5 vital tips to help reduce readmissions in hospitals
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Dr. Joseph A. DeFeo, CEO, Juran GlobalScott A. Regan, MBA, MHSA, SVP, Juran Global
5 Vital Tips to Help Reduce Readmissions in Hospitals
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Today’s Agenda
1. Attacking the readmission rate problems most effectively
2. Using the right tools for addressing readmission rate problems
3. Engaging a multi-functional team to address readmission rates
4. Engaging leadership to ensure the organization is set up for success
5. Picking the best place to begin
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Our Legacy Ignited a Global Movement
Our Research and Experience is well published.
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Healthcare Organizations We’ve Worked With
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This Month’s Healthcare Headlines
Medicare Readmissions
Penalties Create
Quality Metrics Stress– August 8, 2015
Half of U.S. Hospitals Face Readmission PenaltiesHospitals Will Lose a Combined $420 Million
– August 4, 2015
38 Hospitals
Facing Highest Penalties
for Readmissi
ons– August 4, 2015
1
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About the CMS Readmission Program
Learn Everything You Need to Know The Hospital Readmissions Reduction Program was created under the
Affordable Care Act, which requires CMS to reduce payments to hospitals with excess readmissions.
Penalties are based on readmissions for Medicare patients who were originally admitted for:
– heart attack– heart failure– Pneumonia– chronic obstructive pulmonary disease– elective hip or knee replacements
This year’s penalties will take effect from Oct. 1 through Sept. 30, 2016, and are projected to cost hospitals a combined $420 million.
The maximum penalty this year is a 3% reduction in Medicare payments; the average penalty this year is 0.61%.
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Healthcare’s Latest Cottage Industry
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The Physician’s Treatment Process
Chief Complaint
H&P, Diagnostics Diagnosis Therapeutic
InterventionMonitor,
Follow Up
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The Administrator’s Treatment Process
Chief Complaint
Therapeutic Intervention
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The First of Five Vital Tips
Off-the-shelf interventions will work, but only if you are lucky enough that the intervention you select matches a correct diagnosis
Which means you first need a correct diagnosis Which means you need valid analysis of the root cause of
your readmissions problems not someone else's
Tip #1: Contrary to what you read there is no magic potion for a solution – But there is a magic
potion to analyze the problem
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Tip #1: Magic Potion
What the root cause isn’t:– It is not the initial reaction or response– It is not merely restating the finding– It is not a symptom
What the root cause usually is:– Process or program failure– System or organization failure– Poorly written instructions– Lack of training
Use the right method not the easiest to identify the root causes
H & P Diagnostics Diagnosis
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Tip #1: Magic Potion
1. Define the problem WITH PRECISION2. Collect and analyze facts WITH REAL
DATA 3. Develop theories and possible causes
BEFORE SOLUTIONS4. Systematically reduce the possible
theories and causes using FACTS5. Develop possible solutions BASED ON
ANALYSIS6. Define and implement an action plan TO
CHANGE IT 7. Monitor and assess results TO HOLD
GAINS
Most effective means to determine the real root causes
H&P, Diagnostics Diagnosis
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Tip #1: Magic Potion
We use Six Sigma as the starting point:– Define the baseline and goal– Measure current performance – Analyze why, who, what, when…
• Pareto analysis (vital few vs. trivial many)• Brainstorming• Flow charts and process mapping• Cause-and-effect diagram
– Analysis of data– Improve with best affordable solution– Control to hold the gains
Right Methods for Identifying the Root Cause
H&P, Diagnostics Diagnosis
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Tip #1: Magic Bullets
Implementing solutions because you know why the readmits exist
Looking for a single cause– Often two or three causes
contribute and may be interacting Ending analysis at a symptomatic
cause Assigning as the cause of the problem
the “why” event that preceded the real cause
Common Errors of Root Cause Analysis
H&P, Diagnostics Diagnosis
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The Second of Five Vital Tips
Tip #2: Using the Right Method Right
READMISSION
REDUCTIONor
H&P, Diagnostics Diagnosis
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Tip #2: Bring the Right Method to the Job
Chief Complaint
H&P, Diagnostics Diagnosis Therapeutic
InterventionMonitor,
Follow Up
Define Measure Analyze Improve Control
The Magic Potion for Analysis
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The Third of Five Vital Tips
C
Multi-Functional Team
Tip #3: Engage a Multi-Functional Team
