5 Vital Tips to Help Reduce Readmissions in Hospitals

All Rights Reserved, Juran Global 1
Dr. Joseph A. DeFeo, CEO, Juran Global
Scott A. Regan, MBA, MHSA, SVP, Juran Global
5 Vital Tips to Help Reduce
Readmissions in Hospitals

Today’s Agenda
1. Attacking the readmission rate
problems most effectively
2. Using the right tools for
addressing readmission rate
problems
3. Engaging a multi-functional team
to address readmission rates
4. Engaging leadership to ensure
the organization is set up for
success
5. Picking the best place to begin

Our Legacy Ignited a Global Movement
Our Research and Experience is well
published.

Healthcare Organizations We’ve Worked With

This Month’s Healthcare Headlines
1

About the CMS Readmission Program
Learn Everything You Need to Know
 The Hospital Readmissions Reduction Program was created under the
Affordable Care Act, which requires CMS to reduce payments to hospitals
with excess readmissions.
 Penalties are based on readmissions for Medicare patients who were
originally admitted for:
– heart attack
– heart failure
– Pneumonia
– chronic obstructive pulmonary disease
– elective hip or knee replacements
 This year’s penalties will take effect from Oct. 1 through Sept. 30, 2016, and
are projected to cost hospitals a combined $420 million.
 The maximum penalty this year is a 3% reduction in Medicare payments; the
average penalty this year is 0.61%.

Healthcare’s Latest Cottage Industry

The Physician’s Treatment Process
Chief
Complaint
H&P,
Diagnostics
Diagnosis
Therapeutic
Intervention
Monitor,
Follow Up

The Administrator’s Treatment Process
Chief
Complaint
Therapeutic
Intervention

The First of Five Vital Tips
 Off-the-shelf interventions will work, but only if you are
lucky enough that the intervention you select matches a
correct diagnosis
 Which means you first need a correct diagnosis
 Which means you need valid analysis of the root cause of
your readmissions problems not someone else's
Tip #1: Contrary to what you read there is no
magic potion for a solution – But there is a magic
potion to analyze the problem

Tip #1: Magic Potion
 What the root cause isn’t:
– It is not the initial reaction or response
– It is not merely restating the finding
– It is not a symptom
 What the root cause usually is:
– Process or program failure
– System or organization failure
– Poorly written instructions
– Lack of training
Use the right method not the easiest
to identify the root causes
H & P
Diagnostics
Diagnosis

1. Define the problem WITH PRECISION
2. Collect and analyze facts WITH REAL
DATA
3. Develop theories and possible causes
BEFORE SOLUTIONS
4. Systematically reduce the possible
theories and causes using FACTS
5. Develop possible solutions BASED ON
ANALYSIS
6. Define and implement an action plan TO
CHANGE IT
7. Monitor and assess results TO HOLD
GAINS
Most effective means to determine the real root causes
H&P,
Diagnostics
Diagnosis

 We use Six Sigma as the starting point:
– Define the baseline and goal
– Measure current performance
– Analyze why, who, what, when…
• Pareto analysis (vital few vs. trivial many)
• Brainstorming
• Flow charts and process mapping
• Cause-and-effect diagram
– Analysis of data
– Improve with best affordable solution
– Control to hold the gains
Right Methods for Identifying the Root Cause
H&P,
Diagnostics
Diagnosis

Tip #1: Magic Bullets
 Implementing solutions because you
know why the readmits exist
 Looking for a single cause
– Often two or three causes
contribute and may be interacting
 Ending analysis at a symptomatic
cause
 Assigning as the cause of the problem
the “why” event that preceded the real
cause
Common Errors of Root Cause Analysis
H&P,
Diagnostics
Diagnosis

The Second of Five Vital Tips
Tip #2: Using the Right Method Right
or
H&P,
Diagnostics
Diagnosis

Tip #2: Bring the Right Method to the Job
Chief
Complaint
H&P,
Diagnostics
Diagnosis
Therapeutic
Intervention
Monitor,
Follow Up
Define Measure Analyze Improve Control
The Magic Potion for Analysis

