WHA Improvement ForumFor April

“Prioritizing New Interventions”

Stephanie Sobczak

Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation.

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Today’s Webinar

Agenda

Will, Ideas, Execution Sifting through the evidence Determining what to implement Driver Diagrams Prioritization Tools Leveraging Data Analysis as a Decision Making Tool

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The WHA Improvement Workbook follows has tools and templates you can use

Available on the Quality Center:http://www.whaqualitycenter.org/PartnersforPatients/PFPWave2Materials/PfPImprovementWorkbook.aspx

Using the Improvement Workbook

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WILL IDEAS

EXECUTION

CHANGE

This is often the culprit behind a lack of improvement!

WILL

Ask yourself or Ask your team:Do I (we) really know why I (we)

want to tackle this problem?

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Without WILL you are unlikely to be successful!

IDEAS Analyze the data Do a literature review and choose the intervention

with the best evidence Find best practices from peers Complete a root cause analysis Ask our frontline staff what to improve Everybody else is doing __________, so should we!

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Have you been “over-reliant” on one source of ideas?

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1) How do we know there is a problem?2) What drives our results?3) Do we really do “best practice” processes?4) Do we know how well processes are working?

EXECUTION

Ensure alignment

You must relate the changes you make

to the problem you are trying to solve.

If not, you run the risk of spending resources working on the wrong things

What Intervention is Right for My Hospital?

The Question: How can we prevent falls on the M/S unit?

The Rationale (the WILL): Prevent harm to patients!

AIM: We will reduce falls on the M/S unit by 50% by Dec 2013.

EXECUTION: What and How?

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Expert analysis

“Do it yourself” literature search OR

Use change packages from reputable sources:

IHI, AHRQ, HRET National collaboratives (CUSP, CLABSI, GWTG) Applied Research – if you like the leading edge!

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Take Inventory of the Driver Diagram

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Example:Workbook 1-8

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• Do we conduct a fall risk assessment upon admission?• Do we conduct ongoing reassessments of fall risk?• Do we consistently perform hourly rounds?• Do we move high risk patients closer to nursing stations?• Do we target interventions to reduce the side effects of meds?• Do we use Visual/Audible Cues?• Do we communicate to all staff which pts. at risk?

Inventory your practices as compared to the evidence

Ask yourselves: How do you really know?

Readmissions Example Our All Cause readmission rate is 14%

Is this a problem?? How do we know?

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• We had Medicare penalties.• Hospitals in the Partners project average a 7% rate.• Our readmission rate has been the same for 3 years.• Our patients are not satisfied with d/c instructions – we are at the 50th percentile nationally.

Drilling into your data

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• 6,478 Medicare FFS admissions among 4,732 people• 6,148 Medicare FFS alive discharges (some exclusions)• 908 30‐day readmissions; 14% all cause readmission rate

First Level Analysis – How many are readmitted?

• 50% 30‐day readmissions <10 days of d/c; 25% <96h• Top 10 READ dx: HF, RF, UTI, sepsis, respiratory infect.

Second Level Analysis – When and Why are pts readmitted?

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– Among high utilizers, 495 30‐d READ; rate 38%– Among high utilizers, 55% d/c to home w/no services(N=716)– Top diagnoses among this group: COPD, GI, CHF, sepsis, UTI

Third level analysis – Who is readmitted the most?

Fourth level analysis – How many of these were preventable?

PPR Report – 30% of COPD readmissions are preventable

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• Discharge disposition (home, home health, SNF, hospice, other)• Discharge zip code/county• Discharge day of week; readmission day of week• Days to readmission• Discharge diagnoses; readmission diagnoses• Discharging service; readmitting service• Subgroup analysis (freq. pts, d/c home, d/c SNF, diagnoses, etc)

Digging deep into your data

Ask for help with this

How to decide what to work on

Workbook Section 1

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Caregiver FeedbackAsking front-line staff about opportunities for

improvement is a valuable exercise!

• May confirm or refute what your data is saying• Staff learn about the need and effort to improve• Begins building buy-in for participating in change

when the time comes to test & trial.

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Gathering Feedback

• When does the problem occur? (example: weekends, at night)• Where does the problem occur? (example: only in the OR, in

patient bathrooms)• Who is involved when the problem occurs? (example: CNAs, RNs)• What are the symptoms of the problem? (example: test results

are not on the cart at the time of report)• Why does the problem occur at the places indentified above?

(example: supplies are not handy at the bedside)

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Understanding Process

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Perspective Process TheoriesHow could you

prove or disprove this theory?

When

Where

Who

What

Why

The idea is to narrow down to actionable interventions

Workbook 1-2

Staff Safety Assessment

How to use: 1.Gather staff feedback on a specific issue.2.Categorize the types of issues mentioned in the

feedback.3.Analyze, (consider graphing) then…. Deep dive into process mapping or root

cause analysis to gather specifics.

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Staff Safety Assessment Just two (2) very important questions to learn from:

What do you think are the most common factors resulting in a patient falling?

Please describe what you think can we can reasonably do to prevent or minimize falls?

Thank you for helping improve patient centered care!

Tally Responses

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Patients won't / can't use call bell IIIIFamily leaves without letting us know IIIIIIIIIIHourly rounding isn't happening IIIIIIIIIIIIIIIIIILack of grab bars in bathroom IIIIIIITakes to long to answer call bell IIIIIIIPt's things are left too far away IIIIIIIIIIIIIILack of teamwork between RN and NA's IIIIIIIIIIIIIIILack of PT services on weekends IIPatients overmedicated/confused IIIIII

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Priorities

Simple Root Cause Analysis

Patient Risk FactorsTask FactorsStaffing/Caregiver FactorsCommunication FactorsEducation FactorsEquipment Factors**Different than a Sentinel Event process

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Example:Workbook 1-7

This is a method to better understand a process and find opportunities for improvement

Root Cause Analysis Points to ProcessFindings from the root cause analysis may point to

specific process problems that might be looked into, for example:

Hourly Rounding isn’t Happening Do staff consistently perform hourly rounding?

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Process Diagramming

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Example:Workbook 1-7

Consider asking two people who work on the same process to diagram their steps.

Look for inconsistencies = your opportunity for improvement

How to prioritize from a list of ideas

Once you have several good ideas, a next step can be to assess the impact, cost, ease of implementation – or other factors using a matrix

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Patient handouts given at d/c

Calls to Primary Care @ d/c

Conference with family, d/c planner

Scripts for doctors to use w/ pts.

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Example:Workbook 2-1

Prioritization Matrix

Sweet Spot!

Taking it all into account• Do we have data that show there is a

problem?• Do we do the best practices?• What processes are related to these

findings?• Where is there an opportunity to

improvement?• What is a best choice for a first step?

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Data Drill-down

Driver Diagram Inventory

Staff Feedback

Process Analysis

Prioritization Matrix

In Summary

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When EXECUTING an improvement initiative,time taken to carefully determine what

interventions to test and trial in PDSA cyclesis time well-spent!

Next Month:

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Strategies for ‘in process’ Measurement

May 30Noon

Measurement as part of daily work Finding existing data vs. gathering data “When can I stop measuring?”

References• WORKBOOK SECTION 1• The Improvement Guide: A Practical

Approach to Enhancing Organizational Performance, Langley, Moen, & Nolan

• WHA Quality Center Tools and Templates http://www.whaqualitycenter.org/PartnersforPatients/PfPTools.aspx

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Thank You!Questions

Please complete 3 question survey when closing webinar window.

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