Going For the Extra Mile

Sydney West Area Health Service

This project won the 2006 Baxter Nsw Health awards, Effectiveness of Care category.

 Presentation given at the 2006 NSW Health Expo.

Contact: Stella Kok

Abstract

In the new Sub-Acute and Non-Acute Patient classification (SNAP) funding model, patients' Length Of Stay (LOS) is not only used as a clinical indicator, it is also proposed that it could be used to determine funding for a rehabilitation unit. Thus, extended LOS could have a financial impact on the unit.

Analysis of data for the year 2003 indicated that both the Length of Stay (LOS) and Clinical Outcome (Length Of Stay Efficiency) in the Medical Rehabilitation Unit (MRU) were outside benchmark (National average).

A 12-month project was introduced in 2004 to address the issue. When inpatients exceeded benchmark LOS, relevant clinicians were consulted. Various quality tools were used to identify the priority areas requiring attention. After implementation of a series of interventions, LOS of MRU was reduced from 5.3% above the benchmark to 18.1% below the benchmark. Patients' clinical outcome also improved from 12.1% less efficient than the benchmark to 50.7% better than the benchmark.

Aim

To reduce Length of Stay of patients in the Medical Rehabilitation Unit and to increase their rehabilitation outcome so that it is equal to or exceeding the national average in a 12-month period.

Background

In the new Sub-Acute and Non-Acute Patient classification (SNAP) funding model, Patients' Length Of Stay (LOS) is not only used as a clinical indicator, it is also proposed that it be used to determine funding for a rehabilitation unit. Thus, extended LOS may have a financial impact on the unit.

The Australasian Rehabilitation Outcome Centre (AROC) receives data from over 100 rehabilitation facilities, representing public and private sectors across Australia. Length Of Stay and Length Of Stay Efficiency* are major clinical indicators used in rehabilitation facilities.  AROC data was used as benchmark in this project.

Analysis of SNAP Data for the year 2003 indicated that both the Length of Stay (LOS) and Clinical Outcome (Length Of Stay Efficiency)* in Medical Rehabilitation Unit (MRU) were outside benchmark). The overall LOS bed-days of 5.3% exceeded the benchmark and their clinical outcomes (LOS Efficiency) were 12.1% lower than the benchmark.

*Length Of Stay Efficiency indicates the average functional improvement per day.

Method

Clinical Practice Improvement methodology was applied in the 12-month project. Data from the Australasian Rehabilitation Outcome Centre (AROC) database was used as benchmarks for comparison. It was decided to set the project boundary from a patient's referral for rehabilitation to their discharge from the rehabilitation unit.

Ex-patients who exceeded benchmark LOS by more than 30% and their carers were interviewed to explore their views on extended inpatient stay. They expressed their lack of understanding of rehabilitation and their different expectations on LOS. Only 50% of participants indicated that they had expected to stay as an inpatient for a short period, most participants had the perception that a longer stay would result in better improvement.

Clinicians including medical, nursing and allied health staff, who were involved in direct patient care in the Medical Rehabilitation Unit, formed the project team. The project team established a flow chart to identify activities in patient movements in the rehabilitation process and used various quality tools to identify the nature and extent of the problems. 

From the brainstorming session and ex-patient's feedback, A cause and effect analysis on extended LOS for MRU patients was conducted. The followings main issues were noted (Fig.1):

• The patient was not ready to transfer to rehabilitation and some of them had no discharge destinations.
• The family/carer had unrealistic expectation of rehabilitation and some were not able to provide supports after the patient's discharge.
• Most staff were not aware of the SNAP system. Disjointed rehabilitation plan was also noted.
• Referral Source lacked understanding of the role of rehabilitation and patient was transferred prematurely.
• Difficulty in finding a nursing home for patients who were young or required specific procedures. Prolonged waiting time for community nurses, outpatient therapies.
• Time for major home modifications and the long waiting list for getting equipment in the community.

Figure 1

Planning and Implementation

Multivoting was taken by all team members to target the most important factors that required addressing in the project. The votes for each category were very close (Figure 2). The highest vote was patient related factor (22.3%) and the lowest was equipment-related factor (11.3%).

 Figure 2

The following interventions were developed based on the 6 target categories. The project team members were divided into small groups and each group was responsible for their allocated interventions in a set time frame:

• Incorporating SNAP data into patients' rehabilitation plan.
  A computer program, displaying Casemix (SNAP) data on the case conference list was developed. The output of the program assisted staff to develop individual rehabilitation plans.
• Preparing pre-admission information for patients and staff of the referral sources.
  These included a pre-admission information pamphlet to patients before their transfers to the rehabilitation unit, a pre-admission checklist to assist referral process. A contract will be made with the families/carers before transfers for the patients on trial of rehabilitation.
• Identification of transitional beds for non-rehabilitation patients
• Preparing a proposal for weekend therapy

A 12-month action plan was drawn to guide team members during the implementation period. Interventions were implemented by using a PDSA (Plan, Do, Study, Act) cycle.  Each intervention was trialled for a 6-month period before evaluation took place. Patients' LOS and their rehabilitation outcomes were compared monthly with benchmarks. Results are plotted on a run chart and feedback was provided at project meetings.

Outcomes and Evaluation

At the end of 12 month period, The LOS bed-days showed more than a 23 % improvement. Compared with AROC data patients' LOS reduced from 5.3% above benchmark in 2003 to 18.3 % under benchmark in 2004. (Figure 3) Patients' clinical outcomes also improved more than 62%. The LOS efficiency of SJH in 2003 was 12.1% under the national average and was 50.7% better than national average in 2004. (Figure 4) The unit operated with improved performance.

 Figure 3

Figure 4

Future scope

After the 12-month project, LOS and LOS Efficiency were identified as the key performance Indicators of Medical Rehabilitation Unit. Suggested interventions for continuous improvement have been incorporated into the unit strategic plan. Strategies identified through this project, which were mentioned under planning and implementation, are also transferable to other rehabilitation facilities.

With the introduction of the new SNAP funding model in NSW Health, patient's Length Of Stay (LOS) is not only a clinical indicator, it also determines funding for a rehabilitation unit. As extended LOS could have a financial impact on the unit, It is important for clinicians to develop a rehabilitation program with good understanding and application of the benchmark LOS and LOS Efficiency.

References

Langley G., Nolan K., Nolan T., Norman C.& Provost L, The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, Jossey-Bass Publishers, San Francisco, 1996.