Multidisciplinary Rehabilitation Practice: An Example From the Field

History of Center 

A musculoskeletal diagnostic and conservative treatment facility for primarily back and neck pain was started February 1999 by a chiropractic doctor out of a desire to work with other professionals. It was developed to 34 full- and part-time staff and grossed Can $2 million at its peak 2 years into operation. The facility included professionals under written contract in the disciplines of medicine, chiropractic, physiotherapy, occupational therapy (OT), psychology, massage therapy, clinical dietetics, and acupuncture. Eight medical specialists in the fields of orthopedic surgery, neurosurgery, neurology, and medical radiology provided on-site consultation services.

Third-party payers touring the facility were positive with the multidisciplinary concept and the physical operation; they observed a modern 8000–sq ft (750 m2), 40-room operation where blood work and a full x-ray service were standard practice. After understanding what the center was, guests left feeling they were introduced to a “safe” place to refer.

The facility developed expedited access for advanced hospital imaging (eg, magnetic resonance imaging, computed tomography, arthrogram, myelogram) through exclusive worker compensation (WC) programs: (1) an injured worker rehabilitation program (using OT work conditioning, chiropractic rehabilitation, and multidisciplinary educational seminars); (2) a vocational capacity evaluation (testing IQ, aptitude, and transferable work skills through 8 hours of standardized psychological testing); and (3) a comprehensive diagnostic program (an examination of a patient by 8 professionals including a chiropractic doctor, using advanced diagnostic imaging as indicated, was completed for a final team conference, including diagnosis and recommendations with the third party in attendance, within 2 weeks).

Patients saw the health care provider of their choice upon making their first appointment, with exception to those who entered into formal programs through referral from third parties like WC. Thus, every provider was independent within the center.

Patients who did not now know what professional to see could receive a “directional consultation” where a physician would take a brief clinical history and direct the patient to the appropriate provider within the center.

The biweekly team conference was the forum where a representative of each discipline would meet to triage internal referral and any complicated patients' care; the case would then be reviewed every 2 weeks, as needed.

The facility met its demise in its third year through multiple reasons including high overhead, high salaries, and a human resources crisis; key professionals were discovered to be independently developing their own operation, and were either terminated or chose to resign. Despite valiant efforts to recruit additional staff, unfavorable publicity caused contracts to be cancelled and the facility was unable to recover, resulting in a large financial loss and closure. Since the center's demise, there have been at least 4 other major multidisciplinary operations open in our city; of these, one has gone out of business. Thus, multidiscipline practice is attractive, yet risky.

Breaking New Ground 

Traditionally excluded from the hospital setting, the chiropractic doctor is provided with a wonderland of opportunities in a large multidisciplinary center, exchanging ideas and developing professional networking and collegial relationships. The environment becomes an educational and clinical experience. Working with traditionally antagonist therapists or inaccessible specialists is an appealing juxtaposition, maximizing productive teamwork.

Medical opinion and behavior toward chiropractic is mixed; some medical doctors still do not embrace chiropractic. 32, 33, 34, 35, 36, 37, 38, 39 The concept of having chiropractic doctors on staff at a large medical center was a source of adversity for some of the facility's professionals dealing with their peers outside the office, mostly the physiotherapists (PTs). However, specialists were more inquisitive and cooperative. Although not favored by some chiropractors who hold strong to philosophical dogma, what seemed to work to develop a collegial relationship between the chiropractors and the other health care providers were: (1) clarifying unsubstantiated chiropractic claims (eg, treating organic pathology like diabetes and cancer); (2) abandoning the use of the word “subluxation” principally because the chiropractic definition is confusing to medical professionals; and (3) defining a musculoskeletal scope of practice. Acknowledging the historical and current adversity against the chiropractic profession, it was thought that pronouncing conviction to a dogmatic chiropractic philosophy would have destroyed chances of partnership and, thus, any multidisciplinary experience. Medical and rehabilitation professionals welcomed discussion that emphasized the chiropractic practitioner's acceptance of evidence-based principles and practice.

Advantages of Partnerships 

It is not the purpose of this article to discuss advantages and disadvantages of the 3 types of business structures: sole proprietorships, partnerships, and corporations. 40 Each form of business has advantages and disadvantages, and legal or accounting advice is recommended to best advise on which structure is most suitable under certain circumstances. However, the business structure for this type of multidisciplinary enterprise is an important one to consider.

Insofar as working with other professionals, there is the potential for conflict regardless of the type of organizational/business structure. Global experience indicates that relationships and “partnerships” may not work and disagreement is inevitable. However, a partnership, or partnership within a corporation, with clearly defined understandings specific to this type of operation, may be the best option for a large multidisciplinary operation with many key players.

Despite divided authority and the possible development of conflict between partners, partnership may provide (1) substantially broader distribution of liability; (2) significantly improved motivation to develop and maintain goodwill and loyalty among key players, notwithstanding; and (3) lower individual capital costs/investments for all (as compared with a sole proprietorship).

