Patient Safety Organization Drives Inpatient Rehabilitation Quality Improvement

Patient Safety
April 2017

The Carolinas Rehabilitation Patient Safety Organization (PSO), which serves 34 freestanding inpatient rehabilitation hospitals and inpatient rehabilitation units, is facilitating the improvement of quality and patient safety across 19 States. Improvements have been particularly notable in the prevention of falls and hospital-acquired pressure ulcers.

As the first AHRQ-listed PSO targeted specifically for inpatient rehabilitation settings, the Carolinas Rehabilitation PSO fills a niche to help improve patient care in these settings. For example, the PSO recognized that quality and safety metrics for acute and post-acute settings did not take into account the unique characteristics of inpatient rehabilitation—a critical setting in the post-acute continuum of care.

To help its facilities reduce harm and improve the quality of care, the PSO leveraged the AHRQ PSO Web site to create a database that tracks quality and safety events in the rehabilitation setting.

"We are focused on patient care and safety, so we are constantly seeking ways to improve," said Robert Larrison, Jr., president of the Carolinas Rehabilitation. "We created [a database called] the Exchanged Quality Data for Rehabilitation (EQUADRSM) to help foster a collaborative community for rehabilitation quality professionals. It allows the PSO to provide benchmarking data that rehabilitation facility staff can learn from in a protected space."

Alan Zaph, P.T., coordinator of the PSO, noted that the most significant improvement reported has been in the rates of unassisted falls and hospital-acquired pressure ulcer rates. "From 2010 to 2015, the reported rate of unassisted falls per 1,000 patient days improved by 18.9 percent. In 2010, the reported rate was 5.39 unassisted falls per 1,000 patient days, and in 2015 the rate dropped to 4.37," Mr. Zaph said.

The PSO shared tools from AHRQ's Preventing Falls in Hospitals guide with its facilities. Specific sections that were considered to be helpful include universal fall precautions (including the scheduled rounding protocols), standardized assessment of fall risk factors, care planning and interventions addressing risk factors within the overall patient care plan, and post-fall procedures (including a clinical review and root cause analysis).

Overall improvement has also been reported from 2010 to 2015 in rates of restraint use, which dropped 40.6 percent; hospital-acquired venous thromboembolism, which fell 25.9 percent; catheter-related urinary tract infections, which were reduced 70 percent; and urinary catheter use, which fell 41.7 percent.

Unassisted falls per 1,000 patients days dropped from 5.39  in 2010 to 4.37 in 2015.

Impact Case Study Identifier: 
2017-05
AHRQ Product(s): Patient Safety Organization (PSO)
Topics(s): Blood Clots, Healthcare-Associated Infections (HAIs), Long-Term Care, Outcomes, Patient Safety, Pressure Ulcers, Quality of Care, Patient Safety Organizations
Geographic Location: National
Implementer: Carolinas Rehabilitation Patient Safety Organization (PSO)
Date: 04/14/2017
Page last reviewed April 2017
Back To Top