Even though restrictions are lifting, experts predict Covid-19 will be with us for some time. In this episode, we check in with Dr. Erika Kuehnel, an Ontario chiropractor, registered massage therapist and multidisciplinary clinic owner. We discuss lessons learned and how you can lead forward in a Covid world. As a member of OCA’s Return to Practice Working Group, Dr. Kuehnel, also took an extra deep dive into discovering best practices from the pandemic’s early days. She shares what her clinic did and will keep doing to safely care for patients and best support clinicians and staff. Dr. Kuehnel also chats about business changes and new practices that help her clinic continue to flourish. Listen to discover tips that may help you enhance your patient care and make your clinic thrive. (26:54 minutes)
Even though restrictions are lifting, experts predict Covid-19 will be with us for some time. In this episode, we check in with Dr. Erika Kuehnel, an Ontario chiropractor, registered massage therapist and multidisciplinary clinic owner. We discuss lessons learned and how you can lead forward in a Covid world. As a member of OCA’s Return to Practice Working Group, Dr. Kuehnel, also took an extra deep dive into discovering best practices from the pandemic’s early days. She shares what her clinic did and will keep doing to safely care for patients and best support clinicians and staff. Dr. Kuehnel also chats about business changes and new practices that help her clinic continue to flourish. Listen to discover tips that may help you enhance your patient care and make your clinic thrive.
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Key Links to References/Resources Discussed:
About Dr. Erika Kuehnel:
Dr. Erika Kuehnel is a Chiropractor, Registered Massage Therapist and CMCC graduate.
She owns and operates a multidisciplinary practice in Milton, Ontario, at Milton Back Doc, provides assessment services to the Low Back Pain Rapid Access Clinic, teaches in the massage therapy program at Oxford College, and is on the Board of Directors for the Registered Massage Therapists' Association of Ontario (RMTAO) Her prior involvement with the OCA includes working with the OCA advocacy program (now the Local Leaders program) and the Return to Practice Working Group.
Dr. Kuehnel lives in Milton with her husband, her two children and two dogs. She can be found hiking and camping in her spare time.
Lessons Learned to Lead Forward in a Covid World
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Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
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Intro:
Even though restrictions are lifting, experts predict Covid-19 will be with us for some time.
Since March 2020, Ontario chiropractors have learned and adapted to ensure exceptional health care prevailed.
I’m Leslie from the O-C-A. In this episode, I check in with Dr. Erika Kuehnel, a chiropractor, registered massage therapist and multidisciplinary clinic owner. We discuss lessons learned and how you can lead forward in a Covid world.
As a member of O-C-A’s Return to Practice Working Group, Dr. Kuehnel, also took an extra deep dive into discovering best practices from the pandemic’s early days.
She joins us to share what her clinic did and will keep doing to safely care for patients and best support clinicians and staff. Dr. Kuehnel also chats about business changes and new practices that help her clinic continue to flourish.
Listen to discover tips that may help you enhance your patient care and make your clinic thrive.
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Leslie:
During the pandemic that's been going on for a while, what best practices did you and your staff successfully implement to protect your patients, clinicians and staff?
Dr. Erika Kuehnel:
From the beginning, a big priority for us was to be able to communicate to our staff and our providers and also to our patients that we were making safety a priority. So we made sure to be very clear about what measures we were taking and to really over communicate on all of those measures. I had individual calls with each of our providers. It's in all of our email reminders for patients. We put it on our social media. We put it on our website as a popup that you would have to read before seeing anything else. We don't have a huge waiting room and we removed furniture to avoid any of that sort of contact. So we've asked patients to call from the parking lot before coming up. And then our receptionist is acting as the traffic flow manager to make sure that we don't have too many people in the waiting room at once.
We also put out physical distancing markers in any of those common areas, to make sure that when people came in again, the signage was really clear. Like everyone else, pre-screening before patients come to the office. We pre-screened using email from our online patient management software, and then we screen when they arrive at the office using whatever the current Ministry of Health screening.
