The STAAR Initiative

The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1

Table of Contents STAAR Collaborative Charter... 3 Statement of Need... 3 Mission... 4 Goals... 4 STAAR Collaborative Activities... 4 Getting Started... 5 Step 1. The Hospital CEO Selects an Executive Sponsor for the Hospital s Participation in the STAAR Collaborative... 5 Step 2. The Sponsor Convenes a Cross-Continuum Improvement Team... 5 Step 3. Identify Opportunities for Improvement... 6 Step 4. Develop an Aim Statement for the STAAR Collaborative... 11 Step 5: Prepare for Particiaption at the Learning Session... 12 Appendix: IHI STAAR Diagnostic Tool... Error! Bookmark not defined. Institute for Healthcare Improvement, 2010 Page 2

STAAR Collaborative Charter Statement of Need James, a 68-year-old man, lives at home with Martha, his wife of 48 years. He was admitted to the hospital with shortness of breath and diagnosed with pneumonia and underlying onset of heart failure. He and Martha were provided with instructions about new medications and diet before discharge and asked to see his physician in the office in two weeks. A few days after returning home, Martha reminded James to schedule his visit to the physician s office, but James had difficulty reaching the scheduler. Finally, he was able to set up a visit for three weeks later. James didn t mention to Martha that he took the three-day supply of Lasix the hospital sent home with him but never filled his prescription; he felt well again and thought the expense unnecessary. When he noticed swelling in his legs, he didn't want to bother the "busy doctor" and dreaded the ordeal of calling the office again. After 11 days, James was readmitted to the hospital with increased shortness of breath, marked edema of his lower legs, a weight gain of 25 pounds, and mildly elevated brain natriuretic peptide (BNP), a marker of cardiac insufficiency. His hospital stay went well, but James stress level was high, his blood pressure was elevated, and another drug was added to his medication regimen. While James was in the hospital, Martha was admitted for an emergency surgery. After his discharge, James began eating in fast food restaurants as he worried about his wife, juggled visits to Martha s bedside, and managed a roofing project on their home. The day Martha came home from the hospital, James was readmitted with exacerbation of heart failure. Poorly executed transitions in care like the one described above negatively affect patients health, well-being, and family resources. They also unnecessarily increase the costs incurred by health care systems and the patients, families, and communities they serve. Maintaining continuity in patients' medical care is especially critical following discharge from the hospital, and for older patients with multiple chronic conditions this "handoff" period takes on even greater importance. Research shows that one-quarter to one-third of these patients have to return to the hospital due to complications that could have been prevented. 1 1 Naylor M. Making the bridge from hospital to home. The Commonwealth Fund; Fall 2003. Available at: http://www.commonwealthfund.org/spotlights/spotlights_show.htm?doc_id=225298. Accessed July 12, 2009. Institute for Healthcare Improvement, 2010 Page 3

Mission The mission of the STAAR Collaborative is to bring together patients, cross-continuum care providers, and other stakeholders in Massachusetts to improve transitions in care after patients are discharged from the hospital and to reduce avoidable readmissions. The STAAR Collaborative will be led by the Institute for Healthcare Improvement (IHI) whose expert faculty and improvement advisors will provide ongoing education and coaching for teams from participating hospitals. The STAAR Collaborative will focus on creating an ideal transition out of the hospital and into the next setting of care. Medical-surgical units from participating hospitals will work on improving processes in four key areas: 1) perform an enhanced assessment of post-discharge needs; 2) provide effective teaching and facilitate learning; 3) conduct real-time handoff communications at discharge; and 4) ensure timely post-acute follow up. Goals The overall aim of the STAAR Collaborative is for participating hospitals to decrease all-cause 30- day readmission rates and to improve HCAPHS scores related to discharge preparations. By the end of this phase of the STAAR Collaborative, collaborative teams should demonstrate success in implementing the key changes and display progress in the process measures for the four key changes. STAAR Collaborative Activities The IHI faculty team in collaboration with state leaders will conduct the following activities: Lead a Learning Session February 2-3, 2011. The learning Session will equip teams from participating hospitals with the change ideas and skills needed to begin making improvements in their processes of care. Organize and lead bi-monthly conference calls and WebEx sessions that bring together expert faculty and teams from participating hospitals to discuss progress, address challenges, and share details of successful changes. Provide an online communication system to share information and resources, and to serve as a hub of shared learning across the participating hospitals. Review monthly progress of participating hospitals and provide guidance to the collaborative teams to assist them in achieving their stated aims. Institute for Healthcare Improvement, 2010 Page 4

