The success of Institut Guttmann lies in its own working method in the right management of the rehabilitation team and in the team’s skills, experience and motivation. This adds to the participation of patients themselves and their families.
Each new patient admitted to the hospital is assigned a rehabilitation team specifically designed for him/her. The team is made up of a team leading rehabilitation doctor, a nurse from the patient’s unit, a physiotherapist, an occupational therapist, a social worker and a psychologist or a neurophysiologist (depending on the patient being either spinal injury or brain damage). These members of staff will be responsible for the patient’s whole care process, independently of the remaining staff contributing to the patient’s treatment.
This team meets after the patient has been in the hospital for three weeks. The team meets in a clinical conference, debates the individual case and sets the rehabilitation goals in accordance with the type and severity of the disability and with other personal, psychological, family and social factors. It also designs the treatment and surgery plan, estimates the length of the process and a sets a provisional discharge date.
The doctor is responsible for reporting the conference’s conclusions to the patient and his/her family. The doctor will also inform them about the rehabilitation goals suggested by the team (which may or may not coincide with the patient or his/her family’s expectations). The doctor must also discuss his estimation about achievement dates and always try to involve the patient and his/her family in setting up mechanisms for trouble shooting in the patient’s environment (in adapting living premises, transport, family events, community resources, job, etc.). All this information will be given sensitively but clearly.
The minutes of the conference, including team members’ evaluations, the goals set and a summary of the doctor/team leader’s comments, are kept in the patient’s electronic medical record. In this way, they can be perused by the staff in the hospital as a whole, help furthering the care process and record any progress or key remarks.
Around two weeks before the provisional discharge date, the rehabilitation team meets again to establish whether the goals have been achieved, any incidental problems or difficulties have arisen and ways to solve them. As a result of this meeting, the required strategies and the final discharge date are decided.
This formal work method is characteristic of Institut Guttmann. It helps collecting together all the information related to a patient. It also helps to efficiently coordinate the care team’s efforts. In addition, it promotes long-term permanent improvements in the care process, this becoming key to Institut Guttmann’s quality policy.