2.  Patients spend 60% of their day alone and only 13% on therapeutic activities (Bernhardt et al, 2004)  The earlier therapy starts the better (frontloading) (Kalra et al., 1994)  Positive relationship between scheduled therapy time and outcomes (Lohse et al., 2014)  Higher intensity therapy associate with better outcomes and reduced LOS (Jette et al., 2005)

3.  Significant relationship between therapeutic duration and functional outcomes – significantly better for those receiving 3 to 3.5 hours of therapy per day (Wang et al., 2013)  Patient to staff ratio is not the only or main factor contributing to difference in therapy time provision (De Wit et al, 2007)

4. LOS determined by RPG grouping http://www.strokebestpractices.ca

5. 5.3.iii Patients should receive a minimum or three hours of direct task specific therapy, five days a week, delivered by the Interprofessional team Canadian Best Practices Recommendations for Stroke Care 2010 (Evi

6.  Patient time spent in individual rehabilitation therapy that is aimed at achieving therapy goals  Face to face treatment  Monitored or guided by a rehabilitation therapist  Provided by OT, PT, SLP and OTA, PTA, CDA  Does not include: groups, other disciplines

8. 180 minutes ManagementPatients Other team members Therapists

9. 180 minutes Therapists Management

10.  Group activity PDSA Airplane Exercise

11.  Group identified 8 Interprofessional issues  Prioritized to allow for the greatest impact  Implement – PDSA  Question: Will assigning caseload to OTA/PTA increase satisfaction and time spent in therapy for stroke patients, and therefore increase intensity to align with BP?

12. 180 minutes of core rehabilitation therapy Providers Processes / procedures Patients Place / equipment Policies  Time spent educating, comforting or counseling patients and their families  Language barrier  Unrealistic expectations of patients and families with too much or too little involvement  Lack of understanding of expectations of being in rehab  Patient unable to tolerate therapy  Patient refuses therapy for various reasons or is unmotivated  Patients not ready for schedules therapy on time  Patient medically unstable and complex or bariatric  Patient at tests, dialysis or on IV meds  Emotional status so pt. not being addressed  Lack of access to needed space for treatment  Poor location of space  Worn out equipment or lack of appropriate equipment and supplies  Time spent searching for equipment (wheelchair, cushions etc.)  Ratio of staff to patients is too high  Therapy provided 8-4  Unable to access MRP or specialist in timely fashion  Lack of access to education to improve skills  Coverage issues (working short staffed)  Pt.'s require 2 staff members to transfer or mobilize  Difficulty getting patient ready in time for therapy due to heavy caseload  Scheduling issues (scheduling in blocks vs. based on need, conflicts with groups or classes, not ready for scheduled therapy time)  Consults to specialists take too long  Timing of toileting routines  Lack of flexibility in therapists schedules  Case management model  Meals not delivered on time  Flow issues/bed pressures  Transporting patients to/from therapy  Inefficient rounds  Lack of community resources to discharge to  Limited LOS creates pressure to prioritize  No dedicated time for education on evidence based practise related to stroke  No budget for casuals staff or replacement therapists for sick or holiday

13.  Staff: PTA/OTA practice change  Patients: Increased intensity of therapy  Scheduling: Changes in scheduling practices

14. TimeTherapy 0900OTA30 ADLs in pt room 1000PTA30 in PT gym 1100SLP60 in pt room 1300OT30 in OT gym 1400PT30 in PT gym TimeTherapy 1000PTA30 in PT gym 1100SLP30 in pt room 1300OT30 in OT gym BEFORE AFTER Total Time = 90 minutes Total Time = 180 minutes

15.  3 hours of combined direct therapy from OT/PT/SLP per stroke patient per day achieved  88 percent increase in rehab intensity from baseline!

17. Staff satisfaction:  39 % reported feeling less stressed  60% report they did not feel less stressed  78 % reported they felt the patient was getting better  56% reported feeling great job satisfaction Patient satisfaction: 82% of patients satisfied with amount of therapy they are receiving 88% report they felt they were improving towards their goals 94% reported they were happy with the timing of their therapies

18. Top left intersection Top right intersection Bottom left intersection Bottom right intersection Top left square Top right square

20.  Decreased intensity for other patients  Resources  Patient fatigue – too busy?  Scheduling therapy appointments  Space constraints  Equipment limitations  Engaging all staff

21. Practice: Wins  Improved therapy intensity  Patients expressed they felt they were improving  OT/PT Assistants had increased involvement with the patient  Heightened awareness of best practice  Ongoing attempts to maintain rehab intensity post- PDSA  PDSA provided staff with a new framework for future quality improvement projects

22.  Shifting Culture on the unit  Transparency –open communication throughout the project  Acknowledge best practice  Motivated Staff driven rather than top down driven  Supportive Manager as well as West GTA stroke network.  Sustainability – dedicated resources