Client Communication

Speech pathologists: 5 best practice ways to improve your advice to clients

16 July 2016 By David Kinnane Leave a Comment

In one capacity or another, I’ve been a professional advisor for almost 20 years. Although advice-giving is a core part of what speech pathologists do, few of us are trained formally in how to do it well.

Bad professional advice can lead clients to make flawed decisions. It can also strain relationships and tarnish your reputation.

It’s sometimes assumed that advice-giving skills emerge organically, with experience and through a painful process of trial and error. But giving good advice is a skill. And, as with most skills, you can get better at it with the right knowledge, systems and practice.

So where should we look for the right knowledge?

Recently, Harvard Business School Professors David Garvin and Joshua Margolis reviewed the research about advice-giving in business and developed a framework of best practices. Applying their guidelines to speech pathology practice, here are 5 evidence-based ways to improve the quality of your professional advice:

1. Before you start, check you’re the right person for the job

Ask yourself: do you have the time, expertise and experience to help? Are there alternative and/or additional sources of guidance to advise the client comprehensively given his/her needs? Do you have a conflict? Would a second (or third) opinion help the client make a decision?

2. Develop a shared understanding with your client

(a) Set the scene: allow clients enough time to explain their challenges, ensure privacy and choose a place free from distractions like buzzing phones or the next appointment.

(b) Listen actively and without prejudice – resist the urge to jump in with your preliminary view.

(d) Agree on the scope of advice sought. Is it:

(i) one-off advice for a single decision (e.g. “Do I have a clinical issue?”, “Should I be treated now, or later?”);

(ii) counselling on how to approach a complex situation (e.g. “How do I prioritise my child’s many communications needs?“);

(iii) coaching to enhance skills (e.g. identity mapping to generate and pursue meaningful, client-centred goals); or

(iv) mentoring to provide guidance to aid long-term success (e.g. acting as a sounding board for an adult who stutters or an accent modification client facing specific challenges at work, e.g. with an important presentation).

Don’t overstep boundaries or give unsolicited advice – especially advice that is outside your scope of practice.

3. Craft alternatives

Make it clear to the client that you are an adviser – not the decision-maker. If possible, help the client generate several, evidence-based, viable choices. Spell out the rationale, principles, assumptions and evidence behind each of the options and your advice. Be prepared to challenge assumptions if the facts or situation changes (or if the client changes his or her mind).

4. Help the client make the decision

Ensure all options are evaluated, including the risks and benefits of no treatment. Communicate clearly and in Plain English. Make sure the client understands your advice. Don’t jump straight to a conclusion, e.g. that a child is a “speech” or “language” kid or assume that your client will choose the treatment you consider to be the most logical or evidence-based. Pause frequently for client/family reactions. Make sure the client knows you are available for further clarification and elaboration if and when needed (i.e. that they don’t need to make a decision on the spot, and can think about other options, risks and benefits and come back with questions or concerns).

5. Help put your client’s decision into action

Reaffirm and support the client in making an informed decision, even if the decision is ultimately not your preferred first choice. Document it. Again, convey your availability for additional guidance and support to help the client to pursue his/her goals, including during treatment.

Bottom line

Speech pathologists advise clients in several ways, from face-to-face and tele-health consultations, assessment reports, management plans, home programs, email and SMS responses to queries, therapy and training activities, outcome measurement, discharge recommendations and referrals to other health professionals. Giving professional advice competently requires us to look at our competence and impartiality, the scope of advice sought and our role in giving it, the technical content of our advice, and the process through which we evaluate different options and give our advice. Skilled advising requires creativity and collaboration with clients. We need to understand clients’ problems fully to generate evidence-based, client-centred solutions over the whole term of the professional relationship. Garvin and Margolis’ framework for advising is a useful tool to do this methodically.

Principal reference: Garvin, D.A., & Margolis, J.D. (2015). The Art of Giving and Receiving Advice, Harvard Business Review, January-February, 61.

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Speechies in Business

Speechies in Business is owned and operated by David Kinnane, a Certified Practising Speech Pathologist, lawyer, writer and speaker in private practice in Sydney, Australia. You can read more about David’s professional background, qualifications and experience here.David also co-owns and co-manages Banter Speech & Language, an independent private speech pathology clinic, and Bodkin Wood Legal & Advisory, a law firm specialising in allied health issues.

