The Road to PPS Success

Team conferences lower hospital’s length of stay

Technology, paper forms increase efficiency

A green monster may not be the first thing you would like to see when you get to work in the morning. But for one rehab hospital, the green monster has been a key to successful implementation of the inpatient prospective payment system (PPS).

At National Rehabilitation Hospital (NRH) in Washington, DC, a bright green pen-and-paper form has taken up residence in each patient room to help team members document the initial functional independence measure score required under PPS. The green form is hard to miss, but if someone neglects to record a score in the required first three days, the hospital’s PPS coordinator will make sure it gets done.

"Before PPS, we used to rate the patient as to level of function. With PPS, you have to rate what the burden of care is," says Rosemary Welch, RN, MSA, CNA, vice president for patient care services. "It’s very important for all team members to do the ratings. If the patient had one incontinent event in the middle of the night, the day nurse wouldn’t know about it. That one event creates a whole list of actions nursing must do — look at medications, clean up, notify the physician. We would have missed that had we only been rating them the old way, which was usually on the day shift. It has made us more aware of what happens to the patients. Obviously, the patients get better care the more we know about them."

NRH also has changed to daily team conferences and has added a nurse coordinator with no patient load to ensure communication and follow-up with nursing staff.

It’s working. In the first two months of using the system, NRH’s average length of stay (LOS) dropped two days to 18 days, the lowest in the hospital’s 17-year history. NRH has maintained that LOS for more than a year. The hospital, which had budgeted for a first-year $1 million loss due to PPS, ended up in the black. But more important, patients are benefiting from a more cohesive, efficient approach to care.

Cathy Ellis, PT, director of physical therapy, occupational therapy, vocational rehab, and therapeutic recreation, says while PPS has its problems, the new system has resulted in positive changes at NRH. "It has improved our team functioning. The real positive thing has been the way we approached PPS from the perspective of process improvement," she says. "The entire team was included in the process, from staff level up to VPs. Our medical director was integrally involved. We didn’t fall into a situation of we hate PPS.’ Instead, we improved our team function."

The NRH staff is most proud of the redesigned team conference system, which grew out of an intensive benchmarking process. "Each team member called several facilities they were familiar with, and we did conference calls and a site visit. We looked at best practices, examined data, and pulled in standards from the Commission on Accreditation of Rehabilitation Facilities and the Joint Commission on Accreditation of Healthcare Organizations," Ellis says. "Our goal was to create a patient-focused model of care that would actually improve the quality of patient care. We knew we wanted a model that was patient-focused, with a highly integrated team that would allow us to manage our patient care tightly day to day."

Previously, team conferences were held twice weekly for one to one-and-a-half hours. Each patient would get a formal conference once a week. But the meetings were not particularly efficient, and team members were concerned about fragmentation and confusion over such issues as discharge dates, Ellis says. Now, the teams meet daily for half an hour, with two to four patients scheduled for formal conferencing on a rolling basis. The case manager runs the meeting, which begins with a five- to ten-minute discussion on big issues such as pain management or discharge plans and moves on to the formal conferencing.

One logistical hurdle was setting a time for the meetings that could accommodate the schedules of physicians, nurses, therapists, case managers, social workers, and psychologists. The hospital settled on meetings at 8:30, 9, and 9:30 a.m. and another at 1 p.m. for its various teams.

Because nurses busy delivering patient care often missed the team conferences under the old system, NRH appointed a nurse coordinator with no patient load to attend the meetings. "She serves as the liaison between the team and the nursing staff," Welch says. "Nurses often felt they were out of the loop on the team conferences, but it is so important to have their input. We also get improved action because now there is somebody to actually follow through. The nurse coordinator doesn’t have a patient load, so if there’s some piece of equipment that needs a rush order or a different dressing needed, she has the ability and the time to get it. It relieves stress for the nurses."

Ellis notes that the nurse coordinator provides cohesiveness to a staff of constantly rotating nurses. "The coordinator position is full-time permanent, and she is at the team conference every day," Ellis says. "She communicates regularly with front-line staff nurses who are delivering most of the care to the patient."

The team’s case manager runs the meeting, and it falls to that person to prepare reports on the patients ahead of time. The advance preparation, while time-consuming for the case manager, makes the meeting much more fruitful, Ellis says. The hospital has alleviated some of the burden on the case managers by making their conference report also serve as their weekly progress note for therapy. Because the reporting has already been done, conference time can be used for productive discussion on how to address any issues. "We put the report up on a screen at the front of the room," Ellis says. "Everyone can see the report, whether the patient’s goals are being met or not met, any barriers to achieving their goals, and adjustments to the treatment plan."

Paul Rao, PhD, vice president for clinical services at NRH, says another component of the hospital’s PPS success has been the change to eRehabData, the web-based outcomes system offered by the American Medical Rehabilitation Providers Association. During team conferences, case managers can modify the report on-line and can even interject benchmark data simultaneously.

Another benefit is that physicians have easy access to the data. "We now have physicians every morning looking at how their program is doing. That was never the case before," Rao says. "They used to have to wait three months for the data. Web access has allowed every physician and every manager to see how their patients are doing compared to the nation, how we did over the last three quarters, how we did today. It’s a huge change in terms of how our physicians have been analyzing data and managing results." 

Need more information?

Rosemary Welch, RN, MSA, CNA, National Rehabilitation Hospital, 102 Irving St., N.W., Washington, DC 20010. Telephone: (202) 877-1000.