Rancho Los Amigos Rehabilitation Center in Downey, California, used the lessons learned from the Disability Competent Care Learning Community (DCCLC) to better meet the needs of their patients. (The DCCLC is a CMS-funded initiative supported through a contract with The Lewin Group and the Institute for Healthcare Improvement). In this interview, Charmaine Dorsey, Rancho’s Director of Continuum of Care, talks with Gilbert Salinas, Rancho’s Chief Clinical Officer and former IHI Fellow, to describe how listening to patients helped them make important changes in their system of care.
Charmaine Dorsey (left) and Gilbert Salinas (right)
GS: The Rancho Los Amigos Patient Advisory Council has provided feedback about how access to medical equipment following discharge from our facility was a major issue. What other feedback has the council provided?
CD: Prior to joining the Disability Competent Care Learning Community, members of our Patient Advisory Council provided feedback about wait times for processing and getting the medical equipment they needed at home. For some patients it may take up to 88 days for them to receive their equipment. The first month after discharge from the rehabilitation center is crucial for a patient’s quality of life and the continued rehabilitation process. I can think of one patient who should have received a motorized wheelchair right after discharge from Rancho, but he waited six months for the wheelchair delivery. By then, the patient didn’t want the chair because he had fallen into a deep depression, and the delivery people didn’t know what to do. They ended up contacting the patient advocate office to alert us to the situation. Eventually, we saw the patient and got him the therapy and services he needed. His story made us wonder how often this happens. We discharge close to 4,000 new patients each year. We realized we needed to work with everyone in the medical equipment process, from order to delivery, to make improvements.
GS: How did participation in the Disability Competent Care Learning Community help?
CD: I didn’t know what to expect, but the experience of sharing our issues with other participants in the Learning Community, receiving guidance on how to bring together other stakeholders such as our health plan and vendors, getting feedback on our work, and hearing what people in other organizations and communities were doing was really incredible.
GS: How did you put together your improvement team and develop a common aim for this work?
CD: We identified the key stakeholders who represented parts of the medical equipment process. This included physical therapy and one of our vendors, for example. We also involved staff from our Seating Center where they evaluate patients and match them with the right equipment. We included providers who write the orders for evaluation at the Seating Center. We invited someone from an insurance company because they’re the ones who authorize payment for the equipment. We knew we needed all these people at the table for the discussions or we might miss the best way to design a comprehensive solution.
Once the improvement team was in place, we then needed to agree on an aim for our work. What was really empowering was that everybody on the team accepted the goal of reducing medical equipment delays because it was a significant issue. I’ve been on other improvement projects and you don’t always get that kind of consensus. With input from each of the stakeholders, we all gained a deeper understanding of the various parts of the process by creating a value stream map. For example, we learned about how the vendor operates and it helped us understand how what they do affects what we were doing, and vice versa. It helped us see what each key stakeholder was responsible for and we started to identify gaps in the process and areas that needed streamlining.
GS: What is an example of a process that the team was able to improve?
CD: One part of the process that we identified through value stream mapping was the time from the appointment for the patient to receive an initial evaluation and referral to the Seating Center, to the time from the referral to the actual appointment at the Seating Center. We could not bypass this process due to funding paperwork requirements. However, our clinic director implemented same-day appointments, and we made improvements in our access issues to the outpatient clinic. This means that newly discharged patients receive a transition to outpatient clinic appointment within 7 to 10 days after discharge from the rehabilitation center; those who are already outpatients can also make appointments in a more timely way. This helps get the medical equipment process going much more quickly. We also have care managers, RN III, in the clinic who serve to help with our high-risk patients and they follow up very closely on these types of processes and help problem solve as needed.
GS: What are the next steps for the team?
CD: Using the value stream map of the medical equipment process, we were able to identify improvements that we could make in other parts of the process. We now want to follow up on those processes, test improvements, see the results, and make additional changes here at Rancho. Bringing together all the stakeholders and doing the value stream mapping also helped us understand the entire system that is involved in providing medical equipment in a timely way. We also continue to develop relationships with external partners such as vendors, insurance companies, and state funding agencies in order to address the wider systems issues affecting how quickly our patients can receive their much needed medical equipment.
GS: For me, one key learning as a participant in the Learning Community has been to see the complexity of the process. What has been the key thing you’ve learned so far?
CD: I have a renewed appreciation of the importance of our patients in the community. The members of our Patient Advisory Council are consumers of our services at Rancho. We are very lucky to have such an active group of volunteers that partner with staff to create improvement in quality outcomes for our population. When they raise important issues, we listen to and focus on them. We have an opportunity to help with our patients’ quality of life, their continued rehabilitation, and their integration back into the community.
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