Teams from participating hospitals will: Attend the Learning Session. Actively participate on collaborative conference calls and WebEx sessions to share learning and results. Conduct tests of recommended changes in the four areas to improve transitions home. After successful testing and adapting changes, implement the changes in each pilot unit. Submit process and outcome data on a monthly basis. Submit quarterly a completed STAAR Collaborative Storyboard (a template will be provided) that describes the changes the improvement team has tested, implemented and spread; describes ongoing learning; and provides details about successful changes. Getting Started This Getting Started Kit is designed to assist participating hospitals in preparing for their participation in the STAAR Collaborative. The activities outlined below should be completed prior to the Learning Session on February 2 and 3, 2011. Step 1. The Hospital CEO Selects an Executive Sponsor and a Day-to-Day Leader for the Hospital s Participation in the STAAR Collaborative. The role of the executive leader is to link the goals of the STAAR Collaborative to the strategic priorities of the organization. The leader will provide oversight and guidance to their teams work. Depending on the size and organizational structure of the hospital, typical executive leaders may include CEOs, COOs, Chief Nursing Officers, Medical Directors, or Chief Quality Officers. The executive leader should also select a day-to-day leader for the STAAR Collaborative who will coordinate project activities, provide guidance and support to the medical/surgical unit teams, help to lead the cross-continuum team, and serve as the hospital s key contact to the STAAR Collaborative. This person is often a quality improvement leader, a physician champion, or a nurse director. Step 2. The Sponsor Convenes a Cross-Continuum Improvement Team. Form a multi-stakeholder team with representatives from across the care continuum, as well as patients and family members. This team will provide oversight for the STAAR Collaborative s efforts to assist participating hospitals in creating an ideal transition to their home or a skilled nursing facility. By understanding the mutual interdependencies and identifying internal customers and suppliers for every step of the patient journey across the care continuum, the team will shape redesigned processes. Collectively, team members will explore the ideal flow of information as the patient moves from one setting to the next and learn how to improve transition handoffs. Consider choosing team members from the following: Institute for Healthcare Improvement, 2010 Page 5

Patients and Family Members 2 Hospital Staff, such as: Nurse Managers, Nurse Educators and Staff Nurses; Hospital Physicians or Hospitalists; Case Managers; Pharmacist; or Quality Improvement Leaders Staff from Skilled Nursing Facilities, such as: Nursing Leaders or Physician Leaders Clinicians and Staff from Office Practice Settings, such as: Primary Care Physicians and Specialists; Nurses or Nurse Practitioners; or Practice Administrators Staff from Community Social Services Agencies, such as: Case Managers, Home Care Nurses, or Staff from Elder Services At the first meeting of the Cross-Continuum Team, describe the goals of the STAAR Collaborative and the role of this team in providing oversight for its improvement work. Initial activities for the Cross-Continuum Team include: participation in the in-depth review of last five rehospitalizations; attendance at the learning session (October 27 and 28); and supporting the pilot unit improvement team when co-design of processes across care sites is needed on an ad hoc basis. Examples of these processes include the handoff of information out of the hospital, or assuring that the PCP office has appointments for individuals being discharged. Many organizations find that creating small workgroups to complete the pre-work (outlined in steps 3 through 5) is helpful. Step 3. The Team Identifies Opportunities for Improvement. 3a. Perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement.! Conduct chart reviews of the last five readmissions, transcribing key information onto the data collection sheets (see Appendix, Worksheet A).! Conduct interviews with patients recently readmitted and their family members. If possible, interview the same patients whose charts were reviewed. Next, conduct interviews with clinicians in the community who also know the readmitted patient (physicians, nurses in the skilled nursing facility, home care nurses, etc.) to identify problem areas from their perspective. Transcribe information from these interviews onto the data collection sheet (see Appendix, Worksheet B). 2 For more information on including patients and family members on improvement teams go to: http://www.ihi.org/ihi/topics/patientcenteredcare/patientcenteredcaregeneral/literature/p artneringwithpatientsandfamilies.htm http://www.ipfcc.org/tools/downloads.html Institute for Healthcare Improvement, 2010 Page 6

