these changes, one ticipants. Her goal was to determine the best day of the
can take a proactive approach to position a product or week, time, frequency, and level of interest prior to devel-
service in response to the trends in the greater environ- oping her program. See Exhibit 12.2, which lists various
ment. An occupational therapy practitioner should do a marketing and promotional tactics best match her patient
market analysis to make sure that the product or service demographics.
being offered fulfills a need for potential customers or cli- 3. When promoting the group program, your target market
ents and that it will stand out amongst other competitors may extend beyond patients themselves to include mar-
products or services. keting to their caregivers, caseworkers, and other poten-
3. The primary components of a marketing plan are: tial referral sources. Suggestions may include posting on
■ Description of products or services the hospital’s website, soliciting internal referrals from
■ Company mission statement physicians by sending information via fax or mail, using
■ Vision statement social media such as Facebook, networking with similar
■ Description of the target market meetup groups in the community, announcing the group
■ Positioning strategy in the hospital newsletter, and so on.
■ Online marketing strategy
■ Advertising and promotional strategy CHAPTER 13. BUILDING CAPACITY
■ Sales and conversion strategy
■ Referral and retention strategy Chapter 13—Essential Considerations (p. 136)
■ Key performance indicators 1. As occupational therapy practitioners, we are trained to
■ Goals. use the evaluation process to gain an understanding of
A marketing plan is important for a business to establish our client’s strengths (capacities), weaknesses, potential,
its brand or image; create awareness about the company’s and goals. It is through this process that we collaborate
product or services; and strategically influence the group of with the client to develop a plan of approach, implement
customers, clients, or visitors who are most likely to select change through intervention, and assess for effective-
and purchase the products or services so the company meets ness. Like our occupational therapeutic process, capac-
its goals. ity development starts with the evaluation to identify
the stakeholders (client and support system), complete
a needs assessment (client interview and development
of occupational profile), identify a plan of approach
(development of care plan), implement a plan of action
1. It is important to identify the company’s target market (client specific interventions), and then complete ongo-
so the company’s time and resources are directed toward ing evaluation and review of the program (reassessment
consumers and clients most likely in need of and most and progress toward goals). In essence, the occupational
likely to purchase the goods or services being offered. therapy process is focused on capacity development at
2. For example, AOTA could use Pinterest, Twitter, Face- the individual level in order to recover, remediate, reha-
book, or Instagram to help promote the profession on an bilitate, and adapt after illness or injury. Both align with
ongoing basis. (Note. AOTA does have official accounts the goal to improve the current situation through a sys-
and regularly uses those social media channels regularly.) tematic approach.
3. A unique selling proposition differentiates how the com- 2. Identifying and engaging stakeholders and completing
pany’s services or product offerings are unique to the a needs assessment are 2 important steps for building
capacity. Efforts to build capacity without identification 2. Generally, no academic department or clinic operates
of stakeholders results in work that may not be supported solely, and individually, without interacting with others.
or accepted. Stakeholders are vital for program growth, While an individual program may be the priority, the fact
support, and even funding. Proceeding without accu- remains that those departments around us are stakehold-
rately engaging these individuals may ultimately result ers, either directly or indirectly, in the program develop-
in failed capacity development. The same holds true for ment. A capacity development plan that only looks at the
a needs assessment. Failure to complete a thorough needs internal department’s stakeholders, capacities, and infra-
assessment may also result in capacity development fail- structure should be wary and should revisit identification
ure by not fully understanding the needs, capacities, and and engagement of stakeholders.
gaps in occupational therapy practice before starting de- 3. Answers will vary from project to project and may even
velopment. Failure to complete a needs assessment may change depending on the people engaged in the capacity
also result in redundancy of work if time is spent devel- building process. Remember that each part is vital and
oping an area that is already established or by focusing on should be given weight and focus to be successful
a capacity that is not truly needed.
3. a. A bottom-up approach is ideal for expanding into a Chapter 13—Case Example 13.1 (p. 140)
new clinical practice, such as hand therapy, driving,
1. Having 2 occupational therapy practitioners would cost
lymphedema, etc. This model supports the capacity
more, but would immediately provide a solid foundation
development of the practitioner and then the pro-
of support with 2 skilled practitioners ready to share their
gram. . In these cases, capacity development works
knowledge, implement changes, and support growth.
nicely by building the skills of the occupational ther-
Training 2 practitioners ensures continuation of knowl-
apy practitioner and then developing the program to
edge if 1 person were to leave, fall ill, or depart from the
distribute those skills.
capacity development. Training a single practitioner may
b. A top-down approach may work well when you hire
be more efficient, especially in a small department, as
a clinician with a specialty skill set (such as an oc-
it costs less and s less of a burden on others while they
cupational therapy practitioner who is also a certi-
are being trained. However, it would also mean only 1
fied driver rehabilitation specialist). The capacities
practitioner is able to provide training to the other staff
are already present, so for this approach you may
members. Risk for poor program follow through in-
develop the policies and procedures from the top
creases when only 1 person is trained, especially if that
down to ensure the infrastructure is in place to then
person were to fall ill or go on a leave of absence.
connect the occupational therapy’s capacities with
2. When engaging stakeholders remember to focus on re-
potential clients.
ciprocal relationships. Ask yourself how the stakeholder
c. A partnership approach may work well when you
will benefit. For example, how will physicians or social
want to improve the overall performance of the
services benefit from this program? Physicians may ben-
therapy team (e.g., developing partnerships between
efit by having a new resource to address their driving
occupational therapy and physical therapy practi-
concerns and social services will now have a resource for
tioners to work with patients who are drivers and are
families and drivers who are concerned about driving or
having frequent falls). A system may be developed
looking for opportunities after recovery.
to allow entry of this patient through either occu-
3. Examples of primary and secondary gains from outside
pational therapy or physical therapy; the patient is
stakeholders’ relationships may include the DMV gain-
then referred for full rehabilitation by engaging the
ing a better understanding of occupational therapy’s role
other discipline.
with assessing fitness to drive, improved understanding
d. A community approach would work well for im-
of the DMV medical reporting process that will help with
plementing a CarFit Event to provide education to
answering patient questions, improved flow of commu-
older drivers in the community and serve as a mar-
nication between the 2 groups, and potentially increased
keting opportunity for the volunteer practitioners
referrals to the driving program. Both would benefit from
at the event.
improved public safety by working together to address
medically based safety concerns.
Occupational Therapy (p. 138) CHAPTER 14. STARTING NEW
1. Although there are clear steps to capacity building, the PROGRAMS
process is ongoing and often dynamic. Steps such as im-
plementation and evaluation may co-occur, and evalua-
tion may result in revisiting of stakeholders, needs, and 1. A
plan of approach. Revisiting and returning to steps is a 2. B
sign of thorough evaluation, it is healthy, and it is most 3. B (In academic medical centers or where there is a clinical
like to result in more stable, sustainable development. faculty practice, at times it could include A and B)
Chapter 14—Practical Applications in ■ The contact with the community and ability to de-
Occupational Therapy (p. 151) sign occupational therapy–inclusive programming
can support societal need and develop a program as
1. Answers may include seeking guidance from professional
needed to improve care delivery models in a fiscally
associations regarding how to approach this. If working for
responsible manner.
an agency, contact a supervisor to seek training/guidance
Cons:
regarding how the agency wants to respond. Generally, if
■ It may be difficult to get initial funding for participa-
an agent is involved, an administrative representative from
tion in initiatives, but if value can be demonstrated
the agency would come to the facility to meet with the ad-
during an initiative, the agency may provide funding
ministration in the facility (for consistency of response).
for a part-time or a full-time position over time.
Readers should also review the planned recommendations
■ For staff who are traditionalists, participation could
to assure that they are ethical and non-discriminatory.
be a hard sell.
The occupational therapy supervisory team should have
■ There may be a budget shortage for equipment in the
a chance to give input regarding team roles and scope of
initial phase of inclusion.
practice in delivery of services under the new guidelines.
2. Clinical expansion
2. Readers should show leadership and recommend to the
■ If the institution is interested in expanding to care de-
team in the work community work to address plan-
livery, they may support the project with a set limit
ning and best practice initiatives to better manage all
of funded hours of therapist inclusion in the develop-
phases of dementia management. Taking leadership on
ment process.
an emerging concern is one way of ensuring inclusion
■ With positive feedback about inclusion of occupa-
of your services in a developing model. Have evidence
tional therapy services, the institution may seek fund-
in hand from professional literature and trade literature
ing to support program development from nonprofit
regarding programs communities may already be de-
grant-funding organization.
veloping for use in brainstorming. Partner with entre-
Student training
preneurial clinicians in the community, state, region, or
■ A high level of student inclusion could be gained using
country who have expertise in this area. Learn from the
the experience as a doctoral capstone experience for
experts when developing new specialty services. The net-
an OTD student.
working group may be composed of a fair representation
■ Fieldwork Level I and Level II students could assist
of interprofessional team members, community, and
with initial programming and support of program-
caregiver community representatives.
ming during the development phase under the su-
3. Seek membership from a diverse group, including rep-
pervision of a licensed therapist or other qualified
resentatives from clinical settings that may already have
team member.
occupational therapy students and who may wish to take
students. Add representatives from the non-profit sector,
where occupational therapy may be able to contribute and Scenario 2
develop a professional presence if there are not already 3. The proposal could include:
occupational therapy practitioners in the setting (such as ■ Seek feedback from interdisciplinary team members
free clinics), or consumer-driven organizations that have to gain insight into what they envision occupational
membership of persons from groups that have historically therapy contributing, or what they observe is missing
benefited from occupational therapy services. Add inter- from the services provided.
professional team representatives. For example, represen- ■ Do a formal needs assessment for targeted practice
tatives from feeder programs could be a good addition. areas. Start with those that may already have clinical
Consumer representatives are great advisors, as well. In- pathways. Is there a role for occupational therapy?
clusion of student representatives can also be a win-win. ■ Look at feedback from clients who have received
treatment in the setting to determine if there are any
Chapter 14—Case Example 14.1 (p. 143) themes that indicate what would improve the ability
to address their unmet needs (perhaps seek input from
Scenario 1
quality improvement staff).
1. Pros: ■ Brainstorm possible roles for occupational therapy–
■ Occupational therapy has a history of inclusion in based on practice parameters and future practice po-
community based nonprofit models of care delivery. tential and present it to administration and the team.
The development is in a familiar setting to occupa- ■ Create a plan for occupational therapy inclusion with
tional therapy practitioners. a finite timeline. Research and provide relevant ev-
■ The therapist who is chosen as liaison will have a idence on the topic and potential funding sources
change of pace from their routine duties, which can that could support new program development within
enrich their work experience. the setting.
Scenario 3 9. There is a current focus on quality of services of services

