Hospital Topics, 92(3):7479, 2014

C Taylor & Francis Group, LLC

Copyright 
ISSN: 0018-5868 print / 1939-9278 online
DOI: 10.1080/00185868.2014.937971

Creating a Culture of Mobility:

An Interdisciplinary Approach
for Hospitalized Patients
TOM CZAPLIJSKI, DIANNE MARSHBURN, TRACY HOBBS, SCOTT BANKARD,
and WANDA BENNETT

Frequently, patients are placed on bed rest upon

admission and remain there, often without valid
medical reasons (Brown et al. 2009; Brown,
Friedkin, and Inouye 2004).
In related studies of required nursing care that
was either significantly delayed or missed altogether,
patient ambulation was found omitted most frequently (Kalisch, Landstrom, and Hinshaw 2009;
Kalisch et al. 2011; Fisher et al. 2010). Patients
identified barriers to mobility during hospitalization as the need for assistance with ambulation in
combination with a lack of available staff to assist
(Brown et al. 2007). Nurses also frequently cited a
lack of assistive devices to facilitate ambulation of
patients and this increased their concern about the
potential for patient falls (Brown et al. 2007). Despite one study showing no association between fall
outcomes and ambulation initiatives (Fisher et al.
2011), more than 75% of study participants indicated that fear of a patient falling was a significant
barrier to mobilizing patients.
Attitudes toward mobility also reflected a difference between healthcare professionals and patients.
Whereas providers indicated a lack of motivation
from the patients, patients perceived the healthcare
professionals not being interested in mobility and
viewed it as less important than their other duties

Abstract. The risks of bed rest and decreased activity during

hospitalization are substantial. Immobility is a significant cause
for delay of discharge, suboptimal care and can contribute to
poor patient outcomes. An interdisciplinary team approach
was implemented to change an organization culture on early
patient mobility. The program goals were to focus physical and
occupational therapy services for patients who would benefit
from their skilled expertise, and to develop nursing protocols,
physician order sets, expectations, and education to promote
movement of all patients according to their needs and abilities.
Keywords: early mobilization, immobility, interdisciplinary
team, patient mobility

he negative effects of hospitalization and immobility on patient outcomes are well documented. Immobility and bed rest are associated with deconditioning, pressure ulcer formation,
and longer hospital stays (Kalisch, Lee, and Dabney
2014; Padula, Hughs, and Baumhover 2009). The
elderly patients are potentially at high risk and often
require skilled nursing placement post acute discharge. It has been noted that between 29% and
65% of hospitalized adults experience a decline in
function and mobility during their hospital stays
(Rukstele and Gagnon 2013; Brown, Friedkin, and
Inouye, 2004; Covinsky et al. 2003; Sager et al.
1996). Indeed, low mobility in hospitalized older
adults has been labeled an unrecognized epidemic.

Tom Czaplijski is the former Vice President of Hospital Operations at Vidant Medical Center in Greenville, North Carolina.
Dianne Marshburn is Director of Clinical Research at Vidant Medical Center in Greenville, North Carolina. Tracy Hobbs is an
assistant nurse manager at Vidant Medical Center in Greenville, North Carolina. Scott Bankard is Director of Rehab Admissions
and Acute Rehab Services at Vidant Medical Center in Greenville, North Carolina. Wanda Bennett is a senior administrator of
Rehab Services at Vidant Medical Center in Greenville, North Carolina.
Color versions of one or more of the figures in the article can be found online at www.taylorandfrancis.com/vhos.
74

HOSPITAL TOPICS: Research and Perspectives on Healthcare

and responsibilities. Lack of collaboration and communication between bedside nurses and healthcare
professional often can lead to missed opportunities in mobilizing patients (Dammeyer et al. 2013).
In the current healthcare system, where the focus
is on positive patient outcomes while working with
limited resources, it is important to incorporate mobility in the hospitalized patients daily plan of care.
An 861 bed academic medical center located in
southeastern United States began its journey toward
a culture of mobility in 2009. As a tertiary level
1 trauma referral center, the organization provides
acute, intermediate, rehabilitation and outpatient
health services as a tertiary referral center for 29
counties. In 2009, a physician satisfaction survey
was conducted and revealed that clinical inefficiencies were a concern among the physician group.
Focus groups discussions between physicians and
hospital administration narrowed the clinical inefficiencies issue down to turn around times related to
three core processes: 1) magnetic resonance imaging, 2) noninvasive cardiologic procedures, and 3)
perceived delays in physical (PT) and occupational
(OT) therapies evaluating and treating patients.
CHANGING A CULTURE: THE TIGER TEAM
APPROACH
In July 2010, a multidisciplinary team was constituted. Appropriately named the Tiger Team, it
comprised an aggressive group of problem solvers,
dedicated to improving hospital operations and efficiency. Members included the medical director and
vice president for operations as co-chairs, quality
office members, data analysts, process management
experts, and representatives from finance, information technology, and nursing. Team members were
added from physical and rehabilitative medicine, including PT and OT and leadership to focus on the
perceived issues in these areas by physicians. The
Tiger Team quickly recognized that the perceived
delays in obtaining PT and OT services were in
fact the result of a culture of immobility that had
developed within the organization. Mobilization of
patients had shifted from a nursing responsibility toward PT and OT staff. This led to an overwhelming
workload on the therapists resulting in an environment where it could take up to 48 hr to initiate
these services. Somehow patient mobility had morphed from being a team responsibility, including
physician and nurse resources, to a responsibility of
PT and OT services.

