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QBP Rehabilitation Planning

Achieving Best Practice for

Stroke Therapy Intensity

October 22, 2015

Welcome!

“Start by doing what’s necessary; then do what’s

possible; and suddenly you are doing the

impossible.”

Francis of Assisi

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What to expect today

• Knowledge exchange

• Research evidence

• Lived experience

• Practice-based experience

• Time to learn from each other and plan together

Planning Group

Kendra Truant

Tazdia Burnett

Denise St Louis

Linda Dykes

Eileen Britt

Ellen Richards

Joan Ruston-Berge

Jennifer Beal

Deb Willems

Sheila Cook

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Site Visit Recap

May 2015

When it comes to Rehab Intensity, where are you on

the emotional voyage of change?

Denial

Anger

Bargaining

Depression

Acceptance

Hope

Embrace

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What are you feeling hopeful about?

Better outcomes for stroke clients

Better coordinated, comprehensive, consistent

stroke care

More team work and opportunities to use skills

What are you feeling hopeful about?

More concise documentation

Tracking will ensure intense treatment

Focus on implementing best practice in stroke

rehab will spill over to other diagnostic groups

Increased awareness of issues frontline staff face;

and need for more staff

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What are you concerned about?

Therapists

Adequate staffing; burnout

Therapist time spent on cleaning, portering, etc.

Amount of time spent charting and documenting

College regulations

Limited time/focus on updating skills

No feedback to staff about performance; NRS data

System issues Not meeting QBP target of 3 hours/day

Decreased LOS; pressure to meet discharge date; lack of input into exceptions; complexity of patients

Lack of understanding by decision makers

What are you concerned about? Models of Care

Using a cookie cutter approach; not addressing variability in stroke

Rehab intensity trumping clinical reasoning

Loss of value for the emotional, social and recreational aspects of recovery

Practicing in silos; less collaboration

Reducing group work

Practicality of seeing patients for shorter, more frequent sessions

Patient considerations

Non-stroke clients getting less therapy time

Patient tolerance; patient compliance; patients are more acute

Meeting needs of clients only requiring one therapy

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Priorities for Improvement

0102030405060708090

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Frequency

Frequency

Priorities for Improvement Related to Increasing Rehabilitation Intensity

Staffing Resources All

Patient Access • patient readiness for therapy times • competition for limited treatment times

Bluewater, Owen Sound, St Thomas Woodstock, Parkwood (portering)

Scheduling • improve coordination, maximize efficiency and

communication • provide options to rapidly build tolerance

Windsor Chatham, Owen Sound, St Thomas, Bluewater

Team Coordination/Processes • efficiency of time spent in rounds, meetings • appropriate personnel for each task

Bluewater, Windsor, Stratford

Space & Equipment • availability of necessary equipment • access to sufficient space

Parkwood Chatham

Patient Expectations • provide culture/expectation of active participation • seek patient experience to inform change

Woodstock Windsor

Documentation • builds on work already completed in acute care • charting by exception

Stratford

Staff education • build on stroke expertise • availability of education in accessible formats

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Hopes for October Workshop

Networking, collaboration

Better understanding of Rehab Intensity

Identify goals; plan for implementation

Ideas from others

Strategies for achieving targets

Compare data/staffing across facilities

Individual Activity:

Collaboration Central

Collaboration Central

> Big challenge –

collaboration is key

• Who can you

collaborate with to

improve rehab intensity

and improve patient

outcomes?

• Write names/roles on

post-it-notes

National & International

Provincially

Across SW

Your hospital

Stroke Rehab Team

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John Topham

Patient Experience

Small group activity: Discussion

• How can our team get better at using feedback

about patient experiences to improve patient care?

> Worksheet 1

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Break

• Please return at 1040

Why Does Intensity Matter in Stroke Rehabilitation?

Robert Teasell MD FRCPC

Professor Phys Med Rehab

Western University

London. Ontario, Canada

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Brain Reorganization

• The brain has significant capacity to reorganize itself to recover from loss of function following a stroke

• Reorganization depends on training or rehabilitation and will not occur spontaneously

Brain Reorganization: Use It or Lose It

Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery

In animal studies key factors promoting recovery include increased activity and a complex, stimulating environment

Lack of rehab causes decline in cortical representation and delays recovery

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What Evidence Do We Have Therapy Intensity Is Important?

