Block scheduling aids efficiency, cuts turnover
Indiana rehab maintains 99% patient satisfaction
Administrators at Southern Indiana Rehab Hospital in New Albany did a staff survey in 1996 and learned that employees felt there were significant communication problems between shifts and disciplines.
"There was a lack of respect and courtesy for different disciplines and for rules," notes Linda Petree-Moore, OT, director of inpatient therapy services at the 60-bed rural hospital.
Nurses were too uncomfortable to ask therapists for help with procedures they were still learning, and therapists sometimes neglected to let other employees know what had been done with a particular patient, Petree-Moore says.
Plus, both therapists and nurses were spend-ing too much time in meetings, both formal and informal, speaking with 20 to 30 people each day about a particular patient case. That gave them less time to care for patients.
About the same time as the staff survey, managers observed an interesting change in how certain employees interacted. The hospital had held its first stroke camp, and a team of four employees had worked together at the camp. When the camp ended, those four employees exhibited some unusual camaraderie, Petree-Moore recalls. "They laughed more and got along better and were more attentive to their patients’ needs as a whole."
The anecdotal evidence that employees could communicate better and get along better if placed in a structured, small group working environment convinced rehab managers that the hospital should make changes mirroring that experience.
"So we thought we needed to decrease the number of people any staff member needs to talk to on any given day and increase care to patients," she says.
That resulted in the block scheduling change. Previously, therapists had been assigned randomly to patients. The new system required therapists and nurses to be assigned to a block of patient rooms, which were color-coded.
"If we called it Team A or Team 1, there’d be a first and a last, and we didn’t want that perception," Petree-Moore says. "So we have a purple, green, pink, blue, beige, maroon, and light green team."
The color-coded teams are assigned to rooms in a certain geographical block; patients’ name tags outside the door also are color-coded, and each nursing unit has a communication board that is color-coded.
On each team, an occupational therapist, a physical therapist, nurses, and other staff work with the same patients each day, so patients have greater consistency in their care, and patient satisfaction, which always was high, has remained at about 99%.
"Basically, the block scheduling system has made our concept of interdisciplinary team approach much more cohesive," says Suzann Byers, CRRN, MA, director of patient care services for Southern Indiana Rehab Hospital.
"All of the patients have the same team from the day of admission to the day of discharge, and the team interacts truly as a team because they have to deal with their own problems and make their own decisions within the team, reaching a consensus regarding patient care," Byers adds.
Employee opinion surveys taken in 1996 before the block scheduling program was implemented and then again in 1999 show that employees now rate the facility’s supervision, communication, and personal policies as more positive now than in 1996. Their ratings also are more positive than the industry’s norm.
Another benefit has been greater productivity. Whereas therapists before might have seen six patients in a day and spent 1.5 hours on documentation, now they can easily see eight patients, and their documentation has been reduced to one hour per day. This enabled the hospital to cut some costs and eliminate a few jobs through attrition, job shifting, and layoffs.
Petree-Moore says the hospital’s turnover rate has decreased among therapists and perhaps would have decreased among nurses if it weren’t for a nursing shortage that has contributed to more turnover in that area. "Also, the cost of care has gone down or stabilized from year to year," she adds.
Here’s how their program works:
o Everyone is assigned to a team.
Each team has a block leader. Byers, Petree-Moore, and two other managers serve as block managers for the eight teams. Block managers are responsible for ensuring the team is operating as a team and that staff are addressing patient problems appropriately and setting goals. "We make sure the team is operating smoothly," Byers says.
Also, a nonclinical hospital administrator or manager is assigned to each team as a guest relations advocate, whose job is to visit the patient within the first couple of days of admission and make sure the patient is comfortable and satisfied with the care.
The guest relations advocate introduces himself or herself to patients as the liaison for any problems, concerns, or comments they might have during their hospitalization, Byers explains. "We were finding that some of our patients were leaving the hospital with their problems, and their problems were not being resolved," she says. "Now we are taking care of the minor problems before they become major ones."
The guest relations advocates include the hospital’s chief executive officer, a maintenance manager, an environmental services manager, a medical records manager, and a communications manager.
Each team also has a primary nurse who is responsible for the patient’s plan of care, coordinating changes to that plan, chart rounds, and updating staff at patient care conferences.
Other team members are nurses to cover each shift, a registered occupational therapist, who is responsible for all activities of daily living, a physical therapist, a nonlicensed physical therapy aide, and a master’s level social worker/case manager.
A therapeutic recreational specialist works for all teams, and as needed, a team might have assistance from a psychologist and speech and language pathologist.
o Team members use same assessment tool.
