Whether it comes as the result of the aging Baby Boomer generation or an excellent marketing campaign, a rapidly growing client base will put a strain on any organization. As overworked individuals race to keep up with the ever-increasing demands of more and more patients, maintaining a high standard of care must remain a top priority.

For the rehabilitation-department team at the Torrance Memorial Medical Center, Torrance, Calif, working together was the only way to make it happen. Throughout 2002, the department routinely treated approximately 300 patients each month, and the number was growing quickly.

“Things were changing pretty fast, and we were getting into situations where patients were waiting and the staff was working overtime,” says Lynn Riley, PT, CWS, one of the rehabilitation supervisors at Torrance Memorial. “We recognized that we needed to take a look at our processes and change some things.”

Riley started by taking a closer look at the way patients experienced the clinic—from the front desk to leaving the physician. She collected data about wait times at each station along the way, and studied the flow of patients in a performance-improvement project.

According to the research she conducted in May 2005, she determined that the actual time a patient spent in the clinic, on average, was 72 minutes. Some individuals were spending close to 2 hours in the department. Such extended throughput times were significantly taxing a clinic schedule originally built around 30-minute appointments.

A Closer Look
Riley returned to the wound and burn teams within the rehabilitation department armed with the figures. Working as a group, they compiled a list of recommendations to help improve the existing processes and were able to cut “wasted” time.

Their hope was to increase productivity and improve the continuity of care by decreasing the total time patients spent in the clinic. The team also was eager to limit staff overtime and work to closely align the service with the department’s mission to “provide quality, compassionate care with state-of-the-art technique, and smooth flow of patients through the clinic.”

Several time-saving initiatives were put into place in a collaborative effort by staff and physicians. Specific adjustments included restructuring clinic and room assignments, adjusting the number of staff members on each shift, and changing the scheduling procedures. Substantial revisions also were completed to the patient-chart documentation process.

“We pretty much changed everything. For example, we created new forms that allow staff to complete the required documentation in a shorter period of time,” Riley says. Thanks to the new design, information could be indicated with a check mark instead of a written notation. “The forms included boxes where we could measure the wounds and easily and quickly record that information.” The simplified paperwork also made it easier to compare any changes in the size of the wounds between patient visits.

The process-improvement team requested that support staff help expedite patient flow by delaying all nonessential work tasks during high-patient-volume times. Duties like filing records, photocopying files, or stocking shelves are completed during times when the clinic’s physicians are not meeting with patients.

Communication between the secretarial staff and the back office also was improved to keep schedules as up-to-date as possible.

This multifaceted approach occurred through a series of small changes that brought about a large change. After the operational revisions were in place and exercised regularly, a follow-up study found that the average time a patient spent moving through the clinic process had dropped to 47 minutes.

In addition to anecdotal evidence—complaints from patients, staff, and physicians also had decreased—there were considerable tangible benefits. By streamlining the patient-flow process, the staff reports they are able to do more work with less stress. At the time of the initial survey, the clinic had 838 patient visits per month. A year later, in March 2006, the clinic saw 1,057 patients, accounting for an increase in gross revenue of $27,375 that month.

The department also saw an increase in documentation compliance and a decrease in overtime hours. More importantly, clinic staff believed they were able to provide better care for the patients they were seeing.

“Our team put together a new system, tested it, and tweaked it—it was a tremendous team effort to improve the delivery of service to our patients,” Riley says, noting that the job will never be complete. “It’s a continuing performance-improvement project, because things keep fluctuating and changing to the degree that I need to keep my eye on it on an ongoing basis.”

To ensure that progress continues, the clinic plans to track patients, assess the workflow process, and make adjustments as necessary.

“At the moment, we’re monitoring what’s happening on a day-to-day basis and working with the staff to make sure that everybody is OK and things are moving smoothly,” Riley says. “But the long-term plan is to gather the data, analyze it, and redesign the program as needed on a quarterly basis.”

Steady Growth
The hospital’s initial surge of business has yet to wane. Over the past 5 years, local demand for their services has increased considerably. Today, Torrance Memorial’s rehab staff handles approximately 2,000 outpatient visits per month. For inpatient care, they provide care to an average of 50 acute care cases and 30 more in the transitional care unit daily.

In its current location for the past 2 years, the rehabilitation-services department offers 12 patient-examination rooms, staffed by 20 PTs and 10 occupational therapists; and an additional team of about 50 speech therapists, technicians, and support-staff members. The department also offers a specialized gym for pediatrics and outpatient hand therapy, as well as new equipment in the main gym area.

Much of the department’s growth is attributed by the staff to the specialized care they provide.

