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I’m Theresa Richard. I’ve been a medical speech pathologist for 15+ years, I’m a Board Certified Specialist in Swallowing and Swallowing Disorders, and I’m incredibly passionate about evidence-based practice and equally considering patient preferences with clinical experience and research.

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Why You Need a Supporting Cast (The Step-by-Step Guide to Advocating for Access to Instrumentation Part 2)

by | Jul 18, 2017 | The Step-by-Step Guide to Advocating for Access to Instrumentation

This looks way too long, just let me download the FREE 12 page “Guide to Advocating for Instrumentals”



Check out Part 1 of this series, “You just don’t have X-ray vision” first!

Everyday you go on to Facebook and you read the same ‘ol soul-sucking posts, “My admin won’t let me do…”

I’ve always beat to a different drummer, and it’s never been a quiet one. When someone tells me no, I ask them why not. When someone tells me no again, I tell them I’ll be right back. I’ve walked in to quite a few administrators’ offices with stacks of research articles as high as the Tower of Pisa to prove my point.

The point is, they don’t know what they don’t know, until they know that they didn’t know it… because you told them.

Sure, you didn’t go to grad school to learn to defend your profession to every colleague you have, but you DID go to grad school to advocate for your patients and the best practices that they deserve.

“So Shy Sherry is walking down the hall way, “Ooooh I really think Larry might need a swallow study, his family will NOT leave me alone about getting him off of those thickened liquids.”

“Excuse me Mr. Spendnomoney? I would like to um maybe um ask you if maybe um that we could send Larry out to the hospital for one of those swallow tests?”

“Well Shy Sherry, why do you think he needs one of those? He’s been on honey thick liquids for years, and he just came back from the hospital on honey thick, if they thought he could be upgraded, they would have done the test while he was there.”

“Well yeah but they must not have had time to do it at the hospital and his family keeps calling and asking if I can take him off that stuff and I keep reading on Facebook that I really should get one of those tests done first.”

“Ok well I don’t think we need to be spending the money on that, you went to grad school to learn to do this, use your best judgement.”

“Ok sounds good, thanks Mr. Spendnomoney.”

Alright Shy Sherry, congratulations you waltzed down the hall and asked your administrator! But did you present any type of evidence as to WHY it’s critical to have the VFSS done? Did you CONFIDENTLY state why it was necessary to bring in the mobile FEES company? Did you bring supporting research articles with you? Did you have a conversation with your DOR ahead of time explaining why this is best practice and really isn’t up for negotiation? And when he accepted Larry as a Part A back in to this building he accepted that he is responsible for paying for all necessary appropriate diagnostic testing? No, you didn’t do any of that.

That’s right, now you’re stuck with a classic case of myadminwontletme syndrome.

I think there are 2 very valid sides to this argument. One being that yes, the administrator said no. The other being that you didn’t really do a darn thing about it. From his point of view, this VFSS at the hospital costs him approximately $1500. Why would he spend that, when in his mind, you went to school to learn this stuff? He isn’t a mind reader, and he’s just doing his job of keeping costs down. And you haven’t done your job of collecting all of the research and actually running some numbers to prove to him that by spending a little bit now, you can potentially save the facility 10s of 1000s of dollars down the road. (Yes I’ll get to how that all works.)

There comes a point where you have to pull up your big girl (or boy) pants and take a stand. You can’t just have 1 conversation, be told no, and turn back around with your tail between your legs and vent on Facebook that you caught a case of myadminwontletme. By not advocating for our profession, we’re just shooting ourselves in the foot. All of the researchers that spend day in and day out pouring their heart and soul in to their work should just pack it in because it’s all for naught, because you don’t have the cajones to relay what they’ve uncovered to your boss.

