Reducing Readmissions - Idea Generation

1. Reducing Readmissions - Idea Generation Stephanie Sobczak ssobczak@wha.org READ Improvement Advisor WHA

2. Today’s Call Past 30 days review Process measurement Overview evidence based practices for Risk Assessment and Post-discharge appointments More on small tests of change What to do about patient non-compliance Next 30 days

3. Past 30 Days

4. Results of mid-month survey YES • Have you evaluated your options for interventions to reduce readmissions? • Has your readmissions team developed an AIM statement for the unit or department level? • Has the team selected a first intervention to try with a small test of change? • What is your selected intervention • Patients are discharged with follow-up appointments • Improving discharge instructions (HCAHPS) • Conducting post-discharge follow-up phone calls • Using DKAT to determine if patients understand care plan • Have not selected an intervention to test yet/ No answer 75% 63% 63% 20% 20% 20% 15% 25%

5. Readmissions Coaching Calls

6. Data Submission Schedule for Readmissions Data Submission is now posted in the data portal New buttons have been added 

7. Data Submission Schedule Process Measures are due at the end of the month in which they are collected http://www.whaqualitycenter.org/Portals/0/Partners%20for%20Patients/Data%20Submission%20Schedule%20-%20READ%20%20Outcome.pdf

8. Questions from survey Process Measure – useful if you have determined this is a driving factor and is missing or inconsistent Readmission – Outcome measure. Auditing only readmitted patients points you to processes that could be improved. But you would still want to measure if your improvement work is having an impact What benefit is it to audit a random sampling of patients to see if they had a scheduled post-discharge appt? Wouldn't it be better to audit readmitted patients to evaluate causality look for preventable trends?

10. Readmissions Evidence Based Practices Sources: Project BOOST screening tool, IHI Guides

11. General Assessment of Preparedness (GAP) Tool Sources: Project BOOST screening tool

12. Simple Classification System Sources: IHI Guide to Care Transitions

13. Readmissions Evidence Based Practices Sources: IHI Guide to Care Transitions

14. Cross Continuum Suggestion • Primary Care • Skilled Nursing Care • Home Health • Into the Community Consider providing specific partners the IHI / STAAR Guide specific to their setting.  IF you will be working in partnership with them 

15. Readmissions Evidence Based Practices

16. Readmissions Evidence Based Practices

17. About testing your interventions This may be a new approach for your staff! Once you have selected a practice that may drive down your readmission rate, then begin testing it with front-line staff

18. A common improvement approach The “old” 7 step process

19. A More Sustainable Process Sustainable Improvement

20. A Readmissions Example Sustainable Improvement Most 5W readmissions occur within first 7 days of d/c. Most are d/c to home We don’t do follow-up calls

21. Discussion Does anyone have a story about successful small tests of change and engaging staff? (Doesn’t have to be related to readmissions) Please MUTE your lines unless you are speaking – thanks.

22. Revise and Re-evaluate: Key Decision Remember the first interventions usually do not work Adapt, adopt, abandon? Adapt—make the changes needed to make it workable, and test again. Adopt – keep it (document and report results). Abandon—let it go, if it didn’t work, don’t try to force the adoption.

23. Cross Continuum Test of Change

24. You are probably wondering… Won’t this take too much time?

25. Why go so slow? Engagement is Non-linear

26. Action Item 1: Your Tipping Point # Staff involved in process x 20-30% = The Unit Tipping Point Example : 30 RNs who discharge patients x 20% to 30% = at least 6-9 front line staff need to really buy in  In a slow to change culture, it may be 50-60%!

27. Consider the following Are you in danger of any of these situations? • Moving too fast to ‘Policy and Procedure’ • Don’t have the right people involved • Forgotten to engage frontline staff in trying new changes – little buy in • Not monitored your measures consistently over time • Forgot to reinforce training on the new way of doing things • Used the same core group of people to fix the problem • Not address the root causes of performance deficiency

28. Go slow now to go fast later Keep tests very simple to do. Plan your testing approach. Use quick huddles to get feedback from staff (you don’t need a meeting…) Make changes and re-test soon after. Review hard numbers (process data) in meetings.

