MAPPING YOUR DISCHARGE PROCESS AND HANDOFFS

Sara Butterfield RN, BSN, CPHQ, CCMChristine Stegel RN, MS, CPHQBrenda Maynor, RN, MSJune 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).

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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

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% urgentAnnals 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

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Investigation of Root Cause

Mapping Current To Desired ProcessFor 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

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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

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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

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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 stateHelpful 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

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Process Assessment

Process Assessment Tools

Cause & Effect Diagram

Fault Tree Analysis

Value Stream Mapping

5-Whys

Process Mapping

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Process Mapping

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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

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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

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Process Mapping

Two stages to process mapping…

1.Understand what happens to the patient, where it happens and who is involved

2.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

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Process Mapping Steps1. Define what you are trying to achieve

2. Identify the start and end point of the process

3. List what measures are you going to use to demonstrate that changes actually do improve the process

4. 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

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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

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Process Map Guidance

Keep the patient at the center of the processDefine the first and last steps in the processIdentify the steps that occur at the same timeCross over departmental boundaries Include what happens when there are problemsAt decision points choose what occurs the majority of the timeIdentify branches or gaps as the map is developed

• At the end, go back to fill in branches

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Process Mapping Symbols

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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 the direction / flow of the process

Shows where documentation is required

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

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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

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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

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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

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Common Discharge Planning Gaps

Communication related:

- transfer of patient information

- pending lab values

- caregiver involvement

- patient’s discharge plan

- discharge medications

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Common Discharge Planning Gaps

Care Coordination related:

- primary care physician

- community services

- home health agency/SNF

- outpatient services

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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

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

The Desired Process for Discharge Planning

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The Reality……

Process Mapping Examples

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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

Patient isadmitted

MD writesadmission

orders

Pharmacistprovides

medications

Nursing initiateadmission

assessment

Care andtreatmentprovided

Dischargeorder iswritten

Dischargesheet is filled

out

Patient isdischarged

Discharge sheetis reviewed withpatient/family

Example: Current State Patient Discharge

Source: Project RED Principles of the Re-Engineered Hospital Discharge

Physician

Nursing

DischargeAdvocate

Pharmacy

Sample Process Map: Patient Discharge

Patient AdmissionOrders

Initiate postdischarge phone

call

EstablishClinical

Pathway

AdmissionAssessment

MedicationReconciliation

Educate patientabout diagnosis,

tests, and studies

Identifytarget patient

Initiate dailydischarge

huddle

Initiate AfterHospital Plan

Collect data reProcess and

Outcome metrics

Schedule Postdischarge f/uappointment

Verify MDorders

Create MARAssist withmedication

reconciliation

Assist withmedicationteaching

Participate inDC Rounds

Educate patientabout diagnosis,

tests, and studies

Initiate DCorders

ReinforceDischarge Plan

Provide careand treatment

CompleteAHCP

Physician

Nurse

Discharge Advocate

Pharmacist

Example: Desired Patient Discharge Process Map

Source: Project RED Principles of the Re-Engineered Hospital Discharge

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Brenda L. Maynor, MS, RN

Director, Clinical Resource Management

St. Mary's HealthcareAmsterdam, New York

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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

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St. Mary’s Healthcare

Desired Referral Process Hospital to Home Health

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St. Mary’s HealthcareDesired ProcessHome Health to Hospital

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St. Mary’s HealthcareDesired 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 & Qualityhttp://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 & Improvementhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping_-_a_conventional_model.html

Project RED (Re-engineering Discharge)https://www.bu.edu/fammed/projectred/index.html

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For more informationSara Butterfield, RN, BSN, CPHQIPROSenior Director(518)426-3300 ext. 104 sbutterfield@nyqio.sdps.org

IPRO CORPORATE HEADQUARTERS

1979 Marcus AvenueLake Success, NY 11042-1002

IPRO REGIONAL OFFICE

20 Corporate Woods BoulevardAlbany, NY 12211-2370

www.ipro.org

Template 1/13/2012

Christine Stegel, RN, MS, CPHQIPROSenior Quality improvement Specialist(518)426-3300 ext. 113cstegel@nyqio.sdps.org

Brenda L. Maynor, MS, RNSt. Mary’s HealthcareDirector, Clinical Resource Management(518)-841-3896Brenda.Maynor@smha.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