A common statistic in business is that it usually takes 5 correspondences within 1 month before a key decision maker will even CONSIDER something. Mr. Spendnomoney’s got so many things going on from corporate breathing down his throat, to the Department of Health’s upcoming survey, to dealing with the Ombudsman that was called, and a new case of C-diff that’s spreading like wildfire down the A hallway. So when Shy Sherry waltzes in to his office and stumbles over her words and asks for a test that costs $1500 with no reasoning whatsoever to support it, what do you think his answer is going to be? Good, now go back to your office, collect some research, get yourself together, because you’ve got at least 4 more meetings this month before Mr. Spendnomoney starts listening.

The fact of the matter is that we as speech-language pathologists suck at showing just how smart we are. You busted your butt to get good grades in undergrad then wanted to tie someones shoelaces together in grad school if they got a better grade than you. Then you get out in to the field, ride the therapy hamster wheel, collect your check, go home, drown your sorrows in wine, and vent it all out on Facebook. You don’t have access to instrumentation in your facility and when you ask your rehab director you hear NO one time, put your tail between your legs, and go back to riding the therapy hamster wheel. Please let’s get you some cheese for your w(h)ine.

Well, do you know why you were told no? Easy! Because you haven’t earned it! You haven’t earned the respect of your colleagues to take you seriously enough for them to carve out time in their day to meet with you. You tell them there is a great mobile swallow study service that they may want to consider, but no they aren’t going to take a meeting with them because they have no clue why it’s necessary, how it works, or how it can be cost effective. And you haven’t done the research yourself to answer those questions ahead of time. Some of the buildings I am at the most, have highly intelligent speech-language pathologists that are WELL RESPECTED at their buildings, and are excellent COMMUNICATORS. You actually have a degree in communication disorders and you have no idea how to communicate!

Think of the last time your DOR asked you to give an update on a resident. Did you say “well she’s tolerating nectar think liquids so we can discharge her at the end of the week,” while sucking your thumb? Or did you say “Well due to the R CVA we’re seeing some cranial nerve damage to blah affecting blah muscles, we’re working on the Shaker, Mendleson, CTAR doing some Estim and she is now able to blah blah.. I’d really like to get an instrumental and confirm that our treatments are improving the underlying physiologies. Once we’ve confirmed that we can possibly upgrade her back to thin liquids which is my ultimate goal since she did present with a UTI in the hospital as well, and we really don’t want to risk another re-hospitalization.”

Which SLP do you think is going to get the swallow study? The one that has a clue what she’s doing? Or Blind Barbara that thinks nectar thick is the fountain of youth.

If you sit in the dining room and act as a glorified CNA just feeding your patient, or worse – sit back and watch the CNA feed your patient while you threaten the patient and their family that they must comply with your orders of thickened liquids because you said so, then it’s not a surprise that you lack respect.

Are you sitting around your nursing home every day watching the same people eat, making sure they “tolerate” their diet, thickening all the liquids, pureeing all the foods, and not trying one single new evidence based treatment strategy that’s not (gasp) done in the dining room? Step away from the dining room friends. It all comes down to respect. If your co-workers, DOR, and administrator respect you and you’re providing evidence based treatments then they will support you when you ask for the appropriate diagnostic imaging.

I know this may sound harsh and you may think I’m completely off my rocker here, but the reality is that this happens ALL THE TIME. So maybe you aren’t nearly as crappy as Shy Sherry or Blind Barbara, but you still can’t seem to make some headway with your admin. What in the heck can you do?

Have you sat down with your administrator? Have you asked Mr. Spendnomoney if you could have 10 minutes of his time? And not just waste his time, but provide the facts, research, and cost savings? Offered to have lunch with him? As much as you want to just go in see your 10 patients and clock out, this is a helping profession which means helping out your colleagues to understand what you need to do your job and why.

Let me just clarify something here as well, if you work for a rehab company that is SEPARATE from the skilled nursing facility, then sure you may want to get your DOR on board, however with the way the Consolidated Billing guidelines work through CMS (Centers for Medicare & Medicaid Services), the FACILITY is responsible for the swallow studies. So although your DOR is your direct boss, the cost does not affect your rehab company, it affects the SNF. That’s why you want to really start to build relationships within the facility, the DON, the Business Office, the administrator because those are the ones whose pockets are affected, not your rehab company’s.

