OCTH 233: Professional Development Midterm

Critical thinking

Critical thinking processes are used to inerpret, analyze, infer, evaluate, explain, and self regulate what is going on in a situation

Core Critical Thinking Skills

Interpretation

Analysis

Evaluation

Inference

Explanation

Self-Regulation

Interpretation

- to comprehend and express the meaning or significance of a wide variety of experiences, situations, data, events, etc

- ex. "what does this mean?'

Analysis

- to identify the inferential relationships, statements, questions, experiences, information, and opinions

- ex. "why do you think that?"

Evaluation

- to assess the credibility of the statements that describe the person's perception, experience, situation, judgment, belief, or opinion

- ex. "how credible is that claim?"

Inference

- to identify and secure elements needed to draw reasonable conclusions

- ex. "what does this evidence imply?"

Explanation

- present in a cogent and coherent way the results of one's thinking and how they arrived at that judgement

- ex. "how did you come to that interpretation?"

Self-regulation

- apply the powers of critical thinking to oneself and improve on previous opinions

- ex. "how good is our evidence?"

Characteristics of critical thinkers

Clarity in stating the question

Orderliness in working with complexity

Diligence seeking relevant information

Reasonableness selecting/applying criteria

Care focusing attention on concerns

Persistence through difficulties

Precision to the degree permitted

Dispositions of critical thinkers

- Inquisitiveness

- Alertness

- Trust

- Self-confidence

- Open-mindedness

- Flexibility

- Understanding

- Fair-mindedness

- Honesty

- Prudence

-Willingness

System 1

- Renders quick, holistic associational judgements

- Automatic, well-trained, reactive

- Seeing the big picture, poor on the details

- Can block out or derive support from system 2

System 2

- Renders considered, deliberative judgements

- Reflective, reasoned, systematic

- Great on the details, poor on seeing the big picture

- Can bolster or override System 1

Aspects of Reasoning in OT

- Scientific

- Diagnostic

- Procedural

- Narrative

- Pragmatic

- Ethical

- Interactive

- Conditional

Cognitive heuristics

a thinking maneuver

Scientific reasoning

condition, theory, evidence, "typical" pathway

Scientific reasoning example

What theories and research are available to guide assessment and intervention?

Diagnostic reasoning

Blend of science and subjective client-based information

Diagnostic reasoning example

What are the occupational performance problems this client has or may have in the future?

Procedural reasoning

Therapy regimes based on science, habit or culuture of the practice setting

Procedural reasoning example

How are clients like this usually handled in my setting?

Narrative reasoning

Used to understand the client's situation based on their story and personal experience with the condition

Narrative reasoning example

What is this person's life story?

Pragmatic reasoning

Realities of services delivery: scheduling, payment, skills

Pragmatic reasoning example

Who referred this person and why? Who is paying for services?

Ethical reasoning

"right" action with competing principles, benefits

Ethical reasoning example

Are the benefits of therapy worth the cost? Are the risks of therapy worth the benefits?

Interactive reasoning

Used to form collaborative interpersonal relationships

Interactive reasoning example

How can I best relate to this person? How can I put them at ease?

Conditional reasoning

Blending of all forms for the purpose of responding to changing conditions or predicting ct.'s possible future

conditional reasoning example

Given these future possible trajectories, what is the best action I can take now for the ct.?

Novice

- No experience in situation of practice; dependent on theory to guide practice

- Uses rule-based procedural reasoning to guide actions; no recognition of contextual cues

- Narrative reasoning to establish social relationships

- Pragmatic reasoning is stressed

- Recognizes overt ethical issues

Advanced beginner (

- Enough experience to note recurring, meaningful situational components

- Principles, based on experience, begin to be formulated to guide actions

- Still has difficulty prioritizing what is most important and what can be left out

- Gaining skill in pragmatic and narrative reasoning

Competent (1-3 years)

- Developing a sense of mastery or confidence with a population, more organized, efficient

