1. Comoss, Pat BS, RN, FAACVPR

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Excellence as defined by Webster is the fact or condition of being superior, of surpassing others.1(p435) It is an elusive quality, constantly being sought after, always just out of reach. As we each strive to get closer to our own personal and professional vision of excellence, the wise among us come to realize that the work of getting there is the essence of what excellence is all about. It is about the doing-the actions we take along the way, not the awards we end up with. It is about what we can give, not what we can get. A philosophy of excellence is imperative not only for success in today's healthcare environment but also for survival in cardiac and pulmonary rehabilitation settings specifically.



In recent years, cardiac and pulmonary rehabilitation programs have come under intense external scrutiny from government regulators whose duty is to search out fraud and abuse and increased internal pressure from business-minded administrators whose focus is the organization's bottom line. These combined expectations have created a high-pressure work environment that translates to job stress for many rehabilitation workers. Chronic job stress gives rise to daily struggles to do even the simplest tasks well. If continued too long, that mode of operation sacrifices the ability of workers to think clearly, to focus on priorities, to solve problems efficiently in the short term, or plan ahead effectively for the long run.


Some rehabilitation professionals think they or their programs are alone in experiencing this stress and struggle cycle. Others blame their personal shortcomings or their hospital's indifference for the discomfort they feel. Those of us who have had the opportunity to see many programs in action know differently. The symptoms are widespread. They are evident in programs of all sizes and seen in all parts of the country. If you are feeling them, you are not alone!! And clearly, some symptom relief is indicated.


The purpose of this discussion is to suggest a remedy that will not only relieve the symptoms of distress but also begin to heal the underlying cause that I believe is a sense of professional helplessness. The suggested remedy is illustrated through the use of frequently asked questions (FAQs) in 4 strategic areas of program operations (see Figure 1). Some of these questions you have heard before. The fact that they are still being asked confirms their symptomatic nature. Some of the answers you may not agree with. That is acceptable because there are no right or wrong answers-just different points of view. While most of what we do in rehabilitation is built on scientific fact or clear technical guidelines, the discussion here is not so absolute. The questions asked are about bigger, broader concerns that signal the state of our collective professional psyche. Consider each question in the context of your own program and each answer as an ingredient of the potential remedy.

Figure 1 - Click to enlarge in new windowFigure 1. Types of frequently asked questions.


My vice president keeps hinting that our program may be in jeopardy because we barely break even. Do other programs in midsized community hospitals actually make money to justify their existence?


Answer # 1

What you should know

Some programs make money, usually through additional services, for example, stress testing, maintenance programs, exercise programs for self-pay populations, etc, but not typically just from the operation of a phase II monitored cardiac rehabilitation program. Most phase II programs strive to be a break-even operation or at least to cover direct expenses, the bulk of which is staff salaries.


Does this mean that you should start adding on services to what you already do? Not necessarily. To do so without a clear plan as to what/why additional services might be needed may doom a new service to failure and make the department look even worse. Therefore, before going down the add-on path, revisit the question being asked. Perhaps you are hearing the wrong question. Is the concern really about the dollars your program brings in or is it about the value your program puts out for your facility. If it is not about value first, it should be. That does not diminish the need to manage the program in a fiscally responsible way that aims to increase revenue and decreases expense-that should be standard operating procedure for every manager of a rehabilitation program. It does suggest 2 purposeful actions on your part.


What you should do


1. Articulate the overall value of your program up the chain of command by emphasizing its nonmonetary assets such as those listed in Table 1. Many rehabilitation programs are supported and appreciated for contributing such assets to the bigger organizational picture.


2. Expand the visibility of your program in the hospital and in the community-get yourself noticed!! Not just through the occasional health fair participation, but also through more dynamic media exposure. For example, volunteer to do a question/answer panel on your local television or radio station during Cardiac/Pulmonary Rehab Week. Activities that keep the name and/or image of your program in front of the public further build perceived value. When was the last time your staff or your patients were featured in the local newspaper or seen on the most-watched television station in your community? If you cannot remember, now is the time to seek some fresh publicity. Being visible can mean being viable.



Getting our physicians to send patients to rehabilitation can be a major challenge. When we ask, they refer. Otherwise, they seem to forget us. How can we get our physicians to refer more routinely?


Answer # 2

What you should know

Most physicians are not anti-rehabilitation. As many have told me recently, they are just pre-occupied with other priorities in their own practice. Some of them are struggling to survive, too. Given that insight, perhaps you are asking the wrong question. Rather than struggling with how to get them to change, ask how you and your staff can help with patient recruitment. Take the active role!!


What you should do


1. Find ways to do the referral work for your physicians, to make patient enrollment easier for them. Several suggestions are outlined in Table 2.


2. More active recruitment does not change the need for physician involvement in your program. Obviously, referral orders, exercise prescriptions, etc, are still required medico-legally. It just shifts the burden of who initiates the process and generates the paperwork involved. Yes, it may be more work for the cardiac or pulmonary rehabilitation staff. But if more work equals more patients enrolled in rehabilitation, it is clearly worth the effort. Program stability and job security may depend on your recruitment activities.