3b. Review patient experience data regarding communications and discharge preparations to identify opportunities for improvement. Evaluate trends in the scores of the communication and discharge preparation questions on your patient satisfaction or patient experience survey for the last year. Use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or tailored hospital survey questions, if equivalent. Refer to www.hcahpsonline.org for the complete list of HCAHPS questions. Display this trending data on a run chart which depicts the data for the entire hospital, by month, for the last 12 months. Measure Description Numerator Denominator Data Collection Strategy Outcome Measures: Patient Experience HCAHPS Communication Question 7 How often did doctors explain things in a way you could understand? (Q7) Number patients surveyed in the month who answered, always Number of surveys completed in the month for the hospital with an answer for this question Report the data provided by your survey vendor or the results of surveys you conduct. HCAHPS Communication Question 3 During this hospital stay, how often did nurses explain things in a way you could understand? (Q3) Number patients surveyed in the month who answered, always Number of surveys completed in the month for the hospital with an answer for this question Report monthly HCAHPS Discharge Question 19 Did hospital staff talk with you about whether you would have the help you needed when you left the hospital? (Q19) Number patients surveyed in the month who answered, yes Number of surveys completed in the month for the hospital with an answer for this question HCAHPS Discharge Question 20 Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? (Q20) Number patients surveyed in the month who answered, yes Number of surveys completed in the month for the hospital with an answer for this question Institute for Healthcare Improvement, 2010 Page 7

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Measure Description Numerator Denominator Data Collection Strategy Outcome Measures: Readmissions 30-Day All-Cause Readmissions Readmissions Count Optional Measure 30-Day All-Cause Readmissions for a Specific Clinical Condition Percent of discharges with readmission for any cause within 30 days Number of readmissions (numerator for % readmissions) Percent of discharges with a specific clinical condition who were readmitted for any cause within 30 days of discharge Number of discharges with readmission for any cause within 30 days of discharge. Exclusion: planned readmissions (e.g., chemotherapy schedule, rehab, planned surgery, renal dialysis) The number of discharges in the month. Exclusions: labor and delivery, transfers to another acute care hospital, patients who die before discharge Write a report to run no sooner than 31 days after the end of the measurement month. This report will: 1a. Pull all the discharges in the measurement month 1b: Remove exclusions (transfers to other acute care, deceased before discharge, Labor and Delivery) $ The number of discharges after you remove the exclusions is your denominator (or index discharges ) 2a. Through the unique medical record identifier, identify those (index) discharges that resulted in readmissions within 30 days of the discharge $ 2b. Remove exclusions (planned readmissions like chemotherapy, radiation, rehab, planned surgery, renal dialysis)$ The number of (index) discharges that resulted in readmissions within 30 days will be your numerator NA NA Use the numerator for the above measure Number of discharges with a specific clinical condition readmitted for any cause within 30 days of discharge. Exclusion: planned readmissions (e.g., chemotherapy schedule, rehab, planned surgery) Number of discharges in the month with the specific clinical condition. Exclusions: labor and delivery, transfers to another acute care hospital, patients who die before discharge See above Institute for Healthcare Improvement, 2010 Page 9

