Review of individual readmissions by hospitalists: Preliminary findings of a quality improvement project

Sumanta Chaudhuri SainiVipul Rana Bipin ThapaAdil Jadoon Binod Dhakal Ritesh Panwar Kathleen Idstein Mary ContiKartik ReddySiddhartha Singh

OUTLINE

1. The Readmissions Problem2. Our Project Goals3. Conceptual Basis of Our project4. Project Timeline and Process5. Preliminary Findings

Readmissions: A National Problem

An Expensive Issue

Readmissions accounted for $17.4 billion of the $102.6 billion total hospital payments made by Medicare

Reimbursement methods are changing to address readmissions

A Common Issue

Readmissions: A Local Problem

2008-01

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Froedtert Hospital ranked 107th out of 113 academic medical centersData from University Healthsystems Consortium

The Goals of the Hospitalist Readmissions Project

1. Understand reasons for our high readmission rates

2. Change key processes and systems in our hospital medicine practice

3. Improve readmission rates

The ‘Hospitalist Readmissions Project’ Conceptual Model

Knowledge about PERFORMANCE

Knowledge about PROCESS

Measurement

Motivation

Care Delivery Teams &

Practitioners

OUTCOME

CHANGE SYSTEMS AND

PROCESSES

Adapted from: Berwick, James and Coye (2003)

Consumers

SELECTION

Process and Timeline

JAN 2011 MAR 2011OCT 2010

KICKOFF MEETINGNARRATIVE REVIEWS

INITIATED

READMISSIONS TOOL

IMPLEMENTED

CORE GROUP REVIEWS

READMISSIONS MONTHLY MEETINGS

BEGUN

Monthly Meeting Format• Review – trends in section readmission rates– case review completion rates– suggestions for improving tool– select literature on readmissions

• Highlight individuals with lowest readmission rates in the last month

• Discuss 3 readmission cases– Analysis of process errors and systems

break-down with group input

Standardized Data Abstraction Tool

Lessons Learned

• Individual learning • Group learning• Standardization of hospitalist practice• System changes impacting section of hospital medicine

Next Steps• System changes impacting hospital and medical group

practice• Search for positive deviance• Survey hospitalists for their perception of changes

Results: Case review completion rates

670/1210 55% completion

A B C D E F G H I J K L M N O P Q R S T U V0

102030405060708090

100

Completion rates

Individual Hospitalists

How many readmissions are preventable?

Preventable Readmissions

264 Preventable Readmissions

670 Total Read-missions

39%

Inpatient Outpatient ED Non-Acute Facility0

10

20

30

40

50

60

34

53

7 5

Percent Preventable

Preventable Readmissions by Category

Early Impact on Readmissions

Period % 30 day readmissions Number readmitted Total

admissions P value

Jan – Dec 2010 18.74% 837 4466<0.05

Jan – Dec 2011 (Intervention period)

15.74% 906 5755

January

February

March

AprilMay June

July

August

Septem

ber

October

November

December

January

February

March

AprilMay June

July

August

Septem

ber

October

November

December

January

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

In Summary

• Readmissions are complex phenomena that may be resistant to traditional improvement methods

• Case review of each readmission by discharging physician is feasible

• This will lead to learning and system change that improves readmission rates

Special Thanks

• Janice Lewis• Lee Biblo, MD• Beth Vrba

Healthcare system factors• Healthcare system factors

1. Inpatient: Readmission occured as a result of an error or oversight* during index admission/discharge

2. Outpatient: Readmission occured as a result of an error or oversight* during outpatient care, including subspecialty care

3. ED: Readmission occured as a result of an error or oversight* during emergency room care, including index admission and/or readmission

4. Non-Acute Facility: Readmission occurred as a result of an error or oversight* during care in an outpatient facility, such as a SNF or rehabilitation facility

*including a health care provider’s lack of understanding of disease process or underestimation of disease severity