2000 OPTIMA AWARD.

The Problem

The first indication of a need to analyze this situation arose when families and affiliate hospitals initiated conversations with various staff members stating, in so many words, that "families' ability to receive transportation by the facility van [there was one with limited availability at the time] made resident visitation a reality." Personal financial difficulties or reliance on mass transit puts an extreme burden on some people. This realization grew when the facility received a certificate of need for outpatient rehabilitation; it became clear from input from various staff members that there was a need for free transportation by outpatient rehabilitation clients.

Furthermore, the facility has many residents who either enjoy going out on trips or would like to conduct personal business outside the facility. One van on a limited schedule could not accommodate all these needs. Finally, as outpatient rehabilitation geared up, the facility began to experience an increase in short-term residents and, with it, a potentially increased need for visitor transportation.

An exhaustive review of the literature yielded little information specific to the type of transportation initiative we had in mind. We would have to break new ground. We needed to establish a process, and then analyze whether it improved residents' quality of life. To further structure and organize our plan, the facility's Performance Improvement Department used the FOCUS performance improvement model--Plan, Do, Check, Act (PDCA) (table 1).

There were three important factors to be considered: (1) Personnel: An individual would have to commit to organizing and scheduling resident trips, family/significant other transportation and outpatient transportation. Also, the number of drivers would have to increase. (2) Budgeting: There would have to be a financial allocation to purchase more vehicles and meet the cost of routine maintenance. (3) Administration: The availability of the increased transportation would have to be managed safely and effectively.

Objectives and Planning

The initiative had several objectives: providing a better quality of life for residents; maintaining and increasing the trips in the various categories; and doing all this with financial viability. The team formulated a plan and continually followed it.

The facility's ability to involve staff in the initiative was based on two approaches: (1) asking staff to be involved in the process, and (2) assigning appropriate staff to undertake certain tasks. Underlying the success of this approach, as it developed, was the facility's traditional interdisciplinary and team approach.

The specific performance measure used would be quality of life. The team asked, would increased availability of transportation allow residents to see their loved ones more? Would it increase customer satisfaction for outpatient rehabilitation clients? Would it allow for more individualized resident needs to be met?

Implementation

As with all our initiatives, administration and the facility owner reviewed the proposal and received input from the other disciplines involved. The owner and the administrator planned for an additional driver and van and for further expansion of the proposal as reassessment warranted.

Performance measures were tracked through a Customer Satisfaction Survey distributed to families/significant others on a quarterly basis (table 2), as was a Resident Satisfaction Survey to residents (table 3). The number of trips was monitored daily. Monthly record keeping was conducted, which led to quarterly reporting (table 4). All questionnaires were anonymous to allow respondents to provide information more honestly.

A randomly selected 10% of family members/friends/outpatients received a Customer Satisfaction Survey and 60 residents received a Resident Satisfaction Survey. The residents were, in turn, divided into three groups: 20 using the transportation service as part of our Out-On-Pass program, 20 who went on excursions and 20 who received visitors at the facility. This allowed for a standardized comparison base to use for our quarterly data. We strove for simplicity in our data so that we could easily evaluate positive outcomes and detect any needed changes as they arose.

Data were collected from March 1998 through March 2000. Since the outpatient rehab service began in June 1998, our data collection for that group commenced in September 1998. None of these data could be compared to a national standard because the type of transportation we provide is not used to this extent, nor are such outcomes measured in most nursing homes. Most nursing homes provide transportation for resident trips only. Nevertheless, although data are never 100% accurate or complete, and there is always a margin of error, for the purpose of this study we believe that the data are sufficient to substantiate outcomes.

Fortunately for the initiative, there were no major obstacles or resistance to overcome. Both the owner and the administrator tend to "think out of the box." Their main purpose is to continually improve quality of life for all customers. The one potential obstacle related to the safe transportation of infants and children. The facility, in response, purchased infant and toddler child safety seats for each vehicle to transport children.

The drivers the facility employs were all highly motivated, and the administrative secretary cordially scheduled all visitors and trips. She also relentlessly kept track of all the data.

As noted, the process is centralized through the administrative secretary, who sets up the monthly and daily planner for scheduling in four main areas: outpatient rehabilitation, resident trips, family transportation and miscellaneous resident out-on-pass day trips. Additional staff involved in this initiative included the director of social work, whose department arranges for resident excursions and out-on-pass day trips; the director of recreation, whose department arranges for facility resident trips; the director of performance improvement/inservice, whose department is responsible for monitoring, reviewing and assessing the plan and the data and evaluating the training and competency of the drivers; and the director of rehabilitation and the director of nursing, who are involved with all aspects of resident care. We derived input from additional staff in each department, the residents and their families/significant others. The initial driver and the security guards were also part of the team. The admini strator was, of course, ultimately responsible for upholding the facility's mission and vision statement in implementing the program.

Tools used for planning and data analysis were the FOCUS-PDCA performance improvement model, the customer and resident satisfaction surveys, and transportation statistics, which were kept monthly and reported quarterly. We also kept a time line that tracked specific events, such as data collection periods and scheduling of drivers.

Evaluation

The overall outcome of this initiative was very positive. Review of overall numbers in the various areas of transportation (table 4) shows that a significant number of trips occurred on a quarterly basis and that, overall, the goal of increased resident visitation was realized.

The Resident Satisfaction Survey (table 3) shows the impact on residents' quality of life from having family present, both short- and long-term. As of March 2000, a satisfaction level of more than 90% was achieved. The data were also evaluated from a financial perspective (table 5). Although outlays were substantial, the initiative was found to be long-term cost-effective. There is an overriding advantage to employing a facility's own drivers versus retaining commercial ones: The drivers work for the facility and are personally involved with the residents and families/significant others. Aside from the satisfaction survey data, this can be illustrated by a small sampling of verbatim comments:

Resident comments extracted from the Resident Satisfaction Survey:

* If I could rate the drivers on a scale of one to 10, they would berated an 11. They are all helpful, courteous and kind to all. I would like to thank the facility for bringing my wife to visit every day. She brought me much comfort and helped me get better.

