The VUMC Pillar Goal for

Heart Failure Readmissions is

15.6%. Our most current

data in May shows we met

the goal with a readmission

rate of 13.2%. However,

consistency is the key. Since

January 2012 we have only

met this goal 53% of the time

(9 out of 17 months).

Keep reading to learn your

role in reducing heart fail-

ure readmissions.

The Transitions of Care

Team began working with the

Multidisciplinary Heart Failure

Team a few months ago to

develop standardized pro-

cesses around patient educa-

tion for heart failure patients.

The Transitions of Care

Team is the same team that

helped us successfully imple-

ment transition huddles to

facilitate the coordination of

discharge planning.

Why Heart Failure?

The Affordable Care Act es-

tablished the Hospital Read-

missions Reduction Program,

which requires CMS (Centers

for Medicare and Medicaid

Services) to reduce payments

to hospitals with excess read-

missions, effective for dis-

charges, beginning on Octo-

ber 1, 2012.

Readmission is defined as an

admission to a hospital within

30 days of a discharge from

the same or another hospital.

Health Care Reform

Heart Failure Education

Transitions of Care Project

S P E C I A L

P O I N T S O F

I N T E R E S T :

Health Care Reform

Transitions of Care

Project

Bull’s Eye

Teach Back

Contributors: Shelly

Padgett, Pam Bruce, Melis-

sa Powell, Brittany Cun-

ningham

P A G E 2

-Institute for Healthcare

Improvement

Caption describing

picture or graphic.

How do we reach the AIM?

Heart Failure Transitions of Care AIM: To develop a reliable process to deliver standardized

Heart Failure Education across the continuum while

utilizing consistent tools and content

1. Develop Standardized Content

All patient education content is available in the new

rack located in the middle hallway on 7N

Heart Failure Bull’s Eye—Multidisciplinary

Patient Education & Engagement Tool

Living Well with Heart Failure—bifold

Understanding Heart Failure—book

2. Develop a Reliable Process

Involve key stakeholders in helping define the pro-

cess—VHVI Bedside Nurses

Develop a plan for the Heart Failure Bullseye: The

admitting nurse will hang the Heart Failure Bullseye in every patient room ad-

mitted with Heart Failure. The tool should hang below the whiteboard in the

patient’s room. This initiative starts 7/9/13.

3. Set Clear Roles and Expectations

Next steps: Develop a teaching pathway based on 3 day length of stay that

includes specific content delivered on each day of hospital stay—every patient,

every time.

Define which patients receive the bifold v. the book

4. Deliver evidence based patient education using the principles of teach back.

Principles of Teach Back has been assigned as a learning module in The Learning

Exchange. Log in to make sure you have completed yours.

Teach Back Facilitators will observe RN teaching sessions and provide 1:1 feed-

back.

5. Expand PEER out of the pilot phase to see patient progression across the continuum.

PEER Version 2 is currently being built

Staff education on PEER Version 2 being planned

After implementation, the leadership team is to incorporate teaching record

audits into daily Quality Huddles.

H E A R T F A I L U R E

E D U C A T I O N

T R A N S I T I O N S O F C A R E

7N Team Members

involved in this pro-

ject:

Cayce Ake

Kristen Bartlett

Erin Bucha

Greg Harrington

Rita Hayle

Mara Hutchings

Leslie Sigler

What is the Heart Failure Bull’s Eye about? P A G E 3

The Heart Failure Bull’s Eye is

about engaging the patient as

well as the health care provider.

The goal is to have every health

care team member addressing

the bull’s eye when they enter

the patient’s room.

RN

MD during rounds

Case Manager

Transition Care Coordina-

tor

Pharmacist

Nutritionist

Education is done by the multi-

disciplinary team. We each

have a role to do.

The ultimate goal is to see the

patient progress toward the

center of the bull’s eye.

Red: We provide the edu-

cation.

Yellow: We assess their

knowledge of the education

through the principles of

teach back.

Green: We see the patient

perform the skill related to

the education provided.

Seeing every health care team

member address the bull’s eye

reinforces to the patient the

importance of acquiring the

knowledge.

The long term goal is to see the

patient progress toward self

care—to provide care for

themselves at home, analyze the

information before them (i.e.

VS, weight, and symptoms) and

make informed decisions about

their care by calling the doctor

at early recognition of warning

signs and preventing hospital

readmissions.

Each

healthcare

provider

will fill in

a heart

when the

patient

meets that

goal.

Bull’s Eye in pa-

tient’s room

Remember: the bull’s eye is your patient engagement tool. It will be given to the patient

upon discharge. You will still document in the patient’s record all teaching that was done.

“Asking that patients recall and restate what they have been

told” is one of 11 top patient safety practices based on the

strength of scientific evidence.—AHRQ, 2001 Report, Making

Health Care Safer

Use a caring tone of voice and atti-

tude.

Use plain language—no medical

terms.

Simple, living room language

Sit down with the patient giving them

your undivided attention.

Make eye contact

Use positive reinforcement through

nodding and gestures.

Create a comfortable atmosphere

with small talk.

We set people at ease by trying to

relate to them, demonstrating empa-

thy and caring.

Use humor.

Creating psychological safety is im-

portant.

Circle important points on handouts.

Draw pictures as needed.

Teach Back Is the Only Way We Know for Sure

Elements of Good Patient Teaching Patient Safety

Current national research demonstrates that even

though teach back is a highly effective strategy, it is

used only about 39% of the time by physicians and

nurses to check for patient understanding as part of

a larger approach to education and engagement.

Why don't we use it?

We think we are already doing it.

We don’t think we need to do it. We make

assumptions that clearly the patient “gets it.”

The patient is smiling and nodding appropriate-

ly and they said they don’t have any questions.

Time—we think we save time by not doing it.

In reality we may be creating more work for

ourselves.

Teach Back is the only way we know for sure what

the patient does or does not understand.

Fast food restaurants do it well at the drive thru

window. Why can’t we?

Key Points:

Ask patient and family to explain using their own

words (not yes/no questions).

Word questions in a non-shaming manner: Can

you tell me what you will tell your wife about our

conversation?

The responsibility is on you the healthcare team

member: I want to make sure I did a good job of

explaining this well to you. Can you tell me…

Chunk and Check Method: Teach 2-3 main

points and check for understanding before mov-

ing on to the next concept.