C10 This presenter has nothing to disclose Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections David Renfro, MS, RN NE BC Kelly Farnam, BSN, RN Gloria Martinez, MS, RN, NEA BC Denise Renfro, MS, RN Jennifer Ellman, MSN, RN, NE BC, CEN Tuesday, December 6 1:30pm #IHIFORUM Coordinated by Emily Stallings Session Objectives P2 Describe proven strategies for leveraging nurses to improve rates of readmission, sepsis, and healthcare associated infections Understand the potential impact of direct care nurse leadership Identify focus areas at your facility in which nursedriven improvement could have a positive impact on clinical outcomes #IHIFORUM 1
Session Guide P3 Four short presentations about improvement work led by direct-care staff. 1. Readmission Reduction (Project RED) 2. Transition Education 3. Reducing Sepsis Mortality 4. Reducing Healthcare-Associated Infections Time for questions between each presentation Lessons learned and advice to take with you 2
VA Palo Alto Health Care System P5 Enrolled Veterans 84,432 Veterans treated in FY 15: 67,640 Outpatient visits: 829,990 Inpatient Admissions: 6,144 Catchment area: 13,500 Square miles Total Budget: $930 million Total FTE: +4,000 Academic Affiliation Characteristics for Nurse-Driven Improvements P6 Patient safety or satisfaction focused Evidence based practice change Includes a range of environments Willingness to lead at the direct care level Strong leadership commitment, support and coaching Change evident in patient outcomes Commitment to developing confident, competent, credible nursing staff 3
P7 Leveraging the Expertise of Direct-Care Staff to Reduce Hospital Readmissions Kelly Farnam, BSN, RN Willie Payton Jr., MHSA Nicole Briones Identifying a Problem P8 Lack of standardized discharge process Readmission rates rising 2011 rate of 13% Medication discrepancy rate of 38% 4
Choosing a Strategy P9 Strategy options: BOOST, STAAR, TCM, Project RED Existing case management structure Nurse engagement for planning The RED Model: 12 Elements 7. 1.Educate Review the patient what the throughout patient to do the in throughout an emergency the stay hospital and who stay to contact 2. Make post discharge appointments prior to discharge with patient input 3. Discuss pending tests and studies and how to learn results 4. Organize post discharge services 5. Medication reconciliation 6. Reconcile the discharge plan with national guidelines and clinical pathways P10 7. Review what to do in an emergency and who to contact 8. Ensure discharge summary follows patient to next care location 9. Utilize teach back to assess patient understanding of instructions 10.Give the patient a written discharge plan 11.Call the patient after discharge to answer any questions and follow up on any pending items 12.Ascertain the need for language assistance 5
Empowering Direct Care Staff P11 Standardize Discharge Across the Board Multidisciplinary collaboration Focus on the whole transition of care Empower bedside nurse to ensure a safe discharge Discharge education documents are created by nurse to eliminate education gaps P12 6
A Strategy for Success Direct actions for bedside nurses Voice concerns about readmission before discharge Transition Coordinators Access patient data for those readmitted within 30 days Facilitate communication between inpatient and outpatient providers Attend daily multidisciplinary meeting to identify patients with key diagnosis, and assess need for enrollment in Project RED P13 A Strategy for Success ICU Discharge All Intensive Care Unit patients being discharged directly home have their care coordination assessed by Project RED Transition Coordinators Discharge Appointment Coordinator Works with each individual patient prior to discharge to schedule follow up appointments at the most convenient time and date for the patient After Hospital Care Plan (AHCP) P14 7
Outcomes Decreased readmissions by >30% Established reliable nursing discharge process Increased nursing communication with interdisciplinary teams Created a culture focusing on process, not people Decreased medication discrepancies P15 P16 20% 30 Day Readmission Rates 18% 16% 14% 12% 10% 8% 6% 30 Day Rate Baseline (12.8%) Goal Linear (30 Day Rate) 4% 2% 0% Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2014 2015 2016 8
P17 Determined Preventability of Readmissions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2014 2015 2016 70 60 50 40 30 20 10 0 Non Preventable Questionable Preventable N Readmits Lessons Learned P18 NOT EVERY READMISSION IS PREVENTABLE! Daily review is necessary to identify gaps for early resolution Post discharge calls by RN help bridge any gaps in care 9
P19 Questions? P20 Improving Education Through Engaging Direct-Care Staff Gloria Martinez, MS, RN, NEA BC Kelly Farnam, BSN, RN Nicole Briones 10
