Quality report 2023

Content

Introduction
Systematic quality and patient safety work
User Interaction
Goal achievement for selected indicators
Patient data per rehabilitation programme

1 Availabilityt
1.1 Waiting time – average number of waiting days
1.2 Inpatient and Outpatient consultation discharges
1.3 Outpatient consultations – Video and telephone
1.4 Use of interpreters, remote interpretation
1.5 Passed scheduled hours for patient appointments

2 Efficiency
2.1 Average length of stay per programme
2.2  Patient no-show rates at outpatient clinic
2.3 Discharge sent within one day

3 Effect
3.1 Functional Independence Measurement – FIM
3.2 Improvement in EQ VAS
3.3 Discharges per programme

4 Patient safety
4.1 Unplanned transfers per programme
4.2 Fall incidents
4.3 Risk screening
4.4 Antibiotic use
4.5 Prevalence of health-associated infections

5 Patient satisfaction
5.1 Response rate
5.2. "Goals for your stay were prepared with your help. Did you reach these goals?"
5.3 "All in all, how satisfied are you with your stay?"
5.4 Patient and relative complaints

6 Summary

Introduction

Sunnaas Rehabilitation Hospital is a specialized hospital in physical medicine and rehabilitation, and one of eleven health trusts in the Southern and Eastern Norway Regional Health Authority. Most of the patients come from the southeast part of Norway. The hospital also welcomes patients from all over the country and interacted with approximately 230 municipalities in 2023. Based on the national values of quality, safety and respect, Sunnaas Hospital also adds the following values of professionalism, commitment, and joy.

Sunnaas Hospital offers highly specialized rehabilitation for patients with spinal cord injuries, brain injury, stroke, multitrauma, cognitive challenges, pain conditions, severe burns, neurological diseases, and rare congenital diagnoses.  The clinical services are organized as bed units, ambulatory and outpatient services, in-person attendance and digital consultations. Rehabilitation services are provided in different phases after the injury or illness has occurred. The hospital has lifelong follow-up responsibility for some of the target groups.

Systematic quality and patient safety work

Regulations on management and quality improvement, the National Action Plan and regional secondary strategy for patient safety and quality improvement form the framework for quality and patient safety work. We also adhere to an international quality assurance system adapted to medical rehabilitation, the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is an international non-profit organization that accredits medical rehabilitation service providers worldwide. In 2024, the hospital will re-accredit several programmes, such as spinal cord injury, stroke, traumatic brain injuries and specialized pediatric programmes.

Comprehensive improvement system and quality register

Sunnaas Hospital uses the EK-quality system, which consists of modules such as improvement system for adverse events and document management system. Several modules are being updated, and the system ensures that the hospital has a comprehensive system for quality assurance and performance management.

A major focus area in recent years is the Sunnaas Quality Register. Throughout 2023, data has been systematically registered in the Quality Register, and this forms the basis for several extractions of results for our quality report. Systematic registration of high-quality data with a high degree of coverage will make the work of analyzing performance information easier and will be a support for further development of the improvement work.  Sunnaas also reports data to the national (NorSCIR) and Nordic (NordicSCIR) spinal cord injury registries and to the Rehabilitation Registry.

Working environment and patient safety 

A good working environment has an impact on patient safety and should be seen in conjunction with each other. It is important to pay attention to the importance of the working environment for patient safety. Advisers from the personnel unit and the safety delegate service participate in key quality and patient safety committees.

Safe employees and openness about incidents are key to learning from and preventing patient injuries. Continuous work on a good reporting culture is important, especially in areas that are reported less frequently. Management involvement and good follow-up of undesirable incidents are important criteria for succeeding with a good reporting culture. Undesirable patient incidents are discussed at all management meetings, and there is an increased focus on learning value at the system level.

Improvement Visits

All clinical departments and units with patient services conduct improvement visits annually. Here, representatives from senior management and healthcare professionals meet in clinical practice at dialogue meetings on patient safety.

Internal audits

Internal audits are conducted according to the approved audit programme. Internal auditing is a self-check that helps ensure that the hospital follows internal and external requirements, reduces risk and identifies areas for improvement.

Increase competence in patient safety and quality improvement

One of the regional focus areas is to increase competence in patient safety and quality improvement among employees and managers. A crucial factor in succeeding in improving the health and care services is to increase competence in improvement work. Improvement knowledge is a separate subject that must be learned, and the knowledge area should be incorporated into competence mapping and plans.

