Jobs Applied: Know Both the Big Picture and The Details


Steve Jobs had a penchant for dreaming big.  His far-reaching vision brought personal computers into the home, revolutionized the music industry and contributed to the advent of today’s world of cloud computing.  Yet at the same time, he also kept his hands in the nitty-gritty details of the products Apple was producing.  He set not only the destination of Apple, but he paid attention to every turn along the way.  This ability to ‘zoom out’ to the big picture and ‘zoom in’ to focus on details is part of what made him so effective.

Small business owners, particularly in service industries like physical therapy, are often pulled in a thousand directions.  We have to make decisions on a grand scale – ‘Do I buy this building?’, ‘How big do I want to grow?’, ‘should I participate in this ACO?’.  However, we also have an overwhelming flood of details to oversee.  ‘who has the best price on theraband?’, do I have time to put another patient in my 2:30 slot?, ‘should I give my technician a $.25 raise?’.

“Details matter, it’s worth waiting to get it right.” – Steve Jobs

Focusing in on just the big picture can create problems.  In today’s challenging payment environment, the margin is often found in our management of expense details and avoiding unnecessary costs.  It takes almost $1.25 of revenue growth to equal $1.00 of cost savings.  This means that controlling costs is often an underutilized mechanism for improving performance.  The success of our teams often also happens due to paying attention to details.  Getting the right people on the bus and making sure that we only tolerate A players has everything to do with careful selection of every member of our team.14866993_m

However, focusing only on the details stifles innovation.  Strategic thinking, big picture goal setting and innovation are necessary ingredients for a vibrant culture and practice growth.  We have to have a vision and a strategic plan for reaching that vision.  As Vince Lombardi said “hope is not a strategy.”  As leaders in healthcare, we have to be part of the nationwide conversation going on right now.  We need to be involved in coming up with the ideas that guide our changing healthcare system, and we will need to be ready to adapt to the new reality that is coming.

“I want to put a ding in the Universe” – Steve Jobs

To grow and to be successful we have to know both the big picture and the details.  

This Jobs Applied lesson reminds me of one of my favorite principles from Jim Collins.  My next #Browdering series will apply this principle and several others from ‘Good to Great’, ‘Great by Choice’ and ‘How the Mighty Fall’ to our world of physical therapy management and leadership.  I hope you will join me next week as we discuss ‘The Stockdale Paradox’.

Jobs Applied: Engage Face to Face


“There’s a temptation in our networked age to think that ideas can be developed by e-mail… that’s crazy. Creativity comes from spontaneous meetings, from random discussions.” – Steve Jobs

While he valued face to face engagements and meetings, Jobs had nothing but disdain for the typical corporate ‘death by powerpoint’ session. What he looked for was live engagement and problem solving.

The hectic pace of physical therapy, with what sometimes seems like every moment taken by scheduled patient care makes it difficult to create time for face to face engagement. While we occasionally make time for clinical education activities like journal clubs, it is easy to replace face to face engagement for leadership activities with phone or email communication.

Creating regular face to face engagement is difficult in organizations like our private practice, with 17 facilities spread across a few hundred miles. In even larger companies with hundreds of facilities, face to face engagement between executives and local team leaders is even more rare.  My short stint working with US Physical Therapy (we were temporarily partners after an acquisition) showed me the reality of this.  The executive I reported to had about 260 direct reports.  We met face to face perhaps twice each year.

Face to face engagement… which we affectionately term 121s (one to ones) between a leader and those they lead is a key leadership task. In my opinion it is a key component of the cadence of accountability we should try to maintain with our teams. One of the most difficult but most rewarding activities we have undertaken as our practice has grown has been to maintain a regular regimen of contacts between our leaders and those they lead. Here is an example cadence that has worked well for me:

  1. Weekly – small group, very focused video teleconference focused on activities being completed to meet our most important goals.  We do 3 of them to allow small groups so they take no more than 20′.
  2. Monthly – face to face 121s between leaders and those they lead.
  3. Quarterly – Summits with key leaders meeting to share results, insights and progress toward meeting goals.
  4. Annually – Strategic planning with a small, focused group and then subsequent meetings to share aspirations and strategies with the entire team.