and client satisfaction with the outcome of treatment.
4. Interventions that occupational therapy practitioners
It would be helpful to have client satisfaction data, both
could use include:
quantitative and qualitative, to tailor recommendations
■ “Setting goals (behavioral and self-management; for improvement of services. This is time sensitive, as
physical and participation)
CMS is studying these parameters currently. It is crucial
■ Addressing ergonomic issues in the workplace that to have a needs assessment, business plan, evidence-based
may lead to pain
practice resources, and projection of improved outcomes
■ Conserving energy and managing fatigue available when presenting the proposal to management.
■ Exercising (advising clients on making appropriate 10. One resource for guidance and networking is the higher
choices and goals)
education community. It could enhance the process if the
■ Learning self-management of pain flare-ups plan was developed by an OTD capstone student in col-
■ Creating distraction from pain laboration with both clinical and faculty mentors guiding
■ Receiving vocational rehabilitation the process. Other resources are industry groups that sup-
■ Receiving education on body mechanics and good port evidence-based practice and quality care. AOTA and
posture
the CMS website are also valuable sources of information.
■ Using heat modalities or electrical stimulation
■ Establishing effective sleep habits
■ Managing stress Chapter 14—Case Example 14.2 (p. 146)
■ Getting help from a peer-support network Scenario 1
■ Making use of psychologically based management
strategies, including cognitive–behavioral therapy 1. Ideas could include: Identify mentor(s) through networking
and psychotherapeutic approaches” (Costa, 2016, opportunities, visit university websites, and read the stra-
p. 15). tegic plan and mission statement for several occupational
therapy programs. Create a list of your strengths and weak-
Scenario 4 nesses to work in each of the targeted programs. Reflect on
what you hope to achieve as an educator. Which program(s)
5. Ask for updated electronic CVs/resumes from the staff appeal to you through their messages? Network through
and create a master document that identifies credentials, specially targeted social networking sites to meet others in
job experience, and training/certification in specialty academia, particularly clinicians who have transitioned.
areas. Create a calendar for updating this information on Find a peer colleague and perhaps a recently retired col-
a consistent basis (such as quarterly). Obtain substantiat- league. Ask them to confidentially review your curriculum
ing documents, such as certificates, and scan or upload to vitae (CV) and make recommendations for improving it.
an electronic file for each employee to track credentialing. 2. List your items on your CV from the most recent to the
6. Meet with others at your institution who may track this. most distant from the present. Consider including a re-
Contact administrative personnel and ask if they are sumé that focuses on the highlights of the position to
aware whether anyone uses or tracks this information. which you are applying. This will serve as a guide for you
For example, hospitals often have a managed care coor- when writing your letter of interest.
dinator who may need access to this when negotiating 3. It is helpful to consider what you are planning in your
with large benefit groups in order to successfully be a personal life for the year ahead. Make a list of pros and
preferred provider. cons for moving. Will benefits be negatively (or positively)
affected through the move? Will your vacation plans or
Scenario 5 plans for major life events interfere with the timing of
making the move? Can you adjust your periods so that it
7. I would ask for a meeting with the nursing home ad- will not interfere with your academic schedule? What are
ministrator and bring copies of the announcement of your goals? Identify them in concrete terms.
changes from my professional association and from the
CMS website. If I had any insights form networking with
Scenario 2
peers through discussion groups, I may mention those. I
would have a list of suggested strategies concerning how 4. It may be possible to continue to provide OTA level of
day-to-day care delivery and staffing may change in view education if an entry-level bachelor’s degree for occupa-
of the proposal. tional therapy assistants becomes mandated by ACOTE.
8. The proposed changes may indicate either a need to in- Your institution can create a bridge program to another
crease staffing or decrease staffing. If there would be a cut 4-year degree college so that the students in your program
in the amount of overall services, less staffing would be can complete their bachelor’s degree. If a formal agree-
needed. If the funding for services expands services, then ment exists, then this should be the proof required for
additional staff may be needed. ACOTE to consider. It may be challenging to negotiate if
there are different institution types (e.g., publicly funded, also be imperative, as will knowledge about core fac-
religiously affiliated, private colleges) in the region. ulty advancement. It is also good to have knowledge
5. Readers might consider institutions that are nearby or of administrative stability. For example, one would
institutions that offer online alternatives to students that want some guarantee of working with the support of
they can afford; programs need to include debt margin of a dean who is in support of the program development.
cost of education in their planning. b. Adequate funding, staffing, budget, space, profes-
sional support including access to an accreditation
Scenario 3 consultant, structural coherency with in the higher
education structure (what college in the university
6. The Carnegie Foundation
will the occupational therapy program be located
7. The differences are the depth and breadth of knowledge,
within, for example), occupational therapy and pro-
which extends beyond the generalist degree of knowledge
fessional community support, and consumer support
in the profession. The capstone component is also dif-
for the presence of the program.
ferent. The doctoral level has both a research and an ad-
vanced practice component and prepares students to work
beyond direct care. It prepares them to engage in policy CHAPTER 15. CULTIVATING A POSITIVE
and program development at an advanced level in settings AND COLLABORATIVE WORKPLACE
where the services may or may not have historically been
delivered and provides skills to entry-level practitioners Chapter 15—Essential Considerations (p. 155)
to be able to develop programming as health care policy 1. The vision provides a unifying focus for your team.
shifts. Occupational therapists with entry-level doctoral When starting projects, the leader can ask, “How will
degrees are trained to work with individuals and groups, our approach to this project support our vision?” When
but also with communities and populations. everyone knows about and shares the vision, there is an
8. Managers should consider ACOTE’s calendar for phasing expectation that all communication will reflect the vision.
in changes. Once a final transition date is set, acceptance 2. You can observe actions to determine how leadership
into the programs has to anticipate the expectation for views strengths-based approaches. Strengths-based lead-
students who enter to have transitioned by the AOTE ers comment on team members’ contribution in a positive
deadline. For example, if the transition date is in 3 years and growthful way (e.g., “I really appreciate how Sam took
and your program is 3 years in length, then the current the team’s ideas and got the additional information so
class will be your last master’s degree class. Another fac- the team could make an informed decision”). Strengths-
tor is part-time students, who will have to be informed of based leaders also foster others’ use of their strengths (e.g.,
pending changes and transitioned or taught out in view of “Maddy, you are so good at influencing others with your
the accreditation changes. enthusiastic way of explaining our approach. Why don’t
you go to the next manager’s meeting to talk about it?”).
Scenario 4 3. Followers need to feel trust, compassion, stability, and
9. You should find out who is on the selection committee. It hope in their work environment.
would be helpful to understand the diversity of the selec-
tion group and to be able to anticipate contingent questions Chapter 15—Practical Applications in
based on culture of campus communities, for example. You Occupational Therapy (p. 156)
should also find out how long the interview will be (hours/ 1. The coaching relationship is a collaborative partnership.
days) and whether you will travel to the interview or attend The families get to decide the goals and focus of the
virtually (there is a trend to have airport interviews, where coaching relationship. The therapist as coach asks re-
candidates come to the airport but do not go to the campus flective questions to reveal options, foster insights, and
itself), and whether the interview committee will arrange support decisions and plans.
your travel/expenses and how that will happen. 2. We ask reflective questions to foster deep thinking. Exam-
a. For an institution to be a good fit, you would need ples could include: When in the past have things worked
assurances about time frame for completion of a can- with you and your child? How can we use that idea here?
didacy document, space and equipment purchase What else have you tried? What happened? What does
planning or construction/capital investment in the that mean for our planning now?
program, funding for and willingness to hire suffi- 3. Strategic thinkers see possibilities and connections. Exec-
cient faculty, support staff availability (e.g., clerical utors have the skills to develop clear goals and plans.
support, advisory and admissions support), funding
for course registration and travel for training and
Chapter 15—Case Examples 15.1–15.3 (p. 157)
professional community participation, and other
benefits as indicated as well as things like hardware 1. The operatives in these examples are using strengths to
and software policies. Workload information will move ideas forward. They are leveraging the aspects of
strengths-based leadership to involve others in the pro- 3. If yes, contact the other manager(s) to make appoint-
cess of planning and taking action. ments to discuss what they are doing to manage these is-
2. Executing leaders focus on getting things done, and sues. Consider whether their programs would be a good
sometimes there is processing that needs to happen be- “fit” for your staff and program. They might also want to
fore taking definitive actions. Using strengths of other sit in during a training session if appropriate. If no, put a
members can foster collaboration for both process and message on CommunOT and ask what other programs
outcomes. are doing. Attend diversity offerings during an AOTA an-
3. Influencers can help build a practice; they can also foster nual conference or your state or local occupational ther-
support for new ideas in the practice when others want to apy conference. Find and read occupational therapy and
stay the same. Influencers can develop relationships with other professions’ diversity literature.
other partners as well.
CHAPTER 16. PROMOTING AND 1. If the respondents felt that the hospital is culturally com-
MANAGING DIVERSITY petent, they might identify the racial mix of staff, the
presence of a diversity coordinator, and the presence of
diversity training as evidence to support their decision.
1. Readers may discuss their level of effectiveness by ad- If respondents replied no to this question, they must give
dressing their self-awareness, their knowledge about examples of why they hold this position.
other cultures, and their experience with people who 2. Readers may consider various issues in answering this
differ from themselves. They may also talk about how re- question. Reflection techniques might include talking
flective they are when working with people who are cul- with other managers in the organization or with other
turally different from themselves. staff about her feelings; journaling about it; and research-
2. Answers may range from “not at all” to “very effective” ing various emotional responses to interacting with
and may use examples such as the inclusion (or lack diverse people.
thereof) of a culturally diverse staff, inclusion of depart- 3. There are pros and cons for either yes or no responses
mental goals that address diversity, ongoing diversity to the first question. For a more complete response,
training, language translation services, notices written readers should give rationales for their answers. Sarah
in several languages, and attitudes of manager and staff could meet with staff individually, ask each person to
towards culturally different clients. journal about their reactions and feelings with each
3. Readers should recognize that the lack of cultural compe- other, have the diversity coordinator come to a depart-
tency care contributes to increased health disparities. mental meeting to begin a conversation about inter-
actions with diverse clients and staff, as well as other
reflective activities.
1. Readers may suggest any of the components identified CHAPTER 17. VOLUNTEERING
above, including Chapter 17—Essential Considerations (p. 168)
■ Promotion of diversity through the updating of the de-
partment’s mission, vision, and value statements; up- 1. Local opportunities may include volunteering for Boy
dating the strategic plan; updating the budget to fund or Girl Scouts, sports such as Little League or soccer,
diversity strategies; and providing signage in multiple churches, and many other organizations.
languages. 2. Service learning is an educational approach to volun-
■ Organizing and staffing to help achieve diversity by teering. It combines student learning objectives with
hiring diverse staff community service.
■ Educating for diversity by mentoring, coaching, and 3. Occupational therapy practitioners generally have a
training staff; committing to ongoing education; and strong background in dealing with people especially
practicing reflection in trainings and cross-cultural those who have disabilities, knowing how to modify de-
interactions. vices, and being able to organize projects.
2. If “no,” readers may consider going to the organiza-
tion’s diversity coordinator to discuss appropriate
training programs. They might also consider reviewing
programs online or discussing training options with
the occupational therapy staff. Another suggestion is 1. Volunteering can help occupational therapy practitioners
to review the literature on effectiveness of particular gain skills in financial and personnel management, nego-
programs. tiation, and marketing.
2. Many volunteer assignments require coordinating activ- are uniquely skilled at identifying what others value
ities and working with many people with diverse back- and using it to engage them and improve occupational
grounds to achieve the project objectives. Useful contacts well-being.
are often made by volunteering. 2. This depends on what occupations you value. Some
3. Managers can provide time to work on volunteer projects, popular answers include cooking, gardening, photogra-
recognize the volunteer’s efforts and supply resources. phy, and computer technology. When volunteering, oc-
cupational therapy practitioners are uniquely skilled at
identifying what others value.
3. The answer depends on your skills. Some examples are
1. This answer depends on your skills and knowledge. proficiency in computer software, smart phone applica-
When volunteering, occupational therapy practitioners tions, and constructing adaptive devices.
SECTION
Navigating Change and Uncertainty:
Answers to Review Questions III
CHAPTER 18. MANAGING sustain action: Monitor the stages of change, utilization
ORGANIZATIONAL CHANGE and absorption of new knowledge, acceptance of change,
and the outcomes of the change process.
1. Although organizational change theories, models, and Chapter 18—Practical Applications in
frameworks vary in the type of innovation required, the Occupational Therapy (p. 181)
sequence of change implementation, and the stages re-
quired for change, they all provide guidance that informs 1. Occupational therapy managers use change implemen-
change design, implementation, and sustainability. Com- tation processes to increase access and equity, improve
mon change theories, models, and frameworks include service delivery processes, embrace evidence-based inno-
■ Agents of change: Developing and leveraging change vation, and improve client outcomes.
leaders in the organization to support change imple- 2. Organizational change requires relational engagement
mentation and sustainability; throughout the change effort. This is achieved through,
■ Readiness for change: Developing a workforce culture inviting, affirming, and clarifying communication prac-
that negotiates change through acceptance, engage- tices; facilitating dialog, developing shared meaning, con-
ment, independence, and loyalty; and ceptual reframing, and expansion; and co-constructing
■ Steps of change implementation: Establishing the scope new knowledge.
and sequence of the change design, implementation, 3. The change effort life cycle enables occupational therapy
and sustainability processes. managers to create a change-ready organization and im-
2. Competency drivers: A selection of key competencies for plement evidence-based innovation in health care and
innovation and the resources, training, and coaching includes the following:
required for effective performance. Competency drivers ■ Define and plan: Consider strategic issues, cultural
ensure the tools and mechanisms are in place for effec- disputes, inadequate clinical/technical skills and pro-
tive and efficient practice and metrics to measure prog- cedures, and structural limitations that limit program
ress and outcomes. Organizational drivers: Organization capacity and prioritize the needs of the organization
support systems, policies and practices, and data systems and its stakeholders. Collect data regarding the orga-
that facilitate decision making and performance. Orga- nization’s barriers and readiness to change and de-
nizational drivers ensure that the barriers to change have velop a vision for change.
been considered and resources have been put in place to ■ Design: Identify change leadership and design the pro-
mitigate them. Leadership drivers: The adaptive (group cesses that will be used in the innovation.
cohesion and collaboration) and the technical (goals and ■ Build and test: Ensure stakeholder commitment and
effort) resources of the enterprise. Leadership drivers align change processes with strategic vision and
build and nurture relationships that will enable change plans of the enterprise. Identify targets and outcome
within the organization. measures.
3. Create a climate for change: Assess and identify the needs ■ Train and deploy: Train personnel and execute the
of stake holders, access and link research and practice, and change effort.
build awareness of the need for change, build a sense of ■ Operate and innovate: Observe and emulate practice
urgency for change and consensus among stake holders, exemplars. Expand and distribute leadership and re-
create a guiding team of credible and influential organiza- inforce mechanisms.
tional leaders who are empowered to work together with
creativity and imagination to develop a change vision, and
communicate a shared vision for organizational change.
Engage and enable the organization: Allocate resources for 1. The unique body of knowledge required of occupational
successful change implementation (including training and therapy practitioners is dynamic and changes rapidly.
coaching) and develop iterative mechanisms to empower Occupational therapy practitioners often report that
action and achieve initial short-term wins. Implement and access to relevant clinical literature, ability to interpret
733
research findings, and translation of knowledge to school the organization, describe the organization’s information
teams are difficult. Lack of knowledge of effective practice gathering procedures for reducing uncertainties, and set
can have a significant impact on client outcomes and the smaller and shorter term objectives as part of a “rolling”
efficient delivery of services. Occupational therapy prac- strategic plan.
titioners report that practice change occurs most effec-
tively in collaborative learning contexts.
2. There has been a dramatic increase in the generation and
dissemination of scientific evidence in health care and re- 1. Management determined that they did not have sufficient
search suggests that it can take up to 17 years for research knowledge of the proposed CMS changes to be able to de-
to be effectively translated into practice. Clients have in- velop a single plan. Until further information was gath-
creasingly complex health care issues. Delays in trans- ered, management determined that the organization was
lating evidence into best practice within the health care at Level 3 uncertainty.
setting can have a profound impact on client outcomes 2. The occupational therapy manager was responsible for
3. Building awareness: Assess the needs of all stakeholders reviewing and maintaining the mission and vision of the
and empower the staff to use creativity and invention to organization, gathering information from AOTA on the
achieve the goals established through the change effort. impact of the CMS policy change on occupational ther-
Building community and competency: Network and em- apy, and communicating with occupational therapy staff
power stakeholders to build a collaborative blueprint to to prepare for the impending change.
implement and integrate change. Building momentum: 3. Given the uncertainties, executive and departmental
Monitor the stages of change, the use of new knowl- managers worked together to create if/then scenarios for
edge, and the outcomes of the change effort. Building planning, using a “rolling” strategic plan technique. They
acceptance: Establish continuous improvement efforts focused on gathering more information from several re-
(e.g., feedback loops, qualitative and quantitate data liable sources and narrowed potential actions as more in-
collection) and ensured resources to support distrib- formation clarified the situation.
uted leadership.
CHAPTER 20. HANDLING RESISTANCE