Therapeutic Intervention
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Tip #3: Engage a Multifunctional Team
Conditions that Cause Most Readmissions (2011) NumberMedicare
1. Congestive heart failure 134,5002. Septicemia 92,9003. Pneumonia 88,8004. Chronic obstructive pulmonary disease 77,9005. Cardiac dysrhythmias 69,400
Medicaid and Commercial6. Mood disorders 61,2007. Schizophrenia and other psychotic disorders 35,8008. Maintenance of chemotherapy or radiotherapy 25,5009. Diabetes mellitus with complications 23,70010. Complications of pregnancy 21,500
* According to the Agency for Healthcare Research & Quality, April 2014
Medicare Penalties
Regardless the Condition, They Span Job Functions
Therapeutic Intervention
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Tip #3: Engage a Multifunctional Team
Exit Writer PACS
WhiteboardSign-In Sheet
EPICare Amb
MS4
Chart Rack
Chart
Pyxis
US Rack
RALS
MUSE
Sign InTriage Form
Triage/Primary Assessment
MD Assessment/Orders
Registration/Armband Placement by RN
RN Assessment Treatment/Procedure Prep/IV/Labs Drawn Diagnostics MD Evaluation/
Disposition
Discharge Instructions Discharge/Admit/Transfer
Admitting Office/Admin. Supervisor Bed Placement
EDWaiting
ED Exam/Hallway
MedStation
Supplies
Tube
Registration
Consult
They Also Span Departments
Therapeutic Intervention
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Tip #3: Engage a Multifunctional Team
Effective Teams Use Effective Methods
Therapeutic Intervention
Define Measure Analyze Improve Control
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Measure
Analyze
Improve
Control
Define
Lean Six Sigma Roadmap
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Problem and Goal
Problem Statement:For My Hospital during the calendar year 2013, the readmission rate for APR DRG 140 Chronic Obstructive Pulmonary Disease (COPD) was 21.89%, which is above the expected rate of 18.21%. Readmission rates higher than the national rate result in decreased quality of care, poor patient outcomes and decreased reimbursement and penalties from the Centers of Medicare and Medicaid Services (CMS).
Goals/Objective(s):Reduce the readmission rate for COPD from 21.89% to a minimum of 18.21% (measured quarterly) or less starting 6/30/2014.
Define
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Financial Impact: Business Case1. Medicare penalties for excess readmissions2. Medicaid penalties for excess readmissions3. Cost of care of patients readmitted for COPD in excess of the expected number.Performance worse than the expected rates adjusted for MSH results in penalties and decreased reimbursement from CMS. Cost avoidance also is anticipated.
By achieving the project goal (57 to 47 readmission cases), the hospital can reduce total COPQ to $401,145, realizing $133,692 in savings.
Note: My data do not include readmissions at other facilities; Medicaid claims are tracked by Dept. of Healthcare and Family Services (affects final penalty).
COPQ ComponentCurrent
Annualized CostGoal
Annualized CostMedicare penalties $2,319 $0Medicaid penalties $46,023 $0Cost of poor care $486,495 $401,145TOTAL COPQ $534,837 $401,145
Define
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Project Team Membership
Project Champions:• Two MDs (one being CMO)
Project Core Team Members:• Director of Disease Management• Med/Surg Floor Nurse• Clinical Pharmacy Manager• Medical Intern• Director of Respiratory Therapy• Respiratory Therapy Day Supervisor
Ad Hoc Members or SMEs:• Hospitalist• Disease Management
Define
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High Level Process Map (SIPOC) and CTQs
SIPOC: COPD Readmissions
SUPPLIER INPUT(use nouns)
PROCESS(use verbs)
OUTPUT(use nouns) CUSTOMER CTQs
Patient or familyPatient
complaints / symptoms
Admit patient Patient in room Treatment Team Bed readily available at appropriate level of care; Appropriate admission
TransportTechs
Nursing & medical staff
PatientDiagnostics Assess patient H&P
Plan of Care
PhysicianNurse
RT
Correct Plan of Care; Timely verification of COPD Order Set
Treatment Team H&PPlan of Care Treat patient Interventions Patient
Timely availability of Plan of Care; Timely implementation of COPD Order
Set; Appropriate spacer use
Treatment Team AssessmentDiagnostics Evaluate patient
Achievement of treatment
expectations
PatientTreatment Team
Appropriate evaluation according to GOLD standards; Timely evaluation
(Nursing: every shift; Medicine: at least daily)
Treatment Team
Education materials and
equipmentVerbal instruction
Educate patient
Patient/family with increased knowledge and
skill base
Patient/family
Delivery of standardized education (verbal & written); Documented confirmation of patient/family
understanding & demonstration
Treatment Team
DC ordersDC
Plan/paperworkMedications &
equipment
Discharge patient
Discharged patient to
home/next level of care
Patient/familyNext level of care
GOLD discharge criteria are met; Discharged to appropriate setting;
Additional training needs identified; Discharge paperwork reviewed;
Appointments scheduled; Inhalers provided
Define
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Detailed Process Map
Typical COPD inpatient LOS is about 3 days.
