Quality Improvement/Patient Safety Issues Relevant to Rehabilitation

Overview and Description

Definition of quality improvement and patient safety

Quality improvement (QI) and patient safety (PS) are closely linked. PS, viewed as a component of quality, refers to preventing unnecessary harm to the patient. QI activities may improve outcomes such as reducing costs, enhancing efficiency, improving satisfaction, and preventing harm.

QI consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of a targeted patient group. Competence in QI is important for medical trainees, as the Accreditation Council of Graduate Medical Education (ACGME) now recognizes QI as a required component of graduate medical education. Involvement in QI can take many forms through improvements in educational programs, patient care and safety, and research.

There are many definitions of quality. Donabedian classical review on quality of medical care concludes that “quality of care is a remarkably difficult notion to define”; often based on value judgments as they relate to general goals or standards.¹ Donabedian suggests that, in general, quality has to do with the following measures:

• Processes of medical care, that is, the way care is performed.
• Outcomes of these processes, that is, the results.
• Settings/structure in which these processes take place, that is, the people, buildings, and organization.

Quality improvement, as defined by Centers for Medicare and Medicaid Services, is “the framework used to systematically improve care.”² Systematic behavior allows standardization of processes to reduce variation, identify best practices, and improve overall outcomes. The Institute for Healthcare Improvement (IHI) espouses the Model for Improvement as their framework for instituting change.³ The model starts with a question rooted in understanding of a system and then creates a plan of change with importance placed on measuring effectiveness of the change.

Each of these definitions has its value and limitations. Processes are the functions over which healthcare providers have the most control. Certain processes, such as mortality discussion and patient satisfaction questionnaires, have been linked to improved outcomes. However, improving the process may not always improve the overall quality of care perceived by the patient. For example, the esthetic appeal of structures (e.g., hospital buildings) may have little to do with the quality of care provided. Although QI often strives to improve outcomes, multifactorial aspects of outcomes need to be considered. For instance, length of hospital stay as an outcome may be influenced by psychosocial factors, disease severity, and comorbidities which make it challenging when comparing length of stay among different patients with the same diagnosis.

Relevance to Clinical Practice

Educational curricula in PM&R training

Given that the Accreditation Council of Graduate Medical Education (ACGME) requires QI training, there has been a significant effort to develop formal curricula for PM&R residency programs. A needs assessment by Jaffe et al. highlighted significant variability among these programs and found that many program directors felt both their faculty and graduating residents had less than proficient QI skills, leading to a strong interest in a standardized curriculum. ³ Effective quality improvement curricula in PM&R combine didactic learning, such as lectures and online modules, with annual resident-led projects. Successful implementation hinges on strong faculty mentorship and dedicated teams, though time constraints are a common barrier. These structured programs have been proven to improve residents’ comfort with QI principles and increase scholarly productivity, serving as models for future curriculum development.^4-5

QI requirements for practicing physiatrists

The commitment to quality improvement extends beyond residency training. The American Board of Physical Medicine and Rehabilitation (ABPMR) requires its diplomates to engage in continuous professional development as part of its Continuing Certification program. This includes activities focused on assessing and improving the quality of patient care. PM&R physicians must complete one QI project every 5 years which involves systematically evaluating their clinical practice using QI methods, implementing changes, and re-evaluating performance to demonstrate improvement. Participants have the option to develop their own QI project from scratch or to apply already-developed QI projects developed by your own or other organizations to your practice.

The role of accrediting bodies in quality standards

Quality standards are often dictated and monitored by external review organizations that set standards for quality and patient safety. These bodies play a crucial role in driving QI activities at an institutional level.