The Third of Five Vital Tips
C
Multi-Functional
Team
Tip #3: Engage a Multi-Functional Team
Therapeutic
Intervention

Tip #3: Engage a Multifunctional Team
Conditions that Cause Most Readmissions (2011) Number
Medicare
1. Congestive heart failure 134,500
2. Septicemia 92,900
3. Pneumonia 88,800
4. Chronic obstructive pulmonary disease 77,900
5. Cardiac dysrhythmias 69,400
Medicaid and Commercial
6. Mood disorders 61,200
7. Schizophrenia and other psychotic disorders 35,800
8. Maintenance of chemotherapy or radiotherapy 25,500
9. Diabetes mellitus with complications 23,700
10. Complications of pregnancy 21,500
* According to the Agency for Healthcare Research & Quality, April 2014
Medicare
Penalties
Regardless the Condition, They Span Job Functions
Therapeutic
Intervention

Exit Writer PACS
Whiteboard
Sign-In
Sheet
EPICare
Amb
MS4
Chart Rack
Chart
Pyxis
US Rack
RALS
MUSE
Sign In
Triage Form
Triage/Primary
Assessment
MD Assessment/
Orders
Registration/Armband
Placement by RN
RN Assessment
Treatment/Procedure
Prep/IV/Labs Drawn
Diagnostics
MD Evaluation/
Disposition
Discharge Instructions
Discharge/Admit/
Transfer
Admitting Office/
Admin. Supervisor
Bed Placement
ED
Waiting
ED Exam/
Hallway
Med
Station
Supplies
Tube
Registration
Consult
They Also Span Departments
Therapeutic
Intervention

Effective Teams Use Effective Methods
Therapeutic
Intervention
Define Measure Analyze Improve Control

Measure
Analyze
Improve
Control
Define
Lean Six Sigma Roadmap

Problem and Goal
Problem Statement:
For My Hospital during the calendar year 2013, the
readmission rate for APR DRG 140 Chronic Obstructive
Pulmonary Disease (COPD) was 21.89%, which is above the
expected rate of 18.21%. Readmission rates higher than the
national rate result in decreased quality of care, poor patient
outcomes and decreased reimbursement and penalties from
the Centers of Medicare and Medicaid Services (CMS).
Goals/Objective(s):
Reduce the readmission rate for COPD from 21.89% to a
minimum of 18.21% (measured quarterly) or less starting
6/30/2014.
Define

Financial Impact: Business Case
1. Medicare penalties for excess readmissions
2. Medicaid penalties for excess readmissions
3. Cost of care of patients readmitted for COPD in excess of the expected number.
Performance worse than the expected rates adjusted for MSH results in penalties
and decreased reimbursement from CMS. Cost avoidance also is anticipated.
 By achieving the project goal (57 to 47 readmission cases), the hospital can
reduce total COPQ to $401,145, realizing $133,692 in savings.
 Note: My data do not include readmissions at other facilities; Medicaid claims are tracked by
Dept. of Healthcare and Family Services (affects final penalty).
COPQ Component
Current
Annualized Cost
Goal
Annualized Cost
Medicare penalties $2,319 $0
Medicaid penalties $46,023 $0
Cost of poor care $486,495 $401,145
TOTAL COPQ $534,837 $401,145
Define

Project Team Membership
Project Champions:
• Two MDs (one being CMO)
Project Core Team Members:
• Director of Disease Management
• Med/Surg Floor Nurse
• Clinical Pharmacy Manager
• Medical Intern
• Director of Respiratory Therapy
• Respiratory Therapy Day Supervisor
Ad Hoc Members or SMEs:
• Hospitalist
• Disease Management
Define

