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    Rehabilitating Rehab

    Impact of transdisciplinary collaboration in design and cultural transformation on operational and quality outcomes

    By Cathy Kennedy, P.T., Therapy Manager

    Davies Campus inpatient rehabilitation roomThe environment is a constant partner in our daily activities. Where are you now while you are reading this? Is the noise level distracting? Can you think of furniture you avoid because it is uncomfortable?
    Are there places you steer clear of because you don’t like the way they affect you?

    Forty-two years ago, the first hospital in California designed specifically for inpatient and outpatient physical rehabilitation was built in the present location of California Pacific Medical Center’s Davies Campus. That hospital, R.K. Davies, was a model of innovation for rehabilitation services and accessible design at the time it opened in 1968. But sometime between its creation and the year 2000, cultural priorities changed. The environment proved distracting to patients, visitors, and employees. Complaints about noise had become continuous, patients had difficulty sleeping, and visitors were uncomfortable. Privacy was a challenge. Prospective patients often went elsewhere, preferring private rooms to effectiveness. Ten years ago the CPMC acute rehabilitation leadership team could no longer envision a dynamic and successful future without redefining the rehabilitation environment and the delivery of care.

    For the most part, the impact of the environment we inhabit from moment to moment does not typically cross the threshold of our conscious awareness unless it causes noticeable satisfaction or frustration. But people with musculoskeletal or neurological impairments are more likely to find the causes of frustration pervasive in the environment. They are more likely to find that the environment itself imposes disadvantages to their participation in activities they want or need. In other words, the environment alone can be a cause of greater disability. Those same environmental factors may also affect the ability of people to aid and assist others. In contrast, an environment intentionally designed and constructed to minimize disability can promote independence for people with impairments; and it can support a highly skilled clinical team in helping its patients achieve superior rehabilitation outcomes. With this recognition, a strategic vision of a new era in CPMC’s acute rehabilitation level of care was launched. That vision became clarified through establishing the business context for what has become California Pacific Regional Rehabilitation Center.

    Scott Rome, M.D., Medical Director, California Pacific Regional Rehabilitation Center, and the acute rehabilitation leadership team were instrumental in developing a business model for acute rehabilitation that gained the confidence of CPMC’s President and CEO at the time, Martin Brotman, M.D., and the financial support of Sutter Health executive leadership. Their support ultimately led to concept design meetings between the clinical and architectural teams responsible for initiating the first phase of the Institutional Master Plan at the Davies Campus. The concept design phase quickly expanded to include clinicians, patients, community stakeholders, interior designers, furniture and equipment specialists, information technology and communication specialists, tradespeople, project managers, and others who were essential in turning a concept into reality.

    The guiding principle of the project was the team’s focus on creating a rehabilitation milieu intentionally designed to complement the clinical strengths of the rehabilitation team and enable it to improve function more safely and more effectively. A transdisciplinary design and construction model enabled the project’s team to preserve this intention over several years. The insights and requirements of the people who receive rehabilitation services and who do the work of rehabilitation were reinforced by clinical representatives through each phase. When alterations in the plan were required, clinicians worked with the architects to find compromises that would not sacrifice the project’s primary goal.

    Every detail, from the lights to the floor patterns and furniture selections, kept a focus on the needs of people with physical or cognitive impairments, and the work of rehabilitation. The end result is a unique environment with fully integrated resources to support specialized rehabilitation care. The aesthetic qualities of the unit create an impact that cannot be overstated. The colors, lighting, and seamlessly complete design are perceived immediately on entering the unit. The new units are enthusiastically regarded by employees, visitors, and temporary residents as welcoming, restful, beautiful, and accessible. Still, the Acute Rehabilitation leadership team’s goal of improving the delivery of rehabilitation services encompassed much more than design and construction.

    Acute rehabilitation has long been recognized as an area that sets the standard in health care for interdisciplinary teamwork and coordinated plans of care. Acute rehabilitation programs dedicated to catastrophic care require an extraordinary degree of teamwork and professionalism to produce an acceptable outcome. Those programs, like CPRRC, require a specialized level of experience and skill from every member of its clinical team. Clinicians with general inpatient experience often delay rehabilitation progress. Those clinicians often struggle with anticipating the complex rehabilitation risks and needs of patients with catastrophic injury. As in other team endeavors, experience and skill are important. But implementation of a rehabilitation team’s shared plan of care is only as effective as its least engaged member, its least defined role, and the clarity of its objectives.

    A well-conceived environment of care cannot deliver exceptional outcomes without an engaged clinical team possessing expert-level skill. During the final years of design and construction, the leadership team redefined the standards of service within CPRRC programs and its continuum of care. A shift in the culture of care delivery was needed to achieve the levels of patient and staff satisfaction necessary to meet the programs’ outreach goals. Under the guidance of Scott Rome, M.D., the leadership team formulated a plan based on outcomes data and customer feedback. Each effort led to a change directly linked to the patient’s experience of care. To date, the program has established a cultural dynamic of teamwork that is unique within CPMC. While this work is ongoing, the achievements to date include:

    • Restructuring the tools used by the physiatrist to communicate an overall plan of care to the clinical team.

    • Initiating the use of a shared taxonomy in team discussions about the primary neurobehavior impairment and its plan and goal for each patient.

    • Elevating the role of the rehabilitation R.N. in the team process.

    • Creating a distinct new team position (rehabilitation associate) to reinforce rehabilitation techniques and teaching outside of therapy sessions and direct R.N. interventions.

    • Breaking down barriers to teamwork through interdepartmental meetings, committees, and projects.

    • Setting a new direction in team dynamics through interdisciplinary peer interviews of all candidates for rehabilitation positions.

