IMPROVING INPATIENT DISCHARGE PROCESS TO REDUCE READMISSION

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1 1 IMPROVING INPATIENT DISCHARGE PROCESS TO REDUCE READMISSION Vanda Ametlli; Industrial & Systems Engineering, Wayne State University, Detroit, Michigan Abstract The cost of a preventable readmission to a hospital is estimated to be $7200 by Center for Medicare and Medicaid Services (CMS). If a hospital incurs 100 preventable readmissions in a year, it incurs a loss of $720,000. Crittenton Hospital Medical Center (CHMC) is a 290- acute bed healthcare facility serving communities in Oakland, Macomb and Lapeer counties in Michigan. The hospital houses a Process Engineering Department aimed at improving patient experience through process improvement projects. In Winter 2010, the hospital supported an interdisciplinary team of fifteen members with the task of finding solutions to reduce readmission rate in order to provide clinical excellence for the patient but avoid cost related penalties for treating a readmitted patient with a similar diagnosis. The team used Lean Six Sigma methodology to reduce readmission rate by scheduling followup appointments for patients, improving cycle time through better communication cues for the clinical team and increasing discharge completeness through enhancements in the electronic medical record system. Introduction Medicare Payment Advisory Commission (MEDPAC) estimated that nearly 18% of Medicare patients are readmitted within 30 days of discharge (Guadagnino). Many hospitals are or have already attempted to improve their discharge process with the expected outcome of improving readmission. The need to re-engineer the discharge process has a two-fold purpose. One reason is to reduce discharge time for patients in order to open up capacity for patients being admitted from Emergency Department or as direct admits. Second reason for improving discharge is a standardization of the discharge process reduces readmission rate by providing patients with complete and well-planned information to address after treatment medical needs. To identify a solution to reduce readmissions at CHMC, an interdisciplinary process improvement team of nurses, social workers, information systems project manager, medical specialists under the guidance of performance improvement specialists was formed to identify and implement opportunities for improvements. Medicare defines a patient readmission as a part of consecutive hospital admissions to the same hospital where the time between discharge from the first hospitalization and admission for the second hospitalization was less than 30 days. Current healthcare reform changes have forced hospitals to review readmission rate in order to be receive the most financial benefit out of lowering the readmission rate while improving patient care. According to one healthcare reform document it is estimated that Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30- day period saving $26 billion over 10 years (Project RED). National Health Care Reform is also a reason why many hospitals are trying to improve their discharge process. Improving the current discharge process will ultimately lead to a decreased readmission rate that positively affects patient care and Crittenton s hospital financial viability. As mentioned many hospitals make an effort to address the issue of rehospitalization, however there is no standard formula that will guarantee decreased readmission. Different hospitals have different solutions that align with their strategic objectives and patient population. In the State of Michigan during 2007 and 2008, the best in class readmission rate for Medicare patients

