5 Vital Tips to Help Reduce Readmissions in Hospitals

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Dr. Joseph A. DeFeo, CEO, Juran GlobalScott A. Regan, MBA, MHSA, SVP, Juran Global

5 Vital Tips to Help Reduce Readmissions in Hospitals


Today’s Agenda

1. Attacking the readmission rate problems most effectively

2. Using the right tools for addressing readmission rate problems

3. Engaging a multi-functional team to address readmission rates

4. Engaging leadership to ensure the organization is set up for success

5. Picking the best place to begin


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This Month’s Healthcare Headlines

Medicare Readmissions

Penalties Create

Quality Metrics Stress– August 8, 2015

Half of U.S. Hospitals Face Readmission PenaltiesHospitals Will Lose a Combined $420 Million

– August 4, 2015

38 Hospitals

Facing Highest Penalties

for Readmissi

ons– August 4, 2015

1


About the CMS Readmission Program

Learn Everything You Need to Know The Hospital Readmissions Reduction Program was created under the

Affordable Care Act, which requires CMS to reduce payments to hospitals with excess readmissions.

Penalties are based on readmissions for Medicare patients who were originally admitted for:

– heart attack– heart failure– Pneumonia– chronic obstructive pulmonary disease– elective hip or knee replacements

This year’s penalties will take effect from Oct. 1 through Sept. 30, 2016, and are projected to cost hospitals a combined $420 million.

The maximum penalty this year is a 3% reduction in Medicare payments; the average penalty this year is 0.61%.


Healthcare’s Latest Cottage Industry


The Physician’s Treatment Process

Chief Complaint

H&P, Diagnostics Diagnosis Therapeutic

InterventionMonitor,

Follow Up


The Administrator’s Treatment Process

Chief Complaint

Therapeutic Intervention


The First of Five Vital Tips

Off-the-shelf interventions will work, but only if you are lucky enough that the intervention you select matches a correct diagnosis

Which means you first need a correct diagnosis Which means you need valid analysis of the root cause of

your readmissions problems not someone else's

Tip #1: Contrary to what you read there is no magic potion for a solution – But there is a magic

potion to analyze the problem


Tip #1: Magic Potion

What the root cause isn’t:– It is not the initial reaction or response– It is not merely restating the finding– It is not a symptom

What the root cause usually is:– Process or program failure– System or organization failure– Poorly written instructions– Lack of training

Use the right method not the easiest to identify the root causes

H & P Diagnostics Diagnosis



1. Define the problem WITH PRECISION2. Collect and analyze facts WITH REAL

DATA 3. Develop theories and possible causes

BEFORE SOLUTIONS4. Systematically reduce the possible

theories and causes using FACTS5. Develop possible solutions BASED ON

ANALYSIS6. Define and implement an action plan TO

CHANGE IT 7. Monitor and assess results TO HOLD

GAINS

Most effective means to determine the real root causes

H&P, Diagnostics Diagnosis



We use Six Sigma as the starting point:– Define the baseline and goal– Measure current performance – Analyze why, who, what, when…

• Pareto analysis (vital few vs. trivial many)• Brainstorming• Flow charts and process mapping• Cause-and-effect diagram

– Analysis of data– Improve with best affordable solution– Control to hold the gains

Right Methods for Identifying the Root Cause



Tip #1: Magic Bullets

Implementing solutions because you know why the readmits exist

Looking for a single cause– Often two or three causes

contribute and may be interacting Ending analysis at a symptomatic

cause Assigning as the cause of the problem

the “why” event that preceded the real cause

Common Errors of Root Cause Analysis



The Second of Five Vital Tips

Tip #2: Using the Right Method Right

READMISSION

REDUCTIONor



Tip #2: Bring the Right Method to the Job

Chief Complaint

H&P, Diagnostics Diagnosis Therapeutic

InterventionMonitor,

Follow Up

Define Measure Analyze Improve Control

The Magic Potion for Analysis


The Third of Five Vital Tips

C

Multi-Functional Team

Tip #3: Engage a Multi-Functional Team



Tip #3: Engage a Multifunctional Team

Conditions that Cause Most Readmissions (2011) NumberMedicare

1. Congestive heart failure 134,5002. Septicemia 92,9003. Pneumonia 88,8004. Chronic obstructive pulmonary disease 77,9005. Cardiac dysrhythmias 69,400