High Level Process Map (SIPOC) and CTQs
SIPOC: COPD Readmissions
SUPPLIER
INPUT
(use nouns)
PROCESS
(use verbs)
OUTPUT
(use nouns)
CUSTOMER CTQs
Patient or family
Patient
complaints /
symptoms
Admit patient Patient in room Treatment Team
Bed readily available at appropriate
level of care; Appropriate admission
Transport
Techs
Nursing &
medical staff
Patient
Diagnostics
Assess patient
H&P
Plan of Care
Physician
Nurse
RT
Correct Plan of Care; Timely verification
of COPD Order Set
Treatment Team
H&P
Plan of Care
Treat patient Interventions Patient
Timely availability of Plan of Care;
Timely implementation of COPD Order
Set; Appropriate spacer use
Treatment Team
Assessment
Diagnostics
Evaluate patient
Achievement of
treatment
expectations
Patient
Treatment Team
Appropriate evaluation according to
GOLD standards; Timely evaluation
(Nursing: every shift; Medicine: at least
daily)
Treatment Team
Education
materials and
equipment
Verbal instruction
Educate patient
Patient/family
with increased
knowledge and
skill base
Patient/family
Delivery of standardized education
(verbal & written); Documented
confirmation of patient/family
understanding & demonstration
Treatment Team
DC orders
DC
Plan/paperwork
Medications &
equipment
Discharge patient
Discharged
patient to
home/next level
of care
Patient/family
Next level of care
GOLD discharge criteria are met;
Discharged to appropriate setting;
Additional training needs identified;
Discharge paperwork reviewed;
Appointments scheduled; Inhalers
provided
Define

Detailed Process Map
Typical COPD inpatient LOS is about 3 days.
Measure

Measure Process Capability
The baseline CMS readmission rate was 21.89% for CY 2013,
above the expected rate of 18.21%.
Measure

Graphical Analyses – Selection of COPD
COPD and CHF readmissions were in the vital few APR DRGs, and determined
to be relatively controllable vs. other diagnoses.
Measure

Graphical Analyses – Readmission Trend
Both observed and expected readmission rates are variable over time, displaying
gradual decline over the prior two years. Observed readmission rates exceeded
the expected rate in 16 of 24 months.
Measure

Graphical Analyses – Readmission Reasons Measure
Most principal diagnoses for readmissions relate to respiratory problems or CHF.
Common secondary diagnoses include tobacco and drug use, diabetes, hypertension
and hyperlipidemia.

Severity Score at Index & Readmission
There is no significant difference in severity score between Index and Readmitted
patients. Are some patients readmitted more often?...
Measure

Graphical Analysis – Readmissions by Patient
Although 9 (14%) of the 66 readmitted patients accounted for 38% of all
readmissions, the majority of patients (57, or 86%) had only 1 or 2
readmissions, accounting for 62% of all readmissions.
66 patients generated
113 readmission visits
Measure

Process Issues
Analyze
Many process issues were identified, especially near time of discharge.

