Systematic Improvement for Reducing Readmissions

1. Systematic Improvement for Reducing Readmissions Stephanie Sobczak, MS, MBA Manager, Quality Improvement WHA • Courtesy Reminders: • Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) • Please do not take calls and place the phone on HOLD during the presentation.

2. Today’s Call • Measurement update • Past 30 days review & mid-month survey results • Staff Readmissions Assessment • Model for Improvement (including PDSA and Small Tests of Change) • Supporting Information for Readmissions Work • Next 30 days

3. Measurement FYIs Baseline data can be submitted through May. Data up to May 2012 should be submitted on the baseline portal. Monthly Outcome data Beginning with your June data point, please enter that on the monthly portal. You will continue to enter data on this portal in the months ahead • If you have submitted prior today – all is OK

4. Measurement FYIs Process measures – if you have process measure data already, feel free to submit it. Need at least one process measure entered by August 30th.

7. Past 30 Days What went well? What could be improved?

8. Mid-Month Reminder Results Percent of responses indicating “YES” Submitted Baseline data: 93% Reviewed baseline data with team: 64% Scheduled team meetings: 75% Conducted staff readmissions assessment: Complete 4% In process 50% Starting soon 46% Will not do 0%

9. Review Action Item #1 – Review Staff Readmissions Assessment Review staff feedback on the assessment and compare to evidence based practices - Look for connections -

10. Staff Readmissions Assessment Just two (2) very important questions to learn from: What do you think are the most common factors resulting in a patient being readmitted? Please describe what you think can we can reasonably do to prevent or minimize readmissions? Thank you for helping improve patient centered care!

11. Open Line Discussion What did you learn from your staff? Were there ideas for prevention or reduction that you hadn’t considered yet? During this part of the call, please be sure your line is on MUTE , or *6. Background noise must be at a minimum in order to have conversation.

12. From Practice to Application:What to do next? Engaging Front-line Staff in Innovation and Quality Improvement

13. Staff input How do we know what to improve from all the possible drivers of readmissions? • Try an evidence based best practice • Learn from staff input • Do nothing & hope the rate changes 

14. Every improvement is a change, but every change is not always an improvement

15. Where to start?

16. Prioritizing Your Ideas Easy to Implement Target Area • Best Practice #1 • Best Practice #3 • Best Practice #2 Low Impact High Impact • Best Practice #5 • Best Practice #4 Difficult to Implement

17. Prioritizing Your Ideas Patients D/c with appts. Better D/c Instructions Follow-up Phone Call Pts. understand care plan 24 hr Pt. record is transfer Hold D/c huddles in AM Easy to Implement Low Impact High Impact Difficult to Implement

18. Prioritizing Your Ideas F. Hold D/c huddles in AM C. Better D/c Instructions Easy to Implement Target Area B. Follow-up Phone Call E. 24 hr Pt. record transfer D. Pts. understand care plan Low Impact High Impact A. Patients D/c with appts. Difficult to Implement

19. Achieving significant change:The Model for Improvement

20. PDSA Cycle for Learning and Improving Act Plan Objective, questions and predictions (why) Plan to carry out the cycle (who, what, where, when) What changes are to be made? Next cycle? • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data Do Study

21. Add three key questions

22. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

23. AIM Statement –What are we trying to accomplish? • By when? • What? • For whom? • How much? Sample Aim Statement • By January 4th, 2013, 3W will reduce preventable readmissions by 20% through implementing follow-up calls for Medicare patients with CHF.

24. What is missing from these AIM Statements? • Our unit will have better discharges this year. • 5 North will reduce readmissions by 1%. • In 2 years we will have 15% fewer readmissions on the Med/Surg unit. • By January 4th, 2013, 3W will reduce preventable readmissions by 20% through implementing follow-up calls for Medicare patients with CHF.

25. Action Item #2 – Develop Your AIM Statement Don’t improve aimlessly!

26. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

27. Measurement We measure to learn: -- What works -- What doesn’t work It’s not rocket science -- but it does take planning and persistence.

28. Measurement Display Annotated Run Chart – plot small samples frequently over time. New D/C Instruction Sheet Began Follow-up Calls Observed Data Value 30 day Readmission Rate Time (e.g., Month) “In God we trust.All others bring data.” Dr. W. E. Deming

29. Poll Question Do you display your monthly readmission rate as a run chart? Yes No

30. Why? You want to tell your story…. How did you improve? Why aren’t we improving? How much can we improve? How can the whole hospital improve like you did?