Medicaid and Commercial6. Mood disorders 61,2007. Schizophrenia and other psychotic disorders 35,8008. Maintenance of chemotherapy or radiotherapy 25,5009. Diabetes mellitus with complications 23,70010. Complications of pregnancy 21,500

* According to the Agency for Healthcare Research & Quality, April 2014

Medicare Penalties

Regardless the Condition, They Span Job Functions




Exit Writer PACS

WhiteboardSign-In Sheet

EPICare Amb

MS4

Chart Rack

Chart

Pyxis

US Rack

RALS

MUSE

Sign InTriage Form

Triage/Primary Assessment

MD Assessment/Orders

Registration/Armband Placement by RN

RN Assessment Treatment/Procedure Prep/IV/Labs Drawn Diagnostics MD Evaluation/

Disposition

Discharge Instructions Discharge/Admit/Transfer

Admitting Office/Admin. Supervisor Bed Placement

EDWaiting

ED Exam/Hallway

MedStation

Supplies

Tube

Registration

Consult

They Also Span Departments




Effective Teams Use Effective Methods


Define Measure Analyze Improve Control


Measure

Analyze

Improve

Control

Define

Lean Six Sigma Roadmap


Problem and Goal

Problem Statement:For My Hospital during the calendar year 2013, the readmission rate for APR DRG 140 Chronic Obstructive Pulmonary Disease (COPD) was 21.89%, which is above the expected rate of 18.21%. Readmission rates higher than the national rate result in decreased quality of care, poor patient outcomes and decreased reimbursement and penalties from the Centers of Medicare and Medicaid Services (CMS).

Goals/Objective(s):Reduce the readmission rate for COPD from 21.89% to a minimum of 18.21% (measured quarterly) or less starting 6/30/2014.

Define


Financial Impact: Business Case1. Medicare penalties for excess readmissions2. Medicaid penalties for excess readmissions3. Cost of care of patients readmitted for COPD in excess of the expected number.Performance worse than the expected rates adjusted for MSH results in penalties and decreased reimbursement from CMS. Cost avoidance also is anticipated.

By achieving the project goal (57 to 47 readmission cases), the hospital can reduce total COPQ to $401,145, realizing $133,692 in savings.

Note: My data do not include readmissions at other facilities; Medicaid claims are tracked by Dept. of Healthcare and Family Services (affects final penalty).

COPQ ComponentCurrent

Annualized CostGoal

Annualized CostMedicare penalties $2,319 $0Medicaid penalties $46,023 $0Cost of poor care $486,495 $401,145TOTAL COPQ $534,837 $401,145

Define


Project Team Membership

Project Champions:• Two MDs (one being CMO)

Project Core Team Members:• Director of Disease Management• Med/Surg Floor Nurse• Clinical Pharmacy Manager• Medical Intern• Director of Respiratory Therapy• Respiratory Therapy Day Supervisor

Ad Hoc Members or SMEs:• Hospitalist• Disease Management

Define


High Level Process Map (SIPOC) and CTQs

SIPOC: COPD Readmissions

SUPPLIER INPUT(use nouns)

PROCESS(use verbs)

OUTPUT(use nouns) CUSTOMER CTQs

Patient or familyPatient

complaints / symptoms

Admit patient Patient in room Treatment Team Bed readily available at appropriate level of care; Appropriate admission

TransportTechs

Nursing & medical staff

PatientDiagnostics Assess patient H&P

Plan of Care

PhysicianNurse

RT

Correct Plan of Care; Timely verification of COPD Order Set

Treatment Team H&PPlan of Care Treat patient Interventions Patient

Timely availability of Plan of Care; Timely implementation of COPD Order

Set; Appropriate spacer use

Treatment Team AssessmentDiagnostics Evaluate patient

Achievement of treatment

expectations

PatientTreatment Team

Appropriate evaluation according to GOLD standards; Timely evaluation

(Nursing: every shift; Medicine: at least daily)

Treatment Team

Education materials and

equipmentVerbal instruction

Educate patient

Patient/family with increased knowledge and

skill base

Patient/family

Delivery of standardized education (verbal & written); Documented confirmation of patient/family

understanding & demonstration

Treatment Team

DC ordersDC

Plan/paperworkMedications &

equipment

Discharge patient

Discharged patient to

home/next level of care

Patient/familyNext level of care

GOLD discharge criteria are met; Discharged to appropriate setting;

Additional training needs identified; Discharge paperwork reviewed;

Appointments scheduled; Inhalers provided

Define


Detailed Process Map

Typical COPD inpatient LOS is about 3 days.