Australian Speech Pathologists: consent to treatment for children aged 0-13 years with separated or divorced parents

21 June 2016 By David Kinnane Leave a Comment

If you work with kids and provide quality, client-centred care, you really work with families. Sometimes, you’re working with Mum and Dad and the kids together. Other times, you might be working with a single parent, alternating parents, a relative (e.g. a grandparent), a guardian or another carer.

One question that crops up a lot in speech pathology forums is about what to do if you are working with a child whose parents are separated, going through divorce proceedings or divorced. This is a complex area of law and practice (particularly for children who are 14 years old or older – a topic for another day).

For children aged 0-13 years, here are some principles I use to manage the risks:

In most cases, the consent of either parent to provide speech pathology services to their child is sufficient. The Family Law Act 1975 (Cth) makes it clear that:
- both parents are responsible for the welfare of their children (including healthcare) until their children turn 18;
- there is a presumption that arrangements which involve shared responsibilities and cooperation between parents are in the best interests of children (section 61DA);
- each parent of a child has responsibility for the child unless:
  - the court makes a parenting order to the contrary; or
  - the parents make a parenting plan that allocates parenting responsibility differently; and
- a change in the relationship of the parents – e.g. separation, divorce, marrying or remarrying – does not affect the basic rule that each parent has responsibility for the child (section 61C).

If a non-parent relative attends with a child, I usually ask to see written confirmation from a parent authorising the relative to consent to assessment and treatment for the child.

If a guardian attends with a child, I usually ask to see evidence of the guardianship.

If a delegate of the guardian attends with a child, I usually ask to see evidence of the guardianship and a written delegation of the authority to consent from the guardian to the delegate.

In cases where I know that the parents have separated, are divorcing or are divorced, and in particular, where it is clear Court proceedings are underway, I ask the attending parent to confirm if any parenting orders have been made or are pending, or if any parenting plans have been agreed that affect the rights of the parents to make healthcare decisions for his or her child and document the response (e.g. in progress notes). Documenting the attending parent’s response to this question can be important, e.g. if you are later subpoenaed by the other parent to provide documents or to appear in Court to provide evidence.

If parenting orders have been made by a Court that appear to give one parent the sole right to make decisions for the child’s ‘day-to-day welfare and development’ or, more specifically, to make healthcare decisions for the child, consent from that parent must be obtained in accordance with the order. Without such consent, I will not assess or treat the child.

If there are no Court orders in place, and one parent consents to you treating a child and the other parent contacts you to refuse consent, I try to get the parents to talk to each other to make a decision about what they think is in the best interests of the child. I also try to inform each parent objectively about the risks and benefits of different assessment and/or treatment options (including no treatment). This usually works.

If the parents can’t reach an agreement on whether the child should be treated, I’m reluctant to assess or treat the child. If Court proceedings are threatened or in progress, I might hold off assessment or treatment and suggest that the parents seek legal advice on the matter in the context of their wider Court proceedings.

At each stage, I document all communications, keep my input factual and evidence-based, and take great care not to do or say anything to any person that could make it appear that I am “taking sides”.

Consistent with principles of Australian family law, my paramount concern is the welfare of the child and my key professional obligations are to the child. For example, I remain aware of my obligations as a mandatory reporter under child protection legislation in my State.

Further reading:

Disclaimer: This article does not constitute any kind of legal advice, opinion or recommendation about rights, obligations, remedies, defences, options, or strategies. You should obtain legal advice specific to your circumstances.

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Dealing with negative online reviews: evidence-based strategies for speech pathologists

4 April 2016 By David Kinnane Leave a Comment

Online review sites are fairly new in speech pathology and healthcare generally. Australian examples include Whitecoat and the NDIS-inspired Care Navigator.

Negative reviews hurt

Negative reviews on sites like these – or on social media platforms like Twitter and Facebook – hurt. They may make us angry, anxious, embarrassed, sleepless – even sick. They can decimate team morale and confidence. They can tarnish reputations. They can lose us business. In extreme cases, they can even drive practices into the ground.