I believe that your average ‘meeting’ is a great way to avoid working. That said, focused face to face engagement and communication between leaders and those they lead is essential to building a great team.

Jobs Applied: Tolerate Only ‘A’ Players


Steve Jobs, despite all of his redeeming features, was famously ‘impatient, petulant and tough with the people around him”. He also delivered results, while maintaining a loyal cadre of high achievers that stayed with him much longer than was typical of the computer industry at the time.

“CEOs who study Jobs and decide to emulate his toughness without understanding his ability to generate loyalty make a dangerous mistake”. – Walter Isaacson

Jobs believed that part of his job was to unfailingly deliver the brutal truth, rather than sugar coat failures. His belief was that many organizations employ managers who are so polite and forgiving as to become ineffective, allowing mediocre employees to feel comfortable and thus encouraging them to stay.

Jack Welch, famed CEO of GE had a similar style and philosophy when it came to an intolerance for mediocrity. Indeed, Jim Collins, in ‘Good to Great‘ found that one of the key features of great companies is that they were good at ‘getting the right people on the bus’. Along with that inevitably comes the need to get the wrong people off of the bus. GE famously utilized a performance feedback system that systematically ensured that the bottom 10% of employees were terminated or rehabilitated… slowly raising the bar for all employees.

Leaders and managers in physical therapy practices attempt to hire the strongest clinicians, with an attitude that lends itself great customer service and teamwork. This gets more difficult in tight job markets or when timing limits our choices. The adage of ‘hire slow, fire fast‘ is often harder to do than we like, and it goes without saying that the best time to ensure we have the right people on the bus is during the hiring process. We occasionally hire someone that isn’t a good fit (a C or D player). These are difficult enough to deal with.   Even harder than the obviously insufficient are those that are ‘OK’, the B players.26325920_s

By tolerating ‘B players’ we prevent the opportunity for an A player to join our team. True – we can develop B players into A players… but when you determine that they are a B player with no potential, they can set the bar for everyone around them. A team member’s status as a A or B or C doesn’t have to be defined only by phenomenal clinical skills, or amazing personality or steadfast work ethic… although it could mean any or all of those things. We should employ good clinicians with great empathy and a strong work ethic. We should employ great clinicians with good customer service skills and great ability to teach others. We should employ resilient, gritty grinders that never complain and make sure that the work gets done. But we should never tolerate mediocre clinicians with an OK attitude that give us no reason to complain.

How we deal with professionals that ‘meet standards’ or are ‘good enough’ determines whether our practice is doomed to mediocrity or if it has the capacity to be great. Tolerate only A players.

Jobs Applied: Push for Perfection


Steve Jobs was a famous perfectionist – often delaying the release of a product until a minor issue could be reworked, or even totally scrapping and reworking a design that didn’t feel right. A famous example is the design of the Apple retail stores. He famously delayed the initial openings several months to reorganize the layouts around activities instead of product categories.

Successful physical therapy practices are constantly working to improve the patient’s outcomes and overall experience. In order to provide consistent services efficiently, countless processes have to be accomplished behind the scenes. We should always be looking for places to improve – striving for perfection in the areas that are most important to our customers.  However, we can’t be perfect at everything – down that path lies a lack of focus and likely mediocrity at everything. How do we decide where we should focus?


In Nov 2013, Larry Benz and I presented the results of a conjoint analysis of ‘what patients really want’ to well over 500 passionate attendees of the Private Practice Section annual conference. This was a University performed, privately funded study that surveyed almost 500 patients, from 3 companies with 31 outpatient facilities.

This is was patients told us they value the most in their physical therapy experience:

  1. The therapist is very knowledgeable.
  2. The instructions from the therapist were very clear.
  3. Appointments are on time, with a minimum wait time to see a therapist.
  4. All the staff is very friendly.
  5. A doctor recommended this clinic.

