Schuylkill Rehabilitation Center Inc
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420 South Jackson Street Pottsville PA 17901 USA
To provide rehabilitation medicine services focusing on the whole person to meet the needs of those in the community who have experienced disabling injury or illness; to include patient and family in planning the goal oriented interdisciplinary program; to provide a nurturing climate for the personal and professional growth of staff; to maintain financial viability.
Schuylkill rehabilitation center's ("src") process improvement plan was developed through all of the facility's committees along with the marketing plans and fiscal audit incentives. The committees include information and outcomes management (ioms), case record review, safety, accessibility, continuing education, equipment, infection control, and program quality assessment & peer review (pqapr). Each committee's chairperson highlighted their accomplishments for the year and any future goals of their own committee or the facility. This information was then integrated into a facility plan for improvement in the coming fiscal year. These accomplishments and goals are as follows:see schedule o. Ioms committee* made a goal to increase overall patient satisfaction to 70% (68% in 2012). This goal was not achieved; ranking in 2013 was 65%. * attempted to increase the reason for discharge to have a program completion rate of 68% (65% in 2012). In 2013, 60% of the patients completed their program and 5% did not respond. Therefore, 63. 3% of the patients who were recorded had completed their program as reported by their therapist. This is similar but slightly lower than previous years. The largest reason for non-completion continues to be non-compliance of the patient. The second highest reason for a patient not to complete the program was listed by their therapist to be the referring doctor's decision. Insurance limitations as a reason continue to be lower than expected. This goal was not achieved and should continue. * attempted to increase completion rate to national benchmark (foto). (in 2011: src-60 & 69 foto and in 2012 src 58 foto 72). In 2013 src had a completion rate of 70% in completing foto surveys but the benchmark for foto was 78%. This was an 8% difference but better than the 14% difference between src and the benchmark in 2012. In the second quarter of 2013 we began a new process of using a folder to hold the patient's information on their needs for their foto survey, and the foto survey was also completed after the evaluation rather than before. This was done to provide the front desk staff with accurate information to better categorize the patient into the survey requirements and to have a physical reason for the patient to stop at the front desk to complete the survey. The committee should continue to assess with this process now in place why it has not helped with meeting the benchmark of getting more patients to complete their foto survey. This goal was not achieved and should continue. * established a goal to improve the functional status change rate to national foto benchmarks. (see scorecard for all diagnostic categories. ) this goal was achieved for the following: wrist/hand, elbow, neuro peripheral nervous system (pns), orthopedic all, shoulder, and knee. This goal to meet or exceed the functional change rate was achieved except for the categories of cervical, hip, foot/ankle, lumbar, other ortho, cardio neuro all, cva, and cns. * set a goal to decrease the duration of services to equal or less than the national foto benchmark for all diagnostic categories. This goal was achieved in all areas except for neuro. Case records committee *established a goal to continue to review the case record review process for more expedient but thorough review of each chart. (goal achieved)* established a goal to update flow charts & e-forms as needed for standards of documentation and completeness of chart. (goal achieved)safety committee *reviewed and updated all policies/procedures. Src codes were revised and updated according to the schuylkill medical center code system. * continues to run regional disaster drills in conjunction with schuylkill medical center; and is in contact with jack brobst for updated information related to emergency management. * continues to monitor employee incidents and log events to determine if there are any trends and will implement an action plan to decrease if appropriate. * continues to provide input and is involved in the development of the annual risk management report. * continues to keep all staff cpr and first aid certifications current. *updated annual scope competency to reflect the updated code system. Staff attended annual in-service and participated in discussion and written scenario competenciesaccessibility committee*established a goal to update the community resource binder with current accessible facilities/recreational activities/information. (continue goal) continuation of goal for further information on accessible facilities/east campus needs to return information. * set up a goal to educate staff on continued cultural diversity regarding: race, gender, sexual orientation, etc. * established a goal to provide an in-service regarding accessible transportation for county resident. Education committee* upgraded all of the competency tests on to the new computerized educational tracking program, health-streams, from the current scope system. * educated all staff on how to use the system and will make appropriate changes/additions as needed. * worked with staff in addressing an annual learning needs assessment. * worked with the needs assessment and leadership to assess for outside speakers to present courses at src with ceu opportunities by discipline. Equipment committee* monitored regularly scheduled preventative and corrective maintenance of equipment. * monitored and assessed needs for capital and minor equipment and purchased as appropriate/needed. * worked with the education committee to provide education in-services to clinical staff related to the use of therapeutic training, testing, and education tools including staff in-services on use of the bte, the reformer, aquatic therapy update, and the exercise pro software. * purchased cleaning supplies and hand sanitizing wipes and placed them at all equipment to ensure proper cleaning of equipment before/after patient use. * continued working toward reorganization of pt/ot supply closet for cleanliness and maintaining an updating pricing of therapeutic supplies that are sold to patients. * assessed, purchased, and restocked items that can be sold to patients as part of their home exercise program. Price list has been updated. * continues to acquire joint-specific patient education models to assist with educating patients as part of their plan of care including new spine models. Infection control committee* established a goal to continue to educate the staff on the importance of tb, flu, and h1n1 vaccinations and set a goal of 100% compliance. * in 2013, 32 of 34 employees or 94. 12% at src received flu shots. The two employees who did not get flu shots had reasons with their physician's approval and completed the required paperwork that they were not having the flu shot administered. Doing so made src compliant at 100% by the employee health department's requirement. * set a goal to have an annual in-service for all therapists regarding proper procedures for culturing open wounds and whirlpools and also proper cleaning techniques of the whirlpools. (annual in-service to all therapists was completed in 2013. Will continue with annual in-service as well as committee staff to continue individual education as needed with staff when questions arise. )* established a goal to monitor and complete the hand hygiene monitor tool of all therapy staff on an ongoing basis for proper hand washing and the proper cleaning of equipment by staff. Goal of compliance will be set at 100%. (compliance with use of monitoring tool- to 96% for proper cleaning and hand washing. Continued reminders in monthly staff meetings. )*set a goal to monitor results noted from proper hygiene and if trends are identified, will report results to leadership. (no specific trends as areas of non-compliance were identified. The 4% noted areas were washing of hands post patient contact, proper placement of soiled linen into container, and proper cleaning of equipment. )
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