To compound the problem, speech pathologists are constrained by legal and ethical rules about advertising (e.g. testimonials) and client privacy. In practice, these limit our ability to respond to negative reviews, even if the reviews are exaggerated, incorrect, anonymous or even fabricated.

Review sites are here to stay

Consumers have a right to be informed about their treatment options. Despite all the risks of review sites for speech pathologists and other health professions, it’s clear regulators (and some self-regulatory bodies) in Australia see review sites as an important way of promoting consumer rights.

Speech Pathology Australia’s Advertising FAQs state that:

“advertising is not considered to include…comments made by a patient/consumer about a practice or a practitioner where the comments are made on a social media site or account or patient/consumer information sharing site or account which is not used to advertise a health service, and that site or account is not owned, operated or controlled by the practice or practitioner referred to in the comments”.

Similarly, the advertising guidelines that apply to regulated health practitioners like occupational therapists and physiotherapists in Australia state that:

“There are many opportunities for consumers or patients to express their views online that are not affected by the National Law restriction on testimonials in advertising. Patients can share views through their personal social media such as Facebook or Twitter accounts or on information sharing websites or other online mechanisms that do not involve using testimonials in advertising a regulated health service.

For example, consumer and patient information sharing websites that invite public feedback/reviews about experience of a regulated health practitioner, business and/or service are generally intended to help consumers make more informed decisions and are not considered advertising of a regulated health service.”

Although hard to forecast with certainty, it’s likely that managing online reviews will be an increasingly important part of business for speech pathologists in private practice.

What do we know about negative reviews?

We can learn from the experiences of business owners who’ve been dealing with online reviews for years: owners of restaurants and hotels. These businesses have had to deal with sometimes very harsh reviews on sites like Yelp, Urbanspoon/Zomato, Menulog, OpenTable, and TripAdvisor. A growing body of research exists about these reviews. It shows:

1. Online reviews matter. Online reviews: (a) can attract a wide audience (Hennig-Thurau et al., 2004); (b) are perceived by consumers as credible and trustworthy (Flanagin & Metzger, 2013); and (c) play an important part in shaping client opinions and purchasing decisions (Sparks and Browning, 2010).

2. Online reviews can help improve the quality of services. In traditional management literature, customer complaints are often seen as positive because they give the business a chance to fix problems and improve services (e.g. Reynolds and Harris, 2005).

3. Reviews can also hurt you, your team, and your business. As noted above, negative reviews about your business can affect you, your reputation, your business, your employees and contractors; can affect your morale, health and finances; and may attract the attention of third parties, including government regulators and industry associations.

4. Consumers post negative reviews for lots of reasons and in different ways. Online reviews may be posted for personal, social and even commercial reasons. The trigger is usually a negative experience. The decision to post an online review depends on lots of factors, e.g. a client’s motivations, past experiences, general attitude to complaining, age, and familiarity with the Internet (e.g. Yagil, 2008). Posting reviews may provide an emotional release (e.g. to allay anger, embarrassment or disappointment, or even to provoke laughter), seek “revenge” for a perceived slight, or even the hope of economic gain (Cantallops and Salvi, 2014). Some may be heat-of-the-moment “rants”. Others may be fair descriptions of legitimate concerns. Some will be trivial. Others may allege civil wrongs (e.g. negligence) or even criminal acts. Some may be exaggerated. Others may be completely fabricated (e.g. by ex-employees with a gripe, or unethical competitors). Some are short. Others are encyclopedic. Some will be shared with one or two followers. Others may go viral. Some will be posted by named people you know. Others may be anonymous. Service quality is very much in the eye of the client, rather than the provider (e.g. Sparks, 2001).

5. Online reviews can be personal. They may name and single out individual staff (e.g. Bradley et al., 2015). They may even be discriminatory or defamatory.

So how can speech pathologists in private practice manage negative online reviews?

Again, we can learn from the experience of hospitality businesses. As with restaurants, most speech pathology private practices are small businesses with limited time and resources to dedicate to online review management. In this context, the research identifies four broad categories of strategies employed by businesses to manage negative reviews:

(A) Preventative strategies

Improve your services. In theory, improving the quality of your services will reduce problems, complaints and the risk of negative reviews.
Conduct “real time” checks on client satisfaction to identify and, if possible, fix small problems before they become big problems (e.g. Johnston and Fern, 1999).
Manage client expectations about your services.

