Challenges and potential improvements in the admission process of patients with spinal cord injury in a specialized rehabilitation clinic – an interview based qualitative study of an interdisciplinary team
© The Author(s). 2017
Received: 24 September 2015
Accepted: 20 June 2017
Published: 26 June 2017
The admission process of patients to a hospital is the starting point for inpatient services. In order to optimize the quality of the health services provision, one needs a good understanding of the patient admission workflow in a clinic. The aim of this study was to identify challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic from the perspective of an interdisciplinary team of health professionals.
Semi-structured interviews with eight health professionals (medical doctors, physical therapists, occupational therapists, nurses) at the Swiss Paraplegic Centre (acute and rehabilitation clinic) were conducted based on a maximum variety purposive sampling strategy. The interviews were analyzed using a thematic analysis approach.
The interviewees described the challenges and potential improvements in this admission process, focusing on five themes. First, the characteristics of the patient with his/her health condition and personality and his/her family influence different areas in the admission process. Improvements in the exchange of information between the hospital and the patient could speed up and simplify the admission process. In addition, challenges and potential improvements were found concerning the rehabilitation planning, the organization of the admission process and the interdisciplinary work.
This study identified five themes of challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic. When planning adaptations of process steps in one of the areas, awareness of effects in other fields is necessary. Improved pre-admission information would be a first important step to optimize the admission process. A common IT-system providing an interdisciplinary overview and possibilities for interdisciplinary exchange would support the management of the admission process. Managers of other hospitals can supplement the results of this study with their own process analyses, to improve their own patient admission processes.
KeywordsRehabilitation Acute care International classification of functioning disability and health (ICF) Process measures Clinical pathways Patient admission Workflow
Care of spinal cord injury (SCI) patients includes safe rescue, acute treatment, rehabilitation and life-long care. An SCI affects the patient on structural and functional levels and leads to impairments in activities and social participations, which are influenced by the patient’s individual environment (e.g. support from others) . Because rehabilitation of SCI patients is long lasting and complex, the treatment requires specific treatment concepts. Thus, SCI patients are often transferred to specialized clinics where they can receive comprehensive treatment. At the specialized clinic, the new patient must first go through an admission process in which an individualized rehabilitation program is defined. The admission process to a specialized clinic is very important, as problems during this transition process can result in an inefficient use of resources and can cause complications for the patients .
However, the process of identifying the specific needs of a new patient can be quite challenging. After the SCI patient is admitted to the specialized clinic, various health professionals assess the patient in a multidimensional way to identify the patient’s individual physical and psychological needs. In this complex admission situation, patient pathways can help to guide the admission process at a specialized clinic and to structure all working tasks that are done by health professionals . Patient pathways are plans “of anticipated clinical practice for a group of patients (client group) with a particular diagnosis or set of symptoms” . The use of patient pathways has been shown to reduce in-hospital complications, improve documentation, reduce length-of-stays, and decrease hospital costs . Process managers at specialized clinics for SCI patients often attempt to implement patient pathways in the admission process in effort to standardize procedures. However, the variety of SCI patients makes it difficult to specify predefined processes for SCI rehabilitation . Indeed, health professionals at SCI clinics often complain about various aspects of the admission process that complicate their daily work. It is therefore important to identify challenges and potential improvements that can enable hospital managers to make process adaptions. Described challenges in the patient admission process of emergency departments, psychiatric or heart clinics are long waiting times for the patient, low patient satisfaction, insufficient interdisciplinary communication and the amount of administrative paperwork for health professionals [6–8]. In the field of SCI, different aspects of pre-hospital management (e. g. early transfer to a specialized center) are known as challenges in the admission process [9, 10]. To add knowledge in the continuum of the admission process, this study aims to identify challenges and potential improvements in the admission process of SCI patients in a specialized clinic from the perspective of an interdisciplinary team of health professionals. The results of this study may also help in the context of health conditions other than SCI, where the admission process of patients is coordinated in an interdisciplinary team.
