A Quality Improvement Initiative to Standardize Clinical Processes
in Outpatient Rehabilitation
At Intermountain Healthcare, the team used quality improvement tools like a Pareto Chart to identify the most commonly treated conditions and important opportunities for improvement. They found that low back pain was the most common reason for seeking outpatient physical therapy and there was substantial variation in clinical care and outcomes. So, the team got to work standardizing clinical processes (e.g., workflow).
First, they selected a high-quality clinical practice guideline that included a Treatment-Based Classification System which provided recommendations on how to accurately apply diagnostic classifications AND match treatment to that classification. They integrated the classification system with matched treatments into a standardized workflow for Physical Therapists (PTs). The key aspects of the process were embedded into their Electronic Medical Record (EMR) system to enable measurement of process compliance and clinical outcomes. Percent of charts with complete data, correct classification and correctly matched treatment were tracked. A successful clinical outcome was when the patient achieved a clinically important change in the self-reported measure of symptoms and function, the Modified Disability Questionnaire.
To address barriers to uptake, a range of approaches were used. A culture of improvement, professional engagement and leadership was cultivated through communication, timely feedback, and incentives. Clinicians learned about the Classification System, standardized process, and documentation in the EMR through online educational modules. Tools such as a decision tree pocket guide were also provided. The team developed and tested a Quality Review Tool, “the scorecard,” to support regular chart audits and feedback to clinicians and clinics. Audit results were aggregated and sent to clinic managers to share with their teams. Clinical outcomes were incorporated into job performance reviews and to maximize their chance of success they launched a pay for performance incentive for therapists linked to their scorecard results.
Over the course of the project process compliance increased steadily from just over 30% to 100%. The proportion of incomplete charts decreased from 29.1%to 19.7%, nearly a 10% improvement in process compliance. The proportion of patients who failed to achieve a clinically meaningful outcome decreased from 35.1% in 2015 to 22.7% in 2017.
Applied LeaRRning Case
Dr. Gerard Brennan, PT, PhD, FAPTA, is a senior clinical research scientist for rehabilitative services at Intermountain Healthcare. This Applied LeaRRning Case is based on a presentation by Dr. Gerard Brennan at the CoHSTAR Implementation Science Institute entitled: The Synergy of Implementation & Improvement Science. In his presentation, he explains how Intermountain Healthcare used quality improvement methods and implementation science principles to address variation in management of individuals with low back pain.
“Improvement and Implementation Science need to be more closely aligned so that health care providers and researchers can harness the power of a synergistic approach that is greater than its parts.”
Dr. Gerard Brennan, PT, PhD, FAPTA