Working with Change
Rehab Professionals Adjust to Patient-Centered Care
By Renée C. Adams
In today's health care arena, it seems as though nothing stays the same. What most facilities are finding is that if they want to survive in this environment, change is a must.
Even facilities that are thriving are embracing change to offer their patients better quality care. Daniel Keating, PhD, administrative director of the neurocognitive division at Bryn Mawr Rehabilitation Hospital in Malvern, PA, told ADVANCE that Bryn Mawr Rehab has always had good patient outcomes, but they thought they could improve them even more. So change they did.
In fact, they re-engineered their entire organizational structure so as to more directly focus on the needs of their patients. "Our goal was to create teams of professionals who would interact together and provide concise quality care," noted Dr. Keating. This was different from the previous set up that utilized and communicated between departments.
Today, the rehab staff at Bryn Mawr Rehab are assigned program teams. There are no more departments. For example, there are two stroke teams and one amputee team. The idea is that with the 10 specialty teams, patients will receive more consistent care because the same protocols are used by all the professionals on that specific team.
"ONE OF THE REASONS we wanted to implement this new model was to reduce the number of people the patient had to interact with," commented Dr. Keating. "One of the complaints we would get on patient satisfaction surveys was that patients were asked the same questions numerous times."
The teams help to eliminate this because one professional on the team acquires the information and distributes it to the rest of the team. It also allows therapists to make more decisions at the patient care level, because all the members of the team are informed of the patient's status.
Another tactic Bryn Mawr Rehab implemented was to create multiskilled clinicians called rehab technicians. The creation of the rehab tech combined the duties of the nursing assistants and the therapy aides. This way patients have one person who helps them get ready in the morning, takes them to therapy and then helps with therapy. It provides more consistency and less people to deal with.
"We were also interested in reducing cost, which is always a consideration in this health care environment. If you can reduce a layer of administration you will reduce costs, which is what we did when we eliminated the departments and their directors."
Now, instead of having department directors Bryn Mawr Rehab has program managers, but fewer of them then there were department directors. They also have team coordinators who are part of the team and are responsible for the supervision of their team. For example, one stroke team has a PT team coordinator to whom the OT, nurses, psychologist and everyone else on that team reports. The team coordinator also has clinical responsibilities, as well as administrative and supervisory duties.
ONE BIG ADVANTAGE of having these teams is that two worlds have been brought together: nursing and therapy. "By having nurses and therapists integrated on the same team and reporting under the same supervisory structure, you get more integration and follow up, because you have more opportunity for integration and dialogue. And the rehab techs are familiar with the nursing and therapy needs because they are responsible for carrying out both programs," Dr. Keating explained.
These changes didn't occur overnight. In fact, it took a year to investigate Bryn Mawr Rehab's needs. The planning started in 1995 and the new model was implemented July 1, 1996.
Even though positions were eliminated, all Bryn Mawr Rehab employees who chose to, remained, some getting new positions.
Because most people are afraid of change, the organizers of the project kept the employees very informed. "We did a number of things to keep people involved," said Dr. Keating. "We had a question and answer box. We had a number of task forces. We conducted open forums on hot topics, such as the rehab tech issue. And we have 'On My Mind' cards that employees can submit anonymously or with their name on it and the administration replies directly to that person or through a hospital-wide publication."
Of course, it's too soon to tell whether the changes have worked for the better, noted the administrative director. However, Bryn Mawr Rehab reports that patient satisfaction scores for the first three months of implementation of the patient-centered care model are the highest they have been in the past two years.
AND AS FAR as the therapists' attitude toward the change, Amanda Starr, PT, the stroke team coordinator, said that the overall atmosphere is positive--now. "One thing that I've learned from all of this is that everyone accepts change in a different way. It took about two months for people to realize that it wasn't that bad and they actually could do it."
Starr concurred, one factor that helped make the transition fairly smooth was the amount of communication that was provided by the administrators of the model to the employees. "I felt very informed and that was the key because the change definitely happened all at one time," said Starr.
Before Starr became the stroke team coordinator, she was a senior PT on the stroke unit and acted as a mentor/supervisor. "The biggest change for me was that I was no longer supervising PTs only. I am now supervising PTs, OTs, SLPs, nurses, rehab techs and patient support attendants."
Starr told ADVANCE that she was nervous in the beginning because it was a brand new position. Basically, the team coordinators had to set the standards and develop the position as they went along. Although there is a job description, Star and the other nine team coordinators have had to modify it as they find necessary. "It has been very exciting and challenging for all of us."
STAR HAD TO GET to know what the other disciplines did and how they functioned from an operational standpoint in the hospital. What she realized was how different each discipline really was and how much it was going to take to bring them together.
Although the team coordinators didn't have any formal training before taking over the position, they've done a lot of walking in each others' shoes in the first three months.
Not all problems can be anticipated, some are realized as they happen. For example, one problem that Starr has run into is that the nurses on her team are not in close proximity to the therapy area. "One of the initial complaints I got was that I was not able to be up in the nursing area enough, and my partner, who is a nurse and the other stroke team coordinator, was not able to be down in the therapy area enough, just because of the physical location of the old departments."
Starr related that another concern the therapists had prior to the model change was how were they going to get their clinical information and discuss discipline issues if they no longer had departments. They ended up keeping their weekly discipline meeting on an informal level in order to continue to communicate clinical information. "The administration respects our need to still have some component of togetherness among our discipline for education purposes and mentorship," noted Starr.
This respect can also be seen in the buddy system that exists on the teams. On each team there are either two PTs or a PT and a PTA. If one person is out, the buddy always knows what's going on and how to communicate about the schedule and how to help get the absent therapist's patients covered. This process has been decentralized and brought closer to the patient. It has also encouraged general responsibility among staff members.
ANOTHER ISSUE of concern was the rehab tech. "It was difficult for the PTs to let go of their PT aides and to accept nurses aides as they used to be called and vice versa. Also, some of the PT aides who wanted to go to PT school weren't interested in going up to the nursing floor and the same was true with the nurses aides."
What the PT aides found is that it wasn't detrimental to them as far as getting into a school. In fact, doing both gave them a better picture of their patients and their experience in the hospital, related Starr.
In fact, according to Starr, the rehab tech is the best thing about the new system. The techs enhance communication by telling team members, for example, how the patient did getting dressed in the morning or what a patient's blood pressure was that morning.
The teams have also helped with being more flexible with the intensity that they see patients, commented Starr. "We are more flexible in that if the patient is more in need of OT than PT, we are more apt to communicate that now. The old mind-set was--and still is to a degree as we go through this--that PT has to see this patient for so many hours a day, which really is not the case as long as that patient has multiple needs for multiple therapies."
A LOT OF cotreating goes on among the team, too, added Star. This has been enhanced by integrating the different therapies in one large area. It used to be that PT sat on the one side of the room and OT was on the other, but now PTs, OTs and recreational therapists in the neurocognitive division sit on the one side together and the orthomedical division sits on the other. "Intertwining the different disciplines has really helped to enhance communication among the staff in that division. You can turn around and consult with the OT or [other team member] who works with the same patients you do."
Starr noted that in addition to enhancing communication, the teams have provided the different disciplines with the opportunity to see what each other is doing. "People are more respective of each other because of it.
"I'm very encouraged about the model," emphasized Starr. "There are some aspects of it that we are re-evaluating to see if they are the most efficient way of doing things, but overall it is a good model." *