These are the things that we should strive continually to improve upon, even at the cost of not improving in other areas.  Focusing on these areas with the laser-like focus and dedication that Steve Jobs exemplifies will allow us to push for perfection in the most important areas for our practice.

Jobs Applied: Bend Reality

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His staff called it the ‘Reality Distortion Field’.  I can almost imagine the super-geek (no offense intended) hallways of Apple ringing with the mythical storytelling that had to surround Steve Jobs as he pushed people to go beyond what they thought they could accomplish.  Steve Jobs would set what I would call BHAGs (Big Hairy Audacious Goals) such as creating the iPad – which was essentially impossible until it came out.

“People that want the future to be different don’t accept the status quo – they push against it” – Steve Jobs

The coming period of transition in healthcare is going to force us to rethink how we do things.  What things do we think are impossible now that we could make happen if we had to?  I think this is a very useful exercise and can help us to position ourselves to adapt to the changes in our own marketplace.  Here are some examples:

– Could you fill a schedule with patients paying $200 cash?

– Could you provide services if the most you could be paid per visit was $55?

– Could you take care of 24 patients in a day if you were the only therapist?

– Could you see 15 new patients every day in a walk-in clinic?

– Could you provide excellent clinical care to 3 patients at the same time?

– Could you base your income on your outcomes?

I don’t know which of these things you will need to be able to do in the future… but I believe they are all possible.  In order to create the future we want, we may need to bend reality.  What do you think of the examples above? What do you think your personal distortion field might need to create in order for you to succeed in the future of physical therapy?  Bring on the discussion below, post it on Facebook on my page or throw it on twitter – use the hashtag #browdering.

Jobs Applied: “Don’t be a Slave to Focus Groups”


Steve Jobs was famous for the strange duality of his relationship with his customers.  From one perspective, he cared very deeply about the customer’s experience.  However, he thought that this was different than asking them what they wanted.  He is quoted as saying to his design team:

“Customers don’t know what they want until we’ve shown them”  – Steve Jobs

This lesson from Steve Jobs has been much on my mind lately.  In Nov 2013, Larry Benz and I presented the results of a university led, privately funded research project into ‘what patient’s really want’.  The service features that this study delivered as being the most important included these as the top 3: ‘The therapist is very knowledgeable’, ‘The instructions were very clear’ and ‘appointments are on time, with a minimum wait to see a therapist’.  Watch for a webinar coming soon where Larry and I will present the full findings of this study.

While presenting and then discussing this topic over the past several months, this leadership lesson has come to mind frequently.  Giving the patient these features they tell us they desire is a worthwhile exercise and I think the foundation of an excellent service strategy.11268773_m

That said – what if we could figure out what the patient craves, but can’t tell us?  Here are a few things I think might make a big difference but would be difficult to pull out of patients in a focus group:

  • A warm voice on the telephone when answering the first phone call.
  • Staff members that remember the patient’s name.
  • Therapists that notice when a patient doesn’t make it and are concerned instead of irritated.
  • Therapists that listen more than they talk.
  • Employees that enjoy each other and the patients.
  • A ‘positive vibe’.

Perhaps for Steve Jobs not being a slave to focus groups was about innovation and giving customers a computer they never knew was possible.  For physical therapy practices I think it is about that indefinable feeling that only exists in a practice where the staff is highly engaged in the business of creating powerful, healing connections with patients.  Our healthcare system is so broken that the patient’s don’t remember to include ’the therapist cares about me’ as their first priority.  Perhaps we can make sure that we deliver it anyway.

Jobs Applied: Impute

physical therapy browdering

Have you ever noticed that the packaging for Apple products is simply beautiful?  I hate to throw these things away – its obvious great attention and time goes into each one.  Steve Jobs personally spent time on the design of the packaging for the iPhone, believing that it set the tone for the experience.  He put his own stamp onto every facet of the product so that there was intention behind every aspect of it.