• The Joint Commission (TJC): TJC accredits healthcare organizations nationwide. It publishes comprehensive standards on areas critical to patient safety, such as medication management, infection control (e.g., sterilization and disinfection), and environmental safety like fire prevention. TJC also mandates specific processes for responding to adverse events, such as the use of Root Cause Analysis (RCA) for sentinel events.
• Commission on Accreditation of Rehabilitation Facilities (CARF): CARF provides accreditation for rehabilitation facilities. Its standards are specific to the needs of rehabilitation populations and programs. For instance, CARF has extensive guidelines on the composition of the interdisciplinary team and the types and intensity of therapy services that must be available for a program to achieve accreditation as a comprehensive inpatient rehabilitation program.
• The Centers for Medicare and Medicaid Services (CMS): CMS is a U.S. federal agency that administers national health insurance programs. manages programs such as the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), which requires facilities to submit standardized patient assessment data and quality measures (ex. length of stay, 30-day re-hospitalization rates, functional improvement scores) or the Quality Payment Program (QPP) which provides financial incentives to clinicians to encourage high-quality care.
• Accreditation Council for Graduate Medical Education (ACGME): The ACGME governs graduate medical education and recognizes Quality Improvement (QI) as a required component.

The QI project lifecycle: frameworks and tools

A critical aspect of implementing any QI initiative is following a systematic approach, of which there are many formal frameworks that can be utilized. For example, some of the most common examples of QI models used in healthcare include the Plan-Do-Study-Act (PDSA) Cycle, Lean Six Sigma, and the SMART goal framework.^1,6 SMART helps QI initiatives establish clear objectives that are Specific, Measurable, Achievable, Relevant, and Time-bound (ex. refining an objective to “improve stroke care” to “for all patients admitted to the inpatient rehabilitation unit with a primary diagnosis of stroke, we will increase the rate of aspirin prescription for secondary prevention from 75% to 90% within the next 3 months”). Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Table 1

Clinical examples in physical medicine and rehabilitation

Process

• Single vial dosing for epidural steroid injection.
• Use of appropriate venous thromboembolism (VTE) prophylaxis during an inpatient rehabilitation stay.
• Prescription of aspirin for secondary stroke prevention.
• Deprescription of potentially inappropriate medications in populations at risk of harm from polypharmacy.
• Documentation of red flags in initial evaluation of a patient with back pain.
• Performance of hand hygiene in the hospital or clinic.
• Predicting and/or preventing falls.

Assessment of implementation of established processes is often measured as adherence to guidelines. These guidelines may be established by expert panels (e.g., American College of Chest Physician Guidelines for VTE Prophylaxis) based on various levels of evidence. Physical Medicine and Rehabilitation (PM&R) specific guidelines developed and/or endorsed by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) are available online.⁷ The proliferation of guidelines has led to criticism, including some finding that adherence to ever-increasing guidelines often remains low.⁸ Novel approaches, such as guideline-powered clinical calculators (ex. MDCalc) clinical-decision support tools (ex. AvoMD), or evidence-based large-language model chatbots (ex. OpenEvidence) are attempting to make guidelines more accessible and impactful. 

Outcomes

• Cost
• Length of stay for inpatient rehabilitation
• Medical complications after injections
• Improvement in function during outpatient therapy
• Uniform Data Set FIM for inpatient rehabilitation
• Patient satisfaction
• Thirty-day re-hospitalization rates
• Mortality rates

Outcomes are generally compared with criterion standards or by benchmarking them against similar institutions regionally or nationally. A classic example is the FIM, used by most inpatient rehabilitation programs throughout the United States to measure the level of a patient’s disability and how much assistance they need to carry out activities of daily living. Outcome measures should be risk-adjusted for factors such as disease severity, comorbidities, and psychosocial status.

Gathering data for QI

Sources and methods of obtaining information include:

• Electronic health record data and metadata (timestamps, audit logs, clinical-decision support usage patterns).
• Technological sources such as ambient or wearable sensors, computer vision, apps, algorithms, etc.
• Direct observation by a colleague, for example, secret shopper for hand hygiene.
• Indirect methods, for example, surveys, data quality assessments, global ratings, and 360° evaluations.

Establishing measurement standards

Collected data may be assessed against internal or external standards.