When patients are admitted, the staff uses an interdisciplinary assessment form that is completed by all nurses and therapists on the team, Byers says. "From the beginning, they collaborate on the assessment," she adds.
Before switching to the current assessment tool, each employee would do his or her own assessment, and other staff wouldn’t know what had been written on the forms. The new tool makes it easy for everyone on the team to see what other therapists or nurses have said about the patient.
"The tool has a psychology section that can trigger a psych consult; it has a nutrition section that can trigger a dietitian consult, and the case manager fills out one part," Byers explains. "It’s left with the patient’s chart, and when staff are on the unit to see the new patient, they can grab the chart and go into the room to do an assessment."
o Scheduling, meetings are more efficient.
Scheduling was trickier before the change to block scheduling. When a new patient was admitted, the scheduler would have to see which therapists had time to add another patient. Now, it’s automatic. When a patient is assigned to a room, the patient automatically has the color-coded team assigned to that room. Because each team is assigned three or four rooms, which have up to two patients per room, if there’s an empty room, the team has time for more patients, Byers says.
Also, it was more difficult for managers to find out which patient had which therapists because information was listed alphabetically. Now the schedule is listed according to the color-coded blocks, which makes it simpler to find a particular patient and the team treating that patient, Petree-Moore says.
"This also makes it easy for doctors to recognize what team a patient is on," Byers says. "If the physician sees a light green name tag on a patient’s chart, the doctor will know who the patient’s primary nurse and therapist are."
Each room has two copies of a list of the patient’s team members and phone numbers. One copy stays on a bulletin board in the patient’s room, and the other can be carried home by the patient’s family.
Each week, the team meets with the patient’s physician to hold a patient care conference, which is called "chart rounds." They discuss the plan of care, set and revise goals, and discuss discharge planning.
"Before, when we met with physicians, we had nurses and therapists constantly coming and going from the team conference room for different patients," Petree-Moore says. "That was inefficient. Now, we have one team go to the chart rounds to discuss all of the patients in their block, and then they leave."
Family members also may attend the chart rounds, although they rarely do, Byers notes. "If there’s a special need, we can arrange for the whole block team to meet with the family and patient at a different time, and that’s one of the advantages of having a team," she says.
o Team members resolve their own problems. "Prior to block scheduling, if there was a problem with a patient, the nurse would go to the nursing director, the OT to me, and the PT to the PT director, and now we have a team leader who the staff will go to with problems," Petree-Moore says.
The block leader is responsible for resolving conflicts or problems that the staff cannot handle on their own. But team members also are encouraged to take care of their own problems through team discussions.
For example, Byers holds a quarterly meeting with her team to discuss problems, concerns, and other issues. "I do team-building exercises with them and discuss problems of patients or other things that might be a great concern to them and they can’t seem to work it out on their own," Byers says. "We usually have lunch and meet for an hour, once a quarter."
As a result of the block scheduling and teams, employees have had fewer communication misunderstandings and other conflicts, Byers says.
"Now there’s less finger-pointing between therapists," she explains. "It’s a team, so if there are certain techniques that a therapist needs to carry through to nursing, it gets done. It used to be that, The therapist didn’t tell me this,’ or The nurse didn’t do that.’"
Now each nurse and therapist knows exactly who the patient’s other team members are. For instance, Byers says, if the nurse doesn’t make a change, the therapist can approach the nurse and ask, "What happened yesterday, because we agreed to upgrade the patient to this exercise, and we told you about it, and you didn’t do that today?" That approach resolves the communication problem immediately, without anyone having to approach a supervisor. "There’s less whining because they have to fix these problems themselves," she says. "They know exactly who the therapist on their block is and who the nurse is."
o Patients are given clearer information.
Previously, a patient’s family might arrive around 4 p.m. or 5 p.m. and immediately ask the nurse who the patient’s physical therapist is. Because the nurse had just come on the shift at 3 p.m., she might not know who had been treating that particular patient, and she couldn’t give the family any information about the therapy.
Since the change to block scheduling, the evening shift nurses and other members of the team are able to tell family members exactly who has been caring for the patient.
"They are communicating a little more and are able to give out information," Byers says. "Or if the family says, Who should I see about this transfer technique or taking the patient out on a pass?’ the nurse can say, Your OT is Brian or your PT is Michael, and you should see such and such a person tomorrow.’"
Need More Information?
Suzann Byers, CRRN, MA, Director of Patient Care Services, Southern Indiana Rehab Hospital, 3104 Blackiston Blvd., New Albany, IN 47150. Phone: (812) 941-6111.
Linda Petree-Moore, OTR, Director of Inpatient Therapy Services, Southern Indiana Rehab Hospital, 3104 Blackiston Blvd., New Albany, IN 47150. Phone: (812) 941-8300.
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