Measure


Measure Process Capability

The baseline CMS readmission rate was 21.89% for CY 2013, above the expected rate of 18.21%.

Measure


Graphical Analyses – Selection of COPD

COPD and CHF readmissions were in the vital few APR DRGs, and determined to be relatively controllable vs. other diagnoses.

Measure


Graphical Analyses – Readmission Trend

Both observed and expected readmission rates are variable over time, displaying gradual decline over the prior two years. Observed readmission rates exceeded

the expected rate in 16 of 24 months.

Measure


Graphical Analyses – Readmission Reasons Measure

Most principal diagnoses for readmissions relate to respiratory problems or CHF. Common secondary diagnoses include tobacco and drug use, diabetes, hypertension

and hyperlipidemia.


Severity Score at Index & Readmission

There is no significant difference in severity score between Index and Readmitted patients. Are some patients readmitted more often?...

Measure


Graphical Analysis – Readmissions by Patient

Although 9 (14%) of the 66 readmitted patients accounted for 38% of all readmissions, the majority of patients (57, or 86%) had only 1 or 2

readmissions, accounting for 62% of all readmissions.

66 patients generated 113 readmission visits

Measure


Process Issues Analyze

Many process issues were identified, especially near time of discharge.


Brainstorm Theories of Causes

COPD Readmission

Admission

Resources Discharge Post-Discharge

Fragmented care following D/C

Patients do not consistently meet

GOLD discharge criteria

Appt not made

Patients unable to obtain

meds following 3-day supply

Inconsistent coordination of education b/w

pharmacy and nursing team

Variation in patient demonstration of skill in inhaler use

Inconsistent communication to Nursing Team of repeat admission

Documentation of education lacking or does not

reflect education quality and/or needs

Patient leaves AMA

Reduced pharmacist coverage on weekends or

evening

Insufficient assessment of patient understanding

of teaching

Limited staff to educate and assess competency (all meds)

Delay in communicating

with DME provider, & equipment delivery

Spacer use not considered for adults

Inpatient inhaler lost / non-standard storage

& handling

Process Variation

Social Worker/Staffing

EducationEducational content not at appropriate level for patient

Ineffective media type used for education (TV, etc.)

Smoking cessation not high priority

Coordination problems prevent effective inhaler use

Inconsistent inhaler education & resulting

poor pt techniqueVariation in

recognition of primary home

caregiver

Med history not completed for all COPD patients

Patients not D/C to appropriate

level of care / setting

Providers unaware of pending discharges

Necessary services not available

during weekends

Patient not provided inhaler

COPD not flagged in auto-trigger list

Social Worker engaged late in process

COPD order set inconsistently used

Limited communicationof order set availability

O2 6 min ordered late in process

Excessive variation in patient care

Perceived as cumbersome

Single, generic content @ 6th grade level

Too complex

Rushed / not planned

Knowledge deficit of caregiver Not identified

Limited options

No doc’n pharmacy teaching

Fragmented

Not asked

Asked too late

Limited standardization

Limited staff allocated to

high priority pts

Not considered

Pt financial issues

No/under insurance

Not asked/planned

Not assessed for need

Need not identified

Appts not patient-centric

Access (e.g.,

transport)

ForgetNurses

cannot find

Nurses not know

Pt not fill inhaler RxPt not know to fill / diff

rescue/maint

Pharmacy access

Unaware empty

Not policy

Unaware

Too much info

Not all relevant

parties involved

Home caregiver

not available

Not enough

time

Not all teaching programs make appts

Comm’y docsnot make appts

Pt not follow up on appt or

recomm’n

Fill too late

Docs not know

to document /significance

Co-morbidities

overlap

Not know do not need

Admission order set

Access issues (transport)

Inconsistent teach-back

No standard protocol

No / too many caregivers

No or ineffective

review of D/C instructions

InconsistentID of

readmission

Non-Sinai

Not documented /Inconsistent location /

Difficult to find /No expectation

Not coordinated prior to D/C Poor D/C

planning COPD not a standard referral for Social Work

Multiple factorsPossible readmission factors were organized in a fishbone format.

Analyze


Critical To Quality and Theories (Xs)

Possible causes related to CTQs:

X1: Insufficient assessment of patient understanding of teaching.

X2: Patients do not consistently meet GOLD discharge criteria.

