project red: the reengineed discharge reducing 30 day all cause rehospitalization rates: a cqi...
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Project RED: The ReEngineed Discharge
Reducing 30 Day All Cause Rehospitalization Rates:A CQI Adventure
Charles Telfer Williams, MD
Vice Chair for Clinical Affairs and QualityDivision of Family Medicine – Boston Medical Center
Assistant Professor
Department of Family Medicine - Boston University School of Medicine
Heart Failure and Readmission Reduction SummitAugust Maine, March 30, 2010
Basic quality improvement
• Select an area for improvement.
• Establish goal.
• Describe current system (Process Map)
• Select Measures
• Standardize the process
• Rapid Cycle improvement (PDSA)
• AND then Spread it. (Today is that)
Plan for Today
I. The ChallengeII. How We Got Started - CQIIII. NQF ‘Safe Practice’ IV. Is ‘Safe Practice’ Safer?V. Risk Factors for RehospitalizationVI. Barriers to ImplementationVII. Roll-out VIII.Can Health IT Deliver?
Case 1—Gloria• 61 yo female admitted to hospital with cellulitis. She has a history of
hypertension for which she takes Lisinopril at home. While in the hospital she was treated with antibiotics for her cellulitis. She was noted to have persistently high blood pressure and the decision was made to increase her blood pressure medicine. Her blood pressure responded appropriately to the new dose.
• On the day of discharge she was given a prescription for clindamycin, motrin and a new prescription for lisinopril with a new dose.
• She went home, got her new prescriptions filled and took them as instructed on her discharge papers and as well as what was written on the medication bottles. But also continued to take her old dose of Lisinopril as well.
• Patient started to have problems of feeling light headed, family brought her back to ED and she was readmitted to the hospital with acute renal failure.
Case 2– Alex• 80 yo male admitted to hospital to have his pacemaker
adjusted. Was found to have new onset of atrial fibrillation and started on coumadin.
• On the day of dc he was given prescription for coumadin and follow up appts to his PCP, cardiologist and Coumadin clinic. Teaching was done and he was given reading material on Coumadin.
• Patient’s 79 yo wife was waiting in the car outside while their son came up to get his father. They were in the hospital room getting patient’s shoes on when the nurse came in and said, “the doctors decided you should be bridged with Lovenox while at home. Here is a box with all your information and there is a CD inside for you to watch on how to give yourself the medicine.”
The ability of hospitals to safely The ability of hospitals to safely discharge a patient in a reliable way discharge a patient in a reliable way is low (very low) and it costs a lot (too is low (very low) and it costs a lot (too much!).much!).
In 2006, there were 39.5 million hospital discharges with costs totaling $329.2 billion!
The Challenges:The Challenges:Poor Quality & High CostPoor Quality & High Cost
Major Changesin Hospital Payments
• "Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period saving $26 billion over 10 years"
Obama Administration Budget Document
• MedPAC recommends reducing payments to hospitals with high readmission rates
MEDPAC Testimony before Congress March
‘09
Current Developments
• All cause hospital readmission rates released this summer http://www.hospitalcompare.hhs.gov/
• CMS: 14 Quality Improvement Organizations “Safe Transitions” demonstration projects
• AHA H2H - goal to reduce readmissions by 20% by 2012
Patients Are Not Prepared at Discharge
At Discharge:
• 37% able to state the purpose of all their medications
• 42% able to state their diagnosis
Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Amgad N. Makaryus, MD, Eli A. Friedman, MD. Mayo Clinic Proceedings. August 2005; 80(8):991-994.
Little Time Spent on Discharge
• Audiotaped 97 discharge encounters• 8 Elements - Roter Interactional Analysis
– Nurse, Pharmacist, Physician, Nurse Case Manager
• Averaged 8 minutes (range, 2 to 28.5 min)
• No teachback 84% of the time
• Patient is a passive participant– Two initiated questions
• Not comprehensive– 4 or fewer elements covered 50% of time
Documentation of Pending Tests in Discharge
Summaries• 668 pts
• DC summaries mentioned only 16% of pending tests (482 of 2,927)
• All pts had at least 1 pending result, but only 25% of dc summaries mentioned a pending result
Were, MCWere, MC et al. J Gen Internal Med 24(9):1002-6et al. J Gen Internal Med 24(9):1002-6
Pending Tests Not Followed
• 41% of inpatients discharged with a pending test result
• 37% actionable and 13% urgent
• 2/3 of physicians unaware of results
Annals of Internal Medicine. 2005; 143(2):121-8.