    • Supporting rehabilitation staff with mentorship and education specific to rehabilitation and the new environmental resources.

    • Requiring staff engagement in patient satisfaction activities, public relations, and community outreach efforts.

    • Maintaining a visibly collaborative, engaged, and active model of transdisciplinary leadership based on shared programmatic goals.

    Now, one year after opening the new acute rehabilitation environment, the transdisciplinary design process effectiveness and the efforts of cultural transformation are reflected by positive trends in both clinical and quality outcomes.

    FIM Change in Locomotion at CPMC

    The integrated ceiling lifts permit earlier and more intensive progression of walking and balance activities without risking falls. Physical and occupational therapists have advanced standard therapeutic balance strategies using this equipment. The data represent the change in scores from admission to discharge in the locomotion section of the The FIM System®. Locomotion in FIM rating includes walking and stairs. Aggregate data are reported by Uniform Data System for Medical Rehabilitation® (UDSMR®). UDSMR data provide a wide array of data, including comparison of our facility against regional and national benchmarks for providers of acute inpatient rehabilitation. This data set presents only CPRRC historical UDSMR data. (Tables 1-4)

    FIM Change in Locomotion at CPMC
    Locomotion graphs measure walking, wheelchair use and using stairs, going up and down for CPMC patients only.





    Data for Tables 1, 2, 3, 4
    FIM Change in Locomotion at CPMC

    Note: a higher FIM change in locomotion is better as more patients are walking, using a wheelchair or going up and down stairs
    Patient Diagnosis Q1-3 2009
    (Jan – Sept)
    Q4 2009
    (Oct – Dec)
    (moved to new acute rehabilitation unit)
    Q1 2010
    (Jan – March)
    Q2 2010
    (Apr – June)
    All Patients 4.65.25.25.1
    Spinal Cord Injury 4.85.85.45.3
    Brain Injury 4.54.86.55.5
    Stroke 4.04.64.54.35


    Patient Satisfaction

    Patient satisfaction is measured against national benchmarks by IT Healthtrack National Follow-up Services. These data represent CPRRC historical data compared to national benchmarks. (Tables 5-8)

    Overall Satisfaction
    Our overall satisfaction is measured against national benchmarks by IT Healthtrack National Follow-up Services. Our patient satisfaction scores measure all patient diagnosis. The charts measure brain injury, spinal cord injury and stroke satisfaction for consistency with our other outcome measurements.






    Data for Tables 5, 6, 7, 8
    Overall Patient Satisfaction
    Patient Diagnosis CPMC
    Q1-3 2009 (Jan – Sept)
    CPMC
    Q4 2009 (Oct – Dec)
    (moved to new acute rehabilitation unit)
    CPMC
    Q1 2010 (Jan – March)
    National Benchmark
    2009 (Jan – Sept)
    National Benchmark
    Q4 2009 (Oct – Dec)
    (moved to new acute rehabilitation unit)
    National Benchmark
    Q1 2010(Jan – March)
    All Patients3.823.83.983.83.83.8
    Traumatic Brain Injury3.893.954.03.783.783.78
    Spinal Cord Injury3.833.874.03.763.763.76
    Stroke3.83.613.953.83.83.79

    Employee Injury

    Ceiling lifts and bed technology provide the resources to eliminate the need for staff to lift or reposition patients. Employee injuries related to moving patients have plummeted in the new environment. The reduction in employee injuries could also be attributed in part to increased collaboration among therapy and nursing staff to increase consistency in patient-specific mobilization techniques across all disciplines and shifts. (Table 9)

    Employee Injury
    Employee injury measure the volume of employees injured while on the job while assisting with patient movement from one location (such as from bed, wheelchair, or toilet) to another (such as to wheelchair, toilet or bed). Comparing the number of injuries beginning in 2007 to the volume in 2010 when the new acute rehabilitation unit opened.

    Note: Fewer injuries is better.

    Data for Table 9
    Employee Injury from Patient Transfers: Incidence

    Note: Fewer injuries is better.
    2007200820092010
    6230

    Fall Rate

    The new units integrate bed sensor technology with the nurse call system and nurse paging. This technology has contributed to a reduction in patient falls in a minimal-restraint environment. To minimize the risk of injury for the highest-risk patients, the rehabilitation program also uses dedicated staff to observe patients, following a shadow protocol. (Table 10)

    Fall Rate
    Fall rate data compares the number of patient falls for every 1,000 inpatient days. The data compares the number of falls per 1,000 patient days in 2007 to the number of falls per 1,000 patient days in 2010 when the new acute rehabilitation unit opened.


    Data for Table 10
    Fall Rate per 1,000 Patient Days
    2007200820092010
    117.810.55.8

    Patient Referral and Admission Volume

    Patient referral and admission volume is a reflection of the satisfaction of patients, families, and referring entities. Sustained volume increases suggest growth in public confidence in CPRRC outcomes. (Tables 11–12)

    Percentage Growth
    The percentage growth in external referral volume and the percentage growth in external admissions compare the volume of patient referrals from outside CPMC and the volume of patient admissions from outside CPMC in 2008, 2009 and 2010 when the new acute rehabilitation unit opened.


    Data for Table 11
    Percentage Growth in External Referral Volume
    200820092010
    9%12%70%




    Data for Table 12
    Percentage Growth in External Admissions
    200820092010
    5%15%71%

    Conclusion

    These outcome measures suggest that the decision to invest in our program was well founded. The team knows the work to maintain support within Sutter Health and the community at large is ongoing. It also knows the real success of the program is revealed in the recovery of each patient and family that enters our care. Fortunately, the confluence of an exceptional clinical team and an innovative environment of care have set the stage for further advances in the field of rehabilitation at CPRRC.