Measure
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Measure Process Capability
The baseline CMS readmission rate was 21.89% for CY 2013, above the expected rate of 18.21%.
Measure
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Graphical Analyses – Selection of COPD
COPD and CHF readmissions were in the vital few APR DRGs, and determined to be relatively controllable vs. other diagnoses.
Measure
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Graphical Analyses – Readmission Trend
Both observed and expected readmission rates are variable over time, displaying gradual decline over the prior two years. Observed readmission rates exceeded
the expected rate in 16 of 24 months.
Measure
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Graphical Analyses – Readmission Reasons Measure
Most principal diagnoses for readmissions relate to respiratory problems or CHF. Common secondary diagnoses include tobacco and drug use, diabetes, hypertension
and hyperlipidemia.
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Severity Score at Index & Readmission
There is no significant difference in severity score between Index and Readmitted patients. Are some patients readmitted more often?...
Measure
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Graphical Analysis – Readmissions by Patient
Although 9 (14%) of the 66 readmitted patients accounted for 38% of all readmissions, the majority of patients (57, or 86%) had only 1 or 2
readmissions, accounting for 62% of all readmissions.
66 patients generated 113 readmission visits
Measure
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Process Issues Analyze
Many process issues were identified, especially near time of discharge.
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Brainstorm Theories of Causes
COPD Readmission
Admission
Resources Discharge Post-Discharge
Fragmented care following D/C
Patients do not consistently meet
GOLD discharge criteria
Appt not made
Patients unable to obtain
meds following 3-day supply
Inconsistent coordination of education b/w
pharmacy and nursing team
Variation in patient demonstration of skill in inhaler use
Inconsistent communication to Nursing Team of repeat admission
Documentation of education lacking or does not
reflect education quality and/or needs
Patient leaves AMA
Reduced pharmacist coverage on weekends or
evening
Insufficient assessment of patient understanding
of teaching
Limited staff to educate and assess competency (all meds)
Delay in communicating
with DME provider, & equipment delivery
Spacer use not considered for adults
Inpatient inhaler lost / non-standard storage
& handling
Process Variation
Social Worker/Staffing
EducationEducational content not at appropriate level for patient
Ineffective media type used for education (TV, etc.)
Smoking cessation not high priority
Coordination problems prevent effective inhaler use
Inconsistent inhaler education & resulting
poor pt techniqueVariation in
recognition of primary home
caregiver
Med history not completed for all COPD patients
Patients not D/C to appropriate
level of care / setting
Providers unaware of pending discharges
Necessary services not available
during weekends
Patient not provided inhaler
COPD not flagged in auto-trigger list
Social Worker engaged late in process
COPD order set inconsistently used
Limited communicationof order set availability
O2 6 min ordered late in process
Excessive variation in patient care
Perceived as cumbersome
Single, generic content @ 6th grade level
Too complex
Rushed / not planned
Knowledge deficit of caregiver Not identified
Limited options
No doc’n pharmacy teaching
Fragmented
Not asked
Asked too late
Limited standardization
Limited staff allocated to
high priority pts
Not considered
Pt financial issues
No/under insurance
Not asked/planned
Not assessed for need
Need not identified
Appts not patient-centric
Access (e.g.,
transport)
ForgetNurses
cannot find
Nurses not know
Pt not fill inhaler RxPt not know to fill / diff
rescue/maint
Pharmacy access
Unaware empty
Not policy
Unaware
Too much info
Not all relevant
parties involved
Home caregiver
not available
Not enough
time
Not all teaching programs make appts
Comm’y docsnot make appts
Pt not follow up on appt or
recomm’n
Fill too late
Docs not know
to document /significance
Co-morbidities
overlap
Not know do not need
Admission order set
Access issues (transport)
Inconsistent teach-back
No standard protocol
No / too many caregivers
No or ineffective
review of D/C instructions
InconsistentID of
readmission
Non-Sinai
Not documented /Inconsistent location /
Difficult to find /No expectation
Not coordinated prior to D/C Poor D/C
planning COPD not a standard referral for Social Work
Multiple factorsPossible readmission factors were organized in a fishbone format.