“They ‘do’ judge a book by its cover.”  -Steve Jobs


Everybody utilizes first impressions to make judgements.  Patients ascribe (or ‘impute’) characteristics to their therapist based on the packaging.  Can we intentionally design the patient’s first impression to create confidence that we can solve their problem?  I suggest that how we appear and how we dress plays a role in patient confidence, and thus in our ultimate outcome with that patient.

How do we want to be perceived?  I think patient’s for the most part don’t really know where to put us in the hierarchy of healthcare professionals.  What style of dress gives the best impression?  Is it different for different people?  There has been a little bit of research in this area, but nothing all that definitive and it seems obvious to me that setting makes a difference.  Interestingly, this research did not include the style I would choose for men in outpatient settings (dress shirt no tie).

‘Scrubs’    – I loved that show. Have you washed those recently?









‘The Coach’   – Are physical therapists like really smart personal trainers? Hey – P.T. – the initials are the same!










‘The Golfer’  – Are physical therapists like athletic trainers? I had one of those in high school.

Physical-Therapist polo


‘Business Casual’     – Nice shirt! Is that stain from massage lotion?



‘The Coat and Tie’    – Did you just come from the bank?  Is that tie uncomfortable?







’The White Coat’    –  Are physical therapists like physicians?











What kind of ‘packaging’ sends the best message in your opinion?  I’d love to discuss it with you below and we’ll be #browdering on twitter as well.


Jobs Applied: Put Products Before Profits


Steve Jobs, when creating the first Macintosh computer, famously ignored cost trade-offs and profitability in favor of making the computer ‘insanely great’ and with a mantra ‘don’t compromise’. This actually led to his ouster in the early ’80s as the Macintosh ended up both amazing and too expensive to compete with the cheaper PCs of the day. In response, Apple hired a less product-oriented CEO recruited from Pepsi, John Sculley, who focused on profits. Focusing on profits led to a decline in quality and Apple nearly died before Jobs’ return in the early ’90s. The return to a focus on innovative, ‘amazing’ products led to Apple’s emergence as a market leader.  Even in the face of challenges, such as we are facing in healthcare today, Steve Jobs kept the focus on providing the best product, rather than on profits.

A few weeks ago I  posted ‘Jobs Applied: When Behind, Leapfrog‘-  a discussion of Harvard strategy guru Michael Porter and Thomas Lee’s timely HBR article “The Strategy That Will Fix Health Care”. One of the key principles Dr. Porter brings up is the definition of value in healthcare.

“Value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes or both.” (Porter and Lee, HBR Oct 2013)

79 ethics road sign

In health care and other service industries the ‘product’ is a patient’s experience and a health outcome… so the lesson here would be ‘Put the patient’s experience and health outcome before profits’. As the payments for providing health care services decline this is a reminder to continue to put the patient’s needs first.

Our physical therapy practice has been a leader embracing a care model that allows for improved efficiency, but keeps the physical therapist (PTs) firmly engaged with each patient. Texas allows physical therapists to utilize technicians (unlicensed assistants)to assist with some treatments under the direct supervision of the physical therapist. While when we first started in this model we were challenged by PTs providing ‘1 patient for 1 therapist for 1 hour’, these practices are increasingly failing in states with the greatest payment challenges and have either evolved or are hanging on by a thread. While in part due to other issues, the 2013 chapter 11 filing of the largest physical therapy provider in the US accentuates the idea that this lesson might be better termed ‘put products before survival’.

Medicare logo

Many states have strict requirements requiring care be provided by only licensed personnel (PTs and PT assistants – or PTAs) and federal payers (i.e. Medicare and Medicaid) will only pay for services provided directly by one of these licensed personnel. These regulations in our ‘over-licensed society’ (Litan, R. HBR Apr 2012) have created a perverse incentive where a model that may decrease value to the patient actually becomes the most easily sustainable model of provide PT services.

