A. Identify a quality improvement model that can be implemented.

B. Describe the steps of the quality improvement model you chose.

Lauren works in a small health information management (HIM) department in a sub-acute/ rehabilitation facility located in a suburb. She has an associate's degree in business office management and a certified coding professional credential. She is also working toward a bachelor's degree in health informatics. She is looking forward to taking the registered health information administrator (RHIA) exam as her next professional goal. She has been working at the rehabilitation facility for about two years.

The rehabilitation floor is the first floor and accommodates 30 patients; the second floor of the facility has 20 beds and houses the medically compromised patients. A variety of patients are seen for rehab: their diagnoses include cerebrovascular accident (CVA), spinal cord injury, amputations, cardiac surgery, and total joint arthroplasty. The rehab disciplines are composed of physical, occupational, and speech therapy, and a licensed clinical social worker serves as a counselor and assists with case management. The patients on the second floor are treated for serious medical conditions. The physical therapy department includes Tom as the department head, along with Joe, Karen, and April as physical therapists. The occupational department includes Dawn as the department head and Al, Phil, and Mara as occupational therapists. The speech therapy department includes Allie as the department head and Mike, Joseph, and Tina as speech therapists. Sally is the licensed clinical social worker.

There are many patients on ventilators, others recovering after open heart surgery or new amputations, and those with serious decubitus ulcers requiring wound care. The facility has a wound care team and receives patients from several local nursing homes when wounds become too advanced for nursing home staff to care for. Most of the patients on the second floor receive only nursing care or wound care, although some, as they are physically improving, receive therapies and eventually may be moved downstairs to rehab or discharged to their homes or a nursing home.

Lauren's supervisor, Betsy, RHIA, manages the small HIM departments of this facility and three others, all owned by the facility and located within a 200-mile radius. Betsy phones in several times a week and visits Lauren twice monthly unless there are problems. Lauren likes having the responsibility of managing all the health records for this facility and has a good professional relationship with all the physicians and staff. She developed several databases in addition to her regular work, one of them for the vascular surgeon who heads the wound care team. The surgeon was looking for a way to track the length of stay of patients with certain types of wounds. The surgeon had also asked for a comparative study on numbers of patients transferred in from nursing homes. The surgeon was pleased with the results of Lauren's work. The surgeon mentioned Lauren's work to the chief executive officer (CEO) of the company. In a rare visit to the facility, the CEO stopped in Lauren's office to compliment her and tell her what a great job she was doing. Lauren knew the CEO had an MBA and was said to be tough when it came to finances. She also knew that the CEO had a background as a respiratory care technician before coming into the business side of healthcare, so she thought the CEO still had a bit of a soft side.

Lauren likes working for the facility, and she would like to move up into management, perhaps into Betsy's position if it ever opened. She is always looking for new opportunities and new challenges. This morning, as Lauren was working on some release of information documents, one of the physical therapists, Karen, came into her office and sat down rather abruptly. "Houston, we've got a problem!" She leaned forward. Lauren laughed because it always amazed her that therapists kept such a great sense of humor, despite how tough their jobs could be. So many of them would stop in her office to drop off a patient chart or look for Medicare forms and stay for a few minutes to discuss the challenges their patients were having. Thinking the problem had something to do with patient records, Lauren immediately agreed to help. "We'd like you to lead a quality improvement team," Karen stated. "We've been having problems for a while now. Patients are not being brought down for therapies on time. The transporter goes for them but ends up waiting or coming back to the department. Sometimes we even run down to the nurses' station to see what's going on. The nurses all know we have a tight therapy schedule for a lot of these patients. Some of them are being seen for physical, occupational, and speech therapy, and we're supposed to have a 45-60-minute session in each therapy, twice a day. The nurses know that. Therapies take up the whole morning and afternoon for these folks sometimes. That's why they call it rehab." Lauren could sense Karen's agitation and began to say something she hoped would calm Karen down. But Karen started right up again. "We're tired of running back and forth to the unit, and whenever we say anything about why the nurses' aides cannot get the patients up on time, it turns into an argument. I am tired of hearing about how short-staffed and overworked they are. When we get the patients late, we can't give full treatment because they need to be seen by all therapists. It is not fair to the patients. It wouldn't be bad if it happened occasionally because we all know sometimes patients are having bad days and it is hard to get them going. But it is happening all the time now, and yesterday was the icing on the cake!" Karen stopped only long enough to gulp her coffee and went on.

