Lean update -- Readmissions

Several of you have asked for updates on our Lean process improvement efforts. There is lots of stuff going on at the hospital in this regard, and it is not possible to put it all in this blog. But here is a summary of the work on an important set of clinical projects related to transitions of care. It is in the form of an email from Doctor Julius Yang, who is coordinating the effort.

I offer these as works in progress, with a full admission of current flaws in our processes. I know folks in other hospitals will find the subject matter familiar, as the issue of readmissions is one we all face. Perhaps our approach will provide you with useful suggestions. We also welcome yours.

Notice below the involvement of residents. This is very important in an academic setting, as they are key participants in the delivery of care. It also provides these young doctors with a chance to learn process improvement methods, something that is usually not taught in medical schools.

Notice, too, the beginning of more outreach to patients after they leave the tertiary setting. This is likely to be a growing trend nationwide. We are certainly not the first place to do this, but it remains relatively unusual for hospitals, which have tended to focus only on the acute care setting.

Hello all,

I wanted to take this opportunity, now five weeks after the close of our Multidisciplinary Quality Improvement Retreat, to once again thank all of you for your participation and important contributions towards improving the transition from hospital to home, and then to clinic, for our patients. Our rate of readmissions to the hospital within 30 days of discharge from the Medicine service remains high, hovering at about the 20% range. We've run more detailed analyses of these cases, and continue to find a wide variety of "root causes" for these readmissions, including medical decision-making at discharge, poor coordination of care plan with extended care facilities, lack of outpatient visit prior to readmission, ambiguous contingency planning when symptoms recur, among others. Based on this analysis, we continue to pursue multiple avenues for improvement simultaneously.

In terms of the two specific project streams generated from the QI Retreat (telephone follow-up with patients within 24hrs of discharge to home, and an electronic discharge checklist), over the past month a number of workgroups have made progress towards implementation of these initiatives. A brief update:

1. Post-discharge Telephone Follow-up

With strong support from our Nursing Directors in medicine, cardiology, and our Director of Patient Safety, we have received approval to conduct a pilot intervention for a "Nurse Discharge Specialist" whose role will include post-discharge telephone follow-up with patients at high risk of readmission. The target population for the pilot will be those patients who have been admitted to the hospital with heart failure, and especially those who have had prior readmissions. The intervention will consist of a dedicated nursing role to visit with these patients prior to discharge for both education and assessment of factors that may lead to readmission. Once discharged, this nurse will then follow-up with the patient by telephone the following day, to reinforce education and to ensure continuity in the discharge plan. The telephone "scripts" that were developed in the retreat will help to inform how this encounter is designed. During the pilot, there will be one nurse each weekday to serve in this role, to be shared across Farr 3, CC7, and Farr 2, with the intention of capturing 6-8 patients per day. The goal of the pilot will be to refine the logistics of this position, assess feasibility and generalizability, and assess impact on readmission rate for those patients seen by the Nurse Discharge Specialist. We anticipate the pilot will begin in May.

2. Electronic Discharge Checklist

Although we do not yet have a "live" electronic checklist, there has been some important progress over the last month. First of all, our Case Management leadership have embraced the concept of a "discharge checklist" to ensure that all requisite factors have been addressed prior to discharge of our patients at high risk of readmission (for now, we are defining "high risk" to include patients with heart failure, or patients who have been readmitted previously). We are therefore planning a pilot intervention in which our case managers will be in charge of a "checklist" (resembling the concept explored in our retreat) that will be used to guide care planning at daily case management rounds. The goal of the pilot will be to refine the checklist tool and its use, assess feasibility and generalizability, and assess impact on readmission rates. We anticipate this pilot to begin in the next two weeks.

Secondly, two of our QI retreat alumni, Elena and Andrea, have worked with another one of our residents, John Greenland, to develop a highly-detailed mock-up of an electronic discharge checklist, viewed through the POE alternate dashboard. It looks fantastic, and appears quite feasible to execute from existing data resources. We are now planning to present this model to I.S. for their review, with the goal of collecting their assessment of feasibility and timing for further development and implementation of such a tool.

As we continue to further develop these two project streams, I see that a major challenge still lies in establishing "stability" for change and continuous improvement at the front-line, "unit staff" level. Because of competing schedule demands, it has been difficult to coordinate routine meetings for front-line staff on each unit, in order to help teach and develop "kaizen mindset". I would like to try to gather us, as QI retreat alumni, perhaps in the next two weeks to further explore the best model by which to pursue this goal, and welcome any input or thoughts you may have in the interim.

Again, thanks to all for your work last month - the improvement continues.

Julius