Engaging Front Line Staff in Readmission ReductionRegina Truong, RNTelemetry Charge NurseReadmission Reduction Team Lead
May 6, 2014
Staff LeadPerformance Improvement at Saint Francis - Model
Sustainable Improvement
Right careRight timeRight place
Evidence-Based Data-Driven Hands-On
Holistic
Lean/Six Sigma Methodology
Engages Community
Partners
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Hands On & Holistic….
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Staff LeadPerformance Improvement at Saint Francis - Process
• Identify problem, root cause & realistic, sustainable solution
• Select a single test site (small test of change)
• Communicate and educate
• Test
• Monitor/Assess/Adjust/Test Again/Repeat
• Spread the proven process
• Champion sustainment
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Staff LeadPerformance Improvement at Saint Francis - Opportunities
Improved Quality of
Care
Increased Patient
Satisfaction
Increased Staff
Satisfaction
More Collaborative
Culture
Improved Revenues
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Staff LeadPerformance Improvement at Saint Francis - Challenges
Keeping Teams
Focused
Integrating Solutions
Proving a Solution Has
Value
KeepingLeadership
Engaged
Continuously improving
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• 2010 – first Inpatient Discharge Team formed and laid the foundation for ongoing performance improvement
– Identified process inefficiencies and siloes
– Initiated improvements in discharge timing and patient throughput
• 2013 – Discharge Team becomes Readmission Reduction Team with renewed focus on interdisciplinary collaboration and effective patient discharge education
– Integrated 10am Discharge Rounds
– DRG-specific Discharge Patient Education Cards with Teach Back
Staff-Lead Readmission Reduction Efforts at Saint Francis
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Integrated Discharge Rounds
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Patient Discharge Education – Pilot Focus on COPD
15.03%
12.42%
9.15%
6.54%
4.58%
0%
2%
4%
6%
8%
10%
12%
14%
16%
COPD CHF Pneumonia RespiratoryInfection
Cellulitis
Top Readmissions by DRG% of Total
Notes -Source: Midas Readmit Toolpack, excludes Rehab & PsychDate Range: 1/2013 – 6/2013DRGs: COPD – 190,191,192, CHF – 291,292,293, Pneu – 193-194-195, Resp. Inf. – 177,178,181,189,204, Cellulitis – 602,603N = 153
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10
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Will support readmission reduction for high risk patients by:
• Planning, developing, implementing, coordinating and evaluating overall readmission reduction program
• Collaborating with multidisciplinary clinical team, Readmission Reduction Team and community partners
• Providing hands-on discharge education and follow up for patients and families
• Providing ongoing education for staff and leadership
Nurse Navigator
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30 Day All Cause Readmissions
Notes -Source: Midas Readmission ProfileDate Range: 1/2011 – 12/2013All Cause Readmissions
8.95%9.31%
7.29%7.52%
8.26%8.09%
7.53%
6.22% 6.11%
5.64%
6.94%
5.93%
5.00%
4%
5%
6%
7%
8%
9%
10%
Readmission RateJanuary 2011 - March 2014
Readmit Rate Target (6.4%)
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Thank You
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