Example of Continuous Quality Improvement in Physical Therapy

October 13, 2022 Post a Comment

How the inpatient PT team maximized patient care time through elimination of the daily morning meeting using the Plan-Do-Study-Act model

By Michelle Borgwardt, DPT, assistant manager, Rehabilitation Therapies

For many years, the inpatient physical therapy (PT) group met each morning to discuss how to cover scheduled and unscheduled absences. The meetings lasted anywhere from 10 to 30 minutes. In the old system, we would write the names of the therapists that were absent, how much patient care help was needed, and who would cover. The meeting either went quickly and the areas would get covered, or we spent an uncomfortable amount of time waiting for therapists to take one or two patients until we felt we were adequately covered for the day.

As inpatient hospital census steadily increased and therapist time and resources declined, it was clear that something needed to change. As a group, we decided the morning meeting should be time we spend with patients. The difficult part was determining how we would cover absences without meeting every day.

That's when I heard a lecture in my Executive Leadership Academy course by Randy Fry from the Department of Operations Excellence. We learned about the Lean philosophy that emphasizes continuous improvement by making problems visible using scientific problem solving (Plan, Do, Study, Act—a.k.a., PDSA), with the guidance of a coach and with management's support. I immediately contacted Randy to see if he could offer some guidance to our group, and thankfully he agreed to help.

As an inpatient PT group we performed the PDSA model for improvement:

Plan-Do-Study-Act (PDSA), a quality improvement model based on an iterative process of learning and making changes

Here are our answers to the three guiding questions:

1. Setting aims: What are we trying to accomplish?

Find alternatives to the morning meeting to increase the amount of time spent with patients
Improve patient outcomes
Create less stress for and less "wasted" time for therapists

2. Establishing measures: How will we know if the change is an improvement?

Improved productivity by inpatient physical therapists
Improved patient outcomes and patient satisfaction
Earlier evaluation and treatment of patients
Earlier discharge from PT times
Overall therapist satisfaction

3. Selecting changes: What changes can we make that will result in improvement?

We decided to tackle this step in our inpatient PT staff meeting. The following is the email sent to staff:

Inpatient PT team,

Our next staff meeting is scheduled for Wednesday 1/17/18 12:30 – 1:30 PM.

The only agenda item is the PT Morning Meeting. Think about ways to improve this process. Are there any solutions that would eliminate the a.m. meeting?

We will be plotting our ideas on a chart that evaluates Impact (y-axis) vs. Difficulty (x-axis).

Please come with any ideas you may have. Chances are someone else has had the same idea. Let's brainstorm!

During this meeting, we worked together to create an impact graph.

Some of the ideas included:

A central scheduler
Coverage communication via Voalte and/or email
A manager assigning therapists to uncovered areas on a rotational basis
Smaller teams

At this meeting, the inpatient PT group decided that coverage by smaller teams would be classified somewhere between "Quick Win" and "Major Project." We thought the concept may be somewhat difficult to implement, but it would have high impact.

The next step was creating a "PT Morning Meeting Revamp Task Force" to create smaller teams, made up of Shelly Hons, Janine Kelly, Natalie Kruse, and Michelle Borgwardt. Prior to the meeting, data was collected on the total PT orders by unit or floor for the month of December to give us an idea of the relative "busy-ness" of each floor. This data was used, as well as the number of therapist FTEs, location of patients, and population of patients.

Team	Full-time employees (FTEs)	Total PT orders in December
Team 1: 6JC, SNICU, 8JC	5.5	519
Team 2: 4RC, CVICU, MICU	4.8	353
Team 3: 3RC, 6RC, 2RC, 7JCP	6	397
Team 4: 3JPP, 4JPP, 7RC, 2JCP, 2BT, 3BT, 1JP, 2JP, 5 South	5	302
Team 5: Peds (NIC1, SFCH, SFCH NICU)	3.4	120

The next step was implementation of the teams on Feb. 5, 2018. We also created guidelines for how teams would function.

Team guidelines

First, try to cover absences and need for help within your team.
If you cannot cover all the needed help, send a text out to the rest of the group by 9 a.m., then throughout day as needed.
Cross train when you have time within your team.
Scheduled absences: Leave a list in same folder by pulmonary gym. Please prioritize your list with high, medium, and low priority patients as well as PT vs. PTA appropriate.
When we have PRN help and/or Monday–Tuesday help, Michelle, Andy, and/or Wendy will look at the absences and decide how to distribute the help.
Meet weekly on Wednesdays at 8:05 a.m. for announcements and updates.
This is a learning curve. There will be times when we succeed, and there will be failures. Please try this for one month giving your best effort to see if we can improve patient care, expedite discharge, efficiency, and productivity.

We trialed the teams for one month, then met to discuss what's working and what's not working. Overall, most therapists felt that it was very successful. Therapists felt they were able to see more patients per day, spend more time with their patients each session, and begin evaluating and treating patients earlier in the day. We did hit some minor bumps when it came to organization when multiple team members were gone, but we worked through this with strong communication, teamwork, and streamlining.

Outcomes

Average inpatient PT productivity improved from 47 percent in January (before teams) to 51 percent in February (after teams), 48 percent in March, and 49 percent in April.
The start of the first evaluation and/or treatment was improved by an estimated 15 to 30 minutes.
Number of patients evaluated and/or treated daily improved by an estimated one to two patients per day.

The smaller teams' project has been up and running for four months. One of our group's biggest fears was that we would miss the socialization and lose our overall group comradery. Now, we meet once a week, briefly on Wednesdays, for a fun team building activity, led by our resident comedian Amber Spratt.

The fun activities have included answering questions like, "What are you most looking forward to this summer?," "Tell us about a time you won something?," and "Show us your favorite dance move." Amber has also led a "fill up one another's cup" activity where we anonymously write small appreciation notes to each other and put the note in the therapist's cup (see picture). We have also done group breakfasts, a lively game of flip the plastic spoon into the Tupperware bowl, and show us your senior high school class picture.

As an inpatient PT group, we would like to acknowledge and thank Randy Fry for leading us through the Lean process. We are really pleased with the results. We look forward to implementing more Lean models and PDSA cycles into our workflow.