Reducing Avoidable Readmissions by Improving Transitions in Care Pat Rutherford MS, RN Vice President Institute for Healthcare Improvement July 13-14, 2011 Denver, CO

Welcome! Who is attending the seminar? Why are you here today? What do you hope to learn?

IHI Background Founded by Don Berwick and colleagues Current President and CEO: Maureen Bisognano Grew out of National Demonstration Project on Quality Improvement in Health Care (NDP) First National Forum was the NDP Summit Incorporated in 1991 From 4 employees to now 114 Office in Cambridge, Massachusetts Remote employees in many other locations Work in North America, Europe, and Africa

IHI Staff

We Are… The Institute for Healthcare Improvement (www.IHI.org) is an independent not-for-profit organization that works with health care providers and leaders throughout the world to achieve safe and effective health care. IHI focuses on motivating and building the will for change, identifying and testing new models of care in partnership with both patients and health care professionals, and ensuring the broadest possible adoption of best practices and effective innovations. Based in Cambridge, Massachusetts, IHI mobilizes teams, organizations, and increasingly nations, through its staff of more than 100 people and partnerships with hundreds of faculty around the world.

Institute of Medicine, Crossing the Quality Chasm, 2001 We Exist Because… “Between the health care we have and the care we could have lies not just a gap, but a chasm.” Institute of Medicine, Crossing the Quality Chasm, 2001 IHI exists because. There is an enormous gap between the health care we have and the health care we should have – a quality gap so large that the Institute of Medicine refers to it as a “chasm.” The flaws in the current system are indisputable: best-known science is not reliably applied; widespread inefficiencies waste precious resources; and our system, which aims to heal, too often does just the opposite, leading to unintended patient harm and unnecessary deaths.

The IOM’s Six Aims for the Health Care System: Our Goals Are… The IOM’s Six Aims for the Health Care System: Safe – no needless deaths Effective – no needless pain or suffering Patient-Centered – no helplessness in those served or serving Timely – no unwanted waiting Efficient – no waste Equitable – for all The IHI’s blueprint for its work – the goals we aspire to – come from the Institute of Medicine’s landmark 2001 report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. In it, the IOM identified six urgently needed “Aims for Improvement” of health care in America. IHI has translated these goals into what we call the “No Needless” list: Safe – To reduce the harm done to patients by errors in care – defects which, according to the IOM, kill between 44,000 and 98,000 Americans each year in hospitals alone; Effective – To promise patients that they will receive care faithfully according to science, and that they will not be subjected to care that cannot help them; Patient-centered – To redesign care so as to restore dignity, self-esteem, and control to patients and families who too often feel helpless, forgotten, and unheard; Timely – To reduce the waiting and delays that pervade health care for both patients and those who give the care; Efficient – To recover a substantial portion of the money wasted in health care through administrative complexity, unnecessary procedures, and lack of coordination; Equitable – To close the racial and socio-economic gaps in health status, access, and outcomes.

Our Mission Is… To improve the lives of patients, the health of communities, and the joy of the health care workforce. ….and to close the Quality Gap as fast as possible And that is where the Institute for Healthcare Improvement (IHI) comes in. Improving health care is IHI’s mission, its promise, and its daily work. IHI is here to help raise the bar on health care performance – ultimately improving the lives of patients, the health of communities, and the joy of the health care workforce – by translating innovative ideas into practical results that are truly meaningful in the lives of our patients.

We Do This By… Building the Will for Change Cultivating Promising Improvement Ideas Putting those ideas into action through effective Execution We achieve this mission by: 1. Inspiring optimism for change. We call this “Building Will.” 2. The intent to change is empty optimism without novel ideas and new solutions. So, IHI finds, cultivates, or invents great improvement ideas. 3. Strong will and good ideas must then be channeled by a practical implementation model. IHI supports action by bringing organizations and individuals together to “all teach and all learn,” and by providing the tools and methods for rapidly achieving meaningful and sustainable results. Tom Nolan, one of IHI’s senior leaders, taught us this model: improvement of any system requires WILL, IDEAS and EXECUTION. IHI’s strategy focuses on all three of these elements simultaneously.

Some of Our Groundbreaking Initiatives Include… 100,000 and 5 Million Lives Campaigns IHI Open School for Health Professions The IHI Triple Aim The Improvement Map & Passport STAAR (STate Action on Avoidable Rehospitalizations) TCAB (Transforming Care at the Bedside) Safer Patients Initiative (UK) Scottish Patient Safety Programme Chronic Care Initiative (Indian Health Service) WIHI

IHI Open School for Health Professions

The IHI Improvement Map

A 12-month membership program for hospitals, including: Unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements Training for middle managers to effectively lead quality improvement initiatives Enhanced strategic planning for member organizations through customized whole systems data and selected benchmarking information Exclusive access to On Demand tools and resources, including podcasts, videos, and presentations on a variety of topics For details, visit www.IHI.org/passport, call 617-301-4800, or email improvementmap@ihi.org.

