Quality review involves team, not management

System has sparked changes in rehab program

When it comes to quality review, the staff involved in hands-on care is much quicker than management to pinpoint a problem or come up with a solution, assertsKathryn Foster, RN, MSN, CRRN, clinical specialist for the Rehabilitation Center at Moses Cone Hospital in Greensboro, NC.

"The staff have their finger on the pulse of what is happening on the unit at all times," says Foster, who facilitates the center’s quality review process.

The quality review process at Moses Cone is conducted solely by staff who provide hands-on patient care. Staff feel empowered because they have the opportunity to identify issues and make changes. Staff also recognize the quality review process as an opportunity to discuss difficult cases and to be reviewed by their peers in a constructive manner, Foster adds.

Based on input from staff involved in the quality review process, the hospital has identified the need for case managers to coordinate care, improved documentation of patient attendance at therapy, and added a safety component to its patient education program.

The hospital developed and implemented its quality review process in preparation for the 1995 accreditation survey from CARF...The Rehabilitation Accreditation Commission.

The staff spent a lot of time reviewing CARF’s requirements for "Assessing the Quality of Services Provided to the Persons Served," outlined in the CARF manual, and talked with other rehab providers about their successes and failures in developing a quality review process, Foster says.

The review of other organizations revealed that many simply rely on quantitative medical record reviews and audits, which are used by administrative and supervisory staff to implement changes. Most did not review the findings with the treatment team, Foster says.

"Our staff felt strongly that our review process should be more interactive and should include a case review, in addition to the required medical audit," she says.

The nuts and bolts

At Moses Cone, the quality review process is called Quality Review Rounds. Here is how it works:

Two groups of staff are involved in the quality review process at Moses Cone: a quality review team, made up of staff who did not treat the patient; and the care provider team, comprising staff who did. The quality review team audits the records and shares its findings with the care provider team. The two teams come up with conclusions and recommendations.

Each month the quality review team audits the medical records of one or two current patients or patients who have been discharged within the past three months. Staff often suggest complex cases for the quality review process, Foster says.

If the staff haven’t suggested a patient, Foster chooses patients at random. She monitors the selection process to make sure there is a representative sampling of patient diagnoses.

The Quality Review Team includes a physiatrist, a registered nurse, a physical therapist, an occupational therapist, a social worker, a recreational therapist, and a case manager. Speech- language pathology and psychology are included if necessary.

The Moses Cone rehab staff is assigned to one of three treatment teams: brain injury, orthopedics, or stroke, each of which is designated by a letter of the alphabet. The quality review process is set up so that no team reviews its own patients, Foster says. For instance, if Team B treated the patient, Team A will automatically be designated the quality review team.

First, each member of the quality review team completes an audit of his or her peer on the treatment team being reviewed. In other words, the physical therapist reviews the PT records. The questions come directly from the CARF standards and examine the individual treatment plan for completeness and timeliness.

The second part of the review uses a questionnaire — developed by the Moses Cone staff — which guides the reviewers through an analysis of the services provided from initial screening through discharge and follow-up.

Among the questions included are:

• What was the overall goal for rehabilitation?

• Is there evidence the patient/family was committed to this goal throughout the admission?

• Was there evidence of team collaboration?

• Were all outcomes goals met? If not, are the reasons documented?

• What did the treatment team do exceptionally well?

• What could it have done differently?

Once the audits are completed, the two teams meet for a quality review conference, which is coordinated by the rehab clinical specialist.

The two teams review the services provided to the patient and family and outline any recommendations for changes. Foster writes a conference report and shares the feedback at all staff meetings and management team meetings. The reports are kept in a quality review notebook to which all staff have access.

"The process helps us identify areas where changes are needed, but there have been patients where we concluded that there was nothing we could have done any differently. In these cases, we concluded that the staff deserved a pat on the back for the way they handled the case," Foster says.

At least twice a year, staff review the records of a patient who was served by all levels of the rehabilitation continuum: acute, subacute, comprehensive inpatient, and outpatient. The chart review process is the same, but the conference also focuses on how each level communicated with the next. Among the issues discussed are:

• Were goals and treatment plans shared?

• Was there duplication of paperwork that could have been eliminated?

• Was the overall goal for rehabilitation consistent throughout the patient’s rehabilitation and recovery?

• Did the treatment teams communicate relevant patient information that could have affected the length of stay and achievement of outcome?

The continuumwide audit is conducted by rehab staff because patients tend to stay longer in rehab than in other parts of the continuum, Foster says. The other three departments are asked to audit their patient records and attend the quality review conference.

The quality review process at Moses Cone has prompted major, far-reaching changes as well as smaller ones. Here are a few of them:

Institution of a case management system. The staff concluded that many patients and families were coming into the rehab center with little idea about how the rehabilitation process worked and that more coordination was needed among payers, the hospital, and the families.

Improved documentation of therapy hours. There was no structured communication process to keep physicians, payers, and staff informed about patients’ attendance at therapy sessions. Review showed that some patients were getting only two hours of therapy a day, which had the potential to create reimbursement problems. ow patient therapy hours are tallied at each team conference.

Revisions of the education flowsheet to include safety issues. The quality review team concluded patients were not getting enough safety training.

Development of a carbon form for physician consultations conducted at the acute care hospital. In the past, the form stayed with the acute care record, and the rehab staff had difficulty finding out what consulting physicians had in mind when they recommended patients for rehab.

[Editor’s note: The quality review standards are in Section III-B of the CARF Standards Manual and Interpretive Guidelines for Medical Rehabilitation. For more information on the Moses Cone quality improvement project, contact Kathryn Foster at (910) 974-7900, ext. 3045.]