• Internal standards assess change from a baseline for a given program, for example, an increase in the average Functional Independence Measure^TM (FIM) efficiency from one year to the next.
• External standards are guidelines, which may be normative (e.g., expert opinion), empirical (i.e., supported by clinical evidence), or comparative data from multicenter datasets.

Tools for delineating problems

• Clinicians performing quality improvement activities need a toolbox of methods to collect and analyze data. The IHI website serves as an excellent resource for detailed descriptions of several QI tools.¹⁰ Tools can generally be subdivided into 2 categories: (1) tools that delineate problems and (2) tools to assess possible solutions to those problems.
• Brainstorming with focus groups can provide qualitative analysis of the source(s) of a deficiency in quality. It is particularly important to include representatives of all stakeholders in these focus groups.
• Cause and effect diagrams (also referred to as Ishikawa or fishbone diagrams look like fish skeletons and identify all the inputs/causes leading to a given outcome. Generally, inputs are subdivided into categories, such as people, buildings, information systems, communication, and training.
• Flowcharts track the processes and structures from the beginning to the end of an event. More sophisticated flowcharts also include the time required to complete each step, to better define rate-limiting steps to achieve completion in a timely manner. Many free digital tools exist to aid in the efficient creation of flowcharts such as draw.io or lucidchart.

Example: Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Chart 1

Cause and effect/fishbone diagram to identify barriers for discharging patients on naloxone (Van et al).¹¹

Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Chart 2

Flowchart created using draw.io to identify the process of a patient attending a clinic visit.

Tools for assessing solutions

QI assessment and interventions can be done by scrutiny of single cases or by analyzing general trends.

• Analyze single cases
  • Root cause analysis (RCA) is a tool prescribed by TJC for analyzing a sentinel event, that is, an error that led to death or permanent disability. It requires interdisciplinary input from frontline staff.
  • Morbidity and mortality rounds are designed to explore situations that contributed to medical error or adverse outcomes in patient care. Morbidity and mortality models can vary but should involve interprofessional discussions with all team members to ensure in-depth review and root cause analyses.¹² Increased implementation of “Good Catch Awards” have created positive incentives for providers and staff to report patient safety events by identifying and reporting adverse events, near-misses, and other medical errors.¹³
• Analyze general trends
  • Control charts are used to monitor a process over time, study variation, and its source. It not only allows tracking of results over time, but also evaluation of how different interventions influence results (e.g., staff education, signage, self-monitoring programs). For example, monitoring compliance with hand hygiene over time. One simple version of a control chart is a run chart.
  • An Effort-yield matrix helps the team decide which of the possible solutions to implement will have the best impact/outcome with the least effort.
  • Histograms are used to describe different categories of outcomes.
  • Scatter plots describe general trends in two sets of variables to determine their correlation.

Pareto charts are a combination of a bar and line graph. Individual inputs into an outcome are represented in descending order by bars, and the cumulative total is represented by the line. This allows one to see the relative contribution of each input into an outcome. A Pareto chart follows the 80/20 principle for many events, roughly 80% of the effects come from 20% of the causes.¹⁴

Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Chart 3 Run chart

Source: Institute for Healthcare Improvement Run Chart Tool, https://www.ihi.org/resources/tools/run-chart-tool#downloads

Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Table 2

Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Chart 4 Pareto Chart

Source: East London NHS Foundation Trust’s quality improvement programme, https:/qi.elft.nhs.uk

Implementing changes

If assessment of the current problem or process fails to yield satisfactory results, a QI intervention may need to be planned and implemented. Pronovost et al¹⁵ laid out the following criteria for QI interventions to be successful

• Evaluate the progress of improvements
• Use more evidence-based practices
• Improve the culture of safety and open communication
• Use prospective and retrospective analyses to identify and address patient safety hazards at all levels of the organization
• Evaluate the characteristics of the organization that affect patient safety practices in both positive and negative ways