75

Strategic planning and initiatives alone are not

enough to ensure success for hardwiring change in
an organization or for creating sustainable and continual improvement of processes (Hopkins, Spuhler,
and Thompsen 2007). The Tiger Team understood
that creating a set of strategies and tactics alone
would not achieve the ultimate goal, which was to
create a culture of mobility, such that every patient
moves an optimal amount each day.
Changing the culture of mobility required
fundamental changes to the current thought,
practice and approach to patient mobility within
the organization. To this end, the team looked to
senior nursing staff to discuss past approaches to
patient care and also looked to the literature to help
define optimal approaches to care. Through these
steps, the team identified a multipronged approach
to improve care through the implementation of
numerous strategies.
In the attempt to achieve a transition of culture,
seven key action steps were completed by the Tiger
Team, which included the following:

Education of the Tiger Team members

Extensive literature review
Education for hospital and physician leadership
Detailed goal selection and refinement.
Development of a Mobility Project Gantt Chart
Planning the pilot project
Hospital wide implementation of the program on
all inpatient nursing units. This included a rollout
of education and training, and conducting a full
scale marketing and media blitz

To facilitate the nurse in addressing patient activity, the Greenville Early Mobility Scale (GEMS;
Vidant Health 2012) was developed (Figure 1).
Through the development of this scale, the team
hoped to achieve three specific goals. First, was that
every patients mobility would be assessed once per
shift to determine their level of function. This included broad activity levels consisting of in bed activity (level 1), edge of bed activity (level 2), standing activity (level 3), and independent activity (level
4). Second was to identify a common language that
could be used by all members of the healthcare team
including the family in order to communicate what
the patient was physically able to accomplish. A deliberate attempt was made to simplify the scale and
use pictures to prevent ambiguity. The final goal
of the GEMS was to be therapeutic to the patient.
The act of assessing a patients GEMS level once
per shift was very beneficial for multiple reasons

76

Vol. 92, no. 3 2014

FIGURE 1. Greenville Early Mobility Scale (GEMS).

HOSPITAL TOPICS: Research and Perspectives on Healthcare

including benefits to integumentary, musculoskeletal, cardiopulmonary, and psychosocial systems as

well as a positive perception toward improvement
to quality of care.
The GEMS underwent validity and reliability
testing to confirm that either nursing staff or PT
and OT staff could utilize the scale to accurately
assess a patients mobility level. There was a significant intergroup correlation (between nurses and
therapists) of 0.96.
The GEMS protocol was taken before the nursing
council for feedback and support. Stakeholders had
an opportunity to evaluate the policy and make suggestions before it was officially accepted. The team
enlisted the help of the information technology (IT)
department to create the necessary electronic health
record (EHR) documentation sections in the nursing flow sheets so that the GEMS level could be documented during each shift. Next, a comprehensive
education plan was developed for the nursing staff.
Unit based education was provided to the nursing
staff with regard to the GEMS, use of lifting and
moving equipment, and gait belt use. Educational
materials included screenshots of the EHR, a training video on the hospitals intranet, a YouTube video
assessable from a home computer or smart phone,
digital signage strategically placed in high traffic areas, and reminder cards that could be attached to
the employees badge. Illustration posters demonstrating the GEMS were created and placed in each
patients rooms to cue the patients, families, and
staff about the culture of mobility. Incorporating
the families coincided with our patient and family
centered care initiatives.
In anticipation of increased mobility on the units,
team meetings were held to review what resources
that the patients and nursing staff would need in order to insure dignity and safety during mobilization.
The team partnered with the purchasing department and central supply to order and stock needed
items on the unit. These included safe footwear,
long paper gowns to preserve modesty, gait belts
to be issued to individual patients, and walkers for
each unit to be available whenever needed.
The final steps that were taken to ensure a successful transition of culture focused on the PT and OT
department and their ability to efficiently meet the
needs of the patients. The team learned that PT and
OT consults were routinely ordered and viewed as a
single entity without regard for specialization of the
individual fields. It was also learned that often times,
physicians and residents ordered PT and OT near