X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does not include family/caregiver).

X4: Appointment not made or inappropriate for patient (e.g., have outside provider).

X5: Patients are not being discharged to the appropriate level of care / setting.

X6: Patient not provided inhaler. Additional possible causes:

X7: Readmission rate is a function of day of week discharged.

Analyze


Data Collection Plan for Analyze Phase

Data Collection Plan for the Analyze Phase

Ref.

Theories To Be Tested (Selected From The C-E

Diagram, FMEA, etc.)

List Of Questions To Answer for

Evidence of Each Selected Theory

Results that will support

theory

Results that will rule out

theoryTools To Be Used

Data To Be Collected

Description/Data Type

Sample Size,

Number of

Samples

Where/How To Collect

Data

Who Will

Collect Data

How Will Data Be

Recorded

X1 (CTQ)

Insufficient assessment of patient understanding / demonstration of standardized teaching, including additional training needs.

Does a second-teach-back improve patient administration?

A second teach-back improves patient administration.

A second teach-back does not improve patient administration.

Bar chart

Categorical: Percentage patients with

improved administration.

84 patients

Inhaler instructi

on session

Karen Excel

X6 (CTQ)

Patient not provided inhaler.

What is the incidence of lost or missing inhalers?

A high number of inhalers are lost or missing.

A low number of inhalers are lost or missing.

Bar chartCategorical:

Count of lost or missing inhalers.

6 weeksReconciliation tally

Karen Excel

X7Readmission rate is a function of day of week discharged.

What is the proportion of patients readmitted w/in 30 days by day of week?

Proportion readmitted differs by day discharged.

No difference in proportion by day discharged.

Stacked bar chart,

Chi-square

test

Categorical: Number of patients w/

Index discharge by day of week, and number of

these readmitted.

All COPD discharges over prior 2 years

Premier Lynda Excel

A subset of CTQs and Xs were tested (others had sufficient anecdotal evidence and/or were difficult / time-consuming to test).

Analyze


Test of Theories Example

Theory: Insufficient assessment of patient understanding of teaching.

Analysis: Pharmacy assessed patient inhaler demonstration technique at t0 (baseline), t1 (after instruction), and t2 (24-72 hr. after initial instruction, t1). Scoring based on number of steps missed (detailed description in Notes View)

The t2 (24-72 hr.) assessment better reflects actual skill after discharge than the t1. Instruction improved scores but remained <100% scores; this and the slight decline between t1 and t2 indicate that reinforcement and assessment are beneficial.

Practical Conclusion: Additional teach-back improves patient inhaler administration; current teaching is insufficient.

Spiriva (n=15) Symbicort (n=36) Albuterol (n=35)

Score,

out of 9 %Score, out

of 9 %Score, out

of 9 %t0 5.8 64 4.5 50 4.1 46t1 8 89 7.2 80 6.7 74t2 7.2 80 6.6 73 6.2 69Δt1-t0 +25 +30 +28Δt2-t0 +16 +23 +23Δt2-t1 -9 -7 -5

Analyze


CTQ and X Summary

X1: Insufficient assessment of patient understanding of teaching. Administration of inhalers improved from 25% at baseline to 50% after a second teach back session that occurred between 24-72hr post initial test.

X2: Patients do not consistently meet GOLD discharge criteria. Application of GOLD discharge criteria is not standard practice.

X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does not include family/caregiver). Anecdotal evidence from nursing and RT indicates review of D/C instructions is not consistently effective.

X4: Appointment not made or inappropriate for patient (e.g., have outside provider). Follow-up appointments (PCP, pulmonologist) are made for some but not all patients, and are made late in the inpatient care process.

X5: Patients are not being discharged to the appropriate level of care / setting. GOLD discharge criteria not used to guide choice of care setting; palliative care is underutilized.

X6: Patient not provided inhaler. Inhalers frequently are lost or misplaced, and not available to provide to patients upon discharge.

X7: Readmission rate is a function of day of week discharged. Day of week discharged does not affect subsequent readmission rate.

Analyze


Selected Solutions

Theme Selected SolutionsAdmission & Inpatient Care

COPD Care Pathway and Order Set, with triggering of Order Set and supplemental services via pathway. Eliminate need for duoNeb ordering via teaching aids (placebo inhalers and disposable spacers).

Education - Patient

Bronchial Hygiene Program upon admission. Include early symptom identification, trigger identification, hand-washing, exercise.

