Narrowing the Scope of a QI Project Using Root Cause Analysis IDEAS Alumni event October 13, 2015 Nicole Robinson and Rachel Stack www.ideasontario.ca 1
Meet Bob patient with high care needs Male patient in his 70s Lives alone in Elgin County History of CAD with stents, angina, recurrent falls, GERD, rheumatoid arthritis Had 28 visits to ER in 2014 Was admitted/readmitted to St. Thomas Elgin General Hospital 15 times in 2014 Has substance abuse concerns www.ideasontario.ca 2
Readmissions.It s a BIG Problem The Cost of Inpatient Readmissions Based on a recent study (September 2012), inpatient readmissions within 30 days of discharge cost the Canadian health care system an estimated $1.8 billion during the study period CMAJ September 4, 2012 vol. 184 no. 12 First published August 7, 2012, doi: 10.1503/cmaj.109-4245 www.ideasontario.ca 3
Readmissions..it is complex! Ross Baker, November 2011 www.ideasontario.ca 4
The problem at a Hospital Level St Thomas Elgin General hospital consistently experienced higher than expected readmission rates (~20% actual, compared to ~16% expected). data reported as of September 2014 www.ideasontario.ca 5
Case Study (Part 1) At your table, please review the case scenario and divide the team roles amongst the group. Step 1: Identify what happened - Start by process mapping Bob s journey. Begin at point of the team identifying discharge at bullet rounds to readmission to the hospital. (15 minutes) Step 2: Determine what should have happened - After you have mapped the current state, discuss in the team what the ideal or future state process should have looked like. (10 minutes) www.ideasontario.ca 6
Process Map with Key Data Where are the greatest opportunities? www.ideasontario.ca 7
Case Study (Part 2) Step 3: Determine causes - At your table, apply the five whys to determine the root cause of Bob s readmission to hospital. Step 4: Based on the five whys discussion, develop a causal statement(s). Remember: A causal statement has three parts: the cause ( This happened ), the effect ( which led to something else happening ), and the event ( which caused this undesirable outcome ). www.ideasontario.ca 8
St. Thomas Elgin General Hospital Step 5: Generate a list of recommended actions to prevent the recurrence of the event What could STEGH do? Step 6: Write a summary and share it How did STEGH summarize and share? www.ideasontario.ca 9
3 What will have the greatest impact?...and would be the easiest to implement? 1 Where to start? What are the key drivers/ contributors to improving transitions of care from hospital to primary care consider the literature and /OR the data? 2 How can you scope/ focus? Where are the GAPS? -identification of top problems - data driven? By pareto? -where is other work happening that can be leveraged? (complimentary) -should you scope or focus based on emerging or planned disruptive technologies? 4 What can you learn from understanding the patient experience? www.ideasontario.ca 10
Understanding the Data Audit on Medical Unit 4 th and 5 th (45 admit pt charts reviewed, 41 correct (91%)) + (54 admits 49 correct (90%)) *only 3 with no family doctor noted at all Average summary dictation time 25 hours, October, 11% or 25 patients had no discharge summary?proportion of patients seeing primary care provider within 7 days of discharge? Health Records Not meeting 24 hour turn around time goal. Currently no standard for priority transcriptions, almost 36% in October were flagged priority Scorecard Tracking 31.6% of (all) discharge summaries were sent from St. Thomas Hospital to primary care providers in 48 hours (patient discharge to sign off) Primary Care Physician Audit result 43% of discharge summaries received within 48 hours of patient discharge www.ideasontario.ca 11
Narrowing the Focus Focus on the transition to primary care Starting point is improving communication between hospital and primary care discharge summary timeliness Process included 3 key steps: dictation, transcription, and authentication/ send. New transcription system was implemented, the focus narrowed further to include dictation and authentication/send processes. Finally ensuring patients have timely follow ups with primary care post discharge www.ideasontario.ca 12
Using the Data to Narrow the Scope Early results that were used to drill down: Data for October (Cerner Report) shows an average dictation time of 25 hours. This average was influenced by some outliers. Follow up is underway to understand the reasons for the outliers. An audit was conducted by an Elgin County primary care provider to verify the proportion of discharge summaries for acute medical patients discharged in October, that were received in 48 hours (total 43%). From this audit we found the following: The barrier/delay seemed to be with the sign off or authentication time for many of the summaries Next Steps include: Expanding the primary care audit to increase sample size from one physician to a group, Confirm the number of patients that actually went for an appointment within 7 days of discharge Establishing regular reporting for baseline capture and on-going monitoring of discharge summary process measures www.ideasontario.ca 13