“We decided that rather than focusing only on regular therapy offered by private practices in the area, we would offer programs that aren’t readily available in the community,” says Azmina Haji, PT, director of rehabilitation services at the Torrance Memorial Medical Center. “We specialize in lymphedema, incontinence, and vestibular disorders; we have an outstanding stroke program; and we provide hand therapy and pediatrics care.”

The clinic treats all types of wounds, including those resulting from trauma, surgery, arterial insufficiency, venous insufficiency, diabetes, or pressure. Burn injuries treated include those caused by chemicals, electricity, or fire. This unique set of skills and expertise came as the therapists working in Torrance Memorial’s burn center grew interested in and became involved with the wound care aspect of the hospital’s burn patients.

“Wound care therapists developed a skill set and applied that knowledge to the wound care patients on the hospital floors,” Haji says. “Soon, a number of doctors in the community started referring their patients to the outpatient side for follow-up care.”

In time, the hospital hired a full-time burn-center medical director who also had a keen interest in wound care. Since there was not a dedicated wound care physician in the community, the new medical director soon became known for her expertise. As the referrals to her clinic increased, the therapists’ involvement increased as the numbers of patients with chronic wounds grew.

Today, the medical-staff team includes two surgeons, both of whom specialize in burn victims and wound care. Many members of the clinical staff, including nurses and physical and occupational therapists, have obtained the additional training and specialized education necessary to provide the best possible burn and wound care to these types of patients.

“Having two physicians with this expertise helps set our services apart from other outpatient burn centers. Equally important is that we’ve been able to assemble a unique team, a talented blend of clinicians to service this particular population,” Haji says.

A Strong Ally
Part of that team includes the administrators at Torrance Memorial, who are dedicated to staying on top of medical advancements, according to Haji.

One such example was the recent addition of protocols overseeing the implementation of maggot debridement therapy (MDT), which is the medical use of live maggots (or fly larvae) for cleaning nonhealing wounds.

Initially suggested by a patient, Haji and her team researched the possibility, looping in both the infection-control department and the pharmaceutical team.

“The nice thing was that not only was the physician excited about this, but all of our ancillary departments were actually more excited than we were,” she says. “We try to look at what we’re doing and use different products to test for better outcomes.”

Though MDT has not been employed to date, “we have a policy and procedure in place, so we are ready to roll with the appropriate patient,” says Tracey Mullan, PT, rehabilitation supervisor with Torrance Memorial. “We are open to studying new ideas in hopes that it may help our patients.”

Besides being forward thinking, working within a sizable metropolitan hospital provides other benefits.

“We have access to all of the resources we could need, compared to how it might be if we were a stand-alone facility,” Haji says. “We have access not only to a variety of physicians, but to a purchasing department that helps us get better prices on our products and more visibility from different vendors.”

Haji believes that having the backing of a large medical center makes the specialty of wound care more appealing to recent medical school graduates.

“We have students who have completed a rotation with us and then have stayed on board, because now they know that they can learn many different things at this location,” Haji says. “Being connected with a hospital helps us attract future employees to this very unique specialty.”

The medical center also is able to staff its facilities from a patient-focused perspective. The clinic is open from 7:30 am to 6 pm, and weekend appointments are available when patients need them. Phone consultations are a regular occurrence.

“Any time the patient calls and has a concern or a question about their wound, there is always somebody who will reassure them and provide direction on a correct action,” Mullan says.

Strength in Numbers
It came as no surprise to the therapists in Torrance Memorial’s rehabilitation department that the solution to their patient-flow issues were solved with teamwork—it’s a philosophy they subscribe to in every aspect of their business.

Each patient is seen by a team consisting of a PT, a medical assistant, a technician, and a physician. The group evaluates the wounds and all contributing factors, and cooperatively they make a decision about a treatment plan.

Beyond just administering care, the clinic’s staff work to educate their patients.

“One of our biggest concerns is patient accountability,” Haji says. “A lot of these patients are in very poor health to begin with—they have problems healing, they have problems with reoccurrence of the wound—so we try to get them to be a little bit more accountable and to take a little bit more charge and control of their life.”

That effort extends to terminally ill patients as well. Staff in the rehab department are very involved in the hospital’s palliative care programs, including hospice care and providing guidance and assistance with end-of-life and quality-of-life issues.

Haji attributes the department’s success to her staff’s dedication to providing high-quality care to patients and their families.

“You really need a dedicated, passionate team,” she says. “And we have a select group of people for whom this work is their passion.”

Dana Hinesly is a contributing writer for Physical Therapy Products.