Chapter 2: Health Care Organization and Administration in Athletic Training

System of Healthcare Management Strategic Plan Development Determine why there is need for such a program Determine function of program and what the goals should be Decision of administrators will determine extent of health care program in athletic training Develop written mission statement to focus direction of program

Strategic Plan Development (cont.) Strategic plan development must include administrators, other allied healthcare providers, student-athletes, coaches, physicians, athletic trainers, parents and community health leaders Ongoing process that reviews strengths and weaknesses of program

Development of Policy & Procedures Manual Creation of policies and procedures for all involved in health care Policies = clear written out statements of basic rules Critical element for operation of athletic training clinic Procedures = describe the process

Issues Specific to Athletic Training Program Operations Scope of Program Who will be served by program? Athlete: to what extent and what services will be rendered (systemic illness, musculoskeletal injuries) Institution: who else can be served medically and educationally and what are the legalities Community: outside group and community organizations with legalities again being an issue

Providing Coverage Facility Personnel Coverage Sports Coverage Appropriate coverage of facility and sports Setup of treatments, rehabilitation, game and practice coverage vary Sports Coverage Certified athletic trainer should attend all practices and games Different institutions have different levels of coverage based on personnel and risks involved with sports

Hygiene and Sanitation Athletic Training Clinic Rules concerning room cleanliness and sanitation must be set and made known to population using facility Operation should abide by policies set forth by OSHA Examples No equipment/cleats in the athletic training room Shoes off treatment tables Shower prior to treatment No roughhousing or profanity No food or smokeless tobacco

Division of responsibilities Maintenance crew Cleaning responsibilities should be addressed appropriately by athletic training staff and custodial staff Division of responsibilities Maintenance crew Sweep floors daily, clean and disinfect sinks and tubs, mop hydrotherapy room, empty waste baskets Athletic Training staff Clean treatment tables, disinfect hydrotherapy modalities daily, clean equipment regularly

Gymnasium (general issues concerning facility and equipment cleanliness) Cleaning of gymnasium floors Drinking fountain and shower/locker facility disinfecting Mats cleaned daily (wrestling) Equipment and clothing Proper fitting equipment Frequent clothing and equipment laundering Appropriate equipment for weather conditions Use of clean dry towels and equipment daily

Athlete Promotion of good health and hygiene is critical Prompt injury and illness reporting Follow good living habits Showering after practice Avoid sharing clothes and towels Exhibit good hygiene practices Avoid common drinking sources Avoid contact with athletes with contagious disease or infection

Emergency Telephones Accessibility to phones in all major areas of activity is a must Should be able to contact outside emergency help and be able to call for additional athletic training assistance Radios, cell and digital phones provide a great deal of flexibility

Budgetary Concerns Size of budget Different settings = different size budgets and space allocations Equipment needs and supplies vary depending on the setting (college vs. secondary school) Continuous planning and prioritizing is necessary to effectively manage monetary allocations to meet programmatic goals

Supplies Expendable Non-expendable Involves supplies that cannot be reused- first aid and injury prevention supplies Non-expendable Re-useable supplies - ace wraps, scissors…etc) Yearly inventory and records must be maintained in both areas

Equipment Items that can be used for a number of years Capital (remain in the athletic training facility including ice machine, tables) Non-consumable capital (crutches, coolers, athletic training kits)

Additional Budget Considerations Purchasing Systems Direct buy vs. competitive bidding Lease alternative Additional Budget Considerations Telephone and postage expenses Utilities – heating/cooling, electricity Contracts for outside services Purchases relative to liability insurance and professional development

Developing a Risk Management Plan Security Issues Accessibility to athletic training clinic (staff, physicians, athletic training students) Athletic training students must be supervised when in the clinical setting Coaches may have access in secondary school settings Fire Safety Post evacuation plan in case of fire Smoke detectors/alarm system and fire extinguisher should be tested and in place

Electrical and Equipment Safety Major concern Be aware of power distribution system to avoid accidents Emergency Action Plan Accessing emergency personnel outside setting in the event of emergency Include transportation of athletes to emergency facilities Meeting with outside personnel is necessary to determine roles and rules regarding athlete and equipment care