These are sensible ideas. But, owing to the intangibility of services and the variability of client perceptions, expectations and preferences, preventative strategies are never going to eliminate the risk of negative reviews entirely (e.g. Sparks, 2001).

(B) Protective strategies

The emphasis of these strategies is to shape – not prevent – complaint behaviours to minimise damage to your business.

Give your clients clear encouragement and guidance as to where and how to comment and complain. This can be offered orally, via a leaflet, on your website, or an email. For example, I have a feedback and complaints policy I share with all clients.
Include a request in your feedback and complaints policy that complaints first be presented to staff or the practice directors before being posted online.
Have a physical and email suggestion box for anonymous comments and complaints.
Provide short in-house satisfaction questionnaires and reward clients for using these, rather than going online.
Monitor online reviews and respond:
- privately by email or, better yet, with a phone call or face-to-face open discussion; or
- publicly.

In the hospitality industry, public responses are increasingly viewed as a vital reputation management strategy. Review sites like Yelp and TripAdvisor have even published guidelines on how to do it. These guidelines encourage restraint, courtesy, a focus on specific concerns and an emphasis on the business’ positive qualities.

Jay Baer, author of “Hug your Haters: How to Embrace Complaints and Keep your Customers” says that when you don’t answer a complaint it decreases customer advocacy by up to 60%: when you answer a complaint it increases advocacy by 25%. Customer advocacy – i.e. the client advocating for your service.

Complaint-handling studies (e.g. Davidow, 2003; Bitnet et al., 1990), show that effective public responses often include:

acknowledgement of the problem(s) raised;
an apology for the business’ contribution to it;
an explanation for its occurrence; and
a commitment to take appropriate preventative or remedial action.

Two important points on public responses for speech pathologists:

It can make sense, from a business perspective, to respond to negative reviews in a constructive way, acknowledging the client’s concerns (even if you don’t agree with them). However, it’s also important to support staff and others affected by the review, recognising that there are always at least two sides to any story (e.g. Jung & Yoon, 2014).
As noted above, speech pathologists must comply with their codes of ethics and legal obligations when responding publicly. This means, among other things, that speech pathologists cannot disclose any sensitive, health-related or personal information about clients or their care, which means we need to be very careful when responding in a public forum. I’ve given some thought on how best to do this.

Most review sites have moderation guidelines or terms of use that prohibit defamatory or offensive comments. For example, Whitecoat’s Moderation Guidelines and Care Navigator’s Terms of Service (see Sections 9 and 12). If you feel a review breaches those guidelines, you should alert the review site citing specific breaches and ask that the offending review be removed.

(C) Positive strategies

In hospitality, it’s common for businesses to actively encourage positive reviews from happy clients. Evidence shows that this tactic can help push negative reviews down the list and “off the page” and also result in a more balanced picture of the business (e.g. Sparks and Browning, 2011). It can also help build staff morale.

Unfortunately, actively encouraging positive reviews is not an option for speech pathologists in Australia. As with regulated health professionals, we’re not allowed to encourage testimonials or positive comments from clients for ethical reasons.

Speech pathologists can – and should – gather and share unsolicited positive feedback with staff to bolster morale. But we cannot encourage or take active steps to share this kind of feedback with the public as this would fall foul of our advertising rules.

(D) Palliative strategies

These emotion-focused strategies seek to counteract the negative emotions and stress caused by negative reviews. Examples of these strategies include things like:

building physical resilience – going for jogs, joining gyms, etc.;
enlisting support from colleagues, families and friends, including through professional networks and bodies (online and offline);
recognising that reviews are transient, surmountable, and often of limited consequence in themselves;
providing professional and emotional support to any staff affected by a review; and
stress management activities, e.g. yoga, meditation, etc.

Although simple and perhaps obvious, these strategies provide powerful ways to combat feelings of powerlessness and isolation, and to keep the real effects of negative reviews in perspective.

Bottom line

Online review sites are here to stay and can help members of the public to make informed choices about their healthcare. Online reviews can help speech pathologists to improve their services. But they can also inflict significant emotional and financial stress on owners and staff.

