HLCA

Learnings From The ‘MN’ Community Rehabilitation Centre’s Health System: Strategies for Future Success.

‘MN’ Community Rehabilitation Centre (MNCRC) provides an allied health day therapy program (DTP) for geriatric Australian’s requiring slow-stream rehabilitation following a hospital admission. Given the vulnerability of geriatric Australians requiring rehabilitation prior to discharge, it is essential that this system operates efficiently to improve the health and safety of this population. Excellence in consumer-centred care is outlined in MNCRC’s mission statement which highlights their endeavours to ‘provide ethical, innovative and sustainable healthcare to empower geriatric Australians…by enhancing their holistic capacity’ (Personal Communication). As such, MNCRC leaders are responsible for continually evaluating services within the various system components to maintain care accountability in alignment with their mission statement. Whilst MNCRC’s foundational strengths guide geriatric Australian’s to improved health outcomes through individualised rehabilitation, there are inherent weaknesses which impair long-term benefits for clinicians and consumers. These barriers include, the absence of telehealth services, poor workforce retention and facility capacity limitations. A systems thinking approach promotes the strengthening of health systems by analysing the complex relationships between system components and their outcomes through healthcare intervention planning to overcome these weaknesses. (Pounder, 2022). This is supported by Backhouse & Ogunlayi, (2020) affirming that by redesigning inadequate aspects of service provision, this can enhance the provision of evidence-based care. As such, this report will critically analyse the failures of the MNRC health system, with recommendations formulated to ensure future success for all pertinent stakeholders.

System Failures

Lack of Telehealth Technology

The absence of telehealth technology is a major issue impacting service delivery and accessibility due to the large rural population travelling to metropolitan Queensland for health services. Telehealth technology allows clinicians to extend service provision to rural locations without the burden of travel-time and costs. Li et al., (2022) supports telehealth usage in community settings, highlighting that outcomes are just as effective as inpatient rehabilitation. As such, prioritising organisational opportunities to advance healthcare technology correlates with improved efficiency and quality of services, as trends in evidence-based practice can be collected and analysed (Bonner et al., 2021). Once discharged from MNCRC, consumers are expected to attend monthly review appointments to monitor outcomes and performance data. Whilst rural consumers still benefit from completing the program, long-term consumer satisfaction and performance data is compromised without a structured telehealth system. Further, 2021 discharge data indicated that rural consumers accounted for approximately 40% of annual admissions to MNCRC, which highlights that data for almost half of the facility’s clientele was disregarded without telehealth services (Personal Communication). This creates significant inequities in service accessibility, as individualised program modifications cannot be completed for consumers who cannot attend review consultations. This foreshadows poor adherence, incorrect technique and underloading, leading to comparatively poorer outcomes (Andersson et al., 2018).

While MNCRC have previously proposed telehealth initiatives to improve accessibility, these attempts have been largely ineffective. Digital health initiatives have historically been unsuccessful due to resistance from health professionals where clinical support was inefficient to ensure adequate understanding and implementation. Furthermore, MNCRC healthcare leaders have historically used command and autocratic leadership behaviours to propose new or revised policy initiatives. These leadership behaviours are associated with a top-down approach, whereby policy initiatives are dictated by directors without the consideration or engagement of stakeholders during implementation (Pounder, 2022). This approach results in resistance from team members, impairing buy-in due to lack of understanding and communication. This is supported by Gopee & Galloway, (2017) who affirmed that during periods of complex change, open communication is essential to reduce barriers and uncertainty. Therefore, leadership behaviours, in conjunction with effective communication and involvement of all key stakeholders needs to be reviewed to facilitate staff engagement in telehealth implementation.

Inadequate Workforce Retention

Retention of highly skilled allied health clinicians is essential for the provision of evidence-based care given the complexity of geriatric presentations admitted to MNCRC. Workforce retention of specialty-skilled clinicians has direct influence on the quality and safety of care provision which directly effects consumer outcomes (Li et al., 2022). The Covid-19 pandemic has significantly impacted healthcare staffing, with specialised clinical staff choosing to leave the profession due to increased stress, safety concerns, workload, and unrealistic management expectations (Levell, 2022). Workforce limitations are reflected in the reduced number of patients discharged monthly. Prior to the Pandemic, 85 clients were discharged monthly, with an 87% 12-month success rate (indicating nil readmissions) (Personal Communication). During this period, MNCRC had a 1:2 clinician to client ratio, contributing to efficient discharge statistics (Personal Communication). The 2021 data however reveals that only 45 clients were discharged monthly (Personal Communication). This correlates with significant clinician retention issues evident by the 1:3 clinician to client ratio during this period (Personal Communication). The reduction in discharge efficiency correlates with reduced time allocated for personalised rehabilitation guided by health professionals, as shortages of allied health clinicians has resulted in decelerated achievement of discharge criteria and consumer outcomes (Andersson et al., 2018).