CHAPTER 19. PLANNING DURING DURING CHANGE
UNCERTAINTY
1. The 3 basic characteristics of change are amount, inten-
1. Population demographics, including aging, increased sity, and time. An occupational therapy manager who
prevalence of chronic diseases, limited access to health plans for the impending change in advance by making
care, and changes Medicare funding, have increased un- sound, informed judgments about how much change the
certainty about the overall state of the health care system. staff can manage, the degree and impact of the change,
2. Progressing from Level 1 to Level 4, the degree of un- and the amount of time it will take to make the change
certainty becomes more complex. Level 1 describes a will reduce the stress, anxiety, and emotional reactions
manageable level of uncertainty in which there is a fore- that are inevitable when change is proposed.
seeable future. Level 4 describes a wide range of factors 2. Anderson and Anderson (2010b) identified 6 basic
that greatly contribute to creating instability and com- needs of workers: (1) security, (2) inclusion/connection,
plete uncertainty in the system. (3) power, (4) control, (5) competence, and (6) justice/
fairness. As workers feel increasingly more insecure, less
included and connected to the organization, and less em-
powered and in control, they begin to resist change in
negative ways. Furthermore, workers will resist change
1. When uncertainty prevails within an organization or when they feel that it will make them less able to perform
department, the strategic plan must capture shorter time their jobs or that it is unfair or unjust.
periods and have a “rolling” quality to allow for quick 3. Occupational therapy managers must be aware that
shifts in procedures. resistance to change may be communicated subtly as
2. The mission and vision are the foundation of the organi- tones of discontent, ambivalence, resignation, or anger.
zation and therefore serve as the primary guide to plan- While they may feel the need to take action toward
ning for the future when uncertainties cloud the process. making the change, their speed and effectiveness in im-
3. Managers can use transformational and transactional plementing it will reflect limited enthusiasm. Occasion-
leadership skills to motivate workers while also main- ally a worker will feel the need to be blatantly resistant
taining high-quality procedures. Managers can provide by rallying coworkers to resist or sabotaging change-
assurance by demonstrating knowledge about the need related activities. When that happens, managers must
for changes, remind workers of the mission and vision of take immediate action.
SECTION III. Navigating Change and Uncertainty: Answers 735
Chapter 20—Practical Applications in CHAPTER 22. ADDING VALUE