Education - Staff

Bronchial Hygiene Program upon admission. Build in shortcut to ordering of spacers based on RT vs. direct MD order. Use admission smoker status as basis for referral to Disease Mgmt. / Lawndale Clinic smoking cessation classes.

Resources Social Worker engaged via Care Pathway to identify & initiate post-discharge meds process, oxygen, etc.

Discharge Marketing and education of palliative care. Include palliative care and GOLD discharge criteria in COPD Care Pathway and Order Set. Deploy AccuDose® inhaler tracking & storage (patient-specific). Initiate discharge planning upon admission per COPD Care Pathway, including appointments. Social Worker identifies COPD-relevant programs relevant to patient. Make follow-up appointments (PCP, Specialist) as early as admission. Implement clear, concise COPD-specific D/C instructions, including prescription transition & eligibility for free inhalers/prescriptions.

Staff Augment med history by having Pharmacists or ER Pharm Tech complete for patients beyond Disease Mgmt. (Long-term).

Improve


Updated Process Map(s)

TBD: Smoking cessation intervention

Improve


Control Plan Process Control Plan for: COPD Readmissions

Date: 11/11/2014 Revision Level: 1

Approved By: COPD Readmission Team

Ref. Control SubjectSubject

Goal (Standard)

Unit of Measure Sensor

Frequency of Measure-

mentSample Size

Where Measurement

RecordedMeasured by Whom

Criteria for Taking Action

What Actions to Take Who Decides Who Acts

Where Action

Recorded

1 COPD readmission(30 day rate)

≤ 18.21% % Premier Monthly All COPD readmissions

COPD Readmissions spreadsheet

Lynda >18.21% Investigate CTQs Lynda Refer to CTQs

Control Plan Log

2 COPD Order Set(use) 100% % Meditech Weekly

All COPD discharges (trailing 4 weeks)

COPD Order Set Report Lynda <90%

List of Non-Compliant Attending & Resident Physicians and Report to Dept. Chairs, Program Directors,

Chief Residents

Dr. Iliescu Dr. Iliescu Control Plan Log

3Bronchial Hygiene

Program(use)

100% % RT Consult (Meditech) Weekly


Bronchial Hygiene

Program ReportLynda <90%


Chief Residents


4 COPD education(documentation) 100% % Education

checklist* Weekly


Patient Chart Lynda <90%List of Non-Compliant

Departments (Pharm, Nursing, RT) and Report to Dept heads

Dept HeadsDept Heads Control Plan Log

5 GOLD D/C criteria(use) 100% %

Physician checklist done at

discharge

Weekly


Meditech Report Lynda <90%


Chief Residents


6Discharge paperwork(review)

100% %COPD

Education Screen

Pilot-Daily (First 2 wks)

Weekly


Meditech Report Lynda <90% List of Non-Compliant Nurses and Report to Unit Directors Raquel

Raquel and Unit

Directors

Control Plan Log

7Patient appointments

made prior to discharge

100% %Discharge

module (Meditech)

Weekly

All COPD discharges

(trailing 4 weeks)

FM-Appt Report from D/C Module

IM-F/U with Kathy

Lynda <90%List of Non-Compliant Resident Physician and Report to Dept.

ChairsDr. Iliescu Dr. Iliescu Control

Plan Log

8Discharge inhaler(provisioning of

inpatient inhaler)100% %

Nursing discharge checklist

Weekly


Meditech Report Lynda <90% List of Non-Compliant Nurses and Report to Unit Directors Raquel

Raquel and Unit

Directors

Control Plan Log

9 Smoking cessation(referral conversion) N/A % Meditech Weekly

All COPD admissions w/ "Yes Want To Quit" (trailing

4 weeks)

Meditech Report Lynda

>10% change

from baseline

Investigate root cause(s) (patient refusal / RT not asking) Phyllis Phyllis Control

Plan Log

Palliative Care

Criteria, Consults

TBD

Audit (# consults / #

meeting criteria)

TBD Q4 2014 Control Plan Log

Improve


Change Management & Communication Plan

Planned Change Who is Affected? Potential Objections Facts (What will really happen)

Benefits to those affected (Business and Personal

Benefits)

Communication (How will change be

communicated?)

Admission & Inpatient Care: Implement COPD Care Pathway, including use of COPD Order Set and guidelines.