Being a sole shareholder within a corporation is a structure that ironically creates a situation providing little control. Even if management is healthy and professionals are inspired, ideas for progressive development can be suppressed by key players who have established importance and authority within the organization. On the other hand, partners are “investing” professionals. Partners have profound motivation to develop their goodwill and not to disturb their investment. Simply put, one who has everything given to them without effort or toil may undervalue it.

Nonpartners in a large multidisciplinary environment are important associates yet bring limited skills in exchange for a large well-equipped building, diverse professional relationships, and the reputation and patient referral source of the facility. When a nonpartner professional leaves, he usually plans this exit so that there is minimal or no loss to self. The departure is usually advantageous to the leaving party because that individual is leaving with patient files (provided through prearranged professional contracts or by law in some jurisdictions) and goodwill (from marketing their practice within the facility most of at the facility's expense). Partnership reduces the risk of associate attrition and the arduous task of recruiting replacements, and subsequent loss of business from reduced patient volume and file departures.

It is difficult to make operational decisions affecting a large group and please everyone no matter what structure of business is chosen. One professional in the group cannot be permitted to veto important marketing plans or shifts in policy. Decision-making would be easier within a partnership because operational matters would be decided by a voting mechanism established early among the partners.

In addition to encouraging organizational loyalty and reducing the risk of attrition of key staff, partnership provides lower start-up costs, shared maintenance costs and tasks, more sources of emergency financing, investment capital, broader management skills, possible tax advantages, and clearly defined decision-making structure among other things.

Operational Challenges 

Cross-training reception staff to manage patient files across all disciplines was a recurrent challenge. Training support staff to learn the individual office practices of different professionals is one thing, but trying to train individual support staff to learn all facets of every discipline was frequently confusing and a source of frustration for both the professional and support staff. After trial and error, specific support staff became responsible for specific departments.

Integrating and managing the medical discipline of the facility was the greatest challenge in most respects. Recruitment required highest commissions of any of the professionals, and regular financial analysis revealed the department was operating at a loss. But as a credible, full-service facility, this department was a necessary part of “the package.”

The general medical practice required extra support staff servicing in the form of escorting patients to rooms, cleaning the rooms after patient visits, and maintaining a provincial health care plan billing system and large accounts receivable. There were also increased expenses associated with the general medical practice, such as a daily blood collecting and courier service.

The desire and the ability among all parties to market are necessary to satisfy unmet needs. 41 Resistance to marketing efforts by one party may cause conflict and likely impact negatively on needs and revenues. In Canada, the marketing of general medical practice has traditionally been conservative compared with private health care. The medical physician who is recruited to work in a large private center needs to embrace marketing as a necessity. Therefore, ensuring that every stakeholder clearly understands the necessity of marketing is essential. Having detailed written guidelines about marketing at the onset is necessary; voting rights and vetoing policy need to be established.

To avoid interprofessional friction in this environment, the scope of practice needs to be clearly delineated from the onset. Will PTs perform functional capacity evaluations commonly performed by occupational therapists? Will PTs perform spinal manipulation, which is normally (and perhaps more appropriately based on research on skill levels) 42 performed by chiropractic doctors? Will occupational therapists provide physical rehabilitation, commonly provided by PTs? Who performs acupuncture? Who prescribes nutritional supplements? Important considerations are required, and scope of practice needs to be defined. For example, in this facility, chiropractic doctors performed all manipulative therapy. Physiotherapists provided all modality and extremity treatment. Occupational therapists performed all FCEs and work-related evaluations. Rehabilitation was provided by all disciplines. Acupuncture could be provided by anyone who was a member of the Acupuncture Foundation of Canada Institute and had all the necessary qualifications. There was never a problem in this area after scope was clearly established.

Within a large organization, policy traffic will increase and policy issues will be important. Some will argue thick policy manuals and standard operating policies on every subject and procedure is necessary. Although it is important to have written policies to maintain a healthy work environment and for legal reasons (eg, sexual misconduct and harassment), caution should be used because making the practice “policy-driven” can result in the center taking on a very corporate mentality, which is not conducive to office efficiency (overproduction of emails, memos) and good morale.

As part of the role of managing the center, the senior office manager should have the task to enforce staff adherence to policy. Depending upon the hierarchical structure, this person would likely report to the group of partners; however, for practical reasons, reporting to one superior such as the clinic director (vs to any one partner) during day-to-day operations is required. Important decisions affecting operations and the professional staff in general (eg, hiring of staff, donating money, and problem solving) can be accomplished with regular partner meetings. It was our experience that weekly meetings were taxing, whereas biweekly and monthly meetings were adequate. The office manager's attendance is needed at all regular partner meetings to maintain unity and coherence.

We learned that for the office manager to perform his/her job effectively, the professional staff cannot be permitted to bully or otherwise undermine this individual's authority. The office manager's responsibilities and authority must be clearly delineated to all concerned. The office manager is the most important administrative team player whose objective is to organize an effortless work environment for partners, and the manager has to be given sufficient authority to perform this job.