Brainstorm Theories of Causes
COPD
Readmission
Admission
Resources Discharge Post-Discharge
Fragmented care
following D/C
Patients do not
consistently meet
GOLD discharge criteria
Appt not
made
Patients
unable to obtain
meds following 3-day supply
Inconsistent coordination
of education b/w
pharmacy and nursing team
Variation in patient
demonstration of
skill in inhaler use
Inconsistent
communication to
Nursing Team of
repeat admission
Documentation of education
lacking or does not
reflect education quality
and/or needs
Patient leaves
AMA
Reduced
pharmacist
coverage on
weekends or
evening
Insufficient assessment
of patient understanding
of teaching
Limited staff
to educate and assess
competency (all meds)
Delay in
communicating
with DME provider, &
equipment delivery
Spacer use not
considered for adults
Inpatient inhaler lost /
non-standard storage
& handling
Process
Variation
Social Worker/Staffing
Education
Educational content
not at appropriate
level for patient
Ineffective media type
used for education (TV, etc.)
Smoking cessation not high priority
Coordination problems
prevent effective inhaler use
Inconsistent inhaler
education & resulting
poor pt technique
Variation in
recognition of
primary home
caregiver
Med history not completed
for all COPD patients
Patients not
D/C to appropriate
level of care / setting
Providers unaware
of pending discharges
Necessary services
not available
during weekends
Patient not
provided inhaler
COPD not flagged
in auto-trigger list
Social Worker
engaged late
in process
COPD order set
inconsistently used
Limited communication
of order set availability
O2 6 min ordered
late in process
Excessive variation
in patient care
Perceived as
cumbersome
Single, generic
content @ 6th
grade level
Too
complex
Rushed /
not planned
Knowledge deficit
of caregiver
Not identified
Limited options
No doc’n pharmacy
teaching
Fragmented
Not asked
Asked too late
Limited
standardization
Limited staff
allocated to
high priority pts
Not considered
Pt financial issues
No/under insurance
Not asked/planned
Not assessed for need
Need not identified
Appts not
patient-centric
Access
(e.g.,
transport)
Forget
Nurses
cannot find
Nurses not know
Pt not fill inhaler Rx
Pt not know
to fill / diff
rescue/maint
Pharmacy access
Unaware
empty
Not policy
Unaware
Too
much
info
Not all
relevant
parties involved
Home
caregiver
not available
Not
enough
time
Not all teaching
programs make appts
Comm’y docs
not make appts
Pt not follow
up on appt or
recomm’n
Fill too late
Docs not
know
to document /
significance
Co-
morbidities
overlap
Not know
do not need
Admission order set
Access issues
(transport)
Inconsistent
teach-back
No standard
protocol
No / too many
caregivers
No or
ineffective
review of D/C
instructions
Inconsistent
ID of
readmission
Non-
Sinai
Not documented /
Inconsistent location /
Difficult to find /
No expectation
Not
coordinated
prior to D/C Poor D/C
planning COPD not a standard
referral for Social Work
Multiple factorsPossible readmission factors were organized in a fishbone format.
Analyze

Critical To Quality and Theories (Xs)
Possible causes related to CTQs:
X1: Insufficient assessment of patient understanding of teaching.
X2: Patients do not consistently meet GOLD discharge criteria.
X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does
not include family/caregiver).
X4: Appointment not made or inappropriate for patient (e.g., have outside provider).
X5: Patients are not being discharged to the appropriate level of care / setting.
X6: Patient not provided inhaler.
Additional possible causes:
X7: Readmission rate is a function of day of week discharged.
Analyze

Data Collection Plan for Analyze Phase
Data Collection Plan for the Analyze Phase
Ref.
Theories To Be Tested
(Selected From The C-E
Diagram, FMEA, etc.)
List Of Questions
To Answer for
Evidence of Each
Selected Theory
Results that
will support
theory
Results that
will rule out
theory
Tools To
Be Used
Data To Be Collected
Description/
Data Type
Sample
Size,
Number
of
Samples
Where/
How To
Collect
Data
Who
Will
Collect
Data
How
Will
Data
Be
Recor
ded
X1
(CTQ)
Insufficient assessment of
patient understanding /
demonstration of
standardized teaching,
including additional
training needs.
Does a second-
teach-back
improve patient
administration?
A second
teach-back
improves
patient
administration.
A second
teach-back
does not
improve
patient
administration
.
Bar chart
Categorical:
Percentage
patients with
improved
administration.
84
patients
Inhaler
instructi
on
session
Karen Excel
X6
(CTQ)
Patient not provided
inhaler.
What is the
incidence of lost or
missing inhalers?
A high number
of inhalers are
lost or missing.
A low number
of inhalers are
lost or
missing.
Bar chart
Categorical:
Count of lost or
missing
inhalers.
6 weeks
Reconci
liation
tally
Karen Excel
X7
Readmission rate is a
function of day of week
discharged.
What is the
proportion of
patients
readmitted w/in 30
days by day of
week?
Proportion
readmitted
differs by day
discharged.
No difference
in proportion
by day
discharged.
Stacked
bar chart,
Chi-
square
test
Categorical:
Number of
patients w/
Index discharge
by day of week,
and number of
these
readmitted.
All COPD
discharge
s over
prior 2
years
Premier Lynda Excel
A subset of CTQs and Xs were tested (others had sufficient anecdotal
evidence and/or were difficult / time-consuming to test).
Analyze