Work-ups Not Completed
• 25% of discharged patients require additional outpatient work-ups
• More than 1/3 not completed
Archives of Internal Medicine. 2007;167:1305-11.
Communication Deficits at Hospital Discharge Are
Common
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41.
Discharge summary not readily available:• 12-34% at first post-discharge appt• 51-77% at 4 weeks
Discharge summary lacking key components:•Hospital course (7-22%)• Discharge medications (2-40%)• Completed test results (33-63%)• Pending test results (65%)• Follow-up plans (2-43%)
Direct communication, 3-20%
Days to Rehospitalization
0 20 40 60 80
0.4
0.6
0.8
1.0
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Discharges are Variable by Day of the Week
Errors Lead to Adverse Events
• 19% of patients had a post-discharge AE• 1/3 preventable and 1/3 ameliorable
• 23% of patients had a post-discharge AE• 28% preventable and 22% ameliorable
CMAJ 2004;170(3):pp.
Arch Intern Med 2003;138:pp.
A Real Discharge Instruction Sheet
“Perfect Storm" of Patient Safety
• Loose Ends • Communication • Poor Quality Info • Poor Preparation • Fragmentation • Great Variability
• 20% of Medicare patients readmitted within 30 days20% of Medicare patients readmitted within 30 days1 1
• Only half had a visit in the 30 days after dischargeOnly half had a visit in the 30 days after discharge1
• The hospital discharge is non-standardized and The hospital discharge is non-standardized and frequently marked with poor quality.frequently marked with poor quality.
Jenks NEJM 2009. Jenks NEJM 2009.
Quality goals
• Do the right thing (evidence-based care)
• For this patient (individualized) and every patient (equal care)
• Every time (consistency)
Basic quality improvement
• Select an area for improvement.
• Establish goal.
• Describe current system (Process Map)
• Select Measures
• Standardize the process
• Rapid Cycle improvement (PDSA)
Two Questions
We asked:
• Can improving the discharge process reduce adverse events and unplanned hospital utilization?
Grant reviewer asked:
• What is the “discharge process”?
Approaches to improving reliability
Method 1 -- Prevent errors
Method 2 -- Catch and correct errors
Definition: Failure free performance over time.
Reliability
Method 1Preventing Errors
• Goal: Prevent system failure from occurring in the first place.
• Method: Standardization of the system. There is good evidence that quality improves with standardization.
• Simple test: Ask 5 people. Roger Resar suggests that one ask 5 people to describe the process or standard work of a system. If you do not get the same answer the process is not standardized.
Method 2Catch and correct errors
• Goal: To identify failures and minimize further harm.
• Method: Redundancy in the process
• Measure: – Track adherence to standard process AND– Number of failures identified and mitigated by
redundancy in the process
Poka YokeError - proofing
• Fit the system to the human not the other way around
Principles of the RED:Creating the Toolkit
Readmission Within6 Months
HospitalDischarge
Patient Readmitted
Within 3 Months
Probabilistic Risk
Assessment
Process Mapping
Failure Mode and Effects
Analysis
QualitativeAnalysis
Root CauseAnalysis
RED Component #1Educate patient about their diagnosis
throughout the hospital stay
o RED intervention starts within 24 hours of the patient’s admission to the hospital
o Continues daily until discharge
NQF Safe Practice-15: “preparation for discharge occurring with documentation, throughout the hospitalization”
RED Component #2 Make appointments for clinician
follow-up and post-discharge testingo Schedule PCP appt within 2 weeks after dischargeo Review the provider, location, transportation and plan to
get to appointmento Consult with patient regarding best day and time for
appointmentso Discuss reason for and importance of all follow up
appointments and testing
SP-15: “explicit delineation of roles and responsibilities in the discharge process”
RED Component #3 Discuss tests/studies completed and
who will follow up on results
o Information listed in After Hospital Care Plan (AHCP), which is transmitted to PCP
o Patient knows to discuss this with PCP at follow-up appointment and where to find it on their AHCP
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”
RED Component #4 Organize post-discharge services
o Communicate with case manager and social worker about post-discharge services that they scheduleo Provide patient with contact information for these services (phone number, name of company, etc.)