So in the next post, I am going to really dive in to the statistics and cost savings that having access to swallow studies can have, but today, I just want you to get comfortable speaking with your colleagues. Maybe you don’t have the best relationship with your DOR, but you and the DON compare daily notes on the best new latte at Starbucks. Ask her if she would like to grab a coffee during lunch someday! I’m sure if she’s the DON, then she has some sort of relationship with the administrator and will be able to tell you the best way to approach the subject. Sure, the administrator has the final say, but they most often rely on their support staff to yay or nay a decision.

Let me reiterate, you have a degree in communication disorders, you took a class on pragmatics and social language, but you did not take a course on relationship building and sales in business. But let me help you out with that.

Sure, some of us truly don’t know better and weren’t trained properly, but it’s time we started to change. I’m not expecting you to change all at once, I’m not an info vomiting-machine, I know we need solutions a little bit at a time, so we’ll start off slow here.

In business, you have to build relationships before you can even ask for the sale, so you really have to look at it that way. There are so many other people that work in your facility that may be able to help you convince the administrator that you need access to instrumentation.

Ok, so who are these other people in my building that I should get to know? Mr. Spendnomoney has the final say so why bother with these others cats? By building relationships within the building, building rapport, and educating your colleagues on the importance of instrumentation, when you finally land that meeting with the Mr. Spendnomoney, you will be so very well versed and very well supported by your peers, so when you *SELL* him on the idea of meeting with that mobile FEES/MBSS company, and he consults the DON, RD, and business office manager about their opinions, they immediately respond with a resounding “HELL YES” our residents deserve that! See how that works?

Here are some colleagues that you should invest some time in:

1. We’ll start with the most obvious – your DOR. Sure, you’ve asked him/her 97 times to send Larry out for a VFSS but to no avail. Does your DOR have any idea WHY it’s so important? Have you presented to him/her all of the evidence as to why you don’t have X-ray vision? Explain to your DOR that by knowing the underlying pathophysiologies of your patient’s swallow, you will be able to keep them on caseload and provide the necessary documentation and evidence based treatment strategies to support it, otherwise, you’re spinning your wheels, and your outcomes are going to be rather bleak. Again, if you work for a company that is contracted out by the facility, the decision is not in the DORs hands, but at least now they understand why you won’t just let it go.

2. Speak to your DOR’s boss. There’s strength in numbers. Don’t corral all of the SLPs and gang up on your DOR, but if you can get all of the SLPs in your region on board, and present it to your DOR and his/her boss, that’s one more key decision maker on your team when you bring your case to administration. Some administrators will immediately consult with the owner or VP of the therapy company, so it is in your best interest to have all of your subordinates on board in your company before starting a rebellion within the facility.

3. Setup a meeting with your DON. The DON is actually one of the best, key decision makers that you can involve. She has to hear from the nurses about how Larry has difficulty taking his meds and the thickener breaks down the miralax every day. She hears from the CNAs, that there are way too many people on aspiration precautions, with compensatory strategies, and thickened liquids, that there is no way they can stay compliant with all of the demands. The DON is also the administrator AND the Medical Director’s right hand (wo)man. This is a great person to get on your side.

4. The Registered Dietician or dietary staff – An RD can be your BFF. They speak our language in thickened liquids land and they are one of the first ones to take the heat when Larry’s nectar thick is now pudding, and his pureed stew has gigantic chunks of beef in it. Their job might be the tiniest bit easier too in helping the residents maintain adequate nutrition and hydration if they know that Larry does need the thickened liquids per imaging and not just because you kinda sorta maybe think he might because he coughed 5 weeks ago.