2 2 was at 10% while CHMC s Medicare readmission rate was 21% as shown by the black line in Figure 1 for Q2 FY Figure 1: Medicare Readmission Rate from Q1 FY 2007 to Q4 FY 2009 Source: Pepperresources.org Problem The discharge process is last the process step during a patient s length of stay. As a patient is discharged, they expect a timely and quality discharge from their care providers. CHMC does not have a standard procedure to follow for discharging patients. Lack of standardization, preparation, communication combined with non-value added steps not only create a bottleneck in the system but impact patient outcomes. Discharge incompleteness such as not providing physician follow-up appointment can be a factor in causing a readmission to the hospital. The Center for Medicare and Medicaid defines a readmission in their Claims manual as When a patient is readmitted to the same hospital on the same day as discharge for symptoms related to, or for evaluation and management of, the prior stay s medical condition, hospitals are instructed to adjust the original claim by combining the original and subsequent stays onto a single claim. Under this definition, hospitals are expected to combine two or more hospital visits under a single DRG payment for same day or within 30 days of discharge date readmisison. Improvement of the current discharge process using Lean Six Sigma tools will significantly reduce readmission rate. Project Objectives The purpose of this project was to identify a complete and efficient patient discharge process while meeting CMS core measure requirements to reduce readmissions and improve patient outcomes. To meet efficiency and completeness requirements the team defined the following metrics as project deliverables: Identify elements of a complete discharge that meet core measures requirements while improving patient outcomes Improve process inefficiencies throughout discharge process to reduce variability in discharge cycle time Reduce readmissions while improving patient care provided in Medical and Surgical Units. Methodology Industrial Engineering Applications This process improvement project was completed using a mix of improvement and change management tools. The project utilized Lean Six Sigma methodology along with Change Acceleration tools. Through utilization of Lean, the team would remove non-value added steps to the process. Application of Six Sigma allowed statistically driven decisions to address variations. Change Acceleration Tools (CAP) assisted in process change implementation. The discharge process is a very interdisciplinary process. Physicians, nurses, clerks, physician assistants, social workers and case managers all have a stake in the outcome of the process. The WorkOut session enhanced problem solving from front line staff such as nurses and unit clerks. The right mix of tools from each methodology allowed the team to implement improvements that provided the highest quality patient care experience.

3 3 The course of the project was a four month time period. Each month, the team attended a one-day workshop where they were educated on all the different tools that could help with their project. Team members also got the opportunity to work on sample exercises to better help with understanding of the topics. The tools used in each phase of the Six Sigma process are displayed in Figure 2. The team identified six elements that made a discharge complete. Elements were chosen on their ability to meet Core Measures guidelines but also allow for a safe discharge. The hypothesis made was that if a patient received complete discharge information, they are less likely to return as a readmit with the same diagnosis. Date Phase Tools Used January 11 th Define Threat vs. Opportunity Matrix, Stakeholder Analysis, SIPOC, Value Stream Mapping, Process Mapping, Voice of Customer January 12 th Measure Process Targets, Operational Definitions, Measurement System Analysis, Data Sources Identification, Baseline Performance Feb 9 th Analyze Fishbone Diagram, Why/Why/Why Diagram, Waste Walk March 9 th Improve Standard Operating Procedure, Failure Mode and Effects Analysis April 13 th Control Control Charts, Recognition Plan April 30 th Team Final Presentation Figure 2: Six Sigma Project Timeline of Tools Data Analysis Project data analysis was divided up in three components: 1. Readmission Rate 2. Completeness of Discharge 3. Discharge Cycle Time Readmission Rate The readmission rate for Medicare patients was provided by St. Pepper s national report. The baseline readmission rate of 21% for Medicare patients was used for the project. The readmission rate included readmissions for preventable patients, ameliorable and nonpreventable patients who might have encountered unexpected adverse events. Completeness of Discharge The six elements identified as part of a complete discharge were: (1) Activity Level, (2) Diet Activity (3) Follow-up Appointment (4) When to call doctor or go to Emergency (5) Patient Medication List Signed (6) Disease Specific Education. For a patient to have a complete discharge, it would mean that upon discharge all six elements would be found in the patient chart as complete. Operational definitions of what complete consisted for each elements were provided to the data collector. The analysis completed on the completeness of discharge on all readmitted patients found that 64% of November 2009 readmitted patients did not have a complete discharge. A Pareto analysis as shown in figure 3 aided in understanding the most frequent elements that contributed to an incomplete discharge according to the set operational definitions.