SP-15: “explicit delineation of roles and responsibilities in the discharge process”
RED Component #5Confirm the Medication Plan
o Reconcile the patient’s home medication list as close to admission as possible
o Review each medication; make sure that the patient knows why they take it
o Discuss new medications each day with medical team and with patient
SP-15 “completion of discharge plan and discharge summaries before discharge”
RED Component #6Reconcile discharge plan with national
guidelines and critical pathways
o Communicate with medical team each day about the discharge plan
o Recommend actions that should be taken for each patient under a given diagnosis
RED Component #7Review appropriate steps for what to
do if a problem arises
SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.”
o What constitutes an emergencyo What to do if a non-emergent problem ariseso Where to find contact information for the discharge advocate and PCP on the After Hospital Care Plan
RED Component #8Expedite transmission of the discharge
summary to the PCP
o Fax the discharge summary and After Hospital Care Plan to PCP within 24 hours after discharge
SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”
RED Component #9 Assess degree of patient understanding,
ask patient to explain discharge plano Deliver information to reach those with low health literacy
levelo Include caregivers when appropriateo Utilize professional interpreters as needed
SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled. This information must also be communicated to the accepting physician.”
"Use the 'teach back process' to ensure pt understands transition-of-care planning."
RED Component #10 Give the patient a written discharge
plan at time of discharge
o After Hospital Care Plan includes:1) Principal discharge diagnosis2) Discharge medication instructions3) Follow-up appointments with contact information4) Pending test results 5) Tests that require follow-up
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”
After Hospital Care Plan
• Patient-centered discharge instruction booklet
• Designed to reach patients with low health literacy
• Individualized to each patient and hospital
COVER PAGE
MEDICATION PAGE (1 of 3)
MEDICATION PAGE (2 of 3)
MEDICATION PAGE (3 of 3)
APPOINTMENT PAGE
APPOINTMENT CALENDAR
PATIENT ACTIVATION PAGE
PRIMARY DIAGNOSIS PAGE
RED Component # 11Provide telephone reinforcement of the
discharge plan after discharge
• Call patient within 72 hours after discharge• Assess patient status• Review medication plan• Review follow-up appointments• Take appropriate actions to resolve problems
SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations"
Components of RED Intervention
• In Hospital – Nurse Discharge Advocate (DA) – Interacts with care team: medication
reconciliation, appointments, and national guidelines
– Prepares and teaches After Hospital Care Plan (AHCP)
• After Discharge – Clinical Pharmacist– Calls for follow-up @ 72 hours post-dc– Reinforces dc plan and review medications
Rapid Cycle Improvement
• The random controlled trial
EnrollmentN=750
Randomization
RED InterventionN=375
Usual CareN=375
30-day Outcome Data
Testing the RED Process Randomized Controlled Trial
Enrollment CriteriaEnrollment Criteria::•English speakingEnglish speaking•Have telephone Have telephone •Able to independently consentAble to independently consent•Not admitted from institutionalized settingNot admitted from institutionalized setting•Adult medical patients admitted to Boston Medical Center Adult medical patients admitted to Boston Medical Center (urban academic safety-net hospital) (urban academic safety-net hospital)
How well did we deliver intervention
RED Component Intervention Group (No,%)(N=370) *
PCP appointment scheduled 346 (94%)
AHCP given to patient 306 (83%)
AHCP/DC Summary faxed to PCP 336 (91%)
PharmD telephone call completed 228 (62%)
* 3 subjects excluded from outcome analysis: subject request (n=2), died before index discharge (n=1)
What did we find?