• RCT of 146 “middle band” strokes to stroke unit (SU) or gen med (GM) unit

• Median Barthel Index = 4/20 initially in both

• Stroke Unit - BI = 15 after 6 wks; discharged at 6 wks

• General Medical Unit - BI = 12 after 12 wks; discharged at 20 wks

Frontloading

Kalra et al. 1994

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

0

2

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6

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20 SRU

GMU

Weeks

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an

Ba

rth

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

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GMU

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/C

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

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SRU

GMU

Weeks

% D

/C

Frontloading (Kalra et al. 1994)

SRU GMW0

10

20

PT

OT

*

Mean

hrs/p

t

SRU GMW0

10

20

PT

OT

*

Mean

hrs/p

t

Frontloading (Kalra et al. 1994) Amount of Physiotherapy and Occupational Therapy

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Kalra et al. 1994

SRU GMW0

10

20

PT

OT

*

Mean

h

rs/p

t

SRU GMW0

10

20

PT

OT

*

Mean

h

rs/p

t

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

2

4

6

8

10

12

14

16

18

20 SRU

GMU

Weeks

Mean

Barth

el

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

2

4

6

8

10

12

14

16

18

20 SRU

GMU

Weeks

Mean

Barth

el

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

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90

100

SRU

GMU

Weeks

% D

/C

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

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20

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40

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70

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90

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SRU

GMU

Weeks

% D

/C

Therapy Intensity: Front Loading

Role of Intensity of Therapy • Post-stroke rehab increases motor reorganization while lack

of rehab reduces it; more intensive motor training in animals further increases reorganization

• Clinically greater therapy intensity improves outcomes; reported for PT, OT, aphasia therapy, treadmill training and U/E function in selected patients (i.e. CIMT)

• One exception is VECTORS trial (Dromerick et al. 2009); showed high intensity U/E CIMT (6 hrs/day) starting day 10 showed less improvement at 3 mos than less intense Rx; Rationale uncertain – not a large trial

Dromerick et al. Neurology 2009; 73:195-201

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Number of Repetitions in the Upper Extremity • No study has systematically determined a critical threshold of

rehab intensity needed to obtain a benefit (MacLellan et al 2011)

• Research involves thousands of repetitions – EXCITE trial involved 196 hours of therapy per patient

• Threshold not reached, recovery affected arm less; patients develop compensatory movements (Han et al 2008; Schweighofer et al 2009)

• Lang et al. (2007) found practice of task-specific, functional U/E movements occurred in half of U/E rehab sessions: Average number of reps = 32

• Technology (video gaming, robotics) may be necessary to achieve the maximum number of reps (Saposnik et al. 2010)

MacLellan et al. NeuroRehab and Neural Repair 2011; 25(8):740-748 Han et al. PLoS Comput Biol 2008; 4e1000133 Schweighofer et al. Phys Ther 2009; 89:1327-1336 Lang et al. Arch Phys Med Rehabil 2009: 90:1692-1698 Saposnik et al . Stroke 2010; 41(7):1477-184

In a therapeutic day

• >50% time in bed

• 28% sitting out of bed

• 13% in therapeutic activities

• Alone for 60% of the time

Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery

Bernhardt et al. Stroke 2004; 35:1005-1009

Inactive and Alone

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Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke

• International recommendations made regarding therapy intensity variable

• 3 guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes per day each of physical therapy (PT) and occupational therapy (OT) (or all relevant core therapies)

• 3 guidelines made nonspecific statements indicating that increased intensity of therapy was either recommended or in the case of one not recommended

Foley et al. Topics Stroke Rehabil 2012; 19(2):96-103

Best Practice Recommendation 5.3 Delivery of Inpatient Stroke Rehabilitation

ii. Patients should receive a minimum of three hours of direct task-specific therapy, five days a week, delivered by the inter-professional team [Evidence Level C].

• Average therapy hours of direct PT, OT and SLP 5 days per week is about 1.5-2 hours per day; most rehabilitation units do not supply 3 hours of therapy per day

Parkwood Hospital (Foley et al. 2012)

• 123 pts from May - Oct 2009 workload measurement Infomed data for PT, OT and SLP and associated therapy aids measured

• A multivariable model to predict FIM gains achieved during hospital stay was also developed.

• The model explained 34% of the variance in FIM gain; total amount of therapy provided by OT and PT combined emerged as a significant predictor; days from stroke onset and admission FIM scores were also significant predictors.

• Intensity makes a difference

Foley et al. Disability and Rehabilitation 2012; 34(25):2132-2138.

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Three Issues in Providing Intensity

Resources

Innovation

Accountability

Ontario Resources

• Facilities were asked about staffing levels for 7 rehabilitation professions

• Estimated staffing levels were provided as a ratio of rehab beds per FTE to reflect the average case-load experienced by research staff across each region

• Only facilities for which complete bed and FTE information were available were used in the calculations

• Slow stream or LTLD beds not included in analysis

Meyer M et al. The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario. Ontario Stroke Network 2012, 66 pages.