The inadequacy of current staffing models at MNCRC correlates with the absence of clinical support and mentoring frameworks for specialised skill development and diversification. Without these structured professional development programs offered extensively in private facilities, this creates disparities in clinical knowledge and skill between clinicians, accounting for 32% of clinical burnout and career changes (Forbes et al., 2021). Andersson et al., (2018) found that sub-optimal clinical skill sets, and competencies was a major contributing factor in adverse clinical events and readmissions. Furthermore, healthcare leaders are responsible for ensuring that clinicians are adequately equipped to provide high-quality, evidence-based care through the prioritisation of workforce education and development (Andersson et al., 2018). Allied health clinicians’ complete half-yearly rotations through the facility, with performance reviews conducted at the end of each rotation. These reviews have significant influence on departmental promotion into leadership roles. Therefore, career progression and skill diversification is impaired without structured professional development programs to support continual knowledge and skill acquisition (Forbes et al., 2021). Healthcare leaders must address the absence of professional development programs to improve staff retention and thus the safety of consumers.

Capacity Limitations and Delays

Due to the specificity of the DTP, the facility only accommodates for 70 clients at maximum capacity, therefore accessibility is an ongoing issue as referrals beyond capacity remain on public waitlists. Whilst other inpatient rehabilitation facilities in Queensland exist, MNCRC is the only public geriatric centre which places significant demand on the organisation. Consumers not admitted remain in hospitals or are transferred to generalised facilities, impairing satisfaction, and outcomes. Furthermore, admission timeframes are variable due to the array of clinical conditions, typically ranging from 2-10 weeks, dictated by the achievement of discharge criteria (Personal Communication). As such, discharge delays due to inadequate speciality clinician availability to facilitate rehabilitation negatively impacts consumers awaiting admission. Burgess et al., (2022) revealed a poor correlation between increased length of hospital stay and patient outcomes, particularly in post-operative geriatric populations. The study found that for every day a patient does not participate in targeted rehabilitation, an additional week of recovery is cumulated, increasing the burden on the public health system and impairing consumer outcomes (Burgess et al., 2022). Consumers who are admitted to generalised adult facilities receive treatment from clinicians who are not equipped with adequate skills or resources to appropriately manage complex geriatric presentations. As such, these consumers recorded high rates of readmission due to deconditioning, falls or other related morbidities once discharged, as rehabilitation could not efficiently cater for their specific needs (Levell, 2022).

Recently, MNCRC have been unable to fulfill maximum capacity due to inadequate staff and resource availability, meaning that a large proportion of geriatric consumers have been admitted to the general adult facilities (Personal Communication). MNCRC have been operating at a 50-consumer capacity to maintain safe clinician to consumer ratios and safeguard the delivery of high-quality care. Due to the increasing complexity of geriatric healthcare, this population requires access to specialised health professionals to deliver individualised care that caters for their specific needs to ensure safe discharge into home environments (Andersson et al., 2018). Proposing an education scheme at a state level, led by healthcare leaders at MNCRC can address capacity limitations by upskilling clinicians at neighbouring rehabilitation facilities to improve the provision and quality of geriatric care across Queensland. This can assist to relieve discharge pressures at MNCRC. Capacity limitations can also be addressed at an organisational level, with clinical directors creating incentive programs and leadership roles within the facility to build a positive and supportive workplace culture.

System Future and Recommendations

Australia’s ageing population places rising demand on MNCRC to provide specialised geriatric rehabilitation services. Based on the systems’ weaknesses, MNCRC will not maintain the demand for geriatric rehabilitation into the future. A systems thinking approach can be applied to propose future recommendations for MNCRC as discussed below. Strategies to overcome system weaknesses will be discussed using the Plan Do Study Act (PDSA) framework to guide successful implementation and change management (Appendix).

Telehealth Accessibility with Guided Support

Implementation of telehealth services is essential to improve service accessibility for rural Australian’s who represent a significant proportion of consumers at MNCRC. Healthcare leaders must evaluate leadership behaviours and implementation strategies to obtain buy-in and support from clinicians for the longevity of technology-based change projects. Leading technological change in healthcare is recognised as a difficult task, with an 80% failure rate, attributed to autocratic and command leadership behaviours whereby a top-down implementation approach is used (Li et al., 2022). These micro-managerial leadership behaviours are reflected in MNCRCs current practices, creating change resistance from clinicians (Li et al., 2022). Top-down approaches to implementation foreshadow staff resistance, as they are forced to partake in rushed or unexpected changes without appropriate communication and understanding of the purpose and benefits of the project (Pounder, 2022).