Test of Theories Example
Theory: Insufficient assessment of patient understanding of teaching.
Analysis: Pharmacy assessed patient inhaler demonstration technique at t0 (baseline), t1
(after instruction), and t2 (24-72 hr. after initial instruction, t1). Scoring based on number
of steps missed (detailed description in Notes View)
The t2 (24-72 hr.) assessment better reflects actual skill after discharge than the t1.
Instruction improved scores but remained <100% scores; this and the slight decline
between t1 and t2 indicate that reinforcement and assessment are beneficial.
Practical Conclusion: Additional teach-back improves patient inhaler administration;
current teaching is insufficient.
Spiriva (n=15) Symbicort (n=36) Albuterol (n=35)
Score,
out of 9 %
Score, out
of 9 %
Score, out
of 9 %
t0 5.8 64 4.5 50 4.1 46
t1 8 89 7.2 80 6.7 74
t2 7.2 80 6.6 73 6.2 69
Δt1-t0 +25 +30 +28
Δt2-t0 +16 +23 +23
Δt2-t1 -9 -7 -5
Analyze

CTQ and X Summary
X1: Insufficient assessment of patient understanding of teaching. Administration of
inhalers improved from 25% at baseline to 50% after a second teach back session that
occurred between 24-72hr post initial test.
X2: Patients do not consistently meet GOLD discharge criteria. Application of GOLD
discharge criteria is not standard practice.
X3: No or ineffective review of D/C instructions (e.g., too fast, too complicated, does not
include family/caregiver). Anecdotal evidence from nursing and RT indicates review of
D/C instructions is not consistently effective.
X4: Appointment not made or inappropriate for patient (e.g., have outside provider).
Follow-up appointments (PCP, pulmonologist) are made for some but not all patients,
and are made late in the inpatient care process.
X5: Patients are not being discharged to the appropriate level of care / setting. GOLD
discharge criteria not used to guide choice of care setting; palliative care is
underutilized.
X6: Patient not provided inhaler. Inhalers frequently are lost or misplaced, and not
available to provide to patients upon discharge.
X7: Readmission rate is a function of day of week discharged. Day of week discharged does
not affect subsequent readmission rate.
Analyze

Selected Solutions
Theme Selected Solutions
Admission &
Inpatient Care
COPD Care Pathway and Order Set, with triggering of Order Set and supplemental
services via pathway. Eliminate need for duoNeb ordering via teaching aids (placebo
inhalers and disposable spacers).
Education -
Patient
Bronchial Hygiene Program upon admission. Include early symptom identification,
trigger identification, hand-washing, exercise.
Education -
Staff
Bronchial Hygiene Program upon admission. Build in shortcut to ordering of spacers
based on RT vs. direct MD order. Use admission smoker status as basis for referral to
Disease Mgmt. / Lawndale Clinic smoking cessation classes.
Resources Social Worker engaged via Care Pathway to identify & initiate post-discharge meds
process, oxygen, etc.
Discharge Marketing and education of palliative care. Include palliative care and GOLD discharge
criteria in COPD Care Pathway and Order Set. Deploy AccuDose® inhaler tracking &
storage (patient-specific). Initiate discharge planning upon admission per COPD Care
Pathway, including appointments. Social Worker identifies COPD-relevant programs
relevant to patient. Make follow-up appointments (PCP, Specialist) as early as
admission. Implement clear, concise COPD-specific D/C instructions, including
prescription transition & eligibility for free inhalers/prescriptions.
Staff Augment med history by having Pharmacists or ER Pharm Tech complete for patients
beyond Disease Mgmt. (Long-term).
Improve