A regional e-learning course in EHS, patient safety and improvement competence has been prepared. The goal is for all employees to complete the course in 2024. The hospital is also planning its own leadership training in the area in the fall of 2024.

User Interaction 

The hospital has a user committee and a youth council. The committees actively participate in reviewing goals, building plans, development work and strategic processes at the hospital. The user committee and the youth council promote views and issues that can improve patient services for adults and younger users. The hospital arranges general meetings for patients and dialogue meetings with user organizations representing the patient groups at the hospital. When meeting individual patients, the hospital offers dedicated training for patients and their loved ones. The Regional Secondary Strategy for Patient Safety and Quality Improvement supports efforts to increase user involvement in patient work. Patients and their loved ones should be involved in decisions throughout the rehabilitation process. The hospital has 'experience consultants' who play a significant role in assisting patients in the rehabilitation process.

Goal achievement for selected indicators    

The results in this quality report are visualized through the use of "traffic lights" such as green, yellow and red. Key Performance Indicators (KPI) are measurable and show development aimed at specific goals, enabling decision-makers to assess goal achievement within given limits.   

Patient data per rehabilitation programme

The hospital uses the term "primary rehabilitation" for the rehabilitation carried out immediately after acute injury or illness. Primary rehabilitation stays have a longer duration than programmes such as health checks, assessments and other types of follow-ups stays. 

1 Availability    

1.1 Waiting time – average number of waiting days.

The waiting time for stays at Sunnaas Hospital was 59 days in 2023. This is an increase from 56 days in 2022. The waiting time figures do not apply to patients who are admitted for primary rehabilitation.

Waiting time figures are counted once a month. This means that it shows the waiting time at the time the withdrawal takes place, therefore any incorrect registrations in the assessment of referrals may then affect waiting days. Good registration practices and secondary control checks are constantly being worked on.

In the Department of Functional Assessment, there is an assessment of transport needs that has a long waiting list. One preliminary measure that has been initiated to improve the waiting list is where patients are called by health personnel to clarify whether the prerequisites for admission have been met. Due to long waiting lists, referrals for patients from other health regions will be rejected until further notice. This applies primarily to the programme assessment of Transport Needs and Hypermobility Status (group stays).

Waiting time except for primary rehabilitation official 2023

• Outpatient clinic 49
• Follow-up Spinal cord injury 35
• Multitrauma, neurology and burns 20
• Spinal cord injury unit, children/young people 28
• Traumatic brain injury 46
• Stroke 34
• Assessment Department 78
• Follow up brain injury 41    
• Cognitive rehabilitation 68

Sunnaas in total 59
Goal 56

1.2 Inpatient and Outpatient consultation discharges

In 2023, the hospital had a bed capacity of 153 beds and there were 3140 discharges from inpatient stays. This is an increase from 2022, with 64 discharges.  
The hospital will reduce bed capacity by four beds during 2024.  At the same time, outpatient activities will be further increased, particularly in the Department of Functional Assessment, the Department of Follow-up of Brain Injury, and the Department for Follow-up of Spinal Cord Injury. The change is in line with the planned restructuring of clinical rehabilitation services, from bed to outpatient clinic. Outpatient activities at Sunnaas Hospital saw an increase from 9140 consultations in 2022 to 9374 consultations in 2023. Despite the increase in consultations, there were 619 fewer consultations for the entire Sunnaas Hospital in 2023 than planned.

Part of the reason for this discrepancy is the increase in referrals of patients with complex disabilities requiring 1 to 1 treatment at Studio 99 (2 patients per therapist per hour were budgeted at Studio 99 in 2023). Throughout 2023, there have been many discrepancies related to patient transport, which has meant that planned consultations have not been carried out. This has affected operations and planning, as well as led to postponements of consultations and longer patient pathways.   
In 2024, a new programme will start at Studio 99, in addition to several new programmes related to the Interdisciplinary Outpatient Clinic, both individually and in groups. 

1.3 Outpatient consultations – Video and telephone

In 2023, 36 percent of all outpatient consultations at Sunnaas Hospital were conducted over video and telephone. Video accounted for 25 percent and telephones accounted for 11 percent. The requirement from the Southern and Eastern Norway Regional Health Authority is that all health enterprises in the region must carry out at least 15 percent of outpatient consultations via video or telephone. Several other hospitals are seeing a decline in the use of video in the aftermath of the pandemic. Sunnaas has stable figures, but a slight decrease in the number of video consultations of 3 percentage points.  

