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Transcript of MAPPING YOUR DISCHARGE PROCESS AND HANDOFFS Sara Butterfield RN, BSN, CPHQ, CCM Christine Stegel RN,...
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MAPPING YOUR DISCHARGE PROCESS AND HANDOFFS
Sara Butterfield RN, BSN, CPHQ, CCMChristine Stegel RN, MS, CPHQBrenda Maynor, RN, MSJune 21, 2012
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CMS
Leads a national healthcare quality improvement program, implemented locally by an independent network of QIOs in each state and territory.
IPRO
The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).
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Level of Importance of Safe Care Transition
17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending
Estimates show that 76% of these readmissions may be preventable
Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission
Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare
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Level of Importance of Safe Care Transition
41% inpatients discharged w/ pending test results
2/3 of physicians unaware of results
37% actionable and 13% urgentAnnals of Internal Medicine. 2005; 143(2):121-8
25% pts require additional outpatient work-ups
More than 1/3 are not completed Archives of Internal Medicine. 2007;167:1305-11
At Discharge:
37% able to state purpose of all medications
14% knew the common side effects
42% able to state their diagnosis
Mayo Clinic Proceedings. August 2005; 80(8):991-994
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Investigation of Root Cause
Mapping Current To Desired ProcessFor Discharge Planning
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Root Cause Analysis
Definition
A Root Cause Analysis (RCA) is a process for identifying the basic or causal factors that underlie variations in outcomes
Allows you to identify the “root” of the problem in a process, including how, where, and why a problem, adverse event, or trend exists
This analysis should focus on a process that has potential for redesign to reduce risk
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Root Cause Analysis
An RCA focuses primarily on systems and processes, not individual performance
To begin, identify the underlying functions leading to poor outcomes. Then, determine the primary cause(s) and contributing factors
An RCA is generally broken down into the following steps:
●Collect data
●Analyze data
●Develop and evaluate corrective actions, using PDSA cycle
● Implement successful corrective actions
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Root Cause Analysis Purpose
Identify causes of hospital 30-day readmissions within your community
• Health care provider perspective (hospital, nursing home, home health agency, hospice, etc)
• Community perspective (Office for Aging and other community service providers)
• Patient/caregiver perspective
Identify patterns of readmissions for your community
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Process Assessment
A picture of the steps in a process to gain a better understanding of the existing process
Assessing a process in its current stateHelpful to develop benchmarks
Determine opportunities for improvement
Direct observation of processes such as discharge and admission
Interviews with process owners
Mapping of processes at a high level and/or a detailed level
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Process Assessment
Process Assessment Tools
Cause & Effect Diagram
Fault Tree Analysis
Value Stream Mapping
5-Whys
Process Mapping
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Process Mapping
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Why Process Map?
Provides a picture of process – maps the patient’s journey
Helps to clarify a complex process
Establish commonalities
Identify all the process participants
Establish a baseline of what is current process
Identify delays, gaps, work-a-rounds
Identify factors that influence or impact the process
Provides a clear understanding of the processes of care so there is no risk of changing parts of a process which will not result in improvement
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Why Process Map?
Capture the reality of a process….. what is happening versus what you think is happening)
Identify duplication, variation and unnecessary steps
Generates ideas and helps define where to start to make improvements with the biggest impact
Helps all involved to understand the complete process
Allows for identification of problem areas such as bottlenecks that cause unnecessary delays
Improve team building and promotes ownership of the process
Increases staff involvement in design of processes
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Process Mapping
Two stages to process mapping…
1.Understand what happens to the patient, where it happens and who is involved
2.Examine the process map to determine where there are problems
multiple hand-offs
parts of the process that are unnecessary
parts of the process that do not add value
waste, error and duplication of parts of the process which would flow better if undertaken in a different order
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Process Mapping Steps1. Define what you are trying to achieve
2. Identify the start and end point of the process
3. List what measures are you going to use to demonstrate that changes actually do improve the process
4. Identify which staff need to be involved in mapping the process – involve them at the start
Direct Care Staff of all disciplines involved in process
Senior leadership representative(s)
Community service providers
Patients
Caregivers
Stakeholders
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Process Mapping Steps
5. Select a facilitator (not someone involved in process being mapped)
6. Gather supplies●Paper / Marker pens / Post-it notes / Flip charts / Tape
7. Set ground rules – safe environment to share
8. Keep it simple
9. Clearly define each step in the process
10. Start with a high level view●5-10 steps in the process
●20 minutes or less to map
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Process Map Guidance
Keep the patient at the center of the processDefine the first and last steps in the processIdentify the steps that occur at the same timeCross over departmental boundaries Include what happens when there are problemsAt decision points choose what occurs the majority of the timeIdentify branches or gaps as the map is developed
• At the end, go back to fill in branches
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Process Mapping Symbols
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Shows the tasks and activities of process
Shows the start and end of the process
Shows where a question is asked or a decision is required
Shows the direction / flow of the process
Shows where documentation is required
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Alternatives Process Mapping Approaches
