HCM 4040 Module 3 Continuous Improvement Paper Example

Nine Percent of Sessions Lost: Running the Improvement Cycle on Missed Therapy at a Rehabilitation Hospital

Student Name

B.S. in Healthcare Management, Thomas Edison State University

HCM-4040: Healthcare Quality and Outcomes: Measurement and Management

Mentor Name

Month Day, Year

Nine Percent of Sessions Lost: Running the Improvement Cycle on Missed Therapy at a Rehabilitation Hospital

At Rancocas Valley, a fictional South Jersey rehabilitation hospital with 58 beds, the quality council noticed that the stroke and brain injury units were losing therapy time. An audit of eight weeks of scheduling records showed that 9% of scheduled physical, occupational and speech therapy sessions on those two units did not happen or ended early. Every lost session matters in a setting where patients are admitted because they need, and Medicare expects them to receive, an intensive daily program. This paper diagrams the continuous improvement cycle the hospital used to tackle the problem, explains which tool was chosen at each step and why, and reports three linked cycles of testing.

Why Lost Sessions Are Worth Improving

Published work suggests that the problem is common and that therapy time is linked to recovery. Byrd et al. (2025) followed patients on an academic stroke rehabilitation unit and counted 184 missed sessions, about 5% of those scheduled, with physical therapy missed most often. In a larger study of spinal cord injury rehabilitation across six centers, Hammond et al. (2013) found that patients missed an average of about two and a half hours of therapy a week, most often because the patient was not ready or for medical reasons. On the outcome side, MacDonald et al. (2024) studied 12,770 stroke patients in Ontario rehabilitation facilities and found that more minutes of daily therapy were associated with larger functional gains and more discharges back to the patient's prior home, though the added benefit flattened above about 95 minutes a day. Byrd et al. did not find a correlation between missed sessions and functional scores in their smaller sample, so the hospital's case rests on compliance, efficiency and the broader evidence on intensity rather than on a proven effect of each missed session.

The Improvement Cycle Diagrammed

The hospital follows the Plan, Do, Study, Act cycle inside a larger loop of continuous improvement: understand the current process, set an aim, test changes in small cycles, measure, and either adopt, adapt or drop each change before starting the next cycle. The table summarizes the loop as it was applied to missed therapy, with the tool used at each stage.

Choosing the Right Tool for Each Question

Each tool was chosen because it answers one question well. A flowchart was the right first step because nobody on the team had seen the whole morning; therapists saw only late arrivals, nurses saw only the rush. The Pareto chart came next because the audit produced a long list of reasons, and the team needed to know which few accounted for most of the lost time. It showed that patient fatigue or refusal caused 31% of missed sessions, a patient not being ready at the scheduled time caused 24%, and off-unit appointments such as dialysis and imaging caused 18%. Therapist absence, which managers had assumed was the main cause, accounted for only 11%.

For the largest controllable cause, readiness, the team used a cause-and-effect diagram, because the reasons a patient is not ready cross several departments: nursing, dietary, pharmacy and transport. A run chart was preferred to a control chart for monitoring during the tests because only a few weeks of data would be available at first and the team needed a simple picture it could update by hand.

Three Cycles of Testing

Cycle 1 tested a readiness routine on one hallway of the stroke unit for one week. The plan predicted that if the night nurse completed bathing for patients with early therapy sessions and the day nurse gave morning medications by 7:45, at least nine of ten patients would be ready on time. In practice, eight of ten were ready on the first two days and nine of ten after the breakfast trays for that hallway were moved earlier. Studying the results, the team found the routine worked but added work to the night shift, so they adapted it by limiting early bathing to patients scheduled before 9:00. The adapted version was then tested on the whole stroke unit for two weeks.

Cycle 2 addressed off-unit appointments. The team predicted that sharing the dialysis schedule with the therapy schedulers a day ahead would prevent most dialysis conflicts. For two weeks, the unit secretary sent the next day's dialysis times to the therapy office by 2:00 p.m. Conflicts dropped from about six a week to one, and the change was adopted. Imaging conflicts, which depend on the acute hospital's schedule, were left for a later cycle.

Cycle 3 tested splitting therapy for patients who tired quickly. For patients identified by their therapists as fatigue-limited, a 60-minute session was divided into two 30-minute sessions with rest between. Over two weeks on the brain injury unit, sessions cut short by fatigue fell, but scheduling two sessions strained the gym's afternoon capacity. The team adapted the change to apply only to patients in their first week after admission.

Results and What the Cycle Teaches

Over four months, the weekly share of missed sessions on the two units fell from 9% to just under 6%, with the run chart showing a sustained shift after the second cycle. The aim of 5% was not met, and the remaining losses come mostly from fatigue and imaging, which will be the subject of the next round. Reed and Card (2016) warn that improvement cycles are often run as one large project labeled with the cycle's name, without the small, rapid, linked tests the method requires. Taylor et al. (2014) reached a similar conclusion after reviewing published uses of the method, finding that few reports showed a series of cycles building on one another. The Rancocas Valley work tried to avoid that trap by keeping each test small and letting each one shape the next.

Conclusion

Diagramming the improvement cycle forced the team to understand the morning before changing it, and choosing each tool for a specific question kept the work focused on the few causes that mattered. Three small cycles, each with a prediction, a test and a decision, produced a real but partial improvement and a clear starting point for the next round.

References

Byrd, E., Khalidi, S., Azuero, A., Chambers, A., Killingsworth, R., & Jablonski, R. (2025). Frequency and reasons for missed inpatient stroke rehabilitation therapy sessions. Rehabilitation Nursing Journal, 50(3), 98-105. https://doi.org/10.1097/RNJ.0000000000000498

Hammond, F. M., Lieberman, J., Smout, R. J., Horn, S. D., Dijkers, M. P., & Backus, D. (2013). Missed therapy time during inpatient rehabilitation for spinal cord injury. Archives of Physical Medicine and Rehabilitation, 94(4, Suppl. 2), S106-S114. https://doi.org/10.1016/j.apmr.2012.12.023

MacDonald, S. L., Linkewich, E., Bayley, M., Jeong, I. J., Fang, J., & Fleet, J. L. (2024). The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada. International Journal of Stroke, 19(4), 431-441. https://doi.org/10.1177/17474930231215005

Reed, J. E., & Card, A. J. (2016). The problem with Plan-Do-Study-Act cycles. BMJ Quality & Safety, 25(3), 147-152. https://doi.org/10.1136/bmjqs-2015-005076

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862