One of my favorite things that we did is we installed wall-mounted hand sanitizer dispensers throughout the clinics. We were able to get a liquid one that basically has no scent, very economical as well, which was wonderful. It's readily available as soon as patients walk in, but then we also give them the option if they prefer to wash their hands because they're tired of sanitizing everywhere they go. I imagine that's something that's going to stick with us for quite some time. Within the office, I have used hand sanitizer as well, even during an appointment with a patient, where I've been handling my computer mouse, or I've been handling my own tools. And then perhaps it's an older patient and I'm having them do something that might require balance, so I might put my hands out for them to hold onto mine for balance, or if I'm going to help somebody up off the table, then I'll just grab a quick shot of that hand sanitizer. And it just communicates to the patient that even in the context of the visit, it's just rote, it's standard. And they're happy to see us doing those things.
I think as healthcare providers leading by example is really important. Safety comes first, sanitizing hands, whenever we're going to have contact. And I think that's really led toward credibility in terms of patients returning from a safety standpoint.
Leslie:
In hindsight, are there any yet extra steps your office took that may not have been done by most regulated health professionals that really helped?
Dr. Erika Kuehnel:
I think our measures have been quite consistent with other people's. The only thing that really stands out for me is we made sure to prop open the doors to our office. So before, when you came up to our office, you be able to get into the building without touching anything because we had the wheelchair assist on the front. And then when you got up to our floor, you would've had to open the door to our office. And then as you went from the waiting room into sort of the back area of the clinic, we had another door, usually that the practitioner would open and gesture for the patient to come through. We bought a couple of those fold down door stops, and so every day our front door gets propped open and the inside door gets propped open. People are really good now about stopping on the dots and not walking in because we all learned that early in the pandemic, but it means they can get all the way from their vehicle into the treatment room without having to actually touch anything.
Leslie:
Now, did any patients comment on that?
Dr. Erika Kuehnel:
I don't think people commented on it, which to me speaks to what a good measure it is. It didn't stand out. It wasn't cumbersome. It wasn't involved. It's just, "Oh, perfect. Here we are. Walk right in." The other thing that we did was try to have a little bit of fun. I had a very good friend who was in my class at C-M-C-C, and she has one of those Cricut machines. And if you remember at the beginning of the pandemic, when Justin Trudeau made his comment about speaking moistly, she made up a stop side shape and it said, "Stop. Wearing a mask to prevent speaking moistly," which I thought was hilarious. And she was kind enough to send me one. So on our propped open door, that's the first thing you see as you come down the hall. I've had more patients comment on that, finding it funny than I have had patients commenting on the safety measures. And I think to me, that's great because it says that they're comfortable when they come in and that everything flows really logically.
Leslie:
What good practices do you think you'll retain as we begin to open up more and move forward?
Dr. Erika Kuehnel:
I think masks will be with us for a long time to come, particularly in healthcare and education because of the contact and the volume. Most of us would've already had masks in our office for times when we were dealing with immunocompromised patients and that sort of thing. But I think now it will be something that we'll continue to wear even as other restrictions lift. And eventually, even when the masking requirement lifts, I expect that it will be a lot more normalized that, "Hey, I've got a cold. I can still go to work because I feel well, but you know what? I'm sniffly. I'm just going to put on a mask to avoid passing this along to any of my coworkers or patients."
It's a bit mind-boggling to me that if we go back three years, we all just accepted from October to March, we're just going to be sick half the time. You went to work and said, "Oh, it's just a bit of a sniffle." And everybody said, "That's okay. I just got over it." And we're still all running about touching everything and talking to each other. I think normalizing wearing masks when you're not feeling well is something that's probably going to stick around.
I would like to get rid of the calling up from the car. I would like to put back in my waiting room. I know there isn't a strict rule that says we can't have people in the waiting room, so I would like to bring that back. Even if they're spread out a little bit more, that's fine. Even if I have to get different furniture that can be disinfected more often, that's something in terms of serving the providers in our office, that they have not felt is something that we should lift just yet.
I think better utilization of barriers is probably something that's also going to stick with us. We have one of those sliding pass-through windows and it was just always open. So I think that's the type of thing now where when you have instead, say a plastic barrier that's in place, and it's got like a little hole at the bottom that you can put the debit machine through or that somebody can pass cash through, I think those are going to be more the norm than say the glass pass-through window.
Leslie:
As a clinic owner, you have associates and staff in your practice. Do you have any advice on how you managed the needs of staff and colleagues for your business and your patients?