"Late yesterday, just as we were all finishing up our documentation for the day, Tom came barreling out of his office." Tom is the physical therapist department head. "He pulled us all away from our desks and crammed us into his office. He wanted to know why billing charges were down so much last month, but before we could even say anything, he said he received a call from the CEO, and the CEO was pretty mad."

This story gets worse by the minute, thought Lauren. What next? "Apparently Mrs. Kirk called the CEO yesterday," said Karen, "and she wanted to know why her husband hasn't been getting his full rehab sessions as he did when he started a month ago. You know, that's Joe's wife; he is the sweet guy who had the bad stroke and can't talk yet, and we're just now getting him to stand up. She comes every day in the afternoon and then stays to feed him supper." Lauren nodded. She knew the patient and knew that the family was very caring. She also knew the CEO did not like getting calls like that from family members. Karen continued. "She told the CEO that if we couldn't give her husband better care than this, she was pulling him out of here and finding another rehab place for him. The CEO called Tom right away and told him to find out what was going on and fix it. Period! So, when Tom called us into his office and told us what was going on, we told him about the problems we had been having with nursing. He actually was pretty calm about it, which was scary, because his voice became very low, and he turned to me and said, 'Karen, I know I can count on you to make all of this right.' And then he stood up, which we all took as our cue to leave. All of us thought you would be the perfect person to head this up and get it fixed, because you know all of us, both the rehab and nursing staff, and you know the procedures, and you wouldn't be biased. We need someone from the outside who knows about the inside. Does that make sense?" Lauren laughed because it was true. She knew all the personalities and had great respect for all of them. She wasn't surprised by the problem they were having because she had heard about it when people stopped in her office to pick up a chart or when she went by the nurses' station to drop off Medicare forms. It seemed to be one of those problems everyone knew about but did not know how to change. From what she had heard, they all had a different view on why this problem was occurring, and clearly, they were all becoming frustrated with it. It needed to be addressed because it was impacting patient care. Lauren told her she would be glad to lead the team and would be e-mailing a group of staff members by the end of the day to set up the first meeting. Karen checked her watch, smiled, and dashed out of the office. Lauren sent a quick e-mail to Tom, informing him she would be forming a quality improvement (QI) team immediately and would be reporting to him on a weekly basis.

She told Tom that Karen had filled her in on all the details, and she would be glad to help with this. Then she sat back and thought about who she would bring aboard this team. She knew enough about QI activities to know the leader had to be a good facilitator and begin positive team building right away. Then she thought about how she could gather objective data on the problem. So many of the reports from the staff have been subjective rather than objective. But she knew that sometimes perceptions were not always accurate; although, according to Mrs. Kirk, her husband was not getting his full treatments. And according to Tom, the therapists were not billing out for services at their regular rates. Lauren would need to figure out a way to gather objective data and determine where the breakdown in the system was occurring. Her thoughts were interrupted by her ringing phone. It was Tom, the rehab supervisor. "Listen," he said, "I just had a call from the CEO again about this problem, and the CEO will be looking for a report in about six weeks. Include what you find out, where you got your data, and what you think needs to be done. Also, add graphs and applicable images. I just want to let you know you need to plan for that. It is easier to know up front rather than backtracking later. Good luck with this and keep me posted!" Lauren thanked Tom as they ended the call and went back to developing her list for the QI team. This was going to be quite the project. There was clearly an opportunity for improvement in the quality of patient care being delivered at the facility. There was also an opportunity for team building among staff, and these problems translated into a good professional opportunity for Lauren to work on challenging projects.