Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Exploring Opportunities for Change
and Improvement in Acute Care
Physical Therapy: Lessons from the
Science of Health Care Improvement
Acute Care Physical
Therapy Landscape:
Where are we and
Where are we going?
Combined Section Meeting 2009
Las Vegas,
Vegas NV February 9-12
9 12,2009
2009
Roya Ghazinouri, PT, DPT, MS
Clinical Supervisor, In-Patient Physical Therapy,
Department Of Rehabilitation Services,
Brigham & Women’s Hospital,
Boston, MA
Clinical Instructor, Adjunct Faculty,
MGH Institute of Health Professions
Roya Ghazinouri, PT, DPT, MS
Yvonne A. Michaud, RN, MS
Daniel W. Ovitt, MS, PT
Melanie Parker, PT
Outline
Combined Section Meeting 2009
Las Vegas, NV February 9-12,2009
Acute Care:
What are the characteristics?
{
{
{
{
{
Acute Care Practice
Current state of healthcare
Change in complex systems
Quality care and quality improvement
Health Care Landscape: Challenges Facing
Hospitals
{
{
{
{
Rising demand/costs of care
z 30% increase
Growing workforce shortage
z Vacancy rate:
{ PT: 13.8%; PTA: 12.0%
Downward pressures on payment rates
Transparency
z Financial
z Quality outcomes
February 11, 2009
{
Care delivery:
z Patient-centered
z Context of illness/setting
z Multidisciplinary
M ltidi i li
care model
d l
Fundamental elements :
z Collaboration
z Accountability
z Health care as a process/system
z Leading, following and making changes
Top Health Industry Issues in 2009
{
Back to basics approach
z
z
{
Focus on performance
z
z
z
{
Deliver value and service
Innovation (do more with less)
Process improvement
Preventing “never events”
Adequate staffing
Preventive care
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Practice/Change in Complex System:
Quality Improvement
Practice/Change in Complex Systems:
{
{
{
{
Structure of physical therapy
z variable in numbers/roles,
z Different documentation/productivity/
system/guidelines
Process of Physical Therapy
{ Consult service
{ Integration of medical/ rehabilitation goals
{ Short length of stay/ Older patients
Outcomes
{
{
{
{
Science of Quality
Improvement
Work force focused
z Staff development/retention
Work process focused
z Systems and processes
Patient centered
z Evidence based practice
Commitment to quality care
{ Align with hospital matrix
{ Manage by facts and not intuition
{ Continuous process
Committed leadership
z Engage and empower
Definition: Quality
{
Institute of Medicine (IOM):
“Quality of care” is the degree to which health services for
individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge.
Roya Ghazinouri, PT, DPT, MS
Clinical Supervisor, In-Patient Physical Therapy,
Department Of Rehabilitation Services,
Brigham & Women’s Hospital,
Boston, MA
Clinical Instructor, Adjunct Faculty,
MGH Institute of Health Professions
Combined Section Meeting 2009
Las Vegas, NV February 9-12,2009
Reports in Health Care Quality
{
{
{
{
Publishing of IOM reports with specific
recommendations to congress: To Err is Human,
1999; Crossing the Quality Chasm, 2001
CMS & Joint Commission
Commission’ss Public Reporting on
Quality Measures on Internet, 2002
IHI 100,000 Lives Campaign, December 2004
CMS P4P4, forthcoming
February 11, 2009
Reports on Health Care Quality/IOM
{
{
{
{
Level A: Experience of patient
Level B: “Microsystems”, small units of care
delivery
Level C: organizations that house the small units
Level D: environment of policy, payment,
regulations, accreditations……
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Health Care Quality/IOM
{
z
z
{
{
Basic Principles:
z
Knowledge based care
Patient-centered care
System minded care
Message:
z
z
z
Work is a process
Process is the main source of quality defect (not
human error)