Dr. Erika Kuehnel:
The biggest thing that I found made a difference in our office was returning our focus to our office culture and supporting our staff as best we can. Patients can tell when the office is flowing well, patients can tell when providers feel comfortable. So, taking care of your providers, by extension takes care of your patients.
We focused heavily on making sure that we had all the necessary materials so that our providers could be sure that they were reading their regulatory requirements. With all the changing rules that have happened over the last two years, there's certainly been uncertainty. So doing our very best to make sure that we've been aware of what are the rules for the different regulatory colleges that govern our staff and providers and making sure that we have the supplies necessary for those people to meet those rules so that they don't have to go looking it up each time. Basically, we take the regulation from whichever college is the strictest on that point and we make that our office policy.
Beyond that, in terms of taking care of our staff, when people need time off, whether it's because they're not well, whether it's because they need stress leave, and making sure that they feel supported. I think we've all learned in the pandemic when everything was shut down, it wasn't work we missed. It was people, it was being outside, it was our mental health, all those things that make life worth living. And if you can't support your people in terms of doing that, I think you're going to have a much harder time keeping a good quality office environment, and a good quality office environment lends itself well to a nice busy bustling practice.
Everybody went through a bit of a period of adjustment with the pandemic and I think healthcare providers, that was no different. So, we've adjusted some of our staff. Some left, and then we hired on some other folks that I think are just a fantastic fit for what we have built right now. We also tried to make sure to add in a little bit of fun. I started coming in on Saturdays with treats from local businesses, and I made a point of doing that probably three out of every four weekends. Not everyone loves working Saturdays, so at least get a little reward for the people working Saturdays.
We have a full-size fridge in our office and we got some magnet Scrabble tiles. And so every week or so somebody starts a new themed Scrabble board and everybody contributes to it over the week. And we've had a lot of fun with that. We also still made sure to hold our staff events, respecting COVID protocols. So our first one was in March of last year and we did a car rally, so everybody could still participate, but they were in their own vehicles, distanced. And then in the summer, we had an in-person event, but it was outside. And so everyone was able to come to that, and see each other, and engage in a way outside of work. So that's really helped to keep our providers' spirits up as best we can.
Leslie:
Absolutely. Now, I understand that in addition to being a chiropractor, you're also a registered massage therapist or R-M-T. So I'm wondering, did you do or learn anything unique that members should know about on how to best support R-M-Ts working in their clinics, now and as we move into this world where COVID may be with us for quite some time?
Dr. Erika Kuehnel:
The number one thing that I've heard from R-M-Ts, acknowledges us healthcare providers and advocate for us on that. Make sure patients understand, right? I appreciate where some of the confusion can come from. When you also look at the diverse environments that R-M-Ts practice in, there are many R-M-Ts who are practicing in settings that were deemed non-essential like spas and gyms. As chiropractors, we know that we're healthcare providers. We're very confident in terms of where we stand. Understand that our registered massage therapy colleagues stand with us in that same category and help them advocate for that, help to educate patients on that. And for anyone who has connections to any of our decision-makers or political leaders, let's make sure they understand that as well. Outside of that, in terms of the practice environment, registered massage therapists need all the same things that chiropractors do. They need all those same materials in order to adhere to the standards for their regulatory body. So treat R-M-Ts the same way you would treat chiropractic colleagues is probably the best advice I can give in terms of support.
Leslie:
Okay. You've talked about the email that you sent through your practice management platform. How else did you keep in touch with patients during the pandemic, and what did you discover actually made a difference with patients?
Dr. Erika Kuehnel:
When we reopened, we made sure to phone all of those people that had emailed us through that time that we had put on a waiting list. So they got that direct contact and they had the opportunity to ask any and all questions they had. Since then, we've gone back to a lot of our pre-pandemic communications. We switched to a digital or cloud-based patient management software during the pandemic. And we've been able to really leverage that to allow for online booking. Our providers can actually follow up with their patients far more easily because they can even do it from home, as opposed to needing to be able to access that patient's email in the office because, of course, they didn't have our old patient management software on their computers at home. So it's made it a lot easier for people to have just those little touchpoint.
