Quality Indicators Change Score

Research Objectives: To investigate the change score of our quality indicators (QIs) from admission to discharge in overall self-care and mobility.
Historically, the Penn Rehabilitation Medicine has had significantly lower change scores from admission to discharge compared to the region and the nation. Our goal with this quality improvement project was to improve the accuracy of our scoring thereby increase our change score for both self-care and mobility.

Design: We used a qualitative research approach where we gathered the data and analyzed it to help find the gaps. We then introduced an intervention to see how it affected our data.

Setting: The study setting was inpatient acute rehabilitation hospital which is comprised of general rehabilitation floor and brain injury floor.

Participants: All patients admitted to inpatient rehab on the general rehab and brain injury floor were included in the study. Patients excluded from the study included ones admitted back to acute care hospital, discharged AMA, or expired.

Interventions: Our main interventions included various types of education to staff and daily audits of the QIs in our electronic medical record system. Education included huddle sheets, weekly emails with "tips of the day", and discipline specific education sessions in person and virtually. Audits are done manually by therapy manager and quality team in looking at accuracy of scoring upon admission and discharge.

Main Outcome Measures: Primary outcome measure tracked included if our change scores improved in self-care and mobility from admission to discharge as compared to the region and nation. These scores are collected via uniform data system (UDS).

Results: FY 20 Year End Data - Change Self Care=9.9, Region=12; Change Mobility=27.5, Region=30.2
FY 21 Year End Data - Change Self Care=10.6, Region=12.3; Change Mobility=28.2, Region=31.2
FY 22 Year End Data - Change Self Care=12.0, Region=13.1; Change Mobility=31.7, Region=33.1

Conclusions: Since starting the initiative in November 2021, over the quarters we closed the gap between the region’s overall change score and our overall change score. Education and daily audits have helped in improving our consistency with scoring.

Author(s) Disclosures: None