Analyze
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Critical To Quality and Theories (Xs)
Possible causes related to CTQs:
X1: Insufficient assessment of patient understanding of teaching.
X2: Patients do not consistently meet GOLD discharge criteria.
X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does not include family/caregiver).
X4: Appointment not made or inappropriate for patient (e.g., have outside provider).
X5: Patients are not being discharged to the appropriate level of care / setting.
X6: Patient not provided inhaler. Additional possible causes:
X7: Readmission rate is a function of day of week discharged.
Analyze
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Data Collection Plan for Analyze Phase
Data Collection Plan for the Analyze Phase
Ref.
Theories To Be Tested (Selected From The C-E
Diagram, FMEA, etc.)
List Of Questions To Answer for
Evidence of Each Selected Theory
Results that will support
theory
Results that will rule out
theoryTools To Be Used
Data To Be Collected
Description/Data Type
Sample Size,
Number of
Samples
Where/How To Collect
Data
Who Will
Collect Data
How Will Data Be
Recorded
X1 (CTQ)
Insufficient assessment of patient understanding / demonstration of standardized teaching, including additional training needs.
Does a second-teach-back improve patient administration?
A second teach-back improves patient administration.
A second teach-back does not improve patient administration.
Bar chart
Categorical: Percentage patients with
improved administration.
84 patients
Inhaler instructi
on session
Karen Excel
X6 (CTQ)
Patient not provided inhaler.
What is the incidence of lost or missing inhalers?
A high number of inhalers are lost or missing.
A low number of inhalers are lost or missing.
Bar chartCategorical:
Count of lost or missing inhalers.
6 weeksReconciliation tally
Karen Excel
X7Readmission rate is a function of day of week discharged.
What is the proportion of patients readmitted w/in 30 days by day of week?
Proportion readmitted differs by day discharged.
No difference in proportion by day discharged.
Stacked bar chart,
Chi-square
test
Categorical: Number of patients w/
Index discharge by day of week, and number of
these readmitted.
All COPD discharges over prior 2 years
Premier Lynda Excel
A subset of CTQs and Xs were tested (others had sufficient anecdotal evidence and/or were difficult / time-consuming to test).
Analyze
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Test of Theories Example
Theory: Insufficient assessment of patient understanding of teaching.
Analysis: Pharmacy assessed patient inhaler demonstration technique at t0 (baseline), t1 (after instruction), and t2 (24-72 hr. after initial instruction, t1). Scoring based on number of steps missed (detailed description in Notes View)
The t2 (24-72 hr.) assessment better reflects actual skill after discharge than the t1. Instruction improved scores but remained <100% scores; this and the slight decline between t1 and t2 indicate that reinforcement and assessment are beneficial.
Practical Conclusion: Additional teach-back improves patient inhaler administration; current teaching is insufficient.
Spiriva (n=15) Symbicort (n=36) Albuterol (n=35)
Score,
out of 9 %Score, out
of 9 %Score, out
of 9 %t0 5.8 64 4.5 50 4.1 46t1 8 89 7.2 80 6.7 74t2 7.2 80 6.6 73 6.2 69Δt1-t0 +25 +30 +28Δt2-t0 +16 +23 +23Δt2-t1 -9 -7 -5
Analyze
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CTQ and X Summary
X1: Insufficient assessment of patient understanding of teaching. Administration of inhalers improved from 25% at baseline to 50% after a second teach back session that occurred between 24-72hr post initial test.
X2: Patients do not consistently meet GOLD discharge criteria. Application of GOLD discharge criteria is not standard practice.
X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does not include family/caregiver). Anecdotal evidence from nursing and RT indicates review of D/C instructions is not consistently effective.
X4: Appointment not made or inappropriate for patient (e.g., have outside provider). Follow-up appointments (PCP, pulmonologist) are made for some but not all patients, and are made late in the inpatient care process.
X5: Patients are not being discharged to the appropriate level of care / setting. GOLD discharge criteria not used to guide choice of care setting; palliative care is underutilized.