Number of Rehab Beds per FTE in LHINs

(median)

Physiotherapy 6.7 - 26.4 (10.0)

Occupational Therapy

8.2 - 26.4 (11.7)

Speech Language Pathology

15.8 – 60.0 (33.3)

Social Work 16.3 – 125 (30.0)

PT/OT Assistant 9.7 – 24.1 (13.6)

Dietician 64.0 – 236.7 (227.3) *NA in 6 LHINs

Recreational Therapist

28.8 – 166.3 (63.7) **NA in 2 LHINs

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Ontario Hrs of Therapy Per Day

Approximately how many hours of therapy a day were provided for PT, OT and SLP?

• Of 54 facilities surveyed, only 2 reported officially documented number of hours of therapy provided to patients

• Estimated therapy per patient ranged from 20 minutes to 4 hours per day

• 17 rehab units had SLP available on a consult basis only


Replacement of Therapists in Sickness and Holidays

• 45% of rehabilitation units had access to resources to cover therapists when they were sick

• Only 28% indicated they were successful in replacing a sick therapist 80% of the time

• 56% reported access to adequate resources for therapist replacement during holidays and extended sick leaves

• 24% reported availability of some form of weekend therapy

Resources for Stroke Rehab in Ontario

• Therapist to patient ratios are low

• Limited documentation of therapy time spent with patient

• Therapists are not consistently replaced when sick or on holidays


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Innovation (Doing Things Differently) Therapy is Cheap; Length of Stay is Not

• Core Therapies of PT, OT and SLP are most sensitive to intensity

• Only 25% of total hospital budget in subacute rehab is spent on core therapies

• Average length of stay is about 35 days

• Limited weekend or evening therapies

Need for Innovation: Using Resources More Efficiently • Right-size staff numbers and

standardize therapy intensity

• Establish better accountabilities for intensity

• Standardize and simplify assessments

• Simplify and tighten charting

• Reduce non-therapeutic activities

• Utilize Weekend and Group Therapy

• Explore Use of Technologies (i.e Robotics, Gaming)

• Intensify Outpatient Therapy

• Current interdisciplinary stroke rehab team concept developed in the 1950-60’s

• Very discipline-specific • No longer as relevant –

rigid, expensive, inefficient

Rehab Therapies

Program and Interdisciplinary Team

Physio-therapy

Nursing

Speech Therapy

Occup. Therapy

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Rehab Therapies

Program and Transdisciplinary Team

Physio-therapy

Nursing

Speech Therapy

Occup. Therapy

Rehab Therapists Recreational

Therapy Nurse Assistants

• Increasing therapy aids and volunteers

• Large influx of therapy aids or rehab aids (cross between therapy and nursing aids)

• The lines between the therapies becoming blurred and how rehabilitation is done redefined

• Rehab becoming less discipline specific

Collaborative Evaluation of Rehabilitation in Stroke Across Europe (CERISE) Trial

• Study compared motor and functional recovery after stroke between 4 European Rehab Centers

• Gross motor and functional recovery was better in Swiss and German than UK center with Belgian center in middle

• Time sampling study showed avg. daily direct therapy time of 60 min in UK, 120 min in Belgian, 140 min in German and 166 min in Swiss centers

• Differences in therapy time not attributed to differences in patient/staff ratio (similar staffing)

De Wit et al. Stroke 2007:38:2101-2107

Accountability

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Average daily direct therapy time

Hrs T herapy per day

1 2 2.3 2.80

0.5

1

1.5

2

2.5

3

UK B elg ium S witzerland G ermany

Hrs Therapy per

day


European CERISE Trial

• No differences were found in the content of physiotherapy and occupational therapy

• In German and Swiss centers, the rehabilitation programs were strictly timed (therapists had less freedom), while in UK and Belgian centers they were organized on an ad hoc basis (therapists had more freedom to decide)!

“More formal management in the German center may have resulted in the most efficient use of human resources, which may have resulted in more therapy time for the patients”


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Intensity: The 3 Hour Rule

• In Canada we struggle to provide adequate therapy

• The 3 hour rule is an American invention

• Not from the insurers – it is from Medicare

• States that all rehabilitation patients should get 3 hours of therapy per day of patient-therapist direct or face time

• In Ontario/Canada the estimate is the average rehabilitation patient gets 1-2 hours of direct patient-therapist time

• To ensure compliance it is tied to funding

PSROP Centers (Brendan Conroy @ NIH) U.S. Inpatient Stroke Rehabilitation is driven

by Medicare which expects:

1. Participation (“the 3 Hour Rule”)

2. Progress (FIM Gain of 1-1.5/day)

3. Expedited Discharge Home or to SNF if progress is too slow or family unwilling/unable to take home

• Therapist must record face-to-face interactions with pt in 15 min increments

• Manager responsible at end of day to ensure patient received their full 3 hrs of therapy

• Any missed therapy must have a strong medical justification documented by MD and therapist

• Failure to deliver enough time means loss of payment

Small group discussion

• How can our team use this evidence to improve

patient care?

