quality improvement for rehabilitation intensity...brag and steal jana roth performance indicator...
TRANSCRIPT
Quality Improvement for Rehabilitation Intensity
CESN Stroke Rehabilitation Forum
March 21, 2017
Part 2 of 3
Brag and Steal
Andrea GuthWaterloo Wellington District Stroke Coordinator
Grand River Hospital
REHAB INTENSITY
Strategies to get there
March 21, 2017
OBJECTIVES
• Understand the Grand River Hospital Inpatient Rehabilitation Unit
• Review the catalyst for change, including Waterloo Wellington stroke system changes
• Discuss strategies to increase rehabilitation intensity
• Review data demonstrating outcomes of change
• Discuss challenges encountered
INPATIENT REHABILITATION UNIT
• 33 beds
• 18 stroke beds, 15 mixed rehab beds
• Geographically separated on two courts
• Medical coverage with 2 family physicians
2 days per week, 3 days per week
• 4 OT’s, 4 PT’s, 3 TA’s, 1 SLP, 0.6 CDA, 0.6
SW, 0.4 REC, RD
BEFORE AND AFTER
Prior to 2013
• 3 OT’s, 3 PT’s, 2 TA’s
• No OT/PT teams
• Ratio 1:11 for all patients
• All staff attend MDT
• Discharge dates
established based on
team discussion
• Communication with
family as needed
After 2013
• 4 OT’s, 4 PT’s, 3 TA’s
• OT/PT therapy teams
• Stroke 1:6, Mixed 1:15
• One team member attends MDT for group
• Discharge dates established using RPG LOS targets
• Discharge letters/family meeting within 7 days
MODEL OF CARE
• Implemented in 2013
• Integration of therapy staff into morning care routine
• Nursing and therapy communication
• OT’s and TA’s working 0700 – 1530
• PT’s working 0800 – 1600 OR 0830 – 1630
• ADL assessment/practice
• Transfers/ambulation
• Assistance in dining room with containers and U/E tasks
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
0730 - 0800 ADL’S ADL’S ADL’S ADL’S ADL’S ADL’S ADL’S
0800 - 0830 TNSF/AMB TNSF/AMB TNSF/AMB TNSF/AMB TNSF/AMB TNSF/AMB TNSF/AMB
0830 - 0840 ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN
0840 - 0900 BULLET RDS BULLET RDS ADMIN ADMIN BULLET RDS BULLET RDS BULLET RDS
0900 - 0945 PT CARE PT CARE PT CARE PT CARE PT CARE PT CARE PT CARE
0945 - 1030 MDT MDT
1030 - 1115
1115 - 1200
1200 - 1300 LUNCH LUNCH LUNCH LUNCH LUNCH LUNCH LUNCH
1300 - 1345
1345 - 1415
1415 - 1500
1500 - 1530 ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN
GROUP PROGRAMMING
• Sit < - > Stand group
• GRASP group
• L/E group (seated and standing)
• U/E group
• Aerobic training group
• Meeting needs of all patient groups
• Goal: increased goal directed therapy, increased patient activity throughout the day
OUTCOMES
CHALLENGES
• Senior leadership engagement and commitment to achieve QBP targets essential
• Roles and responsibilities in morning care (for therapy staff and nursing)
• FIM documentation
• Staffing (part time availability)
• Staff from other areas not comfortable providing care on unit
QUESTIONS
Brag and Steal
Jana RothPerformance Indicator Specialist, Decision Support
& Mary Jo DemersProfessional Practice Leader, Physiotherapy
Providence Care, Kingston, ON
Rehabilitation Intensity Implementation
Towards 180 minutes/day
Mary Jo Demers, Professional Practice Leader, Physiotherapy
Jana Roth, Performance Indicator Specialist, Decision Support
Key Initiative
GOAL: Provide 180 minutes of therapy per day for 5
days/week
• Formation of a small Rehab Intensity Working Group
• One SLP, OT, PT
• Program Manager
• Decision Support representative
• Regional Stroke Rehabilitation Coordinator, SEO Stroke Network
– Bi-weekly meetings
– PDSA cycles designed, implemented
– New PDSAs based on outcomes of previous
– Discussions led to improvements beyond PDSAs
What Worked
• Meetings with PT, OT, SLP staff and assistants
Needed to a common dialogue and understanding of RI and clear
guidelines for documenting RI in workload system (Emerald)
Initiatives
– Development and distribution of an informational pamphlet about RI
– Distribution of PDSA documents and Quarterly RI Report by Patient
– Discussions about definitions and challenges in delivering
recommended RI and documentation of RI in Emerald
– Review of RI data entry using specific clinical examples
– Opportunity for Q&A, clarifications by individuals therapist/assistants
– Provision of instructions for staff on “How to Obtain RI Minutes by
Patient from Emerald”
Successes
• Meeting with PT, OT, SLP staff and assistants
– Increased understanding of RI by allied staff and assistants
– Improved utilization of assistants (PTA/OTA/CDA)
• Concern around 30% contribution
• Inclusion in quarterly Stroke team process meetings
– Increased understanding of importance of accurate
documentation in Emerald
• Self-monitoring checks using in Emerald to verify one’s own data entry and
need to monitor patients’ RI time in real time
• Identification of possible benefits of tracking a patient’s RI time by discipline
in real time and making adjustments
Successes (cont’d)
• Meeting with PT, OT, SLP staff and assistants
– Identification of areas for improvement
