Acute Care Productivity Measurement, System Next Steps ... · Acute Care Productivity Measurement,...

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Acute Care Productivity Measurement, System Next Steps / Recommendations CSM 2017 San Antonio February 17, 2017 Jim Dunleavy PT, DPT, MS Chair, Academy of Acute Care Task Force on Productivity/Value Mary Sinnott PT DPT MEd Committee Member

Transcript of Acute Care Productivity Measurement, System Next Steps ... · Acute Care Productivity Measurement,...

Page 1: Acute Care Productivity Measurement, System Next Steps ... · Acute Care Productivity Measurement, System Next Steps / Recommendations CSM 2017 San Antonio February 17, 2017 . Jim

Acute Care Productivity Measurement, System Next Steps / Recommendations

CSM 2017 San AntonioFebruary 17, 2017

Jim Dunleavy PT, DPT, MSChair, Academy of Acute Care Task Force on

Productivity/ValueMary Sinnott PT DPT MEd

Committee Member

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Page 3: Acute Care Productivity Measurement, System Next Steps ... · Acute Care Productivity Measurement, System Next Steps / Recommendations CSM 2017 San Antonio February 17, 2017 . Jim
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Outline Review:

Key Elements of 2015 member survey Review key points of the Academy position/ Task

Force Definitions Critical Thinking Clinical Decision Making Review updated measurement system Share the findings from recent use of the new

measurement system Share Task Force Recommendation to the

Academy Board / Next Steps Your input

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Task Force Late 2012

New Task Force charged with trying to find a way to help members with the issues related to Productivity, building on the work of the first Task Force

Task Force Members Jim Dunleavy PT, DPT,

MS Chair Gina Surgenor PT Lori Pearlmutter PT Mary Pyfferoen PT Maureen Eaton PT Ed Dobrzykowski PT Daniel Dziadura PT Mary Sinnott PT

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Key points from 2015 Member Survey

We wanted to see if our approach, definitions and potential outcome tool elements were understood and generally accepted by practitioners most likely to use it

Survey of membership in Feb-March 2015 591 respondents

98% PT 2% PTA 52.4% Staff PT 9.8% Supervisor 31.5% Manager/Director 53 respondents labeled themselves under 30+ other job titles

77% had 5-20+ years experience in acute care

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Current Status: From Acute Care Survey Feb-March 2015 58% of those surveyed indicated their facility was

using an outside consultant for productivity measurement

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Current Status: Measuring/Benchmarking in the Dark…. We have just been told that we are now going to be compared to

other "similar" facilities using xxxxxx, but they have declined to tell us which facilities we are being compared to.

I would appreciate some truthful and honest feedback about xxxxx.

Do you know what facilities you are matched with?Do you feel that the stats accurate reflect your performance and, dare I say, productivity?

How do you weigh evals? Do you do 15 minute increments weighted as "1", or is a single charge, one time weight of say "4" equivalent to 60 minutes of time? Do your reevals weigh 2 or 3?

And any additional information you would feel helpful in this conversation would be appreciated. …from acute care listserv

Presenter
Presentation Notes
IS THIS TRULY BENCHMARKING THAT IS MEANINGFUL TO US OR OUR PATIENTS? THE NEED FOR STANDARDIZATION OF DEFINTIONS IS SCREAMING AT US!
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Acute Care Survey Feb-March 2015 What is your productivity Measure?

Visits 36.1%

CPT Code Counts 18.6%

Units of time per visit (15 minutes) 70.0%

Relative value units (RVUs) 17.0%

None of the above 2.0%

All of the above 2.2%

Other: Please describe 7.0%

Other: APC Value weights, avg charge, BTU= 1 min., Time efficient: 59.375%, procedures per visit, Rule of “8”s, “stat assigned by outside consultant

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Acute Care Survey Feb-March 2015 Which of the following Measures are You Using

(Select all that Apply)

Acute Care Index of Function 3.0%

AMPAC-6clicks 40.6%

Functional independence measure (FIM) 26.7%

Home Grown measure 5.2%

We do not use any clinical measures 26.3%

Other: Please list the measure(s) you are using 21.4%

Other: 10 min walk, times up and go, Tinetti, Berg, Barthel, Modified FIM, Elderly Mobility Scale, DGI, “FIMish”, FOTO, FSS-ICU, Gait Speed, Kansas,

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Physical Therapy has to determine the elements of its own practice and the measures of those elements that

will result in our services being valued by the patient, facility and the

health care system….