77

or on day of discharge out of frustration when the

patient had not been mobilized by the nursing staff.
Therefore, it became evident that a triaging process
would need to be adopted to identify patients with a
documented skilled need (as defined by Centers for
Medicare and Medicaid Services [2012] guidelines),
versus patients that could be mobilized by other personnel. A triaging system that was being utilized at
the Mayo Clinic Hospitals was identified and modified to meet the needs of the organization (Hobbs
et al. 2010). What resulted was a tool consisting of
five questions that a licensed therapist would use
to determine whether skilled services were needed
or whether nursing could address the mobility issue
(Figure 2).
Using this triaging tool and the documentation
in the EHR, the acute rehab department sought
to more efficiently pair staff to patient need. This
department also worked with the IT department
to build reports regarding PT and OT evaluation turnaround times, and care plan compliance.
Benchmarks for the department were adopted and
the leadership staff implemented a scorecard with
these metrics. Additional indicators of success that
were identified by the team were incidence of falls,
Hospital Acquired Pressure Ulcers, Hospital Consumer Assessment of Health Plan Survey scores, and
length of stay.
A research subgroup was formed so that the findings of the team could be captured and published.
One of the first tasks of this group was to evaluate
the pilot project implementation and conduct an
education needs assessment of the nursing staff with
regards to the GEMS initiative. Using this information, the Team was able to strategize how to proceed
with the education cascade to the rest of the hospital.

Five Triage Questions to determine "skilled

need"
Is the patient able to follow commands?
Has the patient been up to a chair? Walked?
Is the patient back to functional baseline?
Is therapy relevant to patients return to function?
Is the patient going to a skilled nursing home
within 48 hours?

FIGURE 2. Triage questions.

78

Vol. 92, no. 3 2014

Research was also conducted to validate the GEMS

tool. Finally, information on the mobility initiatives were shared through formal presentations and
posters presented at a variety of venues such as the
hospitals internal research day, and regional, state,
and national conferences.
RESULTS
One of the goals that the Tiger Team was focused
on was reducing the number of unnecessary PT and
OT consults that were being ordered for general
mobility. Beginning in April 2011, the OT and PT
staff began to triage incoming orders on the pilot
unit using the newly developed five question triage
tool and documentation in the electronic health
record. If it was clear from the EHR that skilled
services were not required, the PT and OT orders
were canceled and the nursing staff were encouraged
to utilize the GEMS scale. During the time period
from April 2011 to April 2012, 1,462 orders for
PT and OT were received and 182 (12%) were
canceled using the triage process. Using 45 min as a
conservative estimate of the amount of staff time to
complete an evaluation, it was estimated that 136.5
hr of time was saved on the pilot unit. Conceptually,
this time could be reallocated to other floors where
skilled need is demonstrated, such as the intensive
care unit.
The Tiger Team also wanted to accomplish same
day turn-around time (TAT) for all PT and OT
orders. Based on previous work with magnetic resonance imaging TAT, leadership felt that this was a
reasonable expectation. Although the volume of PT
orders declined on the pilot unit from 77 in April
2011 to 56 in April 2013, an 18% reduction, we
did not see a similar reduction in PT TAT. In April
2011 the TAT for a PT order was 30.26 hr. This
increased 64% to 49.78 hr in April 2013.
A third goal of the project was to decrease the
time between a physicians order for mobility and
the first time the patient was mobilized out of bed
by nursing. The average nursing mobility TAT in
April 2011 was 31.7 hr compared to 26.38 hr in
April 2013 (16.8% improvement).
As the team reviewed metrics, it was determine
that numerous initiatives were implemented on the
pilot floor concurrently; therefore it became difficult to determine what impact the rollout of mobility program had on falls and length of stay. Trend
toward improvement with falls and length of stay
was noted on the pilot unit immediately following
implementation. From a follow-up physician sur-

vey, clinical inefficiencies were not identified as a

major concern.
LIMITATIONS
Short-term trends were accomplished; however,
sustainability is challenged by competition with
other hospital initiatives. Incorporating best practice established for mobilizing patients, and current
reimbursement not directly linked to this initiative, act as a barrier to the importance and quality
measuring of patient mobility has impeded a true
cultural change. The need for education of new
nursing and physician personnel make it difficult
to maintain the consistency needed to hardwire a
culture of optimal mobility. With numerous falls,
pressure ulcers, and length of stay initiatives underway within the organization, it became difficult
to measure the direct impact of the change in culture on patient mobility on these specific patient
outcomes.
CONCLUSION
The current healthcare environment demands
process improvement as well as improvement of
patient outcomes. Incorporating and increasing patient mobility takes on a new dimension of focus
as healthcare facilities search for the means to decrease hospital-acquired events and length of stays.
The improvements achieved in process and patient
outcomes from this project came from the Tiger
Teams innovative and uncompromising approach
to change. Achieving a culture of mobility required
fundamental changes to the current thought, practice and perceptions of patient mobility. The team
was highly engaged, and remained so, paying special attention to project planning via the Gantt chart
work plan, team dynamics and communication, and
challenged the prevailing paradigm for mobility.
The Gantt chart became the driving tool for team
and individual performance. The Gantt chart acted
as a scorecard that sets, and tracked everyones expected and actual performance and contributions.
It ultimately created and drove responsibility and
accountability for rapid movement on problem and
issue solving. The net outcome was a reduction
of unnecessary OT and PT orders, increased nurse
and physician engagement in mobility, and hospital
wide implementation of the program. Establishing
culture of mobility has significant implications for
patient care.