Setting and study design
This study was conducted at the Swiss Paraplegic Center (SPC) in Nottwil, Switzerland and was based on a master thesis of the University of Lucerne. The SPC is an acute, rehabilitation and outpatient clinic for people with SCI and provides medical care for initial rehabilitation, follow-up treatment, and lifelong medical aftercare. It includes 150 inpatient beds thereof 10 in the intensive care and afforded 52,482 days of care with 1085 finished patient hospitalizations in 2015. The SPC is situated in central rural region of Switzerland and offers care for most of the regions of Switzerland as part of the usual health insurance.
As no literature was found concerning the challenges and potential improvements of the admission process of SCI patients, a qualitative research design was chosen, as qualitative methods help to elucidate experiences and to develop theory . Semi-structured interviews of health professionals at the SPC were conducted and analyzed by a thematic analysis approach.
To obtain profound answers and to cover different professional disciplines that are involved in the admission process, the sampling was based on a purposive maximum variation sampling strategy. The interviewees were selected based on well-defined inclusion criteria. First, the interviewee could only be a medical doctor, a physiotherapist, an occupational therapist or a nurse. Professionals in these disciplines are most involved in the admission process at the SPC and therefore possess a strong understanding of the process. To ensure sufficient familiarity with the admission process, only health professionals in leading positions and with more than three years of working experience at the SPC were included. Medical doctors had to have a degree in physical and rehabilitation medicine or in internal medicine. In total, 8 health care professionals were interviewed, with two interviewees from each discipline (medicine, nursing, physiotherapist, occupational therapist). The interviewees were informed of the aims and the conditions of participation in the study, and they were given guarantees of confidentiality and signed a consent form. The study followed the principles of good clinical practice and fulfilled all institutional requirements.
Topics and content asked in the interviews
- How would you describe the process at the admission day?
- What kinds of problems or challenges do occur at the admission day?
- How could these problems and challenges be solved?
- Does the duration of the admission process differ depending on the patient group?
- How important is the goal formulation in the admission process?
- How is the patient perspective respected in the goal formulation process?
- How important is the interdisciplinary work at the admission day?
- What kinds of problems occur in the interdisciplinary work during the admission process?
- How could we optimize the interdisciplinary work during the admission process?
- Which instruments do simplify/help in the interdisciplinary work of the admission process?
- What kinds of problems do occur in the utilization of these instruments?
- How could these instruments be optimized?
- How do you experience the interface between pre-admission and medical admission
- Do we collect enough professional specific pre-admission information of the patients?
- Who is responsible for the recording of pre-admission information?
- How do you judge the quality of the pre-admission information?
- What kinds of ideas do you have to record better pre-admission information?
- How could we optimize the communication of these pre-admission information?
- How and where do you experience the ICF in the admission process?
- What are the advantages of an ICF implementation in the admission process?
- What kind of ICF instruments do you use in the admission process?
- What kinds of problems or challenges do occur when you use these ICF based instruments?
- Which ICF based instruments are useful for the admission process?
- Does the ICF influence the interdisciplinary work/goal formulation in the admission process?
The interviews were recorded digitally and transcribed verbatim using the program F4. The transcripts were then analyzed based on an inductive thematic analysis method that was structured according to steps described by Braun . As a first step, the transcripts were read to gain an overview of the data as a whole. Researcher-derived codes  were then generated (in German) using Atlas.ti. Three of the eight transcripts were coded together with a rehabilitation quality management expert for quality control and to allow for a different perspective . All codes were then transferred to a database, where the codes for each interview question were compared and arranged into groups of similar codes (in English) (Additional file 2). In a next step, similar groups of codes were grouped to potential sub-themes and themes, then everything was reviewed in relation to the raw data, to make sure that the developed themes still correspond to what was said originally. Finally, two specialists for qualitative research in the field of health science helped to modify the codes, group names and themes according to their professional perspectives. To check for theoretical saturation, an additional interview with a medical doctor of the SPC was performed and the answers were compared to the developed themes. Theoretical saturation was defined as the “point where the data collection does not generate anything (substantially) new” .
