Identifying Opportunities Developing Aim Statementsapp.ihi.org/Events/Attachments/Event-2469/Document-3315/... · 2014. 3. 20. · Identifying Opportunities for Improvement and Developing

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar

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Identifying Opportunities for Improvement and Developing Aim StatementsPeg Bradke

This presenter has

nothing to disclose

April 23, 2014

Participants will be able to:

• Describe the role of the Executive Sponsor

• Identify strategies to establish Cross-Continuum Team

(CCT) collaboration

• Describe methodologies for identifying opportunities for

improvement from the diagnostic review

• Develop an aim statement to provide a focus for

improvement initiatives

Session Objectives


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IHI’s How-to Guide

IV. Infrastructure and Strategy to Achieve Results

Step 1. Executive Leadership:

The Executive Sponsor links the goals of improving

transitions in care and reducing readmissions to the

strategic priorities of the organization

Sponsors may include CEOs, COOs, Patient Safety

Officers, Medical Directors, Nurse Executives or

Community Leaders

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013 Available at www.IHI.org.

Infrastructure and Strategy

to Achieve Results

1. The Hospital CEO selects an Executive Sponsor

and a Day-to-Day Leader to lead the

improvement work

2. Convenes a Cross-Continuum Team

3. Team identifies opportunities for improvement

4. Develop an aim statement


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Executive Sponsor’s Role

• Meet with Day-to-Day Leader and front-line staff:

– Ask about progress, barriers, and “how can I

help?”

– Assist in setting priorities and breakthrough

performance goals

• Ensure that sufficient resources and time is

allocated

Executive Sponsor’s Role (cont.)

• Meet with senior managers to connect this

work with the organization’s strategies and

goals

• Communicate what is learned from the

improvement work to motivate and

mobilize the entire organization to adopt

and spread successful changes


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Vision for Cross-Continuum Teams

Understanding mutual interdependencies,

the hospital-based teams co-design care

processes with their CCT partners and

collaborate to solve problems to improve

the transition out of the hospital and

reception into community settings of care

It promotes a paradigm shift from site-

specific care to patient-centered care,

where the focus is on the patient’s

experience over time

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

Cross-Continuum Collaboration


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Emphasize that readmissions are not solely a

hospital problem and require a community

solution

Have built the foundation for many care settings

participating in ACO development, Patient

Centered Medical homes, and the Community-

based Care Transitions Program

Do you have a Cross-Continuum Team (CCT)?

How often do you meet? Or is your team a virtual

collaboration?

What people/roles/organizations are engaged in your

CCT?

How did you build trust to achieve the transparency

needed to move the work forward?



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CCT Membership Recommendations

• Executive Sponsor

• Day-to-Day Leader

• Patients and family caregivers

• Hospital clinicians and staff

• Supporting staff (QI, IT, Finance, etc.)

• Clinical and administrative staff and/or leaders from the community– Skilled Nursing Facilities

– Office practice settings

– Home health care agencies

– Community facilities (dialysis, diabetes, rehabilitation)

– Public health and Community services

– EMS

– Retail Pharmacy

• Public and private payers

Building Will for the Cross-Continuum

Collaboration

• Start meetings with a patient story

• Spend time on building trusting relationships

• Convene meetings in various care settings

• Specify process and outcome measures

• Connect improvement efforts between hospitals

and partnering community organizations

– Perform PDSA’s/tests of change


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Building Will for the Cross-Continuum

Collaboration

• Do a “deep-dive” into a series of recently readmitted

patients to identify opportunities for improvement

across care settings

• Use the power of observation, have members of

various care settings shadow critical processes such

as admission, discharge, and patient education

• Hear first-hand about the transitional care problems

“through the patient’s eyes”

Rules of Engagement - Part 1 Example from Holyoke Medical Center

1. Throw out old attitudes about work processes

2. Don’t think of reasons “Why it won’t work,” think of

“Ways to make the new ideas work”

3. Don’t make excuses, and don’t accept excuses.

Don’t say, “ We can’t”

4. Don’t wait for perfection; 50% is fine for starters

5. Correct problems immediately


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Rules of Engagement Example – Part 2

6. Wisdom arises from difficulties

7. Ask “Why?” at least 5 times until you find the root

cause

8. Better the “Wisdom” of ten people than the

“Knowledge” of one

9. Improvements are unlimited. Don’t substitute

money for brains

10. Improvement is made at the workplace NOT

from the office

Quotes from

Cross-Continuum Team Members

• “The conversations change when everyone is at

the table. It feels good to have us all in the room

with the patient at the center of our work”

• “Even if we haven’t moved the numbers, we have

moved the mindset”

• “Staff at different sites of care pick up the phone;

they didn't before”


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Quotes from

Cross-Continuum Team Members (cont.)