X6: Patient not provided inhaler. Inhalers frequently are lost or misplaced, and not available to provide to patients upon discharge.
X7: Readmission rate is a function of day of week discharged. Day of week discharged does not affect subsequent readmission rate.
Analyze
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Selected Solutions
Theme Selected SolutionsAdmission & Inpatient Care
COPD Care Pathway and Order Set, with triggering of Order Set and supplemental services via pathway. Eliminate need for duoNeb ordering via teaching aids (placebo inhalers and disposable spacers).
Education - Patient
Bronchial Hygiene Program upon admission. Include early symptom identification, trigger identification, hand-washing, exercise.
Education - Staff
Bronchial Hygiene Program upon admission. Build in shortcut to ordering of spacers based on RT vs. direct MD order. Use admission smoker status as basis for referral to Disease Mgmt. / Lawndale Clinic smoking cessation classes.
Resources Social Worker engaged via Care Pathway to identify & initiate post-discharge meds process, oxygen, etc.
Discharge Marketing and education of palliative care. Include palliative care and GOLD discharge criteria in COPD Care Pathway and Order Set. Deploy AccuDose® inhaler tracking & storage (patient-specific). Initiate discharge planning upon admission per COPD Care Pathway, including appointments. Social Worker identifies COPD-relevant programs relevant to patient. Make follow-up appointments (PCP, Specialist) as early as admission. Implement clear, concise COPD-specific D/C instructions, including prescription transition & eligibility for free inhalers/prescriptions.
Staff Augment med history by having Pharmacists or ER Pharm Tech complete for patients beyond Disease Mgmt. (Long-term).
Improve
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Updated Process Map(s)
TBD: Smoking cessation intervention
Improve
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Control Plan Process Control Plan for: COPD Readmissions
Date: 11/11/2014 Revision Level: 1
Approved By: COPD Readmission Team
Ref. Control SubjectSubject
Goal (Standard)
Unit of Measure Sensor
Frequency of Measure-
mentSample Size
Where Measurement
RecordedMeasured by Whom
Criteria for Taking Action
What Actions to Take Who Decides Who Acts
Where Action
Recorded
1 COPD readmission(30 day rate)
≤ 18.21% % Premier Monthly All COPD readmissions
COPD Readmissions spreadsheet
Lynda >18.21% Investigate CTQs Lynda Refer to CTQs
Control Plan Log
2 COPD Order Set(use) 100% % Meditech Weekly
All COPD discharges (trailing 4 weeks)
COPD Order Set Report Lynda <90%
List of Non-Compliant Attending & Resident Physicians and Report to Dept. Chairs, Program Directors,
Chief Residents
Dr. Iliescu Dr. Iliescu Control Plan Log
3Bronchial Hygiene
Program(use)
100% % RT Consult (Meditech) Weekly
All COPD discharges (trailing 4 weeks)
Bronchial Hygiene
Program ReportLynda <90%
List of Non-Compliant Attending & Resident Physicians and Report to Dept. Chairs, Program Directors,
Chief Residents
Dr. Iliescu Dr. Iliescu Control Plan Log
4 COPD education(documentation) 100% % Education
checklist* Weekly
All COPD discharges (trailing 4 weeks)
Patient Chart Lynda <90%List of Non-Compliant
Departments (Pharm, Nursing, RT) and Report to Dept heads
Dept HeadsDept Heads Control Plan Log
5 GOLD D/C criteria(use) 100% %
Physician checklist done at
discharge
Weekly
All COPD discharges (trailing 4 weeks)
Meditech Report Lynda <90%
List of Non-Compliant Attending & Resident Physicians and Report to Dept. Chairs, Program Directors,
Chief Residents
Dr. Iliescu Dr. Iliescu Control Plan Log
6Discharge paperwork(review)
100% %COPD
Education Screen
Pilot-Daily (First 2 wks)
Weekly
All COPD discharges (trailing 4 weeks)
Meditech Report Lynda <90% List of Non-Compliant Nurses and Report to Unit Directors Raquel
Raquel and Unit
Directors
Control Plan Log
7Patient appointments
made prior to discharge
100% %Discharge
module (Meditech)
Weekly
All COPD discharges
(trailing 4 weeks)
FM-Appt Report from D/C Module
IM-F/U with Kathy
Lynda <90%List of Non-Compliant Resident Physician and Report to Dept.