Theme 1: Characteristics of the patient and his/her family
I can imagine that some patients would like more therapy, but we have to say, “no, at the moment we can’t cover that for financial reasons”. (occupational therapist 1)
I think we are so busy with administrative tasks and paperwork that we don’t ask the easiest question. We don’t have the resources to ask, “what does the patient want?” (medical doctor 1)
Relatives who have had family members here as patients for four, five years for rehabilitation could be recruited to act as supporting peers. Because they are already familiar with the clinic, our staff and the rehabilitation process, they can help the family members of new patients. They are in the best position to say, “I know what you’ve been through, so I know where you are now. This helped me/us”. (…) I think this sort of peer support program should be a central part of the admission procedure. Both the patient and the patient’s family are welcome here. (nurse 1)
Theme 2: Information exchange between hospital and patient
For me, it’s important that the patient is informed in advance about why he is here. For example, a urological patient should know why he is at this clinic, and which issues will be treated here. We just do not have time to explain this to each and every patient. It shouldn’t be our job to tell him why he’s here; he should be informed in advance. (occupational therapist 2)
In part, there are also goals [recorded on the pre-admission forms] that don’t coincide with the goals the patient describes on the day of admission. The goals may have changed, or were never even understood by the patient to be goals. (occupational therapist 2)
It would be super if you had a lot of information in advance [laughs] about the patient, such as about their social situation, for example. Then you could shorten the assessment. (nurse 2)
We get almost nothing from Spitex [external home care institution]. Perhaps we could give them the transfer reports so that they could send them to us filled out. (nurse 2)
Theme 3: Rehabilitation planning
The first step is just telling the patient systematically and repeatedly if the objectives have changed or what the overall goals of the team are. And it can be quite simple things, such as paper printout on the wall. (....) That is actually a great example of communication because the patient, doctor and nurse look at exactly the same information. (....) Perhaps we also have electronic options on the patient’s iPad or through Twitter. (medical doctor 1)
The interviewees noted that context factors, such as changing conditions in the health care sector, also create challenges in the planning a patient’s rehabilitation. For example, increasing financial pressure reduces the time available per patient, which ultimately reduces the amount of therapy that can be planned.
Theme 4: Organization of the admission process
Mostly, they are registered by half past ten. If a patient comes a bit late, we have a scheduling problem. Then (…) the therapist sees the patient later in the day and the whole process is delayed because all the other evaluation appointments have to be rescheduled. (physical therapist 2)
Sometimes there are also other things that are expected of us, like further education or professional development, and then we don’t manage in this period to also see the patients. (medical doctor 2)
First comes the occupational therapists and asks, “What is the problem?” Then the physiotherapist comes and asks the same question [laughs]. Then the doctor and the nurse come and ask again, “What is the problem?”, so the patient has to explain four times that he has a pressure ulcer. (physical therapist 1)
The problem of double questioning can be solved by only asking the question once [during a collective examination]. To schedule this time-wise is difficult for us, though. It is also not possible resource-wise, I think, because you just need to be short one person because of illness or any other reason. (physical therapist 2)
Theme 5: Interdisciplinary work
It would be good if the nurses could be present [at the meetings], but the timing is bad. Some meetings are held in the early morning, when we [nurses] have to care for the patients. It would be better to hold the meetings during the day so the nurses can participate. But I doubt this is possible because it would require changing too many structures. (nurse 2)
If I need information about the patient, then I must first ask the doctor, but they are often not available [because they] are in a consultation. (…) You usually also can’t reach the responsible nurses because shift changes have taken place. (occupational therapist 1)
It is sometimes the problem that we (…) stationary therapists don’t get the background information from the outpatient doctors or physios because the [information] isn’t stored in the same place. (physical therapist 1)
If you simply color code the text [in the documentation systems], then you know, ok, blue is for physio things, where you can write physio things. Green is for things that concern the occupational therapist and (…) red is for things that concern the nurses. All of this is with the goal of finding the information better and more quickly. (physical therapist 2)
The ICF must become better. I mean, the ICF is really just a word that describes the psycho-social approach to a person. And if you look more closely, the ICF is a red book with items inside. Unquantified items, items that are in version 1.0. (…) ICF, you realize clearly, is at version 1.0 and is therefore not applicable in practice. (medical doctor 2)
Results of check for theoretical saturation
Although the analysis of one additional interview with a medical doctor had no effect on the themes developed from the eight original interviews, it provided additional insights. In particular, the interviewee suggested making a clear agreement with the patient regarding the admission time instead of simply informing them about the importance of punctuality. The interviewee also argued in favor of double examinations as a way to detect issues that may have been missed during the initial examination.