Understand variability
10 Simple Rules
{
{
{
{
{
{
{
{
{
{
IOM Specific Aims for Quality in
Healthcare:
Quality Improvement
Care is based on continuous healing relationships
Care is customized according to patients’ needs and values
The patient is the source of control
Knowledge is shared freely
Decision making is based on evidence
Safety is a system property
Transparency is necessary
Needs are anticipated
Waste is continuously decreased
Cooperation among clinicians is a priority
Comparison of QA & QI
QA
QI
{
Improve Processes
– Not Fault
Finding
{
Goal
Meet Minimal
Standards
On-going Process
Improvement
{
Who Is
Involved
Usually 1-2
individuals in SNF
Teams
Driven By
Regulation
Accreditation
Organization
When Occurs
Monthly or
Quarterly
Continuous
February 11, 2009
A planned, systematic, reliable approach to
monitoring analysis and improvement of
monitoring,
performance
Quality Improvement Is…
Catch “Bad
Apples” or Detect
Serious Problems
Focus
Healthcare should be:
z Safe
z Effective
{ Evidence based
z Patient-centered
Patient centered
{ Seamless between levels of care
{ Respect and compassion
z Timely
{ Without delay
z Efficient
{ Done without waste( resources, time, people)
z Equitable
{
{
{
The philosophy that employees want to do their best
Focused on improving systems and processes
Based on measurement, data, and facts
Dependent on teamwork and participation by all
Supported by the facility’s culture, practices, and
shared values
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Quality Improvement Dimensions
Empowerment
{Define
Clinical
management
strategies
Quality
management
strategies
Monitoring
{Tools
{Models
{Data
responsibility
{Skill development
{Evaluation and
feedback
{Recognition
{Guiding
principles
{Methods
h d
communication
FOCUS
{
{
{Data
{Data
collection
analysis
reporting
i
{Priorities
{Actions
{Results
l
{
{
{
Thank You
Roya Ghazinouri, PT, DPT, MS
rghazinouri@partners.org
www.brighamandwomens.org/rehabilitationservices
Find a process that needs improvement
Organize a team knowledgeable about
process
Clarify
y the knowledge
g about the pprocess
Understand the causes of variations in the
process
Select the improvement
Culture of Change
Division of Trauma, Burn, & Surgical Critical
Care
American Physical Therapy Association (APTA)
Combined Section Meeting 2009
Las Vegas, NV February 9-12,2009
Yvonne A. Michaud, RN, MS
Trauma and Burn Program Manager
Brigham & Women’s Hospital, Boston, MA
ymichaud@partners.org
Objectives
1. Review key components of change theory
2. Discuss strategies to accelerate the change
3. Describe two steps in cultivating your
change project
February 11, 2009
Lewin’s Change Theory
Basis of many approaches
applied today
___________________________
_________________________
_________________________
_________________________
_________________________
_________________________
____
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Lewin’s Change Theory
{
{
{
Unfreezing, when the change agent is
accepted, the necessity understood and
accepted
Moving to ward the change or “cognitive
cognitive
redefinition”.
Refreezing occurs when change is adopted
Prochaska and Diclemente
Stages of Change Model
{
Prochaska and DiClemente model- developed
more than 20 years ago
{
Used in health care education
{
Cycle of attitudes ranging from denial to
solidly established commitment to change
Rogers’ Diffusion of Innovation
Most important elements effecting acceptance
of new ideas:
1. Perception of value
2 Communication method of ideas
2.
3. Sufficient time to understand, change
attitudes, and make decision
4. Anticipating how people respond to
change
Rogers’ Diffusion of Innovations
Model
Onion Patch
Lonely little petunia?