Of a total of 2371 video consultations, 26 percent of these were video in group treatment. The Department of Cognitive Rehabilitation has the highest number of group treatments by video, with 503 consultations in 2023. This is now an established service for patients after their primary stay in Cognitive Rehabilitation.  

There was an increase in telephone consultations in some departments for 2023. The Spinal Cord Injury Follow-up Department had an increase of 137 consultations in 2022 to 214 consultations in 2023. This is an expected increase in connection with the development project "Right Patient at the Right Time to the right place" for patients attending control stays.  

Patients are given technical guidance where needed.  Continuing to ensure digital inclusion and ensuring high professional quality when digitizing health services is an important focus area also in 2024. 

In 2023, a campaign was conducted during Patient Safety Week, on the use of video consultations, targeting patients and staff. Two e-learning courses and associated checklists have been developed to ensure the highest quality of video consultations and video meetings. For 2024, training packages are planned for employees, so that more therapists take the e-learning course.  

Digital home follow-up and user-controlled outpatient clinic are focus areas for 2024. Video and telephone consultations, and new asynchronous digital solutions for digital home follow-up, are important in order to provide equal health services, regardless of the patient's place of residence or health condition. In 2024, measures will be taken to further develop video and telephone consultations, as well as combination with asynchronous digital home follow-up in patient pathways, in accordance with the hospital's goals. A decline in telephone consultations is expected when the hospital makes more use of forms sent to patients and treatment-oriented dialogue.

1.4 Use of interpreters, remote interpretation

According to the tender process, Sunnaas Hospital has an agreement with the Interpreter Center (Tolkesentralen) as the preferred provider of interpreters. The figures for interpreters presented in this Quality Report therefore primarily correspond to figures from the Interpreter Center. At Sunnaas Rehabilitation Hospital, the number of interpretations call-outs, the need for language, the interpreter's qualifications and the type of interpreter used are registered. Of a total of 1016 completed interpretation assignments at Sunnaas Hospital in 2023, it appears that 92% of the assignments have been carried out by interpreters with state authorization or interpreting training (Categories A, B, C and D; see www.tolkeregisteret.no).

 A significant proportion of interpretation assignments are provided by interpreters belonging to qualification group D. This is due to the increased demand for interpreters in Russian and Ukrainian in particular, and the fact that there are currently not enough qualified interpreters at a higher level among these language groups. Interpreters have been provided in 24 different languages in 2023. The largest language group is Russian (254 (25%)), followed by Ukrainian (274 (27%)), Polish (112 (11%)), Arabic (91 (9)), Urdu/Punjabi (30 (3%)) and Lithuanian (30 (3%)). The number of interpretation sessions has decreased, from 1073 completed assignments in 2022 to 1016 assignments in 2023. Sunnaas Hospital currently has a goal that 70% of all interpretation assignments should be delivered as remote interpretation. There is varying technological maturity among interpreters for the use of video solutions on a secure platform for disseminating health information. There is reason to assume that some interpretation sessions have not been held as a result of the interpretation services' challenges related to the use of the hospital's platform, and that varying quality has also led to conversations being interrupted.

Sunnaas Hospital interacts with Oslo University Hospital, Akershus University Hospital and the interpretation services to improve this function by using video solutions for interpreters. The graph below shows an overview of the different interpreting methods. Telephone interpreters are also considered remote interpreters but are not recommended if video consultations can be used. The number of telephone interpretations is still high and may be related to the lack of qualified interpreters in some languages/dialects.

1.5 Passed scheduled hours for patient appointments.

Sunnaas Hospital complied with 98 percent of patient appointments at the end of 2023. This means that 2% of the appointments had passed the scheduled time. The target goal is less than 5%. The work on good routines and cooperation on follow-up of waiting lists over the last 2 to 3 years has yielded results.  

