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Improving Coordination of Care to Build Teams & Reduce Readmissions
June 7, 2016
1
Partners
Today’s event is being held in coordination with:
• The Department of Health Services
• The Wisconsin Aging Network
•
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
2
Objectives
Following today’s event, you will be able to:
• Conduct a Gap Analysis and plan Small Tests
of Change.
• Outline the various tools and resources
provided by ADRCs, Aging Units, and other
community-based organizations.
• Connect with or create a coordination of care
coalition.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
3
Agenda
• Break at 10 a.m.
• Lunch at 11:45 a.m.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
4
Community Collaborations and Resources
Kevin Cleary, MetaStarMicki Hill, DHS
Robert Kellerman, GWAAR
5
Wisconsin Care Communities
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
Coming soon:
Sheboygan!
And maybe…
Juneau!
6
Questions?
Natalie Friess, Project Specialist
Kevin Cleary, Project Specialist
Ross Gatzke, Project Specialist
7
Objectives
• The objective of this portion of the Community
Collaborations and Resources is to understand:
• Wisconsin aging population projections
• Aging and Disability Resource Centers
• Aging Units
• Establishment and enhancement of
relationships & partnerships
• Improving health outcomes through partnership
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
8
Wisconsin at a glance
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
9
Wisconsin at a glance
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
10
Community Collaborations and Resources
The first objective of this section is to provide you
with an understanding of the following:
• The scope of Aging and Disability Resources
Centers and Aging Units
• Tribal Aging Units
• The Wisconsin Aging Network
• Community based organizations
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
11
Community Collaborations and Resources
What is an Aging and Disability Resource Center?
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
12
Community Collaborations and Resources
What is an Aging Unit?
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
13
ADRCs and Aging Units in Wisconsin
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
ADRCs and Aging Units
provide service and support to
all 72 counties and 11 tribes
of the state of Wisconsin
14
ADRCs and Aging Units in Wisconsin
Website links to ADRCs and Aging Units:
• ADRCs
https://www.dhs.wisconsin.gov/adrc/index.htm
• Aging Units
https://www.dhs.wisconsin.gov/aging/offices/coagof.htm#Counties
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
15
Relationships in the Community
The second objective is to understand the value of
partnering with Aging and Disability Resource Centers,
Aging Units, and other Community-Based
organizations.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
16
Establishing Relationships in the Community
• The third objective is to understand how hospitals
can establish relationships with ADRCs, Aging Units,
and other Community based organizations.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
17
Maintaining Relationships in the Community
• The fourth objective of this is to understand how
hospitals can maintain relationships with ADRCs,
Aging Units, and other Community-Based
organizations.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
18
The Value
Value of establishing and maintaining
relationships between hospitals and ADRCs,
Aging Units, and Community based organizations
• Creates a partnership
• Shares the burden
• Capacity, quality, cost and price for services
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
19
Next steps
Next steps for action:
1. Establish a relationship
2. Consider “how should we be talking?”
3. Maintain the relationship
4. Analyze resources
5. Identify gaps in service
6. Identify services offered
7. Identify collaborative opportunities
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
20
Community Collaborations & Resources
Why should we invest the time, effort, and
resources in community collaboration,
relationship building, and partnership?
1. To improve patient/consumer outcomes
2. To share and enhance decision-making for
patient & families/consumers
3. To enhance the financial impact for all partners
and consumers
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
21
Community Collaborations & Resources
What do good transitions of care activities in our
communities mean for our patients, families, and
partners?
1. Good transitions of care enhance livable
communities
2. Good transitions of care enhance patient and
family/consumer satisfaction
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
22
Community Collaborations & Resources
In 2015, the JCAHO released the following
statement.
Speak Up Campaign
https://www.jointcommission.org/topics/speakup_a
void_return_trip_hospital.aspx
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
23
Resources
Michele (Micki) Hill, Department of Health Services
State of Wisconsin, Department of Health Services
https://www.dhs.wisconsin.gov
Robert (Bob) Kellerman, Greater Wisconsin Area on Aging Resources,Inc.