4 4 of understanding from patient or other caregivers to the patient is also necessary to increase compliance of discharge instructions. Follow-up Appointments Figure 3: Pareto Analysis of Discharge Completeness The Pareto analysis displayed disease specific education, activity level, diet level and followup appointment as the key categories as not meeting a complete discharge. In addition to the statistical analysis, other elements were viewed such as Did the patient have a bed order and when was it discounted? Our analysis showed that 48% of all Emergency Department Admissions had an automatic bed rest order transferred to the inpatient floor, which was not discontinued. This was a delay on discharge day if a therapist was needed once the physician submitted electronically discharge order. Another element, which was analyzed in more detail, was information regarding follow-up appointments. During the analysis, it was found that 66% of the patient charts only contained vague information such as follow-up with doctor in 2 weeks. To a patient with more than one physician or unaware of specialist to follow-up with, this statement is vague. In addition, the patient might not be aware of what specialty physician to follow-up with. The last element analyzed in more detail was disease specific education. There was a lack of disease specific education documentation throughout patient s length of stay. Disease specific education can be very beneficial to a patient that is at risk for same diagnosis readmission. It is a preventive step that can assure the patient does not get admitted. However, providing a patient with a brochure alone or advocating for good health choices might not be sufficient. Confirmation To understand the quality of follow-up appointment information that the patient was provided, charts were reviewed. The follow-up appointment chart audit focused on determining the quality of follow-up appointment information that the patient was given in the discharge instruction sheet. The metrics measured to determine follow-up appointment focused on how much information regarding physician name provided, specialty of physician and timeframe of when to visit the doctor. A general follow-up appointment note was defined as follow-up in two weeks. The data showed that only 66% of audited patient charts contained only general information such as follow-up with physicians in two weeks. Only nine out of the fifty audited charts, contained specialty of follow-up physician. Discharge Cycle Time The discharge cycle time was defined from the time physician discharge order was submitted to time patient left the hospital. The physician discharge order was either electronic or handwritten. A handwritten order had to be placed in the computer system by the clerk to indicate discharge to the nurses and social workers. A value stream map was created to indicate inefficiencies occurring from the cycle time. The baseline total process time, which was collected using manual and electronic timestamps for discharge, was found to be minutes or approximately three hours in a half. In addition to a high average there was a lot of variation in the discharge cycle time. Standard deviation was found to be at minutes. The discharge process was found to run at a 1.6 six-sigma level. Since a good process runs at 6 six-sigma level this allowed for many improvement opportunities. Process capability analysis on the baseline process was

5 5 completed as shown in Figure 4. Based on the upper specification limit of 190 minutes, the current process showed to falling outside the USL. The implementation was based on the hypothesis that a patient with a scheduled appointment is more likely to follow up with their primary care physician or specialist rather then providing information such as followup in two weeks. Medical complications will be addressed much quickly and reduce likelihood of hospitalization. 4. Implemented a standard procedure for scheduling follow-up appointments. Figure 4: Transformed Process Capability Analysis on Discharge Cycle Times Process Improvements Through brainstorming sessions and focusing on the voice of the customer, which included not only the patients but also clinical providers such as nurses and physicians, the following improvements were implemented: 1. Improved Disease Specific Education by implementing a 24-hour continuous reminder to remind nurses to provide patient with disease specific education. Enforced relationship-base care to reinforce patient understanding of education. 2. Provided option for electronic submission of patient s activity and diet level, which would be printed in their discharge instructions by creating a field at discharge for physician to indicate upon entering their discharge order. 3. Scheduled follow-up appointments for patients prior to their discharge made it easier for patient but also reinforced the need to visit a physician in order to not return to the hospital with the same problems presented on first admission. 5. Nurses were provided with the ability to enter patient appointment-scheduling preference at their patient needs adult assessment, which occurred upon patient floor admission in the EMR system. 6. Implemented a standard procedure for after doctors office hours to schedule patient appointments. 7. Implemented a 24-hour continuous bed rest evaluation to evaluate patient s action to reduce delays caused by therapist consultations. 8. Improved communication between interdisciplinary discharge team by notifying social workers and case mangers and unit clerks of patient s discharge order. 9. Created a consultant sign-off upon consult completion in order to improve communication across discharge team and eliminate Discharge if okay by Implemented electronic medication reconciliation form. All improvements listed impacted discharge completeness criteria, discharge cycle time and readmission rate for Medicare and non- Medicare patients.