Updated Process Map(s)
TBD: Smoking
cessation intervention
Improve

Control Plan
Process Control Plan
for: COPD Readmissions
Date:
11/11/2014 Revision Level: 1
Approved By: COPD
Readmission Team
Ref. Control Subject
Subject
Goal
(Standard)
Unit of
Measure
Sensor
Frequency
of Measure-
ment
Sample Size
Where
Measurement
Recorded
Measured
by Whom
Criteria for
Taking
Action
What Actions to Take
Who
Decides
Who Acts
Where
Action
Recorded
1
COPD readmission
(30 day rate)
≤ 18.21% % Premier Monthly
All COPD
readmissions
COPD
Readmissions
spreadsheet
Lynda >18.21% Investigate CTQs Lynda
Refer to
CTQs
Control
Plan Log
2
COPD Order Set
(use)
100% % Meditech Weekly
All COPD
discharges
(trailing 4
weeks)
COPD Order
Set Report
Lynda <90%
List of Non-Compliant Attending &
Resident Physicians and Report to
Dept. Chairs, Program Directors,
Chief Residents
Dr. Iliescu Dr. Iliescu
Control
Plan Log
3
Bronchial Hygiene
Program
(use)
100% %
RT Consult
(Meditech)
Weekly
All COPD
discharges
(trailing 4
weeks)
Bronchial
Hygiene
Program Report
Lynda <90%
Chief Residents
Control
Plan Log
4
COPD education
(documentation)
100% %
Education
checklist*
Weekly
All COPD
discharges
(trailing 4
weeks)
Patient Chart Lynda <90%
List of Non-Compliant
Departments (Pharm, Nursing,
RT) and Report to Dept heads
Dept
Heads
Dept
Heads
Control
Plan Log
5
GOLD D/C criteria
(use)
100% %
Physician
checklist
done at
discharge
Weekly
All COPD
discharges
(trailing 4
weeks)
Meditech
Report
Lynda <90%
Chief Residents
Control
Plan Log
6
Discharge
paperwork
(review)
100% %
COPD
Education
Screen
Pilot-Daily
(First 2 wks)
Weekly
All COPD
discharges
(trailing 4
weeks)
Meditech
Report
Lynda <90%
List of Non-Compliant Nurses and
Report to Unit Directors
Raquel
Raquel and
Unit
Directors
Control
Plan Log
7
Patient
appointments
made prior to
discharge
100% %
Discharge
module
(Meditech)
Weekly
All COPD
discharges
(trailing 4
weeks)
FM-Appt Report
from D/C
Module
IM-F/U with
Kathy
Lynda <90%
List of Non-Compliant Resident
Physician and Report to Dept.
Chairs
Control
Plan Log
8
Discharge inhaler
(provisioning of
inpatient inhaler)
100% %
Nursing
discharge
checklist
Weekly
All COPD
discharges
(trailing 4
weeks)
Meditech
Report
Lynda <90%
List of Non-Compliant Nurses and
Report to Unit Directors
Raquel
Raquel and
Unit
Directors
Control
Plan Log
9
Smoking cessation
(referral conversion)
N/A % Meditech Weekly
All COPD
admissions w/
"Yes Want To
Quit" (trailing
4 weeks)
Meditech
Report
Lynda
>10%
change
from
baseline
Investigate root cause(s) (patient
refusal / RT not asking)
Phyllis Phyllis
Control
Plan Log
Palliative
Care
Criteria,
Consults
TBD
Audit (#
consults / #
meeting
criteria)
TBD Q4 2014
Control
Plan Log
Improve