> Worksheet 2

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Current State Data

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1 HOUR

SWO Rehab Intensity Q1 2015/16

0 20 40 60 80 100

GBHS

HPHA

WGH

SJHC

STEGH

BWH

HDGH

Therapist Time

Assistant Time

27%

14%

28%

22%

17%

13%

27%

Rehabilitation Time in Minutes

1100 1100 1110 1110 1120 1120 1130 1130 1140 1140 1150 1150

LOS by RPG for 2014/15

Rehabilitation Length of Stay in Days

QBP LOS Targets

0 10 20 30 40 50 60

SJHC

BWH

CKHA

HDGH

1160

1150

1140

1130

1120

1110

1100

24

1100 1100 1110 1110 1120 1120 1130 1130 1140 1140 1150 1150

LOS by RPG for 2014/15


QBP LOS Targets

0 10 20 30 40 50 60

GBHS

HPHA

WGH

STEGH

1160

1150

1140

1130

1120

1110

1100

1100 1100 1110 1110 1120 1120 1130 1130 1140 1140 1150 1150

LOS by RPG for Q1 2015/16


QBP LOS Targets

0 10 20 30 40 50

SJHC

BWH

CKHA

HDGH

1160

1150

1140

1130

1120

1110

1100

25

1100 1100 1110 1110 1120 1120 1130 1130 1140 1140 1150 1150

LOS by RPG for Q1 2015/16


QBP LOS Targets

0 10 20 30 40 50 60

GBHS

HPHA

WGH

STEGH

1160

1150

1140

1130

1120

1110

1100

Make Quality Improvement Principles Real: Small group activity

Principle How well do we do this now?

How could we get even better

Work together to solve problems

Involve those closest to the work

Keep patients’ experience and needs front and centre

Focus on improving processes, systems and tools (rather than blaming individual performance)

Always look for ways to get even better. Learn from experiences.

Use data to inform decisions

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Knowledge Exchange

> Use Worksheet 4 to Track Examples and Ideas of QI

principles put into action

REHAB INTENSITY

Strategies to get there

October 22, 2015

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OBJECTIVES

• Understand the Grand River Hospital Inpatient Rehabilitation Unit

• Review the catalyst for change, including Waterloo Wellington stroke system changes

• Outline quality initiatives implemented at Grand River Hospital – Inpatient Rehabilitation

• Discuss strategies to increase rehabilitation intensity

• Review data demonstrating outcomes of change

• Discuss challenges encountered

INPATIENT REHABILITATION UNIT

• 33 beds

• 18 stroke beds, 15 mixed rehab beds

• Geographically separated on two courts

• Medical coverage with 2 family physicians

2 days per week, 3 days per week

• 4 OT’s, 4 PT’s, 3 TA’s, 1 SLP, 0.6 CDA, 0.6

SW, 0.4 REC, RD

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BEFORE AND AFTER

Prior to 2013

• 3 OT’s, 3 PT’s, 2 TA’s

• No OT/PT teams

• Ratio 1:11 for all patients

• All staff attend MDT

• Discharge dates

established based on

team discussion

• Communication with

family as needed

After 2013

• 4 OT’s, 4 PT’s, 3 TA’s

• OT/PT therapy teams

• Stroke 1:6, Mixed 1:15

• One team member attends MDT for group

• Discharge dates established using RPG and QBP targets

• Discharge letters/family meeting within 7 days

QUALITY INITIATIVES

• Quality Council

• Model of Care

• Group Programming

• Discharge Planning

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MODEL OF CARE

• Implemented in 2013

• Integration of therapy staff into morning care routine

• Nursing and therapy communication

• OT’s and TA’s working 0700 – 1530

• PT’s working 0800 – 1600 OR 0830 – 1630

• ADL assessment/practice

• Transfers/ambulation

• Assistance in dining room with containers and U/E tasks

MONDAY TUESDAY WED. THURSDAY FRIDAY SATURDAY SUNDAY

0730 -

0800

ADL’S ADL’S ADL’S ADL’S ADL’S ADL’S ADL’S

0800 -

0830

TNSF/A

MB

TNSF/A

MB

TNSF/A

MB

TNSF/A

MB

TNSF/A

MB

TNSF/A

MB

TNSF/A

MB

0830 -

0840

ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN

0840 -

0900

BULLET

RDS

BULLET

RDS

ADMIN ADMIN BULLET

RDS

BULLET

RDS

BULLET

RDS

0900 -

0945

PT

CARE

PT

CARE

PT

CARE

PT

CARE

PT

CARE

PT

CARE

PT

CARE

0945 -

1030

MDT MDT

1030 -

1115

1115 -

1200

1200 -

1300

LUNCH LUNCH

LUNCH

LUNCH

LUNCH

LUNCH

LUNCH

1300 -

1345

1345 -

1415

1415 -

1500

1500 -

1530

ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN

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GROUP PROGRAMMING

• Sit < - > Stand group

• GRASP group

• L/E group (seated and standing)

