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Rehab facilities, like other health care organizations, will be increasingly focused on outcomes and quality in coming years as the prospective payment system and other market forces push the industry to find new ways to do everything better. While rehab therapists and other staff immediately think of clinical care when they hear the word "quality," there’s another aspect of health care quality that cannot be overlooked, and that is quality in documentation.
St. Francis Specialty Hospital in Monroe, LA, formed a quality team in 1996 to look at improving the 30-bed rehab department’s medical record charts and documentation, says Eileen Stephan, PT, MA, administrative director of rehab services. "Accreditation agencies wanted more interdisciplinary collaboration, and so they were looking at documentation," Stephan says.
The quality team consisted of administrators, rehab nurses, physical therapists, a recreational therapist, a speech therapist, a dietary specialist, and a social worker. They found that there were 18 steps and nine disciplines involved in a case before patient assessment was considered complete. The team identified 815 items and 101 of them were duplicated on the assessment forms. The combination of duplication and complexity of the assessment process made frequent errors likely, says Stephan. "We decided we definitely needed an improvement," Stephan says.
Here are the steps the team took to improve assessment documentation:
1. Analyze assessment procedure.
The team wrote a goal that states, in part: "The current process causes customer frustration, lacks efficiency and timeliness, is repetitious, fragmented, and costly (staff time involved), and improvement should result in improvement of quality and efficiency of patient care with improved integration of services for the patients and staff on the rehabilitation unit."
The multidisciplinary quality team developed a flow chart that outlined the current procedure. The flow chart listed each of the 18 steps taken during assessment, along with the therapists and other disciplines conducting each of those steps. For example, one flow chart box reads, "Nurses assess within two hours, complete within 24 hours." Part of the analysis involved obtaining input from former rehab patients in focus groups.
2. Rewrite the assessment tool.
Convinced by the focus group response, the team decided to eliminate all duplication on the assessment by giving all disciplines the same assessment tool to complete. The team worked together to create a 12-page assessment tool with 250 items and no duplication. After the assessment was complete the team presented it to the staff for comments and to involve everyone in the process since some employees were concerned about the idea of using a single assessment tool for all disciplines. "The change from owning their own assessment to putting it into one was a little bit of a problem," Stephan says.
An interdisciplinary assessment staff survey, conducted in August 1997, showed that all of the staff agreed that the new tool reduced the number of repetitious questions, and most rated it as significantly improved. But some employees were less pleased with the amount of time they would spend on the assessment and how helpful its information would be.
3. Rewrite and improve assessment form.
By the end of August 1997 the quality team made three major revisions of the form and many minor revisions, incorporating some of the suggestions from staff. Then in 1999 the rehab facility switched the assessment tool to a computerized format. "We looked at all of this and decided we needed some revisions," Stephan recalls. "We streamlined it into using check items."
The new form was more concisely organized, with boxes and bold-faced categories in which staff put check marks at appropriate responses. The first revision was called the Transdisciplinary Form and the newer version was named the Interdisciplinary Assessment Form. (To see sample pages of first revised form and latest revision in PDF format, click here.)
4. Write care maps to accompany assessment documentation.
In addition to improving the rehab facility’s assessment documentation, the quality team worked on improving the overall quality of care by making standard guidelines through the creation of care maps. The quality team researched what other facilities were using for care maps and then created their own care maps to fit the hospital’s needs.
The completed care maps include one for general rehab, stroke, amputee, hip replacement, knee replacement, brain injury, burn treatment, and spinal cord injury. Each care map seven or eight pages long. Since the rehab facility now has documentation on the computer, it is easier for staff to retrieve and print out copies of the care maps. The care maps have five categories, corresponding to five columns on a printed page: stage one, stage two, stage three, stage four, and stage five.
Staff were instructed to follow the care map, recording variables when there is some treatment or circumstance that falls outside of the care map, which are in a checklist format. Then under each of the four areas the staff can check whether the task was completed, whether a variable was needed, or whether it was not applicable. Beside each of those items, there is a place to date it.
5. Assess outcomes and audit documentation.
Stephan began to assess the number of errors on documentation forms soon after the facility began using the new assessment tool. She found about 50 errors on the assessment tools. However, after staff education and revision of the tool, the error rate began to decline. By the end of 2000, Stephan could find only three errors, and the therapists and social workers had a 100% rate of completion on the forms. Previously the completion rate had been a bit of a problem, she acknowledges. To improve the completion rate, managers told the staff that the assessment tool was owned by all disciplines and if any member of the staff saw an incomplete area that person was to complete it if he or she had the skills to do so, Stephan says.
Also, each rehab team has a coordinator who is held responsible for making sure the assessments are complete. "Everyone understands how to do both the assessment and care maps," Stephan says. "And everyone is pretty much happy with it."
• Eileen Stephan, PT, MA, Administrative Director of Rehab Services, St. Francis Specialty Hospital, P.O. Box 1532, Monroe, LA 71210-1532. Telephone: (318) 327-7046.