Occupational Therapy (p. 196) DURING CHANGE
1. The occupational therapy manager can analyze the social Chapter 22—Essential Considerations (p. 215)
context of the organization; recognize workers who strive
to create a supportive, change-oriented environment; and 1. According to the OTPF–3, clients are “persons, groups,
place those workers in leadership roles in the change process. and populations” (AOTA, 2014, p. S2). Person includes
2. Short-term objectives are more achievable and render the person receiving care but also individuals who are
more immediate feedback that the change can actually involved in the client’s care. The OTPF–3 defines group
progress toward the long-term goal. For occupational more broadly than a group of individuals receiving care
therapy managers, this is a process that the manager and in a group format; the term encompasses group systems
the staff have learned and typically use. including families, workers, students, and communities.
3. Workers may alienate themselves from their superiors Population refers to a collective of groups living in similar
when change is imminent, so it is important for the man- locations (e.g., cities, states, countries). Additionally, the
ager to demonstrate the positive impact communication OTPF–3 articulates organization- or systems-level occu-
with superiors and consultants can have. Communica- pational therapy practices. Organization- or systems-level
tion about the change also demonstrates support from practice involves serving needs of individuals or groups
superiors and solidarity throughout the organization. within an institution to fulfill the organizational mission
(AOTA, 2014).
2. Restall et al. (2003) identify 5 levels of client-centered
Chapter 20—Case Example 20.1 (p. 198) practice: (1) personal reflection (learning about your
1. A senior occupational therapy practitioner shared con- strengths and challenges and assessing your communi-
cerns expressed by more junior staff that supporting cation skills and knowledge of client-centered practices),
change could lead to further problems, and the occupa- (2) client-centered processes (evaluating and demonstrat-
tional therapy manager allowed staff to express concerns ing client-centered practices in your setting), (3) practice
about what the change meant. settings (advocating for and supporting client-centered
2. She attended to change-related issues of amount, inten- practices throughout the workplace), (4) community
sity, and time; observed and obtained feedback from staff; organizing (engaging in community development, plan-
sought assistance from superiors; and made alterations in ning, and organizing to improve the health of commu-
the initial plan for change without becoming defensive nities), and (5) coalition advocacy and political action
or authoritarian. (being secure in advocating for your perceptions and
3. The occupational therapy manager used senior staff who positions within different spheres, such as individual, de-
demonstrated prosocial behavior, relied on insights and partmental, institutional, public).
collaboration from her peers in physical therapy and 3. (1) Identify as many stakeholders as possible (proximal,
nursing, and sought assistance and support from her di- distal, and diverse stakeholders); (2) analyze and listen to
rector to minimize resistance. the stakeholders’ perspectives and the importance they
place on their point of view; (3) visualize the relationships
among stakeholder perspectives (e.g., create a drawing of
CHAPTER 21. COMMUNICATING each stakeholder and their receptivity and commitment
DURING CHANGE OR UNCERTAINTY to change; (4) prioritize mutual commitments, objectives,
and where the influence for change exists.
1. B Chapter 22—Practical Applications in
2. C Occupational Therapy (p. 219)
3. B
1. Developing occupational therapy programs at an individ-
ual, population, and organizational level demonstrates
Chapter 21—Practical Applications in the value of occupational therapy across multiple layers
Occupational Therapy (p. 208) of society. These levels of OT practice demonstrate the in-
1. B terconnectedness of individuals engaging in occupations
2. D in their communities, in the public sphere, and within
3. C institutions. An occupational therapist should develop a
comprehensive and cohesive system of assessing and en-
gaging in all types of occupations throughout society. The
practitioner’s involvement at all levels strengthens the
1. B profession’s impact on “health, well-being, and participa-
2. C tion in life through engagement in occupations” (AOTA,
3. B 2014, p. S4).
2. Occupational therapy models alone do not address how remain open-minded and flexible. They carefully manage
to integrate programs or services within an organization risk. They listen to feedback and demonstrate effective
or society’s social system. Occupational therapy models negotiation skills.
coupled with social business models address the clinical 3. Health care is changing rapidly, and the profession needs
needs and strategies in an economically resourced and confident change agents who will help to modify exist-
sustainable manner. Social business models are particu- ing occupational therapy practice contexts to keep pace
larly useful, as compared to other general business mod- with the times. The occupational therapy profession
els, because social business models serve to improve the needs confident, impactful change agents and leaders to
social and human conditions. continue advancing the profession into emerging areas
3. Typical assessment formats include standardized clinical of practice.
assessments, observational tools, surveys, interviews, and
focus groups. Chapter 23—Practical Applications in
1. Share your ideas; take risks; make the decision and then
1. Program development ideas should arise from know- make it right; collaborate; select a context in which you
ing what is of value to the service recipient more than thrive; cope effectively with setbacks.
whether your idea is a good idea. Identifying what the 2. Supportive leadership allows the person to implement
service recipient values requires managers and practi- the proposed idea. Supportive leadership may also help
tioners to view situations from their point of view. Creat- to communicate key messages related to the effort. Con-
ing something of value increases the likelihood there will texts that foster innovation tend to be more open to new
be a target audience for the program. ideas and therefore ready for change. Available financial
2. A stakeholder map was created that addressed every as- resources help to ensure that any costs related to the effort
pect of the experience or occupation, not only the end will be covered; available space may also often be import-
experience (e.g., going to the theater). The map should ant, especially if the change initiative involves expansion
address every activity, task, and occupational role that of any kind. Mentorship from professionals within the
directly or indirectly influences the participation in the context helps to foster the change agent’s desire for ongo-
program (e.g., transportation). ing growth and learning.
3. The ecology of human performance model and the so- 3. Garnering support from others helps to share the burden
cial entrepreneurial business canvas model were used. of the vision. Collaboration helps to share the workload.
The use of models to guide program development or Having more people committed to the effort may re-
practice are personal decisions, but this author suggests sult in achieving the goals sooner. Collaboration allows
using occupation-based and social business models con- the various members of the team to use their specific
currently to address the clinical and business factors for strengths to support the effort. What one may achieve
a new program. collectively is often greater than what one may achieve
working individually.
CHAPTER 23—BECOMING A
CHANGE AGENT Chapter 23—Case Example 23.1 (p. 229)
1. Optimism and belief that the vision was possible; flexible;
build motivation and support; resilient; persistent.
1. A change agent is someone who can influence others to 2. All of the 6 principles identified in this chapter are rele-
create change to improve something, such as a situation, vant in this case example.
function, system or context. 3. Remaining true to the overall purpose of the initiative
2. Qualities that enable a person’s ability to function effec- helps to keep the change agent grounded in the effort
tively as a change agent include first and foremost be- and motivated to achieve desired results, despite setbacks
lieving that change is possible. Effective change agents along the way.
SECTION
Outcomes and Documentation:
Answers to Review Questions IV
CHAPTER 24. MANAGING QUALITY CHAPTER 25. UNDERSTANDING
AND PROMOTING EVIDENCE-BASED CLIENT-CENTERED PRACTICE
PRACTICE Chapter 25—Essential Considerations (p. 246)
Chapter 24—Essential Considerations (p. 237) 1. Client-centered practice is an approach to providing oc-
1. Health care quality is “the degree to which health care cupational therapy, which embraces a philosophy of re-
services for individuals and populations increase the spect for, and partnership with, people receiving services.
likelihood of desired health outcomes and are consis- Client-centered practice recognizes the autonomy of in-
tent with current professional knowledge” (IOM, 1990, dividuals, the need for client choice in making decisions
p. 21). about occupational needs, the strengths clients bring to a
2. The aims of the National Strategy for Healthcare Quality therapy encounter, the benefits of a client-therapist part-
are better care, healthy people and communities, and af- nership, and the need to ensure that services are accessi-
fordable care. ble and fit the context in which a client lives.
3. The 3 elements of the Donabedian Model of Patient 2. The CMOP supports the client’s unique needs and abili-
Safety are structures of care, process of care, and ties, and involves the client in joint goal setting and joint
outcomes. decision-making. It views the distinct value of occupa-
tional therapy to be the integrated and balanced approach
of occupational performance areas using a client-centered
Chapter 24—Practical Applications in approach.
Occupational Therapy (p. 240) 3. There are 8 dimensions for health care centered on
the client: (1) respect for values, preferences, and ex-
1. C
pressed needs; (2) coordination and integration of
2. A
care; (3) information, communication, and education;
3. B
(4) physical comfort; (5) emotional support and allevia-
tion of fear and anxiety; (6) involvement of family and
Chapter 24—Case Example 24.2 (p. 241) friends; (7) transition and continuity; and (8) access
to care.
1. After a standardized number of treatment sessions (e.g.,
after 5 treatment sessions) or at the midpoint of treatment,
especially if the manager needs to present preliminary or
progress outcome data.
2. Possible qualitative questions: 1. The occupational profile is a summary of the important
■ Did the animal-assisted therapy session improve or occupations, routines, and roles that a client engages in. It
enhance the quality of your therapy visit in any way? describes their occupational history, interests, and values
■ Were there any drawbacks to having animal-assisted and can be effectively used to document the client’s pref-
therapy as part of your sessions? erences for engagement in occupation.
Possible quantitative questions: 2. Occupational therapy managers and practitioners
■ Please rate how helpful it was to have animal-assisted should actively model how to actively engage a client in
therapy in your sessions, on a scale of 1 (not helpful at making decisions, prioritizing the components of their
all) to 5 (very helpful). treatment programs, and documenting the specific
■ How many times was animal-assisted therapy used in methodologies in which the client is at the center of their
your sessions? own care. Intentional collaboration could include tak-
3. Input the satisfaction survey questions into a privacy- ing the lead at presenting the client’s occupational pro-
compliant online program. file during the first interprofessional team conference
737
for that client and providing updates on the status of CHAPTER 26. EVALUATING
their goal attainment in occupational therapy. Leading OCCUPATIONAL THERAPY SERVICES
the client-centered process with the interprofessional
team demonstrates the distinct value of occupational
AND CLIENT SATISFACTION
therapy and ensures that the team sees the occupa- Chapter 26—Essential Considerations (p. 253)
tional therapy practitioner as central to client-centered
programming. 1. The 3 classes of health care quality measures are struc-
3. Managers can use several methods, including 1:1 men- ture, process, and outcome measures.
toring, shadowing, and co-treating. Videotaping a client 2. The health care system is moving from a volume-based
evaluation and treatment session with feedback is another approach to a value-based approach, where the best out-
effective tool in assisting staff in gaining valuable insight comes with the lowest cost and the highest level of client
into their strengths and weaknesses and overall effective- experience are rewarded for high performance.
ness with executing a client-centered program. Manag- 3. The COPM can be used both as an outcome measure
ers can also monitor the outcomes from clients by using and a measure of client satisfaction by having the client
the COPM to track outcomes related to performance and self-identify goals and priorities for their occupational
satisfaction by each occupational therapy practitioner to therapy program and measure their perceived perfor-
determine which staff are most effective in delivering a mance and satisfaction from admission to discharge of
client-centered program and those that may need addi- the occupational therapy program.
tional mentoring to be successful.
1. Standardized assessments should be valid and reliable,
1. Respect for values, preferences, and expressed needs; co- should focus on the distinct value provided by occupa-
ordination and integration of care; information, commu- tional therapy, and should be related to occupational en-
nication, and education; physical comfort; and emotional gagement and occupational performance to reflect that
support. specific contribution from occupational therapy. The
2. An occupational profile is a summary of the important measures should be linked to health, well-being, and
occupations, routines, and roles that a client engages quality of life.
in and describes their occupational history, interests, 2. Client-identified goals are obtained and prioritized by the
values, and can be effectively used to document the client utilizing a scale that measures importance on rating
client’s preferences for engagement in occupation. In importance on a scale of 1–10 and the client’s self-perceived
Lynn’s case, her occupational profile revealed that she performance and satisfaction on a scale of 1–10. Outcomes
was a graduate student studying marine biology and en- are then measured at the conclusion of the occupational
joyed being in the classroom and laboratory, connecting therapy program to determine whether the client’s per-
with friends over the phone and through social media, ceptions of their performance and satisfaction improved
and getting dressed up to go out to dinner with family as a result of the occupational therapy program.
and friends. 3. In evaluating client-centered occupational therapy pro-
3. Occupational therapy practitioners should model how grams, managers and practitioners should use data-driven
to actively engage the client in making decisions, pri- methods of assessing whether their client population is
oritizing the components of their treatment programs, improving and reporting higher levels of performance
and documenting the specific methodologies by which and satisfaction with ADLs. Electronic health records
the client is at the center of their own care. Intentional can provide information in regularly scheduled reports.
collaboration could include taking the lead at presenting Managers should look to implement quality improvement
the client’s occupational profile during the first inter- initiatives when clients show declines in performance and
professional team conference for a client and providing satisfaction. Managers can also introduce training for oc-
updates on the status of their goal attainment in occu- cupational therapy practitioners to enhance their effec-
pational therapy. In Lynn’s case, the occupational ther- tiveness, using evidence-based interventions.
apy practitioner took the lead on the interprofessional
team in activating a client-centered approach to give
Lynn opportunities for decision-making, goal setting,
communication preferences, and ensuring physical and 1. The COPM is an instrument used to identify problem areas
emotional support. By asking for Lynn’s input, the OT in occupational performance and establish goals for treat-
slowly achieved Lynn’s full participation and engagement ment; provide a rating of the client’s priorities in occupa-
in her treatment program. Lynn developed a trusting and tional performance; evaluate self-perceived performance
collaborative relationship with the occupational therapy and satisfaction with the activities the client has identified
practitioner. as important; and measure outcomes by assessing changes
SECTION IV. Outcomes and Documentation: Answers 739
in a client’s perception of their occupational performance 2. Selection of assessment tools must be guided by both
over the course of occupational therapy intervention. Lynn philosophical and practical considerations. For example,
identified her primary goals as return to school, be able to a tool that utilizes universal terminology for global im-
type on an adapted laptop, use her smartphone, and dress pact must also be affordable, require a reasonable amount
with only a little assistance from her caregiver. of resources, and be accessible for the daily practitioner.
2. Evaluation data are analyzed to identify strengths and Tools that meet requirements of payers and regula-
prioritize the issues; intervention methods are then iden- tory bodies must be feasible to complete as part of daily
tified in collaboration with the client. In this case, the workflow for the frontline provider in terms of time and
occupational therapist presented the evaluation results resources.
to Lynn, discussed them with her, and then collaborated 3. E
with her to create occupation-based goals. At this point,
the occupational therapist discussed potential interven- Chapter 27—Case Example 27.1 (p. 266)
tion methods and the respective evidence. The occupa-
tional therapist clearly communicated with Lynn on her 1. E
status and educated her on treatment options. 2. Outcome measures provide qualitative and quantitative
3. At the end of Lynn’s occupational therapy program, the oc- information to support positive contributions of occu-
cupational therapist had Lynn reassess her self-perceived pational therapy services rendered. When selected pru-
level of performance and satisfaction on the COPM (Law dently, they can support the distinct contributions and
et al., 2014); she indicated a clinically significant change value derived from occupational therapy specifically, sep-
in both performance and satisfaction, indicated by an in- arate from other providers.
crease of 2 or more points over her COPM scores at ad- 3. Sample table setup:
mission for each activity.
TOOL #1 TOOL #2 TOOL #3
Target health outcome(s)
CHAPTER 27. MEASURING
OUTCOMES How does tool capture
occupational therapy
Chapter 27—Essential Considerations (p. 262) influence on outcome(s)
1. B Psychometric properties
2. B
3. Pragmatic considerations include clinical and institu- Resource burden (financial,
tional viability of measuring outcomes. The process and time, etc.)
actual measures must provide value to the institution, in Pros/Cons
that they meet clinical and institutional needs. Measur-
ing outcomes should meet payer requirements to support Methods for incorporating
reimbursement (e.g., Hospital Value-Based Purchasing into daily workflow
Program). Requirements from regulatory bodies should
be met to ensure compliance and lawful practice (e.g.,
state department of public health). Measures that con- CHAPTER 28. GUIDELINES FOR
tribute to quality benchmarking, such as participation EFFECTIVE DOCUMENTATION AND
in performance improvement collectives, help develop QUALITY REPORTING
a competitive edge in the market. Measuring outcomes
provides the opportunity for an institution to impact
health care at multiple levels, from individual to global. 1. The occupational profile is essential for establishing the
unique needs of each client for occupational therapy ser-
Chapter 27—Practical Applications in vices. It provides readers with important information on
the client’s view of the situation, environmental and con-
textual factors that support or inhibit occupational per-
1. Quality benchmarking is the voluntary, active collab- formance, and the client’s priorities.
oration targeting use of optimally efficient indicators, 2. Best practices in occupational therapy documentation
practices, and costs. Global scale impact means broadly include:
resonating, potentially long-lasting effects of targeted ■ Document as close to the time when the service was
initiatives. Our profession seeks to be a well-recognized delivered as possible.
provider on the global scale in health care and has a re- ■ Write using terminology that is easily understood by
sponsibility to contribute to the scientific community at other professionals and third-party payers. Avoid ex-
large through intellectual exchange. cessive use of abbreviations and jargon.
■ Proofread documentation before submitting it to the ■ Did the documentation demonstrate the necessity of
record. occupational therapy services as distinct from physi-
■ Document in accordance with professional and ethical therapy and other services offered?
cal standards. ■ Were reasons for missed intervention sessions
■ Reflect the unique needs and situation of each client. documented?
■ Demonstrate the distinct value of occupational therapy. ■ Was there evidence that the client or caregiver under-
3. Documentation that is clearly written and shows what the stood any instructions provided by the occupational
client will be doing as a result of occupational therapy in- therapy practitioner?
tervention will demonstrate the necessity of occupational ■ Was there documentation of any adaptive equipment
therapy intervention. Goals should be occupation-based. or assistive technology provided to the client?
All documentation must reflect the occupations the cli- ■ Did the documentation reflect the unique needs and
ent will be successful in completing as a result of the circumstances of each client?
skilled intervention provided by occupational therapy ■ Did the documentation comply with the ethical stan-
practitioners. dards of the profession?
4. Some reasons to document occupational therapy services
include: Chapter 28—Case Example 28.1 (p. 274)
■ Chronological record; tell the story of the client’s de-
velopment or recovery. 1. The manager could have intervened sooner, perhaps when
■ Comply with reimbursement requirements. she first noticed Hannah was staying so late every day.
■ Communication among team members. She might have noticed how stressed Hannah seemed
■ Clinical reasoning that shows the skills of an occupa- and started a conversation with her early on. The man-
tional therapy practitioner are necessary. ager is responsible for providing the staff education and
■ Collect data to assist in quality improvement efforts training needed for staff to do their jobs, so the manager
and inform future practice. in this case should have assured that Hannah was prop-
■ Courtroom defense; provide a legal record of services erly trained in efficient ways to document her services.
provided. On the other hand, Hannah could have approached her
manager about her problem rather than seeking advice
outside the organization. High productivity demands are
common, but fraught with ethical concerns. Both Han-
nah and the manager have ethical responsibilities to deal
1. Documentation shows the distinct value of occupational with the high productivity demands. See the resources
therapy when it addresses the client’s participation in available under Dealing With Productivity Standards:
occupations that are meaningful to the client. Docu- Resources for Ethical Practice on the AOTA website
mentation that simply gives numbers of repetitions of an (https://bit.ly/2p1PBoZ).
exercise or measures of range of motion does not convey 2. Using copy and paste makes it easy to fall into a pattern
the distinct value of occupational therapy. This starts and do what Hannah did—reduce or stop personalizing
with providing an accurate and complete occupational the documentation. A payer might look at that and de-
profile and continues throughout all occupational ther- termine that the therapy provided was not individualized
apy documentation. and did not require skilled intervention.
2. Documentation should provide evidence of what hap- 3. Discussing what you are writing about the client with the
pened in the occupational therapy session(s), evidence client is a good way to assure that both the client and oc-
of the patient’s response to intervention, and the occu- cupational therapy practitioner agree on what transpired
pational therapy practitioner’s interpretation of that evi- and agree on the next steps. It can help build rapport and
dence. The documentation must be clear about the client’s trust between the client and the occupational therapy
need for skilled occupational therapy intervention. All practitioner because the client is not wondering what the
rules and regulations set by the payer for documentation clinician has written about them.
and establishing the necessity for services need to be fol-
lowed. Documentation should be written as close to the
day and time of intervention as possible and appropri- CHAPTER 29. FEDERAL HEALTH CARE
ately signed by the person who wrote it. PROGRAMS AND OUTCOMES
3. A manager might look for any or all of the following:
■ Was the documentation written in accordance with
standards for timeliness? 1. NQF runs the Measure Applications Partnership, which
■ Was the client’s baseline and terminal occupational reviews all performance measures before they can be im-
performance clearly documented? plemented into federal programs.
■ Was a clear and concise occupational profile established 2. A process performance measure calculates whether
at the beginning of occupational therapy services? a best practice was implemented by the practitioner.
SECTION IV. Outcomes and Documentation: Answers 741
Outcome performance measures identify and quantify 4. A

the results of health care services that clients achieve. 5. C
Readers should visit www.qualityforum.org/qps. They 6. D
can search for any topic of interest. Select the filter button 7. C
on the left for process and then for outcome. The instruc- 8. A
tor can verify the measure by searching on the same site 9. C
and clicking on the details of the measure. Under “Clas- 10. B
sification:” and “Measure Type:” check to see that the stu- 11. B
dent has correctly identified the measure.
3. This list is continually updated. The instructor or pro-
fessor should review the programs and compare the stu-
dents’ answers to the current information made available
by CMS. 1. D
2. A
Chapter 29—Practical Applications in 3. D
4. B
5. A
1. The 4 goals are: (1) Improve the experience of care 6. D
for consumers, (2) improve the health of popula- 7. C
tions, (3) reduce the cost of care for populations, and 8. D
(4) improve the experience and joy of practice for practi- 9. C
tioners. The quadruple aim adds the practitioner experi-
ence to the triple aim.
2. Readers may identify: AOTA Practice Guidelines, evi-
dence-based practice project, occupational profile tem- 1. D
plate, CMS QPP website, National Quality Forum. 2. B
3. C
1. Change in self-care can directly be affected by occupa- CHAPTER 31. WORKERS’
tional therapy. By focusing here, improving the quality COMPENSATION
of clinical practice of occupational therapy should also
improve the measure.
2. Communication across departments is critical for clinical 1. C
quality measurement. Other disciplines and departments 2. C
will also contribute to clinical quality improvement. By 3. B
communicating with other departments, occupational
therapy can contribute to the overall improvement of Chapter 31—Practical Applications in
care and can demonstrate the distinct value that the field
brings to quality improvement.
3. Occupational therapy can affect outcome performance 1. C
measures, some of which affect reimbursement. Improv- 2. C
ing the client-centered evidence-based practice of occupa- 3. C
tional therapy in a setting can affect outcome measures. It
is important for occupational therapy practitioners to be Chapter 31—Case Example 31.1. (p. 308)
familiar with the outcome measures to discuss how the
practice of occupational therapy influences measures im- 1. C
portant to clients and payers. 2. A
3. C
CHAPTER 30. PRIVATE HEALTH