The development project "The right patient at the right time to the right place" is form-based follow-up of patients with spinal cord injuries, who are to be checked at the Follow-up Department. Patients report digitally about their health condition to the hospital. The first forms were sent from the hospital on 7 December 2023. Before then, the coordinator in the department contacted the patients and asked the questions by telephone. This was registered as outpatient clinic work in the department. Based on the patients' information and needs, the chief physician in the department assesses what services the patient should receive. The department finds that the waiting list for control stays has been reduced and updated. The department also sees that some patients want an outpatient service. The department works to develop work processes and how the information from the patient can best be used in the planning process. 

2 Efficiency 

2.1 Average length of stay per programme

The length of stay in the hospital varies according to the patient's needs and the rehabilitation programme to which they are admitted. Patients admitted to primary rehabilitation after new injury or illness have longer stays than patients admitted to assessment and follow-up stays. These patients often have complex and difficult challenges, and there may be a wide variation in the extent of injury and the patient's condition. To meet the needs of patients and to ensure a good transfer from hospital to home, many patients are discharged for shorter periods of time in an attempt to remain at home after an illness or injury before finally ending the rehabilitation stay. 

Length of stay for some groups, assessment and control stays are predetermined and vary little over time: 

• Rehabilitation of cognitive sequelae: 31 days
• Rehabilitation for long-term complex pain conditions: 10 days
• Assessment of ability to work: 14 days.
• Group courses to cope with cerebral palsy: 5 days.
• Group programme Master Hypermobility Status is 20 days (3 weeks)
• Outpatient clinic and one follow-up week after 1 year. 
• Assessment of poliomyelitis: 5 days
• Assessment of rehabilitation needs: 14 days
• Assessment of spastic paralysis: 3-5 days
• Assessment of eating and swallowing difficulties: 2 days
• Assessment of transportation needs: 3 days 
• Control stays vary in time from 1 to 10 days. 

2.2 Patient no-show rates at outpatient clinic

The proportion of patients "not showing up for an appointment" for 2023 is 1.6 percent in total. This is a decrease of 0.2 percent compared to 2022. The target figure is less than 1.5 percent.  

In Oslo, 1.1 percent are registered as not attending an outpatient consultation. This is a decrease of 0.5 percent compared to 2022. In Oslo, the staffing situation has been stable in terms of mercantile staff during 2023. Accessibility and good work processes have contributed to a positive direction.   

At Nesodden, the figure is 2.4 percent, which is about the same as in 2022. In general, at Sunnaas Hospital, there is a great focus on correct registration as outpatient activities, which continues to increase throughout the hospital. Awareness and knowledge of the correct registration of "no-show" helps to highlight the actual picture.

Influential factors:

• All patients who have registered their phone number online (Helse Norge) receive an SMS reminder 72 hours before their scheduled appointment.
• All patients are offered assistance in connecting to the digital platform prior to a video consultation. Many patients take advantage of this offer.  
• The "no-show" fee was raised in 2023. This also applies to consultations where there are children who do not attend.

2.3 Discharge summary sent within one day.

Sunnaas Hospital sent a total of 83 percent of discharge summaries within one day in 2023. At least six occupational groups must document their assessment before the doctor can complete the discharge summary, so this is a joint responsibility of the entire interdisciplinary team. The discharge summary period is followed up monthly per department and individually as needed, and at least once a year during the doctors' performance appraisals.

The hospital is pleased that there has also been an increase in the number of discharge summaries sent within one day in 2023, but this requires continuous follow-up. The scheme is well implemented, and all departments have reached the goal of 70 percent, with the exception of one that is very close to the target. In total, Sunnaas Hospital increased from 36% in 2019 to 83% in 2023.

3 Effect 

3.1 Function Independence Measurement – FIM    

Functional Independence Measurement (FIM) is a measurement that illustrates the ability to perform daily tasks. The FIM tool is used in the individual patient's rehabilitation process and can be compiled to present data per patient group. The degree of activity limitation changes during the rehabilitation period. The changes that appear in the FIM results can be used to capture improvements in the ability to do daily tasks and to analyze the results of rehabilitation.

FIM measurements are made on patients admitted to primary rehabilitation. A change in points shows how great an improvement in independence the patient has achieved from admission to discharge.

Sunnaas Hospital does not consider FIM a good enough nuanced tool to reflect changes in cognitive function for patient groups with cognitive difficulties. 
For 2023, the results show an average change in functional improvement for all primary rehabilitation programmes, totaling 18.8 points. The hospital has a goal of average improvement of over 20 points.