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Establish Assumptions Physical Therapy has value to the patient, the

hospital and the healthcare system in the acute care practice setting Areas of Practice identified as having value:

Early determination of appropriate next level of care Validity and timeliness of discharge recommendations Decrease cost of ICU Stays Impact on LOS Decreased variation of practice Patient / Family / Caregiver / staff education Consultation services Identification of at risk for readmission cases based on

current versus previous level of function and other factors Avoid unnecessary admissions/readmissions in ER

Presenter
Presentation Notes
WHERE DO WE HAVE VALUE? DO WE HAVE PROOF OF IT?
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Establish Assumptions In acute care our value is not driven by revenue. It is driven and

determined by: The patient:

timely, clinical outcomes Determine the severity of patient condition Adjusting the intensity(time) of our treatment to meet patient

needs Patient satisfaction

The healthcare facility: Through cost efficient delivery of services:

early determination of next level of care ER: identify patients not needing admission Identify potential readmissions before they leave the first time

managing the clinical care we deliver Determining who needs our care

The healthcare system as a whole: by providing care at the level of value that meets the patient goals and

that the patient proceeds seamlessly to other levels of care

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Unique Role of Physical Therapy 30,000 foot view of the patient that takes into

consideration: Acuity/Chronicity Simplicity/Complexity ICF

Health conditions Contextual factors

FUNCTION Triage to the next level of care

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Unique Role of Physical Therapy Complex decision making Experience and expertise of staff

Novice vs expert clinicians Ability to prognosticate functional recovery

Appropriate utilization of resources

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Establish Assumptions Value:

Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.*

*Porter ME, What is Value in Healthcare, NEJM Perspective, December 23, 2010

Presenter
Presentation Notes
THE TASK FORCE HAS USED THROUGHOUT ITS WORK THIS DEFINTION OF VALUE FROM MICHEAL PORTER. ITS FOCUS IS NOT ON THE PROVIDIER BUT THE CUSTOMER AND WHAT THEY GET OUT OF OUR CARE. KEY TERM: VALUE BASED ON RESULTS NOT INPUTS. SO HOW CAN WE TRY AND SHOW OUR VALUE BY SHOWING THE #VISITS WE PRODUCED IN AN ENVIRONMENT…ACUTE CARE….WHERE EVERYTHING WE DO IS A COST WITHOUT REVENUE. WE HAVE TO FOCUS ON MEASURING CLINICAL OUTCOMES TO BE SURE, BUT WE ALSO HAVE TO MARRY THAT WITH THE COST OF PROVIDING THE SERVICE (TIME, INTENSITY WHAT IS IT WE DO) IN ORDER TO TRULY MEASURE THE VALUE WE BRING….OR NOT BRING I WOULD SUGGEST TO YOU HERE THAT THERE ARE PATIENTS THAT WE DO NOT BRING VALUE TO, YET DUE TO TRADITIONAL WAYS THAT WE RESPOND TO REFERRALS IN ACUTE CARE, WE WASTE RESOURCES THAT COULD BE USED WITH PATIENTS WHO WE CAN EFFECT THEIR CLINCAL OUTCOME, AND THUS HAVE VALUE TO THEM
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Position Statement – Key Elements Measuring value must be a blended measurement

Patient severity Patient defined outcomes Patient Satisfaction The cost to deliver the care

Measuring “productivity” by time units, visits etc does not determine the value of our care

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Shifting Language and Debunking the Myths CPT Codes:

While Hospitals will continue to run on CPT code structures for cost reporting etc. CPT codes/definitions/rules are best suited to

the outpatient environment and do not serve as a good productivity statistical tool