Change Management & Communication Plan
Planned Change Who is Affected? Potential Objections
Facts
(What will really happen)
Benefits to those affected
(Business and Personal
Benefits)
Communication
(How will change be
communicated?)
Admission & Inpatient Care:
Implement COPD Care Pathway, including
use of COPD Order Set and guidelines.
Physicians, Nursing, IS,
Social Work, Respiratory
Therapy, Pharmacy
Resistance to pathway and
order sets (primarily
physicians)
Resistance will be overcome
with consistent monitoring
Treatment team: applying
best practices. Social Work:
reduced medication costs.
Finance: COPQ reduced.
Patients: receive better care.
Physician and Nursing
leadership meetings. Staff
meetings with nurses,
physicians and other
departments affected. Email
notifications. See Training
Plan.
Education - Patient:
Reinstate modified Bronchial Hygiene
Program w/ RT involvement early in
inpatient process. Include early symptom
identification, trigger identification, hand-
washing, exercise.
Respiratory Therapy, Nursing
Expansion of RT duties.
Providing adequate RT
staffing to accomplish goals
Restructuring the Bronchial
Hygeine Program to shift
responsibility for delivery of
MDIs and education from
nursing to the Respiratory
RT is better skilled in the use
of various inhalers/will
identify the need for spacers.
Patients receive better
education and improved self-
care.
Revision of the Bronchial
Hygiene Program and MDI
Protocol w/ RT staff
education. See Training
Plan.
Education - Staff:
Bronchial Hygiene Program to address
inhaler education via RT involvement and
identification of spacer candidates. Offer
Level 2/3 smoking cessation classes.
As above As above
As above. Focus on
education will start with the
patient; Information
regarding Smoking
Cessation class will be
incorporated in current
packet.
As above As above
Resources:
Social Workers engage patients in
corporate pharmaceutical programs for
post-discharge meds. Establish Social
Work consult on admission per Care
Pathway to assess DME / equipment
needs.
Social Work, Utilization and
Nursing Departments;
Patients
Patients may object to / not
comply with paperwork for
pharmaceutical program
requirements
Care Pathway will specify
appropriate timing of SW
engagement and activities.
Saves SW costs and patients
receive consistent supply of
meds.
Social work, utilization and
nursing department meetings
(leadership and staff level).
See Training Plan.
Discharge:
Facilitate appropriate discharge and post-
discharge care by incorporating D/C
planning as part of Care Pathway.
Elements to include GOLD criteria,
provisioning of inpatient inhaler stored in
unit-based locations, D/C instructions that
educate patient re: free inhaler &
prescription transition, and need to follow
up w/ Pulmonologist/PCP. Educate
physicians & patients re: palliative care &
availability.
Physicians, Nursing,
Respiratory Therapy, Social
Work, Pharmacy
Use of GOLD criteria.
Resistance to change
towards earlier discharge
planning.
Care Pathway will provide
guidance on discharge
events and timing.
Early and more
comprehensive discharge
planning will smooth
discharge process and
facilitate appropriate,
improved patient self-care
following discharge.
Educational/training sessions
with physicians, Nursing, RT,
SW, Pharmacy, per Training
Plan.
Control

Training Plans
The training needs for different stakeholder groups were identified.
Training delivery format, frequency, etc. were determined for each group…
Topic / Area of Change
Teaching
Attending &
Residents,
Hospitalists
Community
Physicians
Nursing
Respiratory
Therapy
Social
Work
Pharmacy
Disease
Managem
ent
ED Staff
COPD Care Pathway X X X X X X X
COPD Order Set X X X X X X
Bronchial Hygiene Program X X X X X
Placebo inhalers & disposable spacers (edu,
storage, tracking, use)
X X X X
Smoking cessation referral X X X X X X
Social Worker role & engagement X X X X X
Palliative care X X X X X
GOLD discharge criteria X X X X
Discharge (planning, instructions, follow-up
appointments)
X X X X X X
Other – Patient Identification X
Control

Conclusion: 30-day readmissions have been running at 12% (27/204) since
the beginning of Improve phase in September. Overall readmission rate
compares favorably YOY.
Desired direction:
Control Subject Control

Conclusion: COPD Order Set use is showing a very gradual upward trend,
doubling since Q4 2014. There will be continued reinforcement to ensure this
positive trend continues.
Desired direction:

Conclusion: A BHP was not used for several years prior to the project start. Now
revised and revived, BHP use initially was limited by staffing, but gradually
improving.
Desired direction:

Conclusion: COPD education of patients* has averaged around 67% since early
April. A nursing form change in April facilitated compliance that has not yet been
sustained. * Education includes COPD Education Pamphlet and inhaler instructions.
Desired direction:

Conclusion: Historically not used, use of the GOLD discharge criteria has
averaged just under 70%.
Desired direction:

Desired direction:
Conclusion: The pattern of documented provisioning of COPD discharge
instructions to patients has closely tracked that of Gold discharge criteria (prior
slide). The target is 100%.