Physicians, Nursing, IS, Social Work, Respiratory

Therapy, Pharmacy

Resistance to pathway and order sets (primarily

physicians)

Resistance will be overcome with consistent monitoring

Treatment team: applying best practices. Social Work: reduced medication costs. Finance: COPQ reduced.

Patients: receive better care.

Physician and Nursing leadership meetings. Staff

meetings with nurses, physicians and other

departments affected. Email notifications. See Training

Plan.Education - Patient:Reinstate modified Bronchial Hygiene Program w/ RT involvement early in inpatient process. Include early symptom identification, trigger identification, hand-washing, exercise.

Respiratory Therapy, NursingExpansion of RT duties. Providing adequate RT

staffing to accomplish goals

Restructuring the Bronchial Hygeine Program to shift

responsibility for delivery of MDIs and education from nursing to the Respiratory

RT is better skilled in the use of various inhalers/will

identify the need for spacers. Patients receive better

education and improved self-care.

Revision of the Bronchial Hygiene Program and MDI

Protocol w/ RT staff education. See Training Plan.

Education - Staff:Bronchial Hygiene Program to address inhaler education via RT involvement and identification of spacer candidates. Offer Level 2/3 smoking cessation classes.

As above As above

As above. Focus on education will start with the

patient; Information regarding Smoking Cessation class will

be incorporated in current packet.

As above As above

Resources:Social Workers engage patients in corporate pharmaceutical programs for post-discharge meds. Establish Social Work consult on admission per Care Pathway to assess DME / equipment needs.

Social Work, Utilization and Nursing Departments;

Patients

Patients may object to / not comply with paperwork for pharmaceutical program

requirements

Care Pathway will specify appropriate timing of SW

engagement and activities.

Saves SW costs and patients receive consistent supply of

meds.

Social work, utilization and nursing department meetings (leadership and staff level).

See Training Plan.

Discharge:Facilitate appropriate discharge and post-discharge care by incorporating D/C planning as part of Care Pathway. Elements to include GOLD criteria, provisioning of inpatient inhaler stored in unit-based locations, D/C instructions that educate patient re: free inhaler & prescription transition, and need to follow up w/ Pulmonologist/PCP. Educate physicians & patients re: palliative care & availability.

Physicians, Nursing, Respiratory Therapy, Social

Work, Pharmacy

Use of GOLD criteria. Resistance to change

towards earlier discharge planning.

Care Pathway will provide guidance on discharge

events and timing.

Early and more comprehensive discharge

planning will smooth discharge process and facilitate appropriate,

improved patient self-care following discharge.

Educational/training sessions with physicians, Nursing, RT, SW, Pharmacy, per Training

Plan.

Control


Training Plans

The training needs for different stakeholder groups were identified. Training delivery format, frequency, etc. were determined for each group…

Topic / Area of ChangeTeaching

Attending & Residents,

Hospitalists

Community Physicians Nursing Respiratory

TherapySocial Work Pharmacy

Disease Manageme

ntED Staff

COPD Care Pathway X X X X X X X COPD Order Set X X X X X X Bronchial Hygiene Program X X X X X Placebo inhalers & disposable spacers (edu, storage, tracking, use) X X X X

Smoking cessation referral X X X X X X Social Worker role & engagement X X X X X Palliative care X X X X X GOLD discharge criteria X X X X Discharge (planning, instructions, follow-up appointments) X X X X X X

Other – Patient Identification X

Control


Conclusion: 30-day readmissions have been running at 12% (27/204) since the beginning of Improve phase in September. Overall readmission rate

compares favorably YOY.

Desired direction:

Control Subject Control


Conclusion: COPD Order Set use is showing a very gradual upward trend, doubling since Q4 2014. There will be continued reinforcement to ensure this

positive trend continues.

Desired direction:



Conclusion: A BHP was not used for several years prior to the project start. Now revised and revived, BHP use initially was limited by staffing, but gradually

improving.

Desired direction:



Conclusion: COPD education of patients* has averaged around 67% since early April. A nursing form change in April facilitated compliance that has not yet been

sustained. * Education includes COPD Education Pamphlet and inhaler instructions.

Desired direction:



Conclusion: Historically not used, use of the GOLD discharge criteria has averaged just under 70%.

Desired direction:



Desired direction:

Conclusion: The pattern of documented provisioning of COPD discharge instructions to patients has closely tracked that of Gold discharge criteria (prior

slide). The target is 100%.



Conclusion: Documentation of patient appointments made prior to discharge averaged 64% since March (target is 100%).