Primary Outcome: Hospital Utilization within 30d after Discharge
Usual Care
(n=368)
Intervention (n=370)
NNT P-value
Hospital Utilizations *Total # of visits Rate (visits/patient/month)
1660.451
1160.314
7.3
0.009
ED VisitsTotal # of visitsRate (visits/patient/month)
900.245
610.165
12.5
0.014
ReadmissionsTotal # of visits Rate (visits/patient/month)
760.207
55
0.149
17.2
0.090
* Hospital utilization refers to ED + Readmissions
Cumulative Hazard Rate of Patients Experiencing Hospital Utilization
30 days After Index Discharge
0 5 10 15 20 25 30
0.0
0.1
0.2
0.3
Cu
mu
lati
ve H
azar
d R
ate
Time after Index Discharge (days)
Usual care Interventionp = 0.004
Hospital utilizations among people with acute MI, CHF, or pneumonia
Primary outcomes within 30days after index hospitalization
Control group (n=49)
Intervention group(n=45) P value
No. of hospital utilizations,* (No.visits/patient/month)
36 (0.73) 14 (0.31) 0.004
Incidence rate ratio of hospital utilizations, IRR (95%CI)
REF 0.42 (0.23 , 0.79) -
Outcome Cost Analysis
Cost (dollars)Usual Care
(n=368)Intervention
(n=370)Difference
Hospital visits 412,544 268,942 +143,602
ED visits 21,389 11,285 +10,104
PCP visits 8,906 12,617 -3,711
Total cost/group 442,839 292,844 +149,995
Total cost/subject 1,203 791 +412
We saved $412 for each patient given REDWe saved $412 for each patient given RED
Elderly: Outcomes For Ages >=65yrs (121/738 Total Participants)
Primary outcomes ≤30 days after index hospitalization Controln=60
Interventionn=61
P value
Hospital utilizations, n (visits/patient/mo) 32 (0.53) 14 (0.23) 0.001
Emergency department visits, n (visits/patient/mo) 12 (0.20) 2 (0.03) 0.01
Readmissions, n (visits/patient/mo) 20 (0.33) 12 (0.20) 0.13
Secondary Outcomes
How well were your questions answered before you left the hospital?
15 (47%) 19 (76%) 0.03
How well did you understand your appointments after you left the hospital?
35 (73%) 44 (88%) 0.06
Self-Perceived Readiness for Discharge: 30 days post-discharge
0
10
20
30
40
50
60
70
80
90
100
Prepared UnderstandAppts
UnderstandMeds
UnderstandDx
Questionsanswered
Usual CareRED
%
Median Clinical Time RequiredDA: 90 minutes/subject *• Collect information from patient, teach AHCP• Communicate with medical team, enter data into AHCP*** Some information collection redundant with existing hospital staff** Can be expedited using workstation software and ECA character
PharmD: 30 minutes/subject• Prepare for call• Call patients• Conduct interventions post-call
Medication Errors (MEs)Medication Errors (MEs)Error Frequency,
number (%)
Patient did not fill did not need prescription money/financial barrier intentional non-adherence non-intentional non-adherence did not fill, insurance issue
16 (3.5)
1 (0.2) 19 (4.1)
170 (36.7) 57 (12.3)
18 (3.9)
System Rx given w/ known allergies conflicting info from different sources d/c instructions incomplete/inaccurate duplication incorrect dosage incorrect quantity pt needed to fill at special pharmacy pt does not know how to use no Rx given at d/c
3 (0.6)
111 (24.0) 13 (2.8) 14 (3.0)
8 (1.7) 2 (0.4) 1 (0.2) 2 (0.4)
28 (6.0)
Total errors 463 (100.0)
Should the NQF/RED be Done for Discharge at Every Hospital?
Hypotheses A comprehensive discharge will:
–Lower hospital utilization
–Improve readiness for discharge
–Increase PCP follow-up
Implications
The components of the RED should beprovided to all patients as
recommendedby the National Quality Forum, Safe Practice.
Who is at risk of Rehospitalizations?