{
{
{
February 11, 2009
Thinkk big
Thi
bi but
b stay close
l
to your roots
Select efforts within your control
Be patient
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Reorganization of
Take-Aways
In-Patient Physical
Therapy Service:
{
Identify your team early
Service Based Care
{
Communicate vividly
{
Communicate regularly
{
Strategies to “Hold the Gains”
Dimensions of Quality
{
Five Quality rights
{ The right care
{ For the right person
{ In the right place
{ At the right time
{ At the right price
Daniel W. Ovitt, MS, PT
Lead Physical Therapist, Oncology Service,
In-Patient Physical Therapy,
Brigham & Women’s Hospital, Boston, MA
CSM 2009
February 11, 2009
Las Vegas, Nevada
Quality Improvement Is…
{
{
{
{
{
FOCUS
{
{
{
{
{
Find a process that needs
improvement
Organize a team knowledgeable
about the process
Clarify the knowledge about the
process
Understand the causes of variations
in the process
Select the improvement
February 11, 2009
The philosophy that employees want to
do their best
Focused on improving systems and
processes
Based on measurement, data, and facts
Dependent on teamwork and participation
by all
Supported by the facility’s culture,
practices, and shared values
FOCUS
{
{
{
{
{
F: physical therapy service delivery
O: leadership, senior staff
C: history of care delivery
U: variations
i i
iin response times,
i
care
S: redesign of structure of physical
therapy in-patient service
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Applying Concepts of Quality to Delivery of
Physical Therapy in Acute Care
Quality design
z Structure
{ Acute care in-patient physical therapy
{ Align organizational structure with hospital
{ Create
C
t a new staff
t ff role:
l “Lead
“L d Therapist”
Th
i t”
z Process
{ Case load management
z Outcome
{ Right care at the Right time for the Right
patient
{ Staff development, accountability
{ Interdisciplinary collaboration
{
Structure:
{
{
Supervisor
Physical therapy
{ Leadership
{ Staffing
z
z
z
Staff level
Senior level
Clinical specialists
Roles and
responsibilities
Occupational therapy
{
z
Red Team
Blue Team
Green Team
Yellow Team
Director
Supervisor
{
Supervisor
Introduction of “Service Based Care”
z Alignment of our practice with the
hospital organizations’ goals and service
delivery
de
e y model
ode
z Clustering of service lines into teams
managed by “ Lead Therapists”
z Improved dissemination of information
z Collaborative Supervision
Process: Improvement Plan
Supervisor
{
{
OT
Women’s Health
Burns/Vascular/Plastics
ORTHO
Neurology/Neurosurg
TRAUMA
Cardiology/Cardiac Surg
Thoracics/Pulmonary
Gen Med/Gen Surg
ONCOLOGY
February 11, 2009
747-bed acute care hospital/
academic teaching affiliate of
Harvard Medical School.
z Level I Trauma and Burn Care
Center.
z Comprehensive Cancer Center
z Average Length of stay = 4.5 days
Structure: Improvement Plan
In-Patient
rehabilitation
department
z
Structure:
{
Transparency
Staff driven
z Program development
z Staff mentoring/competencies
z Standardizing
d d
care
z Identify areas for improvement
Resource allocation by leadership
z Time
z Space
z “walk the talk”
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Process: Improvement Plan
{
{
{
“Staff empowerment is achieved in a environment of
interdependence and accountability.”
The goal is to create an environment consisting of
mutual respect and unity within the staff and
l d
leadership.
h
Every staff member should feel accountable for their
individual efforts and expertise, taking
professionalism to a new level.
Outcome: What was Improved?
Efficiency and timeliness of care
Interdisciplinary care
{ Program development
{ Staff clinical experience
{ Staff retention
{ Resource allocation
{
{
Hayhurst,Chris. “Autonomous Practice Through
Staff Empowerment”. PT Magazine. Apr 2007.
APTA Vision Statement for Physical
Therapy 2020
Thank You & Questions
“…Guided by integrity, life-long learning, and a commitment to
comprehensive and accessible health programs for all people,
physical therapists and physical therapist assistants will render
evidence-based services throughout
g
the continuum of care and
improve quality of life for society. They will provide culturally
sensitive care distinguished by trust, respect, and an
appreciation for individual differences. While fully availing
themselves of new technologies, as well as basic and clinical
research, physical therapists will continue to provide direct
patient/client care. They will maintain active responsibility for
the growth of the physical therapy profession and the health of
the people it serves.”
Tools for Quality
Improvement
Daniel W. Ovitt, MS, PT
dovitt@partners.org
www.brighamandwomens.org/rehabilitationservices
Quality Care/Big Question
{
Roya Ghazinouri, PT, DPT, MS
Clinical Supervisor, In-Patient Physical Therapy,
Department Of Rehabilitation Services,
Brigham & Women’s Hospital,
Boston, MA
Clinical Instructor, Adjunct Faculty,
MGH Institute of Health Professions
How do we go from “the evidence that says this is the
correct way to manage a patient’ to “how can we make
it happen consistently for each patient?
patient?”
