Case Study: Bryn Mawr Rehabilitation Hospital 2024 Achievement Award

Optimal Operations—Small/Medium Division

Systematic Approach to Standardize CMS Quality Indicator Scoring for Acute Inpatient Rehabilitation Patients at Discharge

The Goal

Auditing of CMS Quality Indicator discharge mobility and self‐care scores identified a substantially higher rate of patients discharging from the facility at a supervision level when compared to regional and national benchmarks. Staff observations and interviews revealed a discrepancy between scoring guidelines and skilled assessment of performance.

Intervention

Using the DMAIC model, a quality improvement process was undertaken to improve intra‐ and inter‐rater consistency of discharge scoring with the goals of improving the percentage of patients discharged at an independent level for self‐care and mobility and improving the percentage of patients meeting or exceeding their risk‐adjusted quality indicator discharge score.

Educational modules were developed and presented to staff. Education included:

• Guidance on the need for objective justification of supervision scoring
• Appropriate reasons and scenarios where a patient would match supervision‐ or independent‐level scoring

Performance was assessed through chart audits, and learning was reinforced through a direct feedback loop to staff regarding accuracy in scoring and documentation.

Results

Within three months of education, an 8 point overall improvement in discharge Quality Indicator scores was noted, with facility performance exceeding regional and national benchmarks.

The team identified 13 underperforming self‐care and mobility skills and, upon conclusion, 10/13 had met or surpassed the regional and national benchmarks. Additionally, the facility demonstrated an 11.8 percent increase for individuals meeting or exceeding risk-adjusted self‐care goals and a 7.8 percent increase for mobility goals.

 

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Topics: Quality Initiatives

Revision Date: 2/20/2024

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