• Frequent Fliers
• Health Literacy
• Depression
• Men
• Substance Abuse
• Elderly
• LOS
• Co-morbidity
Grade 3 and below Grade 4-6 Grade 7-8 Grade 9+
Usual CareIntervention
010
2030
4050
60HEALTH LITERACY: Risk of hospital re-utilization
REALM category
Ris
k of
re-
utili
zatio
n
p=0.06 p=0.59 p=0.38 p=0.04
Hospital Utilization Depression Screen*Negative Positiven=500 (68%) n=238 (32%)
p-value IRR* (CI)
No. of Hospital Utilizations†
30-day Hospital utilization rate
1400.296
1340.563
<0.001 1.90 (1.51,2.40)
No. of Hospital Utilizations†
60-day Hospital utilization rate
2310.463
2050.868
<0.001 1.87 (1.55,2.26)
No. of Hospital Utilizations† 90-day Hospital utilization
rate
3240.648
2751.165
<0.001 1.79 (1.53,2.10)
Depression: # Hospital Utilizations, Hospital Utilization Rate, and IRR at 30, 60 and 90 days
IRR = Incident Rate Ratio
GENDER: Primary outcomes ≤30 days after index hospitalization
Males Females P value
Patients, n 367 370
Hospital utilizations, n (visits/patient/mo) * 174 (0.474) 108 (0.292) <0.001
IRR (95% CI)1.62 (1.28,
2.06)REF
Emergency department visits, n (visits/patient/mo)
101 (0.275) 50 (0.135) <0.001
IRR (95% CI)2.04 (1.45,
2.86)REF
Readmissions, n (visits/patient/mo)
73 (0.199) 58 (0.157) 0.09
IRR (95% CI)1.27 (0.90,
1.79)REF
GENDER: Outcome data collected at 30-day follow-up call by gender
Males Females P value
Able to identify PCP name 77% 88% <0.001
How well did you understand your appointments?
78% 87% 0.005
Visited PCP 49% 57% 0.04
Able to identify discharge diagnosis 73% 77% 0.24
How well did you understand how to take your medications after leaving the hospital?
84% 88% 0.12
RED Effectiveness by Risk Stratified Groups
Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, high hospital utilization, and homelessness
Conclusions• Hospital Discharge is low hanging fruit for
improvement• RED is NQF Safe Practice• RED:
– Can be delivered using AHCP tool– Can decreased hospital use
• 30% overall reduction• NNT = 7.3• Saves $412 per patient
• Health IT Could Help– could improve delivery– further improve cost savings and build the
business case
Using Health IT to implement RED
Can Health IT assist with providing a comprehensive discharge?
Software to print AHCP
Embodied Conversational Agents• Emulate face-to-face communication• Therapeutic alliance using empathy, gaze, posture, gesture• Teaches RED AHCP• Determine Competency• Can drill down• Maps of CHCs
Using Health IT to Overcome Challenge of RN Time
Characters: Louise (L) and Elizabeth (R)
Studies of Nurse-Patient Interaction
Patient Interacting with Louise
Automated Discharge Workflow
Who Would You Rather Receive Discharge Instructions From?
“I prefer Louise, she’s better than a doctor, she explains
more, and doctors are always in a hurry.”
“It was just like a nurse, actually better, because
sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains
everything.”