• U/E group

• Aerobic training group

• Meeting needs of all patient groups

• Goal: increased goal directed therapy, increased patient activity throughout the day

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DISCHARGE PLANNING

• Bullet Rounds

• Multidisciplinary Team Rounds

• Primary Contact

• Family meetings

• Discharge letters

• Community Stroke Program

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OUTCOMES

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

GRH11/12

GRH12/13

GRH13/14

GRH Q1 GRH Q2 GRH Q3 Q4

Median number of days between stroke (excluding TIA) onset and admission to stroke inpatient rehabilitation (RCG-1 and

RCG-2). Target 6

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0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

GRH11/12

GRH12/13

GRH13/14

GRH Q1 GRH Q2 GRH Q3 GRH Q4

Proportion of inpatient stroke rehabilitation patients achieving RPG active length of stay

Target 73.1%

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0.0

0.5

1.0

1.5

2.0

2.5

GRH 11/12GRH 12/13GRH 13/14GRH Q1 GRH Q2 GRH Q3 Q4

Median FIM Efficiency for moderate stroke in inpatient rehabilitation (RCG-1). WWLHIN 12/13 - 0.8

Target 1.2

CHALLENGES

• Roles and responsibilities in morning care

(for therapy staff and nursing)

• FIM documentation

• Staffing (part time availability)

• Staff from other areas not comfortable

providing care on unit

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QUESTIONS

Team Huddle

• What did you hear that was interesting, exciting

and/or practical?

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Lunch

• Please return at 1245

Knowledge Exchange Fair

Snappy Overviews Visit Displays

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A Lean Approach to Maximizing

Stroke Rehab Intensity Neenah Navasero, Stefan Pagliuso, Sarah Rose, Brenda St. Amant, Gorana Zubic

Presentation Overview

• Goal of the Project

• Challenge/Opportunity

• Quality Improvement Initiatives

• Results/Impact

• Lessons Learned/Survey Results

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Goal of the Project

• In trying to achieve maximal stroke rehab intensity, this project undertook a Lean Processing approach to maximizing physiotherapy intensity being delivered to persons significantly affected by stroke

Challenge/opportunity

• 2 West/2 East at St. Peter’s Hospital is a Restorative Care unit

– AFIM® admission score between 20-60

– Approximately 50% stroke patients on the unit

• Opportunity to look at efficiencies to maximize rehab intensity for persons with stroke

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A set of principles, concepts, and techniques designed for a relentless pursuit in the

elimination of waste.

Lean Six Sigma

Value Stream Mapping and Spaghetti Diagram

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Fishbone Diagram and Pareto Analysis

Projects

• Physical Gym Environment – Removal of unnecessary equipment – Reorganization – New equipment

• Application Review Process – Assigned schedule – Inclusion of OTs

• Referral Expectations – 1-pager for referral sources – Stakeholder breakfast

• Patient Transport – Volunteer transport

• Scheduling Changes – Reconfiguration of scheduled gym times

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Participant Survey Results

Statement Average Level of Agreement (1-5)

Process

Using a lean process to find opportunities for improvement was effective.

4.75

Mapping exercises were effective 4.5

Spaghetti Diagram was effective 4

Fishbone was effective 4.5

Pareto Analysis was effective 4.75

Participant Survey Results


Results

Modifying gym space increased efficiency 4

Modifying gym space increased safety 4.75

Application Review Process changes created more available time to spend with patients

3.5

Information 1-pagers have created realistic expectations in patients and families

4

Patient/gym scheduling changes allowed for more effective treatment time spent with patients

5

Volunteers assisting with patient transport has increased amount of available treatment time

4.75

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Participant Survey


Recommendations

I would recommend that team looking for opportunities for improvement to achieve a specific goal utilize the Lean Methodology as an effective means of achieving their goal

4.75

Conclusion

• Taking a Lean Processing approach to maximizing physiotherapy intensity for persons with stroke at St. Peter’s Hospital created an effective way to evaluate the current state of a program and develop projects to create a more efficient future state maximizing therapists time spent with patients admitted with stroke.

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Contact Info

Gorana Zubic

Physiotherapist

Hamilton Health Sciences

[email protected]

Stefan Pagliuso

CS Regional Rehabilitation and Community Coordinator

[email protected]

Project Rehab Intensity

86

mailto:[email protected]


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Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga

Mississauga Hospital 100 Queensway West, Mississauga

Queensway Health Centre 150 Sherway Drive, Toronto

Project REHAB Intensity

Background:

Best practice for stroke care is to provide 3 hours of direct task-specific therapy

per patient per day.

