MAPPING YOUR DISCHARGE PROCESS AND HANDOFFS Sara Butterfield RN, BSN, CPHQ, CCM Christine Stegel RN, MS, CPHQ Brenda Maynor, RN, MS June 21, 2012

CMS Leads a national healthcare quality improvement program, implemented locally by an independent network of QIOs in each state and territory. IPRO The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).

Level of Importance of Safe Care Transition 17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending Estimates show that 76% of these readmissions may be preventable Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare 3

Level of Importance of Safe Care Transition 41% inpatients discharged w/ pending test results 2/3 of physicians unaware of results 37% actionable and 13% urgent Annals of Internal Medicine. 2005; 143(2):121-8 25% pts require additional outpatient work-ups More than 1/3 are not completed Archives of Internal Medicine. 2007;167:1305-11 At Discharge: 37% able to state purpose of all medications 14% knew the common side effects 42% able to state their diagnosis Mayo Clinic Proceedings. August 2005; 80(8):991-994

Investigation of Root Cause Mapping Current To Desired Process For Discharge Planning

Root Cause Analysis Definition A Root Cause Analysis (RCA) is a process for identifying the basic or causal factors that underlie variations in outcomes Allows you to identify the “root” of the problem in a process, including how, where, and why a problem, adverse event, or trend exists This analysis should focus on a process that has potential for redesign to reduce risk

Root Cause Analysis An RCA focuses primarily on systems and processes, not individual performance To begin, identify the underlying functions leading to poor outcomes. Then, determine the primary cause(s) and contributing factors An RCA is generally broken down into the following steps: Collect data Analyze data Develop and evaluate corrective actions, using PDSA cycle Implement successful corrective actions

Root Cause Analysis Purpose Identify causes of hospital 30-day readmissions within your community Health care provider perspective (hospital, nursing home, home health agency, hospice, etc) Community perspective (Office for Aging and other community service providers) Patient/caregiver perspective Identify patterns of readmissions for your community

Process Assessment A picture of the steps in a process to gain a better understanding of the existing process Assessing a process in its current state Helpful to develop benchmarks Determine opportunities for improvement Direct observation of processes such as discharge and admission Interviews with process owners Mapping of processes at a high level and/or a detailed level

Process Assessment Process Assessment Tools Process Mapping Cause & Effect Diagram Fault Tree Analysis Value Stream Mapping 5-Whys Process Mapping

Process Mapping

Why Process Map? Provides a picture of process – maps the patient’s journey Helps to clarify a complex process Establish commonalities Identify all the process participants Establish a baseline of what is current process Identify delays, gaps, work-a-rounds Identify factors that influence or impact the process Provides a clear understanding of the processes of care so there is no risk of changing parts of a process which will not result in improvement

Why Process Map? Capture the reality of a process….. what is happening versus what you think is happening) Identify duplication, variation and unnecessary steps Generates ideas and helps define where to start to make improvements with the biggest impact Helps all involved to understand the complete process Allows for identification of problem areas such as bottlenecks that cause unnecessary delays Improve team building and promotes ownership of the process Increases staff involvement in design of processes

Process Mapping Two stages to process mapping… Understand what happens to the patient, where it happens and who is involved Examine the process map to determine where there are problems multiple hand-offs parts of the process that are unnecessary parts of the process that do not add value waste, error and duplication of parts of the process which would flow better if undertaken in a different order

Process Mapping Steps Define what you are trying to achieve Identify the start and end point of the process List what measures are you going to use to demonstrate that changes actually do improve the process Identify which staff need to be involved in mapping the process – involve them at the start Direct Care Staff of all disciplines involved in process Senior leadership representative(s) Community service providers Patients Caregivers Stakeholders

Process Mapping Steps 5. Select a facilitator (not someone involved in process being mapped) 6. Gather supplies Paper / Marker pens / Post-it notes / Flip charts / Tape 7. Set ground rules – safe environment to share 8. Keep it simple 9. Clearly define each step in the process 10. Start with a high level view 5-10 steps in the process 20 minutes or less to map

Process Map Guidance Keep the patient at the center of the process Define the first and last steps in the process Identify the steps that occur at the same time Cross over departmental boundaries Include what happens when there are problems At decision points choose what occurs the majority of the time Identify branches or gaps as the map is developed At the end, go back to fill in branches

Process Mapping Symbols Shows the tasks and activities of process Shows the start and end of the process Shows where a question is asked or a decision is required Shows where documentation is required Shows the direction / flow of the process

Alternatives Process Mapping Approaches Walk through the patient journey yourself Interview staff on the who, what, where & how & record each step Set up a mini process mapping session Use a staff meeting to discuss & record the process Follow a patient through the process Best if external person not involved in process Be a patient and travel through the process

Redesigning the Process to the Desired State Identify where the process can be improved by re- designing or removing elements of it Consider impact of redesign on the rest of the organization Test ideas for improvement to show potential and any unwanted side-effects of your changes Key Components 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?

