1. WHA Improvement Forum For April    “Prioritizing New Interventions”   Stephanie Sobczak Courtesy Reminders: Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) Please do not take calls and place the phone on HOLD during the presentation.

2. 2 Today’s Webinar Agenda  Will, Ideas, Execution  Sifting through the evidence  Determining what to implement  Driver Diagrams  Prioritization Tools  Leveraging Data Analysis as a Decision Making Tool

3. 3 The WHA Improvement Workbook follows has tools and templates you can use Available on the Quality Center: http://www.whaqualitycenter.org/ PartnersforPatients/PFPWave2 Materials/PfPImprovementWork book.aspx Using the Improvement Workbook

4. 4 WILL IDEAS EXECUTION CHANGE  This is often the culprit behind a lack of improvement!

5. WILL Ask yourself or Ask your team: Do I (we) really know why I (we) want to tackle this problem? 5 Without WILL you are unlikely to be successful!

6. IDEAS  Analyze the data  Do a literature review and choose the intervention with the best evidence  Find best practices from peers  Complete a root cause analysis  Ask our frontline staff what to improve  Everybody else is doing __________, so should we! 6 Have you been “over-reliant” on one source of ideas?

7. 7 1)How do we know there is a problem? 2)What drives our results? 3)Do we really do “best practice” processes? 4)Do we know how well processes are working? EXECUTION

8. Ensure alignment You must relate the changes you make to the problem you are trying to solve. If not, you run the risk of spending resources working on the wrong things

9. What Intervention is Right for My Hospital? The Question: How can we prevent falls on the M/S unit? The Rationale (the WILL): Prevent harm to patients! AIM: We will reduce falls on the M/S unit by 50% by Dec 2013. EXECUTION: What and How? 9

10. Expert analysis “Do it yourself” literature search OR Use change packages from reputable sources:  IHI, AHRQ, HRET  National collaboratives (CUSP, CLABSI, GWTG)  Applied Research – if you like the leading edge! 10

11. Take Inventory of the Driver Diagram 11 Example: Workbook 1-8

12. 12 Do we conduct a fall risk assessment upon admission? Do we conduct ongoing reassessments of fall risk? Do we consistently perform hourly rounds? Do we move high risk patients closer to nursing stations? Do we target interventions to reduce the side effects of meds? Do we use Visual/Audible Cues? Do we communicate to all staff which pts. at risk? Inventory your practices as compared to the evidence Ask yourselves: How do you really know?

13. Readmissions Example Our All Cause readmission rate is 14% Is this a problem?? How do we know? 13 We had Medicare penalties. Hospitals in the Partners project average a 7% rate. Our readmission rate has been the same for 3 years. Our patients are not satisfied with d/c instructions – we are at the 50 th percentile nationally.

14. Drilling into your data 14

15. 15 6,478 Medicare FFS admissions among 4,732 people 6,148 Medicare FFS alive discharges (some exclusions) 908 30 ‐ day readmissions; 14% all cause readmission rate First Level Analysis – How many are readmitted? 50% 30 ‐ day readmissions <10 days of d/c; 25% <96h Top 10 READ dx: HF, RF, UTI, sepsis, respiratory infect. Second Level Analysis – When and Why are pts readmitted?

16. 16 – Among high utilizers, 495 30 ‐ d READ; rate 38% – Among high utilizers, 55% d/c to home w/no services (N=716) – Top diagnoses among this group: COPD, GI, CHF, sepsis, UTI Third level analysis – Who is readmitted the most? Fourth level analysis – How many of these were preventable? PPR Report – 30% of COPD readmissions are preventable

17. 17 Discharge disposition (home, home health, SNF, hospice, other) Discharge zip code/county Discharge day of week; readmission day of week Days to readmission Discharge diagnoses; readmission diagnoses Discharging service; readmitting service Subgroup analysis (freq. pts, d/c home, d/c SNF, diagnoses, etc) Digging deep into your data Ask for help with this