Impact Impact v Effort Effort Major Improvement / Benefit Difficult to Do Primary Care to participate in LENs notifier Use EDMS to predict discharge date Std for dictation complete within 24hrs Make it mandatory for primary care to use SPIRE Easy to Do Survey primary care re notification preference + fax numbers Survey primary care fax numbers to reduce mail distribution annual? Ward clerk to schedule an apt for pt prior to pt leaving hospital Criteria for priority transcript Send discharge summary to CCAC for pt s Minor Improvement / Benefit Contact primary care to notify of admitted pt (ward clerk, Dr to Dr communication) Ward clerk notify primary care provider (phone) that pt admitted (same day or in am) Dr to Dr conversation discuss plan would be helpful in some cases? (criteria) Criteria for follow up apt with primary care 7 days (i.e. med changes select CMG s etc) www.ideasontario.ca 14
Our Aim Statement High level Aim (goal) To optimize transitions of care for acute medical patients (hospital to community post discharge) Reduce Readmissions Aim To increase the proportion of acute medical patients with select CMGs (as appropriate) discharged from St Thomas Elgin General Hospital seeing primary care provider within 7 days of discharge from ~23% to 30% by March 31, 2015 Increase percent post discharge with follow up Aim To increase the proportion of discharge summaries sent within 48 hours from St. Thomas hospital to primary care or community provider for acute medical patients from 41% to 80% by March 2015 Timeliness of Discharge Summaries www.ideasontario.ca 15
Change Idea Categories Partnership with CHC Eat dinner earlier A S P D Schedule follow up appointments prior to discharge Reduce Readmissions Patient Education (BPMH, standard) Try new blinds on windows Physician Scorecards/ Discharge Summaries/ Auto-send www.ideasontario.ca 16 16
RESULTS www.ideasontario.ca 17
Snapshot Impact Summary Dictation turn around times were reduced from ~24 hours to 9 hours (mean) Transcription turn around times were reduced from ~48 hours to 2 hours (based on new system implantation) Discharge summary process streamlined to eliminate report authentication auto send Overall percent of discharge summaries sent from hospital to primary care within 48 hours increased from 41% (august 2014 to 87% (September 2015) Improved patients having a scheduled following up appointment to 100% Over the past 8 months, a significant reduction in readmissions was demonstrated this translates into an actual cost avoidance of $325,699 (based on net reduction of 47 readmissions in 8 months) www.ideasontario.ca 18
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Impact at the Patient Level Bob s Experience January April 2015 2. Emergency Department Reduced visits to ER 2014-28 visits to ER 2015 7 visits to ER (so far) 1. Living in Community ACTION - Connecting to supports in the community Discharge summary sent to primary care on Feb 14 (21:32) On Feb 19 patient had a follow up appointment with primary care provider. He has not had another ER visit since 22the follow up. 3. Acute Care/ Sub-Acute Care Admissions to Hospital 2014 15 admissions 2015 3 admissions Feb 12, discharged on Feb 14 22 *Baselines established between 2007-2011
Impact at the Patient Level Bob s Experience April - September 2015 2. Emergency Department Reduced visits to ER 2014-28 visits to ER 2015 17 visits to ER (10 more visits since Feb) 1. Living in Community ACTION - Connecting to supports in the community Discharge summary sent to primary care on Feb 14 3. Acute Care/ Sub-Acute Care Admissions to Hospital 2014 15 admissions 2015 6 admissions On Feb 19 patient had a follow up appointment with primary care provider. He has not had another ER visit since the follow up. 23 23Next ER visit was May 5 *Baselines established between 2007-2011 www.ideasontario.ca 23
SPREAD www.ideasontario.ca 24
Quality Improvement Plans Identified Cross Sector Focus Areas 1 Targeting an improvement in readmissions Key Focus for 2016-17 (cross sector) is aligned to the following key strategies: 1. Support reduced readmissions to hospital within 30 days by spreading implementation of the following change ideas: a. Increasing the timeliness of discharge summaries sent within 48 hours from hospital to primary care providers (Hospital) b. Increasing the proportion of patients with a post discharge follow up appointment scheduled with primary care (Hospital) c. Increasing the percent of patients seeing their family health care provider within 7 days of discharge (Community Health Centres, Family Health Teams) d. Increasing the percent of unattached patients connected to a primary care provider post discharge (Community Health Centres, Family Health Teams) www.ideasontario.ca 25
QIP Spread Strategy Facilitating on-going collaborative sessions between LHIN, St Thomas; and London Hospitals Spread and sustainability plan implemented through. the Health Links Learning Collaborative (standard change ideas for teams on the ground) Leadership Steering Committees across South West - reflected in key QIPs across sectors (Primary Care, CHC, and Hospital) Partnership and referral process to refer unattached orphan patients www.ideasontario.ca 26
Further Improvement Opportunities Survey primary care providers in Elgin County to understand their perspective on progress and further improvement opportunities Improve accuracy of discharge summary communication to CCAC and Long-term Care and Retirement Homes Consider risk of readmission in determining best follow up approach www.ideasontario.ca 27