31. MonthREADAverage

32. Poll answer Do you display your monthly readmission rate as a run chart? Yes No

33. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

34. Change Ideas What change can we make that will result in an improvement? The intervention selected related to your AIM Statement: By January 4th, 2013, 3W will reduce preventable readmissions by 20% through implementing follow-up calls for Medicare patients with CHF.

35. From Paper to Action By January 4th, 2013, 3W will reduce preventable readmissions by 20% through implementing follow-up calls for Medicare patients with CHF. What does this really mean? Translated: The staff on 3W should be involved with determining how follow-up phone calls will happen, who will do them, and how will everyone know they are done. We have 6 months to improve.

36. Do we….. JUST DO IT!?! Unintended Consequences: “WHY ARE WE DOING THIS?” “WHO HAS TIME?” “IT’S NOT MY JOB…” “ANOTHER THING ON MY PLATE!”

37. Action Planning • The staff on 3W should be involved with determining how follow-up phone calls will happen, who will do them, and how will everyone know they are done. We have 6 months to implement. Questions: Which staff will be involved in designing the call process? What should staff say on these calls? Who will trial the calls? How long should we trial the new process? How will we know it works? When should we start?

38. Poll Question How does your hospital plan and test with staff involvement when a new tool or process is introduced at your hospital? We always plan and test before implementing We are good at testing, not so good at planning We are good at planning, not so good at testing We “Just do it”

39. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

40. Testing change Ideas To be considered a real test… • Test was planned, including a plan for collecting data • Plan was carried out and data was collected • Time was set aside to analyze data and study the results • Action was based on what was learned!

41. A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Change Ideas IHI – Adapted from “The Improvement Guide” by Lloyd Provost et al Very Small Scale Test

42. Action Planning PDSA (plan-do-study-act) worksheet PROCESS: STEP:CYCLE: PLAN I plan to: I hope this produces: Steps to execute: DO What did you observe? STUDY What did you learn? - OR - Did you meet your measurement goal? ACT What did you conclude from this cycle? What will you do next?

43. Action Planning PDSA (plan-do-study-act) worksheet PROCESS: Implement DKAT assessment STEP:1CYCLE: 1 PLAN I plan to: Test the DKAT assessment tool – BOOST version I hope this produces: Feedback to further implement the tool Steps to execute: 1. Find a volunteer or two 2. Try it with the next two patients being discharged by Friday. 3. Gather feedback from volunteers DO What did you observe? Took a long time to do – this would be a barrier to use. STUDY What did you learn? 1. Need to measure length of time 2. Pilot the short form? ACT What did you conclude from this cycle? What will you do next? Conduct next test with short form and time it. PDSA (plan-do-study-act) worksheet PROCESS: Implement DKAT assessment STEP:1CYCLE: 1 PLAN I plan to: Test the DKAT assessment tool – BOOST version I hope this produces: Feedback to further implement the tool Steps to execute: 1. Find a volunteer or two 2. Try it with the next two patients being discharged by Friday. 3. Gather feedback from volunteers DO What did you observe? STUDY What did you learn ACT What did you conclude from this cycle? What will you do next?

44. Poll Answers How does your hospital plan and test with staff involvement when a new tool or process is introduced at your hospital? We always plan and test before implementing We are good at testing, not so good at planning We are good at planning, not so good at testing We “Just do it”

45. Practical Application In the next 30 days: • Select an intervention • Plan testing • Conduct a small test of change – with an actual staff person or two.

46. More on Readmissions

47. Coaching Calls? Question was asked on the mid-month survey about your interest in coaching calls Here are the results: Yes, on inpatient processes 8% Yes, on the care continuum 4% Yes, on both 58% No, not interested 30%

48. Poll Question Would one call per month, alternating between focusing on inpatient processes (even months) and care transition processes (odd months), meet your needs? Yes No I have a different idea

49. Just For Your Information: • WHA is partnering with MetaStar to train Nursing Homes in INTERACT II. • Webinars launched July 11 and will continue through December. • 260 Nursing Homes are enrolled • Data will be submitted to MetaStar during the collaborative (monthly count of hospital/ER transfers)