Improving Care Transitions using PDSA Methodology Catherine Payne, MD, FHM Care Transitions Physician Champion Medical Director of Clinical Informatics Erlanger Medical Center Chattanooga, Tennessee Objectives 1) Define various process improvement methods 2) Describe each component of the Institute for Healthcare Improvement (IHI) Model for Improvement including each step of a PDSA cycle 3) Understand how to apply the Model for Improvement to a hospital based performance improvement project 4) Introduce the A3 format for coordination and communication of a large performance improvement project throughout an organization 1
Introduction To Err is Human (1999) medical errors kill 44,000 to 98,000 people every year in US hospitals Crossing the Quality Chasm: Health Care in the 21st Century (2001) - Identifying six key dimensions of our health care system and setting aims for each dimension Six Key Dimensions Safe Timely Efficient Effective Equitable Patient centered 2
How to Achieve the Six Dimensions? IOM provided a high level road map for health care Evaluate your organization and develop your own road map for achieving the six dimensions Use known process improvement methods for success Process Improvement Methods Six Sigma Lean Institute for Healthcare Improvement (IHI) Model for Improvement 3
Six Sigma Reducing variation or the defect rate Define - Define the problem in detail Measure - defects per million or Sigma level Analyze Use process measures, flow charts, and defect analysis Improve - Define and test changes aimed at reducing defects Control - Maintain performance Lean Improvement Method Improving value from the customer s point of view, by reducing waste of time and resources Develop a value stream to determine steps, value added, identify waste Improve flow, cycle time, and value 4
IHI Model for Improvement Langley et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2009) www.ihi.org Development of Team Leaders Executive champion Physician champion Clinical-Technical Expertise Subject matter expert QI expert Data analyst Frontline staff Physicians Nurses Unit Clerks 5
IHI Model for Improvement Characteristics of an Aim Statement How good? What are you trying to achieve? By when? Define a timeline For who? Define patient population Example: Reduce urinary catheter associated urinary tract infections by 30% on hospitalist service by June 2013 6
IHI Model for Improvement Measures Types of Measures Outcome Measures - Where are we ultimately trying to go? Process Measures - Are we doing the right things to get there? Balancing Measures - Are the changes we are making to one part of the system causing problems in other parts of the system? 7
IHI Model for Improvement Concept changes High Level Change Concepts Critical thinking about current process (may need flow diagram) Benchmarking with best practices Use technology when appropriate Creative thinking Use change concepts (eliminate steps, decrease reliance on memory, reduce handoffs) 8
The PDSA Cycle for Learning and Improving Keys to Rapid Spread of Improvement Link several PDSA cycles together for rapid improvement Small tests of change Plan several cycles ahead Plan parallel cycles that occur simultaneously 9
Model for Improvement: PDSA Cycle Form A c t Pla n Stu d y D o MODEL FOR IMPROVEMENT: PDSA Cycle Form Cycle #: Date: PLAN: Objective for this PDSA Cycle: Questions to be answered (predictions): List What needs to be done for this PDSA Cycle (including for data collection) 1- Who is responsible When to be done Where to be done 2-3- 4- DO: (Carry out the plan; document problems and unexpected observations) STUDY: (Summarize what was learned) ACT: (What changes are to be made? What is the Plan for the next cycle?) Tools for use http://www.ihi.org/knowledge/pages/tools/plandostu dyactworksheet.aspx http://www.who.int/patientsafety/education/curriculu m/en/index.html http://sites.hospitalmedicine.org/qsea/ http://www.hospitalmedicine.org/resourceroomred esign/rr_landingpage.cfm 10
An example. Reducing Readmissions Aim Statement Reduce the occurrence of congestive heart failure (CHF) readmissions to Baroness Erlanger Hospital (main campus) within 30 days of discharge to 10 percent or less by September 2012 11