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For the first 10 years of my career I was a physical therapist in the US Air Force. I am proud to say that the US Military employs perhaps the finest orthopedic and sports oriented PTs in the US. Direct access to PT services and an advanced level of musculoskeletal screening and cross-collaboration with other specialties is integrated in a manner that the public sector should look to when reforming our health care system. There is mounting evidence that early referral to PT, which is sometimes available in the military system and now available in some states improves outcomes and reduces downstream costs.

One of the challenges, particularly in military medical centers, is that many of the actual treatments are not provided by PTs. A typical patient encounter would include an evaluation with a PT, then multiple treatment sessions with personnel roughly equivalent to a physical therapy assistant (PTA) with a follow-up visit with the physical therapist at somewhere between 2 weeks and 1 month after treatment.

PTAs have associates degrees and are licensed to provide PT treatments under supervision. Manual therapy is a key challenge to providing care that is centered around the utilization of PTAs in an outpatient orthopedic setting. The APTA has issued guidance discouraging PTs from allowing their assistants to provide manual therapy interventions. One of the reasons I eventually left the military medical system was to be able to provide these evidence based interventions without requiring a lesser-trained intermediary.

The regulations imposed primarily by the federal government in conjunction with steadily declining payment for services have created a concerning incentive. The care model long utilized by the US military looks as if it may become one of the few viable business models for private practice. Driven by a high median income ($52,160 in 2012)there is a flood of interest in becoming a PTA. With the median salary for physical therapists (doctoral degree) at $79,860 this is no surprise. There are now 21 PTA programs in Texas (compared to 12 PT programs) with more on the way.  In my opinion, the relatively high cost of PTAs (and their wages) will likely dramatically decrease as demand is met and then exceeded over the next few years. At that time the incentives provided by declining payment for services  and regulatory requirements align very well with a business model where a single physical therapist provides minimal oversight to multiple PTAs.

1194984910785474358stop sign miguel s nchez svg medI have encountered this model recently, when interviewing PTs for director’s positions within our practice. One PT I encountered reported evaluating over 100 new patients while supervising 2 PTAs providing over 900 visits in a single month. By his report he was able to follow up with his patients for a short time approximately every 4-5 visits.

Utilization of PTAs, in itself, is not what I would argue is the problem with this business model. I believe there are models where PTAs can be leveraged as part of a tightly knit team to improve efficiency and to maintain or improve quality. However, as the ratio of PTAs supervised by each PT increases, the level of involvement of the PT in the patient’s care invariably diminishes. In the Air Force we would see this in the variability in the quality of care provided at medical centers versus in the smaller outpatient facilities or the deployed setting. My wife, Alexis, has experienced this in the home health setting, where she was asked as the PT to provide an initial evaluation and a follow-up visit at 30 days. I believe it is hard to make the argument that the patient’s progression is meaningfully guided by the physical therapist in that scenario.

A counter-argument would be to compare this scenario to the increase in utilization of care extenders to decrease the cost for primary care providers to care for patients or even the explosion of ‘minute clinics’ and the like. While the situation is similar on the surface, it is perhaps more extreme when looked at more closely. To compare these arguments would put the doctorally trained physical therapist in the provider role (not inappropriate from my perspective), but would put the PTA in the same category as a physician assistant or nurse practitioner. While I have worked with excellent PTAs, the training received at an associates degree level is not comparable to the masters degree level that physician’s assistants and nurse practitioners receive.

The lesson of putting the patient’s experience and outcome before profits may come into play if we allow over-utilization of PTAs or any other extender to disconnect the PT from the patient’s intervention. In the face of ever-increasing costs of doing business, it is my hope that we can continue to ‘put products before profits’ and create innovative care models that meet Dr. Porter’s charge of improving patient experience and outcomes while doing so at a decreased cost. Removing well-meant but misguided regulatory hurdles would improve our ability to meet the charge to provide high quality care by PTs in a model that can accept lower payments for services while maintaining the patient’s experience and outcomes.

I suspect that this post might touch a few nerves – even in some of my good friends and fellow private practice owners – and I am looking forward to engaging in respectful debate on the topic. Please add your perspective!  I don’t pretend to know the answers and freely admit I might be wrong.  Maybe we can come up with some ideas together to move our profession forward in these challenging times.

