Team used brainstorming, surveys, committees

Here's how the CQI process worked

The Rehabilitation Cycle of Service team at Gibson Rehabilitation Center in Williamsport, PA, included 16 members from various disciplines and hospital campuses.

The initial committee included a patient, but when he could no longer serve, the team was too far into the project to bring another patient up to speed and relied instead on written and telephone surveys for patient input.

"Because of the diversity of our team members' professional backgrounds, we spent a lot of time initially understanding and defining the scope of rehab services within our health system," says Julie Hawkins, OTR/L. Hawkins is program director for neurologic rehab service occupational therapy and team leader of the continuous quality improvement project.

Look across the continuum of care

The team began by identifying the customer as the patient and the continuum of care as acute rehab services, the inpatient rehab unit, home health rehab, and outpatient rehab.

During a brainstorming session, the team devised a list of potential areas for improvement. It surveyed the rehab staff throughout the continuum and asked them to determine the top opportunities for improvement. Discharge coordination topped the list.

The staff consensus was backed up by a written survey sent to all patients who received rehab services in February 1996.

The discharge area also had the greatest number of negative ratings on the patient survey, Hawkins says. The team formed subcommittees to map out the discharge process from the patient's standpoint. They devised flowcharts for each part of the continuum that showed each step patients went through in the discharge process. They asked staff outside the committee where snags occurred and identified the causes of the problem.

The top issues that surfaced repeatedly were delays in completing details of discharge, duplication of services, and lack of patient focus, Hawkins says. They concluded that the "root causes" of those problems were the following:

· Patients were not involved in planning their discharge.

· Patients did not understand the criteria for discharge and were not ready for it.

· Coordination and communication with patients and their families needed improving.

To further confirm its findings, the team added a question on discharge procedures to the telephone follow-up surveys of former patients. Nearly half (48%) of the randomly selected patients contacted by phone 100 days after discharge answered "no" to the following question: "Did the rehab staff involve you in decisions about your discharge?"

After identifying the problems, the team brainstormed to develop potential solutions. Their recommendations were divided into four major areas: tools, role definition, team conferences, and environmental issues. The team then divided into smaller committees that developed a total of 21 possible solutions to the problems.

The team has surveyed patients again to determine if the changes in the discharge process have increased patient satisfaction. It continues to monitor progress.