Increasing the Percentage of Heart Failure Patients Who Receive Heart Failure Discharge Instruction from 45.3% to at Least 90%
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1 Increasing the Percentage of Heart Failure Patients Who Receive Heart Failure Discharge Instruction from 45.3% to at Least 90% Submitted by Joe DeFeo, President, Juran Institute, Juran Health Care, and J. Er Ralston, VP & Client Relationship Executive, Juran Health Care
2 A case study presentation from the ASQ Healthcare Division: Copyright 2009, Juran Institute. Used with permission. Submit your own case study to be considered for publication. What other content would you like to see on the Healthcare Division site? Let us know!
3 About the Organization A not-for-profit healthcare system Client of Juran Health Care
4 The Project Team Chief nursing officer (project champion) Director, clinical outcomes management (project team leader) Clinical coordinator, respiratory therapy Clinical coordinator, nursing unit Professional practice coordinator Management engineer
5 The Problem A not-for-profit healthcare system found that adherence to clinical quality observed metrics for inpatient heart failure discharge instruction was consistently below national standards. For fiscal year 2006, the average rate of compliance was 45.3%. Noncompliance could result in penalties with reimbursements from the Centers for Medicare and Medicaid Services (CMS), additional costs because of the potential of harm events, and a decrease in patient satisfaction.
6 Project Goal Increase observed rate of compliance for inpatients receiving heart failure discharge instruction from 45.3 to at least 90% by January Heart failure discharge instruction included written instructions or educational materials addressing a patient s activity level, diet, discharge medications, potential follow-up appointments, weight monitoring, and what to do if symptoms worsened.
7 Root Cause Analysis The Juran-coached team chose the Six Sigma DMAIC (define, measure, analyze, improve, control) approach and identified the following potential failures: No heart failure discharge form available Inadequate discharge planning Multiple discharge forms and types No single, definitive process owner Lack of standardized process Physicians discarding heart failure discharge instructions Medication reconciliation incomplete at time of discharge No accountability or ownership for process compliance
8 Addressing Root Causes Using Juran s Pareto Analysis, the project team identified the vital factors contributing to the problem: The nursing unit discharging the patient The specific type of pre-printed physician heart failure discharge instruction The hospital employees' knowledge level of the six discharge instruction elements: 1. A patient s activity 4. Any potential follow-up level appointments 2. His/her diet 5. His/her weight monitoring 3. His/her discharge 6. What a patient should do if medications symptoms worsened Having all six discharge instructions on the various pre-printed physician cardiac forms
9 Addressing Root Causes To counter these vital Xs, the team developed strategies that would improve the process: Standardizing the discharge process across all nursing units Standardizing the most effective type of discharge instruction Improving the knowledge level of heart failure discharge instruction elements unit-by-unit with oneon-one training Standardizing and simplifying the heart failure discharge instruction process
10 Results Based on a three-month pilot, the project was able to reach its goal of a 90% compliance rate with heart failure discharge instruction. A control plan was developed to monitor the observed rate of compliance and use of the heart failure discharge form on a monthly basis.
11 Ongoing Improvement The implementation of standardization in each segment of the process bred improvements for the overall process. Included in the standardization of processes were the discharge of patients in nursing units, finding the most effective type of discharge instruction, improving the overall knowledge of staff through training of heart to failure instruction, and, finally, simplifying the heart failure discharge instruction process.
12 Critical-to-Quality (CTQ) Matrix
13 Pareto Analysis
14 For More Information Learn more about the Juran Institute and Juran Health Care: More case study presentations are available from the ASQ Healthcare Division: Read healthcare case study articles from ASQ: To find articles, books, courses, and other resources on healthcare quality, search the ASQ Knowledge Center:
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