Walk through the patient journey yourself ● Interview staff on the who, what, where & how & record each step
Set up a mini process mapping session● Use a staff meeting to discuss & record the process
Follow a patient through the process● Best if external person not involved in process
Be a patient and travel through the process
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Redesigning the Process to the Desired State
Identify where the process can be improved by re-designing or removing elements of it Consider impact of redesign on the rest of the organization Test ideas for improvement to show potential and any unwanted side-effects of your changes
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Key Components
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
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Application of Process Mapping Discharge Planning
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Discharge Planning Process
Process for planning the post-acute care for patients prior to discharge
Acute Care Hospital
Short-term Rehab
Skilled Nursing Facility
Home Health
Includes several HANDOFFS (the passing of a patient’s care from one clinician to another clinician)
• To referring agencies/facilities
• Nurse to nurse
• Hospitalist to community physician
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Common Discharge Planning Gaps
Communication related:
- transfer of patient information
- pending lab values
- caregiver involvement
- patient’s discharge plan
- discharge medications
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Common Discharge Planning Gaps
Care Coordination related:
- primary care physician
- community services
- home health agency/SNF
- outpatient services
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Explicit delineation of roles and responsibilities Discharge process initiation upon admission Patient education throughout hospitalization Timely accurate information flow:
From PCP ► Among hospital team ► Back to PCP
Complete patient discharge summary prior to discharge
Source: Project RED Principles of the Re-Engineered Hospital Discharge
The Desired Process for Discharge Planning
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Comprehensive written discharge plan provided to patient prior to discharge
Discharge information in patient’s language and literacy level
Reinforcement of plan with patient after discharge Availability of case management staff outside of
limited daytime hours Continuous quality improvement of discharge
processes
Source: Project RED Principles of the Re-Engineered Hospital Discharge
The Desired Process for Discharge Planning
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The Reality……
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Process Mapping Examples
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High Level View
Detail Level View
Institute for Innovation & Improvement: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping_-_a_conventional_model.html
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Patient isadmitted
MD writesadmission
orders
Pharmacistprovides
medications
Nursing initiateadmission
assessment
Care andtreatmentprovided
Dischargeorder iswritten
Dischargesheet is filled
out
Patient isdischarged
Discharge sheetis reviewed withpatient/family
Example: Current State Patient Discharge
Source: Project RED Principles of the Re-Engineered Hospital Discharge
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Physician
Nursing
DischargeAdvocate
Pharmacy
Sample Process Map: Patient Discharge
Patient AdmissionOrders
Initiate postdischarge phone
call
EstablishClinical
Pathway
AdmissionAssessment
MedicationReconciliation
Educate patientabout diagnosis,
tests, and studies
Identifytarget patient
Initiate dailydischarge
huddle
Initiate AfterHospital Plan
Collect data reProcess and
Outcome metrics
Schedule Postdischarge f/uappointment
Verify MDorders
Create MARAssist withmedication
reconciliation
Assist withmedicationteaching
Participate inDC Rounds
Educate patientabout diagnosis,
tests, and studies
Initiate DCorders
ReinforceDischarge Plan
Provide careand treatment
CompleteAHCP
Physician
Nurse
Discharge Advocate
Pharmacist
Example: Desired Patient Discharge Process Map
Source: Project RED Principles of the Re-Engineered Hospital Discharge
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Brenda L. Maynor, MS, RN
Director, Clinical Resource Management
St. Mary's HealthcareAmsterdam, New York
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St. Mary’s Healthcare High Level Process Map
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Barriers to Process
Identifying which MD to sign home care orders. (The hospitalist sees patient in hospital)
Missing parts of referral/discharge orders
A clear understanding of Home Health care and what the agency is able to provide
Lack of assessment of home supports and ability to manage basic necessities at home prior to discharge
Skilled Nursing needs/therapy needs
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St. Mary’s Healthcare
Desired Referral Process Hospital to Home Health
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St. Mary’s HealthcareDesired ProcessHome Health to Hospital
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St. Mary’s HealthcareDesired Process
Initiating Home Health Referral for ED Patients
RCA Process Improvement:•Identify during triage if a pt currently has home care services in the home. Currently this is not addressed during the ER visit•Sent message to ER Manager to inquire adding this to interview screen•If the pt currently has services, refer back to that same agency•If the pt does not have services, initiate a new referral
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Questions
Comments
Plans for Next Week?
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Resources
Agency for Healthcare Research & Qualityhttp://www.ahrq.gov/qual/projectred/swimlane.htm
Colorado Foundation for Medical Care National Coordinating Center http://www.cfmc.org/integratingcare/toolkit.htm
Institute for Innovation & Improvementhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping_-_a_conventional_model.html
Project RED (Re-engineering Discharge)https://www.bu.edu/fammed/projectred/index.html
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For more informationSara Butterfield, RN, BSN, CPHQIPROSenior Director(518)426-3300 ext. 104 [email protected]
IPRO CORPORATE HEADQUARTERS
1979 Marcus AvenueLake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods BoulevardAlbany, NY 12211-2370
www.ipro.org
Template 1/13/2012
Christine Stegel, RN, MS, CPHQIPROSenior Quality improvement Specialist(518)426-3300 ext. [email protected]
Brenda L. Maynor, MS, RNSt. Mary’s HealthcareDirector, Clinical Resource Management(518)[email protected]
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-N-12-07