Identify potential barriers to implementation

• Potential barriers to the intervention should be considered prior to development of an implementation strategy.¹⁶Tools, such as an effort-yield matrix and Pareto charts, may be helpful in determining which intervention to employ.
• Quality Improvement / Patient Safety Issues Relevant to Rehabilitation – Table 3 Barriers to QI and Potential Solutions

Implementation strategies

• Once a planned intervention has been determined to satisfy the criteria, implementation strategies must be developed.
• Successful studies have used feedback reports in conjunction with implementation strategies, as well as educational tools and programs.¹⁷
• QI interventions are most effective when interventions are evaluated continuously. Tools, such as a plan-do-study-act cycle, minimize negative outcomes throughout the implementation of new strategies and continues to advance improvements.¹⁰
• Continuous QI is most effective when implemented systematically and organization wide.¹⁶
• Successful implementation also benefits from a culture that is receptive to change with capable, sustained leadership and a strategic implementation plan that is not burdensome.¹⁶
• Involvement of leadership, such as the use of executive rounds, that is, Comprehensive Unit-based Safety Program teams, allows senior management to meet with staff regularly and evaluate current practices.

Putting it all together: example QI project

Van et al (2019) successfully implemented an interdisciplinary quality improvement project for opioid risk reduction in the Acute Comprehensive Inpatient Rehabilitation setting.¹¹ The project conducted a Plan-Do-Study-Act framework in a multidisciplinary setting with flexibility to adopt changes in response to feedback. Since initiation of a take-home naloxone program, there was a 7-fold increase in the likelihood of patients on opioids receiving a naloxone prescription and a 10-fold increase in the likelihood of patients being weaned from opioids.

Cutting Edge/Unique Concepts/Emerging Issues

Growing interest in quality improvement (QI) in health care has led to a proliferation of quality measures (QMs)—standardized metrics used to assess and report health care performance. These include reporting requirements from programs like the Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Quality Reporting Program.¹⁸ While reporting and monitoring of QMs can enhance care quality, this approach has challenges including: 1) requiring substantial time and resources that increase costs, 2) overlooking differences between clinical sites and patient populations, and 3) losing value when measures become targets for performance incentives rather than tools for improvement.¹⁹ QMs resulting from QI efforts must be continuously revisited to limit their overall number and prioritize digital, automatable metrics that have ongoing relevance and value.

Artificial Intelligence (AI) has recently emerged as a potentially transformative tool in quality improvement and patient safety.²⁰ Physical Medicine & Rehabilitation is uniquely positioned to benefit from AI-driven quality improvement. With its focus on complex, functional outcomes and interdisciplinary care, PM&R often struggles with subjective measurement and time-intensive documentation. AI could streamline quality metrics, quantify function through novel approaches like sensors or video, and predict adverse events like falls or readmissions.²¹ By integrating multimodal data, producing actionable insights, and reducing reporting burdens, AI offers a powerful opportunity to enhance quality improvement and patient safety in rehabilitation.

Despite the promise of AI-driven digital tools for advancing quality improvement and patient safety in rehabilitation, their reliance on interconnected digital infrastructure introduces vulnerabilities that can disrupt care. For example, ransomware attacks can lead to adverse patient outcomes, including at nearby hospitals overwhelmed by increased patient volumes after a targeted system shuts down.²² Systems must employ evidence-based cybersecurity measures and robust downtime preparedness to ensure patient safety and mitigate potential negative consequences of a growing reliance on technology in healthcare.

