CQI improves discharge process, satisfaction

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 and coordinating the discharge planning process for rehab.

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.

In an initial telephone survey in 1996, only 52% of patients 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" to that question.

Identify all potential customers

Susquehanna Health System has a commitment to improving customer service, whether its 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 big 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 that 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 story, p. 97.)

"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 develop action plans. Among the changes they suggested and implemented were these:

o Forming a weekly discharge planning group for new neurology patients.

Run by a social worker and attended by the therapists, the group is for all new patients on the neurology unit. Patients are asked upfront to decide where they want to go and what the treatment team can do for them. Groups have ranged from one to six patients, 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 work out discharge issues further. If a patient is unsure of family support at home, for instance, 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.

o Creating a collaborative home program packet for all patients.

In the past, each therapist would give home instructions and hand-outs. The team devised a coordinated package that includes 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.

o Designating a discharge coordinator for each 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 workers coordinate all the discharge planning. She will set up the family training sessions, for instance, but the therapists handle them.

o 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 take a more active role in helping hospital staff determine the most appropriate placement for patients after discharge. Therapy staff participate in the acute care discharge planning meetings. 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.

o Creating 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 team member writes findings and recommendations on the form and goes over them 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.

o Putting the entire treatment team in the same office.

At the time of the CQI project, the rehab center was in the middle of 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.

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

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

o 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 modifications are needed to maintain satisfaction as 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.]