Format for Strategic Plan – 3 year plan



Contributors:

Kay McGee, MS, OTR/L

Aileen Eviota, PT, NCS

Edlyn Laviste, RN

Julie Welsh, RN

Marika Greiff, MD

Sriramjini Muthukrishnan, MD

Keir Ringquist, PT, PhD, GCS

Paul Gorksi, Hospital Administration

Mamie Kutame, MSW

Linda Banks-Woodard, RN

Kimberly Zimmerman, SL/P, CCC-S

Gail Buenventura, RN

Multidisciplinary Clinical Team

Stakeholders

Statement of Purpose for the Strategic Plan for UI Health Rehabilitation Unit

The purpose of the strategic plan for the UIH Rehabilitation Program is to ensure that the program makes a strategic contribution to the mission of the Hospital and the University.

The UIH Rehabilitation Program Mission Statement

The mission of the rehabilitation program is to provide excellent quality, patient-centered inpatient rehabilitation services, to promote a culture of respect within the health system for persons with disabilities and to provide excellent quality educational experiences for students in the health professions. In alignment with the organizational goal, UIH Rehab Unit focus is on eliminating health disparities for those we serve.

Vision for the UI Health System’s Rehabilitation Program

The UIH Rehabilitation Program is perceived within the Health System and the Chicago Rehabilitation Community as offering comprehensive inpatient and outpatient rehabilitation services through a variety of interdisciplinary programs with a specialization in servicing patients who have sustained a cerebral vascular accident.

The vision for the Inpatient Rehabilitation Services is to offer Comprehensive Medical Rehabilitation Unit on an expanded 25 bed rehab unit (currently UIH Rehabilitation has Medicare certification for 18 beds) and to be the provider of choice for rehabilitation for providers and patients within the hospital. The vision for Outpatient Services is to increase multidisciplinary follow-up to patients who need outpatient services.

The UIH Rehabilitation Program make significant contributions to the mission of the University through the provision of excellent patient care, high quality education of health professionals and an active program of rehabilitation research. UIH Rehabilitation Professional Staff have an active role in facilitating the full participation of persons with disabilities through campus and community activities and share their expertise in local and national forums.

SWOT Analysis with Rehab Unit Staff

Strengths

1. Quality Monitoring (KPI board)

2. Great teamwork

3. Strong leadership team

4. Continuity of care (therapy acute care to rehab; MD does pre-op screens to unit)

5. Discharge planner and social worker

6. Availability of consulting services as needed during patient rehab stay

7. Medical/Surgical desire for rehab services

8. PPS Coordinator

9. Dedicated and committed staff to patient care

10. Specialized/advanced skills of staff

11. Daily Huddle Communication

12. Pre-admission planning

13. Stroke Support group

14. Rehab Psychologist

15. Student Involvement

16. FIM Efficiency improvement

17. ROUT Forum for leadership meetings

18. RUSM Forum for staff education, communication, meetings

19. Nursing Education

20. Staff engagement

21. Cater to multi-disease, low socio-economic population

22. Patient-centered

23. Patient satisfaction

24. Profitable unit for organization

25. Evidence-based practice

26. Interdisciplinary communication

27. Most Wired Hospital

Weaknesses

1. Lack of equipment/environmental issues (SCI, Bariatric, Single Occupancy)

2. Staffing issues – MD backup

3. Population specific preparedness/deficits (SCI)

4. Skill Knowledge deficits in specific areas (SCI, Splinting, etc.)

5. Physical environment limiting

6. Limited weekend provisions

7. Limited weekend social opportunities

8. Therapy carryover by nursing

9. Completion of depart process

10. Pre-admission process

11. No weekend admissions

12. Software doesn’t support pull through options easily

Opportunities

1. Have dedicated therapy teams on rehab

2. Decreasing insurance network issues/delays

3. Single occupancy rooms/bariatric room

4. Review of patient cases lost to outside facilities

5. Community reintegration groups

6. Other UI Health medical service education, communication, marketing

7. Reducing pressure ulcers

8. FIM Improvement and sustainability (outcomes progress in general)

9. More Rehab Certified Nurses

10. External Referrals (internal reliance too high)

11. Formal measure of staff engagement

12. Resident education – timeliness of referrals

13. Rehab led consulting for hospital wide activity increase for patients

14. Volunteer usage (weekends and evenings)

15. Therapy carryover by nursing

16. Pushing activity in therapy and on weekends/carryover

17. Interdisciplinary communication

18. Increased marketing to outside facilities that don’t have rehab (U of C) – become preferred rehab facility

19. Utilization of students from UIC on the unit

20. Enhancing brain injury programing for patients

Threats

1. Low census

2. Unkown payment mechanisms

3. Insurance network issues/delays/denials

4. Rapidly changing healthcare system

5. Budget cuts

6. Lack of external referrals

7. Percent of undocumented/uninsured patients

8. Registration issues

9. Old facility

Current Environment

Identified Strengths by Rehab Leadership

• The Inpatient Rehabilitation Staff members are team and patient oriented, they have a positive attitude about rehabilitation and they are committed to achieving positive outcomes for our patients.