One of our R-M-Ts who was away for a while, and she was able to put together a list of patients and reach out to all of them directly, instead of us sending a form email. The best feedback I've had from patients has been our personalized approach has made a big difference, giving them the opportunity to ask those questions, to invite that from them so that we can make sure that all of their concerns are addressed. And on probably I think three or four occasions now, I've had patients who disclosed to me that the biggest reason they returned to our practice and not elsewhere was due to our clear communications around our safety measures, and the fact that we've maintained them at the same level, particularly when we consider there are people who are just frightened of COVID. But when we consider that lot of people who they themselves, or they have people they care about in their lives, who would be profoundly impacted and could possibly die if they were to get COVID, the idea of being able to go somewhere and feel safe was such a huge relief for them.
So I think being able to communicate to patients what those safety measures are and that they can feel confident in coming to our place, even if they don't feel confident coming to the grocery store, made a huge difference.
Leslie:
We're now seeing restrictions ease in non-essential settings like restaurants, stores, and gyms, but from what we're hearing, it sounds like restrictions will remain in healthcare settings for some time. How will you best help your patients and others manage the contrast between these settings?
Dr. Erika Kuehnel:
So the restrictions in the other areas are going to come down, but meanwhile, we're sort of staying here. As I said, I think masking in healthcare is going to be with us for a long time to come. I think particularly in our field where we spend a lot of time in close contact with patients, even if the Ministry of Health says that we don't need to, the C-C-O could say, "We think our member should." And even if the C-C-O drops it, that individual member could say, "You know what? This is the better choice for me and my family." I don't think we'll have a lot of issues in terms of communicating that with patients simply because everyone's very used to it now. So to say to a patient, "Hey, I'm going to continue doing this because I think that this is the way to keep our staff and our providers and our patients as safe as possible," I don't think anyone's going to complain about being in the presence of someone else who is masked.
I certainly could see a scenario where if the requirement for masking of patients is dropped by the Ministry of Health and the regulator, and it's no longer recommended from those sources and to realize we can have exemptions now, but if instead of it being an exemption issue, it's just, "Hey, nobody has to wear it anymore," I think that we will see more patients who will decide to drop the mask as well. But I think if, as a provider, you're able to communicate to your patients why you are still wearing one if that's what your choice is, then looking at my patient base, I imagine a number of them would still continue to wear it.
I'm hopeful at the end of all this, that we've learned, all of us, that a little more compassionate and a little more concerned for others actually goes a long way. So I think it'll just be important to make sure that we're clear about where those recommendations or rules are coming from. Are they coming from the regulator? Are they coming from the Ministry of Health, or is this an office policy, or is this a practitioner of policy? I think it's made life a lot easier to have really firm clinic policy so that our individual providers haven't had to take that burden on themselves.
I would survey my providers to see what they feel about any measures that might come up for change. And I would probably as an office, stick to a policy that keeps the strictest measures so that all of our staff and providers feel comfortable and that nobody feels as though they have to be the one to stand out and say, "No, I want to keep this measure in place," and have to explain that to patients on their own. I think a lot of providers feel a bit of safety in being able to say, "Hey, this is the office policy, so this is what we're going with." And I think patients will continue to be accepting of that for quite a while.
Leslie:
What about patients who haven't yet returned to care during the pandemic, do you have any plans to entice them to return to care, or give them that comfort level that you'd want to share with members?
Dr. Erika Kuehnel:
I would say we're still getting some trickle-ins, people who haven't been before COVID or haven't been back to the office since before COVID. That being said, I don't know that they haven't been in because of concern over COVID. There have been a lot of other concerns in the last two years. People have lost jobs. People have moved. Since we've had a significant staffing change, some of those patients were coming in to see a specific provider. And if that provider's no longer there, they're not going to come back to our office either way. And then that's often replaced with new patients. I would say if anything, our new patient numbers are in excess of what we had before COVID. Natural attrition that happens is just fine.
I would continue to make sure that we're clear about what measures we are taking, so patients who have been concerned would feel comfortable returning, but we don't have any plans right now to reach out to those people who haven't been in for two years based on the assumption that they haven't been in because of COVID.
Leslie:
Are you still doing a little bit of virtual care or telehealth and how are you using it, and what's been working well for you?