Jobs Applied: When Behind, Leapfrog

When Apple found itself behind, Steve Jobs would innovate his way out of the problem.  The best known example of this is finding that the original iMac, great for creatives and photo handling, wasn’t any good at music… it didn’t even have a CD burner!  Apple was getting trounced by PCs in this area.  Apple not only gained ground, but leaped ahead by creating iTunes and the iPod.  These products literally restructured the entire music industry for everyone but Garth Brooks and a few other holdouts.

Got a job girlLast week as I was pondering this week’s post I thought to myself … ‘Self, how are you going to turn this obviously tech related, innovative ‘leadership lesson’ into something that has utility in the private practice physical therapy world?  I was stumped.

Then I read a fascinating article in HBR by business strategy icon Michael Porter and Thomas Lee titled ‘The Strategy That Will Fix Health Care –  Providers must lead the way in making value the overarching goal.’  You can find the abstract here and I recommend buying the article.  Everybody in the the US healthcare chain should be forced to read it.

” At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost”

Here’s the gist: Providers (OK so he really means hospital systems and physicians) need to do 6 things all at once to fix America’s ailing healthcare system.

  1. Organize into Integrated Practice Units (IPUs).
  2. Measure outcomes and costs for every patient.
  3. Move to bundled payments for care cycles.
  4. Integrate care delivery across separate facilities.
  5. Expand excellent services across Geography.
  6. Build and enabling information technology platform.

What struck me when reading this is that we are already behind!  Dr. Porter did bring us up a few times as excellent examples of how we can save costs and how utilization of ancillary providers (like PTs and nurse practicioners) creates efficiency and cost savings.  For example, we are < 1/4 the cost of a physician visit and there is plenty of evidence to show we can save downstream costs.  As a profession, this single article may do more for us in terms of positioning us as a part of the solution than anything else I’ve seen to date.  However – it was always in the context of the PT in the medical center.


This model would create Integrated practice units, which PTs are certainly a part of and have a role in. IPUs are like a next generation Center of Excellence focused on being the best at one diagnosis or patient type.  These already exist – the example Dr. Porter uses is Virginia Mason Medical Center in Seattle – which focuses on treating low back pain.  After calling a single number, patients are scheduled to visit a PT and later that day a PM&R physician (just in case?).  If the patient needs anything other than PT then they can receive it right there in the same hospital.   In the IPU strategy the expected outcome is that IPUs become bright spots in care delivery for particular diagnoses.  Employers and health systems are then to be encouraged to send exclusively to them to handle the entire course of care… including rehabilitation.  So how then do they take care of the outpatient PT piece? Answer:  they ‘expand excellent services across geography’.  Ouch.

“Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow.”  (Porter and Lee)

So how do we leapfrog ahead of this (admittedly brilliant and needed) strategy to ensure that private practice physical therapists have a place in this New HealthCare World Order.  More to the point – how to we do that in whatever less well thought-out version we end up with?  Do we all have to go work for the hospital?  I think there are two ways we lead our organizations to get there:


First – measure outcomes.  Our company uses FOTO to measure functional outcomes on every patient.  This is the first step in participating in the new healthcare world.  We have to be able to achieve and demonstrate a high level of value for our patients and ‘what gets measured gets managed’ (Peter Drucker).  If we don’t measure it – how do we know how much value we are adding?  How can we improve?

Second, we have to be ahead of the need for efficiency.   We need to figure out the innovative care models that stretches the PT’s capacity to see more patients effectively in a day.  The days of 1 PT caring for 1 Patient for 1 hour are gone… to the same place that the family practice physician visiting your home went.

Where we will continue to have demand for our services is in our ability to be where our patients live, play and work.   People will go across town to see a specialist.  If they work for Wal-Mart and a few other enterprising companies they will travel, expenses paid, across the country to get a new hip.  However – what they can’t or won’t do is travel any real distance to attend physical therapy sessions.  IPUs will have to figure out how to provide high quality rehabilitation to remote patients.  That isn’t the clinics owned by physicians (POPTS) or hospitals (HOPTS) – that’s us.


