Quality and Performance Management and Methods Scenario

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. 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 in situations 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

pretty 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 awhile now. Patients aren‟t 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 can‟t get the patients up

on time, it turns into an argument. I‟m 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‟s not fair to the patients. It wouldn‟t be bad if it

happened once in awhile because we all know sometimes patients are having bad days and

it‟s hard to get them going. But it‟s 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, Ellie came

barreling out of her office.” Ellie was the rehab supervisor, and at a petite five foot one,

Lauren couldn‟t picture her barreling anywhere. “She pulled us all away from our desks and

crammed us into her office. She wanted to know why billing charges were down so much

last month, but before we could even say anything, she said she 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‟s the really 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 didn‟t 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 Ellie right away and told her to find out whatever was going on and fix it. Period! So

when Ellie called us into her office and told us what was going on, we told her about the

problems we had been having with nursing. She actually was pretty calm about it, which

was scary, because her voice became very low, and she turned to me and said, „Karen, I

know I can count on you to make all of this right.‟ And then she 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 didn‟t 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 definitely 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 Ellie, informing her she would be forming a quality

improvement (QI) team immediately and would be reporting to her on a weekly basis. She

told Ellie 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 staff was reporting subjectively. But she knew that sometimes perceptions weren‟t

always accurate; although, according to Mrs. Kirk, her husband was not getting his full

treatments. And according to Ellie, 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 Ellie, the rehab supervisor. “Listen,” she 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‟s easier to know up front rather than backtracking later. Good luck with this, and

keep me posted!”

Lauren thanked Ellie 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 a challenging project.