Saxe-Braithwaite & Gautreau, (2020) affirms that authentic leadership behaviours, using a bottom-up approach to implementation directly correlates with improved stakeholder buy-in and support. This is especially pertinent for technology-based change projects, whereby clinicians are often more resistant due to the increased workload on top of clinical duties to learn and integrate new technology. Authentic leadership behaviours encourage open communication with clinicians from the initial planning stages to support transparent and ethical relationships (Li et al., 2022). This encourages participation and engagement from team members, supporting the communication of ideas and concerns in a safe environment. This empowers clinicians to collaboratively contribute their multifaceted skill sets to instigate long-term project success (Pounder, 2022). Furthermore, authentic leadership behaviours create positive and dynamic group environments, where change projects are valued as clinicians are encouraged to take ownership of the project (Gopee & Galloway, 2017). Engagement of authentic leadership behaviours is essential for the successful implementation of telehealth technology at MNCRC. As such, a strategic implementation plan is outlined below using the PDSA framework.

Plan	· Collaborative engagement of team members in weekly meetings during all phases of telehealth implementation.
Do	· Open communication with team members to ascertain suggestions, opinions, and feedback during implementation. · Continual evaluation of feedback to modify implementation based on suggestions. · Telehealth implementation supported by ongoing training and supervision to ensure expert knowledge and understanding during use.
Study	· Constructive feedback and evaluation sessions fortnightly for clinicians to continually re-evaluate aspects of implementation to suit their clinical needs. · Anonymous monthly reviews via online questionnaires for clinicians to provide honest feedback regarding their satisfaction and involvement during implementation.
Act	· Consistent communication with the team regarding adaptations based on verbal and anonymous feedback.

Improved Workforce Retention

The future success of MNCRC is reliant upon a specialised allied health workforce with diverse skill-sets capable of delivering high-quality care to geriatric consumers. Current workforce retention issues are influenced by the absence of professional development and clinical support frameworks. They are further accentuated by an organisational shift from creating supportive staff environments to simply ensuring daily demands are achieved. Healthcare leaders are responsible for facilitating clinical development through the provision of supportive learning environments, with evidence-based resources available (Forbes et al., 2021). Li et al., (2022) affirms that allocation of clinical time for weekly professional development sessions is essential to continually develop clinical skills and maintain staff satisfaction.

Through the provision of clinical education and supervision at weekly intervals, healthcare leaders can create opportunities for progression into leadership positions, and diversify the services offered through new skill acquisition (Li et al., 2021). This empowers clinicians to continually develop geriatric-specific treatment techniques to enhance their delivery of consumer-centred care (Bonner et al., 2021). Clinical supervision is an approach to professional development whereby experienced clinicians provide clinical guidance to junior staff. Supervision allows clinicians to practice delivery of complex care with real consumers in a safe environment to build confidence and achieve greater consumer outcomes (Backhouse & Ogunlayi, 2020). Forbes et al., (2021) highlights that continually challenging organisations to create a positive learning environment is key to improving staff culture and retention. As such, strategic implementation planning using the PDSA framework is outlined below.

Plan	· Weekly professional development and clinical support programs for allied health clinicians. · Allocation of specialised spaces with evidence-based resources for seminars, focal-group discussions, and private learning consultations.
Do	· Consultation with clinicians to ascertain areas of weakness, or clinical interest areas to discuss. · Engagement of senior clinicians to present seminars and live demonstrations of pertinent topics. · Individual and group practise sessions of new skills to develop confidence prior to public provision.
Study	· Supervised provision of techniques to ensure consumer safety. · Constructive feedback and revision sessions to continually refine skill development. · Individual performance self-reflection for educators to ascertain clinical confidence with skill development. · Anonymous monthly reviews via online questionnaires for honest feedback regarding the program strengths and weaknesses.
Act	· Monthly group feedback discussions inclusive of anonymous data to continually re-evaluate the program. · Open team discussions to ensure presentations remain relevant to clinicians’ interests and development. · Leadership opportunities promoted for clinicians with particular interest in new clinical areas.