• “We make more referrals to home health care as a

result of the improved communications”

• “We are making great strides in opening the

communication of patient care between our

diversified organizations. It is truly encouraging

after 40+ years in health care to see this

transformation”

Diagnose Your Opportunities

• 360° review

― Chart reviews

― Interviews with patients and families

― Interviews with community providers

• Work Processes Observations

― Through Patient/Family eyes

• Data analyses

― Patient and family caregivers experiences of transitions

― Outcome measures

― Process measures


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Diagnostic Reviews: Charts

Step 3a: Review, in-depth, the medical record of the

last five rehospitalizations to yield rich information– Figure 22, page 124 offers a Diagnostic Worksheet

)

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

Engages the “hearts and minds” of clinicians and catalyzes action toward problem-solving

Diagnostic Chart Review Questions

1. The number of days between discharge and readmission? Create a histogram display?

2. Was there a follow-up visit scheduled?

3. Was the patient able to attend office visit?

4. Were there any urgent clinic or emergency department visits?

5. What was the patient’s functional status at discharge?


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Diagnostic Chart Review Questions

6. Was there a clear plan for comprehensive discharge follow-up care?

7. Was there evidence of Teach Back (checking to assess what the patient understood)?

8. Were there specific reasons for the readmission documented?

9. Social conditions contributed to the readmission?

Diagnostic Chart Reviews

• Members from the CCT hear first-hand about the

transitional care problems “through the patient’s

eyes”

• Engages the “hearts and minds” of clinicians and

catalyzes action toward problem-solving

• Opportunities for learning from reviewing a small

sampling of patient experiences are innumerable


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Diagnostic Review: Interviews with

Patients/Families and Care Team Members

• How do you think you became sick enough to come into the hospital?

• How do you take your medicines at home? Any problems? Any side effects?

• Describe your typical meals at home or at arestaurant

• When did you last talk with your doctor or nurse? What did you talk about?

• What, if anything, worried you before you came to the hospital?

Patients Tell Us How to Improve Care!

• They are inadequately prepared for next setting

• They receive conflicting advice for illness management

• They are often unable to reach the right practitioner

• Clinicians often leaving tasks undone or without adequate follow-up

Eric Coleman, MD


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James, 68 years old, lives at home with wife Martha

• Admitted to the hospital with shortness of breath

• Diagnosis: pneumonia + underlying onset of heart failure

• Instructed on new medications + diet before discharge

• Told to see his physician in the office in two weeks

• After returning home reminded to schedule physician’s office

• Finally able to set up a visit for three weeks later

• Never filled furosemide Rx; thought the expense unnecessary

• Noticed swelling in legs; didn't want to bother "busy doctor"

Putting a Human Face on the Problem:

James and Martha

James readmitted to hospital after 11 days• Increased SOB, mildly elevated BNP • Weight increase of 25 lbs., marked edema lower legs• Stress level high; blood pressure elevated, new drug

added

Martha admitted for emergent surgery; James still in the hospital • After James’ discharge he began eating fast food• Worried about his wife, juggled visits to her bedside,

managed the roofing project on their home • Martha came home from the hospital, James readmitted

with exacerbation of his HF

Putting a Human Face on the Problem:

James and Martha


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• Work in pairs or groups to identify and

discuss the failures and opportunities in the

case study

• Report findings back to the large group

– Failures

– Opportunities

– Similarities to findings back home

Table Exercise

What did you learn?

• Did you have any “a-ha” moments?

• What did you learn from each other representing

different roles?

• Did you identify any opportunities for improvement?