Greater Wisconsin Area on Aging Resources & Wisconsin Aging Network:
http://www.gwaar.org/
24
Break – 10:00 to 10:15
JILL HANSONQUALITY IMPROVEMENT MANAGER
WHA
Readmissions Targeted Assessment for Prevention (TAP) Tool
ENERGIZING READMISSION PREVENTION EFFORTS
Utilizing the WHA Targeted Assessment for Prevention (TAP) tool
Decision MatrixEasy to Implement
Low Impact Hi Impact
Difficult to Implement
Brainstorming Your Focus Areas
• Brainstorming Instructions
• For each identified category, generate ideas as a team and record each idea on a separate post-it note.
• Sort post-it notes with similar strategies/suggestions.
• Draw a matrix on a white board or a flip chart easel as seen below
• Use the matrix to assess the feasibility of the post-it notes.
• Alternately, you could evaluate other factors such as High Cost-Low Cost.
• A separate decision matrix would be completed for each identified category.
29
Lunch - 11:45 to 12:45
BETH DIBBERTDIRECTOR OF QUALITY
WHA
IMPROVEMENT PLANNING
AND
SMALL TESTS OF CHANGE
Origins of PDSA
• Ask Questions
• Do Background Research
• Construct Hypothesis
• Test with an Experiment
• Analyze Results/Draw a Conclusion
– If the Hypothesis is True, Report Results
– If the Hypothesis is False (or only partially true), Think! And Try Again
Modern science owes its present flourishing state to a new scientific method which was fashioned almost entirely by Sir Francis Bacon (1561 – 1626)
Deming’s System of Profound Knowledge
Why have a systematic method for improvement?
• It is an evidence based way to improve
• Provides people with a “How” to change
• Reduces the variation in approaches
• Gets people on the same page – even across the organization
• Provides a method for accountability
The Improvement Guide, API, 1996
When you
combine
the 3
questions
with the……the Model
for
Improvement.PDSA cycle,
you get…
W. Edwards Deming
Aims
Measurement
Change ideas
Trying ideas before implementing changes
using Small Tests of Change
PDSA Planning Document
How do we know that change is needed?
• External regulatory requirements
– Measures, mandates
• Internal process or systems changes
– Equipment, staffing, service lines
• An “event”
– RCA finding
• Changes in evidence-based best practices
• Others?
PDSA Planning Document – Here is mine
Reduce spending on groceries by 10% within 3 months.
Measurement is Essential for Learning• The primary purpose of measurement in QI work is for learning.
• The value of a measure is not erased because it may not be perfect.
• What you work on should be guided by measurement & results.
• Measures should always be linked to a defined AIM
• Data should be plotted over time on annotated graphs to connect improved results to the work you are doing.
• Measures should be integrated into the team’s daily routine whenever possible
• Focus on a “Vital Few” measures
PDSA Planning Document
Reduce spending on groceries by 10% within 3 months.
THOUGHTFULLY CONSIDERED MEASURES
Types of Measures
• Outcome Measures: Focus is on the patient or customer. Ask: “What is the result?”
– 10% decrease in 30 day all-cause readmissions by 12/31/16
– 20 point increase in HCAHPs Nurse Communication scores by…
• Process Measures: Focus on the workings of the system. Are the parts/steps performing as planned:
– Percent of patients assessed for fall risk on admission
– Percent of patients answer “Yes” to “Has someone checked on you in the past hour?”
PDSA Planning Document
Consume leftovers within 3 days of original meal Achieve 90% June 1st
Buy food only at grocery stores Achieve 75% July 1st
Reduce spending on groceries by 10% within 3 months.
PDSA Planning Document
Consume leftovers within 3 days of original meal Achieve 90% June 1st
Buy food only at grocery stores Achieve 75% July 1st
HOW?
Reduce spending on groceries by 10% within 3 months.
Where do you get ideas for change?
• Brainstorm: Staff ideas, Low hanging fruit, etc.
• Literature• Clinical Guidelines• Toolkits• From other hospitals• From other industries
What change can we make that will result in improvement?