Current definitions/codes not sensitive to patient severity

Current definitions and codes not sensitive to costs of the interventions we provide

Current definitions and codes not sensitive to intensity of the interventions we provide

Educate other care givers: We generate no revenue (except Part B)

The terms ”billable” and “charges are inaccurate We are actually capturing “costs” in an

antiquated way (charge master) Our “cost capture inputs” are contributions to

cost reporting Adopt PTCPS language for severity and

intervention

Presenter
Presentation Notes
WE HAVE TO MOVE AWAY FROM WHAT IS AND MOVE TO WHAT WE, AND OUR PATIENTS NEED WE NEED TO CHANGE OUR OWN LANGUAGE AND TRULY UNDERSTAND COST AND VALUE. WHILE AT THE SAME TIME TALKING TERMS THAT THE ADMIN. AND FINANCIAL PEOPLE UNDERSTAND
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Decrease Variation in Practice –Working Definitions

Goals: Statements representing the expectation of the

condition of the patient at the time of discharge from acute care (81% agreement)

Prognosis: The determination of the next level of care as defined in

part by the severity of the case and the intensity of the service needed to produce meaningful change in the patient’s condition (60% agreement)

Severity “Lets not reinvent the wheel” (75% agreement)

APTA Severity classification system: www.apta.org/PTCPS/

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Decrease Variation in Practice –Working Definitions Intervention/Intensity : (72% agreement)

The amount of time, which is spent in direct contact with the patient: Input into Hospital charge system:

Direct treatment (CPT)

And… Documentation of care Education of patient/family Time spent in care planning

Rounding, clinical team meetings etc

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Decrease Variation in Practice –Working Definitions

Intervention/intensity: examples of what should not be included: Staff Meetings Competency assessment Time Clinical Education Time

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So Defined where in the system we have value Defined Value and its elements through a position

statement Created new definitions for Goals, severity, prognosis ,

intervention (intensity) that were driven by the membership

Developed and tested x2+ a potential measurement system

….Lets take a look at the system

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Task Force Proposal - Measured Value

Make changes to practice based on data sets

Acute Care Physical Therapy

Value

Determine the cost of your care

Input evaluation level and visit

frequency

Evaluate datasets to identify opportunities

for change

Continue data collection and analysis

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The Measurement System What we are trying to achieve:

To give our colleagues the ability to collect data on the elements we feel make up the value equation

From this data be able to make meaningful changes in their practice Make better informed decisions regarding amount (intensity)

of their services as it relates to Cost Patient outcomes

Monitor patient types to determine whether are services are necessary

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The Measurement System Excel Workbook

Different worksheets for: Determining cost Explanation of evaluation levels Explanation of severity levels Explanation of intervention levels Data sheets for each patient type (up to 25 cases/sheet)

Ortho Neuro Medical

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Determining Your Practice Cost

Time Driven Activity Based Costing (TDABC) Approach* (76% agreement) Relatively easy to do Can be adjusted as situations change Allows for variations of cost capture in different facilities Can be utilized in all acute care settings A language Admin/Finance will understand

*Kaplan R., Porter ME, How to solve the Cost Crisis in Healthcare, Harvard Business Review, September 2011

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Acute Care Resource Cost

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Acute Care Resource Cost

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• Above is the data input for a single patient

• There are 25 of these per patient category: Ortho, Neuro, medical

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Totals for Each Patient Group

Presenter
Presentation Notes
That dates will then be aggregated by patient category. There is a lot of data here that I sensitive to your decision-making about intensity (time) of service and the severity of the case
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Practice Totals

Presenter
Presentation Notes
It will then give you a more global look at your data by a total practice perspective
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Practice Totals

Presenter
Presentation Notes
Not only is this sensitive to the per treatment cost, but this also is affected by the number of visits. Your practice could discuss with these #s whether you can achieve the same outcomes with less intensity or, is this intensity not meeting the patient goals your set and thus higher intensity for that type of patient maybe warranted
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Practice Totals

