Physical therapy and occupational therapy (PT/OT) are an integral part of the interdisciplinary team on the general medicine service line. PTs and OTs are very important members of the interdisciplinary team. PTs and OTs in the acute care setting require high-level thinking to draw conclusions by analyzing and synthesizing findings related to patients' activity and participation restrictions, needs and wants, life context, and ability to participate in therapy.1
PTs and OTs use their clinical decision-making skills to make discharge recommendations, equipment recommendations, activity modifications and progression, and provide caregiver training, which are successful in reducing readmissions rates for patients with heart failure, pneumonia, and myocardial infarcts.2 A study published in 2010 reported a lower incidence of hospital readmission for patients discharged to settings recommended by physical therapists than for patients discharged to settings not in concert with physical therapists' recommendations, suggesting the importance of physical therapists' input in outcomes for patients.3
A prior performance improvement project used a multidisciplinary approach to reduce unskilled consults. They focused on educating the interdisciplinary team with regard to which patients are the right patient versus the wrong patient for a PT/OT consult. They used PowerPoint presentations to both senior and resident physicians, refresher talks throughout the year, and one-on-one training, as necessary. After their intervention of assembling and educating an interdisciplinary team, they reduced their unskilled consults by 33.3%.4
Northwestern Memorial Hospital is a nationally ranked academic medical center that houses 894 beds. The rehabilitation services department staffs 34 physical therapists/physical therapist assistants, and 26 occupational therapists. Baseline data collected from May 2017 to February 2018 showed that PT and OT services were consulted 14.5% of the time for unskilled therapy needs on the general medicine floors. This is problematic because the increased number of unskilled consults results in increased time for response to therapy referral, unproductive time spent performing screening/discussion with nursing staff, questions on what qualifies as skilled versus nonskilled services, and decreased frequency of follow-up treatment sessions. The goal of this study was to identify whether acute care PTs and OTs can reduce unskilled consults using a multidisciplinary education intervention. The authors further explored cost savings as a result of reducing unskilled consults.
The DMAIC (define, measure, analyze, improve, and control) methodology5 was used as the basis of this process improvement (PI) project. DMAIC is a step-by-step methodology used to solve problems by identifying and addressing the root causes (ie, sources of variation/defects of a problem). DMAIC is broken down into phases, including define, measure, analyze, improve, and control. The first author completed formal DMAIC training during the course of the PI project. The creation of the problem statement describes the “define” phase of DMAIC.5
A team of PTs and OTs covering 4 adult inpatient general medicine units strived to decrease the percentage of unskilled PT and OT consults. This team received training to categorize unskilled consults in 4 ways: patient not medically appropriate to participate, patient not cognitively intact to actively participate in a therapeutic manner, patient demonstrating baseline level of functional mobility with nursing/medical team, and patient requiring next level of care to address musculoskeletal issue in the outpatient setting. These 4 categories were used successfully in another study,6 and the therapists in this project agreed that they would be able to effectively categorize these unskilled consults in these ways. The therapists were initially trained through a 1-time meeting on how to define each category, how to select these categories in the electronic medical record (EMR), and how the data would be collected. One follow-up education session was provided to both PTs and OTs and one recurring monthly meeting, which included 3 case scenarios to effectively categorize these consults.
Structured Query Language (SQL) was written and validated by the authors and analytics department to query data from both Cerner Powerchart and Epic documentation systems. SQL is a standard database language that is used to create, maintain, and retrieve the relational database, usually in the form of tables. During the baseline data collection phase, the institution used Cerner Powerchart EMR before transitioning to Epic, which was used during the intervention phase of the project. PT and OT staff clicked 1 of 4 radio buttons to discretely identify 1 of the 4 types of unskilled consults. Data from May 2017 to February 2018 were used to determine the baseline level of unskilled consults (14.5%). This data collection described the “measure” phase of DMAIC.
Following the baseline data collection, the primary PTs and OTs on the general medicine service line established an interdisciplinary focus group, including 2 PTs, an OT, 2 hospitalists (MD), 2 registered nurses (RN), 2 attending (discharge) nurses (RN), and a social worker (SW). The purpose of establishing this group was to gain feedback from providers with regard to the culture of mobility, the role of PT and OT, skilled versus unskilled PT and OT consults, and strategies to reduce these unskilled consults. After discussion, the focus group determined that the primary strategy to reduce unskilled PT and OT consults is to incorporate mobility and activities of daily living (ADL) discussion for each patient into interdisciplinary rounds (IDR).