The Little PDSA
Small Tests of Change
Reasons to Test Changes
Increase belief that the change will result in improvement
Decide whether the proposed change will work in your department
Evaluate how much improvement can be expected from the change
Minimize resistance upon implementation
Decide which of several proposed changes will lead to the desired improvement
Why Small Tests of Change?
To involve, then learn from, those who actually do the work while reducing the potential for
resistance to change resulting in quicker adoption
of best practices and innovations.
PDSA Planning Document
Consume leftovers within 3 days of original meal Achieve 90% June 15
Buy food only at grocery stores Achieve 75% July 1
Reduce spending on groceries by 10% within 3 months.
Cover and refrigerate leftovers Buy gas only at gas stations
BethDan
June 8 – June 29
“Just Do It” Isn’t PDSA
And this isn’t improvement…..
How Do We Know that a Change is an Improvement?
“In God we trust.All others bring data.”
W. E. Deming
We measure!
Let’s Try It!
Rapid Cycle Improvement
An Exercise
You need:
One paper target
A stack of Post-it Notes
A PDSA document
A tape measure
Team Members: Post-it Dropper Measurer Documenter Improvers
InstructionsA team member must hold a post-it note at arms length positioned parallel to the floor.
From this position drop a post-it note so it hits the target below
Repeat till you have dropped 3 different post-its
Measurement
Using the tape measure, add up the total distance from each post-it to the center of the target
11 + 5 + 3 = 19 cmRecord the total
Conduct 4 trials
Try to improve each trial by making small changes (yet staying within the rules)
Total Distance in cm
Trial 1
Trial 2
Trial 3
Trial 4
Bring your completed PDSA form to the front when you are done
Report Out!
• Were you clear on the Aim Statement?
• Reflect on your role and experience during the exercise
• Improvers: where did you get your ideas for suggesting improvements?
• If we repeated this exercise, what changes would you make to improve further?
Keys to Success
1. Engage the engaged
2. Be absolutely clear about what is expected
3. Be transparent with ALL staff about the testing
4. Gather feedback frequently and easily
5. Stay agile and flexible
6. Don’t give up easily!
7. FAIL often and learn quickly
Designing Tests of Change
Key Information before beginning:
1. What is the test?
2. What is the smallest unit of change?
3. Who has to change?
4. How many staff need to change?
5. How many staff need to test the change?
6. When will the testing take place?
How Small Is Small?
Remember the “Rule of One”One nurse
One patientOne shift
One hourOne time
Successful Cycles to Test Changes
• Plan multiple cycles for a test of a change
• Think a couple of cycles ahead
• Make the ‘ask’ small by starting small
• Test with volunteers
• Do not wait to get total buy-in before starting
• Be innovative to make test feasible
• Collect useful data during each test
• Test over a wide range of conditions
Drafting the AIM Statement
• Make sure your AIM Statement is:
–Reached by consensus
–Easily understood and stated
–Doesn’t boil the ocean
–Addresses the who, what, where, and when
–Leaves the “how” for the next steps
Example AIM Statement
• DECREASE HOSPITAL ALL-CAUSE READMISSIONS FROM 9% to 7% BY DECEMBER 31, 2016
• What additional information could be helpful?
– Readmission sources
– Patient types by diagnosis
– Patient demographics: sex, race, marital status, home setting
• Exactly how many readmissions does that 2% difference include?
Measures: How will we know that a change is an improvement?
My example: DECREASE HOSPITAL ALL-CAUSE READMISSIONS FROM 9% to 7% BY DECEMBER 31, 2016
• Decrease Readmissions from patients dc’d to LTC • Increase accurate discharge medication reconciliation information• Create a multi-stakeholder readmissions task force
• All of these need quantifiable details….
Decrease LTC readmissions
Increase D/C Medication Reconciliation
Create Readmissions Task Force
Decrease hospital all-cause readmissions from 9% to 7% by 12/31/16
DETAILS HERE
Tests of Change: What change can we make that will result in improvement?
Measure 1: DECREASE LONG TERM CARE READMISSIONS
Generate ideas! Here’s mine:
• P: Standardize discharge information
• D: Implement a new, comprehensive discharge form
• S: Is the form being used consistently?