Presenter
Presentation Notes
This spreadsheet will also give you bar graph representations of a number of aspects of the data. We will be asking you for feedback as to additional, valuable data set comparisons you feel are important This graph would raise questions related to the level of intensity of the treatment being performed
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Practice Totals

Presenter
Presentation Notes
Relate this to the previous graphs. How would this help you in utilization of staffing resources or finding a place where you can shift staff from in order to increase intensity of service to those who need it?
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Practice Totals

Presenter
Presentation Notes
You could take this and use it as part of your PI, in fact all of this could be your entire PI program. The analysis of the data is vital to performance improvement
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Practice Totals

Presenter
Presentation Notes
Graphs like this scream at us to ask questions regarding the intensity of our services for particular patient groups. Could decreased intensity result in same or better outcomes?
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Practice Totals

Presenter
Presentation Notes
I know the length of our eval time is an issue. This is an area we may have to explore expanding to include=de things such as a screening visit etc.
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Testing the Measurement System

November 2016: Call to Academy members to attend a webinar outlining

the measurement system and a call for facilities to test it December 2016:

Task Force reviewed and accepted 36 facilities 36 Facilities were sent a description of the study and

agreement for signature 17 facilities returned agreement

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Testing the Measurement System January:

Training Webinar for facilities Given 3 weeks to do approximately 50 patients Asked to review the data set created and discuss whether they

feel the dataset is valuable

Each therapist completed a survey online (N: 101) Conference call after data collection with facilities and

Task Force to Discuss Results Survey data reviewed by Task Force and

recommendations made to the Academy BoD

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Survey Results: Facility Demographics Geographic:

Northeast: 2 South: 6 Midwest: 4 West: 5

Location: Rural: 5 Urban: 10 Other: 2

Type: Teaching: 8 Non Teaching: 9

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1 – Completely Disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Completely Agree N/A – Not Applicable

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Q#

N CD D N A CA

1 The measurement of acute care physical therapy has to shift from the concept of productivity (#visits / #units) to a measure of value 101 0% 1% 6% 32% 61%

2 This new measurement system clearly demonstrates the value of our services to the patient

100 0% 20% 29% 44% 7%

3 This new measurement system clearly demonstrates the value of our services to our department/ facility

98 0% 18% 28% 41% 13%

4 This new measurement system clearly demonstrates the value of our services to the American healthcare system

100 0% 20% 28% 44% 8%

5 I agree with the definition of “value”94 0% 5% 14% 60% 21%

6 I agree with the definition of “intensity”99 0% 7% 13% 53% 21%

7 The current patient categories of medical, ortho, neuro are adequate 99 6% 38% 13% 32% 10%

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N CD D N A CA8 The cost calculation system was easy to use 52 0% 19% 21% 50% 10%

9 This data can be useful to allocate staff more effectively 66 3% 6% 30% 50% 10%

10 This system is more valuable than visits/units when discussing the need for changes in staffing and programming with my administration 60 0% 5% 25% 58% 12%

11 I would substitute my current daily statistics collection with this system 58 2% 31% 45% 19% 3%

12 I would supplement my current statistics with this system 58 0% 6% 17% 59% 9%

13 I would use this to collect data on our practice on a monthly basis 55 0% 18% 42% 29% 11%

14 I would use this to collect data on our practice on a quarterly basis 54 0% 11% 20% 57% 11%

15 I would use this to collect data on our practice on a six (6)month basis 59 0% 20% 29% 42% 8%

16 I would not use the system at all 62 23% 52% 21% 5% 0%

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Task Force Review of Survey Results

• High agreement on needing to move to a productivity measure based on value (Q1)

• While positive, there was a lot of neutral when it came to this showing our value to the stakeholders identified (patient, hospital, healthcare system). The TF discussed this and this might be due to this being a new concept and possibly the cumbersome format of the spreadsheet. (Q2,3,4)

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Task Force Review of Survey Results• Continue to have a relatively high degree of

agreement on the definitions which is similar to the findings we received from members in our 2015 survey (Q5,6)

• There is a need for flexibility in setting up patient categories (Q7)