3. Keep current and potential referring physicians informed of the latest research developments pertinent to cardiac or pulmonary rehabilitation. Physicians practice evidence-based medicine. Show them the evidence!! It is especially helpful to share research results that are hot-off-the-press. For example, the recent report from Mayo Clinic by Witt, Jacobsen, Weston, et al, published in the Journal of the American College of Cardiology (JACC) expanded the evidence base on the benefits of cardiac rehabilitation participation and emphasized that this valuable service remains underutilized.2 When your message about the positive outcomes of your own program can be backed up by such credible research, it is a persuasive combination. Did you discuss/distribute this important paper with current and potential referring physicians in your area? If not, there is still time to do so.



So much of what we do prevents short-term complications and long-term recurrence. Why will Medicare not pay for that prevention in all cardiac and pulmonary patients?


With managed care, an increasing number of patients cannot afford to participate in rehabilitation because of higher copays. Why will the hospital not just accept insurance and forget the balance of the patient's bill?


Answer # 3

What you should know

The short answer to both questions is they cannot!! By federal law, Medicare is authorized to pay only for "the care and treatment of an illness or injury."3 While government rhetoric about the need for prevention has increased under the leadership of Mark McClellan, current Administrator for the Centers for Medicare/ Medicaid Services (CMS), the only preventive services that are currently covered are those few for which special legislation has been enacted, for example, diabetic education.


Regarding managed care organizations (MCOs), the hospital and each MCO negotiate a contract for what services will be covered and how much the company will pay for each. The terms of most contracts require the hospital to collect the copay amount from the patient. Not to do so would jeopardize being paid at all for rehabilitation services and would risk losing coverage from that company altogether due to breech of contract.


What you should do

Three actions on your part can help solve the multiple problems inherent in these coverage questions.


1. Education: Help explain the terms and limits of insurance plans to patients. For those covered by a managed care plan, encourage them to discuss their questions/concerns about coverage with their employer's benefits manager. Unless a company knows that its employees are confused or dissatisfied with the health plan provided, nothing will change.


2. Participation: Become politically active. Participation in the political process is essential to impact laws and regulations governing reimbursement. That does not necessarily mean that you need to personally march on Washington to have input into Medicare discussions. It does mean that at the very least you should belong to both your state cardiac and pulmonary rehabilitation society and your national association, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). These organizations provide a voice for your concerns. Your active involvement informs them of priority issues that need to be addressed on your behalf. Your membership fee provides them with the financial resources to work on legislative initiatives and to be in a position to move them forward when an appropriate political window of opportunity opens.


3. Innovation: Look for ways to redesign operations or reorganize services. For example, repackaging selected rehabilitation services in a way that may make them affordable on a self-pay basis may be an option. Keep in mind that it is illegal to charge different fees to different patients for the same service (price discrimination). However, a distinct service for a well-defined purpose in a medically appropriate group of patients can be developed and marketed with its own price tag.




I have heard that patients in other programs are quite independent. They hook up their own telemetry, record their own exercise responses, and even do "homework." How is that possible? My patients expect to be waited on. They could/would never do any of that!!


Answer # 4

What you should know

From program to program, cardiac and pulmonary rehabilitation patients are more alike than not. They will usually strive to meet program expectations, especially when they see their peers doing so. Resistance to change is more often a staff issue than a patient problem. When long-time staff has been used to doing things in a certain way, they prefer to stay within that comfort zone.


What you should do


1. Set a goal of more interactive rehabilitative care. Discuss the need for change openly with the staff and allow them to vent their fears and frustrations, but make it clear that things need to move toward the goal.


2. Form a transition team. Charge this group with the task of developing a plan to map out the steps needed to get from the old behavior (staff and patient) to the new. Consider including a recent rehabilitation graduate on the team to provide the patient's perspective.


3. Allow for exceptions. Acknowledge that there will always be a few patients who truly are not capable of independent functioning. They will continue to need (and get) more hands-on assistance. However, emphasize that most participants can be expected to gradually take charge of their own exercise session with staff guidance and supervision.


4. Encourage staff to think and act more like coaches. Their job is to prepare patients to self-monitor and self-manage their own exercise routine, not to continue to do it for them indefinitely.



Like our colleagues in other healthcare venues, cardiac and pulmonary rehabilitation professionals have experienced increased pressure to perform and produce from sources both within and outside of their own healthcare system. The frustration resulting from this ubiquitous job stress is reflected in the FAQs presented here. The corresponding answers offer a self-remedy-one that each of us can make and take on our own to start feeling better.


It is time for us to STOP whining and waiting for others to solve our basic problems. It is time for us to START stepping up and speaking out on our own behalf. Remember that the word "answer" is not only a noun but also a verb. Webster defines the verb answer to mean1(p51)


* To reply in words or by action


* To act in response to


* To make oneself responsible or accountable



Thus, to "answer" is to do something-even simple action steps such as those suggested here can add up to potent results. Whether your questions involve program administrators, physicians, payers, or patients, the answers begin with YOU, not them. Taking positive, productive action that demonstrates your professional vitality and your program's value is the key to survival and success.


Excellence is about work to be done. Answers are about action to be taken. Take action!! Achieve excellence!!!!




1. Merriam-Webster's Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2004. [Context Link]


2. Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004;44(5):988-996. [Context Link]


3. Torras H. Examples of fraud and abuse. In: Health Care Fraud and Abuse: A Physician's Guide to Compliance. 2nd ed. Chicago: American Medical Association Press; 2003:33-57. [Context Link]