Dr. Erika Kuehnel:
We used virtual care a lot more in the early days of the pandemic. Certainly, on the private side of things, I was able to use a video conferencing virtual platform to offer virtual care to the private patients that were interested. It was a bit of a tough sell. We had to look and say, okay, who was most urgent, contact each of those patients, and then have that conversation with those patients about their comfort level in terms of in-person care versus telehealth. And of course, as part of that, explaining to those patients, what some of the limitations of telehealth were versus in-person care, and answering a lot of questions about what in-person care would look like when it became available. There were a few people who were definitely interested, and we made sure that we took care of them, but they certainly had a preference for in-person care. So when that became available and they felt like our environment was safe and comfortable, they were happy to return to in-person care.
I did use it a little bit more in terms of offering telehealth to some patients through a publicly funded program that I work with, a low back pain, rapid access clinic. The patients who were looking at doing a follow-up and they don't really need to be seen in person, the assessment findings are unlikely to change our recommendations. Instead, we're checking in, making sure they have the additional information that they need to continue and carry on, on their own, and that, we're able to do that by phone. All of my initial assessments though, through that program are back to being in-person.
In my private practice, at this point, the approach is where I'm doing a consultation where I expect it to be just a bit more of a follow-up. How are you doing, checking in? If I can screen that patient for that over the phone, then I'll flag that patient for that and I'll do a phone consultation, but otherwise, I would say all of the care that I'm offering right now is in-person. I'm comfortable in the environment. Our patients thankfully are comfortable in the environment and they've returned. And with the measures that we have in place, I feel confident that we can control outbreaks and transmission and that sort of thing. Knock on wood, we haven't been involved in any outbreaks to date.
Leslie:
Now, you kindly serve done O-C-A's return to practice working group, and we produced a lot of member resources through that group and are still providing F-A-Qs. Are there any resources you're still using, or do you want to comment on that?
Dr. Erika Kuehnel:
Working with the return to practice working group was such a great experience for me because it just gave me one more reason to really go and look at all those different sources to compile that information. For my own practice reopening, I definitely relied on quite a few of those resources. During the reopening, I looked forward to those O-C-A emails whenever I got them, to make sure that I was cross-referencing against what we were doing in office to make sure I had best practices in place. I haven't referenced them as much recently, simply because we haven't made a lot of changes recently. We've really just been staying the course. We're really focusing on returning the customer service aspect to the pre-pandemic levels. And I think that's been a big part of what's helped to maintain our growth through the pandemic, because on top of making sure that our environment is first of all, safe, second of all, pleasant and comfortable, a place people want to come back to. On top of that, we're adding back in those additional customer service elements that we had pre-pandemic, and we've continued to improve on that front.
I think the more recent materials put out by the O-C-A, like the extended health information has been probably of a significant benefit to a lot of chiropractors because I think patients more and more are relying on those extended health benefits, and more and more relying on their healthcare providers to be better informed about some of those items. So if you can help to add that little bit of extra customer service on top of your safe and healthy environment, I think that's probably where things are going now.
Leslie:
So, as we move out of the Omicron phase of the pandemic, what business practices or business models did you employ that you think really helped your practice? And is there anything that you could recommend that members do to protect their practices?
Dr. Erika Kuehnel:
A huge thing for us was better management of our time, because we needed this additional time in between patients to do a more thorough cleaning, because we were keeping fewer supplies in the room and so we're having to go out of the room to go get the necessary materials and we're making sure they're disinfected before they go back. So we were stricter with our patients about where they could book those times in. We definitely tried to accommodate a little bit more in terms of 5 minutes here and 10 minutes there and squeezing a patient in here. We don't do that anymore. This is what we need to do to operate safely and appropriately and stay on the right side of our guidelines, so this is the time that appointments are available.
I think in large part, because we have so many patients where we are, that are working from home, there's been this acceptance that we have to accommodate for this now. Just like when we accepted we had to stand in line outside the grocery store for a half hour, that's definitely a business practice that I really like because it means that our providers feel a lot more organized, they feel less rushed, less hectic. And that I think contributes to, again, that positive office culture, both for our providers and for our patients.