• Staff shared tips for using Emerald system and suggested these should be
included in Emerald training for new staff
• Staff raised possibility of being able to see days patients cancelled or were
no shows to therapy
• Staff requested quarterly meetings to go over the RI Reports and discuss
what data means with regards to service delivery and interventions
– Informed process for new staff orientation as well as existing
staff refreshers on RI documentation in Emerald based on
identified gaps
What Worked
• Collaboration with Decision Support
Team needed better and easier to understand data
Initiatives
– Development of reports for monitoring and selection of
quality improvement opportunities
• Evolution of reports based on face to face discussions
and feedback from RI Working Group as well as entire
Stroke Team
• Detailed RI data at patient level by discipline along
with other key data points
• Trend report
Reports
Reports
Quarterly report available for team to monitor progress towards targets of 180 min
Reports
Successes
• Collaboration with Decision Support
– Reports posted quarterly on shared drive for access by
full stroke team, discussed in Workgroup meetings,
presented at Stroke process meeting
– Resulted in improved staff awareness and education on
data collection and definitions
– Provided support for team discussions on RI
Barriers
• Turnover in allied staff
• Competing organizational priorities
– Move to new hospital
• A 5 day/week therapy schedule is a serious
constraint to reaching 180 minute/day RI over a 7 day
period
Lessons Learned
• Having the right people at the table is crucial
– Dedicated to team and passionate about RI
– Frontline staff supported by Decision Support and
Management
• All therapists and assistants want to see
performance data, receive feedback and help
make improvements to reach RI goals
• Time to dedicate to RI Workgroup meetings and
initiatives is crucial
Future Initiatives/Ongoing Work
• Ongoing discussion with front line staff/managers to
identify gaps and find opportunities to increase RI
• Continue to review RI data quarterly
• Use RI Report to compare attendance days and active
rehab LOS
• Implement RI Tracking PDSA for full stroke team
– Educate on use of RI tracking tool
– Use weekly to attempt to maximize RI
• Continue to inform the process for staff education on RI
documentation in workload tool to ensure consistent
data entry
Highlights
Questions
If you would like a copy of the
report templates or have
other questions please feel
free to contact us:
Mary Jo Demers
Jana Roth
Towards RI - 3 Hours/Day
• OSN Education Materials/Webinars• Data field implemented in Emerald• Staff “education” and go live April 1, 2015
• Stroke team identified areas of opportunity• Team members attended symposium• Learning about PDSAs and Data
• Team: clinical, management, decision support
• Gaps identified: knowledge & access to meaningful data
• Staff engagement/education• Team friendly data report
developed
April 2015RI: mandatory data field
November 2015SEO RI Symposium
December 2015 SMOL RI Workgroup
formed
Jan – May 2016Focus on data quality
• Sharing work to date
• Reviewing data
• Consider change test
June – Sept 2016Focus on readiness for change
Kn
ow
ledge/R
eadin
ess fo
r Ch
ange
Brag and Steal
Mila Bishev, Patient Care ManagerNeurology, Stroke and Oncology Programs
& Gina Lam, Physiotherapist
St. John’s Rehab, Sunnybrook Health Sciences Centre
Striving towards Rehab Intensity on Inpatient Stroke Rehab at Sunnybrook
– St. John’s Rehab
March 21, 2017
REHABILITATION INTENSITY is the amount of time
the patient spends in individual, goal-directed therapy,
focused on their physical, functional, cognitive,
perceptual and social needs.
180
MINS
of individualized daily therapy
(PT/OT/SLP), with no more than 30 per
cent provided by support personnel
(over 6 days/week)TA
RG
ET
Rehab Intensity
Additional
therapy space
with equipment
Treatment models
• More
individualized
therapy versus
group therapy
• Dual roles of
PTA/OTA
Avg. RI = 73 mins(2012)
Avg. RI = 119 mins
(2016)
Revised staffing
ratios
• More clinicians
see fewer
patients for
more time
• 1:6 for OT & PT
1:12 for SLP
?
Creation of a
Stroke cohort
• geographically
defined section of
unit
Team communication processes
• Creation of sub-teams of
NRSG/PT/OT/SLP
• Stroke huddles
• IPC rounds
Modified workload
measurement
• integrating current
categories with
new Rehab
Intensity activities
HOW WE ARE STRIVING TOWARDS
REHABILITATION INTENSITY?
Individual Care Plans
Rehab Intensity
Stroke Huddles
IPC rounds
Caseload Boards
Weekly RI reports
Sub-Teams
Dividing 180 minutes across OT/PT/SLP
Patient A- More cognitive issues- 80/40/60 minutes
Patient B- More speech issues- 40/60/80 minutes
Sunnybrook- St. Johns’ Rehab A3 team
Contact Us
Mila Bishev
Patient Care Manager A-3 Neurology, Stroke and Oncology ProgramsSt. John’s Rehab Sunnybrook Health Sciences Centre
(phone) 416.226.6780 x 7029