Combined Section Meeting 2009
Las Vegas, NV February 9-12,2009
February 11, 2009
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Outline
{
{
{
Major improvement methodology
Starting point for improvement projects
Improvement tools
z
z
{
Dimensions of Quality
Pillars of healthcare quality
Quality improvement
(outcome management)
Process improvement
p
Quality assurance
Risk management
Care management
Utilization management
Safety and regulatory
Plan-Do-Study-Act
Pl
D St d A t (PDSA)
Lean strategy
Measuring quality
Key Steps:
Starting a Quality Improvement Initiative
Model for Quality
Improvement
Assess
Performanc
e
{
{
{
Evaluate for
Improvement
Identify
Problem
{
Quality
Involve
Employees
Education
&
Training
{
Planning
&
Prioritization
of
Processes
Key Steps:
Starting a Quality Improvement Initiative
{
{
{
{
{
Well planned implementation process
Sufficient resource allocation
Checkpoints and deadlines
Fl ibili andd autonomy to choose
Flexibility
h
approachh
{
{
Do background work
Prioritize potential projects
Prepare for the project
Do an environmental scan
Create a data collection system
Create a data reporting system
Change behavior
Clarify expectations, responsibilities and
accountability
PDSA Road Map
PLAN
ACT
DO
STUDY
http://www.IHI.org/
February 11, 2009
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
LEAN Method
Lean Method: key Concept
{
{
{
{
Driving out waste
Looking
ki at processes
z
z
Interdisciplinary
M
Managers
tteach/enable
h/ bl
{ Seek ultimate performance
{ Root cause analysis
{ Rewards: groups
{ Share information
{ Customer focus
{ Process driven
{
{
Eliminating non-value added steps
Focusing on value
Lean Methodology
Lean Method: Key Concepts
{
Leadership
Culture
Process
z
z
z
z
z
z
Available
Adequate
Valuable
Capable
Flexible
Linked to continuous flow
{
5S strategy:
z Sort
{ What
z
do we need? What can we remove?
Set in order
{ Better
system, better organization, better work habits
z
Shine
Standardize
z
Sustain
z
{ Document
Measurement Guidelines
{
Key measures should clarify the aim and
make it tangible
Don’t track too many process measures (vs
outcomes))
z Use sampling
z Integrate measurement in daily routine
z Plot data on measures over time
z Visually display results
Successful measurement=successful improvement
What Should We Measure
{
Outcome measures
z
z
z
z
z
{
Clinical outcomes
{ Impairment
{ Functional/QOL
Interdisciplinary care/ communication
Staff development/education
Hiring and retention rates
Process measures
z
z
z
z
February 11, 2009
and communicate guidelines
Patient flow/assignment/waiting lists
Organizational design
Referral response
Demand and resources
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Physical Therapy
Following Trauma:
Results from a
Quality Improvement Program
Outline
{
{
Melanie Parker, PT
S i Physical
Senior
Ph i l Therapist,
Th
it
Lead Physical Therapist, Trauma, Burns, Plastics Service
In-Patient Physical Therapy Service
Department Of Rehabilitation Services, Brigham &
Women’s Hospital
CSM February 2009
Creation of the Trauma Quality Improvement
Initiative
Improvement model
z
{
{
Plan Do Study Act (PDSA)
Plan-Do-Study-Act
Results
Lessons learned
Bringing Evidence to Practice
Background
{
BWH Trauma Service
{
BWH Inpatient
p
Physical
y
Therapy
py Service
{
Established care model
{
Pendleton et al. (2007) “Factors affecting length of stay
after isolated femoral shaft fractures”
z Patients seen by PT >1 day after surgery stayed an
average
ave
age oof 1 day longer
o ge than
t a patients
pat e ts seen
see by PT in 1
day or less.
{
Chiang et al. (2006) “Effects of physical training on
functional status in patients with prolonged mechanical
ventilation”
z Muscle strength improved significantly
z Total BI and FIM scores increased significantly
Improvement Model
What are we trying to
accomplish?
HOSPITAL
Aims: Integrate rehabilitation
services into the interdisciplinary
care model.
OUTCOME
ASSESSMENT
SERVICE
Standard of care
What changes can we
make that will result in
improvements?