The aim of this study was to identify challenges and potential improvements in the admission process of SCI patients at a specialized clinic. Health professionals from a variety of disciplines shared perspectives that could ultimately be categorized according to five themes: the characteristics of the patient and his/her family, information exchange between hospital and patient, rehabilitation planning, organization of the admission process and interdisciplinary work. As every improvement in the admission process in one area has potential effects in other areas, and as some challenges may be easier to overcome than others, hospital managers have to think very carefully about where to start their interventions.
Challenges arising from the individual characteristics of the patients and his/her family can be especially difficult to overcome because they create challenges elsewhere in the admission process. The results of this study coincide with the conclusions of other authors regarding the difficulty of implementing standardized processes due to the complexity of SCI patients . To be prepared for a variety of SCI patients, standardized processes on a broad level with the potential for adaptions may help to organize the admission process. Therefore a rough framework for main different admission groups should be developed to allow individual adaptation, while enabling the tailoring of processes. Special attention should be given to the immediate admission of newly acquired acute SCI patients to comply with the recommended admission time of 24 h after SCI . It is also important to recognize that a patient’s family is also strongly affected by an SCI and should therefore be integrated in the admission process. Other authors have noted that the family members of SCI patients often experience diseases resulting from the trauma of having a family member affected by an SCI and interventions are needed to help them in their life situation .
With regard to patient information and pre-admission investigations, there is great potential for improvement because this information simplifies the admission process. Ideas concerning the content of the pre-admission forms should be developed through interdisciplinary discussions before adaptions are made, however. As a bio-psycho-social model, the ICF may serve as a guide for developing more detailed and more profession-specific pre-admission forms. Further, the results of this study correspond to those of other studies that have found a lack of information concerning medications, test results and follow-up plans for patients discharged to rehabilitation centers . The results of this study show that health professionals are interested in receiving more patient reports from other professionals, as this information is very useful for the rehabilitation planning. However, ensuring patient privacy and professional secrecy will be important considerations in the discussion about improving collaboration between institutions . In addition, the financing of preadmission activities should be clarified.
With regard to rehabilitation planning, other studies have also described the goal-setting process as a basis for the planning of further interventions . The transparent communication of goals between health professionals and patients was identified as a means of optimizing this process. Other studies have found that patients want written information about set goals , and that allowing room for patients to express their own goals and expectations increases the perceived autonomy of the patient . Nevertheless, it must be recognized that some decision-making processes will still contain divergences between professional opinions and patient wishes. For that reason, it is important to implement measures, which increase the knowledge of the patients about SCI because shared decision-making processes presuppose health literacy of the patient [23, 24].
Some organizational challenges in the admission process are difficult to tackle because situations like simultaneous admissions and sudden emergencies are difficult to anticipate. Flexible processes are needed to help staff manage both unforeseen circumstances and a wide range of SCI patients. Challenges related to organizational optimization should be discussed with staff from a range of disciplines. Although situations such as double questions may be irritating for the patient or a suboptimal use of resources, they can also lead to valuable insights that other health professionals missed. Generally, the interviewees in this study regarded collective examinations with mistrust, so other solutions may be needed. Other authors have proposed using the ICF core sets to assign professional responsibilities among the different ICF categories, which would help to reduce role overlap and redundant examinations .
However, the further implementation of the ICF in the admission process was discussed very critically. Although the interviewees agreed that the common language of the ICF simplifies interdisciplinary communication , some felt that more research is needed about ICF-based assessments before ICF can be usefully implemented. Other authors have also advocated developing additional psychometric tests for the ICF categories and validating the ICF qualifiers before putting ICF into more widespread use . The same authors propose to develop ICF-based electronic documentation systems to facilitate the implementation of ICF tools in the daily work . The experiences of the SPC show that the implementation of an ICF-based documentation system has to incorporate the suggestions of health professionals who actually work with the software to certainly improve the utility of the ICF-based documentation system . Nevertheless ICF core sets are validated and therefore scientifically developed comprehensive sets for categories that could help to optimize the information exchange .
