Over the last month several members of the Rehabilitation Services Department raised concerns about having to work off the clock, being asked to clock out during their shift if not seeing a patient and feeling pressured to clock out during their shifts in order to keep their productivity ratios high. Additionally, legal and ethical concerns were raised over management suggested billing practices in order to improve productivity metrics.
We interviewed members over a period of about two weeks.
“We are asked to clock out if patients cancel, but patients don’t get charged if they don’t cancel in a timely manner. The assumption is that if a patient cancels we should clock out. But we have work to do other than give treatments to patients. We are left with the choice of working off the clock or clocking out; otherwise our productivity stats suffer.”
“They don’t do shift curtailment per contract, they just curtail based on whether or not individual patients cancel.”
“Employees do charting on lunch, about 90% chart on lunch breaks to get our charts done. If a patient calls in the night before we get told to come in late. I get here early to do chart reviews before my shift starts [without pay]. It’s the only way to keep productivity up.”
“If you don’t keep your productivity numbers up you get denied the opportunity for continuing education, you get emails and phones calls.”
“It’s easier to work off the clock than deal with all that.”
One former member spoke with us shortly after she left OHSU to work at a competing health care facility. They state that:
“75% of therapists chart through their break and lunch.”
“You can go into the break room and see people eating and charting at the same time. Managers see it and they know it’s going on but they don’t say anything to discourage it.”
“If you mention working off the clock in an email they will tell you not to because they know it’s wrong, but they set up conditions so that the only way you can meet productivity is to work off the clock for many people.”
“Productivity is impacted by things therapists have absolutely no control over. They feel that they have to make their units this week so they have to work through lunch to make units.”
Members told us if therapists take paid time to chart, they will not have enough units billed in relation to hours worked to make their productivity standards. Several members also said that consideration is not given that some patient cases require more charting than others, especially evaluations. There is pressure to make productivity even if it means working off the clock.
“Employees are denied the right to get time to do continuing education if they don’t maintain productivity for three months in a row, which creates more pressure to work off the clock.”
“My patient had arrived late but had been told they would get a full treatment. The patient eventually arrived but I didn’t know it so some time had passed. I had told the patient that I would see him for the full treatment and therefore I ran late. [My manager] said I should have been going out to check every five minutes to see if the patient was already there. This discounts the fact that I have lots of other work to do – not just charting, but for complex patients there are other resources and staff that must be engaged in a treatment plan, all that takes time, but it’s time that many therapists put in before their shift starts or after it ends, off the clock.”
This member once asked coworkers how they get their charting done and many of them said that they get here an hour early and open all their charts.
“I definitely stayed late working off the clock frequently.” “They would send emails saying you aren’t supposed to work off the clock, but managers would see people on computers charting well before shift, but would never question whether they were on the clock when they obviously weren’t but, if I mentioned in an email that I was working off the clock, they would tell me I should be on the clock for that. They only seemed to care if there was documentation.”
“Some people were billing three units when they should have been billing one, maybe two. I would only bill them one unit. If I only saw them for fifteen minutes I’m not going to bill for three units.”
“I can’t chart while I am in the room because the patient can’t move, I can’t chart and move them at the same time – [Supervisor] said “maybe you should be billing more units if you are taking more time to document.”
“[Supervisor] is the one who encouraged me to bill more units than I felt comfortable with in the ALS clinic. When she took on this job she knew she was going to do ALS clinic, she shadowed a couple of days, and there were times when I wasn’t making productivity because I stayed clocked in to chart.”
[Supervisor] told the member they could bill units for doing charting but the member contacted the licensing board. The board told the member to contact coding compliance and the member found out that type of billing would have been illegal. The member advised the supervisor but the supervisor never advised the rest of the staff that the practice of billing for charting was inappropriate.
One member was told their time was valuable and that they should bill for it. The member’s response was “if my time is valuable you should pay me for it.” The member would work off the clock at the beginning or end or end of shift but refused to clock out for no shows during the day. “I told [Supervisor] I was not going to clock out in the middle of the shift. The supervisor would make a lot of suggestions about things I could do when I was clocked out like go for a run or do errands.”
“I once billed 45 minutes of OT [the manager] told me to “correct this” or give him an explanation.”
A few days after our initial interview we had an opportunity for a follow up interview with our former member.
“Multiple times when I got messages from supervisors, I’ve been told you should clock out because you have two no shows. You should come in late in the morning if patient cancels”
“It’s not fair to make us clock out to keep our per hour productivity up.”
“The only way therapists have control over productivity is if they clock out when they are not seeing a patient. The effect is that they can’t meet standards unless they are willing to clock out every minute they are not seeing a patient and charting. They have no control over scheduling yet they lose money and opportunity due to scheduling.”
When one member finally got her full time FTE her supervisor told her to develop hand therapy skills. The member said “Sure, when are you going to block time for me to learn?” The manager said “you can come in and shadow on your time off, that’s what previous staff did, they came in early and on their day off to shadow and learn” This member was able to give us the name of at least one other therapist who trained during her time off.
Several other members also had information to share:
“I’ve been told by my supervisors that you need to tell therapists to clock out if they are waiting for a patient.”
“They gave me 45 minutes to prepare for a one hour academic presentation.” When this member said you can’t prepare a one hour presentation in 45 minutes, she was told that she “could do it on her own time.”
They told me that they “need to be billing for all the time you spend in clinic whether you are seeing someone or not.”
“If I work overtime they cancel patients the next day so as not to go over 40 hours per week. Which means some patients aren’t getting seen.”
Fear of Retaliation
We asked one member about working off the clock, clocking out for missed appointments, why people do that, and why more don’t express their concerns over these issues.
She felt that many employees were afraid of retaliation. We asked her what forms perceived retaliation would look like. Her answer:
“Some other examples of why individuals worry about speaking up:
- Concerned they will not be allowed to change their schedule to desired shift
- Concerned they will be paged or asked into a meeting where they are confronted
- Opportunities for continuing education, program development, leadership roles will not be offered to them
- Removal from leadership and differential paying roles such as Team Lead
- Concerned they will be assigned to work that is not their preferred work area
- Concerned they will not be granted exceptions for vacation or schedule conflicts or needs.”
- Concerned they will be more closely scrutinized for missteps, errors, productivity and then put on a work plan”
OHSU management should:
- Endorse legal and ethical billing practices
- Follow labor law and contract provisions for scheduling of work and curtailment
- Stop perpetuating a culture of fear and retaliation
- Value all of an employee’s contribution and work by creating systems and environments that pay employees for all of the time to complete the job, not just the billable time.
- Institute productivity measures that encourage the production of completed staff work and which do not pressure employees to work off the clock to meet standards.
Next article: Staffing and Quality of Care.