Accessing Community Based Health Services Must have knowledge of local and community health services and agencies in the event of referrals Referrals should be made with assistance from a physician Parental involvement is necessary when dealing with psychological and sociological events

Human Resources and Personnel Issues Assembling appropriate personnel to achieve program goals and objectives is critical to success. Recruitment, hiring and retaining qualified personnel is necessary to be effective Specific policies are established relative to hiring, firing, performance evaluations and promotions Must adhere to these principles

Roles and responsibilities must be established Job descriptions - job specifications, accountability, code of conduct, and scope Head athletic trainer must serve as a supervisor and work to enhance professional development of staff Performance evaluations should take place routinely

Athletic Training Facility Design Design will vary drastically based on number of athletes, teams, and various needs of the program Size Varies between settings Must take advantage and manage space effectively Interact with architect relative to needs of program and athletes

Location Outside entrance (limits doors that must be accessed when transporting injured athletes) Double door entrances and ramps are ideal Proximity to locker rooms and toilet facilities Light, heat and water source should be independent from rest of facility

Illumination Well lighted throughout Reflective ceilings and walls will aid in process Natural lighting is a plus

Special Service Areas Treatment Area: area that accommodates 4-6 adjustable treatment tables, 3-4 stools, and hydrocollator and ice machine accessibility Electrotherapy Area: area that houses ultrasound, diathermy, electrical stim units, storage units, grounded outlets, treatment tables and wooden chairs, under constant supervision

Hydrotherapy Area: area with centrally located sloping floor to drain, equipped with 2-3 whirlpools, shelving and storage space and outlets 5 feet above the floor Exercise Rehabilitation Area: area that provides adequate space and equipment to perform reconditioning of injuries Taping, Bandaging & Orthotics Area: 3-4 taping tables and storage cabinets to treat athletes with proximity to a sink

Physician’s Exam Room: space for physician to work which may hold exam table, lockable storage, sink, telephone Records Area: space devoted to record keeping which may include filing system or computer based database, that allows access only to medical personnel

Storage Facilities Athletic training facilities often lack ample storage space Storage in athletic training room that holds general supplies and special equipment Large walk-in storage cabinet for bulk supplies Refrigerator for equipment, ice cups, medicine and additional supplies Space should be designated for storage of patient belongings

Figure 2-2

Athletic Trainer’s Office Space at least 10x12 feet is ample All areas of athletic training facility should be able to be supervised without leaving office space (glass partitions) Equipment should include, desk, chair, tack board, telephone, computer and independent locking system

Additional Areas Pharmacy Area: separate room that can be secured for storing and administrating medications (records must be maintained concerning administration) Rehabilitation Pool: if space permits, must be accessible to individuals with various injuries, with graduated depth and non-slip surface Restrooms: Should be at least one available within the facility

Figure 2-1

Issues Specific to Athletic Training Program Operations in Clinic, Hospital Corporate of Industrial Settings Staff must be prepared to provide care to a wide range of patients Pediatrics Adolescents Young adults and adults Geriatric patients May also involve additional duties in management, marketing, outreach, along with fiscal and financial responsibilities

Scope of Practice Diverse patient population In hospital settings time may be spent with in-patient, out-patient and/or ambulatory care Owner of out-patient facility will dictate patient population seen at clinic The AT may be involved with patient care, onsite employee fitness, ergonomics, work hardening programs, outreach programs, athletic event coverage Limitations and restrictions will be dictated by state regulatory statutes

Location of Clinic Patient base is critical and therefore location is key to attracting patients Other factors Zoning Traffic concerns Physician referrals Will physicians use athletic trainers to provide services Can the clinic provide additional services relative to industrial rehabilitation and workplace assessment Sports medicine coverage for schools Direct and indirect competition

Clinic Personnel and Human Resource Issues Hours of Operation Clinic will need to be opened at times that do not conflict with normal working hours Early morning and evening hours Weekend hours may also be useful Clinic Personnel and Human Resource Issues Athletic trainers will work with multiple healthcare provider in clinical/corporate and hospital treatment centers Formal job descriptions are critical for all individuals working in environment Communication and team approach is critical