During focus group meetings, 4 root causes and solutions were determined on why unskilled consults were being placed. The common theme that the focus group determined was the proper utilization of daily IDR to promote the discussion of mobility and ADL performance. A main question that came from the focus group was, what is the expectation of mobility/ADL performance, by whom, and how should this be communicated? The focus group described 4 root causes that likely contributed to the problem: PT and OT orders placed preemptively by hospitalists, hospitalists unsure of mobility level before consulting PT/OT, mobility/ADL expectation as a priority in IDR is not high, and RN unsure of mobility or ADL level. This focus group formation and discussion describes the “analyze” phase of DMAIC.5
A shared leadership model was used to designate a role for each discipline and to facilitate sustainability. PT and OT representatives attended IDR 3 days per week (Monday, Wednesday, and Friday) and led active discussion around mobility and ADL performance in addition to discharge recommendations. Along with the Clinical Coordinator, hospitalists led daily IDR meetings and were in charge of facilitating discussion among disciplines (RN, SW, and PT/OT). For this project, hospitalist representatives were tasked to educate their department to consistently promote performance and discussion of mobility and ADL performance during IDR for their patients.
The hospitalists involved in the focus group were tasked with spreading the word to their colleagues, which was beneficial in working toward a solution to address the expectation of reporting patient mobility and ADL performance during IDR. The nursing representatives felt more of a responsibility to provide this information during IDR when the expectation was set by the hospitalist.
Bedsides RNs, attending RNs, and social workers were tasked with educating their teams on the goals of the project and importance of addressing mobility and ADL performance during IDR via monthly staff meetings. During IDR, all of these disciplines contributed to mobility, ADL, and discharge planning discussions for their assigned patients. Two specific members were tasked with initiating discussion of mobility/ADL performance, the unit Clinical Coordinator and the hospitalist. The unit Clinical Coordinator was provided with and educated on using a handout to stimulate mobility/ADL (Figure 1). The facilitation from all disciplines to promote mobility/ADL discussions describes the “improve” phase of DMAIC.5
Frequentist statistical methods for descriptive and nonparametric inferential analyses were performed following the multidiscplinary intervention. Data collected from April 2018 to June 2018 were examined to explore whether the percentage of unskilled consults was reduced and to quantify the resulting cost savings. During this time frame, the data show that PT and OT services collectively were consulted for unskilled therapy needs 3.05% of the time, which is a clinically meaningful decrease (Figure 2). Frequentist statSPSS 21.0 was used to conduct a nonparametric χ2 test to answer the question of whether the decrease in unskilled consults was significant. A χ2 test of independence was performed to examine the relationship between unskilled consults preintervention and postintervention. The relationship between the intervention and unskilled consults was significant, χ2 (1, n = 324) = 149.38, P < .001. Unskilled consults were less likely postintervention. Subsequently, a χ2 test of independence was performed to examine the relationship between types of unskilled consults preintervention. The relationship between types of unskilled consults was significant, χ2 (3, n = 272) = 332.13, P < .001. “Patient at baseline level of function” was the most likely type of unskilled consult preintervention. Finally, a χ2 test of independence was performed to examine the relationship between types of unskilled consults postintervention. The relationship between types of unskilled consults was significant, χ2 (3, n = 52) = 55.23, P < .001. “Patient at baseline level of function” was the most likely type of unskilled consult preintervention.
These results were translated to assess financial implications resulting from the decrease in unskilled consults. The following formula was used to determine net financial benefit to the organization by reducing unskilled PT/OT consults:
- Total PT/OT consults during intervention period (734) × % reduction in unskilled consults (10.55%) = number of skilled PT/OT consults culled by reducing unskilled consults (78)
- Divided among 3 PTs, the consult volume/week during intervention period = 30.5 consults/week (734/8 weeks = 91.75/3 therapists = 30.5)
- Using the % reduction in unskilled consults (10.55%), after the intervention period = 27.3 consults/week (734 − 78 = 656/8 weeks = 82/3 therapists = 27.3)
- The consult volume reduction from 30.5 to 27.3 (3.2), creates 19.2 weeks of PT time/year, or 0.37 FTE (19.2/52) to respond to skilled consults.
This interdisciplinary approach of mobility and ADL discussion during IDR was the primary factor in reducing unskilled PT and OT consults. The reduction of unskilled PT and OT consults from 14.5% to 3.05% was a result of the multidisciplinary approach. This reduction helped the PT and OT staff have the flexibility to respond to same-day orders to establish discharge recommendations for patients admitted to medicine units. A subjective result of this initiative was improved communication within the interdisciplinary team as well as more opportunities for open discussion regarding each discipline's role in patient mobility while hospitalized.