Conclusion: Documentation of patient appointments made prior to
discharge averaged 64% since March (target is 100%).
Desired direction:

Desired direction:
Conclusion: Supply of inpatient inhaler to patients upon discharge has averaged
close to 50% over recent weeks. This is well below the target 100%, but
gradually improving.

Conclusion: The proportion of COPD patients who indicate they want to quit has
increased over time. This metric will be monitored to establish a baseline, from
which significant deviations can be responded to as appropriate.
Desired direction:

The Fourth of Five Vital Tips
Tip #4: Engage Leadership
Therapeutic
Intervention
Monitor,
Follow Up

Tip #4: Engage Executive Leadership
A Day in the Life of a Healthcare Leader
Therapeutic
Intervention
Monitor,
Follow Up

Monitor,
Follow Up
Therapeutic
Intervention
Effective leadership really makes all the difference. In the end, we
want our quality improvement efforts to be driven from the ground
up. We love to have the folks who are on the front line of clinical
care leading our improvement efforts. But at the end of the day,
they’re going to be looking upward. They’re going to say, “What are
the leaders telling us that we ought to pay attention to?” In many
ways, the leader sets the tone that is going to either facilitate or
mitigate the organization’s response to quality challenges. And you
really need to have a leader effectively engaged in that process.
Dr. Gregg Meyer, Senior Vice President
Massachusetts General Hospital and Physicians Organization
Director, the Edward P. Lawrence Center for Quality and Safety
The Role of Leadership in Quality Improvement Efforts
AHRQ Podcast, November 2011

 Speak the language of leaders by
calculating the margin loss, penalties to
be charged
 Seek the CMO and CNO as Champions
 Use external resources to manage
resistance and guide them
 Do not talk about other hospitals and
what they implemented for solutions –
teach them what they did to analyze it
 Alert them this is not going to be solved in
a day but it could be done in 90 days
 Deal with their resistance
Tips for Engaging Executive Leadership
Therapeutic
Intervention
Monitor,
Follow Up

The Last of Five Vital Tips
Tip #5: Start with the Lowest Hanging Fruit

Tip #5: Start with the Low-Hanging Fruit
Start with Your Biggest Penalty
 Which of these five conditions is causing the greatest pain?
– heart attack
– heart failure
– pneumonia
– chronic obstructive pulmonary disease
– elective hip or knee replacements
 Use an improvement methodology robust enough to get the job done
 Make sure your root cause analysis is thorough and complete
 Identify solutions aimed at eliminating the root cause
 Maintain a control plan
 Identify your second-biggest readmission problem and repeat

Lessons Learned
 The root cause of your readmission problem may not be the same
root cause as any other hospital’s readmission problem
 Unless you first identify the root cause, any solution implemented is
just a roll of the dice
 Obtaining expertise on the use of root cause tools is critical to
successfully reducing your readmission rate
 It is easy to make errors when identifying root causes; these errors
lead to wasted human and financial resources
 Multi-functional issues require multi-functional teams to solve them
 Readmission root causes almost universally span departments and
units
 Tried-and-true improvement methodologies are your best approach
 If leadership is not hands on, the likelihood of success is diminished

Connect With Us
@Juran_Institute
www.youtube.com/user/JuranInstitut
e
www.facebook.com/JuranInstitute
www.linkedin.com/company/juran-
institute

More Resources
 business innovation
 business process
improvement
 continuous improvement
 dmaic
 juran quality handbook
 lean manufacturing
 lean six sigma
 lean transformation
 operational excellence
 process innovation
 quality assurance
 quality control
 quality improvement
 management consulting firm
 iso 9000 2015
 six sigma certification
 what is lean
 what is six sigma
Click any link for more information

Thank you
We hope to see you in our future webinars!
If you would like a copy of this
presentation or would like to
discuss this topic with your
organization, contact me at:
jdefeo@juran.com

5 Vital Tips to Help Reduce Readmissions in Hospitals

More Related Content

What's hot

Viewers also liked

Similar to 5 Vital Tips to Help Reduce Readmissions in Hospitals

More from Juran Global

Recently uploaded

5 Vital Tips to Help Reduce Readmissions in Hospitals

Editor's Notes