We will clarify in 2024 whether we will implement FIM in all departments of the clinic. The Professional Forum Clinic will discuss this as an issue in March. The FIM will be discontinued if the Professional Forum Clinic so decides.

Change in average points from admission to discharge per programme for primary rehabilitation:

• Spinal cord injury adults, 19.0 points. N=25
• Stroke, adults, 19.0 points. N=60
• Multitrauma, burns and Guillain-Barré syndrome, 15.6 points. N=14
• Acquired brain injury, children and adolescents, 11.5 points. N=6
• Spinal cord injury and multitrauma children and adolescents 21.3 points. N=6

3.2 Improvement in EQ VAS

The Norwegian Directorate of Health's National Rehabilitation Register asks patients who are hospitalized for two weeks or more to assess their quality of life on admission and discharge. They assess their quality of life using the measuring tool EQ-5D / EQ VAS. In 2023, 199 patients consented to participation, 175 also responded upon discharge and 116 also 3 months after discharge (as of 1.2.24). On a scale from 0 to 100, patients rated their health at 53 on admission, 63 on discharge and 62 after 3 months, respectively. A change of 10 points is considered a clinically relevant difference.

For the first time, patients in 2023 were also asked 3 months after discharge about their work participation and their experiences with rehabilitation. 18 % were employed after 3 months, 53 % received temporary benefits and 23 % received permanent benefits. With regard to patient experiences, to take one example, 79 % experienced great or very great benefits from their stay, while 66 % respond that the rehabilitation programme to a large or very large extent had a positive impact on their health at the time of response.

 3.3 Discharges per programme

The location to where patients are discharged is analyzed annually in the CARF accredited rehabilitation programmes.

Data is taken from the electronic patient records system (DIPS) and divided into five main categories: home, nursing home, other rehabilitation institution, hospital, other. After a reduction in functionality, there is often a need for extensive adaptations to the home. Some need greater adaptations, others less. Patients may need follow-up at other rehabilitation institutions or at rehabilitation wards in nursing homes or health clinics before they can return home.

Home

Patients who are staying in the assessment and follow-up departments and programmes for mild to moderate cognitive sequelae, live mainly at home and are discharged mainly to their homes. That is why these programmes are not included in the table below. Patients who have been admitted to primary rehabilitation are also discharged mainly to their homes. 

Other institution

Patients may need to continue rehabilitation elsewhere after their stay at Sunnaas Hospital. These patients are then discharged to other rehabilitation centers that Sunnaas Hospital interacts with.

Nursing home

Patients are discharged to nursing homes or care homes. This can be a temporary stay and not necessarily permanent. Patients may need to stay in rehabilitation wards at nursing homes/care homes, for example while waiting for adaptations in the home.  

Hospital

includes all hospital specializations for examination, follow-up and treatment of existing or newly arising health conditions.      

4 Patient safety

4.1 Unplanned transfers per programme

Unplanned discharges per programme is unplanned hospitalizations to other hospitals due to rapid deterioration of health condition. Patients who have been exposed to major trauma or serious illness can rapidly develop a deteriorating condition. It is the primary departments that have most unplanned discharges. A patient may have several unplanned discharges during their rehabilitation process, as the condition may be complex and/or the same issue is recurrent. When the patient has completed treatment, the patient can usually return to his or her rehabilitation process at Sunnaas Hospital. In the primary departments, an annual analysis is carried out where the underlying cause is reviewed, improvement areas are identified, and measures initiated. 

Reasons for unplanned discharge may include infection, fall event, worsening of condition or other acute situations. In total, there were 95 unplanned discharges to other hospitals in 2023. In 2022, there were 102 unplanned discharges.

4.2 Fall incidents

Source – Improvement system for undesirable incidents – reporting fall events.
The Norwegian Coding System for Undesirable Patient Incidents (NOKUP) defines a fall as an incident where the patient fell or was exposed to an accident during treatment or transport/being moved. A fall is an unexpected incident where the person ends up on the ground, floor or at a lower level regardless of whether injury occurs or not. A fall thus includes when someone rolls out of bed or slides down onto the floor from a chair. Patients who are hospitalized are at greater risk of falling. Factors such as newly acquired risk factors, cognitive difficulties and unfamiliar surroundings can increase the risk of falling. At Sunnaas, patients train to regain balance, move from a wheelchair/bed and many practice walking with and without aids. In such training situations, there is a foreseeable risk of falling. 