Application of Process Mapping Discharge Planning

Discharge Planning Process Process for planning the post-acute care for patients prior to discharge Acute Care Hospital Short-term Rehab Skilled Nursing Facility Home Health Includes several HANDOFFS (the passing of a patient’s care from one clinician to another clinician) To referring agencies/facilities Nurse to nurse Hospitalist to community physician

Common Discharge Planning Gaps Communication related: - transfer of patient information - pending lab values - caregiver involvement - patient’s discharge plan - discharge medications

Common Discharge Planning Gaps Care Coordination related: - primary care physician - community services - home health agency/SNF - outpatient services

Explicit delineation of roles and responsibilities The Desired Process for Discharge Planning Explicit delineation of roles and responsibilities Discharge process initiation upon admission Patient education throughout hospitalization Timely accurate information flow: From PCP ► Among hospital team ► Back to PCP Complete patient discharge summary prior to discharge Source: Project RED Principles of the Re-Engineered Hospital Discharge 28 28

Discharge information in patient’s language and literacy level The Desired Process for Discharge Planning Comprehensive written discharge plan provided to patient prior to discharge Discharge information in patient’s language and literacy level Reinforcement of plan with patient after discharge Availability of case management staff outside of limited daytime hours Continuous quality improvement of discharge processes Source: Project RED Principles of the Re-Engineered Hospital Discharge 29 29

The Reality……

Process Mapping Examples

High Level View Detail Level View Institute for Innovation & Improvement: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping_-_a_conventional_model.html

Example: Current State Patient Discharge Source: Project RED Principles of the Re-Engineered Hospital Discharge

Example: Desired Patient Discharge Process Map Physician Nurse Discharge Advocate Pharmacist Source: Project RED Principles of the Re-Engineered Hospital Discharge

Brenda L. Maynor, MS, RN Director, Clinical Resource Management St Brenda L. Maynor, MS, RN Director, Clinical Resource Management St. Mary's Healthcare Amsterdam, New York

St. Mary’s Healthcare High Level Process Map

Barriers to Process Identifying which MD to sign home care orders. (The hospitalist sees patient in hospital) Missing parts of referral/discharge orders A clear understanding of Home Health care and what the agency is able to provide Lack of assessment of home supports and ability to manage basic necessities at home prior to discharge Skilled Nursing needs/therapy needs

Desired Referral Process Hospital to Home Health All patients are seen by a discharge planner to determine if home care services are indicated after hospitalization. Patients/families are given their choice of agency based on their home location and contracted agency through their private insurance companies. Once a homecare agency is established, contact is made to the agency with the pending home care referral. Face to Face documentation is also obtained. If the agency has computer access, this is given to the agency to begin the formal communication process. Those agencies without access either visit the pt in person or documentation is faxed to the agency for review. Once a patient is discharged, the home care agency will visit the pt within 24 hours of discharge unless a greater time is mutually agreed upon with the patient, agency and physician. St. Mary’s Healthcare Desired Referral Process Hospital to Home Health

Home Health to Hospital Patients sent to ER by home care nurse 1. The home care nurses contacts the ER to speak to the charge nurse to give report as to why the pt is being sent to the ER. Community physician is also called. 2. ER staff note in the triage section the conversation as part of complaint for coming to ER. 3. If the patient is evaluated and discharged, the charge nurse will refer the pt back to the agency and/or contact the nurse regarding the course of treatment/evaluation in the ER. 4. If the patient is admitted, the discharge plan is facilitated by the inpatient discharge planners and coordinated with the home care agency post acute stay. St. Mary’s Healthcare Desired Process Home Health to Hospital

St. Mary’s Healthcare Desired Process Patient comes to the ER who does not have home care services. Is not admitted, but needs home care after their ER visit. 1. The ER nurse is able to initiate a home care referral using the Physicians Home Care Referral form. These forms are located in the ER & signed by the ER physician. They are faxed to the agency. 2. If necessary, the next day the home care agency can contact Clinical Resource Management for additional information. St. Mary’s Healthcare Desired Process Initiating Home Health Referral for ED Patients RCA Process Improvement: Identify during triage if a pt currently has home care services in the home. Currently this is not addressed during the ER visit Sent message to ER Manager to inquire adding this to interview screen If the pt currently has services, refer back to that same agency If the pt does not have services, initiate a new referral

Questions Comments Plans for Next Week?

Resources Agency for Healthcare Research & Quality http://www.ahrq.gov/qual/projectred/swimlane.htm Colorado Foundation for Medical Care National Coordinating Center http://www.cfmc.org/integratingcare/toolkit.htm Institute for Innovation & Improvement http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvem ent_tools/process_mapping_-_a_conventional_model.html Project RED (Re-engineering Discharge) https://www.bu.edu/fammed/projectred/index.html

For more information Christine Stegel, RN, MS, CPHQ Sara Butterfield, RN, BSN, CPHQ IPRO Senior Director (518)426-3300 ext. 104 sbutterfield@nyqio.sdps.org Christine Stegel, RN, MS, CPHQ IPRO Senior Quality improvement Specialist (518)426-3300 ext. 113 cstegel@nyqio.sdps.org Brenda L. Maynor, MS, RN St. Mary’s Healthcare Director, Clinical Resource Management (518)-841-3896 Brenda.Maynor@smha.org IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM8-N-12-07 Template 1/13/2012