5. The Billing Office Manager – This is probably not someone that you would consider to be able to help you do your job better, but think of their job. They pay the bills and make sure there’s money in the budget to support it. I have had many business office managers reach out to me because they heard that I have a service that can keep costs down. Yup! You heard right I do! This is another underdog that has the administrator’s ear and can help you from a cost effectiveness standpoint. (This is going to be covered in the next post, or you can download the guide at the top if you insist on needing this info right now.)

6. The Marketing Director – Say what?!? Why the heck would Charismatic Christopher care about what I need? You know why? Because he spends all of his time between the discharge coordinators at the hospital and reporting to the administrators as to why there are empty Medicare beds. I’ve had marketing directors reach out to me before and say that by being able to promote that they have access to dysphagia instrumentation, they’ve been able to recruit more acute patients to their facility. They’ve often had to turn down patients with PEG tubes that want aggressive rehab because they know that they may not be able to provide that service. Yup, keep building your team!

7. Nurse Practitioners or Physician Assistants – I don’t know why and I know this is a wild over-generalization, but at all of the facilities that I go to, I have a great relationship with the NPs. For some reason they are very approachable and have a mutual respect when we present something to them. This person reports directly to the Medical Director and is another colleague that is highly respected by administration. Like I said, I’m not sure why but the NP would probably gladly sit down for a cup of coffee or grab a drink at Happy Hour next door if I presented it, and I can’t think of a better time to discuss increased access to instrumentation!

8. Medical Director – Next to the administrator, this is another person that usually if they want something, they get something. Ask the NP what the best way to approach the MD might be. Maybe he stops at Dunkin Donuts every morning, “casually” run in to him there, start to build rapport. Maybe the MD only wants to communicate via email, go for it send him one, but figure out the best way to get his undivided attention, don’t approach him while he’s waiting for the ambulance to get Larry back to the hospital and he’s admitting 9 new Part As on Friday at 5pm.

9. The Administrator’s assistant – Again, I’m being horrible with the over-generalizations here, but most admin assistants are like the sweetest little ladies. Go on in and chat with Judy. Ask her about her family. Ask her about previous careers. Relate to some of the funny little knick knacks she’s got on her desk. Bring Judy a blueberry muffin tomorrow and thank her for keeping Mr. Spendnomoney organized. Judy will be a great person to let you know what Mr. Spendnomoney might be interested in, or the best time to stop in his office, or if he would prefer a meeting request via email.

10. The Administrator – If you have a good reputation with your administrator already, it may not take too much convincing, but if you barely know each other, you may want to take the time to get to know him/her before you slap down a stack of research articles. Regardless, take the time to prepare a convincing and organized presentation.

11. The Ombudsman – If your administrator just flat out refuses to entertain any type of necessary instrumentation, feel free to reach out to your Ombudsman. Their job is to be a patient advocate in the long term care setting. If the Ombudsman comes knocking on the administrator’s door more than once over this, Mr. Spendnomoney may all of a sudden be interested in hearing what you have to say.

12. Last and absolutely certainly not least – the PATIENT and their FAMILY. If you run in to constant pushback from the facility about ordering instrumentals, I would inform the patient of their rights. You can print out this document from Medicare that explains that they are entitled to diagnostic testing. As we’ve discussed, it is best practice to have an instrumental assessment done before recommending a specific diet or trialing compensatory strategies, therefore it should be discussed with the family that you do not have x-ray vision, and you are recommending an instrumental assessment. If the family is aware that you have requested it, and they understand the importance and ramifications of it, they are more likely to go through their chain of command to see when it’s scheduled for.

Now, after you’ve FINALLY nailed down a time to meet with your colleague, I want you to be so overly prepared, and so well versed in how this all works, that it just casually comes up in conversation. In the next post, I’ll detail EVERYTHING that you need to know to be able to get someone to at least entertain your argument for access to instrumentation. We’ll go over all of the nuances of Part A and Part B and Consolidated Billing. Be sure not to miss the next post, sign up for the updates below.

If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.