IPUs face the challenge of trying to be good at all aspects of care delivery for a given condition. High quality physical therapy providers who measure outcomes and have some geographic spread away from the IPUs can leapfrog ahead by being ready to participate in these IPUs.  Perhaps we can participate as partners through hospital contracts or at minimum by being a provider of choice for the IPUs, who by definition care about outcomes enough to care about the value we provide.

What that means is that your practice will probably be judged in part on your therapist’s ability to communicate back to a coordinating physical therapist at the IPU.  Think this isn’t already happening?  We regularly see patients from the Andrews Institute in Florida (our practice is in Texas).  Why?  Because this high quality orthopedic practice, which receives patients mostly from domestic medical tourism, knows that we use their protocols and are open to discussing cases with the therapist that sees the patients on follow up.  Some good outcomes on initial cases have earned us preferred provider status and they typically call us about patients even before the patients call to schedule.

Steve Jobs was a master at innovation and leapfrogging over Apple’s competition.  We can do the same thing by focusing on what will be important in the New HealthCare World Order.  That is likely to be the best outcomes with the lowest cost.

Jobs Applied: Take Responsibility End to End


Apple has always taken full responsibility for the user’s experience.  This is in contrast to other companies such as Microsoft and Google that take a more open approach – allowing others to use the software with hardware created by others.  An open approach yields more variety in products, but maintaining control of the entire product – from hardware, to software to the sale of the product is what has created a differentiated and premium consumer experience.  Steve Job’s penchant for controlling everything can be reframed as taking responsibility for the entire customer experience.

In physical therapy, we can adopt the same approach.  We can take responsibility for every aspect of the patient’s interaction with us, from when they first dial a number to when we fondly ‘graduate’ them from therapy.  How can we get a handle on the massive number of interactions patients have with us?  Perhaps creating a customer interaction map can help us to identify each touchpoint where we interact with our patients.  What if instead of capturing our patient’s rating of their experience at just one point we could create a map of the key touch points to identify where we can improve?  This idea is written about extensively but not commonly utilized in healthcare.

touchpointsBecause healthcare is a service industry, invariably a great many of the touch-points our patient’s have with our companies will be with specific people rather than a call center, website or automated system. In chasing down this idea I came across a really nice HBR blog post here and I also noted that it is strikingly similar to the approach the Cleveland clinic used in a dramatic customer service turnaround described in this HBR article that anyone in the healthcare business should read.  When the Cleveland clinic decided to turn around their satisfaction ratings as reported to medicare they started by identifying every interaction that patient’s had with staff.  They learned that the physician accounted for less than 5% of the interactions during a patient stay.  This information cued the leader’s of the Cleveland clinic to focus attention on interactions that had not been previously thought to be vital.

Below is a list of interactions I made for our practice… the first step in mapping the key touch points.

Patient Interaction List

The next step would be identifying key points, and either looking at established metrics or creating new measurement methods to quantify our patient’s satisfaction at each point in their journey.  As an example, one of our practices identified that they had a larger than expected number of patients who did not complete their course of care.  The patients were returning after the initial visit, but approximately 15% would drop out by the 3rd visit.  They created a list of interactions similar to the one listed above and tracked how well they thought they were doing and how satisfied the patient was at each point in ‘the journey’.  The staff identified that patients were often not being greeted by the therapist until they had performed as much as half of their exercise intervention.  In the form of a test, the physical therapists resolved to greet the patient and discuss their status while they were warming up.  While difficult in the beginning, before long this habit became an established part of the clinic flow and the number of patients dropping from care in the first 3 visits dropped to a more typical 8%.


Obviously some of these interactions are more important than others, but the leadership lesson of ‘take responsibility from end to end’ is that we should pay attention to each of these interactions and always assume that we can take action to improve them.  When we can make each of these interactions as positive as possible for our patients, we will have created a differentiated experience that will be very hard to compete with.