Navigating Workplace Challenges in Health Care

The health care industry is influenced by an array of stakeholders, including patients, providers, payers, employers, and regulatory and accrediting bodies. To balance the different needs of these groups, managers set policies and practices that streamline operations.

But these policies and practices may also conflict with the clinical judgment and autonomy of speech-language pathologists (SLPs) and other providers. When given an administrative mandate that negatively impacts clinical care, SLPs can advocate for services—and their own well-being—by using facts and data to support alternate solutions.

A manager asks you to do something that conflicts with your clinical judgment and/or autonomy. What are your next steps?

Confirm the policy, and ask questions.

A manager may see a solution to a problem or a way to increase efficiency that has unintended consequences for clinicians. That manager may be responding to financial pressures, or they may not be familiar with speech-language pathology services and how they differ from those of other allied health professionals. Confirming the request and asking questions with respectful curiosity is a first step in understanding their point of view.

Get the proposed policy or directive in writing.
What is the background and/or rationale for the policy?
What is the problem that this policy targets or solves?

Examine the problem.

Once you understand the manager’s perspective and rationale for the policy, you can explore it from different angles.

Consider if the request is supported by or in conflict with
- federal, state, or private payer policy;
- employer policy;
- applicable scope-of-practice guidance from your state’s practice act and from ASHA;
- preferred practice patterns for the profession; and
- applicable professional codes of ethics from your state’s licensing board and from ASHA (applicable to ASHA Certified Members only)
Identify the impact of the policy on
- individual patients’ rights, outcomes, and safety;
- patient care across your caseload and clinical workflow;
- interprofessional team collaboration; and
- cost, risk management, and compliance at the facility level.

ASHA staff can help you think through different considerations and can connect you to resources for your unique situation; contact healthservices@asha.org.

Develop your talking points.

Use your research to lay out a business case using language and terms that mirror the manager’s rationale for the policy. Consider using a framework in which you

restate the requested action or policy and the underlying rationale;
detail the impact of the policy based on your research;
provide supporting background or other information; and
suggest an alternative to the problem, when applicable.

Communicate with your manager.

Consider which format, place, and time will most likely allow the manager to focus on the discussion. Send information and supporting documentation ahead of the meeting for their review, if appropriate. Use your talking points to present your case in a positive, collaborative manner—with an emphasis on solving the problem underlying the policy. Encourage the manager to take time to consider the information you’ve provided; return to the discussion at a later time, if needed.

Stick with it.

If your direct communication with the manager has not been effective, consider getting others involved. Talk with a director or other administrators for guidance on the appropriate steps for escalating your concerns in your facility. This may include Human Resources, your facility’s compliance officer, or an external ombudsman.

An example of a common scenario

You’re an SLP in a skilled nursing facility (SNF). Your manager asks you to complete a comprehensive swallowing, speech, language, and cognitive-communication evaluation on all admissions.

You ask the manager for a rationale; the manager says that they recently read an industry article that SNFs are losing money because they aren’t identifying patients who could bring in additional revenue.

You examine this request, and the underlying rationale, from the following perspectives:

Payer Policy
- Medicare requires that the services that are provided by clinicians are medically necessary and require the skills of a therapist.

ASHA's Code of Ethics
- “Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents them from keeping the welfare of persons served paramount.” (Principle IV, Rule B)
- “Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.” (Principle I, Rule L)
- “Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided, technology employed, and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected.” (Principle I, Rule K)

Workflow and Productivity
- Completing full assessments on all admissions would add as much as 2 hours a day of direct patient care and an additional hour of documentation and follow-up. You are already spending 80% of your time in billable services with residents currently on your caseload.

Based on this examination, you determine that completing and billing for comprehensive assessments as a blanket policy could put the facility—and you—at risk for fraudulent billing and would require additional SLP staffing.

You develop your talking points and collect supporting documents like the admission data for your facility and the Consensus Statement on Clinical Judgment in Health Care Settings [PDF]. You think through alternative solutions, like screening admissions and training staff on referral guidelines [PDF].

You set a morning meeting with your manager and walk them through your business case:

“I understand that you’re asking me to complete full assessments on all admissions so that we don’t miss anyone. I want to make sure that everyone who needs speech therapy services gets them, too. If I see everyone, though, it may raise a red flag to payers or reviewers when there is no related diagnosis or documented need for the assessment, and I have an ethical obligation to use my independent judgment and provide only those services that I think would be beneficial to the residents. Based on our admissions data, it would also add 10–12 hours of direct care to my schedule each week, so I’d need staffing help. I have a few other ideas about how we can meet the common goal of making sure everyone who needs services gets them.”
You share referral guidelines and suggest a plan for (a) conducting a staff in-service later this week and (b) tracking the number of referrals based on the guidelines over the next 90 days.

The manager considers your information and takes some time to talk about it with their district manager—and agrees to implement the referral guidelines.