- More aware of long-term goals

- May lack speed and flexibility. Still has difficulty seeing the "big picture"

- Good with students - able to articulate theory and rationales

Proficient (3-5 years)

- Perceives and understands situations as whole parts

- More holistic understanding with improvement in decision-making

- Creatively combines different diagnostic and procedural approaches

- Learns from experiences what to expect in certain situations and how to modify plans

Expert (5-10 years)

- No longer relies on principles, rules, or guidelines to connect situations and determine actions

- Procedural and pragmatic reasoning more detailed

- Increasing background of experience

- Intuitive grasp of clinical situations

-Performance is fluid flexible, and highly-proficient

Professional Reasoning

Whole-body process

- Observation of occupational performance

- Context and environment

- Client factors

Goal-orienting thinking

Client-focused thinking

Cognitive process

Professional Reasoning pt 2

- Didatic learning

- Theoretical knowledge

- Experience

- Inquisitiveness

- Empathy

- Insight/reflection

Watch for conditions

Look for the moment a conversation turns crucial, Signs that people do not feel safe (silence or violence), Your own Style Under Stress

Learn to Spot Crucial Conversations

Physical signals - their stomach gets tight or their eyes get dry

Emotional signals - Scared, hurt, or angry, and are beginning to react to or suppress these feelings

Behavioral signals - raising their voice, pointing their finger, or being quiet

Learn to Look for Safety Problems

"When it is safe, you can say anything".

"When it's unsafe, you start to go blind"

"Don't let safety problems lead you astray"

Silence and Violence

As people begin to feel unsafe, they either are silent or choose violence

Silence

Masking, avoiding, and withdrawing

Masking

Consists of understating or selectively showing our true opinions. Sarcasm, sugarcoating, and couching are some of the forms

Avoiding

Involves steering completely away from sensitive subjects

Withdrawing

Pulling out of a conversation altogether

Violence

Controlling

Labeling

Attacking

Controlling

Coercing others to your way of thinking (gaslighting)

Labeling

Putting a label on people or ideas so we can dismiss them under a general stereotype or category

Attacking

Belittling and threatening

Learn to Look

Learn to look at content and conditions

Look for when things become crucial

Learn to watch for safety problems

Look to see if others are moving toward silence or violence

Look for outbreaks of your Style Under Stress

Retrace your path

- Notice your behavior. If you find yourself moving away from dialogue, ask yourself what you're really doing

- Get in touch with your feelings. Learn to accurately identify the emotions behind your story

- Analyze your stories. Question your conclusions and look for other possible explanations behind your story

- Get back to the facts. Abandon your aboslute certainty by distinguishing between hard facts and your invented story

- Watch for clever stories.

State my path

- Share your facts. Start with the least controversial, most persuasive elements from your Path to Action.

- Tell your story. Explain what you're beginning to conclude.

- Ask for others' paths. Encourage others to share both their facts and their stories.

- Talk tentatively. State your story as a story-don't disguise it as a fact.

- Encourage testing. Make it safe for others to express differing or even opposing views.

Supervision

the control and direction of the work of one or more employees in a manner that promotes improved performance and a higher quality outcome

Role and function of supervision

Administrative, educational, and support functions

Administrative functions

- Plan and assign workload

- Make schedules

- Set priorities for department's work activities

- Check performance against work standards

- Interpret policies and procedures

- Delegate work

- Provide written and verbal reports to managers

Educational function

- Orient new staff

- Identify training needs

- Develop and provide training programs

- Identify and provide educational resources

- Assess performance and provide feedback

- Discipline

Supportive Function

- Hold group meetings to allow for expression of concerns

- Meet individually with surpervisee on a quarterly basis to check on progress toward work goals

- Provide informal and formal support for performance

Informal Supervision: Peer Supervision

- Oversight provided by another professional who has no formal authority to provide supervision

- Provides feedback and shares knowledge with the intent of influencing the peer professional's practice to improve client outcomes