The target figure for fall events is set at fewer than 1.5 falls per 1000 bed days. The number of reported fall incidents in 2023 was 94, representing 2.2 falls per bed day. This is a slight decrease from reported 108 fall incidents in 2022 (2.6 falls per bed day). The hospital reviews all fall incidents reported each year in the improvement system (EK). The reported fall incidents are categorized according to their severity. 99% of falls are categorized from moderate to low severity for the patient. As part of the systematic work to prevent falls, the Patient Safety Committee reviews fall incidents that are categorized as significant. In 2023, one significant fall incident had been reported. The underlying cause of one-third of the reported falls is categorized as the patient's behavior/cognitive state. Improvement work has been initiated with the goal of working systematically and interdisciplinary with fall prevention measures within training, and information to patients/relatives/primary health service.

4.3 Risk screening

The hospital screens all patients for the following risk areas upon admission:

• Fall
• Pressure ulcer
• Infection
• Malnutrition
• Alcohol use

Identified risks from screening make it possible to follow up patients with an interdisciplinary approach.  Information to patients and relatives about risk is part of the hospital's preventive work.

The identified risk of pressure ulcers is systematically followed up in interdisciplinary wound records. The risk of malnutrition is mapped in the MetaVision electronic curve system. The hospital does not present data on screening for malnutrition at departmental level. If the risk to the patient is identified, measures are set in the treatment plan and a nutrition form is established. Children have their own nutrition form. 

Photo: Sunnaas sykehus

4.4 Antibiotic use

Compared to 2019, Sunnaas Hospital has increased its consumption of broad-spectrum antibiotics.

In 2023, the antibiotic team retrospectively reviewed six months of antibiotic consumption in selected clinical departments. The review showed that a few complex patients largely contribute to the consumption and that these patients are under long-term antibiotic treatments, which are often started at other hospitals. Diagnoses are typically osteomyelitis and complicated wound infections. The review also revealed areas for improvement. We are working on measures to reduce antibiotic use, such as better routines for results of microbiological tests, strengthening the role of nurses in antibiotic management and better routines for documenting antibiotic choices. 

4.5 Prevalence of health-associated infections  

Prevalence registration of infections and antibiotic use is carried out four times a year on a fixed date. These are health-associated infections (HAIs) that have arisen as a result of contact with the health services. The purpose of all infection registration is improvement; no one should be harmed by preventable infections. The quarterly registrations are reported to the Norwegian Institute of Public Health. Targets for HAI are no longer used, but previous targets were set at 3 % in assignments and orders (OBD) from the Southern and Eastern Norway Regional Health Authority.

The national recommendation for prevalence registration is conducted twice a year. Sunnaas Rehabilitation Hospital follows the Regional Health Authority's recommendations to carry out prevalence four times a year. For 2023, the proportion of patients with infections that have occurred in the hospital and on whom it is mandatory to report was: 2.6%, 0.7%, 2.0% and 2.7%. Overall, the incidence was 1.7% in 2023. Training in infection control measures is offered to permanent employees, extra shifts and students in line with the hospital's infection control programme.

5. Patient satisfaction

The hospital conducts an internal User Survey on a continuous basis. The survey is carried out anonymously and all patients are invited to respond upon departure or by contacting the outpatient clinic. Results from the User Survey are published three times a year, and feedback is used for internal improvement work. The results of the patient satisfaction survey were published for patients, staff and stakeholders through:

• The User Committee
• The Youth Committee
• At meeting forums at all levels in the hospital, including the board.
• Information online: sunnaas.no

5.1 Response rate    

In 2023, 41 percent of adult hospitalized patients responded to the user survey. This is 3 percent lower than in 2022. The primary departments have a response rate of 60 percent, and the assessment and follow-up departments have a response rate of 31 percent. The response rate for children and young people in 2023 was 55 percent, which is an increase of 7 percent from the previous year. 

5.2. "Goals for your stay were prepared with your help. Did you reach these goals?"

On the question of whether the goals set for the stay were reached, 69 percent answered mostly or very much. 13 percent respond that goals were not drawn up with them during their stay.

In the primary departments, 75 percent answered mostly and very much, and 7 percent replied that no goals were prepared. In the Follow-up/Assessment/Control departments, the result is 63 percent satisfaction and 20 percent respond that no goals were prepared. There is an increase in satisfaction with questions on goal achievement compared to 2022.  

