Rehab hospital breaks down barriers between nurses, therapists
Rehab hospital breaks down barriers between nurses, therapists
Teams have one leader who supervises both professions
You can’t see the construction debris, but the wall has been torn down the wall in the mind of the caregiver. At Bryn Mawr Rehab in Malvern, PA, the two distinct disciplines of nursing and therapy have been melded into work teams reporting to the same supervisor as part of a restructuring effort to improve patient care.
"They [nursing and therapy] were living in two different cultures," explains Daniel J. Keating, PhD, administrative director for the neurocognitive division. "By putting them on the same team they learn about each other and what each one does. You eliminate the sources of confusion because they’re in the same communication loop. By talking to each other, sparks may be generated. They may come up with some new ideas to improve patient care."
So far the integrated culture is working. Since rolling out in July what it calls patient-centered care, Bryn Mawr has watched patient satisfaction jump to an all-time high for one quarter of 90.6%, placing it in the 99th percentile, according to a survey by Press, Ganey Associates of South Bend, IN. The average score for similar facilities was 86.6%.
"It’s only the first quarter, so it’s too early to tell the impact, but we think it’s working," Keating says. "Like with our patient satisfaction scores, we can’t say we know for sure [patient-centered care] is the reason, but [the increase] does coincide directly with its implementation."
Leader of the pack?
Bryn Mawr’s administrators began preparing for the redesign almost three years ago. Keating says the design team searched for models to emulate, found only ones with separate reporting structures for nursing and therapy, and decided to forge ahead with its own integrated design.
"We don’t know that we’re the only rehab center to do this, but we couldn’t find any others," Keating says.
The redesign team began by looking at the existing structure and its inherent problems, wanting to reconfigure it from the top down. Rehab redesign differs from other hospitals because of the key role therapy plays.
Patients could need treatment from any combination of physical, occupational, speech, recreational, and psychological therapists. Coordinating treatment with all these therapists, plus the nurses, is a challenge, Keating explains.
Charting the new structure
To reconfigure the staffing structure, Bryn Mawr’s redesign team eliminated a tier of management, the directors of each of the therapy disciplines. Now, the clinicians and support staff work in self-directed teams and report to a coordinator, who may be either a nurse or therapist. Job roles have also changed. By cross-training employees to perform a variety of skills, some positions have been combined.
Combining job roles and creating self-directed work teams streamlined communication and pushed decision making closer to the staff. It also cut the number of staff interacting with a patient by 33.4%, Keating says.
The new care team works with 10 to 13 patients, depending on the rehabilitation program. The hospital has six programs under two divisions. The neurocognitive division includes brain injury and stroke programs and the orthomedical division includes musculoskeletal, medical rehab, amputee, and spinal programs. (See staffing structure charts, p. 3.)
Administrators opened the jobs first to existing employees, providing training for any skills they lacked. Once the teams were formed, the staff attended team building classes to promote unity. These programs will be offered three or four times a year on an ongoing basis.
Here, Keating shares Bryn Mawr’s new team-based staffing model with the readers of Patient-Focused Care:
• Administrative director.
Heads the divisions. These two positions are entirely administrative. They provide the vision and leadership for the division. They direct marketing plans and new product development.
• Program managers.
Serve under the administrative director. Slated for RNs or therapists with management backgrounds, these four positions are entirely administrative. The managers create the budget, develop policies and procedures, improve processes, and evaluate the program. Of the two programs in each division, one is slated for a manager with a nursing background, the other a manager with a therapy background to preserve access to resources for discipline-specific questions, such as licensing, skills, or procedures.
"We didn’t want to lose our expertise," explains Keating. "With this, at least one knows the nursing ropes and one knows the therapy ropes."
Three of the four program managers oversee two teams, while the program manager in the orthomedical division oversees four, two medical rehab and two musculoskeletal.
• Team coordinators.
These positions are half administrative and half clinical. Candidates can be either nurses or therapists. The team coordinators implement the patient’s care plan, supervise and evaluate the team members, schedule staff, coordinate communication among staff members, and assist with patient care.
"The team comes up with the patient’s program, and the team coordinator makes sure it is implemented. They are responsible for the follow-through," Keating says.
Under the team coordinators are the clinicians, who include nurses, the therapists, and their assistants, which are also newly created roles. They include:
• Rehab techs.
This position combines the roles of therapy assistants, nursing assistants, patient transportation, phlebotomists, and EKG techs. The rehab techs assist the therapists and nurses, and some are trained to draw blood and give an EKG.
The rehab techs assist one or two teams within a particular program, such as musculoskeletal, medical rehab, or brain injury. They do not cross over into other programs unless a staffing shortage or variability arises, Keating says.
Administrators are re-evaluating the tech position. He says the initial plan was to train all rehab techs in phlebotomy and EKG, but they decided the training time and money would be a waste. "The demand isn’t as high for [EKGs and phlebotomy] as in an acute hospital so if we trained all of them there wouldn’t be enough blood draws or enough EKGs to keep them proficient," Keating explains.
Instead, the administration is considering training a select group in phlebotomy and EKGs. Keating said the administration also is re-evaluating the staff mix and may boost the number of techs because they are being taxed under the current staffing ratio.
• Patient support attendant.
This position, called a PSA, combines the roles of a variety of traditional positions, including nurses’ assistants, dietary, and patient transportation. The PSA has been cross-trained to clean patient rooms, pass out meal trays, escort patients to needed services, and answer a patient’s call bell. The creation of a PSA eliminated some housekeeping positions, but the department is still needed to clean public areas, such as the lobby and hallways.
Two other key positions are also on the team:
• Physician.
The physician leads the team, directing care. "We included this person in the team structure because we wanted people to still know the physician provides the medical leadership."
• Case manager.
The case manager oversees utilization of both internal and external resources. The person is a liaison and resource between the team coordinator, the patient and family, and the insurance company. "The family can go to the case manager with any questions," Keating says. "And, if the family has a concern or complaint the case manager will bring it to the attention of the team coordinator."
The teams are fully staffed during the day but taper during the evening and night shifts when needs decrease. For example, a team serving 12 stroke patients during the day would include 14 nurses, therapists, and support personnel. In the evening it would consist of one RN, one LPN, a rehab tech, and a PSA, whose time would be split with another team. At night, the team is composed of an RN or an LPN and a rehab tech.
In addition to the staff restructuring, Bryn Mawr redesigned portions of the units. The nurse station was dismantled and nurse servers were placed outside rooms, closer to the patients. The servers include patient charts, medications, a computer and printer, and paper and clinical supplies.
Keating says this redesign is the beginning, not the end of change at the hospital. He says the administration will continuously re-evaluate procedures and staffing structure, among other issues, and additional changes are inevitable.
"It’s now part of the way we operate. We need to continue asking is this the best way to do this?"
[For more information about the redesign at Bryn Mawr Rehab, contact Daniel Keating or Jan Bergen at Bryn Mawr Rehab, 414 Paoli Pike, Malvern, PA 19355. Telephone: (610) 251-5604 or (610) 640-3973.]
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