INSURANCE CHAPTER 32. DELIVERING SERVICES
THROUGH TELEHEALTH
1. A
2. D 1. B
3. B 2. D
3. A Chapter 32—Practical Applications in

4. The Department of Health and Human Services’ Office Occupational Therapy (p. 315)
for the Advancement of Telehealth funds 2 national and
12 regional telehealth resource centers providing tele- 1. C
health-related education, assistance, and training. 2. Clinical outcomes associated with the use of telehealth in-
5. Factors that dictate the type of technology used in a tele- clude client satisfaction, decreased caregiver stress, improved
health session include the business model (e.g., hub and access to care, and improved quality of life and well-being.
spoke, direct to consumer, direct to business, remote pa- 3. Efficacy studies and systematic reviews support the use of
tient monitoring), type of clinical services to be delivered telehealth with clients with cardiac disease, hand injuries,
(e.g., client seated vs. mobile), and existing technology orthopedic impairments, and stroke, among other health
available to the client and provider. conditions.
6. C
7. Areas of competency include knowledge, critical reason-
ing, interpersonal skills, performance skills, basic tech- 1. The first 3 steps Nancy should complete to assess the en-
nology-related skills, and ethical practice. vironment and define the proposed program are (1) as-
8. Environmental factors that affect the quality of a tele- sess service needs and environment, (2) define program
health session include room location, room size, equip- model, and (3) develop business case (CTRC Telehealth
ment placement, lighting, position of the camera(s), wall Program Developer Kit, p. 1).
color (light blues and light greys are considered optimal), 2. The essential considerations that Nancy should keep in
and acoustics. mind as she develops the Occupational Therapy Pediatric
9. The AOTA Occupational Therapy Code of Ethics (2015b) Telehealth Community Program include federal and state
and AOTA Telehealth Ethics Advisory Opinion (2017a) policy, reimbursement, malpractice insurance, technical
can be consulted to ensure ethical telehealth practice. The requirements (hardware, software, and data storage),
AOTA (2013) Telehealth Position Paper also discusses clinical considerations (practitioner competency, envi-
ethical considerations. ronmental aspects, and end-user needs), and ethics.
10. A. Telehealth is best characterized as a service deliv- 3. The telehealth program may include interventions target-
ery model—the service being delivered is occupational ing community reintegration to home, school, and other
therapy. Specialized interventions, skilled clinical ser- community settings after discharge from the hospital;
vices, and virtual consultations can be delivered through feeding; fine motor, gross motor, cognitive, social, self-
telehealth. help, and adaptive skills; and caregiver education.
SECTION
Interprofessional Practice and Teams:
Answers to Review Questions V
CHAPTER 33. ADVOCATING 3. Interprofessional teams work differently in different
OCCUPATIONAL THERAPY’S settings. For example, fast-paced settings may require
brief but frequent collaboration between team mem-
DISTINCT VALUE WITHIN bers, whereas other settings may provide greater op-
INTERPROFESSIONAL TEAMS portunity for immersive and sustained collaborative
Chapter 33—Essential Considerations (p. 324) efforts. Co-location of team members also influences
how teams function. Teams that are co-located may
1. Multidisciplinary and interprofessional teams both bring have greater opportunity for face-to-face collabora-
together the clinical perspectives of several disciplines, tions and informal communication and will likely have
but their focus and their approach differ. In multidisci- the benefit of sharing client documentation. Teams
plinary teams, roles and responsibilities are clearly de- that are not co-located may overcome some of these
fined and disciplines work in parallel, largely to achieve barriers through technology (e.g., telehealth, electronic
discipline-specific goals. Communication in multidisci- communication). Organizations also influence the way
plinary teams is mostly to share and collate information teams function as administrative processes and orga-
from the different disciplines. In comparison, interpro- nizational protocol may either support or not support
fessional teams work to achieve person-centered goals interprofessional collaborative practice. Also, organi-
developed in collaboration with the team and the client. zational culture can foster supportive, collaborative
Roles and responsibilities are less defined in interpro- environments, but in some cases teams may operate
fessional teams and scopes of practice will often over- in hostile environments where practitioners keep to
lap. Because the focus of the interprofessional team is to themselves to avoid conflict. Lastly, health care sys-
meet the holistic needs of the client, teams works interde- tems and policy will influence the ways team function.
pendently rather than solely pursuing discipline-specific For example, reimbursement models can influence the
goals. Whereby multidisciplinary teams often have a time and methods in which interprofessional teams
hierarchical structure, responsibility for team processes collaborate.
and achieving client goals is shared by all members in the
interprofessional team. Chapter 33—Practical Applications in
2. Central to an interprofessional approach is the delivery of
coordinated, collaborative, and person-centered services.
To coordinate care, practitioners need to understand and 1. Managers can foster collaborative relationships by pro-
value all disciplines in the interprofessional team. Align- viding an environment that ensures clinical competences
ing with the Code (AOTA, 2015b), occupational ther- and enhance engagements of team members. Examples
apy practitioners need to understand the skillsets of the include ensuring competence with clinical knowledge
other disciplines, acknowledge their expertise, and re- and skill, encouraging engagement with the professional
spect efforts from other disciplines to demonstrate their communities, and exploring safe spaces for how they can
unique value in their advocacy campaigns. The Code make a difference with their clients.
also acknowledges the concept of collaboration in that it 2. E
requires occupational therapy practitioners to promote 3. The OTPF–3 is an official document that provides the oc-
collaborative actions and communication as member cupational therapy profession with a language to demon-
of interprofessional teams. Lastly, person-centered (or strate and document occupational therapy’s distinct
client-centered) practice is a central concept in both in- value. The OTPF–3 identifies terminology that practi-
terprofessional collaborative practice and in occupational tioners can use to define the distinct value of occupational
therapy practice, as described by AOTA’s (2014) OTPF–3. therapy within their practice settings. For example, using
Various aspects of person-centered practice align with the OTPF–3 when describing occupations, client factors,
sections in the Code, such as concern for the individu- performance skills, performance patterns, and contexts
al’s well-being and respect for the individual and their and environments can equip managers to contribute to
self-determination and autonomy. the 3 goals of the Triple Aim.
743
Chapter 33—Case Example 33.1 (p. 326) 2. Supervisors may require that students keep a daily jour-
nal, describing what the student felt that went well each
1. Research evidence will be a critical aspect of your advocacy
day and what they could have improved on each day. In
efforts. Research specific to occupational therapy will pro-
addition, supervisors may require a case study project
vide evidence on the effectiveness of evaluation and inter-
that would demonstrate the student’s clinical reasoning
vention approaches in achieving positive client outcomes.
skills. Supervisors may not have a lot of time each day
It may also help you identify where further research is re-
to spend one on one with students. The journal and case
quired and how your initiative might contribute to filling
study projects could facilitate the student becoming more
the gaps. Interprofessional research will also be useful in
independent with problem solving and helps the supervi-
your advocacy campaign. There may be many examples in
sor assess the student’s growth.
the literature where occupational therapy has collaborated
3. It is important that the job description include a list of
with other disciplines. The outcomes of these collabora-
the job responsibilities, skills needed for the position, and
tions can provide further evidence supporting the value
behaviors that reflect the values of the organization.
of occupational therapy on your interprofessional team.
Interprofessional research may also provide additional
evidence on team processes and cost-effectiveness, which Chapter 34—Practical Applications in
may also be critical to your advocacy efforts. Occupational Therapy (p. 335)
2. Several aspects of your circumstances may be similar of
1. There are opportunities for advancement and the criteria
different to Jo’s in the case example, such as the purpose
for advancement are consistent.
or context. First, consider the purpose of your advocacy
2. The clinical ladder can be applied to multiple disciplines
campaign. In Jo’s case, the purpose was to establish a new
when the criteria are specific but general enough for staff
occupational therapy service. The purpose of your cam-
to provide examples related to their discipline.
paign might be to extend the roles and responsibilities of
3. Ask open-ended questions that reflect the skills needed
occupational therapy on an interprofessional team, en-
for the job and that prompt the interviewee to give exam-
hance collaboration or coordination in care, maintain oc-
ples on the basis of their past experiences. Ask follow-up
cupational therapy services on an interprofessional team,
questions to gain further understanding and insight into
or it might have another purpose. The context of your ad-
the applicants experience.
vocacy effort may also differ from Jo’s case. The way you
approach your advocacy efforts will likely be influenced
by the team structure (e.g., multidisciplinary vs inter Chapter 34—Case Example 34.1 (p. 334)
professional), team culture (whether interprofessional
1. Sue asked leaders and staff for their input in purchasing
collaborative practice is valued or not), and procedural
the van and using it most effectively.
factors (i.e., management and administration processes).
2. Therapists could submit evidence of program development,
The available research evidence available in your clinical
enhanced patient satisfaction, or innovative interdisciplin-
context will also inform the scope and strategy of your
ary treatment programing for the clinical ladder.
advocacy efforts.
3. Supervisors could reinforce the mission and values of the
3. As a member of an interprofessional team, it is imperative
hospital during orientation and training by explaining how
that your advocacy efforts promote a shared, collaborative
interdisciplinary care that is relevant to the patient’s goals
approach to person-centered care. The outcomes of your
enhances positive patient outcomes and patient satisfaction.
advocacy efforts will be dependent on how you approach
to the campaign. To foster interprofessional collaborative
practice, the purpose of your advocacy efforts should be CHAPTER 35. BUILDING
to enhance client outcomes through team collaboration, EFFECTIVE TEAMS
rather than the pursuit of marking disciplinary terri-
tory. To do this, it will be important to consult with other Chapter 35—Essential Considerations (p. 338)
members of the interprofessional team, share informa-
1. Although teamwork may not differ, levels of education
tion, and gain a team perspective throughout your advo-
and training vary among team members, as do levels of
cacy efforts. Collaboration during the advocacy campaign
independence and state practice acts, it is essential that
will drive outcomes, which promotes a shared, collabora-
all members of the health care team work together for
tive approach to person-centered care.
safe, efficient, effective, and compassionate care delivery.
Although professional accountability varies across de-
CHAPTER 34. SUPERVISING livery settings and contexts, all teams rely on “an intri-
OTHER DISCIPLINES cate system of professional supervision, delegation, and
collaboration among caregivers from many disciplines”
(Dineen, 2009, p.247). Because trust is foundational
1. Assessing competence, facilitation professional growth, for teamwork, licensed and unlicensed members of the
and providing orientation and training. health care team must value each other’s contributions
SECTION V. Interprofessional Practice and Teams: Answers 745
and balance individual responsibility with mutual trust or “Tell me more about . . . ” Avoid the urge to provide
to team effectively. answers or immediate solutions. Ask open-ended ques-
2. Each member of the health care team has a defined care- tions, such as “How did your actions influence the out-
giving or client support role. Together the goal is to provide come?” to facilitate critical thinking. Above all, support
a unified voice for the care of a client and their family. your team and ask how you can help. If you sense that
3. Collaboration means different things to different people, mutual respect is breaking down, you may need to help
but at its core is always mutual respect and shared goals/ summarize or rephrase a team members’ opinions to
shared decision making. Clients and families recognize a validate and model effective communication. If the dis-
collaborative care team as one that communicates well to- cussion becomes heated and other members of the team
gether and consistently includes them in the care planning in the room seem uncomfortable, say something like, “I
process. This means that each value the other’s opinion wonder what others might be thinking.” This helps model
and all feel heard. reflective practice and a more unified approach to care.
2. The following communication strategies can be imple-
mented to support effective teamwork and collaboration:
Chapter 35–Practical Applications in
■ Rounds or prebriefings. This team could hold a week-
Occupational Therapy (p. 341) end patient coverage rounds or pre-briefing at the
1. Rounds allow for opportunities for members of the inter- close of day on Friday with the assigned occupational
disciplinary team to come together to ask questions, share therapy staff or the weekend charge occupational
information, seek help, identify and discuss decisions (ones therapist (who can coordinate the coverage communi-
already made and those to be made) and invite feedback cation with any per-diem weekend staff). The prebrief-
to improve clinical care. In these experiences, team mem- ing should be at a consistent time and should be time
bers are able to learn more about the patient, but also learn limited in nature. Best practices in prebriefing models
more about each team member and the important roles all include giving an opportunity to ask questions, clar-
disciplines play on the team. It allows an opportunity for ifying data shared, and confirming the information
all voices to be heard. In promoting professional reasoning, being transmitted for an efficient weekend coverage
interprofessional rounds can allow the team to be more ef- handoff. Face-to-face conversation is preferred for this
fective in providing quality care for the patient and family. type of communication, but a telephone or video con-
2. Effective communication is key for sharing ideas, advo- ference system could also be used. Establishing this
cating for the client, establishing goals, and collaborating routine in the practice assists all staff in upholding a
with other team members. Team members that demon- shared goal of communication excellence.
strate these key elements and continue to develop such ■ Shared mental models: A shared mental model such
skills will in turn be more effective team members who as SBAR or IPASS can be used to improve communi-
are better positioned to contribute to best practices for cation in the practice. The team might also consider
their client and the health care delivery system. Self- re- developing its own acronym to implement for cross-
flecting on these key elements will allow occupational coverage or patient-related communications.
therapy practitioners to be more competent and confident ■ Checklists and forms can provide an effective structure
team members. It is important for managers and prac- for standardizing communication for optimal occupa-
titioners to engage in this self-reflection often because tional therapy care delivery. Forms should focus on the
teams, roles, practice settings, and contexts change. most important items, tasks to be done, and specific an-
3. Responsibilities may include but are not limited to organiz- ticipatory guidance to support clinical decision making.
ing the team, assigning tasks, managing resources, facilitat- 3. The occupational therapy staff and manager should work
ing information sharing, or modeling effective teamwork collaboratively to modify weekend coverage in order to
(see Table 35.1). These responsibilities can guide managers support best practice. This might be achieved by small
and practitioners to optimize team performance. Examples group meetings with a defined objective of establishing
to facilitate these responsibilities may include creative ap- or revising weekend coverage policies and communica-
proaches to scheduling, communication, timeliness, and tions. It is essential that all staff be active participants in
leading by example through transparency. The occupa- this process because their input is vital to work flow and
tional therapy practitioner’s training in group dynamics communication success. The updated policy should in-
and group leadership can serve as an additional resource in clude a minimum standard for written patient coverage
supporting team milieu for a unified approach to care. notes and the use of a departmental electronic commu-
nication system or EMR to support written communi-
cation. Ideally the occupational therapy staff will agree
upon a shared model for coverage communication. This
1. As the occupational therapy manager, you can best sup- model can be implemented and then evaluated as a qual-
port your team by listening, being objective, and facili- ity improvement process. The leadership and support of
tating discussion. Effective facilitators probe by asking the occupational therapy manager is key to establishing a
questions such as, “Could you elaborate further on . . ?” culture of communication excellence.
SECTION
Supervision:
VI Answers to Review Questions
CHAPTER 36. RECRUITING, HIRING, 3. Ensure that you are actively listening and seeking to un-
AND RETAINING PERSONNEL derstand the other party’s perspective in a genuine and
authentic way, which includes reflecting on the feeling
Chapter 36—Essential Considerations (p. 347) and meaning of the other party’s needs so that the other
party feels that their perspective is valued and under-
1. The terms youthful and recent graduate may discourage
stood as you proceed with a compromise for resolving the
people over age 40 years from applying and may violate
conflict. Summarizing what the other person has said is
the law.
also an effective active listening strategy for conflict res-
2. A
olution because it assures the other party that you have
3. True
listened intently to their perspective and builds trust.
Chapter 36—Practical Applications in Chapter 37—Practical Applications in