The hospital focuses on goal-directed rehabilitation. The MAP innovation partnership (Goals and activities focusing on the patient) has developed a digital solution, including the patient's goal plan. The goal is both to streamline the clinical workflow for healthcare personnel and give the patient a significantly greater ownership of their own rehabilitation process. If the hospital decides to purchase the solution, it is planned for implementation in the fall of 2024.

5.3 "All in all, how satisfied are you with your stay?"

In 2023, 93 percent of adults responded that they are mostly or very satisfied with the services offered at Sunnaas Hospital. For children and adolescents from 0 to 17 years of age, 96 percent answered that they were mostly or very satisfied with their stay.

The hospital has selected areas for improvement based on its 2023 results. In general, the clinic wants to improve the response rate. Sunnaas Hospital has set a response rate of 60 percent. In 2023, the response rate was 41 percent overall. An area of improvement for adults inpatients is to increase satisfaction on the question: "Have you received information about medications to use", Satisfaction was 46 percent in 2023. To this question, 40 percent answered Do not know/Not applicable. When it comes to children and young people, the clinic wants to identify measures that can help strengthen the process/transition home to the municipality.

5.4 Patient and relative complaints

In 2023, the hospital received a total of 34 written complaints from patients and their relatives. This is a decrease from 38 in 2022. The hospital works actively with a culture of openness and informs patients and relatives about possibilities for complaints. All feedback is processed systematically and analysed. The analysis is an important contribution to improvement and quality work at Sunnaas Hospital. 
The number of complaints about waiting time was zero in 2023 and complaints about treatment/incidents during the stay have decreased from 12 in 2022 to six in 2023. Interaction/transfer complaints have increased from zero in 2022 to three in 2023.

The hospital has worked systematically to keep waiting times down, as well as to have good processes for interaction/planning of discharge/transfer to other institutions.

The number of rights complaints (complaints of rejections/rights complaints from patients and relatives) is stable at 24 in 2022 and 23 in 2023. In 2021, it became possible to submit complaints electronically through helsenorge.no, which has simplified the process. There has been increasing focus on patient rights, including the right to appeal refusal of referral. All rights complaints have been processed in accordance with applicable guidelines, including that the complaint was forwarded for consideration by the County Governor if the rejection was upheld. It should be noted that none of the forwarded rights complaints were overruled by the County Governor. We choose to regard this as a sign of high quality when it comes to processing referrals and rights complaints.

6 Summary

The national goal is to reduce the risk of patient injury and reduce unwanted variation in offers and quality.  Figures from the hospital's improvement system for undesirable incidents and prevalence measurements show that there are few significant patient injuries at Sunnaas Hospital (hospital infections, falls with injuries and pressure ulcers).

Sunnaas Hospital aims to offer highly specialized rehabilitation with the highest professional quality. Figures on discharge show that patients are largely discharged directly to their homes. Overall, results for 2023 show that the hospital has high goal attainment within many of the indicators that the hospital has chosen to measure. (Table 1- page 6) The hospital shows high goal attainment in several areas within accessibility of the service. During 2023, the availability of outpatient services has increased. There is a high level of goal attainment within video and telephone consultations. The result is in line with the hospital's goal of providing arena-flexible services to patients. Continuous improvement work within the discharge summary period has had an effect, and there is a high goal attainment of discharge summaries sent within one day. Through the User Survey, the patients express that they are largely satisfied with the rehabilitation programme. 

Fall prevention is another area for follow-up. We see a slight decline in the number of reported falls compared to 2022, and few significant fall injuries have been registered.   Balance and strength training, information about fall prevention and proper use of equipment are important factors in preventing falls even after discharge from Sunnaas Hospital.

During 2024, it will be clarified whether the clinic will implement the functional mapping tool (FIM) in all departments of the clinic. The hospital will also continue its efforts to improve satisfaction in the areas of the patient's achievement of their own goals. An internal learning network for improvement methodology in clinics will also be established. All departments and units will work on local improvement areas.

In 2023, the hospital will set up its own quality register that aims to include all patients who are offered consultations at the hospital. The Sunnaas Quality Register will be an important step forward in improving and streamlining improvement work. The register will provide better opportunities for continuous monitoring of the quality of the hospital's services and facilitate more detailed and targeted analyses.