ChairsDr. Iliescu Dr. Iliescu Control
Plan Log
8Discharge inhaler(provisioning of
inpatient inhaler)100% %
Nursing discharge checklist
Weekly
All COPD discharges (trailing 4 weeks)
Meditech Report Lynda <90% List of Non-Compliant Nurses and Report to Unit Directors Raquel
Raquel and Unit
Directors
Control Plan Log
9 Smoking cessation(referral conversion) N/A % Meditech Weekly
All COPD admissions w/ "Yes Want To Quit" (trailing
4 weeks)
Meditech Report Lynda
>10% change
from baseline
Investigate root cause(s) (patient refusal / RT not asking) Phyllis Phyllis Control
Plan Log
Palliative Care
Criteria, Consults
TBD
Audit (# consults / #
meeting criteria)
TBD Q4 2014 Control Plan Log
Improve
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Change Management & Communication Plan
Planned Change Who is Affected? Potential Objections Facts (What will really happen)
Benefits to those affected (Business and Personal
Benefits)
Communication (How will change be
communicated?)
Admission & Inpatient Care: Implement COPD Care Pathway, including use of COPD Order Set and guidelines.
Physicians, Nursing, IS, Social Work, Respiratory
Therapy, Pharmacy
Resistance to pathway and order sets (primarily
physicians)
Resistance will be overcome with consistent monitoring
Treatment team: applying best practices. Social Work: reduced medication costs. Finance: COPQ reduced.
Patients: receive better care.
Physician and Nursing leadership meetings. Staff
meetings with nurses, physicians and other
departments affected. Email notifications. See Training
Plan.Education - Patient:Reinstate modified Bronchial Hygiene Program w/ RT involvement early in inpatient process. Include early symptom identification, trigger identification, hand-washing, exercise.
Respiratory Therapy, NursingExpansion of RT duties. Providing adequate RT
staffing to accomplish goals
Restructuring the Bronchial Hygeine Program to shift
responsibility for delivery of MDIs and education from nursing to the Respiratory
RT is better skilled in the use of various inhalers/will
identify the need for spacers. Patients receive better
education and improved self-care.
Revision of the Bronchial Hygiene Program and MDI
Protocol w/ RT staff education. See Training Plan.
Education - Staff:Bronchial Hygiene Program to address inhaler education via RT involvement and identification of spacer candidates. Offer Level 2/3 smoking cessation classes.
As above As above
As above. Focus on education will start with the
patient; Information regarding Smoking Cessation class will
be incorporated in current packet.
As above As above
Resources:Social Workers engage patients in corporate pharmaceutical programs for post-discharge meds. Establish Social Work consult on admission per Care Pathway to assess DME / equipment needs.
Social Work, Utilization and Nursing Departments;
Patients
Patients may object to / not comply with paperwork for pharmaceutical program
requirements
Care Pathway will specify appropriate timing of SW
engagement and activities.
Saves SW costs and patients receive consistent supply of
meds.
Social work, utilization and nursing department meetings (leadership and staff level).
See Training Plan.
Discharge:Facilitate appropriate discharge and post-discharge care by incorporating D/C planning as part of Care Pathway. Elements to include GOLD criteria, provisioning of inpatient inhaler stored in unit-based locations, D/C instructions that educate patient re: free inhaler & prescription transition, and need to follow up w/ Pulmonologist/PCP. Educate physicians & patients re: palliative care & availability.
Physicians, Nursing, Respiratory Therapy, Social
Work, Pharmacy
Use of GOLD criteria. Resistance to change
towards earlier discharge planning.
Care Pathway will provide guidance on discharge
events and timing.
Early and more comprehensive discharge
planning will smooth discharge process and facilitate appropriate,
improved patient self-care following discharge.
Educational/training sessions with physicians, Nursing, RT, SW, Pharmacy, per Training
Plan.
Control
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Training Plans
The training needs for different stakeholder groups were identified. Training delivery format, frequency, etc. were determined for each group…
Topic / Area of ChangeTeaching
Attending & Residents,
Hospitalists
Community Physicians Nursing Respiratory
TherapySocial Work Pharmacy
Disease Manageme
ntED Staff
COPD Care Pathway X X X X X X X COPD Order Set X X X X X X Bronchial Hygiene Program X X X X X Placebo inhalers & disposable spacers (edu, storage, tracking, use) X X X X
Smoking cessation referral X X X X X X Social Worker role & engagement X X X X X Palliative care X X X X X GOLD discharge criteria X X X X Discharge (planning, instructions, follow-up appointments) X X X X X X
Other – Patient Identification X
Control
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Conclusion: 30-day readmissions have been running at 12% (27/204) since the beginning of Improve phase in September. Overall readmission rate
compares favorably YOY.