Potential Athletic Training Duties Ergonomic Assessment Ergonomics is the science of designing products, machines and systems to maximize comfort, efficiency and safety Based on anthropometry and biomechanics Applied to industrial engineering Used to design, adapt and alter workplace environments to accommodate to a person’s strengths, limitations, sizes and shapes Primary goal often involves injury and accident prevention in workplace by minimizing risk factors Postures, vibration, repetition & force

An athletic trainer may work with an occupational therapist or ergonomist to assess environment Will provide assessment, make recommendations, provide instruction on injury prevention techniques Report is generated and provided to site administrators with follow-up reviews often conducted to ensure implementation of recommendations Figure 2-3

Work Hardening/Conditioning Programs Intensive outpatient therapy for individuals injured on the job Work conditioning = treatment 3 hours/day, 3 days/week Work hardening = 8 hours of treatment daily, 5 days/week Goal is to restore functionality and return to full duty capacity Both an evaluation and report are assembled and are used to develop a rehabilitation plan

The evaluation involves: Musculoskeletal examination (strength, posture, flexibility, gait, neurologic screening) Functional capacity evaluation Prolonged sitting, standing Hand grip strength and lifting abilities Ability to perform repetitive tasks Carrying capabilities Balance These elements are continually monitored and allow for program adjustment in order to facilitate the patient’s return to appropriate levels of performance Figure 2-4

Wellness Center Athletic trainers may be involved in organizing wellness screenings and workshops for: Asthma & diabetes Hypertension & stroke Cholesterol Osteoporosis Prostate/skin cancer Designed for early detection, awareness and prevention Programs designed to educate individuals on nutrition, health and safety may be offered Health fairs are often an effective means of providing screenings and education

Community Outreach and Marketing Some athletic trainers may be clinic or hospital based in the morning and may provide athletic training coverage in afternoons and evenings Outreach may occur in the collegiate setting, secondary schools or for single athletic events Serves as an effective marketing tool to promote and advertise clinic Also provides visibility for the clinic to other healthcare providers and potential future consumers/patients

Corporate Fitness Programs Involves in-house fitness programming for employees Provides numerous health-related benefits to employees Also serves to reduce health costs, increase productivity, reduce absenteeism, improve morale, lower healthcare expenditures and reduce sick leave Often involves fitness screening and individual program design Figure 2-5

Drug Testing Programs Athletic trainers may be asked to oversee drug testing programs Program may act as a deterrent to employees coming in unfit for duty May be necessitated by federal guidelines or pre-employment screenings Legal defensibility is the most important aspect of any drug-testing program The corporation should use federally certified testing laboratories with all positive tests results confirmed via a medical review department

Fiscal Management Having a basic understanding of business practices may be necessary in for-profit clinical settings Knowledge of billing practices is critically important Maintaining positive accounts payable vs. accounts receivable ratio is the goal of all successful businesses Other responsibilities may include Financial planning Establishing contractual obligations Efficient billing and collection systems Budget formulation

Record Keeping Major responsibility The rule not the exception - accurate and up-to-date Medical records, injury reports, insurance information, injury evaluations, progress notes, equipment inventories, annual reports

Maintaining Confidentiality in Record Keeping Release of Medical Records Written consent is required Waiver must be signed for any release (include specifics of information to be released and to whom)

Health Insurance Portability and Accountability Act (HIPAA) Regulates dissemination of personal history information (PHI) by coaches, AT’s, physicians or other members of sports medicine team Guarantees athlete access to information and control over disclosure Athlete may provide written authorization for release of information

HIPAA Authorization Description of information to be disclosed Identification of parties authorized to provide and make use of PHI Description of each purpose of the use or disclosure Expiration date or event Individual’s signature Description of his/her authority to act for the individual if signed by personal representative

Family Educational Rights and Privacy Act FERPA = law protecting privacy of student education records Provides parents with certain rights with respect to child’s educational records When child turns 18 rights are transferred to student School must have written permission prior to releasing information

Administering Pre-participation Examinations Initial pre-participation exam prior to start of practice is critical Purpose is to identify athlete that may be at risk Should include Medical history, physical exam, orthopedic screening, wellness screening Establishes a baseline Satisfies insurance and liability issue