28


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Diagnostic Review: Patient/Family

Observation

• Have members of various care setting

shadow critical processes such as:

• Admission Process

• Rounds

• Patient/Family Education session

• Transitions/Handovers

• Discharge

For more information, please visit Getting Started in Video

Ethnography - A Catalyst for Guiding and Motivating Quality

Improvement at www.kpcmi.org

http://www.kpcmi.org/


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Diagnostic Review: Data

• Patient experience data

– Communication with patients

– Discharge preparation

• 30-day all-cause readmission rates

– All conditions & Conditions or populations of interest

• Number of patients admitted to observation status vs.

acute care

• Days between discharge and readmission (histogram)

• Patients readmitted within 30 days who had an office

visit before return to hospital

Patient Experience: HCAHPS

• Question 19: Did hospital staff talk with you

about whether you would have the help you

needed when you left the hospital?

• Question 20: Did you get information in writing

about what symptoms or health problems to

look out for after you left the hospital?


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HCAHPS

• In 2013, CMS added 3 additional questions known as CTM3 – adapted from Dr. Eric Coleman’s Care Transition program

• Question 23: During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left?

• Question 24: When I left the hospital, I had a good understanding of the things I was responsible for in managing my health?

• Question 25: When I left the hospital, I clearly understood the purpose for taking each of my medications?

Recommended Readmission Measures

• 30-day all-cause hospital readmissions

• 30-day all-cause readmissions for a population

of focus

• The number or percent of patients admitted in

observation status discharged within 30 days

• Count of patient who return to the hospital within

30 days of a discharge (inpatient status,

observation status, plus Emergency Room visit)


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0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

# o

f p

ati

en

ts r

ea

dm

itte

d

# of days between discharge and readmission

Frequency of Readmissions by Number of Days Between Discharge and Readmission

SAMPLE DATA

Develop an Aim Statement

• Use the learning from diagnostic reviews to

develop a clear and focused aim

• Aim statements guide the team to success

through specified magnitude of change

desired and a time frame

• Successful teams regularly review their aim

and keep their work within the scope of the

aim


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The three

questions

provide the

strategy

The PDSA cycle

provides the

tactical approach

to work

Source:

Langley, et al. The Improvement Guide, 1996

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in

improvement?

The Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

Can we answered with a good Aim Statement

A good Aim Statement succinctly answers three critical questions:– How Good?

– For Whom?

– By When?

Example: Shady Oaks Hospital will improve transitions from the hospital to home for all heart failure patients as measured by a reduction in unplanned 30-day all-cause readmission rates for heart failure patients (decreasing the rate from 25% to 15% or less) by December 2014


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How will we know that a change is an

improvement?

Measure…

Measure…

And…

How will we know that a change is an

improvement?

…Measure

Use run charts to track your progress over time

Track your process measures, outcome measures, and balancing measures

Annotate your run charts so your team can easily identify how the changes you are making (or external factors) are impacting your results

Review your data with your team and senior leaders to identify, drive and sustain improvement


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Suggestions for Conducting PDSA Cycles

• Keep tests small, be specific

• Remember- one test of change informs the next

• Refine the next test based on learning from the previous test

• Expand test conditions to determine whether a change will work at different times (e.g., day and night shifts, weekends, holidays, when the unit is adequately staffed, in times of staffing challenges)

For more information please visit the “How to Improve” link within the Knowledge

Center at www.ihi.org.

Model for Improvement Resources

• On-Demand Video: [free]

- For the video, please visit On Demand: An Introduction

to the Model for Improvement, listed under the Virtual

Program section at www.ihi.org

• Open School Module: [free for students]

- For the module, please visit QI 102: The Model for

Improvement: Your Engine for Change, listed under the

Open School course list at www.ihi.org

Two excellent resources for learning (or refreshing your

memory) about the Model for Improvement and how to run

PDSA cycles:

http://www.ihi.org/

http://www.ihi.org/

http://www.ihi.org/


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Considering all of your organization’s

strategic priorities, what is your aim

for reducing readmissions?

Table Exercise

Aim Statement Worksheet

How Good?

By When?

Aim Statement (What’s the problem? Why is it important? What are we going to do about it?)

Population of Focus?


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Reflections?One thing you learned that you are going to take

back and utilize next Tuesday?

Questions?

Documents

Identifying Opportunities Developing Aim Statementsapp.ihi.org/Events/Attachments/Event-2469/Document-3315/... · 2014. 3. 20. · Identifying Opportunities for Improvement and Developing