Desired direction:
Control Subject Control
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Conclusion: COPD Order Set use is showing a very gradual upward trend, doubling since Q4 2014. There will be continued reinforcement to ensure this
positive trend continues.
Desired direction:
Control Subject Control
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Conclusion: A BHP was not used for several years prior to the project start. Now revised and revived, BHP use initially was limited by staffing, but gradually
improving.
Desired direction:
Control Subject Control
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Conclusion: COPD education of patients* has averaged around 67% since early April. A nursing form change in April facilitated compliance that has not yet been
sustained. * Education includes COPD Education Pamphlet and inhaler instructions.
Desired direction:
Control Subject Control
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Conclusion: Historically not used, use of the GOLD discharge criteria has averaged just under 70%.
Desired direction:
Control Subject Control
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Desired direction:
Conclusion: The pattern of documented provisioning of COPD discharge instructions to patients has closely tracked that of Gold discharge criteria (prior
slide). The target is 100%.
Control Subject Control
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Conclusion: Documentation of patient appointments made prior to discharge averaged 64% since March (target is 100%).
Desired direction:
Control Subject Control
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Desired direction:
Conclusion: Supply of inpatient inhaler to patients upon discharge has averaged close to 50% over recent weeks. This is well below the target 100%, but
gradually improving.
Control Subject Control
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Conclusion: The proportion of COPD patients who indicate they want to quit has increased over time. This metric will be monitored to establish a baseline, from
which significant deviations can be responded to as appropriate.
Desired direction:
Control Subject Control
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The Fourth of Five Vital Tips
Tip #4: Engage Leadership
Therapeutic Intervention
Monitor, Follow Up
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Tip #4: Engage Executive Leadership
A Day in the Life of a Healthcare Leader
Therapeutic Intervention
Monitor, Follow Up
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Monitor, Follow Up
Therapeutic Intervention
Tip #4: Engage Executive Leadership
Effective leadership really makes all the difference. In the end, we want our quality improvement efforts to be driven from the ground up. We love to have the folks who are on the front line of clinical care leading our improvement efforts. But at the end of the day, they’re going to be looking upward. They’re going to say, “What are the leaders telling us that we ought to pay attention to?” In many ways, the leader sets the tone that is going to either facilitate or mitigate the organization’s response to quality challenges. And you really need to have a leader effectively engaged in that process.
Dr. Gregg Meyer, Senior Vice PresidentMassachusetts General Hospital and Physicians Organization
Director, the Edward P. Lawrence Center for Quality and Safety
The Role of Leadership in Quality Improvement EffortsAHRQ Podcast, November 2011
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Tip #4: Engage Executive Leadership
Speak the language of leaders by calculating the margin loss, penalties to be charged
Seek the CMO and CNO as Champions Use external resources to manage
resistance and guide them Do not talk about other hospitals and
what they implemented for solutions – teach them what they did to analyze it
Alert them this is not going to be solved in a day but it could be done in 90 days
Deal with their resistance
Tips for Engaging Executive Leadership
Therapeutic Intervention
Monitor, Follow Up
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The Last of Five Vital Tips
Tip #5: Start with the Lowest Hanging Fruit
Start with Your Biggest Penalty
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Tip #5: Start with the Low-Hanging Fruit
Start with Your Biggest Penalty Which of these five conditions is causing the greatest pain?
– heart attack– heart failure– pneumonia– chronic obstructive pulmonary disease– elective hip or knee replacements
Use an improvement methodology robust enough to get the job done Make sure your root cause analysis is thorough and complete Identify solutions aimed at eliminating the root cause Maintain a control plan Identify your second-biggest readmission problem and repeat
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Lessons Learned
The root cause of your readmission problem may not be the same root cause as any other hospital’s readmission problem
Unless you first identify the root cause, any solution implemented is just a roll of the dice
Obtaining expertise on the use of root cause tools is critical to successfully reducing your readmission rate
It is easy to make errors when identifying root causes; these errors lead to wasted human and financial resources
Multi-functional issues require multi-functional teams to solve them Readmission root causes almost universally span departments and
units Tried-and-true improvement methodologies are your best approach If leadership is not hands on, the likelihood of success is diminished
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