GOAL:

Bridge the gap between current practice and stroke BP guidelines for rehab

intensity.

What did we do:

Identified a significant gap between stroke best practice and actual delivered

therapeutic intensity.

OTA/PTA/CDA managed assigned caseload of stroke patients.

Utilized PDSA model to improve rehab intensity.

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Impact

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Time Therapy

1000 PTA/PT co-treat 30 in PT gym

1100 SLP 30 in pt. room

1300 OT 30 in OT gym

Time Therapy

0900 OTA 30 ADL in pt. room

1000 PTA 30 in PT gym

1100 SLP/CDA 60 in pt. room

1300 OT 30 in OT gym

1400 PT 30 in PT gym Total time = 60-90 minutes

Total time = 180 minutes

Before After

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Food For Thought

Lessons

PDSA – effective model for a QI initiative

Not top down driven

START SMALL!!

Challenges

Engaging all staff

Scheduling issues

Patient fatigue

Advice

Find Champions

Get support from your stroke coordinator and manager

Change what you are doing if it is not working!!

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Contact

Sarah Alexander, SLP(Reg)caslpo. - [email protected]

April Scanlon, OTA/PTA - [email protected]

Betty Vukusic, PT- [email protected]

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Rehab Tracking Board

Automatically populate admission and discharge of patients from Cerner

Large, colourful and highly visible for patients, staff and families (provide a road map)

Provide patient safety info – isolation, falls risk

Able to schedule therapy appointments from any staff’s computer

View the tracking board from any computer – internet based

Fluid – refreshes and updates continually

Our Goals

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Visual view of the patient day – therapy and other appointments

Nursing can schedule DI or patient out of building, therapy can be scheduled around it

Both groups and individual therapy can be booked

Colour blending can be used to show when 2 disciplines are working together

Both one time or reoccurring appts can be booked

The Positives

Easy to look at # hours of therapy pt is scheduled for over the day

Source of truth (quick glance) to know where the patient is

Increase collaboration between therapists… planned around patient’s day and care

The Positives

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All Rehab staff (Allied/Key Nursing Staff) need to be scheduled for initial training (4 to 6 hours)

Training now by Allied Health Secretary

Scheduling takes upfront time by Rehab Staff

Schedule/Board must be updated whenever a change is made to remain accurate

Not all Rehab therapy staff work on Rehab exclusively (some in other sites) so must log in for visual

Not all Rehab staff work each day

Challenges

Rehab Tracking Board

G.ACTI

VITIES G.ADL G.BAL G.FIT

G.RECR

EATION

ONLY

G.STRO

KESUP

PORT

NURSIN

G OT PT RD

RECRE

ATION

SPEEC

H

STROK

EED

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Integrated Stroke Unit Stratford General Hospital

Goal

• Enhance the patient experience

• Optimize therapy time by improving patient availability and therapy staff activities

Value Stream Map of a patient’s typical day

Created a “day in the life” outline for therapy staff

Improvement initiatives identified

EXCEPTIONAL PEOPLE, EXCEPTIONAL CARE

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Changes/outcomes

• Dedicated PSW time to the ISU beds in the morning

• Bathing Project: patient’s choice (am, pm, evening)

• Adjusted breakfast tray delivery time

• Adjusted therapy staff schedules – Afternoon therapy available

– Rounds times changed: frequency and time of day

• Communication strategies – bedside & schedule boards

Impact and Lessons

• Impact: – Patients routinely ready for scheduled therapy

– Breakfast taken before therapy

– Increased patient engagement

– Increased staff collaboration and satisfaction

• Lessons: – Involve the whole team in process improvement

– Ensure the patient is represented i.e. UAC or Collaborative Care Planning Team

– Change the solution if it’s not working

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Contact Info

• Bonita Thompson

Manager Inpatient Medicine/Integrated Stroke Unit and Medicine Clinics, Stratford General Hospital HPHA

519-272-8210, Ext 2706

[email protected]

• Ellen Richards

Manager, District Stroke Centre

Huron Perth Healthcare Alliance

519-272-8210, Ext 2298

[email protected]

Bluewater Health

Sonya Maitland




52

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Parkwood Institute 7 Day Admissions and Therapy

Eileen Britt

Goal To implement weekend admissions and 7 day therapy for June 6,2015

Opportunity To align ourselves with QBP standards, sustain best practices, enhance patient outcomes, improve our therapy intensity measures and systematically support our acute care partners with patient flow