18. How to decide what to work on Workbook Section 1 18

19. Caregiver Feedback Asking front-line staff about opportunities for improvement is a valuable exercise! May confirm or refute what your data is saying Staff learn about the need and effort to improve Begins building buy-in for participating in change when the time comes to test & trial. 19

20. Gathering Feedback When does the problem occur? (example: weekends, at night) Where does the problem occur? (example: only in the OR, in patient bathrooms) Who is involved when the problem occurs? (example: CNAs, RNs) What are the symptoms of the problem? (example: test results are not on the cart at the time of report) Why does the problem occur at the places indentified above? (example: supplies are not handy at the bedside) 20

21. Understanding Process 21 PerspectiveProcess Theories How could you prove or disprove this theory? When Where Who What Why The idea is to narrow down to actionable interventions Workbook 1-2

22. Staff Safety Assessment How to use: 1.Gather staff feedback on a specific issue. 2.Categorize the types of issues mentioned in the feedback. 3.Analyze, (consider graphing) then…. 4.  Deep dive into process mapping or root cause analysis to gather specifics. 22

23. Staff Safety Assessment Just two (2) very important questions to learn from: What do you think are the most common factors resulting in a patient falling? Please describe what you think can we can reasonably do to prevent or minimize falls? Thank you for helping improve patient centered care!

24. Tally Responses 24 Patients won't / can't use call bell IIII Family leaves without letting us know IIIIIIIIII Hourly rounding isn't happening IIIIIIIIIIIIIIIIII Lack of grab bars in bathroom IIIIIII Takes to long to answer call bell IIIIIII Pt's things are left too far away IIIIIIIIIIIIII Lack of teamwork between RN and NA's IIIIIIIIIIIIIII Lack of PT services on weekends II Patients overmedicated/confused IIIIII

25. 25 Priorities

26. Simple Root Cause Analysis  Patient Risk Factors  Task Factors  Staffing/Caregiver Factors  Communication Factors  Education Factors  Equipment Factors **Different than a Sentinel Event process 26 Example: Workbook 1-7 This is a method to better understand a process and find opportunities for improvement

27. Root Cause Analysis Points to Process Findings from the root cause analysis may point to specific process problems that might be looked into, for example: Hourly Rounding isn’t Happening  Do staff consistently perform hourly rounding? 27

28. Process Diagramming 28 Example: Workbook 1-7 Consider asking two people who work on the same process to diagram their steps. Look for inconsistencies = your opportunity for improvement

29. How to prioritize from a list of ideas Once you have several good ideas, a next step can be to assess the impact, cost, ease of implementation – or other factors using a matrix 29 Patient handouts given at d/c Calls to Primary Care @ d/c Conferenc e with family, d/c planner Scripts for doctors to use w/ pts.

30. 30 Example: Workbook 2-1 Prioritization Matrix Sweet Spot!

31. Taking it all into account Do we have data that show there is a problem? Do we do the best practices? What processes are related to these findings? Where is there an opportunity to improvement? What is a best choice for a first step? 31 Data Drill-down Driver Diagram Inventory Staff Feedback Process Analysis Prioritization Matrix

32. In Summary 32 When EXECUTING an improvement initiative, time taken to carefully determine what interventions to test and trial in PDSA cycles is time well-spent!

33. Next Month: 33 Strategies for ‘in process’ Measurement May 30 Noon  Measurement as part of daily work  Finding existing data vs. gathering data  “When can I stop measuring?”

34. References WORKBOOK SECTION 1 The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, Langley, Moen, & Nolan WHA Quality Center Tools and Templates http://www.whaqualitycenter.org/Partnersfor Patients/PfPTools.aspx http://www.whaqualitycenter.org/Partnersfor Patients/PfPTools.aspx 34

35. Thank You! Questions Please complete 3 question survey when closing webinar window. 35