* My son is blind. Without your transportation he would not have been able to visit. My stay here is complete with my son. Without him I would worry and could not concentrate on my own recuperation.

* The drivers are very devoted. They take me on great trips. They make me very happy and safe.

* I've already bonded with my driver. He puts a smile in my face. He takes me to run errands THREE times a week.

Outpatient comments extracted from the Customer Satisfaction Survey:

* My husband goes to your facility for therapy. The drivers are the finest and most caring persons I've ever met.

* It was a pleasure to use this excellent service. The driver was courteous, efficient, caring, professional and well-informed.

Family/significant other comments extracted from Customer Satisfaction Survey pertaining to the administrative secretary:

* You are a complete and total gem. I want to thank you for the kindness always shown me. At times there were changes or "can't comes," but it never ruffled your feathers...you always got me to be with my sister.

* As a daily visitor to my dear wife, I would like to express my gratitude for arranging my daily trips.

Family/significant other comments extracted from Customer Satisfaction Survey pertaining to drivers:

* I am a senior citizen and without the convenience of the van service, it would be very difficult for me to visit my son. The van drivers are excellent drivers. I feel totally relaxed and comfortable while riding with them.

* The drivers were courteous and the service they provided was excellent. They were always prompt. If this service had not been provided, it would have made it impossible for me to visit my husband daily.

From the inception of outpatient rehabilitation in June 1998, more than 100 clients per quarter were transported by the facility to and from rehabilitation. The last quarter of 1999 through the first quarter 2000 saw more than 300 clients per quarter transported to and from rehabilitation (and it might be noted that our facility is the first in our state to have outpatient rehabilitation attached to a nursing home). Many of these people are community residents who now have a place to go for care and away to get there. Many of our short-term rehabilitation residents have been able to continue to receive therapy on an outpatient basis with staff they know. Our transportation program has grown to include a driver dedicated to outpatient rehabilitation clients.

Resident trips have remained at a constant number since the recording of our data. However, in addition to three vans, one of our vehicles is a state-of-the-art bus with an 18-person capacity (see inset, page 27). This allows up to three times the number of residents to go on an outing in comfort versus the typical use of a school bus.

We have increased family/significant other visitation by 50% since the initiative began (table 4), with positive responses on satisfaction surveys increasing from approximately 50% of residents to approximately 90%. Residents' health status improved with their loved ones there, along with improved continuity of care and higher motivation levels.

Resident out-on-pass trips--which include visits to friends and outside banking and individualized shopping trips, none of which are planned group excursions--have fluctuated in number, but there is no question that specific needs are being met without limitations.

As for the financial component reported in table 5, this is based on the use of an average 2.5 drivers, seven days a week. It would appear that, over a three-year period, having a facility use its own drivers and vehicles is more cost-effective than contracting with an outside company. An additional positive outcome is the sense of knowing and feeling secure with the drivers.

Replicating the processes used in this initiative is quite achievable on any scale. Overall, the financial advantage can be realized if the program is properly planned. The initiative will continue to be monitored quarterly throughout the year 2000 and will be reviewed by the performance improvement committee and administration. Empirical evidence of the initiative's impact thus far, though, has been impressive.

Improve Resident Quality of Life

F (Find Process)

* There is potential for improvement of customer quality of life by increasing transportation availability.

O (Organize Team)

* Representation from Administration, Performance Improvement, Nursing, Social Work, Rehabilitation, Recreation and Security to form a team and create a plan.

C (Clarify)

* Current driver activities and availability assessed and reviewed.

* Great difficulty noted with increasing workload.

* Financial impact.

U (Understanding Variation)

* Fluctuations in monthly data.

* Approximations in cost factoring.

* Customer surveys will be a percentage, not 100% sampling.

S (Select)

* Committee to review plan.

* Dissemination of responsibilities of various aspects of the initiative.

P (Plan)

* Monthly monitoring of data with quarterly meeting review to assess the data.

D (Do)

* Initially start with one extra driver and vehicle.

* Monitor for expansion of drivers and vehicles.

* Communication -- Cellular phones that are capable of also being walkie-talkies for direct communication with medical director, administrator, administrative secretary, etc.

* Establish databases and satisfaction surveys.

C (Check)

* Monitoring of data indicated the need for additional drivers and vehicles.

* Monitoring of improved satisfaction rates.

A (Act)

* Monitoring of data continues.

* Reporting at performance improvement meetings continues.

* To date, addition of two drivers, one devoted to outpatient rehabilitation transportation.

RESULTS

* Resident family/significant other visits increased.

* Resident trips, individualized excursions and outpatient transportation maintained and/or increased.

* Improved satisfaction, thus improved quality of life.

Program Staff

Alexander Stern

Administrator

Hilary Rizzo

Assistant Administrator

Vincent Marchello, MD

Medical Director

Joan McAuley

Administrative Secretary

Dan Monohan

Director of Social Work

Ron Becker

Director of Recreation

Alice Massa 

Director of Rehabilitation

Toni Mooney

Director of Nursing

Nancy Langdon

Director of Performance Improvement/Staff Development

Alice Sgroi

Director of Finance

Rosemary Spitaleri

Director of Special Projects

Angel Davila, Edward King, Irma Pena, Edwin Rondon

Drivers

Security Guard Staff

We would also like to acknowledge all the employees of Kings Harbor Multicare Center who are daily participants in all our programs and who make everything we do possible.