What We’ve Done to Date • Completed current and future state maps for weekend admissions with discipline

specific detail • The process for Friday team reviews of potential weekend admissions were

developed and refined • Trial admission in partnership with acute care – collaborative and joint learning as

one system • 7 Day therapy consisting of core therapies of PT, OT, SLP and OT/PTA • Several iterations of discipline schedules –union and non-union • A number of models have been experienced to date in order to determine stroke

therapy expert provider group balanced with frequency of weekends, continuity of care, workflow and communication handoffs

• Workload measurement and therapy intensity capture- separate systems currently with plans to use Infomed to provide both. To date, statistics have been captured manually

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Impact Positive outcomes with weekend admissions: • Access to rehab beds for acute care has improved

• LOS targets are more achievable without lost weekend days

• QBP standards for transitioning are more likely to be met and meets the 7 days/week admission standard

• A weekend checklist was created

Outcomes for 7 Day Therapy • Meet QBP standard for minimum of therapy 6 days/week

• Assist with improving our therapy intensity measures with current resources

• Supporting the achievement of QBP LOS targets

• Improving patient outcomes – FIM Efficiency

Lessons learned • Engage staff early and often

• Investigate other sites and learn from their experience

• Determine and uphold the established principles- helps to guide future decisions/dialogues

• Communicate and listen- mini PDSA cycles with each component

CARING FOR THE BODY, MIND & SPIRIT SINCE 1869

Contact

Eileen Britt

519-685-4292 ext. 42537

[email protected]


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INCREASING REHAB INTENSITY

Approaching from many angles

Resources

Documentation

Process

INCREASED REHAB

INTENSITY

FIMs

Customized and changed location of

forms to ease completion by Allied

health

HOLIDAYS

add extra therapist one of the weekend

days of a holiday weekend

WEEKENDS

Full day coverage Saturday and Sunday 1OT,1OTA, 1PT,1PTA over 60 mixed bed

unit

DOCUMENTATION

Review and streamline required forms

charts travel with patients to therapy

ROUNDS

Reviewing what needs to be discussed and who should be there

SCHEDULING

Daily resource huddles between

therapists GROUPS

specific task orientated ; utilize with non stroke

population; more focused therapy

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Managing Change

• Weekly huddles – provide support, feedback,

acknowledge successes

• Evidence from outside the organization that demonstrates that change is required

• Create expectations, don’t allow for general statements

Rehab Intensity: Weekends and Staff Complement

Inter-professional Rehab Team

Presented by Kim de Haan, Manager of Therapy Services

[email protected] October 22, 2015

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Goals and Opportunity

• To increase the number of face to face therapy minutes per stroke survivor on the rehab unit, with a target of 3.0 hours/day, 6 to 7 days/week

• To adhere to the 33% guideline for maximum assistance time within the target minutes

• To examine current practice and creatively enhance current routines

What we did

• Added SLP to rehab unit weekend coverage. OT, PT, SLP and TR already there

• Changed structure of weekend scheduling

• SLP complement: use of Communicative Disorders Assistant’s time on rehab unit and in Transitional Stroke Program

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Outcomes and Impact

• Stroke survivors have access to all therapies 6 to 7 days/week

• Impact on patients with non-stroke diagnoses

• Some of the group work and inter-professional patient activities were put on hold

• Weekends are more structured, but still working on “stimulating environment”

Data Collection

• Worked with IS to have therapy minutes imbedded in patient electronic chart

• New OTA/PTA build, working on CDA build

• Rehab assessor inputs minutes manually and pulling end results is a work in progress

• Still working toward target for minutes, however, the assistant complement is at 20 to 30% (high level analysis)

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Lessons learned

• Three hours/day, 7 days/week can be challenging for elderly and acutely recovering

• Clinical judgement key to treatment decisions

• Activities that were set aside should be revisited

• Data collection is multi-faceted and a work in progress

Communication Tools

Margo Collver

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Priorities for Improvement

were all identified as areas for improvement

Scheduling

Team Processes

Patient Family Expectations

Tools for Patients/Families

Family Rehab Agreement

• Outlines expectations for the family

Discharge Preparation Checklist

• Self management tool for patients

Patient Information Stroke Rehab

• Describes concepts of neuroplasticity

Your Stroke Journey

• A guide for people living with stroke

Community Re-engagement Cue to Action Trigger Tool

• A question guide to help patients think about their needs

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Advocating for Change

Supporting Your Change Efforts

Rehabilitative Care Alliance

120 www.rehabcarealliance.ca

• Ontario-wide collaborative

• Works with stakeholders to

standardize rehabilitative care.

• Funded by all 14 LHINs, the Alliance

aims to:

• Improve long term clinical outcomes

for Ontarians

• Increase community capacity

• So people have access to

rehabilitative care when and where

they need it.

