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Andrew M. Ball, MS, PT -> Re: Functional Independence Measure (March 11, 2001 4:26:00 PM)
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Rose,
I'm glad that you posted here because I'm sure that you're not the only RehabEdge member confused about my response. Your question is difficult for me to easily explain in text. I'll give it a go, but feel free to call me at work sometime at the Durham DEC (919) 560-5600 around lunchtime or so, and we can discuss it further.
The simple statistical answer is the problem of over-generalization. Managers often make inappropriate administrative decisions based upon sloppy internal research.
One problem, for example, is that though most directors of PT departments do not live by the following rule, most healthcare management texts suggest that the director should spend about 20% or his or her time doing clinical work, and the other 80% doing administrative and delegate work. Those that are able to pull off this feat usually take what they perceive to be the most difficult clients, or the ones that no other PT in the department feels comfortable treating.
As a result, when the director of PT examines his or her outcomes, it is expected by all that their FIMS scores aren't going to be quite as good as the rest of the clinic's PT's, and that's as far as it goes. But ARE those clients truly more difficult, and if so, HOW MUCH more difficult are they? It is possible, using the subscription, to examine how other PT's across the country (director's or not) did with a matched caseload. By matched, I not only mean by diagnosis, but by age, race, sex, weight, height, and co-variates (smoking status of patient group, education level of patient group, SES, geographic area, etc. etc.). It may be found that the director is actually doing quite poorly with respect to other PT's with the same population group. He or she will be praised by others in the department or hospital, when in actuality, the director is in need of a remediation plan.
The reverse may be true of a clinic PT who is placed on an action plan because of poor productivity. Upon using the national database, it may be found that the PT actually has a productivity that is among the best in the nation given a matched group of patients. He or she should be prasied, not punished.
I think that the biggest problem, however, is that clinics using the FIMS in a way that you suggest are often too comfortable with the results, and misinterpret the meaning in the real world. For example, a clinic may compile the FIMS results for all like-injured (in terms of etiology and severity) male patients over 65 with a R CVA, to find that 6 months ago, it took 12 visits to rehab that person to walking, and now the clinic does it in 8 visits. They are obviously pleased and the director of PT praises them for working more efficiently in achieving their outcomes.
That's great . . . unless the average in the regional area is actually 7, and across the nation is 5. This clinic is actually in need of help in their management of this kind of patient.
Furthermore, PT's in a given clinic tend to adopt the same philosophy and mode of therapy over time, that's the way that organizational behavior works. Organizations seek equilibrium among employee thought. The problem is that this equilibrium may be toward, or away from, what is optimally efficient. Comparing the work of one therapist to another within the clinic is therefore meaningless.
The only way to access this kind of information is through a national database.
The same can be said for examining individual patient outcomes over time. Usually, the clinic doing the "outcomes research" for the purpose of TQM, lumps say, all the patients with a certain type of CP together. FIMS (or at lest the Wee-FIM) allows for analysis by much more specific criteria (athetoid, severity/severity of IVH, severity of tone, influence of primative reflexes, gender, age, post SDR, etc., etc.).
To summarize, in statistical terms, it allows for ANOVA calculations (which allow for the accounting of multiple patient variables - aka individual differences of patients.) The alternative that you suggest allows for less sophisticated independent t-tests (one therapist's sloppily clumped outcomes against another's or against a sloppily compiled theoretical), or simple paired t-tests (improvements over time, or preRx/postRx results - also clumped).
There's more to this story, but I'll let that digest with everyone for now. Keep asking questions though! This is a good discussion!
Drew
[This message has been edited by Andrew M. Ball, MS, PT (edited March 11, 2001).]
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