Examination by Personal Physician Yields an in-depth history and ideal physician-patient relationship May not result in detection of factors that predispose the athlete to injury Station Examination Provides athlete with detailed exam in little time Team of nine is ideal (2 physicians, 2 non-physicians and 5 managers/student athletic trainers)

Medical History Physical Examination Complete prior to exam to identify past and existing medical conditions Update yearly and closely review by medical personnel Collect medical release and insurance info at the same time Physical Examination Should include assessment of height, weight, body composition, blood pressure, pulse, vision, skin, dental, ear, nose, throat, heart, lungs, abdomen, lymphatic, genitalia, maturation index, urinalysis and blood work

Maturity Assessment Orthopedic Screening Means to protect young, physically active athletes Methods Circumpubertal (sexual maturity) Skeletal Dental Tanner’s five stage assessment is most expedient Orthopedic Screening Part of physical exam or separate Various degrees of detail concerning exam

Sport Disqualification Wellness Screening Purpose is to determine if athlete is engaged in a healthy lifestyle Sport Disqualification Certain injuries and illnesses warrant special concern when dealing with sports Recommendations can be made American with Disabilities Act (1990) Dictates that athlete makes the final decision Potential disqualifying factors should be determined during the pre-participation exam

Personal Information Card Contains contact information for family, personal physician, and insurance information Injury Reports and Injury Disposition Injury reports serve as future references Reports can shed light on events that may be hazy following an incident Necessary in case of litigation All reports should be filed in the athletic training room

Treatment Log Sign-in to keep track of services Daily treatments can be recorded Treatment of daily therapies can be monitored along with compliance Can be used as legal documentation in instances of litigation

Injury Evaluation and Progress Notes Injuries and progress should be monitored by athletic trainer and recorded SOAP note format S: Subjective (history of injury/illness) O: Objective (information gathered during evaluation) A: Assessment (opinion of injury based on information gained during evaluation) P: Plan (short and long term goals of rehab)

Supplies and Equipment Inventory Managing budget and equipment/supplies is critically important Inventory must be taken yearly in order to effectively replenish supplies

Annual/Seasonal Report Summary of athletic training program functions Can be used to evaluate recommend potential changes for program Includes number of patients and types of injuries seen/treated

Computer as Tool for Athletic Trainer Indispensable tool Can make the job more efficient with appropriate software Must maintain security Must determine for what computer will be used

Should consult experts in order to determine what systems are appropriate for specific use Factors to consider Access to mainframe and internet Hardware (desktop, laptop, personal digital assistants) Software – various programs for multiple uses Record keeping needs Word processing, budget maintenance Educational software World Wide Web and access to email

Collecting Injury Data Accident - unplanned event resulting in loss of time, property damage, injury or death Injury- damage to the body restricting activity Case study- looks at specific incident of injury

Epidemiologic studies may assess various areas Age or gender Body part Occurrence in different sports Contact, non-contact, limited contact, collision sports

Catastrophic Injuries 98% of injuries requiring hospital emergencies are treat and release relative to sport Sports deaths (struck with object, heat stroke) Catastrophic injuries also include spinal cord trauma, cardiorespiratory injuries/problems Most injuries are related to appendages Strains, sprains, contusions, fractures, abrasions

Current National Injury Data-Gathering Systems State of the art injury surveillance is still developing Ideal situation involves epidemiologic approach Epidemiology Takes an evidence-based approach for identifying risk factors for injury and determining optimal treatment methods in clinical practice Serves as foundation for intervention in interest of public health and preventive medicine Extrinsic factors (activity, exposure, equipment) Intrinsic factors (age, gender, neuromuscular aspects, structural aspects….etc) Number of different surveillance systems in place

Surveillance Systems National Safety Council General sports injury data Annual Survey of Football Injury Research Public school, college, professional, sandlot football injury data National Center of Catastrophic Sport Injury Research Tracks catastrophic injuries in all levels of sports

NCAA Injury Surveillance System Data collected on most major sports- ATC data collection Converted to web-based data collection system National Electronic Injury Surveillance System Monitor injuries relative to different products --consumer safety, determine if products are hazardous or defective

Using Injury Data Valid and reliable data can be utilized to decrease injuries May allow for: Rule modification Assist coaches and players in understanding risks Help manufacturers Educate parents, athletes and the public on inherent risks associated with sport