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Presentation Toolkits

• Definitions Presentation Toolkit; Definitions FAQs

• Capacity Planning and System Evaluation

Presentation Toolkit

• Frail Senior/Medically Complex Presentation Toolkit

• Outpatient/Ambulatory Presentation Toolkit

• Planning Considerations for Re-Classification of

Rehab/CCC Beds Presentation Toolkit

http://rehabcarealliance.ca/rca-reports-and-presentations-1#Toolkits

121 www.rehabcarealliance.ca

Definitions Framework

Rehabilitation

• All patients who have experienced sudden onset,

life-altering disability (e.g. SCI, ABI, stroke,

amputation, multiple traumas) with an expected

trajectory of recovery/progression should be

considered.

• To accommodate differing levels of tolerance among

patients on admission and increases in tolerance

during the inpatient stay, the intensity of rehab may

vary from low to high intensity (from at least 15 – 30

minutes of therapy 3x per day to 3 hours per day) up

to 7 days per week.

122

www.rehabcarealliance.ca

http://rehabcarealliance.ca/rca-reports-and-presentations-1









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Indicator #11: Proportion of acute stroke

patients (excluding TIA) discharged to inpatient

rehabilitation

Ontario Average: 34.2%

Access in Essex, Middlesex and Oxford

Counties is below provincial average

Ontario Stroke Report Card: Southwestern Ontario 2013/14

HBAM is a ‘made in Ontario’ funding model that distributes

allocations to organizations in accordance with population

needs and their ability to provide cost-effective care.

Quality Based Procedures (QBPs) are clusters of patients

with clinically related diagnoses or treatments that have

been identified by an evidence-based framework as

providing opportunity for process improvements, clinical re-

design, improved patient outcomes, enhanced patient

experience and potential cost savings

Patient-Based Funding will include HBAM and Quality-

Based Procedures

Patient-Based Funding is based on clinical clusters that reflect an individual’s

disease, diagnosis, treatment and acuity

Hospitals, Community Care Access Centres and Long

Term Care are the first sectors incorporated into

the funding strategy

Health System Funding Reform

Patient-Based Funding

(70%)

Health Based Allocation Model

(40%)

Quality-Based Procedures

(30%)

Global

(30%)

(N.B. 40% and 30% noted

is hospital specific; will be

different for other sectors)

MOH Health System Funding Reform

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QBP: Quality Based Procedures

Clinical Handbook for Stroke

(Acute and Postacute) released February 2015

• Secondary Prevention

• Acute Care

• Inpatient Rehabilitation

• Community Assessment and

Treatment

• Cross Continuum Processes

http://www.hqontario.ca/Portals/0/Documents/eds/clinical-handbooks/community-stroke-20151802-en.pdf

Recommendations

Module 4: Admission to Inpatient Rehabilitation

Recommended Practices

4.1.4 The interprofessional team should consist of physiatrists, other

physicians with expertise/core training in stroke rehabilitation,

OT, PT, SLP, RNs, SW, dietitians.

Additionally recreation therapists, psychologists, vocational

therapists, educational therapists and rehabilitation therapy

assistants.

4.1.5 Recommended staffing ratios for inpatient rehabilitation are:

PT/OT: 1 each per 6 inpatient beds

SLP: 1 :12











64

http://ontariostrokenetwork.ca/stroke-qbp-resource-centre/

http://ontariostrokenetwork.ca/stroke-qbp-resource-centre/

65

Rehabilitation Intensity

Webcast

• You can access the webcast:

Every Minute Counts: Stroke Rehabilitation Intensity

Presented by: Beth Linkewich

• Available on the OTN website. Go to webcast.otn.ca

click on Public Archived Events, and in the search window

plug in the Event #: 37425077

• New webcasts coming:

November 18th

January 13th

http://www.otn.ca/

66

Motor Learning

Provincial Stroke Rounds: Wednesday November 4th

Dr. Kara Patterson from the University of Toronto

Motor Learning and its Application to Stroke Rehabilitation

1. Define and describe motor learning and the factors that

influence motor learning.

2. Identify differences in motor learning between healthy

adults and individuals with neurological conditions.

3. Apply concepts related to motor learning to

neurorehabilitation.

Connect what the evidence says about motor learning to

therapy intensity in stroke rehabilitation

Team Action Planning

• Guide

• Work your way through the guide

• 15 minutes left – make sure you have a Next Steps

Action Plan

• Each team give Jenn last 2 pages for photocopying and

you will get it back

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Next Steps

Action Planning:

• Follow-up and support today’s action plans

Education Planning:

• Are there needs related to this work?

Connecting you with others:

• Sharing resources within our region and province

Creating resources:

• Are there resources needed that everyone would

benefit from? e.g. Family Rehab Agreement

Wrap-Up

Paula Gilmore

Regional Director

Southwestern Ontario Stroke Network

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Evaluation

• Please complete the evaluation and leave it on the

table.

• We really pay attention to your feedback.

Safe travels!