6 6 Conclusions The process improvement team developed a project control plan to sustain changes and to measure changes in process metrics. The four process metrics tracked by team members were: 1. Percentage of Appointment Scheduling correlated with the Crittentons s readmission rate, shows a decreasing trend in readmission rate for Medicare patients. The readmission rate decreased from 21.0% to 16.3% at 3Q FY2010. The improvement is significant when the cost of a preventable admission is estimated by CMS to be $7200 per patient. 2. Discharge Cycle Time 3. Discharge Completeness 4. Readmission Rate Due to the high request of Information Systems changes needed to implement follow-up appointment scheduling, the pilot run began November 29 th and available data has not yet made available. The discharge cycle time greatly improved from the baseline data from 194 minutes to 162 minutes. At the same time, variation in cycle time also decreased. Discharge completeness improved from 64% patients not having a complete discharge to 30% patients having a complete discharge. As Figure 5 demonstrates, the discharge completeness non-compliant elements greatly reduced. Disease specific education is the only element that displayed as having the highest frequency of non-compliance. Figure 5: Pareto Analysis after Implementation The next area, which validates the importance of improving discharge process, is readmission rate. Figure 6, displays the Readmission rate for Medicare Patients from fourth quarter 2007 to third quarter The black line, which is Figure 6: Readmission Rate After Implementation up to Q3 FY 2010 Source: Pepperresources.org Recommendations To provide an excellent patient care experience and minimize readmission reimbursement costs, a hospital needs to evaluate their current discharge process, role of process stakeholders and current EMR system electronic submissions. While, not every readmission can be avoided, there is opportunity in decreasing preventable patients and adverse events. Other areas such as community education for common diagnosis causing readmissions can be evaluated to avoid readmission. Collaboration with home health agencies to improve transition from hospital to home health can also be beneficial. Lean Six Sigma methodology was critical to the problem solving process in reducing readmissions. Research on increasing compliance of discharge instructions also is necessary to understand patient s needs. Analysis of patient populations is also necessary to understand which areas might need more specialized instructions. Another future area of improvement resulting from this project is implementing Lean Methodology to further

7 7 streamline the discharge process in order to dramatically reduce cycle time and increase available capacity. This project highlighted the large percentage of time contributed to discharge in a patient s length of stay. The success of the results from this project can be attributed to the continuous support of process engineering team, information systems department and executive leadership. Acknowledgments Karen Delaurier, RN, Medical/Surgical Services Director, Sharon Ulep, SSBB, Quality and Outcomes Management, Kathleen VanWagoner, RN, CNO, Frank Sottile, MD, CMO, Heidi Blizzard, RN, Nursing Information IT Project Manager, Carie Cote, RN, Manager, Angelina DiPiazza, RN, Jenny Dudley, RN, Jackie Jones, NP, Anna Pollack, Social Worker, Kelly Rogers, RN, Sandy Russell, Case Manager, Gail Tack, Medical Quality Specialist, Christine Juett, RN, a special thanks to Inpatient Unit Clerks. Systems Engineering with a specialization in Lean Operations by May She received her B.S.I.E in August As part of her undergraduate internship at Crittenton Hospital Medical Center she participated in a 3 month Lean Six Sigma project to reduce readmission rate. She is currently involved in healthcare systems research of design evaluation for reusable medical equipments aimed at developing an index system for reprocessability while reducing risk of infection and maternal mortality analysis in underrepresented areas. ametlli@gmail.com References Guadagnino, Christopher. "Improving Hospital Discharge." Physicians News Digest. Web. 02 July < /1108.html>. Jack, Brian. "Reducing Avoidable Hospital Readmissions: Slide Presentation." Agency for Healthcare Research and Quality (AHRQ) Home. Web. 02 Feb < missionslides/readslides-contents.htm>. PEPPER Resources. Web. 23 Jan < Biographical Sketch Vanda Ametlli is a student majoring in Industrial & Systems Engineering at Wayne State University, Detroit, Michigan. She will complete her Masters degree in Industrial &