Preventative, protective, and palliative strategies, like those used in the hospitality industry, may help speech pathologists in private practice to manage negative online reviews and their effects. But we need to take care when responding publicly to ensure we act ethically and in accordance with our privacy and other legal obligations.

Principal source: Bradley, G.L., Sparks, B.A., Weber, K. (2015). The stress of anonymous online reviews: a conceptual model and research agenda. International Journal of Contemporary Hospitality Management, 27(5), 739-755.

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Speech pathologists: my top 10 tips for managing client expectations

14 March 2016 By David Kinnane Leave a Comment

Word of mouth can build your practice. Or destroy it.

Are you always meeting or exceeding your clients’ expectations of your service? If not, are you doing enough to manage them?

Over the years, I’ve reviewed thousands of consulting and other service contracts. I’ve also been embroiled in several disputes (for clients!) that boiled down to a simple misunderstanding about the services provided.

Here are my top 10 tips for managing client expectations to reduce complaints, avoid disputes, and to build trust with your clients:

1. Be clear on your scope of service. Does the client understand what you do (and don’t do)?

Lots of people have never been to a speech pathologist before. Maybe they booked in because a teacher told them to. Perhaps, it was a doctor, occupational therapist, dentist or other health professional. Maybe their friend or relative recommended you.
Take the time to explain what speech pathologists do. Don’t expect clients to understand differences between speech pathologists and other allied health professionals such as occupational therapists or educational psychologists.
Explain what you do. Most speech pathologists don’t try to be all things to all people. Our scope of practice is simply too wide. What do you do best? What are your special interests and passions?
Explain what you don’t do. For example, I don’t offer feeding and swallowing services in my clinic. If these issues are flagged in the questionnaire or in the initial assessment, I refer the client on to someone with special training in those areas.

2. Be clear about what you expect from the client

Encourage full and frank disclosure in a safe environment. Understandably, some clients may withhold sensitive information until they know, like and trust you.
Have a booking policy that sets out your expectations about attendance and cancellations.
Have a homework summary sheet that emphasises the need to practice the communication skills worked on in therapy.
For motor-based therapies, inform your client about principles of motor learning and neuroplasticity so they understand why they need to work hard outside the sessions.
Be specific about how much practice you want and how often. Follow-up to find out how they went with the homework. If necessary, tweak the homework plan to suit the client.

3. Agree on the scope of your assessment

Demystify the assessment process. Outline how it will work. For example, this is what I tell parents of toddlers.
In your first session, spend some time with the client reviewing the client’s questionnaire and interview responses. Agree the scope of the assessment. Will it cover speech, language, literacy, voice, fluency and/or dysphagia?
What’s worrying the client the most?
What are the client’s key challenges?
What’s most affecting the client’s participation in the real world? Don’t assume that it’s the client’s most noticeable problem.

4. Double-check: does the client want your help?

Treatment without informed client consent is assault.
Do not assume that the client wants you to treat them.
Inform the client about treatment options – including no treatment – the risks and potential benefits of each, and the evidence base for different treatments.
Inform your clients about risk factors and connections between different communication issues. For example, inform children with speech sound issues about the heightened risk of later literacy issues.
If a client has multiple issues, explain why you recommend treating one of them first, e.g. stuttering over speech sounds or speech versus language.
If you cannot provide the service needed, help the client find someone who can. Have a referral policy to emphasise your independence and integrity.

5. Agree on a time-bound therapy plan

Outline your management plan Plain English in the assessment report. Avoid pointless long words.
In the first therapy session, summarise the report and check that you are all on the same page. Be open to revising the plan to accommodate client priorities.
Most clients want a specific time-frame for therapy. Even for severe disorders, I like to offer a short block of initial therapy (say 5 sessions), followed by a review to check progress and to review the management plan.

6. Agree on how you will communicate, and how often

Will you send out interim progress reports? If so, how often? Make sure you don’t overload the client with reports they didn’t ask for (or want).
Has the client consented to receiving reports and other communications by email, or only by post or hand delivery?
Has the client consented to receiving SMS appointment reminders?

