Quality Improvement Summary for Pulmonary Rehab
For purpose of the AACVPR Certification you will need to show a quality improvement
process you have done with your programs outcomes. AACVPR has a great outcomes
resource tool area with presentations and other information that you will find useful in
your pursuit of getting better outcomes.
https://www.aacvpr.org/Resources/ResourcesforAACVPRMembers/OutcomesResource
Guide/tabid/115/Default.aspx
There are many systems you can use in your program to help you achieve better
outcomes. You may want to check with your quality department to see if your institution
is currently using a set guideline. This may also give you a resource to help you with
the process.
Listed below is a few examples of quality improvement.
FUNCTIONAL STATUS
How many patients completed your early outpatient program from January 1, 2013 through
December 31, 2013?
45
Describe one (1) Functional Status outcome measured in your program during January 1, 2013 to December 31,
2013. Please note: Describe the assessment tool used to measure the clinical outcome.
6 minute walk test
You must report on a minimum of 30 patients. If less than 30 patients completed your program during
the data collection period, and the number listed above is less than 100% of the patients who did
complete outcomes in your program during January 1, 2013 to December 31, 2013, please provide an
explanation below.
43 completed the program
Provide the pre-program score
800 feet walked
Provide the post-program score
920 feet walked
Describe the percent change, units of change or change towards goal between the pre- and postprogram scores
There was a 15% change from the pre Pulmonary Rehab program to the post Pulmonary Rehab
Program.
Briefly summarize your conclusions based on the outcome change found
What we found out with the conclusion was we did see improvement. However, it was noted that since
we used the average of our data that the numbers could be skewed for some people did not show that
much of an improvement and others did. So we are looking at what some of the other factors that
could influence this would be.
Describe how you improved your program based on the results of this clinical outcome
 Standardized the 6 minute walk test
 Some staff were doing it different now it is standard.
 Started interval training with patients.
 Started to do mid program 6 minute walk tests to see if the patient is making gains.
QUALITY OF LIFE
Describe the assessment tool used to measure the Quality of LIfe outcome
SF-36 Health Survey. The patients complete this questionnaire during the first and last exercise session.
Describe the number (N) of patients on which you are reporting data.
35
You must report on a minimum of 30 patients. If less than 30 patients completed your program during
the data collection period, and the number listed above is less than 100% of the patients who did
complete outcomes in your program during January 1, 2014 to December 31, 2014, please provide an
explanation below.
35 completed program 35 filled out survey
Provide the pre-program score
35.92 points (out of 100)
Provide the post-program score
41.76 points (out of 100)
Describe the percent change, units of change or change towards goal between the
pre-and post-program scores
Percent change was + 15.8%.
Briefly summarize your conclusions based on the outcome change found
The physical functioning score reports patient limits in performing self-care, walking, stair-climbing,
lifting, and moderate to vigorous activities.
Describe how you have improved your program based on the results of this health outcome
 In 2012 our percent change for physical functioning was +9.9%.
 We started to look at more functional training.
 We invested in balance equipment to help improve this skill.
 We also sent employees to work functional assessment class.
 The other big thing was looking at the continuum of care outside of Rehab.
DYPSNEA
Describe the assessment tool used to measure the Dypsnea outcome
Borg Dypsnea Scale
Describe the number (N) of patients on which you are reporting data.
30
You must report on a minimum of 30 patients. If less than 30 patients completed your program during
the data collection period, and the number listed above is less than 100% of the patients who did
complete outcomes in your program during January 1, 2013 to December 31, 2013, please provide an
explanation below.
Provide the pre-program score
8.4
Provide the post-program score
6.2
Describe the percent change, units of change or change towards goal between the
pre-and post-program scores
The self reported dyspnea score saw a percent change of-26%.
Briefly summarize your conclusions based on the outcome change found
The program saw some changes from the Borg scale in the right direction but we were shooting to get
the patients to under 6 on the scale.
Describe how you have improved your program based on the results of this health outcome
 Further education with the patients on the scores, we feel that might have been a
misunderstanding for some patients whom consistently answered the same thing over
and over.
 Made the scales a lot more user friendly. We blew them up and had them posted
through out the facility.
 The education we did on this needed to be revamped. We are using various teach back
techniques to get the patients to understand the importance of where there dyspnea is.
SERVICE
Describe one (1) SERVICE outcome measured in your program as listed in the Outcomes Matrix during
January 1, 2013 to December 31, 2013.
We measure patient satisfaction as it relates to patient care, progress, and likelihood of referring others
to our program.
Describe the assessment tool used to measure the Service outcome
We utilize a 10 question survey that rates the patient's experience on a scale from strongly disagree up
to strongly agree. Each choice is weighted and the overall average is calculated on a monthly basis.
Briefly summarize your conclusions based on the outcome change found
We have an overall patient satisfaction rate of 92% based on 50 responses. Our lowest scoring question
is on How do you feel you will continue your exercise prescription at home.
Describe how you have improved your program based on the results of this Service outcome
Based on the results, our team has begun to focus a great deal of our coaching time on identifying
barriers to exercising at home early on in the program and attempting to develop plans to overcome
these barriers long before the completion of the program.
We have contacted other facilities to see if we can get a discount for our patients. One of the real big
hurdles is financial. We are even looking at expanding our service line to offer a low cost alternative at
our facility like a phase IV program.