• Fair agreement that the cost calculation was easy to use. This might be affected by the person doing it and their access to some of the amounts needed (Q8)

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Task Force Review of Survey Results• While again a High % of neutral answers, there seem to be

some agreement that this would be a tool that could be used for staff allocation and that it would be useful to have this information in discussions on staffing and program development with the facility administration (Q9,10)

• Many saw this as a supplement, not a replacement for their current statistics (Q11,12)

• The utilization of this tool would be through a periodic snapshot of the practice and not daily statistical capture (Q13,14,15)

• There seemed to be high agreement that this type of system, in some improved form, would be valuable (Q16)

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Potential Practice Questions to be answered by this data? Are there patient populations that our services bring

limited or no value to? Is our pattern of intensity too high/low? Can we achieve the

same/better outcomes with a different level of care? Same or better outcomes at less cost?

Can we demonstrate value of our services to Administrations/Finance in a better way with this data rather than outside consultant data?

Is this data valuable to begin to have dialogue regarding benchmarking?

Others you might think about…..

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Issues / Discussion Patient Satisfaction These measures should be looked as additions to your

current PI Dashboard Will need to establish benchmarks Current application platform (excel spreadsheet)

cumbersome – need to go electronic “Complexity” vs. “Severity” Single visit – One type valuable….another….not so

much

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Issues / Discussion What to do about discharged patients prior to

performing the final measure? Utilization of this type of measure appears to be more

practical on a “snap shot” basis (monthly, quarterly) rather than every day

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Potential Uses Determine value of our service by patient

population type Questions it can help answer:

What types of cases do we bring the greatest value to? Are there types of patients that gain little to no value from

our care? Who needs us – Who does not?

Will it give us information to change staffing patterns to meet high/low value patient populations?

Assist in determining Prognosis of patient function? Assist in determining FTE enhancement – retraction Effect of patient severity (complexity) on intensity (time) of

our services Data to assist in decreasing variability of practice

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Potential Uses Can determine if higher or lower intensity (Tx time) results

in the same clinical outcome. Begin to classify cases by severity (complexity) and then

have data to support studies related to patient discharge and readmission. Are we making a difference?

Enhance the understanding by admin/finance of our value Staffing levels Other Resources

Appears to be able to utilize existing multiple existing clinical measurement tools

Move towards benchmarking – APTA Registry Linkage

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Imagine if we had the Data… “Does your facility/hospital use any criteria for labeling

referrals for PT eval inappropriate so that the PT does not have to proceed with the eval?Appreciate any input in this matter. ‘

…from acute care listserv

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Summary Physical Therapy, our patients and the facilities where we

practice are best served with a blended approach to measurement that focuses on value that is defined by: Cost patient severity (complexity) treatment intensity the patient’s outcomes

We must standardize our terms now Continue to look for opportunities where we bring value to the

patient, the facility and the healthcare system We must measure our value in a way that is understandable to

different stake holders We must be the catalysts of the change, we cannot wait for

others to “do it to us” We encourage using this data as part of your PI “dashboards”

Presenter
Presentation Notes
WE ASK YOU TO START TO UTIZE THE DEFINTIONS WE HAVE CREATED. WE NEED TO STANDARDIZE OUR LANGUAGE AS WE MOVE FORWARD WITH FURTHER DEVELOPMENT OF THE TOOL
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Summary Task Force recommendations to Academy Board

approved 2/15/17:• Incorporate what we learned from the survey and

incorporate it into the existing excel platform.• Retest this updated version with the same facilities in

order to have people familiar with the system give us input

• Re-Survey• As the above is being done

• Prepare and implement an approach to EMR providers to see if they will incorporate the data sets and to produce reports we need

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Task Force Proposal - Measured Value

Make changes to practice based on data sets

Acute Care Physical Therapy

Value

Determine the cost of your care

Input evaluation level and visit

frequency

Evaluate datasets to identify opportunities

for change

Continue data collection and analysis

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Academy of Acute Care Physical Therapy

Value / Productivity Round TableFriday February 17, 2017

Crockett A, Hyatt3-5pm

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