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

2. 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).

3. 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

4. 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:
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):

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

6. 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

7. 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

8. 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

9. 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

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

11. Process Mapping

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

23. 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?

24. Application of Process Mapping Discharge Planning

25. 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

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

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

28. 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

29. 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

30. The Reality……

31. Process Mapping Examples

32. High Level View Detail Level View
Institute for Innovation & Improvement:

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

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

36. 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

37. St. Mary’s Healthcare High Level Process Map

38. 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

39. 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

40. 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

41. 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

42. Questions Comments Plans for Next Week?

43. Resources Agency for Healthcare Research & Quality
Colorado Foundation for Medical Care National Coordinating Center
Institute for Innovation & Improvement
ent_tools/process_mapping_-_a_conventional_model.html
Project RED (Re-engineering Discharge)

44. For more information Christine Stegel, RN, MS, CPHQ
Sara Butterfield, RN, BSN, CPHQ
IPRO
Senior Director
(518) ext. 104
Christine Stegel, RN, MS, CPHQ
IPRO
Senior Quality improvement Specialist
(518) ext. 113
Brenda L. Maynor, MS, RN
St. Mary’s Healthcare Director, Clinical Resource Management
(518)
IPRO CORPORATE HEADQUARTERS
1979 Marcus Avenue
Lake Success, NY
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY
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