Improved Capacity And Reduced Admission Delays

Capacity limitations is an issue impairing equitable care delivery at MNCRC. Consumers denied admission are forced to extend hospital stays or are admitted to general adult rehabilitation facilities. Outcomes are impaired for these consumers without access to the speciality allied health services resulting in reduced discharge efficiency and increased readmission prevalence due to related morbidities (Li et al., 2022). Specialised clinicians from MNCRC can assist general rehabilitation facilities by offering education and resources to improve care provision and reduce capacity limitations. Levell, (2022) supports the upskilling of less specialised clinicians as an efficient method of improving capacity restraints as it focuses on consumer-centred care to overcome barriers. Education and resource provision to neighbouring facilities can be achieved without further reducing the MNCRC workforce through the employment of ‘Change Champions’. ‘Change Champions’ are employed as educators at generalised facilities following a structured education program to facilitate ongoing learning to ensure safe and effective geriatric care (Pounder, 2022). The ‘Change Champions’ are elected from the MNCRC leadership team and are equipped with expert knowledge and understanding of specialised geriatric care. With increased capacity at generalised facilities, this will improve service and discharge efficiency, allowing more geriatric Australians to access rehabilitation services without compromising service quality. The strategic implementation of ‘Change Champion’ employment is outlined below using the PDSA framework.

Plan	· Weekly education and mentoring sessions at neighbouring rehabilitation facilities to improve the provision of geriatric services and reduce capacity constraints at MNCRC.
Do	· Weekly education and full time mentoring and supervision from ‘Change Champions’ to upskill clinicians on the provision of complex geriatric care. This will continue until independent competency is achieved.
Study	· Skill demonstration examinations prior to provision on consumers. Clinicians must demonstrate clinical competency prior to treating without supervision. · Ongoing evaluation of geriatric discharge data to ensure ongoing satisfactory outcomes. · Consumer satisfaction and outcome surveys to evaluate service success.
Act	· Ongoing education based on flagged areas of weakness in discharge and consumer satisfaction data.

Recommendations

Based on the identified MNCRC healthcare systems’ failures and strategic management plans, the following recommendations can be made to ensure the future success of this organisation.

1. Retention of allied health clinicians through the provision of professional development and clinical support programs for ongoing skill acquisition and development. This will empower clinicians to continually diversify their skill sets and discover new clinical areas of interest.

2. Provision of various leadership opportunities for high-performing clinicians to recognise their ongoing application and interest in improving complex geriatric care delivery.

3. Continual monitoring of discharge data to ensure care provision is meeting efficiency expectations to reduce capacity limitations and admission delays. This includes monitoring consumer outcome data to evaluate and address possible readmission trends.

4. Continual integration of digital health technology with associated authentic leadership behaviours to facilitate clinician buy-in and support during implementation to improve provision of equitable care for rural consumers.

5. Continual monitoring of staff and consumer questionnaires and surveys to re-evaluate system components to meet clinician and consumer expectations.

References

Andersson, C., Frank, C., P., & Hansebo, G. (2018). Factors contributing to serious adverse events in nursing homes. Journal of Clinical Nursing, 27(1-2), e354–e362. https://doi.org/10.1111/jocn.13914

Backhouse, M., & Ogunlayi, F. (2020). Quality improvement into practice. BMJ, 368, m865–m865. https://doi.org/10.1136/bmj.m865

Bonner, J., Peters, M. D. J., & Butler, A. (2021). Workforce—The Aged Care Reform. Australian Economic Review, 54(2), 285–293. https://doi.org/10.1111/1467-8462.12427

Burgess, C., Ray‐Barruel, G., & Kynoch, K. (2022). Association between hospital length of stay and patient outcomes. Research in Nursing, 45(1), 59–93. https://doi.org/10.1002/nur.22201

Forbes, R., Lao, A., Wilesmith, S., & Martin, R. (2021). Exploration of mentoring preferences of physiotherapists within Australia. Physiotherapy Research International, 26(1), e1872–n/a. https://doi.org/10.1002/pri.1872

Gopee, F., & Galloway, J. (2017). Leadership and management in healthcare (3rd edition.). SAGE.

Levell, M. (2022). Outpatient secondary care: challenges and opportunities. Future Healthcare Journal, 9(2), 106–112. https://doi.org/10.7861/fhj.2022-0044

Li, M., Davis, M., Kim, N., & Sussman, S. (2022). Leading Change in Healthcare. Journal of Healthcare, 67(1), 13–24. https://doi.org/10.1097/JHM-D-20-00299

Pounder, P. (2022). Leadership and information dissemination: challenges and opportunities. International Journal of Public Leadership, 18(2), 151–172. https://doi.org/10.1108/IJPL-05-2021-0030

Saxe-Braithwaite, C., & Gautreau, S. (2020). Authentic leadership in healthcare organizations. Healthcare Management Forum, 33(3), 140–144. https://doi.org/10.1177/0840470419890634

Appendix

PDSA Framework (Gopee & Galloway, 2017).

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