March 14, 2012 Lynne Hall

 Best Practice Committee looks at all Core Measure Data ◦ HF-1 Discharge Instructions is one of the lowest measure in Georgia ◦ Hospitals are getting 100% on this measure

54 Hospitals in Georgia are below the National Average

 What is included in the Measure? 1.Activity Level 2.Diet 3.Follow-up Appointment 4.Weight Monitoring 5.What to do if symptoms worsen 6.Discharge Medications

 Addressing all these measures will: ◦ Help cut down on Readmissions  Usually highest population for Readmits ◦ Best thing to do for the patient ◦ Improve patient satisfaction ◦ Improve Core Measure Score

 What is included in the Measure? 1.Activity Level 2.Diet 3.Follow-up Appointment 4.Weight Monitoring 5.What to do if symptoms worsen  The first 5 can be addressed through nursing

 What is included in the Measure? 1. Discharge Medications - this is where the measure can fail  Biggest Issues: 1.Medication Reconciliation 2.Discharge Summary not matching Transition Summary given to patient

 Create a team  Choose a process improvement model ◦ Lean Six Sigma ◦ PDSA ◦ Rapid Cycle Improvement  Have a champion  Measure, measure, measure ◦ Use test of change

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? MEASURES CHANGES AIM

© 2012 Institute of Industrial Engineers SIPOC Project charter Voice of the Patient Process map Measurement plan FMEA Ishikawa diagram Statistical process control Capacity analysis Pareto analysis Lean process design FMEA Correlation studies Statistical process control Design of experiments Simulation techniques Daily control plan Statistical process control Simulation techniques Correlation of variables Confidence intervals Hypothesis testing Regression analysis ANOVA Recognize the problem exists Form Quality Improvement Teams Define the Problem Develop Performance Measures Analyze problem/ process Determine Root Cause Select and Implement Solution Evaluate Solution Ensure Permanence Continuous Improvement PDCA Define Measure Analyze Improve Control Recognize the problem exists Form quality improvement teams Define the problem Develop performance measures Analyze problem/ process Determine root cause Select and implement solution Evaluate solution Ensure permanence Continuous improvement PDSA Define Measure Analyze Improve Implement Control Lean Six Sigma Lean Six Sigma Model

On The CUSP Technical – Practices to Prevent Harm Evidence Based Practice 1. Evaluation 2. Systems Analysis 3. Process Development Education on the Evidence 1. Presentation of evidence 2. Fact Sheet 3. Cost Estimator 4. Summary of Professional Organization Recommendatio ns 5. Annotated bibliography Implementation / Sustaining 1.Checklist 2.Policy / Procedures 3. Protocol s 4. Monitoring 6. Feedback Adaptive (CUSP) Science of Safety 1. Science of Safety presentation 2. Attendance sheet Staff Identify Defects 1.Staff Safety Assessment form 2.Identifying Hazards presentatio n Senior Executive Partnership 1. Education 2. Briefings Learning from Defects 1. LFD toolkit 2.RCA of each incidence Implement Tools for Teamwork and Communication 1. Daily Goals 2. Shadowing 3. AM Briefing 4. Call List 5. Team Check Up tool 6. TeamSTEPPS Tools Assemble a CUSP team, Partner with a Senior Executive; Baseline Data Quality Improvement Tools 1. PDCA 2. Lean/Six Sigma 3. Reliable System Process 4. TCAB 5. Other

1. Project Identification 2. Diagnostic 3. Interventions 4. Impact & Implementation 5. Sustaining

 Culture Change ◦ Need buy-in from senior leaders ◦ Physician buy-in (Champion)  Educate abstractors

 READ the abstraction manual on these measures  Remember that this not only affects Core Measures but also has an impact on: ◦ VBP ◦ Readmission ◦ Medication Reconciliation