HOSPITAL TOPICS: Research and Perspectives on Healthcare

REFERENCES
Brown, C., R. Friedkin, and S. Inouye. 2004. Prevalence and
outcomes of low mobility in hospitalized older patients. Journal of American Geriatrics Society 52:126370.
Brown, C., D. Redden, K. Flood, and R. Allmann. 2009. The
under recognized epidemic of low mobility during hospitalization of older adults. Journal of American Geriatrics Society
57:166065.
Brown, C., B. William, L. Woodby, L. Davis, and R. Allman.
2007. Barriers to mobility during hospitalization from the
perspectives of older patients and their nurses and physicians.
Journal of Hospital Medicine 2:30513.
Centers for Medicare and Medicaid Services. 2012. Medicare benefit policy manual, chapter 15. http://www.cms.hhs.
gov/manuals/Downloads/bp102c15.pdf (accessed November 26, 2012).
Covinsky, K., R. Palmer, R. Fortinsky, S. Counsell, A. Stewart,
D. Kresevic, C. Burant, and C. Landefeld. 2003. Loss of
independence in activities of daily living in older adults hospitalized with medical illness: Increased vulnerability with
age. Journal of American Geriatrics Society 51:45158.
Dammeyer, J., S. Dickinson, D. Packard, N. Baldwin, and
C. Ricklemann. 2013. Building a protocol to guide mobility
in ICU. Critical Care Nursing Quarterly 36 (1):3749.
Dummier, J., N. Baldwin, S. Harrington, B. Christofferson, J.
Christopher, and J. Iwashyna. 2013. Mobilizing outcomes:
Implementation of a nurse-led multidisciplinary mobility
program. Critical Care Nursing Quarterly 36 (1):10919.
Fisher, S., R. Galloway, Y. Kuo, J. Graham, K. Ottenbacher,
G. Ostir, and J. Goodwin. 2011. Pilot study examining the association between ambulatory activity and falls
among hospitalized older adults. Archives of Internal Medicine
92:209092.

79

Fisher, S., Y. Kuo, J. Graham, K. Ottenbacher, and G. Ostir.

2010. Early ambulation and length of stay in older adults
hospitalized for acute illness. Archives of Internal Medicine
170:19423.
Hobbs, J., J. Boyse, K. McGarry, J. Thompson, and J.
Nordrum. 2010. Development of a unique triage system for
acute care physical therapy and occupational therapy services:
An administrative case report. Physical Therapy 90:151929.
Hopkins, R., V. Spuhler, and G. Thomsen. 2007. Transforming
ICU culture to facilitate early mobility. Critical Care Clinics
23:8196.
Kalisch, B. J., G. Landstrom, and A. Hinshaw. 2009. Missed
nursing care: A concept analysis. Journal of Advanced Nursing
65:150917.
Kalisch, B. J., S. Lee, and B. Dabney. 2014. Outcomes of
inpatient mobilization: A literature review. Journal of Clinical
Nursing 24:1486501.
Kalisch, B. J., D. Tschannen, H. Lee, and C. Friese. 2011.
Hospital variations in missed nursing care. American Journal
of Medical Quality 26:2919.
Padula, C., C. Hughes, and L. Baumhover. 2009. Impact
of nurse-driven mobility protocol on functional decline in
hospitalized older adults. Journal of Nursing Care Quality
24:32531.
Rukstele, C., and M. Gagnon. 2013. Making strides in preventing ICU-acquired weakness. Critical Care Nursing Quarterly
36 (1):1417.
Sager, M. A., T. Franke, S. Inouye, C. Landefeld, T. Morgan,
M. Rudberg, H. Sebens, and C. Winograd. 1996. Functional
outcomes of acute medical illness and hospitalization in older
persons. Archives of Internal Medicine 156:64552.
Vidant Health. 2012. Greenville Early Mobility Scale (GEMS).
Greenville, NC: Author.

Copyright of Hospital Topics is the property of Taylor & Francis Ltd and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.