Occupational Therapy (p. 348) Occupational Therapy (p. 354)
1. C 1. Occupational therapy managers should be careful to
2. B ensure that they are always abiding by the organiza-
3. C tional or departmental policies and procedures as they
relate to employee and employer responsibilities for em-
Chapter 36—Case Example 36.1 (p. 349) ployee misconduct. Human resources should always be
consulted when conflicts escalate beyond a reasonable
1. Yes level to ensure that employee law and regulations are
2. Work environment, types of clients on caseload, and adhered to.
work hours. 2. The principles for conflict resolution among colleagues
3. Work hours, specific treatment protocols adopted by the also apply to working with clients and families, but prac-
facility, and documentation expectations. ticing in a client-centered way requires practitioners to
always put the client first. Occupational therapy manag-
ers should empower staff to use the principles of effec-
CHAPTER 37. RESOLVING CONFLICTS tive conflict resolution presented in this chapter and have
opportunities for role play or practice in communicating
with patients and families. If these methods have been ex-
1. Resolving the conflict could include any of the fol- hausted, managers can also mediate by joining the prac-
lowing conflict resolution strategies: practicing active titioner, client, and family to ensure that effective conflict
communication, using I statements, practicing authen- resolution strategies are effectively used.
tic listening, using mutual problem solving, striving 3. Occupational therapy managers should be careful to
for win–win solutions, maintaining a positive atti- ensure that they are always abiding by the organiza-
tude, exercising emotional control, responding to ideas tional or departmental policies and procedures as they
(instead of people), aiming for a solution, communi- relate to employee and employer responsibilities for em-
cating one topic at a time, and observing nonverbal ployee misconduct. Human resources should always be
communication. consulted when conflicts escalate beyond a reasonable
2. When working with a client, caregiver, or colleague, it level to ensure that employee law and regulations are
is important to be cognizant of cultural factors that in- adhered to.
fluence the strategies the parties take in resolving con-
flict. Once you recognize your own approach as more
individualistic or collectivistic, you can effectively adapt
your style and approach to the other party and meet them 1. Sally should address the conflict with her staff directly
where they are at. through 1:1 and group discussions with the staff about
746
SECTION VI. Supervision: Answers 747
the increased productivity requirements. She could CHAPTER 38. MENTORING AND
begin with active listening sessions that give the staff an MOTIVATING OTHERS
opportunity to provide her with direct feedback, which
will build trust and build on the relationships she al- Chapter 38—Essential Considerations (p. 362)
ready established with her staff. Sally may also invite
1. C
the school administrators to visit with staff to discuss
2. D
the rationale behind the increased caseload require-
3. A
ments. Sally may conduct a market analysis with other
school-based programs to determine the community
standard and best practices for caseloads to provide Chapter 38—Practical Applications in
objective data on the need for changes in productivity Occupational Therapy (p. 364)
expectations, which may create and an opportunity 1. C
to proactively work with the school administrators to 2. A
justify an increase level of support staff to ensure that 3. C
high-quality services are provided to children in the
schools while also preventing burnout and staff dis-
tress. Sally may also want to take on a small caseload Chapter 38—Case Example 38.1 (p. 365)
to demonstrate that she also is a part of the solution to 1. D
the new caseload expectations and is still an engaged 2. D
member of the team. 3. C
2. Jane should directly address the differences in expecta-
tions for professional attire in the workplace by reviewing
the dress policy and setting up a meeting with her field- CHAPTER 39. PROMOTING
work supervisor to discuss expectations for professional PROFESSIONALISM
attire. Instead of reacting defensively, Jane must focus on
active listening with her fieldwork supervisor and see this Chapter 39—Essential Considerations (p. 371)
as an opportunity for professional growth. 1. B
3. The resolution of conflict with the client’s mother must 2. Altruism, equality, freedom, justice, dignity, truth, and
be addressed and should not be avoided. Practicing in a prudence
client-centered way requires that the occupational ther- 3. A
apy practitioners and students always put the client and
the family first. Occupational therapy practitioners and
students must demonstrate respect for clients, involve
clients in decision making, advocate with and for clients Occupational Therapy (p. 374)
in meeting the client’s needs, and otherwise recognize 1. C
the client’s experience and knowledge. It is important 2. B
that Tom work directly with his fieldwork supervisor to 3. Answers could include: Promoting creation of a LinkedIn
develop a plan to ensure that the concerns of the client’s profile; encouraging participation in Twitter talks of
mother are addressed and come together with the cli- professional groups; creating clear social media rules or
ent’s mother to discuss resolution opportunities to this policies for employees
conflict. A potential compromise could be that Tom and
his fieldwork supervisor co-treat together with the cli-
ent or alternate schedules so that half of the treatments
are provided by Tom and the other half by his fieldwork 1. The Millennial practitioners have more education that
supervisor. enables them to read and conduct research as com-
4. Roger must address the conflict with each of the reha- pared to their colleagues that hold bachelor’s degrees.
bilitation disciplines now that he is representing all of Therefore, this group will identify research to use for
them. He should not abandon the occupational therapy the literature review and assist in completing the insti-
practitioners but focus on integrating strategies for team tutional review board, study design, and interpretation
building that focus on addressing common challenges of results. The Gen Xers have varying degrees of re-
and opportunities for leveraging the strength of all three search knowledge. Because they have the strongest pro-
disciplines. Roger should conduct group listening ses- fessional writing skills, they will compose the research
sions to identify the concerns of all 3 disciplines and de- study with the assistance of the Millennials. Because
velop a shared mission, vision, and strategic plan that will the Baby Boomers have the least knowledge related
help all members of the team focus on specific goals for to research, their role will be as data collectors. They
improvement in the rehabilitation department during the will work with the other generations to gain research
upcoming year. knowledge.
2. The manager will provide simple articles about the basics of 2. A manager could say to an employee, “Start using a check-
conducting research for the Baby Boomers who hold bach- list to ensure you complete all your assigned daily tasks,
elor’s degrees and lack research experience and bring up keep doing the daily assigned tasks that you are currently
discussions related to research during some lunch breaks completing successfully, and stop doing the negative self-
to slowly introduce concepts to them. Individual, direct talk that convinces you that you are not capable of change.”
communication regarding the importance of the order of 3. The manager could say, “[Employee], I notice that you
steps in research will be used with the Gen X group. This have a goal to by the time of your annual review.
will ensure that steps are not being missed and facilitate How are you doing with achieving that goal? If you are
them as future leaders. The manager will meet with the not on track, what needs to happen for you to achieve that
Millennials in a group throughout the process to provide goal? What do you need to do differently? What resources
them with ongoing feedback regarding their progress. do you need? How can I, as your manager, help you?”
3. The group could form a LinkedIn organization and post
through this organization’s account. Example post: Chapter 40—Case Example 40.1. (p. 382)
Title: The Effectiveness of an Occupational Therapy Vo- 1. The manager allowed the employee to share her feelings
cational Training Group for Individuals with Spinal Cord and frustrations in a safe and open forum so the manager
Injury could truly understand the employee’s perspective before
The occupational therapy staff at ABC Hospital in West- trying to formulate a solution.
chester County, NY, recently conducted a research study 2. After the employee and manager discussed the employ-
to identify the benefits of a vocational training group for ee’s personal goals, they collaborated to determine how to
individuals with spinal cord injuries (SCI). Participants meet the departmental goals.
included 10 individuals 1 year post SCI living in the com- 3. The manager requested monthly informal check-ins to
munity who wanted to return to work. The intervention support the employee’s efforts toward correcting the cur-
included vocational assessments, group discussion regard- rent problems and achievement of the long-term goals.
ing barriers to work, skills training, and contextual mod-
ification techniques. Seventy percent of the participants
returned to work within 6 months of the intervention. CHAPTER 41. WORKING WITH
These results support the role of occupational therapy in OCCUPATIONAL THERAPY
vocational rehabilitation for individuals with SCI.
ASSISTANTS
CHAPTER 40. PROVIDING
CONSTRUCTIVE FEEDBACK 1. The OTA education requires an associate’s degree and an
OT education requires at least a master’s degree.
Chapter 40—Essential Considerations (p. 381) 2. State licensure laws and funding source guidelines deter-
1. mine what an OTA can do during each aspect of service
provision.
■ The giver examines their perceptions and identifies 3. Both the OT and OTA are responsible for being aware of
bias, emotional reactions, and facts of the case the legal and ethical implications of OTA supervision.
■ The receiver reflects on their assumptions 4. If a manager or supervisor requests services beyond legal
■ Both parties structure feedback around behaviors and or ethical guidelines, the OTA or OT should provide
facts instead of emotions written information regarding the legal or ethical conflict
■ Strategies are developed in this environment of collab- to the supervisor and clearly communicate why they will
oration and mutual understanding. not go beyond legal or ethical guidelines.
2. Possible answers include: Did your plan go according to
your expectations? What was your target outcome? What Chapter 41—Practical Applications in
would you change in the future to meet that outcome? Occupational Therapy (p. 390)
3. Empathy means not superimposing my own perspective
onto someone else; it is the ability to understand a given 1. Skill level, legal limitations, and reimbursement guidelines
situation from another’s perspective. should be considered before delegating tasks to an OTA.
2. The OTA can communicate with the OT regarding prog-
ress and make recommendations. The OT must make
all changes to the intervention plan and discontinue
treatment.
1. A manager could provide both positive and constructive 3. Answers could include: As a manager, the OTA could
feedback at every assessment opportunity (formal or in- be responsible for managing the annual reviews for and
formal). A manager can demonstrate the ability to imple- performing any disciplinary actions upon the OT who is
ment change based on employee feedback. supervising them clinically. This could cause conflict.
SECTION VI. Supervision: Answers 749
4. Indirect supervision involves conversations over the Chapter 42—Practical Applications in