Key Outcome Measures Rate of readmissions within 30 days HCAHPS questions 9, 13, 25, 26 Post discharge patient survey CHF Patients Readmitted within 30 Days 25% CHF Patients Readmitted within 30 days, All Payer, All Reasons Readmission Rate 20% 15% 10% 5% 0% Jul-Sep 2010 Oct-Dec 2010 Jan-Mar 2011 Apr-Jun 2011 12
Concept Changes Improved risk assessment to better identify patients at high risk of readmission Improved education packet at discharge Transition liaison to assist in care transition to outpatient setting More involvement from home health care in education and care of patient in the outpatient setting Outpatient pharmacy to provide bedside delivery of meds to patient prior to discharge PSDA Cycle 1 Developed a CHF readmission risk assessment tool Determine the risk stratification for readmissions (high, moderate, low) Evaluate the fluidity of administration of the questionnaire 13
Plan Identify patients admitted with CHF, who have an EF<30% and creatinine < 2.0 Administer the tool to 8 patients within 24 hours of their admission Collect data on how many patients fall into each category Discuss with administrator any difficulties in comprehension of questions or administration of tool Do Too few patients 2 of the questions were difficult for the administrator to answer due to a constantly changing med list during the hospital stay 14
Study 50% of patients classified as moderate risk, only 20% classified as high risk The administrator was seeing patients who she felt like were high risk that were not included in our pilot because of the exclusion (Creatinine >2.0) and inclusion criteria (EF< 30%) Medications for patients with CHF change drastically during the hospital stay Act Continue with the same rating on the tool until we obtain more patients Remove the exclusion and inclusion criteria to include both systolic and diastolic dysfunction and to include patient with renal disease Plan to administer the tool once (within 24 hours of admission) and then a second time (hopefully 24-48 hours prior to discharge) to follow up on any changes that may have occurred during the hospital 15
Rapid PDSA Cycles Repeat of first cycle with changes mentioned Run through a cycle for each intervention simultaneously Follow up appointment with clinician within 2-5 days post discharge Home health care visit within 24 hours post discharge New improved discharge educational packet Overall Communication Plan Used A3 format Powerpoint that then formats it into single sheet (size A3) Develop elevator speech around key points Used for presentation to medical staff, quality oversight committees, and board presentations 16
Overall Communication Plan CHF Care Transition Abbreviations Used AAA: Area Agency on Aging AMI: Acute Myocardial Infarction BEH: Baroness Erlanger Hospital CHF: Congestive Heart Failure CTT: Care Transition Team FY11: July 2010 through June 2011 FY12: July 2011 through June 2012 HHC: Home Health Care PCP: Primary Care Physician PN: Pneumonia SNF: Skilled Nursing Facility Team Info Time: Aug 2011 current (January 2013) Physician Champion: Dr. Catherine Payne Key Participants: AAA BEH (case management, Nurse Leaders, Educators, PT, dietary, lab, RT, pharmacy) Continu-Care (home health agency) Erlanger Pharmacy (outpatient) Erlanger Nurse Practitioners 17
Problem Statement CMS has determined that hospitals with high readmission rates for AMI/CHF/PN will lose reimbursement across the board, so this is a priority for all hospitals nationwide We have opportunities for improvement in the transition of care process: Identifying patients at risk for readmission Improving patient education Validating that follow-up care is in place Improving coordination with community resources and other healthcare providers Desired Condition Reduce the rate of BEH CHF 30 day readmissions to 10% or less by January 2013 Reduce the number of BEH AMI, PN, & Renal 30 day readmissions to 10% or less by July 2013 Improve the transition process, starting with admission to the hospital, through discharge and beyond Participate in the development of a community coalition to better serve the at-risk population 18