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Step 4. Develop an Aim Statement for the STAAR Collaborative 4a. Report findings from Step 3 to the entire Cross-Continuum Team.! Chart reviews for readmitted patients (see Appendix, Worksheet A)! Interviews with readmitted patients, their families, and clinicians in the community (see Appendix, Worksheet B)! Trending data of patient experience with discharge preparations (HCAPHS)! Trending data for 30-day all-cause readmission rates Share the stories of the patients and families and their struggles to navigate transitions in care between participating facilities as well. Such stories will resonate more deeply than the statistics. 4b. Select one or two pilot units for participation in the STAAR Collaborative. Based on the review of hospital-wide data on 30-day all-cause readmission rate, the Cross- Continuum Improvement Team selects one or two medical surgical units where readmissions are most likely to occur. If there is a particular patient population within one or both of these units that accounts for a large percent of the readmissions (e.g., heart failure patients) then the teams may want to focus their testing initially on this patient segment within the unit. Process improvements can then be further tested and implemented for all patients on the selected pilot units. The size of the Pilot Unit(s) Improvement Teams will vary from hospital to hospital but would probably involve 4 to 6 people. The Pilot Unit Improvement Team will be the group of people who test changes in care delivery processes on the unit. Each Team should consist of: Team Leader for each pilot unit who will drive the work on their respective pilot units (e.g., Nurse Manager); Patients and Family Members; Physician Champions (this person may be a cardiologist, intensivist, primary care physician, or specialist depending on the specific unit selected); Staff nurses; Social workers and/or discharge planners; and Ad hoc Cross-Continuum team members as needed. 4c. Write an aim statement. Aim statements communicate to all stakeholders the magnitude of change and the time by which the change will happen. Aim statements help teams commit to the improvement work. The Cross-Continuum Improvement Team develops a clear aim statement for reducing readmissions in the selected pilot units. Effective aim statements include five pieces of information: Institute for Healthcare Improvement, 2010 Page 11

What to improve Where (specific unit or entire hospital) For which patients By when (date specific deadline) Measurable goal Sample aim statements: 1) By December 2011, St. Elsewhere hospital will improve transitions home for patients on 4W and 5S as measured by a decrease in 30-day all-cause readmission rate from 17% to 13% or less. The pilot units will focus on improving planning for discharge, patientcentered handovers to community providers, post-acute follow-up and improving patients understanding of self-care. 2) General Hospital will improve transitions home for elderly patients as measured by a reduction in unplanned 30-day readmissions of elderly patients from 25 percent to 15 percent or less by December 31, 2011. We will focus on enhanced assessment for discharge needs, coordination with community providers, and health literacy. For more on setting aims, see: http://www.ihi.org/ihi/topics/chronicconditions/allconditions/howtoimprove/chronicsettingaims.htm Step 5. Prepare for Participation at the Learning Session! Attend preparatory pre-work calls. Date and Time TBD Date and Time TBD MA STAAR Pre-Work Calls Pre-Work Call (1/3) to focus on cross-continuum team development Pre-Work Call (2/3) to focus on diagnostic review Date and Time TBD Date and Time TBD Day-to-Day Leader Q&A Call to prepare for Learning Session (participation optional) Pre-Work Call (3/3) to focus on key measures Institute for Healthcare Improvement, 2010 Page 12

! Identify who will attend the Learning Session for the STAAR Collaborative. Participants may include the following people: Executive Leader ; Day-to-Day Leader; Patients and Family Members; Members of the Cross-Continuum Improvement Team (e.g., representatives from nursing homes, home health, and physician office practices); and Pilot Unit Team Members (e.g., staff nurses, nurse manager, hospitalist, etc.).! Register for the Learning Session Instructions on registering for the Learning Session will be provided at a later date.! Prepare a Storyboard for the Learning Session Each hospital team in the Collaborative will bring a storyboard to the Learning Session with template provided by IHI. Large poster boards will be available for each team to post their storyboard. Institute for Healthcare Improvement, 2010 Page 13

Appendix: IHI STAAR Diagnostic Tool Worksheets A & B Institute for Healthcare Improvement, 2010 Page 14

Worksheet A: Chart Reviews of Patients Who Were Readmitted Conduct chart reviews of the last five readmitted patients. Reviewers should be physicians or nurses from the hospital and community settings. Reviewers should not look to assign blame, but rather to discover opportunities to improve the care of patients. Question Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Number of days between the last discharge and this readmission date? Was the follow-up physician visit scheduled prior to discharge? If yes, was the patient able to attend the office visit? days days days days days Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Were there any urgent clinic/ed visits before readmission? Yes No Yes No Yes No Yes No Yes No Functional status of the patient on discharge? Comments: Comments: Comments: Comments: Comments: Was a clear discharge plan documented? Yes No Yes No Yes No Yes No Yes No Was evidence of Teach Back documented Yes No Yes No Yes No Yes No Yes No List any documented reason/s for readmission Comments: Comments: Comments: Comments: Comments: Did any social conditions (transportation, lack of money for medication, lack of housing) contribute to the readmission? Yes No Yes No Yes No Yes No Yes No Institute for Healthcare Improvement, 2010 Page 15