References

1. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44:166-206.
2. Centers for Medicare and Medicaid Services. Quality Measurement and Quality Improvement. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-. Accessed April 2, 2025.
3. Jaffe A, Klein M, McMahon M, Pruitt D. Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment. Am J Med Qual. 2017;32(5):541-546. doi:10.1177/1062860616670977
4. Murphy M, Bai S, Barnett J, Eickmeyer S. Patient Safety and Quality Improvement: A Curriculum for Physical Medicine and Rehabilitation. MedEdPublish. 2021;10(1). doi:10.15694/mep.2021.000091.1
5. Grover P, Volshteyn O, Carr DB. Physical Medicine and Rehabilitation Residency Quality Improvement and Research Curriculum: Design and Implementation. Am J Phys Med Rehabil. 2021;100(2S):S23-S29. doi:10.1097/phm.0000000000001550
6. Schriefer J, Leonard MS. Patient safety and quality improvement: an overview of QI. Pediatr Rev. 2012;33(8):353-359.
7. American Academy of Physical Medicine and Rehabilitation. AAPM&R Endorsed or Affirmed Guidelines. Available at:  https://www.aapmr.org/quality-practice/clinical-practice-guidelines/aapm-r-endorsed-guidelines. Accessed April 14, 2025.
8. Kung J, Miller RR, Mackowiak PA. Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards: Two More Decades of Little, If Any, Progress. Arch Intern Med. 2012;172(21):1628. doi:10.1001/2013.jamainternmed.56
9. Institute for Healthcare Improvement. How to Improve. Available at: https://www.ihi.org/resources/how-improve-model-improvement. Accessed April 2, 2025.
10. Institute for Healthcare Improvement. Tools. Available at: https://www.ihi.org/resources/tools. Accessed April 2, 2025.
11. Van SP, Yao AL, Tang T, Rohjani S, Sprankle LA, Hoyer EH. Implementing an opioid risk reduction program in the acute comprehensive inpatient rehabilitation setting. Arch Phys Med Rehabil. 2019;100(8):1391-1399.
12. Wallace SC, Mamrol C, Finley E. Promote a Culture of Safety with Good Catch Reports. PA-PSRS Patient Saf Advis. September 2017;14.
13. Lo A. Morbidity and Mortality Rounds in Rehabilitation – Benefits for Enhancing Quality Beyond Just the “M&M”. PM&R The Journal of Injury, Function and Rehabil. 2018;10:865-869.
14. Quality Improvement East London NHS Foundation Trust. Pareto Chart. Available at: https://qi.elft.nhs.uk/resource/pareto-charts/. Accessed April 2, 2025.
15. Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Framework for patient safety research and improvement. Circulation. 2009;119:330-337.
16. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 2001;76:593-624.
17. De Vos M, Graafmans W, Kooistra M, Meijboom B, Van Der Voort P, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care. 2009;21:119-129.
18. Centers for Medicare and Medicaid Services. Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information. Available at:  https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility/irf-quality-reporting-measures-information. Accessed April 14, 2025.
19. Saraswathula A, Merck SJ, Bai G, et al. The Volume and Cost of Quality Metric Reporting. JAMA. 2023;329(21):1840. doi:10.1001/jama.2023.7271
20. Classen DC, Longhurst C, Thomas EJ. Bending the patient safety curve: how much can AI help? npj Digit Med. 2023;6(1):2. doi:10.1038/s41746-022-00731-5
21. Cotton RJ, Seamon BA, Segal RL, et al. A Causal Framework for Precision Rehabilitation. Published online November 6, 2024. doi:10.48550/arXiv.2411.03919
22. Dameff C, Tully J, Chan TC, et al. Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US. JAMA Netw Open. 2023;6(5):e2312270. doi:10.1001/jamanetworkopen.2023.12270

Original Version of Topic

R. Samuel Mayer, MD, Mi Ran Shin, MD, W. Bernard Abrams MD. Quality improvement/patient safety issues relevant to rehabilitation. 9/20/2013

Previous Revision(s) of Topic

R. Samuel Mayer, MD, Seth Oliphant, MD, Levan Atanelov, MD. Quality improvement/patient safety issues relevant to rehabilitation. 3/23/2017

R. Samuel Mayer, MD, MEHP, Ohmin Kwon, MD, Kavita Nadendla, MD, Bhavesh D. Patel, DO. Quality Improvement/Patient Safety Issues Relevant to Rehabilitation. 6/9/2022

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Matthew R Allen, BS
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