The office manager, particularly one with advanced business training, could handle hiring and other human resources management procedures during the early developmental stages of the business, but a dedicated human resources manager or part-time consultant would be helpful. Among other activities, our office manager performed most day-to-day office accounting tasks including payroll, disbursements, managing accounts receivable and monthly billings, and monthly bank reconciliations and a senior accountant visited monthly to maintain accounting security. Although an office manager may be skilled with human resource activities, there are too many other tasks a busy manager needs to perform. The quality of your recruitment technique will be an extremely important signature of your operation and demand advanced skills, attention, and knowledge.

A new, large facility will occasionally be the brunt of unjustified informal complaints lodged by community-based professionals who apparently believe that you are receiving unfair advantages and attention. Criticism may be pacified by taking anticipatory steps to diffuse any prospective contention. For example, some criticism about our facility arose from matters where external professionals thought we were causing unfair attrition to their patient base (eg, solicitation of their patients while the patient was visiting another professional). We advised professionals at an annual general meeting that we adhered to a strict nonsolicitation policy with regard to any of their patients. Because of our exclusive WC programs, we also received criticism from professionals that we were receiving preferential patient referrals of chiropractic patients, and this matter was once again broached at an annual general meeting. Believability by any stalwart may be equivocal, but at least some of the professionals concerned will be appeased.

Recommendations 

Seek to develop a partnership structure at the onset or early in the facility's development. Investment from key players (eg, full-time professionals) will inject considerable motivation and cooperation into the project. Success depends upon people. Partnerships must be registered and protected by a legally executed written contract, clearly containing clauses such as a buy/sell agreement secured by life insurance.

Without trying to be heavily policy-driven, make sure that there are basic written policies governing office procedures, job descriptions, lines of authority, limits of authority, confidentiality, voting rights, growth and development, and marketing issues. No one partner should have veto over decisions that effect the clinic's overall operation or development.

To streamline policy, make office policies and standard operating procedures amenable to all staff wherever and whenever possible. For example, one policy on one subject matter for every professional and staff member. When different policies are required for different providers, confusion and mistakes occur. Considerations include basic universal policies affecting dress code, confidentiality, and staff parking to more challenging policies such as how the patient file is brought back to reception, administration procedures (collections, small claims court), or whether there is interest added monthly on overdue accounts.

If an associate arrangement is implemented, instead of a partnership, then serious consideration and steps need to be taken to minimize problems such as disloyalty. Ensure that your contract includes a confidentiality clause, which limits discussion and controls damage with other associates regarding any grievances. For example, the contract should state that the parties shall not disclose confidential information, records, files, or matters relating to the aspect of their contract or working relationship, except as required by law, and unless agreed upon in writing. Associates should not be able to privately meet and overtly discuss activities potentially hostile to your business.

Logistically, separate departments into separate reception areas. Combining a few departments would be acceptable, such as privacy-intense departments like medicine and psychology, traditionally friendly chiropractic and massage, and traditionally hospital aligned physiotherapy and OT. It is virtually impossible to cross-train support staff in all disciplines in a large multidisciplinary practice.

The professional staff cannot be permitted to challenge, bully, or otherwise undermine the office manager's authority. Clearly delineate the office manager's responsibilities to all concerned.

Improve human resources skills. Carefully evaluate the personality attributes instead of just looking at the credentials and work experience of your future work colleagues. Human resources consultants would be invaluable. Acknowledging attributes of future partners maximizes potential for leadership. Use great skill in hiring your office manager. Managers including clinic directors should have management background and take ongoing business improvement education regularly.

Do not offer high salaries just to attract personnel; personnel will understand overhead. We offered 60% to 70% commission initially, when 50% would have been reasonable and fair. Although there are different variables for every operation, 50% would have allowed our center to operate at a profit and promote for a secure buffer zone for monthly financial maintenance and further development, at the same time considering the volume of patients being attended, and would still have provided competitive salaries. The associate enjoys a good salary while working in a state-of-the-art, well-equipped center and where their responsibility is limited to patient care.

Exercise prudence and fiscal modesty in running your business operation, and personally around colleagues and subordinates, such that one does not incite envy and invite greed, or encourage any other negative attitudes which will affect morale. Personally use fiscal restraint on personal tangible items such as new cars and big houses around subordinate players.

Remember the basics of business. Be concerned of your location and be on a major thoroughfare. Have great visibility and negotiate great signage. Try to anticipate every expense including municipal taxes, business taxes, and WC premiums. Although all associates in our center were independent and self-employed, despite appeal, WC ruled them to be employed by the center and thus levied a large, unanticipated annual payroll tax. Sit down and develop a written plan and establish monthly written goals. Keep overhead low.

Conclusion 

An increasing number of health care professionals are considering working together in large multidisciplinary centers. The concept may be rewarding for both practitioners and patients. Patients appreciate the convenience of receiving many services under one roof as found in a small hospital. Practitioners appreciate sharing ideas and developing relationships with other health professionals. This type of clinical enterprise may have some potential disadvantages that, if not adequately addressed from the inception of the project, can seriously undermine its success. The organizational structure of the business, and particulars affecting decision-making via voting and/or vetoing among partners, are among the most critical concerns to address.

Some final words of advice as stated by Booker T. Washington: “Success is to be measured not so much by the position that one has reached in life as by the obstacles which he has overcome while trying to succeed.”