Worksheet A: Reflective Summary of Chart Review Findings What did you learn? What trends or themes emerged? What, if anything, surprised you? What new questions do you have? What are you curious about? What do you think you should do next? What assumptions about readmissions that you held previously are now challenged? Institute for Healthcare Improvement, 2010 Page 16

Worksheet B: Interviews with Patients, Family Members, and Care Team Members If possible, conduct the interviews on the same patients from the chart review. Use a separate worksheet for each interview. Ask Patients and Families: How do you think you became sick enough to come back to the hospital? Did you see your doctor or the doctor s nurse in the office before you came back to the hospital? Yes If yes, which doctor (PCP or specialist) did you see? No If no, why not? Describe any difficulties you had to get an appointment or getting to that office visit. Has anything gotten in the way of your taking your medicines? How do you take your medicines and set up your pills each day? Describe your typical meals since you got home. Ask Care Team Members: What do you think caused this patient to be readmitted? After talking to the provider and the care team about why they think the patient was readmitted, write a brief story about the patient s circumstances that contributed to the readmission: Institute for Healthcare Improvement, 2010 Page 17

Worksheet B: Summary of Interview Findings What did you learn? What were the most common failures discovered? What trends or themes emerged? What, if anything, surprised you? What new questions do you have? What are you now curious about? What do you think you should do next? What assumptions about readmissions that you held previously are now challenged? Institute for Healthcare Improvement, 2010 Page 18

List of Typical Failures: Typical failures associated with patient assessment: Failure to actively include the patient and family caregivers in identifying needs, resources, and planning for the discharge; Unrealistic optimism of patient and family to manage at home; Failure to recognize worsening clinical status in the hospital; Lack of understanding of the patient s physical and cognitive functional health status may result in a transfer to a care venue that does not meet the patient s needs; Not addressing whole patient (underlying depression, etc.); No advance directive or planning beyond DNR status; Medication errors and adverse drug events; and Multiple drugs exceed patient s ability to manage. Typical failures found in patient and family caregiver education: Assuming the patient is the key learner; Written discharge instructions that are confusing, contradictory to other instructions, or not tailored to a patient s level of health literacy or current health status; Failure to ask clarifying questions on instructions and plan of care; and Non-adherent patients (resulting in unplanned readmissions): a. About self-care, diet, medications, therapies, daily weights, follow-up and testing; and b. Caused by patient and family-caregiver confusion. Typical failures in handover communication: Poor hospital care (evidence-based care missing/incomplete); Medication discrepancies; Discharge plan not communicated in a timely fashion or adequately conveying important anticipated next steps; Poor communication of the care plan to the nursing home team, home health care team, primary care physician, or family caregiver; Current and baseline functional status of patient rarely described, making it difficult to assess progress and prognosis; Discharge instructions missing, inadequate, incomplete, or illegible; Patient returning home without essential equipment (e.g., scale, supplemental oxygen, or equipment used to suction respiratory secretions); Having the care provided by the facility unravel as the patient leaves the hospital (e.g., poorly understood cognition issues emerge); and Poor understanding that social support is lacking. Typical failures following discharge from the hospital: Medication errors; Discharge instructions that are confusing, contradictory to other instructions, or are not tailored to a patient s level of health literacy; No follow-up appointment or follow-up needed with additional physician expertise; Follow-up too long after hospitalization; Follow-up is the responsibility of the patient; Inability to keep follow-up appointments because of illness or transportation issues; Lack of an emergency plan with number the patient should call first; Multiple care providers; patient believes someone is in charge; Lack of social support; and Patient lack of adherence to self-care, e.g., medications, therapies, daily weights, or wound care because of poor understanding or confusion about needed care, transportation, how to get appointments, or how to access or pay for medications. Institute for Healthcare Improvement, 2010 Page 19