The other thing is we got a lot more consistent about our no-show fees. No-show fees have always been an issue. As health care providers. We care about our patients and we don't like charging for a service that we haven't delivered, but at the same time, that time was set aside for that patient and we have to account for that somehow. So our policies around no-show fees have gotten firmer and we have gotten more consistent. They were always communicated in advance before, but we had so many exceptions, that, "Oh, well that's okay. Oh, she never does this." And we just said, "You know what? No, we have to be really clear and make sure that that expectation is across the board." And our patients, again, they've come to recognize that as part of the requirement for being a patient in our practice.
So more often than not, if somebody is calling with a cancellation of less than 24 hours, for example, that's our policy, they're leading with, "And I know that there's going to be a no-show fee. That's just fine. Please go ahead and charge me." And that's something, I think three years ago, we were far more apprehensive about implementing.
Leslie:
Now, there is still some leniency with people who suddenly have an infection, or health issues. How do you manage that?
Dr. Erika Kuehnel:
Absolutely. We question our patients if they're having to cancel late, or if we have a no-show, we question our patients as to their reason for it. And we've gotten far better at recording that data. Being a little bit stricter with patients about no-show fees does mean that they have been more compliant in giving us more advanced notice. And so that's really where the biggest benefit has come in. And the person who needs to stay home can stay home. They don't worry about a no-show fee. The person who's waiting for the appointment gets one.
And my time at clinic is utilized efficiently. That did not happen with the same success when we weren’t as diligent about collecting the data and enforcing it. There's only so many times you can plead COVID symptoms before you just need to pay the $25. Our fee is just $25. It's meant to not be punitive. And of course, if we fill the spot, we waive the fee. And if the patient hasn't done it in a long time, we're still waiving the fee. We are still reasonable. We definitely don't want to encourage patients with symptoms to come to the office under any circumstances.
The other thing that I think is a really positive practice, the COVID screening in advance, and then the digital software sending our intake forms in advance, because you never know how long that person is going to take with an intake form when they show up at your office. Most people, 5, 10 minutes. Great. But some folks it's a half hour, and to have them doing that at home, that's keeping our providers on schedule. And of course, if our providers are on schedule, our patients are much happier as well. So we have providers who have better expectation about when they can go home, when they have time to eat, when they have time to do their charts. We have patients who know that when they show up, their provider is going to be ready for their appointment. The receptionist isn't having to manage patients who are in the lobby, waiting for a provider because something else ran over. Everything just runs so much more smoothly with the time management piece.
Part of that is the expectations in the pandemic, and part of that is definitely the online software helping us out. So if there's anybody contemplating switching to an online cloud-based software, where you're able to send that information to patients in advance and you're able to communicate with them more readily through electronic means, I cannot tell you enough, please go right ahead and do it.
The biggest thing for our office and for my practice in particular, will be that focus on our office culture and our providers. I really feel that if you take care of the other people that are in your office, whether that's your staff or your providers, they will take care of your patients as well. Pre-pandemic, we had gotten away from that a little bit. So with everything that happened in the pandemic with people changing careers, dropping out of professions, and shifting their priorities about what they felt was important and what they willing to do for work, I think a lot of employers had to realize if you want to keep good people, you have to treat them well. So that really bolstered up that renewed focus on taking care of our providers and making our office environment a place that both providers, staff, and patients all want to come to, where they can really feel comfortable. We've learned that means a lot more, I think, than we thought it did.
I think the biggest take home message for me as a chiropractor and as an RMT in this past two years, is patients really do value the care that we offer, particularly in terms of that human connection piece, in addition to good quality diagnosis, good quality hands-on care. And we as chiropractors, I think do that so, so well, so that's really a feather in our cap. Moving forward, I think we want to capitalize on that and make sure that we're continuing to connect with our patients and provide them with a good quality environment. You should love going to work and your patients should love coming to see you. So I think we need to keep that up.
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Outro:
Thank-you Dr. Kuehnel for sharing changes your clinic has made to protect patients and ensure a culture that creates a positive experience for everyone. Thanks also for discussing how you’re now managing late fees, using a cloud-based practice management solution to drive efficiencies and planning to address future Covid challenges.
We’ll be back soon with an episode on recent O-C-A-commissioned research on Ontarians' Attitudes on health care and what the data tells us about opportunities for Ontario chiropractors.
I hope you’ll join us.