• A: Is the form working/needing a tweak/a disaster?
• I’ll repeat this process for each measure I have named
Designing Small Tests of Change:
• Initiative: Implement a new, comprehensive discharge form
• Intervention: Pilot form on ortho unit beginning July 1, 2016
• Smallest Change: One discharge, one unit, one time
• Scope: Ortho Unit Discharges to LTC
• Total # of Staff Impacted: UR/Case Manager/Unit Discharge Coordinator (1 to 3?) plus form reviewers = 20
• Planned Testing Timeframe: July 1-15, 2016
• Testers: Sue (UR), Joe (Unit Discharge Coordinator)
Designing the Tests
A. Begin with the smallest unit of change possible
“Rule of 1’s”: One care team, one patient, one day
B. Plan for easy and efficient collection of feedback from your volunteer ‘testers’
C. Spread systematically:
1 day 2 days 4 days and/or
2 teams/ 1 patient 2 teams/ 4 pts 4 teams/ 8 pts
Pair an experienced tester with someone new
D. Know when to report progress & to whom
How to Move Forward with Testing
Expanding the number of Participants
Expand the scope of Tests
Expand the conditions of the test
(i.e. the tests are not abandoned
when census is high or staffing is low)
Document what is learned from the test
Lessons Learned, Decisions, Adaptations
• Let’s say that during the initial testing period:
– Only one ortho patient was discharged to an LTC, OR
– Neither Sue nor Joe was available for the Saturday morning discharge, OR
– Someone points out that the form is missing a space for the patient’s date of birth….
• What are the Lessons Learned?
• Can you make a decision to adapt, adopt, or abandon the process?
Practice: Designing Tests of Change
1. Consider your chosen initiatives/changes
2. Use the Design Plan for Small Tests of Change Worksheet
3. Work together to design aim statements, measures and small tests
You have 10-12 Minutes – then we will report out
Report out
• What is your Aim Statement?
• What are your measures?
• What is your plan for testing?
– What
– Who
– When
– How
• How will you measure?
Gathering Feedback During Tests
You will be more efficient, and improve faster, if you do not rely solely on scheduled meetings to gather feedback:
Quick “standing” huddles Scheduled huddlesWhite board / sticky notes E-mail Quick surveys 5 minute phone calls
Be Transparent and “Public”
1. Post the PDSA sheet where staff can see what is going on – it is a working document
2. Clearly note names of those involved.
3. There should be something new on it every few days during active tests of change
4. Please: Don’t waste time making it pretty!
Repeated Use of the PDSA Cycle
Theories Ideas
Predictions
Changes That Result in Improvement
A P
S D
A P
S D
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Troubleshooting Small Tests of Change
Troubleshooting Continued…
Have anything to share about small tests of change?
When are you “done” with testing?
Only when you are ready to:
Standardize Process and Tools
Document
Train those who need to change
Resource the effort
Measure for Maintenance
Implementation Ready??
When to move to formal spread and implementation can seem like a tough decision.
Consider these 3 factors:
1. Everyone who needs to test the change, has
2. The process is stable, with few changes
3. Staff are satisfied with the current state
Moving to the Last Step
• Don’t assume the implementation went as planned
• Too often we move on to the next project and we gradually slide back to the “old way of doing things”
• Time to put processes in place to “hold the gains”
Integrating the Change
• At this point, the change should be tied to an existing accountability structure
– Quality Committee
– Safety Committee
– Shared Governance
– Management Team
• At least annual spot checking of the outcome measure; may need a process measure if the outcome is “slipping”
• Think about a contingency plan – new PDSA cycles – if performance starts to slip
Implementation Follow-Up Checklist
• Is it clear which department and manager is accountable for sustaining the gains?
• Accountability includes continued measurement
• Schedule a touch-based with the team lead and manager 60 days from now
• Ask to see any measured results
QUESTIONS??
This material was prepared by the Lake Superior Quality
Innovation Network, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the
U.S. Department of Health and Human Services. The
materials do not necessarily reflect CMS policy.
11SOW-MI/MN/WI-TASK-YY-## MMDDYY