phone, email, written notes, and other confidential elec- Occupational Therapy (p. 399)
tronic communications. This occurs when the OTA has
demonstrated competency in all areas and the OT agrees 1. A
that they do not need direct supervision with the current 2. The environment should be private, away from others,
clients. and should allow for a calm, unhurried approach. There
5. Frequency in which contact occurs, the type of supervi- should be enough physical space for both parties to be
sion provided and methods of supervision, content areas comfortable, and there should not be many interruptions.
covered that evidence was provided to show service com- 3. The person receiving feedback should know whether or
petency, and the names and credentials of all personnel not they were successful and what changes they need to
involved make to be (more) successful.
6. Strategies include: clear communication, establishing 4. Every occupational therapy practitioner (OTR and OTA)
regular uninterrupted meeting times, creating a list of needs to know the scope of practice in the state they prac-
items to discuss during meetings, using open communi- tice in as outlined by their state practice act.
cation, being open to feedback, addressing conflicts im-
mediately, and establishing clear expectations. Chapter 42—Case Example 42.1 (p. 399)
1. Sharon asked for training on what the job entails, what
Chapter 41—Case Example 41.2 (p. 388) the expectations are, and how she will be measured for
1. Routine success.
2. AOTA Guidelines for Supervision, state licensure laws, 2. Sharon set up 1-on-1 rounding sessions to get to know
AOTA Occupational Therapy Code of Ethics (2015) each teammate, learn about their clinical passions and
3. When Ivan demonstrates competency or the client is strengths, and identify their communication style.
discharged 3. Sharon set up a schedule that everyone can see and out-
lined when she completes her treatment, as well as her
supervision and management tasks. She allows open of-
CHAPTER 42. OCCUPATIONAL fice time so that teammates can bring forth questions or
THERAPY ASSISTANTS AS MANAGERS concerns to her.
1. More task-based duties of being a manager include sched- CHAPTER 43. MANAGEMENT OF
uling patients, managing practitioners’ time-off requests, FIELDWORK EDUCATION
and preparing reports.
2. Leadership tasks include duties that move the department
forward as a collective unit, such as strategic planning or 1. A
budgeting. 2. A
3. Managers are largely responsible for getting work tasks 3. C
done, whereas leaders are focused on influencing others.
Phipps (2015a) demonstrated several differences between
managers and leaders. One difference pertains to the
scope of focus, with managers being more internally fo-
cused, and leaders being more externally focused. Leaders 1. A
influence others by building consensus among people on 2. A
a vision for the future and what action steps are required 3. A
for goal attainment. Another difference is that managers
tend to focus on the short term, but leaders focus on the
big picture or long term. Managers control and direct the
work that needs to be done, and leaders operate by in- 1. Take the 2-day Fieldwork Educator Certificate Program
spiring and empowering others to succeed. Recognizing workshop offered by AOTA.
and solving problems is the primary focus of managers, 2. On the AOTA website under “Fieldwork Educator
whereas leaders focus on empowering people to engage in Resources.”
decision making and problem solving. 3. The Essential Guide to Fieldwork Education (Costa, 2015).
SECTION
Communication:
VII Answers to Review Questions
CHAPTER 44. COMMUNICATING therapy, to educate patients, or to better understand a

ACROSS GENERATIONS AND client’s perspective
CULTURES
1. The occupational therapy practitioner asked direct ques-
1. Wells et al. (2016) describe a culturally effective practi- tions while still giving Thomas time to process his an-
tioner as someone who develops the skills to understand swers before discussing them. Simple explanations were
and use a various communication skills to understand the provided in terms of the positioning strategies, and the
effects of culture on human development and disability, use of email was an effective mode of communication for
adapt and create interventions to meet the client and the tech-native teenager.
family’s specific cultural needs, address power disparities 2. No. Whether managing staff or working with a client, one
that might exist between the client and practitioner, and cannot assume what another person is thinking. A cul-
support and address a client’s cultural needs specific to turally effective practitioner seeks to create interventions
the influence on behaviors within the therapeutic process. to meet the client and family’s specific cultural needs.
2. Douglas et al. (2015) suggests 5 specific strategies that 3. Social media and email were essential components
can improve the function of multigenerational teams. of Thomas’s culture and were preferred means of
They include establishing a signed team agreement to communication.
support accountability and a safe environmental culture,
providing 1:1 coaching to address individual needs and
to facilitate real-time feedback, conducting a communi- CHAPTER 45. USING SOCIAL MEDIA
cation workshop to support developing effective com- APPROPRIATELY
munication skills, probing for conflict by facilitating and
providing a safe culture for debate, and creating a culture Chapter 45—Essential Considerations (p. 422)
of appreciation through recognition. 1. d
3. A general understanding of generational differences is 2. b
a “predictive clue” in determining how to most effec- 3. Privacy settings prevent people you do not know from view-
tively connect and communicate, understand potential ing your posts or personal information. Privacy settings
technology needs, workplace motivation, preferred lead- allow you to control whether a post is shared publicly or just
ership styles, and need of feedback or recognition. with friends (i.e., Facebook) or followers (i.e., Twitter). Pro-
file information (e.g., your birthday, places you have trav-
Chapter 44—Practical Applications in eled, individuals you are related to, where you work) can also
Occupational Therapy (p. 416) be kept private from individuals you do not know through
privacy settings. This helps to ensure personal safety.
1. Practicing mindfulness; pausing between statements
and before answering; observing the person’s responses Chapter 45—Practical Applications in
and striving to create a rapport; being inquisitive; asking
questions for clarification; paraphrasing the other per-
son’s statements; summarizing your understanding of the 1. Other platforms that could be used include LinkedIn or
discussion when concluding a conversation. Twitter.
2. Paying attention to nonverbal signals; looking for incon- 2. It depends on the platform and who is posting. For ex-
gruent behaviors; focusing on your tone of voice; bal- ample, people who use Twitter but are not considering
ancing good eye contact; asking questions; understand- accessibility may post images that are not captioned or
ing body language; and being aware of your own body videos that are inaccessible (e.g., no subtitles). The same
language could occur for someone watching videos on YouTube.
3. Storytelling can be used to communicate evidence, to ar- Also, advertisements may create challenges for individu-
ticulate the distinct value of the practice of occupational als with visual impairments using voiceover features.
750
SECTION VII. Communication: Answers 751
3. (1) Employees are allowed to associate themselves with 2. The idea must be well thought out and supported by pre-
the company, hospital, center, or organization when post- liminary data for any funding agency to consider funding
ing on personal social media accounts, but it must be the grant.
clear that the information being shared in a public place is 3. The needs assessment is an informal or formal evaluative
personal and purely their own. (2) Employees should not process to assess an individual, group, or community
connect with clients on personal social media accounts. for gaps in service or other unmet physical, emotional,
(3) Content about clients or any sensitive information or psychological needs. Specifically, the process is un-
should never be shared on social media accounts and dertaken to identify discrepancies between the resources
to the public. (4) All privacy and confidentiality policies available and the resources that are needed.
apply to social media accounts. (5) Dishonorable content
on social media sites (even personal accounts) will never
be tolerated.
Chapter 45—Case Example 45.1 (p. 425) 1. A summary or abstract serves to concisely summarize the
literature review and results of the need assessment. The
1. As an occupational therapy student, I could host a Twit- statement of the problem or needs section of the grant
ter chat about test-taking strategies or interviewing tips application can come from the needs assessment and
and skills for entry-level practitioners. One way that should describe specific unmet needs of an individual,
I could promote the chat would be to create a hashtag community, or other entity.
for the chat and share it through Twitter, Facebook, and 2. The “Methods” section may include information regard-
LinkedIn. I could share the information about the Twitter ing personnel, policies, and procedures; recruitment of
chat (e.g., time, who is hosting) in occupational therapy clients; how a program, service, or device will be used;
student Facebook groups, and @ mention various occu- data collection; and data analysis.
pational therapy programs on Twitter for them to retweet 3. Direct costs reflect all allowed cost lines, such as personnel,
and share. equipment, supplies, training, and travel. Indirect costs
2. Project Career could use LinkedIn to connect profession- reflect “the cost of doing business,” such as space, utilities,
ally with other organizations that support clients with insurance, maintenance, and administrative costs.
traumatic brain injury (TBI). Project Career could also
create a YouTube channel to share client testimonials,
iPad app training videos, webinars, job interview tips,
and other relevant content. 1. Given that the case example presents only a brief over-
3. Sharing information at conferences and publishing in ac- view, it may be difficult to determine whether all the
ademic journals is important for disseminating research steps were included. Certainly, the interprofessional
findings and sharing information with a particular au- group conducted a needs assessment. Developing a clear
dience, but it may not be the best way to reach everyone. idea for program, service, or device delivery would de-
Social media allows Project Career to reach individuals pend on having more details, but the group could use the
with TBI who are not searching through academic liter- template offered by the already-developed program in a
ature to find supports. It also helps parents, family mem- nearby town (with adjustments to fit the local commu-
bers, caregivers, providers etc. to learn about a program nity). Conducting a literature review and developing or
that could benefit someone they may know with a TBI. finding theoretical foundations to support the program
Social media also allows the sharing of information more are important (but not specifically mentioned). All of the
consistently than journal publications and conference developers would need to be well-aware of the literature
presentations. For example, a social media account can in the field of community programing for people with
share updates monthly, weekly, daily, or a multiple times ABI. It appears that the founding group had developed
per day. Social media can be used for recruitment and a clear, well written plan (including a statement of prob-
sharing information about Project Career with adults lem or need, objectives, methods, timeline, evaluation
with TBI who may want to participate in the research methods, budget, and dissemination plan), because they
project. were able to attain start-up funding. Given their success,
they likely took great care in following the directions
(including deadlines) provided by the funding agency.
CHAPTER 46. GRANT PROPOSAL Local funding sources are often appropriate for projects
WRITING (such as the proposed) that would benefit the local com-
Chapter 46—Essential Considerations (p. 429) munity. The developers in this case are already demon-
strating collaboration through their interprofessional
1. The initial idea for a grant typically stems from a client or relationships. They may want to seek a mentor at the es-
community need, which may require additional funding tablished program. We cannot ascertain if the group was
beyond the capability of the applicant or employer. patient and/or if they had to re-submit their proposal.
2. National funding resources can be found at the National performance. Images of hope are provided by the prac-
Institute of Health (grants.nih.gov), the Brain Injury As- titioner highlighting future life possibilities. This reason-
sociation of America (www.biausa.org), and by perusing ing type is used in discussions with clients throughout the
the Federal Register (www.federalregister.gov). Librarians therapy process. Intuitive reasoning enables practitioners
can also be very helpful in helping to find local, state, and to attend to the emotional needs of both the client and
national grant resources. the practitioner within the therapeutic process. Similar
3. Outcomes can vary depending on the program, but could to interactive reasoning, this type is used throughout the
include community re-integration, quality of life mea- therapy session as the practitioners responds to the reac-
sures, and cognitive performance measures related to the tions and initiatives of the client.
impairments caused by the brain injury. Although setting 3. Communication is highlighted in the Principle of ve-
up a research project is beyond the scope of this chapter, racity, or the understanding of being truthful within
it is worthwhile to spend some time thinking about therapy interactions including, but not limited to, pro-
designing an outcome study, because granting agencies viding information about the purpose of therapy, goals
will want evidence that their money has been well spent. and approaches used in therapy, and potential outcomes
Many ideas for a specific outcome project related to brain goals. How someone communicates such information is
injury can be found through a literature search on brain influenced by workplace policies, cultural sensitivity, and
injury interventions. Generally one does not need to respect for the client.
design a totally new research study; the new project can
branch off an existing study. Often duplicating a former Chapter 47—Practical Applications in
project, with perhaps 1 or 2 minor changes, will suffice.
1. Workplace policies and productivity expectations, cul-
CHAPTER 47. PRACTITIONER–CLIENT tural differences between practitioner and client, views
COMMUNICATION related to the role of the practitioner in terms of authority
and expertise
2. (1) Providing alternative modes of communication and
1. Therapeutic use of self (TUS) has moved from practi- information dissemination including e-health platforms,
tioner-centered method to having a client-centered focus. augmented communication, online communication, and
The initial emphasis was on how the therapist developed face-to-face interaction. (2) Use various motivational
their skills and attitudes in order to influence the therapy approaches in interactions including coaching, problem-
process. The evolution of TUS shifted and emphasized solving, investigation and clarification. (3) Use oppor-
the value and importance of the client’s perspectives and tunities to expand personal sharing of narratives, life
their personal lived experiences. There was no longer an stories, beliefs and perspectives to build trust, empathy,
emphasis on select best approaches to interact with cli- and respect. (4) Build community capacity and family
ents but rather a greater appreciation for individualized support when applicable. (5) Use openness and sensitivity
and unique intervention and interactional approaches when addressing difficult and challenging conversations.
with each client. In addition, practitioners need to further (6) Provide ongoing communication, including sharing
appreciate and understand the complexities and dynam- assessment results and regular progress reports.
ics of TUS as there are multiple social–political–cultural 3. Professional development may focus on skill building
contexts that affect how practitioners and clients relate to such as communication strategies and select interactional
each another. The expectation for the practitioner is to approaches and may also include building greater emo-
develop greater empathetic listening, openness to differ- tional capacity in personal self-awareness and reflection
ences, and expanded cultural sensitivity. in understanding how we respond to differences and
2. Narrative reasoning provides a more comprehensive and conflict.
holistic understanding of the client’s life story and how
that might affect the current perspective of the client’s
life and the therapy process. This type of reasoning is
often shaped through the initial assessment phase and 1. Mrs. White has clearly stated her wish to go home (ethical
further built upon through the therapy process as the Principle of autonomy) and is seeking some validation
client shares aspects and portions of their past and cur- and consensus of that desire. Jenny needs to be honest
rent life. Interactive reasoning provides opportunities to (ethical Principle of veracity) about her assessment and
consider various ways to best relate to and engage the what may or may not be realistic in terms of going home.
therapeutic relationship. Interactive reasoning happens Jenny needs to consider both the roles and responsibilities
continuously throughout each therapy session and may of an occupational therapy student and the occupational
take on various forms as the needs and demands of the therapist in providing such information and how best to
therapy session suggests. Conditional reasoning consid- offer such opinion in such a way to continue to build trust
ers the client’s future life, prognosis, and occupational and show empathy.
SECTION VII. Communication: Answers 753
2. First, it would be helpful to have a broader appreciation to provide insights into conditional reasoning by sharing
for Mrs. White’s past and current life narrative. What client outcomes and expected or anticipated occupational
is most important or meaningful for her? How does she performance strengths and challenges for Mrs. White.
understand her current health condition and how this Social Services could also provide information related
might impact her return home? How does Mrs. White to ongoing rehabilitation options based on Mrs. White’s
make meaning of her current situation and how has financial resources, community and agency resources
she overcome challenges in the past? In may also be and availability, and Mrs. White’s physical tolerance for
very important to build family capacity by initiating additional therapy services.
conversations with Mrs. White’s daughter, upon consent 3. Describe your observations about the therapy session.
of Mrs. White. Jenny may solicit information and per- What do you believe to be the most important con-
sonal perspectives about previous family involvement cern of Mrs. White at this time? How did you feel when
in providing care, any potential concerns about future Mrs. White asked you to promise her that she could go
care, and beliefs and values related to independence and home? What additional information do you need to know
self-determination. In addition, it would be helpful to fur- to best answer the question if Mrs. White can go home?
ther understand the prognosis of Mrs. White’s recovery What are several ways in which you may respond to
and medical conditions from the surgeon and attending Mrs. White’s request that provides truth and dignity and
physicians. The occupational therapist may also be able empathy to her?
SECTION
Finance and Budgeting:
VIII Answers to Review Questions
CHAPTER 48. UNDERSTANDING Chapter 49—Case Example 49.1 (p. 463)