Embodied Conversational Agenthttp://relationalagents.com/red.wmv
Current Work: Online Louise
• Post-discharge web-based system designed to emulate the post-hospital phone call
• Multiple interactions in the days between discharge and first PCP appointment
• Designed to – Enhance adherence– Monitor for adverse events– Prevent adverse events
• Identifying post-dc “confusion” and rectify• Screening system for who needs 2 day phone call
• Beginning a trial of this system
A moment for reflection
RED Implementation
Why Hospitals Should Use RED• Volume
– Opens beds by decreasing 30 day hospital utilization– Reduces diversion and creates greater capacity for higher revenue patients– Improves PCP follow-up
• Satisfaction – Improves satisfaction of patients and their families– Improves community image – Brands the hospital with high quality
• Safety – National Quality Forum Safe Practice (endorsed by IHI, Leapfrog, CMS) – Exceeds Joint Commission standards– Improves patient “readiness for discharge”– Documents the discharge teaching and preparation– Documents patient understanding of the plan
• Cost - the business case– Saves $412 per subject enrolled– Allows physicians to bill higher discharge level – Improves relationships with ambulatory providers– Improves market share as “preferred provider”– Prepares for change in CMS rules regarding readmission reimbursement
Dissemination• Website diagnostics - Thousands of worldwide contacts• PR - AHRQ webinar - 2,200 hospitals signed up• AHRQ Roll –out
– 6 hospital beta sites across country– Studying the process of implementation
• Joint Commission, AMA, State Hospital Assns, KP etc.• Office of Tech Transfer at BU
– 132 hospitals now actively engaged
• AHA - H2H • CMS: 14 QIO - “Safe Transitions”• IHI Commonwealth Fund - STARS • Society Hospital Medicine - BOOST
RED TOOLBOX• After Hospital Care Plan (AHCP)
– How to create it (paper or IT)– How to teach it
• Discharge Advocate Training Manual
• How to provide RED in other languages – In English to non-English speakers– In Spanish and Chinese language AHCPs
• How to conduct post-discharge telephone call
• How to implement Project RED
• How to evaluate/benchmark progress
Discharge Advocate Training
• Principles of RED• Roles and division of responsibilities• Hire as new role or use existing staff• Use of workstation to enter patient data
and print AHCP• Medication reconciliation review• Patient teaching and activation• Cultural and linguistic competency
DA Workbook• Used to collect patient information:• Allergies• Appointments and Transportation• Substance Use• Medications• Medical Equipment• Diet• Exercise
Post-dc call manual
• Review with patient:• Medical condition• Any new or existing medical issues• Medications• Acquisition, Adherence, Side Effects• Appointments• Communication with patient and with
medical providers
How to implement RED
• Process mapping to understand discharge process at your hospital
• Choose appropriate staff for each task
• Use IT capabilities
• Pilot
• Evaluate
Process Mapping-1Process Mapping-1Ready for Discharge?Ready for Discharge?
Process Mapping - 2 Process Mapping - 2 Discharge SummariesDischarge Summaries
Process Mapping-3 Process Mapping-3 AppointmentsAppointments
Process Mapping – 4Process Mapping – 4Patient EducationPatient Education
• Where does usual hospital care end and Project RED begin?
• What is usual care?• Getting the word out:
– Inservice the floor nurses– Inservice the pharmacists– Inservice the medical teams– Send letters to attendings each month
Delineation of RolesDelineation of Roles
Understanding the risk factors for rehospitalization
• High hospital use
• Limited health literacy
• Depression
• Male
• Substance Abuse
• Elderly
• Longer LOS
• Co-morbidities
How to evaluate RED
• Staff feedback
• Process outcomes: success of delivery
• Patient outcomes: satisfaction, 30-day rehospitalization
Barriers to Providing a Comprehensive Discharge
• Discharge receives low priority for inpatient clinicians • Financial pressure to fill beds as soon as possible • Often unclear about who is responsible for discharge• Medical team too busy• Many errors in the discharge summary
– If done, it is often rushed and incomplete– Relegated to least experienced team members
• Discharge papers are standardized and not personalized
Barriers to Implementation
• Discharges often occur in the late afternoon and evening• Patients are anxious to leave after waiting all day for final
word; teaching is less effective• Lack of communication between hospital physicians and
PCPs• No designation about who will follow up on pending tests
from hospital and post hospital tests
Barriers to Implementation:Medication Reconciliation
• Medication plan is regularly changed late in the hospitalization and not always complete/reconciled
• Frequent inaccuracies in medication reconciliation (between admission and discharge)
• Medication list not reconciled with ambulatory EMR• Team not sure if medication will be added/changed…
need to wait for a decision by someone else• Team trained to do med reconciliation at time of
discharge or after
Barriers to Implementation:Appointments
• Difficult to obtain PCP appointments within two weeks • Patient has no PCP• PCP not accepting new pts• Insurance• Long time to wait on phone• Team not sure of follow up/consults
Health Outcomes – the bottom line
“The ultimate test of the quality of a health care system is whether is helps the people it intends to help.”