Mentoring

- Personal and professional growth of the mentee

- Discussions between the mentor and mentee center on career options and decisions, identification of personal and professional growth needs and resources, and feedback about the mentee's behaviors and choices

Supervisory Process: Ongoing Process

- Overseeing of work is an ongoing process

- Supervisor formally and informally observes and checks on the work of supervisees by talking to them about their work as well as observing them on a regular basis

Supervisory Process: Orderly process

- Establishes a process in which the supervisee understands when regular contacts and meetings will occur

- Clear about performance expectations and consistent in providing feedback

Supervisory Process: Dynamic

- Changes as people grow and work demands shift

- A supervisor might observe an employee daily and meet weekly, after several weeks, the employee might practice more independently without daily observation

Supervisory Process: Interactive

- Exchange or communication between the supervisor and the supervisee

- AOTA "cooperative process in which two or more people participate in a joint effort to establish, maintain, and/or elevate a level of competence and performance"

Functions of the manager

Planning

Organizing

Coordinating

Controlling

Managers must be able to

Manage people

Plan effectively

Control resources

Organize time

Skill sets of the OT manager

- Accountability

- Aligning goals with the mission statement

- Allocation of resources

- Performance assessments

- Conflict resolution

- Fiscal planning

- Policy management

- Progressive disciplinary action

- Staff development

- Strategic planning

Effective managers

- Need to be able to make time and informed decisions based on the best available evidence

- Accomplish goals through collaboration

- Capacity to build trust, maintain integrity, and achieve results

Overlapping skills - OT/managers

- Set goals

- Manage time

- Oversee assistant

- Make important clinical decisions

- Control outcomes

- Collaborate with other disciplines

- Attending meetings

Strategies to Motivate Others

- Achievement: setting realistic target goals

- Recognition

- The work itself -> should be challenging and interesting

- Responsibility

- Advancement

Middle Manager

- An employee of an organization or business who manages at least one subordinate level of workers, and reports to a higher level of managers within the organization

- Duties of a middle manager typically include carrying out the strategic directives of upper-level managers at the operational level and supervising subordinate employees to ensure smooth functioning of the enterprise

Roles of the Middle Manager

- Planner, strategic planner

- Negotiator

- Coordinator

- Problem solver

- Leader

Which personnel do OT's Supervise?

- Fellow OT's

- OTA's

- OT limited permit holder

- OT aides

- OT and OTA FW students

- OT volunteers

- Other personnel

OT supervision

- A process aimed at ensuring the safe and effective delivery of OT services and fostering professional competence development

OT

- After initial certification and state licensure, they are autonomous practitioners who can deliver OT services independently

- Responsible for all aspects of OT service delivery

- Accountable for the safety and effectiveness of OT services and service delivery process

- Peer supervision and mentoring

OT/OTA partnership: OT

OT: master's or doctor entry-level degree responsible for client evaluation

- Responsible for overall service and provision

- Can carry out all facets of service provision

- Can be an advocate, supervisor, and leader

OT/OTA partnership: OTA

OTA: Technical level education, Associate of Arts/Science degree. May assist with evaluation

- Primary role in workplace is service provision

- Can also be an advocate, supervisor, and leader

Supervision of OTA

- Must receive supervision from an OT to deliver OT services

- OT is responsible for the implementation of appropriate supervision of the OTA

OTA supervision

- Frequency, methods, and content depends on complexity of the client's needs

- Number and diversity of clients

- Knowledge and skill level of TO and OTA

- Type of practice setting

- Expectations and requirements of the work setting

- External regulatory or legislative agencies

Methods of OTA supervision

- Direct, face to face: Observation, modeling, client demonstration, discussion, teaching, and instruction

- Indirect: Phone conversations, written correspondence, and electronic exchanges

Service competency

- Process in which the OT determines that the OTA performs tasks in the same way and achieves the same outcomes that the OT would

CBOT: OTA Supervision

-The supervising occupational therapist shall at all times be responsible for all occupational therapy services provided by an occupational therapy assistant, a limited permit holder, a student or an aide. The supervising occupational therapist has continuing responsibility to follow the progress of each client, provide direct care to the client, and assure that the occupational therapy assistant, limited permit holder, student or aide do not function autonomously.