ECONOMIC AND POLITICAL TRENDS 1. True
Chapter 48—Essential Considerations (p. 455) 2. False. An outcome measure is needed to support skilled
occupational therapy services.
1. B 3. Fee for service.
2. B
3. Unemployment can increase the demand on states’
CHAPTER 50. DEVELOPING A BUDGET
Medicaid programs, result in loss of private health insur-
ance, and increase the gap in access to health care based Chapter 50—Essential Considerations (p. 466)
on an individual’s socioeconomic class.
1. The FY is a 12-month period for gathering the financial in-
4. The ARRA provided monetary support to the health
formation of the organization and can run from October
system to sustain Medicaid coverage and to invest in
to September, July to June, or January to December
technology, research, and preventative care.
(i.e., calendar year).
2. Select a period of time and using the costs associated with
the period and divide the costs by the unit of time for
which you want to know the break-even point (e.g., day,
1. B month, week, hour).
2. D 3. Budget; operating plan.
3. B
Chapter 48—Case Example 48.1 (p. 456) Occupational Therapy (p. 469)
1. Pain, money, and medication management. 1. Corporate overhead includes the administrative aspects
2. Maria can contact her state and federal legislators and her of a business that may be centralized. These include the
insurance company to express her concerns. human resources, billing services, medical records, mar-
3. Maria can contact her doctor for an alternative pain keting, and the executive branch of the business.
medication or a referral to occupational therapy for pain 2. Fixed costs are costs that do not change within a time
management. She can also contact the drug company and period, regardless of the output of the business.
her insurance company. 3. Depreciation is a fixed cost that reoccurs in the same amount
per time period throughout the useful life of equipment.
CHAPTER 49. DESIGNING A PAYMENT
STRUCTURE Chapter 50—Case Example 50.1 (p. 466)
1. $1,000,082
2. Without overhead, $3,345.00; with overhead, $3,678.
1. True 3. Divide the costs by the revenue without the overhead:
2. Private pay, insurance companies, grant funding and 756,206/956427 = .790 (percentage). Subract79 from 100
charities to equal 21%.
3. False. Most clients prefer to use insurance policies to
receive occupational therapy services. CHAPTER 51. DETERMINING COSTS
FOR NEW PROGRAMS
Occupational Therapy (p. 462) Chapter 51—Essential Considerations (p. 473)
1. C 1. The vice-president for rehabilitation because, after begin-
2. False ning services, they would fall under corporate overhead
3. True (unless they are planning the project).
754
SECTION VIII. Finance and Budgeting: Answers 755
2. SWOT analysis; the other costs are implemented later is In and of itself, it does not provide a direct answer. As you
the process. can see on the statement, it declined from a year earlier,
3. Historical. showing an improvement between the 2 years. Also, if
you take it as a percentage of Total Revenue ($25,636,155),
Chapter 51—Practical Applications in found on the income statement, Bad Debt is .2% not sig-
nificant. However, it is important to keep in mind because
not all of your receivables will turn into cash. Bad Debt is
1. Corporate overhead is needed because of the services it a normal part of business operations.
supports, such as human resources, billing, and market-
ing, which are centralized and serve the total organiza-
tion; therefore, each group it supports needs to contribute Chapter 52—Practical Applications in
to the expense. Occupational Therapy (p. 484)
2. They are considered as part of the start-up budget and not 1. As you go through your work week, you are earning your
a separate item. salary. Each day your employer owes you an additional
3. 13.41 × 871 = $11,680/12 = $973.33 per month. amount of money. However, until payday, you do not
have any more cash to spend at the grocery store. Cash
Chapter 51—Case Example 51.1 (p. 475) flow also works the same way for expenses. At the grocery
store checkout, you use your credit card to purchase this
1. 213 visits × 52 weeks = 11076 total 1-hour visits evening’s dinner, but you do not have to use any of your
26 days × 8 hours = 208 PTO hours cash until the credit card statement is due at the end of
2080 working hours per year hours – 208 PTO hours = the month.
1872 hours per FTE per year 2. Cash flow is what sustains an organization. Your em-
11076/1872 = 5.91 total FTEs needed ployer might pay you once per month, at the end of the
2. 213 visits × 52 weeks = 11076 total 1-hour visits month, allowing your employer to bill and collect for the
11076/2080 working hours per year = 5.3 FTEs per year services you provide to client before you get paid. You
3. $11.75 × 760 sq. ft. = $8,930.00: $8930.00/12 = $744.17 per may be seeking new equipment for the clinic, but if your
month additional rent employer is short of cash, your request will be denied or
deferred. If your clinic depends on government financ-
CHAPTER 52. MONITORING ing, the failure to fund those obligations can cause opera-
tions, including your paycheck, to be interrupted. Recent
CASH FLOW years have witnessed a number of federal government
Chapter 52—Essential Considerations (p. 483) shutdowns that lead to just such occurrences.
3. Always be looking for ways to speed up your receipt of
1. A capital expenditure is an item purchased that is of funds, such as accepting credit cards, using a lockbox for
significant value and has a useful life of greater than any payment that might come through the mail, or even
1 year. The SoCF is typically the 3rd statement in a set factoring receivables on which you are awaiting payment.
of audited financial statements. Capital expenditures are
found in the section of that statement headed Cash Flows
From Investing Activities. They are usually found in the CHAPTER 53. PROFESSIONAL
middle of the SoCF. For AOTA, the amount for 2017 is LIABILITY INSURANCE
$124,312.
2. There is not always a direct or immediate connection be- 1. As a licensed “professional service,” occupational therapy
tween earned revenue and cash flow or payment for the practitioners are accountable and responsible and thus li-
goods or services. Interestingly, it can go either way. When able for the safety and well-being of their clients.
a college bookstore purchases this textbook, AOTA has a 2. Each state has defined the scope of occupational therapy
sale and earned income and usually will receive payment practice it its licensure laws. It is the individual practi-
30 days after invoicing the store. The reverse happens tioner’s responsibility to be licensed in and familiar with
with AOTA’s Annual Conference & Expo. When you the laws in every state in which they provide professional
register, you pay immediately even though Conference services, even when providing services for free.
does not occur until April. In this set of circumstances, 3. Under the concept of vicarious liability, supervisors have
AOTA receives your money before actually putting on the additional responsibilities because they are liable for the
Conference. Only after Conference does AOTA earn the safety of subordinate practitioners as well as the clients
revenue. treated under their supervisory purview. In addition to
3. The most revealing place on the SoCF would be amount licensure laws and complete documentation of client care,
shown for Bad Debt. In 2017 for AOTA that amount was supervisors need to ensure company policies and proce-
$64,889. This figure is receivables that have turned out to dures are appropriate, communicated, and followed by
be uncollectible and thereby become a noncash charge. those they supervise.
4. Key areas include working within the appropriate scope 5. Claims-based liability insurance only covers claims made
of practice, providing appropriate supervision for clients while the policy is in effect. Occurrence-based coverage
or subordinates, effectively and clearly communicating is preferable because it covers any claims beyond the life
with the client and the medical team, ensuring a safe of the insurance policy. Be sure that the types of inter-
and uncluttered environment, following organizational ventions provided are covered under the basic policy or if
policy and procedures, completed and accurate docu- an additional rider or endorsement should be purchased.
mentation, and keeping competency skills up to date with With the advent of internet-based insurance providers, be
continuing professional education. sure to investigate the company’s financial standing.
SECTION
Professional Standards:
Answers to Review Questions IX
CHAPTER 54. CONTINUING 2. Standards directly related to occupational therapy practice
COMPETENCE should be identified. Once the standards have been iden-
tified, occupational therapy practitioners and managers
Chapter 54—Essential Considerations (p. 516) should determine whether the standards are met or if a
quality improvement plan should be initiated to ensure
1. B
compliance. Ensure that occupational therapy services
2. D
are based on standards and the latest evidence for occu-
3. A
pational therapy effectiveness. Data should be presented
demonstrating clear compliance with each standard. If
Chapter 54—Practical Applications in there is no evidence of standard compliance, then occupa-
Occupational Therapy (p. 517) tional therapy managers should implement a quality im-
1. A provement plan to ensure compliance for at least 6 months.
2. D 3. The accreditation process ensures that occupational ther-
3. D apy managers and practitioners and the interprofessional
team are providing the highest quality of care based on

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The

Rebecca Rutberg, Director, Marketing

American Occupational Therapy Association, Inc.

Cover design by Debra Naylor, Naylor Design, Inc., Washington, DC

To all current and future occupational therapy practitioners:

About the Editorsix Chapter 6. Leading and Managing

Chapter 3. Leadership vs. Management: Chapter 12. Marketing Strategies

Chapter 4. Evolution and Future of Chapter 13. Building Capacity 133

Chapter 15. Cultivating a Positive and Section IV. Outcomes and

Chapter 17. Volunteering: Staff Chapter 25. Understanding

Chapter 26. Evaluating Occupational

Chapter 33. Advocating Occupational

Chapter 35. Building Effective Teams 337 Chapter 47. Practitioner–Client

Section VI. Supervision 343

Chapter 45. Using Social Media

Section X. Ethical and Legal Chapter 68. Returning to the

Chapter 65. Addressing Health

Chapter 67. Succeeding as a

Veda Collmer, JD, OTR/L Winnie Dunn, PhD, OTR, FAOTA

Melanie Concordia, OTD, OTR/L Kimberly S. Erler, PhD, OTR/L

Elizabeth C. Hart, MS, OTR/L Lindsey Jarrett, PhD

Jess Anthony Holguin, OTD, OT/L Ingrid M. Kanics, OTR/L, FAOTA

Susan Touchinsky, OTR/L, SCDCM, CDRS

Figures Figure 54.1. K nowledge translation: What it is

OVERVIEW OF THE OCCUPATIONAL SECTION I. FOUNDATIONS OF

KEY TERMS AND CONCEPTS

OVERVIEW behavioral health workforce staffing certified community be­

CASE EXAMPLE 1.1. Ginny Stoffel’s Leadership Journey

APPENDIX 1.1. VALUES CARD SORT ACTIVITY

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

APPENDIX 1.1. VALUES CARD SORT ACTIVITY (Cont.)

WILD CARD WILD CARD W

WILD CARD WILD CARD W

WILD CARD WILD CARD W

KEY TERMS AND CONCEPTS

OVERVIEW activities important. This chapter provides an overview of the

KEY TERMS AND CONCEPTS

OVERVIEW activities important. This chapter provides an overview of the

FIGURE 2.1. A sample and abbreviated organizational chart.

Chief Executive Chief Medical

Vice-President Vice-President Chief of Chief of

Director of Director of Nursing Staff Staff

Source. Adapted from Braveman (2016, p. 113) with permission.

Special Interest Section (AMSIS) was officially created and the

TOOL OR TECHNIQUE USE OR APPLICATION

Check sheet Standardized tool developed for manual data collection

Nominal group technique/multivoting Team voting method

Process flowchart Graphical representation of the steps and decisions in a process

CASE EXAMPLE 2.1. Robin: Starting as a New Occupational Therapy Manager

CAUSES OF EXTENDED TIME TO RECEIVE

Use of paper logs

KEY TERMS AND CONCEPTS

About the Editorsix Chapter 6. Leading and Managing

Chapter 15. Cultivating a Positive and Section IV. Outcomes and

Section VI. Supervision 343

Section X. Ethical and Legal Chapter 68. Returning to the

Figures Figure 54.1. K nowledge translation: What it is

OVERVIEW behavioral health workforce staffing certified community be