• Team communication is strong and completed in multiple ways including daily huddles, weekly conferences, monthly interdisciplinary and team meetings, and daily informal communications amongst team members, patients and families.

• The unit shows good profitability per case; business measures have also surpassed budgeted expectations.

• Clinical outcomes measurement through KPI board have enhanced our already good effectiveness, efficiency, and satisfaction outcomes.

Identified Opportunities for Improvement

• The rehabilitation unit is small compared to other services. Our annual discharges are low compared to the other highly profitable services. A higher number of discharges and a higher ADC would be beneficial to the Health System and would likely bring increased recognition and support to the unit – improved over past year but still with opportunity to grow.

• More than 95% of our referrals come from within UIH.

• The accessibility of the UIH environment and the overall appearance of the unit and the patient rooms.

• Compliance and accuracy with input of FIM scores can continue to improve across all disciplines.

• Ensuring that we are not only in-network but that we are a preferred rehab provider for insurance companies as well as improve delays in authorizations and registration errors will allow more patients access to the rehab unit.

Priorities

• Continue to provide care of unmistakable high quality

• Build the census including building relationships with internal and external referrals

• Demonstrate the contribution the unit makes to the patient care continuum and the financial health of the organization

• Compliance with input of FIM scores as well as accuracy of FIM scoring

• Staffing levels to be appropriate for full census

• Having appropriate equipment to treat patients of varying diagnoses on the Rehabilitation Unit

STRATEGIC GOALS FOR CALENDAR YEAR 2015

1) Increase ADC to 13

2) Increase external admissions to 20 per year

3) Identify lost patients to outside

4) Identify nurses to take CRRN

5) Identify staffing, equipment and education needs to enhance SCI patient outcomes

6) Develop and educate staff on procedure to obtain bariatric equipment through rental process

7) Decrease pressure ulcers to less than 75th percentile in NDNQI

8) Be at or below 50th percentile for fall rate for NDNQI

9) Dedicated rehab therapy teams

10) Complete at least 2 rehab marketing educational session to internal and external referral sources

11) Maintain >95% patient satisfaction scores

12) Develop and complete formal measure of staff engagement

13) Develop and implement at least 1 additional activity group for patients to participate outside of therapy sessions

14) Improve FIM accuracy and compliance

STRATEGIC GOALS TO BE ACHIEVED IN CALENDAR YEAR 2016

1) Increase ADC to 14

2) Increase external admissions to 25 per year

3) Decrease percentage of lost patients to outside by 5%

4) Have 2 nurses complete CRRN

5) Complete at least 2 items identified on needs assessment for SCI patient outcomes

6) Obtain at least 1 piece of bariatric equipment for the unit

7) Decrease pressure ulcers to less than 50th percentile in NDNQI

8) Complete at least 2 additional rehab marketing educational session to internal and external referral sources

9) Maintain >95% Patient Satisfaction scores

10) Improve FIM compliance and accuracy (ongoing from previous year)

11) Be at or below 25th percentile in fall rate for NDNQI

12) Maintain >95% patient satisfaction scores

13) Pending results, maintain or improve staff engagement

14) Develop and implement at least 1 additional activity group for patients to participate outside of therapy sessions

STRATEGIC OUTCOMES PROJECTED FOR CALENDAR YEAR 2017

1) Increase ADC to 15

2) Increase External admissions to 30 per year

3) Decrease percentage of lost patients to outside additional 5%

4) Have 2 nurses complete CRRN

5) Complete additional 2 items identified on needs assessment for SCI patient outcomes

6) Convert one room to bariatric equipped room

7) Decrease pressure ulcers to 25th percentile in NDNQI

8) Complete at least 2 additional rehab marketing educational session to internal and external referral sources

9) Be at or below 25th percentile in fall rate for NDNQI

10) Have single room occupancy beds

11) Be at or below 50th percentile for pressure ulcers for NDNQI

12) Maintain >95% patient satisfaction scores

13) Maintain high staff engagement scores

14) Develop and implement at least 1 additional activity group for patients to participate outside of therapy sessions

15) Improve FIM compliance and accuracy (ongoing from previous year)

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