7. Know your audience(s)

Check whether your report is to go to the client only, or to others (e.g. schools, employers, etc). Does the client want to see the report first?
When working with children with separated or divorced parents:
- check for Family Court or other custody arrangements about the client’s health care;
- send copies of your reports and other communications to both parents (or other carers) – unless there is a Court or other order or arrangement prohibiting it; and
- if the attending parent asks you not to send the report to the other parent, find out why and assess whether you need consent from both parents to treat the child. If in doubt, don’t treat until you are sure you have all the required consents.
When working with older teenagers, check whether the report should be addressed to the parents, the teenager or both? (Check the age of consent for health treatment in your location.)
If writing for multiple audiences, address both appropriately. For example, if writing for a client with aphasia and their neurologist, present the report using aphasia friendly principles, and then present more detailed data in an appendix for the neurologist.

8. Understand the purpose(s) of your report

Who will be reading the report and for what purpose?
Is the report:
- just for the client’s information?
- a second opinion?
- required to secure funding?
- going to be used in an insurance claim or legal proceedings?
Does the client (or other recipient) have specific requirements for the contents or even formatting of the report?

9. Measure progress and report it to the client

Will you send out interim reports, or something less formal?
How are you measuring whether your therapy is working?

10. Agree on discharge criteria

Have you communicated the length of the proposed therapy block to the client?
Have you given the client the opportunity to give you feedback on their progress?
How will you know when the treatment goals have been achieved?
What are your discharge criteria? Are they the same as your client’s?

Principal source: Maister, D., Green, C.H., Galford., R.M. (2000). The Trusted Advisor. Free Press, NY, NY.

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Writing to persuade people – 21 tips from a professional argument-winner

19 April 2015 By David Kinnane Leave a Comment

Lawyers get paid to win arguments. To win arguments, they need to convince judges and juries. A key way they do this is by writing compelling legal briefs.

Bryan A. Garner is an expert in legal-writing. As the author of several books on legal writing, he knows a lot about winning arguments through clear, persuasive writing. Garner’s “The Winning Brief” contains 100 practical tips for writing persuasive arguments. Most of them apply to all kinds of persuasive writing, including sales, pitches and other presentations. Here are 21 of my favourites:

1. Be organised:

Plan every project. Break it up into small sections; then write each section.
First state the purpose of what you are doing and identify the main issues you will cover. Don’t write to discover your purpose.
Organise the issues from most to least important.
Write the first draft before you edit it. Let it sit awhile before you edit it.

2. Help the reader understand the big picture:

Straight after outlining the purpose and main issues, sum up your argument and your theme in a brief statement.
Weave specific facts into your issues to make them concrete and easy to understand. Don’t just talk about ideas and issues.
Make your points as simply as possible, but no simpler.

3. Write good paragraphs:

Begin each paragraph with a strong topic sentence – tell the reader exactly what the paragraph is about.
Break up long, complex sentences. Aim for an average sentence length of 20 words or fewer.
Bridge from one paragraph to another, but don’t overdo connectors like “further”, “moreover”, “in addition”. Instead, use pronouns (e.g. he, she, it), “pointing words” (like, this, that, these and those) and “echo links” (words that repeat an idea in summary language, e.g. “this rule” to refer to a rule your have just written about at length).

4. Edit for brisk, uncluttered sentences:

Eliminate jargon.
Avoid too much detail in the main body of your work. But don’t put arguments in footnotes.
Put people in your sentences – use real names, not titles or labels.
Search and destroy weak “be” verbs (is, am, are, be, were) and replace them with strong forceful verbs – preferably ones you can picture in your head.
Write in the active voice wherever possible (e.g. “The man slammed the door”, rather than “The door was slammed by the man”).
End your sentences with punch – preferably a strong noun or verb.
Get red of “throat-clearing” filler phrases like (“In my opinion”, “May I respectively submit that”, “It should not be forgotten”, “It is important to remember that”).

5. Choose the best words:

When you edit, don’t just cut words, but also replace boring words with snappy ones that spark interest.
Use interesting nouns and verbs. Minimise adjectives and and verbs.
Use one syllable words when possible. If no one-syllable word exists for what you want to say, aim for two-syllable words.
Simplify wordy prepositions (e.g. replace “with respect to” with “to”, “in order to” with “to”).

Source: Garner, B.A. 1999. “The Winning Brief.” Oxford University Press, NY, NY.