The education and communication from the multidisciplinary team has allowed the discussion of mobility to be implemented into practice. The PT and OT's role in this education was objectifying what constituted a skilled versus unskilled consult, to help the multidisciplinary team come to a conclusion quicker and more accurately. During focus group meetings, 4 root causes and solutions were determined on why unskilled consults were being placed and what they were categorized as. The common theme for improvement that the focus group determined was the proper utilization of daily IDR (Table).
Root Causes and Solutions to Potentially Reduce Unskilled Consults
|Root Cause to Unskilled Consults
|PT and OT orders placed preemptively by hospitalists
||Education to focus group
|Hospitalists unsure of mobility level
||Use input from RN and attending RN during AM rounding and IDR
|Mobility expectation as a priority in IDR is not high
||Incorporating mobility as a discussion point for every patient during IDR
|RN unsure of mobility or ADL level
||Hospitalist/clinical coordinator addressing mobility and ADL concerns for every patient during IDR
ADL, activities of daily living; IDR, interdisciplinary rounds; OT, occupational therapy; PT, physical therapy; RN, registered nurse.
During focus group meetings, it was determined that mobility and ADL discussions were more productive when the expectation for daily mobility with nursing staff was set by the assigned hospitalist on the unit. This way, the nursing staff felt prepared to discuss the mobility and ADL performance of their patients during IDR. When the nursing staff was able to assess their patients' mobility and ADL performance, they were able to communicate when patients were able to perform mobility at their baseline level or not. If a nurse determined a patient to be functioning at baseline level, this left the PT and OT staff time to acknowledge same-day orders for other patients with skilled therapy need for evaluation/treatment. Another purpose for this study was to help the culture of mobility and to ask the question, who is the right provider to be performing tasks like walking and toileting. A question posed to the focus group team was, “Did these patients need the skills of the physical or occupational therapist, or could they be performed by nursing, patient care technician, or family member, if a patient did not have therapy needs?7
Although statistically significant, some limitations are present that suggest findings should be interpreted with further investigation. Discussion may not have been shared to all members of each department, despite each department being represented in the focus group. At times during IDR, some hospitalists were able to discontinue unskilled PT and OT orders in real time. In these instances, the PT and OT staff were not able to choose 1 of 4 radio buttons to categorize the unskilled consult. In a perfect state, all nurses and hospitalists would be able to report their patient's current mobility/ADL level to lead them to the decision whether or not a PT/OT consult was indicated. The PT and OT present in rounds helped to facilitate this discussion when the nursing staff did have the information about mobility/ADL level, but had a difficult time making that decision whether or not a PT/OT consult was indicated.
Results of this project provide preliminary evidence that an interdisciplinary approach using IDR can assist with reducing unskilled consults. Establishing a focus or work group including members from multiple disciplines can assist the initiatives through education on what defines an unskilled consult, collaboration, and improved communication regarding patient mobility and ADL performance while hospitalized. This project can efficiently be organized on other units or organizations over a short period, using strong teamwork and collaboration as a main element for success. Based on the results of this project, using an interdisciplinary approach led by PT/OT can assist with reducing unskilled PT and OT consults.
1. Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224–236.
2. Rogers AT, Bai G, Lavin RA, Anderson GF. Higher hospital spending on occupational therapy is associated with lower readmission rates. Med Care Res Rev. 2017;74(6):668–686.
3. Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90(5):693–703.
4. Myszenski A, Stein K, Trimpe J. Educating the multidisciplinary team to optimize acute PT utilization. Paper presented at: APTA Combined Sections Meeting, Anaheim, California; February, 2016.
5. Gitlow H. A Guide to Six Sigma and Process Improvement for Practitioners and Students: Foundations, DMAIC, Tools, Cases, and Certification. Old Tappan, NJ: Pearson FT Press; 2015.
6. Powell D, Kimura L. Building a Better Referral-Management Process. PT in Motion. http://www.apta.org/PTinMotion/2016/6/Feature/ReferralManagement/
. Published 2016.
7. Boysen J, McGarry K. Redefining the Role of the Acute Care Physical Therapist. Paper presented at: APTA Combined Sections Meeting, Las Vegas, Nevada; February, 2014. http://c.ymcdn.com/sites/www.acutept.org/resource/resmgr/imported/REDEFINING%20THE%20ROLE%20OF%20THE%20ACUTE%20CARE%20PHYSICALTHERAPIST%20handout.pdf