Responsibilities of the OT in OTA Supervision in California

- As part of the responsible occupational therapist's appropriate supervision, he or she (they) shall conduct at least weekly review and inspection of all aspects of occupational therapy services by the occupational therapy assistant.

- Assure that the occupational therapy assistant DOES NOT function autonomously.

- Documentation of the supervision.

- Readily available in person or by telecommunication to the occupational therapy assistant at all times while the occupational therapy assistant is providing occupational therapy services

Responsibilities (Continued)

- Periodic on-site supervision and observation of client care rendered by the occupational therapy assistant.

- The supervising occupational therapist shall determine the occupational therapy treatments the occupational therapy assistant may perform.

- The level of supervision is determined by the supervising OT- ensuring the amount, degree, and pattern of supervision are consistent with the knowledge, skill and ability of the OTA or personnel.

How many OTA can an OT supervise in California

3

Supervision of OT aides

- OT aides are personnel with no formalized education in OT that provide supportive services to OT practitioners

- Can perform non-client-related tasks such as clerical work, clinical maintenance tasks, preparation of work areas and equipment, and transport of patients/client

- Select client-related tasks that are routine and supervised by an OT or OTA (non-billable)

Supervisory Process

Orderly: supervisory contat and expectations are clear to the supervisee

Dynamic: process changes as people grow and work

Interactive: Collaboration, with both supervisor and supervisee actively contributing

Developing a Supervisory Relationship

- Built on trust and integrity

- Supervisor must be clear about expectations and provide regular, objective feedback about performance

- To facilitate a positive supervisory relationship: learn about the supervisee

- Be clear about job expectations

- Develop and implement a supervisory plan

- Document

Fee for Service (FFS)

- traditional

- hospital or Drs/providers are paid a separate fee for what they provided (tx, lab, visit, etc)

Per diem

• a fixed daily rate paid to hospital for each day a pt stays regardless of how many individual services the pt receives 

• Common in: SNFs, rehab, inpatient

Prospective Payment System (PPS)

Payment established before services

• part of Medicare/Medicaid

Diagnostic Related Groups (DRG)

Fixed fee based on diagnosis, give information about illness pre-set rate they allow

Patient-Driven Payment Model (PDPM)

- Medicare Part A: used for patients in SNF

- Value based

- Facility is paid based on the patient's needs and characteristics

- OT payment based on the primary reason for SNF care and functional status

Patient-Driven Grouping Model (PDGM)

the Medicare payment system for home health that uses a case-mix classification based on a service recipient's clinically relevant characteristics

Preferred Provider Organization (PPO)

• network flexibility

• does not require Primary Care Physician (PCP)

• no referrals for specialties

Health Maintenance Organization (HMO)

• in-network only

• requires PCP

• referrals needed for specialty care

Medicare Risk

essentially Medicare Part C (Medicare Advantage)

• contains both Medicare Part A&B

government funded

• pay private provider a monthly fixed rate per member

Managed Medicaid

• government and state funded

• pay managed care organizations (MCOs) rather than providers a monthly fixed rate per member

Medicare eligibility

- 65 or older

- Under 65 with certain conditions

- Disabled for 2+ years

- All ages with end-stage renal disease and ALS

Medicare rules for therapy coverage

- Qualifying medical conditions and complexities

- Skilled service (maintenance is not a skilled service)

- Reasonable and medically necessary

Medicare Part A

- Hospital insurance

- Covers inpatient stays

- No monthly cost to most beneficiaries/member

- Covers inpatient hospital costs, SNF [not custodial care (private, medicaid) or LTC]