“Crossing the Quality Chasm: A New Health System for the 21st Century”. Committee on Quality of Health Care in America –Institute of Medicine. 2001. National Academy Press. p44
What have we learned
• Getting quality right in healthcare is a GREAT challenge. Healthcare systems are very complex and the improvement work is hard. The honesty and humility necessary require significant courage.
Yet I feel it is a worthy and even noble challenge and to shy away from it is immoral.
Conclusions• Project RED:
– Can be delivered using AHCP tool– Can decrease all-cause 30 day rehospitalization
• 30% overall reduction• NNT = 7.3• Saves $412 per patient
• Hospital Discharge is low hanging fruit for improvement• RED should be provided to all patients as
recommended by the National Quality Forum, Safe Practice #15 (2009).
For more information: Project RED Toolkit:http://www.bu.edu/fammed/projectred/
Research questions:[email protected] (Dr. Brian Jack, PI)
Commercial software and implementation
support:[email protected]
BREAK!
Please take a few minutes to stretch and refresh yourselves
An diversion 5 min.
Guiding principles for quality efforts
Must be:
• sustainable
• evidence based
• focus on high impact items
• feedback must be timely
• systems focus
• measures should derive from core values
Guidelines for implementation of changes
• Must be time neutral or saving for each individual user.
• Must be cost neutral or saving to the system • Should be piloted first • No new staff added unless mandatory for … • Insist on standard work and data • Enter information once and only once • Automate where ever possible.
Muda -- Waste
• Inventory: documents, forms, supplies, storage space, waiting
• Overproduction: space, care (churning), over-prescribing
• Correction: apologizing for delays, retaking vitals or H&P, reentry, duplicate entry
• Material & Info Movement: charts, labs slips & samples• Processing: Turning an encounter in to a viable bill for
HCFA• Waiting: waiting, waiting waiting…• Motion: leaving the exam room, looking for charts
Review of key points
• Use Improvement science
• Keep it simple
• Must address people’s concerns
• Look for “Triple aim”; WIN – WIN – WIN items
Resources
• IHI – www.ihi.org• Measurement – www.qualityhealthcare.org• Lean Enterprise Institute – www.lean.org• AAFP Quality Site – www.aafp.org/quality• Future of Family Medicine --
www.annfammed.org/cgi/content/abstract/2/suppl_1/s3
--Sidebar-- How good is your system
• Assume that you audit these 20 and find 1 who did not get appropriate follow up. How big is your problem?
Estimation of error rate for rare events.
• It is difficult to calculate error rates for rare events in most systems.
• The rule of 3 can give an estimate of error rates in such cases.
Rule of 3/n
• If “y” is the number of error (events) in “n” patients, then the upper limit of the 95% confidence interval (CI) can be estimated by the formula x/n.
Observed event (errors) = y
x = Numerator for calculating the
approximate upper limit of the 95% CI
0 3
1 5
2 7
3 9
4 10
Our example.
• 1 in 20 defect/error rate• For a numerator of 1 the table says use a
numerator of 5• 5/n, n=20: 5/20 = 0.25• You found a 5% defect rate (1 in 20) but it
may be as high as 25%.• For a high risk issue is this good enough?
Rule of 3 example
• If you find no errors in an audit of 100 charts, then upper limit of 95% CI is 3/100 (0.03 or 3%). You are fairly sure that your error rate is < 3%.
• However if you do a random sample of 10 charts and find 1 error, then the error rate may be as high as 50%. (numerator = 1; then use 5/n 5/10 = 0.5 or 50%).
--Sidebar--SMART Goals
• A SMART objective is one that is specific, measurable, achievable, relevant and time-bound.
• George T. Doran, There's a S. M. A. R. T. Way to Write Management Goals and Objectives, Management Review (AMA Forum), November 1981, pps. 35-36.
• For additional information in this area search “SMART goals” and you will get much information.
• E.g., http://www4.asq.org/blogs/edu/2006/04/how_smart_are_your_goals.html