IHI Conferences: 2011-2012 23rd Annual National Forum on Quality Improvement in Health Care December 4-7, 2011 Orlando, Florida 13th Annual International Summit on Improving Patient Care in the Office Practice and the Community March 18-2012 Washington, DC IHI/BMJ International Forum on Quality and Safety in Health Care – April 17-20, 2012 in Paris, France

IHI’s Online Resources Subscribe to This Week @ IHI, IHI’s free weekly e-newsletter Listen to WIHI, a free audio program from IHI Check out the great resources, tools, stories, and contacts available on www.IHI.org Follow @TheIHI IHI Fan Page IHI Group

Seminar Agenda (Day 1) Wednesday, July 13, 2011 8:00-8:20 Welcome, Introductions and Overview 8:20-9:20 Getting Started 9:20-9:40 Break 9:40-11:00 Overview of IHI’s Approach 11:00-12:00 Enhanced Assessment 12:00-12:40 Lunch 12:40-2:00 Effective Teaching and Enhanced Learning 2:00-2:20 Break 2:20-3:40 Post-Hospital Follow-Up Care 3:40-5:00 Real-Time Handover Communications 5:00-6:00 Networking Reception (optional)

Seminar Agenda (Day 2) Thursday, July 14, 2011 8:00-8:20 Debrief 8:20-9:00 Cross Continuum Teams 9:00-10:20 Transitions into Community Settings (2 breakouts) 10:20-10:40 Break 10:40-11:40 Engaging Patients and Families 11:40-12:30 Lunch 12:30-1:30 Getting Results 1:30-2:15 Action Planning 2:15-2:30 Wrap-up and Evaluation 2:30–3:00 Faculty Consults (optional)

Kate Bones, MSW Kate Bones, MSW, Project Director, has been with IHI for eleven years managing collaborative quality improvement programs, R&D initiatives, and strategic partnerships for the organization. Most recently, Ms. Bones has directed programs related to waste reduction and serves as IHI’s Operational Lead for the AHRQ ACTION II Partnership, and she will be serving as a Collaborative/Network Director in IHI’s State Action on Avoidable Rehospitalizations (STAAR) initiative. Ms. Bones has a background in community health and health policy.

Peg Bradke, RN, MA Peg M. Bradke, RN, MA, Director of Heart Care Services, St. Luke's Hospital, coordinates services for two intensive care units, two step-down telemetry units, the Cardiac Catheter Lab, Electrophysiology Lab, Diagnostic Cardiology, Interventional/Vascular Lab, and Cardiopulmonary Rehabilitation. In her 25-year career, she has had various administrative roles in critical care areas. Ms. Bradke works with the Institute for Healthcare Improvement on the Transforming Care at the Bedside initiative and Transitions Home work. She is President-Elect of the Iowa Organization of Nurse Leaders.

Eric Coleman, MD, MPH Eric A. Coleman, MD, MPH, is Professor of Medicine within the Divisions of Health Care Policy and Research at the University of Colorado at Denver and Health Sciences Center. He is the Director of the Care Transitions Program that aims to improve quality and safety during care "handoffs" across care settings.

Saranya Kurapati, MD, MPH Saranya Kurapati, MD, MPH, recently joined IHI as its Director of Care Transitions Programs.  Saranya, who recently completed her master’s at the Harvard School of Public Health, will work closely with the STAAR team to align all of IHI’s current work on care transitions and to develop strategies to make the interventions in STAAR scalable.

Gail Nielsen, BSHCA, FAHRA, RTR Gail A. Nielsen, BSHCA, FAHRA, RTR, Director of Learning and Innovation, Iowa Health System, building infrastructure and capability across the 26-hospital enterprise for innovation and process improvement to achieve ideal patient care delivery. She is a George W. Merck Fellow, Patient Safety Scholar and faculty of the Institute for Healthcare Improvement.

Cory Sevin, RN, MSN, NP Cory Sevin, RN, MSN, NP is a Director with the Institute for Healthcare Improvement. She has 30 years of experience in supporting change for improvement-with individuals and healthcare organizations. She has experience working with adolescents and their families in health risk behavior change, adults with chronic conditions, and leading primary care practice transformation as Vice President of Operations at Clinica Campesina Family Health Services. With IHI, Ms. Sevin has lead work in Office Practice Transformation, Operational Excellence in the ED, Spread and Improving Transitions in Care.

Pat Rutherford MS, RN Patricia A. Rutherford MS, RN is a Vice President at the Institute for Healthcare Improvement (IHI). She is leads innovations in the following areas: Transforming Care at the Bedside; Optimizing Care Coordination and Transitions in Care; Improving Efficiency and Flow in Hospitals, Office Practices and Outpatient Settings; and Innovations in Patient-Centered Care. She is currently the co-investigator for the STate Action on Avoidable Rehospitalizations (STAAR) initiative, funded by The Commonwealth Fund.