Getting StartedGail Nielsen

This presenter hasnothing to disclose

September 28, 2015

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

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

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

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

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

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”

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

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

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

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?

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:

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

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

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

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

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?

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

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

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

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

Case Story

How many opportunities did you hear?

Similarities to your findings back home?

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?