Strength and weaknesses
One strength of this study is the broad representation of health professionals, which made it possible to create a multidimensional overview of the admission process of SCI patients. Also the conducted method was appropriate to realize the various challenges of the admission process. The study was conducted by addressing specific aspects considered to be important from a conceptual point of view, however, questions within specific areas left open enough to enable participants free expression of their points of views. Nevertheless, the small number of interviewees is a limitation of this qualitative study and the inclusion of more interviewees would further enrich and explain the results. Moreover, to complete the understanding of the admission process, the opinions of patients and administrative professionals should be also considered in a further study. Saturation analysis showed that all the main themes for the analysis of the problem at stake were identified. However, additional interviews might lead to more detailed descriptions of the themes themselves.. In addition, this study was conducted in a specific hospital setting and with respect to a specific disease (SCI); it is therefore difficult to generalize the results across hospitals and diseases. Further research is needed to draw a conclusion about the admission process of SCI patients at specialized clinics in other countries with different health care systems.
On the basis of the current results, concepts can be developed with regard to including the patient’s family in the admission process and improving the flow of information between the hospital and the patient. Due to the complexity of SCI patients, it is important that hospitals employ flexible processes that can easily be adapted to unplanned and challenging situations as well as acute care and rehabilitation settings. In addition, improvements in rehabilitation planning and measures that optimize the interdisciplinary communication are needed to optimize the admission process. However, hospital managers need to consider their own context-specific factors when deciding how to optimize their admission processes for SCI patients. Other quantitative process analyses concerning costs, time or personnel must also be considered when deciding where to start adapting the processes.
This study is an overview of the challenges and potential improvements in the admission process of SCI patients at a specialized clinic from the perspective of health professionals. This study reflects the complexity of this process from the medical perspective; additional research on the perspectives of patients and administration will complete the picture of the current challenges in the admission process of SCI patients. Due to the complexity and the interfering processes and interests from patient’s, family member’s, health professionals and administration side, all parties should understand the other perspectives and accept compromises to achieve the best quality as a whole. Hospital managers can use this study as basis or as a supplement to their own process analyses in order to improve their admission processes for SCI patients.
We would like to thank Diana Sigrist-Nix and Stefan Metzger for their competent advices. A special thank goes to all interviewees. This research resulted from a cooperation of the Department of Health Science and Health Policy at the University of Lucerne and the Swiss Paraplegic Centre and was part of the master thesis of Fabian Röthlisberger. We thereby thank both institutions to make this publication possible.
No funding was received.
Availability of data and materials
All data and materials are stored and available at the clinical trial unit of the Swiss Paraplegic Centre (email@example.com).
FR conceived the study, participated in the design of the study, conducted the interviews, participated in the data analysis and drafted the manuscript. AS conceived the study, participated in the design of the study, was involved in the sampling procedure of the interviewees, participated in the analysis and was involved in writing the manuscript. SR and KS participated in the sampling procedure of the interviewees and participated in the analysis. SB gave advice on the overall argumentation of the paper. All authors critically read the manuscript and revised it and finally approved the manuscript.
FR has a degree in health sciences and physical therapy and is working as a quality manager and scientific assistant at the University Hospital of Berne. AS works as a specialist for Physical Medicine and Rehabilitation (PMR) and is the leader of the department of rehabilitation quality management research at the Swiss Paraplegic Centre. SB holds a PhD in Economics and is professor in health economics at the University of Lucerne. SR holds a PhD in the areas of logic, argumentation theory and rhetoric and works as assistant professor with focus on health communication at the University of Lucerne. KS holds a degree in business administration and occupational therapy and is the leader of the department of business development at the Swiss Paraplegic Centre.
Ethics approval and consent to participate
All participants signed a written consent to participate. The study was approved by the institutional research board and the responsible ethical committee (Ethikkommission Nordwest- und Zentralschweiz (EKNZ) Req-2017-00427).
Consent for publication
All authors consented for publication.
The authors declare that they have no competing interests.
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