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Getting StartedGail Nielsen
This presenter hasnothing to disclose
September 28, 2015
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Participants will be able to: Identify three key tools for getting started and
accelerating results Describe methodologies for identifying
opportunities for improvement from the diagnostic review
Session Objectives
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Getting Started and Accelerating Results
Infrastructure:1. Specifying the executive sponsor’s role2. Collaborating across the continuum
Methods: A. Leveraging an effective aim statement B. Using a driver diagramC. Identifying opportunities for improvement
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1. Executive Sponsor’s Role
Protect time to engage in the work Connect this work with the organization’s strategies
and goals Assure resources Communicate learning from the improvement work
to motivate and mobilize the entire organization to adopt and spread successful changes
High-Impact Leadership White Paper: http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx
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Promotes a paradigm shift from site-specific care to patient-centered care, where the focus is on the patient’s experience over time.
Enables co-design of safer, more effective transition processes.
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.
2. Cross Continuum Collaboration
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Convening a Cross-Continuum Team
• 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
– Nursing facilities– Office practice settings– Home health care agencies– Community facilities (dialysis, diabetes, rehabilitation, etc.)– Public health and Community services– EMS – Retail Pharmacy
• Public and private payers
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Quotes fromCross-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”
“Staff at different sites of care pick up the phone; they didn't
before”
“Even if we haven’t moved the
numbers, we have moved the mindset”
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A. Leverage an Effective Aim Statement
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
Learning from diagnostic reviews can help develop a clear and focused 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
Setting Aims
Establishing Measures
Selecting Changes
*2001 Associates in Process Improvement
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What are we trying to accomplish?
A good Aim Statement succinctly specifies what we are trying to accomplish in four critical components:– What specifically will we improve?– By How Much?– For Whom?– By When?
Example: Shady Oaks ACO will improve transitions across settings for all patients as measured by a reduction in unplanned 30-day all-cause readmission rates for patients discharged from SE-ACO hospitals (decreasing the rate 20% - from 25% to 20% or less) by December 1, 2016
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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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Model for Improvement Resources
Setting Aims– http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImp
rovementSettingAims.aspx On-Demand Video: [free]
– An Introduction to the Model for Improvement, listed under the Virtual Program section at www.ihi.org
Open School Module: [free for students] – QI 102: The Model for Improvement: Your Engine for Change,
listed under the Open School course list at www.ihi.org
Excellent resources for the Model for Improvement and how to run PDSA cycles:
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B. Use a Driver DiagramWhat’s Your theory? Driver diagrams serve as a tool for building and testing theories for improvement by Brandon Bennett and Lloyd Provost
Use it for – Improving a process
– Redesigning a service
– Creating new products
– Sharing theories of change methods across stakeholders
– Building common knowledge and planning across initiative participants
QP 2015 www.qualityprogress.com
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Supplemental Care:• APN Transitional Care• CTI Coaching Model• Proactive Advanced Directives/ Palliative
Care• Intensive Care Management Models (for
patients at home and in SNFs)• Integrated Models of Clinical Care and
Social Support
Aim:
Reduce Re-admissions by December 1, 2016
Example Driver Diagram: Reducing 30-day Readmissions
Improving Transitions from Hospital to Home
or other Community Care Setting
Provide Supplemental Care for High-Risk
Patients
Redesigning Discharge Processes:• Identify Post Hospital Needs• Provide Effective Teaching and Facilitate
Learning• Activate Post Hospital Follow-up Plan• Provide Real-time Handover
communications
Outcome Measures:1. All-cause 30 day
re-hospitalization rates (reduce by 20%)
2. Patient and family satisfaction with:
• transition out of the hospital (50% increase)
• coordination of care in community (50% increase)
Improving Transitions into Community Care Settings and Better
Models of CareBetter Models of Care:• Primary Care Models (PCMH)• Home Care Programs• Skilled Nursing Home Models
Transition into:• Primary Care and Specialists• Skilled Nursing Facilities • Home Health Care
Primary Drivers Secondary Drivers
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C. Identifying Opportunities 360° case review (“diagnostics”)
– Chart reviews
– Interviews with patients and families
– Interviews with community providers
Work Processes Observations– Through Patient/Family eyes
Measures & Data analyses– Patient and family caregivers experiences of transitions
– Outcome measures
– Process measures
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Diagnostic Reviews: Case StudiesReview, 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
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Sample Diagnostic Chart Review Questions
The number of days between discharge and readmission? Create a histogram display?Was there a follow-up visit scheduled?Was the patient able to attend office visit?Were there any urgent clinic or ED visits other than those leading to admission?What was the patient’s functional status at discharge?
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Diagnostic Interviews with Patients/Familiesand Care Team Members
Ask Patients/Family to Describe:
Becoming sick enough to go to the hospitalHow they take medicines at home, associated problems, and side effectsTypical meals at home or a restaurant.Last discussions with doctor or nurseWhat, if anything, worried them before coming to the hospital
Ask Care Team Members What They Think About:
Contributors to hospitalizationAnything hospital staff need to know:
– While patient is in the hospital
– For the discharge plan
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Simulate Learning from a Case Story
During the description of the story of “James”: Count the number of opportunities you hear
After the case story, share: The number of opportunities you heardSimilarities to findings back home
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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"
Case Stories:Help Teams Identify Problems
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Case Stories: Help Teams Identify Problems
James readmitted to hospital after 11 daysIncreased 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
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Case Story
How many opportunities did you hear?
Similarities to your findings back home?
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Reflections?One thing that you are going to take back and
utilize “next Tuesday”?
Actions?What help do you need to use the tools or
methods described today?