Desired direction:



Desired direction:

Conclusion: Supply of inpatient inhaler to patients upon discharge has averaged close to 50% over recent weeks. This is well below the target 100%, but

gradually improving.



Conclusion: The proportion of COPD patients who indicate they want to quit has increased over time. This metric will be monitored to establish a baseline, from

which significant deviations can be responded to as appropriate.

Desired direction:



The Fourth of Five Vital Tips

Tip #4: Engage Leadership


Monitor, Follow Up


Tip #4: Engage Executive Leadership

A Day in the Life of a Healthcare Leader


Monitor, Follow Up


Monitor, Follow Up



Effective leadership really makes all the difference. In the end, we want our quality improvement efforts to be driven from the ground up. We love to have the folks who are on the front line of clinical care leading our improvement efforts. But at the end of the day, they’re going to be looking upward. They’re going to say, “What are the leaders telling us that we ought to pay attention to?” In many ways, the leader sets the tone that is going to either facilitate or mitigate the organization’s response to quality challenges. And you really need to have a leader effectively engaged in that process.

Dr. Gregg Meyer, Senior Vice PresidentMassachusetts General Hospital and Physicians Organization

Director, the Edward P. Lawrence Center for Quality and Safety

The Role of Leadership in Quality Improvement EffortsAHRQ Podcast, November 2011



Speak the language of leaders by calculating the margin loss, penalties to be charged

Seek the CMO and CNO as Champions Use external resources to manage

resistance and guide them Do not talk about other hospitals and

what they implemented for solutions – teach them what they did to analyze it

Alert them this is not going to be solved in a day but it could be done in 90 days

Deal with their resistance

Tips for Engaging Executive Leadership


Monitor, Follow Up


The Last of Five Vital Tips

Tip #5: Start with the Lowest Hanging Fruit

Start with Your Biggest Penalty


Tip #5: Start with the Low-Hanging Fruit

Start with Your Biggest Penalty Which of these five conditions is causing the greatest pain?

– heart attack– heart failure– pneumonia– chronic obstructive pulmonary disease– elective hip or knee replacements

Use an improvement methodology robust enough to get the job done Make sure your root cause analysis is thorough and complete Identify solutions aimed at eliminating the root cause Maintain a control plan Identify your second-biggest readmission problem and repeat


Lessons Learned

The root cause of your readmission problem may not be the same root cause as any other hospital’s readmission problem

Unless you first identify the root cause, any solution implemented is just a roll of the dice

Obtaining expertise on the use of root cause tools is critical to successfully reducing your readmission rate

It is easy to make errors when identifying root causes; these errors lead to wasted human and financial resources

Multi-functional issues require multi-functional teams to solve them Readmission root causes almost universally span departments and

units Tried-and-true improvement methodologies are your best approach If leadership is not hands on, the likelihood of success is diminished


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http://www.juran.com/resources/juran-university/lean-manufacturing/

http://www.juran.com/resources/juran-university/lean-manufacturing/

http://www.juran.com/resources/juran-university/lean-six-sigma/

http://www.juran.com/resources/juran-university/lean-six-sigma/

http://www.juran.com/resources/juran-university/lean%20transformation/

http://www.juran.com/resources/juran-university/lean%20transformation/

http://www.juran.com/resources/juran-university/operational-excellence

http://www.juran.com/resources/juran-university/operational-excellence

http://www.juran.com/resources/juran-university/process-innovation/

http://www.juran.com/resources/juran-university/process-innovation/

http://www.juran.com/resources/juran-university/quality-assurance/

http://www.juran.com/resources/juran-university/quality-assurance/

http://www.juran.com/resources/juran-university/quality-control/

http://www.juran.com/resources/juran-university/quality-improvement/

http://www.juran.com/resources/juran-university/management-consulting-firm/

http://www.juran.com/resources/juran-university/management-consulting-firm/

http://www.juran.com/resources/juran-university/iso-9000-2015/

http://www.juran.com/resources/juran-university/iso-9000-2015/

http://www.juran.com/resources/juran-university/six-sigma-certification/

http://www.juran.com/resources/juran-university/six-sigma-certification/

http://www.juran.com/resources/juran-university/what-is-lean/

http://www.juran.com/resources/juran-university/what-is-lean/

http://www.juran.com/resources/juran-university/what-is-six-sigma/

http://www.juran.com/resources/juran-university/what-is-six-sigma/


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