29. Option 1: Expand Participants Discharge Knowledge Assessment Testing 1- One RN, one patient 2- Two RNs, two patients each 3 – Four RNs, four patients each

30. Option 2: Parallel Testing Cross Continuum Care Transitions improvement with 3 different sub groups 1- Scheduling follow-ups 2- Post d/c phone calls 3 – Community Resource referral process Group 1 Group 2 Group 3

31. Poll Question • Are you trialing more than one readmissions intervention in the next 2 months? • Yes • No

32. Tips for Multiple Tests Stay a cycle ahead.For example, teams that are redesigning discharge teaching should also be planning how this will be implemented long term. Scale down the scope of tests.Dimensions of the tests that can be scaled down include the number of patients, doctors, and others involved in the test ("Sample the next 3" instead of "Get a sample of 30"), Be sure your pilot is really a pilot.When possible, choose changes that do not require a long process of approval, especially during the early testing phase. Be prepared to end the test of a change.If the test shows that a change is not leading to improvement, the test should be stopped.

33. Tips for Multiple Tests Pick willing volunteers. Work with those who want to work with you.("I know Rob will help us" instead of "How can we convince Sue to buy in?") Don’t reinvent the wheel.Learn from others working on a similar process Pick easy changes to try.Revisit the Ease/Impact matrix from Webinar 2 Avoid technical slowdowns.Don’t wait for the new software to arrive; try recording test measurements and charting trends with paper and pencil instead. Reflect on the results of every change.What was the best thing about this change? The worst? What might we do next?

34. Poll Answer • Are you trialing more than one readmissions intervention in the next 2 months? • Yes • No

35. About Patient Non-Compliance Are patients really non-compliant, as in refusing to conform or yield? Compliance com·pli·ance> /kəmˈplaɪəns/ [kuhm-plahy-uhns] noun 1. the act of conforming, acquiescing, or yielding. 2. a tendency to yield readily to others, especially in a weak and subservient way. 3. conformity; accordance: in compliance with orders. 4. cooperation or obedience: Compliance with the law is expected of all.

36. About Patient Non-Compliance Or are they having trouble following a plan, or directions? Adherence ad·her·ence>  /ædˈhɪərəns, -ˈhɛr-/ [ad-heer-uhns, -her-] noun 1. the quality of adhering; sticking to, steady devotion, support, allegiance, or attachment: adherence to a party; as in adherence to guidelines or instructions.

37. A patient story A co-workers dad was on a Coumadin regimen.  Weekly, or bi-weekly he would go in and get an INR.  It was always out of control.  Frustrating the family and the care team, everyone blamed him, didn't trust him to take his meds.  Eventually, he had a severe bilateral stroke.   No one, family member or clinician, asked him during this time how he managed his meds. How did he decide what to take? How much to take? They assumed he wasn’t taking them, and he insisted he was.

38. A patient story When he was finally asked, too late, he shared his understanding of how to take his meds. Her father was titrating his anti-coagulant based on looking at the bruises on his arms, too many bruises - he cut back. That was his understanding of the right way to do it.    So, teachable moments were lost. Instead the family, including his daughter, were taking a blaming stance, a non-compliance stance. Perhaps a stroke could have been prevented, but everyone stopped at looking for root causes by concluding he was non-compliant.

39. Are almost half of us non-compliant? Evidence is that 40% of patients do not take their medications as prescribed.  It cannot be as simple as noncompliance if nearly half of us do this, right?  How can we suspend judgment long enough to fully hear what the patient tells us?

40. Why the language matters • For those “non-adherent”: • Dig a little deeper for the reasons • Talk to family members • Be a detective or an anthropologist What might we be missing that patients are telling us because we have decided the are “non-compliant”?

41. Resource IHI “How to Guides” on Transitions of Care The section on interviewing the family, patient and person who last cared or touched the pt in the line of care.  It is a diagnostic questionnaire.  It is not the regular assessment process, but this provides understanding of the patient, who they are, how and why they do what they do.  

42. Next Month – Featuring YOU! Looking for 6 or so teams to volunteer to share the following: Option 1: How you used the staff readmission assessment to inform your next steps Option 2: Describe your design for a series of small tests • Template slide will be provided on the QC • E-mail to Stephanie by September 10 • Speak on the next call

43. Hospital NameIntervention Focus

44. Hospital NameName Unit Surveyed

45. The Next 30 Days

46. Resources www.whaqualitycenter.org Tools Available On WHA Quality Center: IHI Guides – Site specific Test of Change design template BOOST Risk Tool