CQI project improves discharge process

Project won health system's quality award

A continuous quality improvement (CQI) project to improve the discharge process has resulted in increased patient satisfaction at Gibson Rehab Center in Williamsport, PA.

The team that developed the project received the Susquehanna Health System's 1997 Chairman's Quality Award for its work on improving the rehab discharge planning process.

Recently discharged patients who responded to a written survey gave the discharge process an overall mean score of 3.34 (on a scale of 1 to 4) before the CQI project, and an overall mean score of 3.67 after the project. Overall satisfaction with the rehab process jumped from 3.64 to 3.84.

On an initial telephone survey in 1996, only 52% of patient responded "yes" to the question: "Did the rehab staff involve you in decisions about your discharge?" A year later, 100% of patients surveyed by telephone responded "yes."

Susquehanna Health System has a commitment to improving customer service, whether the customers are physicians, payers, or patients, says Julie Hawkins, OTR/L, program director for neurologic rehab services at Gibson Rehab and team leader of the Rehabilitation Cycle of Service Team. The team's duties include examining everything a patient goes through while in the system and coming up with ways to improve customer service.

Top quality customer service is particularly important at Gibson rehab because there are two other major rehabilitation providers in its market area, Hawkins adds.

A 16-member team from various disciplines and hospital campuses conducted the 15-month project to improve customer service. They were charged with identifying areas that had a strong effect on customer service and suggesting better ways of delivering those services.

Both the rehab staff and former patients ranked the discharge process as the top area where improvement was needed.

The team looked at the discharge process throughout the continuum of care, including acute rehab services, the inpatient rehab unit, home health rehab, and outpatient rehab. (For details on how the committee worked, see related article on p. 162.)

"We were looking at the patients' perception of their involvement in discharge, their feeling of being prepared to go home, and how coordinated we were in the discharge process," Hawkins says. After determining the problem areas in discharge planning, the team brainstormed to come up with potential solutions and divided into small groups to come up with action plans. Among the changes they suggested and implemented were:

· A weekly discharge planning group for new neuro patients.

The group is run by a social worker and attended by therapists, and is for all new neuro unit patients. Patients are asked up front to decide where they want to go and what the treatment team can do for them. Meeting attendance has ranged from six patients to one patient, depending on the number of admissions during the week.

Based on what happens in the group, the social worker may schedule individual or family conferences to further address discharge issues.

For instance, if a patient is unsure of family support at home, the social worker will schedule a family conference to find out more about the patient's situation, rather than dwelling on it in the group.

· A collaborative home program packet for all patients.

In the past, each therapist would give home instructions and handouts. The team devised a coordinated packet that included all the information a patient needs for discharge. The home instruction packages are available on computer to allow for customizing instructions as needed for individual patients.

· A discharge coordinator for each treatment team.

A social worker assigned to each team acts as the contact person between the patient, family, and clinical staff. Initially, the social workers were assigned to take care of all the patients' discharge needs, but the job proved too much for one person, Hawkins says.

Now, the social worker coordinates all the discharge planning. For instance, she will set up the family training sessions, but the therapists handle them.

· Improving communication between the acute care therapists and the medical staff in planning discharge.

The therapists who work with patients in the acute care hospital now are taking a more active role in helping the hospital staff determine the most appropriate placement for patients after discharge. The therapy staff now participates in the acute care discharge planning meetings. The acute care therapy staff have moved their office from the rehab department to the acute care hospital to facilitate communication.

"The therapists now are taking a more active role in driving whether a patient who needs further rehab services gets them at the skilled nursing facility, with home health, or inpatient rehab," Hawkins says.

· Creation of an interdisciplinary communication sheet for the home health therapy staff.

Because different members of the home health treatment team see patients at different times, they found it difficult to communicate. The team developed a form that is kept in the patient's home. Each member of the treatment team writes his or her findings and recommendations on the form, and goes over it with the patient.

"Since it is in the patients' homes, they know what's going on. In the past sometimes they might not realize that their treatment was coming to an end," Hawkins says.

· Putting the entire treatment team in the same office.

At the time of the CQI project, the rehab center was involved in a re-engineering project that switched from a discipline-specific model to a service-line model. As part of the move, the discharge planning CQI team strongly recommended that all members of a treatment team be in the same office.

"This way, they can be planning not only the treatment but the discharge every day," Hawkins says.

· Providing specialized home health aides for rehab patients seven days a week.

The home health agency trained some of its aides specifically to work with rehab patients.

· Designating a rehabilitation nurse to perform every rehab admission to home health.

The team also recommended cross-training a weekend nurse in rehab procedures to ensure consistency.

The team is monitoring the recommendations and will decide what needs to be modified to continue to make satisfaction a high priority. Questions on discharge are included in the follow-up telephone calls for patients.

For more information, call Julie Hawkins at (717) 321-3728.