February 11, 2009
Identify a measure to assess
outcomes
Test changes and see if they are
promising
EDUCATION
REHABILITATION
Process improvement
How will we know a
change is improvement?
TRAUMA SERVICE
PATIENT &
FAMILY
DELIVERY
SEYSTEM
COLLABORATIVE
TEAM
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
Change Cycle- PDSA Road Map
Change Cycle- PDSA Road Map
{
PLAN
z Delivery system:
{ New order entry system
{
New departmental criteria for response to consults
z
PLAN
z
ACT
Within 24 hours of receiving consults
Trauma team (physical and occupational therapists)
Education:
{ Hospital wide education and introduction of project
{ Departmental educational rounds
{ Emphasis on continuity of care
Outcome assessment:
{ Identification of an outcome measure tool
{
DO
z
STUDY
http://www.IHI.org/
Change Cycle- PDSA Road Map
{
{
{
DO
z From August-October 2006
z Continuous monitoring of data and educational needs
STUDY
z Data analysis
z Ongoing re-evaluation
ACT
z New referral response criteria
z Expanded clinical practice
Outcome Tool
{
Acute Care Index of Function (ACIF)
z Developed to standardize the assessment of functional
status in patients with acute neurological impairment
z Found
ou d to
o de
detect
ec change
c a ge in functional
u c o a status
s a us in patients
pa e s
with lower extremity orthopedic problems
z Established as a valid and reliable tool for patients with
neurological deficit
Roach KE, Van Dillen LR. Development of an acute care index of functional status
for patients with neurologic impairment. Phys Ther. 1988; 68: 1102-1108.
DEMOGRAPHICS
DEMOGRAPHICS
Variable
Prospective
(N=96)
Retrospective
(N=67)
Age
Mean: 49.15
(SD 20.9)
Mean: 46.85
(SD 20.4)
Gender
F=22 (23%)
M=74 (77%)
F= 24 (36%)
M= 43 (64%)
White= 71 (74%)
Other= 25 (26%)
White= 49 (73%)
Other= 18 (27%)
Race
February 11, 2009
Variable
Prospective
(N=96)
Retrospective
(N=67)
ISS
11 94
11.94
14 67
14.67
GCS
12.79
13.56
LOS
8.02
9.45
Not to be copied or reproduced without
permission of the authors
Exploring Opportunities for Change and Improvement in Acute Care Physical Therapy:
Lessons from the Science of Health Care Improvement
QUESTIONS
{
How many patients were evaluated within 24
hours of admission
z
{
Question
Who was appropriate for an early evaluation
and who was not?
Variable
Prospective data:
{ 80 patients
p
What was the difference between evaluation
time in the prospective and retrospective data?
z
z
Prospective :
{ 2.19 days from admission
Retrospective:
{ 4.23 days from admission
QUESTION
{
GCS
Within 24 hours Greater than 24
hours
12.91
12.08
ISS
10.96
Age
48.51
16.81*
(p=0.0041)
52.31
LOS
7.49
10.69
Questions
{
What were the reasons for delayed evaluation
by physical therapy?
What is the frequency of physical therapy
interventions and each therapeutic approach?
Prospective:Mean 4.5 days
Retrospective: Mean 3.3 days
z
z
z Patients
P ti t
in
i OR/other
OR/ th procedures
d
unstable
z Rule out tests
{
Frequency of type of interventions:
57% therapeutic exercise
63% Bed mobility
58.7% transfer training
43% gait training
15% pulmonary therapy
68.9% patient and family education
19% splinting
z
z Hemodynamically
z
z
z
z
z
z
Questions
{
Chronic
care
Home
Home
with
SVC
Jail
Morgue
NH/
SNF
Psych
hosp.
Rehab
Pros
0
40
(41.6%)
19
(19.8%)
2
(2.1%)
1
(1%)
0
0
34
(35.4%)
Retro
1
(1.5%)
22
(32.8%)
17
(25.3%)
0
1
(1.5%)
2
(3%)
1
(1.5%)
23
(34.3%)
Does ACIF show change over time for patient
outcomes?
z
z
{
Discharge destination
At initial evaluation:
{ Mean ACIF score: 44.93
At discharge
{ Mean ACIF score: 65.01 * (p