State of Education Call to Action: Only 40% of patients at discharge could state why they had been admitted Discharge Instructions confusing and hard to read Solutions Implemented: Began discharge education process at admission Implemented a new teaching tool (After Hospital Care Plan) Educated the patient utilizing teach back Have direct care nurses lead and coach the process Created teach back videos to train staff P21 Video- The Bad P22 #IHIFORUM 11
Video- The Good P23 Maintaining the Momentum Teach back as the only way to educate patients Taking ownership of the teaching process Teach back champions on each unit to address unit specific challenges (OR/PACU how to make teach back relevant) Ensure all nurses get teach back education as part of their new hire orientation Incorporate teach back as a part of nursing documentation P24 12
Educational Materials P25 #IHIFORUM P26 13
Get Feedback from Patients! P27 Veteran and family friendly information. No medical jargon Allows for sharing of pertinent information with family/caregivers Has a notes section for patient or family to write questions to ask PCP Lessons Learned and Outcomes P28 Lessons Learned Staff development Investment Actively listen Patients learn better when you engage them Outcomes Peer accountability Active partner in care Patients love the care plan! 14
P29 Questions? P30 Sepsis Initiative: Developing Nurses as Leaders and Evidence-Based Practitioners Denise Renfro, MS, RN 15
Goal Develop emerging nurse leaders with the ability to be: 1. EBP Practitioners 2. Change Agents 3. Facilitators of learning 4. Consultants and initiative champions 5. Collaborators across disciplines 6. Confident communicators and presenters While also improving a facility clinical practice P31 Strategy Evidence Based Practice Fellowship Program Rigorous application process Investment of 72 hours (9 learning sessions) Theory and Application Development of Leadership Skills P32 Regional goal to reduce sepsis mortality rate by 10% 16
Staff-Driven Improvements P33 Johns Hopkins Model Sepsis Guidelines Pilot tests of change Screening Tool Order Set Simulation Outcomes Leadership development of direct care nurses Skill development and confidence Peer accountability and recognition Decreased sepsis mortality by 12% and saved 14 lives! P34 25 VA Palo Alto Sepsis Mortality 20 15 10 5 My Rate Regional Rate Linear (My Rate) 0 2009 2010 2011 2012 2013 2014 2015 17
Lessons Learned P35 Team stability Just in time coaching Interdisciplinary champions Evolving learner milestones Special Thanks P36 EBP Fellows: Kristina Castro, MSN, RN, CNL Kristen Valente, BSN, RN Desiree Picazo, BSN, RN Leisa Ann Bunte, BSN, RN Support From: Jane He, MD Roberta Oka, PhD, Nurse Scientist Jennifer Ellman, MSN, RN 18
P37 Questions? P38 Developing Nurse-Led Teams to Reduce Hospital-Acquired Infections Jennifer Ellman, MSN, RN, NE BC, CEN 19
Call to Action P39 C. difficile CLABSI MRSA Plan: Partner for Excellence P40 20
Develop Direct Care Staff P41 Align units under common goal Support psychological safety Create a culture to improve from within Strategy: Leverage the Workforce P42 Discover common challenges Appreciate uniqueness of specific practice environments Develop an inclusive plan Collaborate to remove barriers 21
Create a Roadmap P43 Assemble the right team Observe current state Review best practices Accountability Develop strategy and plan Root Cause Analysis P44 Why were we not meeting our goals? Education and Training Documentation and Communication Variability in Practice 22
P45 Develop a Mindset for Continuous Improvement Outcome P46 25.0 Hospital Onset Healthcare Facility Associated (HO HCFA) CDI Rate Acute Care Units Rate per 10,000 bed days of care 20.0 15.0 10.0 5.0 0.0 FY14Qtr1 FY14Qtr2 FY14QTR3 FY14QTR4 FY15QTR1 FY15QTR2 FY15QTR3 FY15QTR4 FY16QTR1 FY16QTR2 FY16QTR3 Quarter CDI rate VAPAHCS Acute Care rate goal Linear (CDI rate) 23
Outcome P47 Catheter Associated Urinary Tract Infections (CAUTI) Acute Care Units 3.0 Infection rate per 1,000 urinary catheter days 2.0 1.0 0.0 FY14Q1 FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3 Quarter CAUTI rate VAPAHCS Rate Goal (<=1.25) Lessons Learned P48 Challenges Hardwire the process Resistance High risk population Keys to success: Focus on the patient Leverage direct care staff and decentralize improvement teams Use evidence based practice 24
P49 Questions? Lessons Learned P50 Developing direct care leadership is an investment Focus only on processes, and not on people Develop coaching relationships with your direct care staff Encourage your nurses to showcase their capabilities Provide the time and resources to allow PDCA to work Listen to staff and to patients Empower and appreciate 25
Translating To Your Facility P51 Take the time to plan Build a strong team and include opinion leaders, directcare staff and patients Set ground rules for communication Assign champions and accountability Translating To Your Facility P52 Chunk and check Daily management Don t take no for an answer. Challenge the status quo Bust the myth Take risks and celebrate wins! 26
P53 Final Questions 27