Root Cause / Analysis Readmit volume for FY11 Medicare discharges CHF was highest overall Analysis of possible factors affecting CHF readmission Age of patient: readmissions were younger than expected Day of week of the discharge: Not significant Time of day of the discharge: Not significant Patient s home zip code: Specific zip codes had higher rates Location patient is discharged to: Majority of CHF readmits are from patients home Data Baseline Possible seasonality 19.4% in 2010-2011 Impact of Changes Mar 2012 Readmit Rate 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% CHF 30 Day Readmission Rate - All Payers, All Reasons 0.0% 2010-1 2010-2 2010-3 2010-4 2011-1 2011-2 2011-3 2011-4 2012-1 Calendar Year - Quarter 19
Tests of Change PDSA/Test of Change Rationale When Result Risk Assessment Tool Used with 8 patients Risk Assessment Tool with intervention for Moderate & High Risk patients: Follow-up appt before discharge and HHC visit within 24 hours (Used with 30 patients) Risk Assessment Tool (Used with 99 more patients) Education Bookletsevaluation through postdischarge survey Identify patients that at risk for readmission Identify patients that at risk for readmission Early intervention with at risk patients can reduce readmission rates Patients that really understand care needs are less likely to require further inpatient care Sep-Oct 2011 Oct-Dec 2011 Jan-Sept 2012 Oct 11 Feb 12, July 2012 - Sept 2012 CHF definition changed 2 nd Assessment No need for 2 nd Assessment Only 31% of high risk patients had a known appt before discharge & kept it 50% had HHC visits within 24 hours Low risk -15.4% Moderate risk 15.6% High risk 21.1% Redesigned after more people became involved Tests of Change (cont d) Create a hand-written summary Discharge Sheet that is faxed to PCP Care Transitions Coaches with AAA Better information for PCP, which will improve their ability to respond to patient calls Used Coleman method to involve patients in their disease process Nov 11 - Mar 12 Feb 12- Oct 12 Too difficult for busy hospitalists to do Of 67 patients, 8 were readmitted within 30 days for readmission rate = 11.9% Patient folder with Education Booklet, Fridge Magnet, Care Transitions program description, and Checklist Explain the functions, benefits, and scope of the Care Transitions Program July- Sept 2012 Implemented in August 2012 20
Project Plan Process Change Lead Time Impact Risk Assessment Tool: Develop a tool to identify CHF patients at risk Follow-up Appointment with PCP: Scheduled appointment within 2-5 days Educational Booklet: Revised for CHF to include action plans Home Health Care: Assessment within 24 hours of discharge Coleman Patient Training Method: AAA to train their staff in best practice, possibly to train HHC staff Chattanooga Regional Health Innovation Coalition: Participate in the initiation of the group to coordinate care across as many as 33 community organizations IHI Open School Sep 11 Feb 12 CTT Oct 11 Feb 12 CTT Oct 11 Feb 12 CTT Oct 11 Feb 12 AAA CTT & AAA Feb Apr 2012 Dec 11 Jan 13 Identify specific needs for the patients Consistently being done as of June 2012 Most patients find this helpful Resume phone followup All AAA coaches were trained as of Apr 2012 Currently participating actively Follow up / Unresolved Issues Medication pictures Picture Rx is being piloted. Process issues are being evaluated, but may only work for Erlanger Pharmacy patients Improved communication with PCP, Home Health Care & SNF at Discharge: what happened at the hospital, medication list, postdischarge plan of care Obtaining appropriate resources to continue enrolling CHF patients and to start with AMI, pneumonia, and renal patients 21
In Conclusion Collaboration is important! No need to reinvent! Use a process improvement method to keep focused Plan ahead Spread quickly Communicate effectively Persistence is key! Questions? 44 22
Catherine Payne, MD, FHM Catherine.payne@erlanger.org (423) 778-7958 office (423) 290-8594 mobile Upcoming Events Regional Meetings Wednesday, March 6 Memphis Tuesday, March 12 Knoxville Thursday, March 14 Nashville Register Now! Webinars Monday, March 25 10:00AM CST OB EED Monthly Team Webinar Thursday, March 28 2:00PM CST Overview of Upcoming TeamSTEPPS Friday, April 19 9:00AM CST TCPS Monthly Webinar 46 23
HEN Readmissions SPRINT March through August 2013 Kick off at March Regional Workshops! Call to Action for reducing avoidable readmissions using rapid cycle improvement with focused intention! Monthly coaching calls: Co-leaders: Catherine Payne, MD, Corley Roberts, MHA, CPHQ 1pm CST/2pm EST April 11 th May 2 nd June 6 th July 11 th For more information contact croberts@qsource.org or 615.574.7234 47 24