From the NICU to Primary Care: Improving the Quality of the

Transition

Virginia A. Moyer, MD, MPHProfessor of Pediatrics, Baylor College of Medicine

Chief, Section of Academic General PediatricsChief Quality Officer, Medicine

Texas Children’s Hospital

Cartoon:

Overview• Care transitions

Patient safety challenge Literature

• HFMEA™ Definition Description

• AHRQ Planning Grant NICU to ambulatory follow-up Process Results

HFMEA™ Qualitative

• Next steps

Background• Patient Safety literature increasingly

acknowledges potential risks of care transitions

• Adult literature reveals significant vulnerabilities

• Proactive evaluation of error-prone health care processes can inform interventions to prevent adverse patient outcomes before they occur

Care Transitions• Sometimes called “handoffs”• Movement of patients between health care

practitioners and settings• Shift changes• ER to hospital• OR to post-op or ICU• ICU to floor• One facility to another

Hospital to Home• Prolonged time period during “handoff”

• Unclear lines of responsibility

• Lack of patient understanding of health care problems

• Lack of readiness for self-care responsibilities

• Lack of information for follow-up provider

Pediatric Care Transitions• Inpatient to ambulatory setting

Pediatric literature relatively silent except for measuring follow-up appointments

Focus has been on “lack of compliance” by caregivers rather than on systematic issues around discharge

28% of children discharged from a pediatric ICU (not a NICU) did not receive timely medical follow-up

McPherson ML, Lairson DR, Smith EO, Brody BA, Jefferson LS. Noncompliance with medical follow-up after pediatric intensive care. Pediatrics 2002;109(6):94.

Research in Adults• 19% of patients had identifiable adverse events

in the first 3 weeks home

• 73% of older patients misused at least one medication

• >1 medical error per discharge summary

Research in the NICU

FMEA: Failure Mode and Effects Analysis

What is a FMEA?

“The technique involves identifying potential mistakes before they happen to determine whether the consequences of those mistakes would be tolerable or intolerable”

• Potential failures are identified in terms of failure “modes”

• For each mode the effect on the total system is studied.

Why FMEA?• Powerful approach for proactive risk

assessment Used in other high risk industries such as aerospace, aviation,

nuclear industry

HFMEA™ Process

• Team generates a flow diagram of main process and sub-processes

• Team brainstorms about all potential errors at each step (failure modes)

Each is scored for probability it will occur (frequency) and potential severity if it did occur (severity)

Frequency score x severity score = hazard score High-risk failure modes identified as well as related

causes or contributory factors

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002 May;28(5):248-267, 209.

AHRQ Planning Grant

• Conduct HFMEA on NICU to ambulatory care transitions

• Conduct retrospective review to confirm or modify HFMEA findings

• Conduct qualitative assessment of the process to accomplish the HFMEA

Setting: Texas Children’s Hospital• NICU

78 Level III beds, 62 Level II beds >200 VLBW (<1500gm) babies per year, many other babies with

complex congenital abnormalities

• Special Needs Primary Care Clinic Housed at main campus >100 children on home ventilators; 24-7 coverage

• TCPA 42 private practices, including 5 Medical Homes Shared electronic record with TCH

• TCHP TCH-owned Medicaid Managed Care Plan, ~230,000 kids

Our Project• Perform a HFMEA for the transition in care from

NICU to ambulatory follow up

• Use multiple methods to see if our predictions are correct

• Revise the HFMEA

• Develop a mitigation plan to address the identified risks

It takes a team…• Virginia Moyer, MD, MPH – Principal Investigator• Karen Finkel, RN, BSN – Patient Safety Office• Hardeep Singh, MD, MPH – Patient Safety Researcher (VAH)• Lu-Ann Papile, MD – Neonatologist• Jochen Profit, MD – Neonatologist• Charleta Guillory, MD – Neonatologist• Marcia Berretta, MSW – Social Worker• Teresa Duryea, MD – Pediatrician• Lori Sielski, MD – Pediatrician• Jan Mort, RN – Baylor NICU nurse• Carol Carrier, RN• Adam Kelly, PhD – Survey researcher (VAH)• Myrna Khan, PhD – Patient Safety researcher (VAH)• Eric Thomas, MD, MPH – Patient safety guru (UT-H)• Joseph DeRosier – creator of HFMEA (VAH)

Process DiagramNICU to Ambulatory Care

HIGH LEVEL FLOW

1. Patient identified for

potential discharge

2. Discharge needs

identified

3A. Patient discharged from

NICU 3 or 2

5. Follow up appointment

occurs

This information is privileged and confidential pursuant to Texas Health and Safety Code 161.031-161.033 and Texas Occupations Code section 160.007 and/or TRCP 192.5

4. InterimSupport

NICU to Ambulatory Care

HIGH LEVEL FLOWwith

Sub -Steps(Updated from 12 /05 /07 meeting )

1. Patient identified for

potential discharge

2. Discharge needs

identified

3A. Patient discharged from

NICU 3 or 2

5. Follow up appointment

occurs

This information is privileged and confidential pursuant to Texas Health and Safety Code 161.031-161.033 and Texas Occupations Code section 160.007 and/or TRCP 192.5

A) Caregiver teaching initiatedB) Consulting services contacted for

follow up recommendationsC) Consulting services document recommendations for follow up in

medical recordD) Baylor Clinical RN schedules appts .

E) Contact primary care pediatrician done by licensed care provider (NNP, resident , fellow)

F) Baylor Clinical RN’s ensure home care orders are written

G) Care Coordinators arrange for home care and equipment needsH) Discharge prescriptions written and

given to caregiverI) Caregiver acquires medications

J) Discharge formula order (etc) given to caregiver

A ) Patient is seen by primary care pediatrician

B) Primary care pediatrician follows through on no show

patients

A ) Attending physician decides time for discharge

B) Attending discusses decision with rest of care team

C) Caregiver identified & notified

4. InterimSupport

A) Home Health CareB) Primary Care Pediatrician

C) TCH Emergency Dept .D) NICU staff

E ) Neo AttendingF) SpecialistsG) Vendors

H) Community Emergency Depts .

I ) CPSJ) Community Pharmacist

A) Conduct weekly discharge

planning rounds (NICU 2 only )B) Discharge orders are written by licensed care provider

C) Baylor Clinical RN preparesdischarge packet

D) Discharge packet given to caregiver by Baylor Clinical RNE) TCH discharge instructions

completed and given to caregiver by bedside RN

F) Newborn state screening performed per state requirements or at discharge

G) For all Baylor patients , discharge data summary form

faxed to primary care pediatrician on next business day after discharge

H) Discharge data summary form mailed to PCP

I) Hard copy of discharge summary is mailed to PCP

NICU to Ambulatory Care Diagram

Step 2: Discharge needs identified (page 1)

Caregiver teaching initiated

Consulting services contacted for follow

up recommendations

Consulting services document

recommendations for follow up in medical

record

2A 2C2B

1. Teaching is not initiated2. No one coordinates the teaching3. Medication teaching not done by pharmacy4. Medication teaching is not done with home meds5. Teaching is not documented6. Inconsistency with teaching7. Discharge facilitators are not know by the care team8. Lack of primary nursing9. Nurse lacks knowledge for teaching of all required elements for discharge10. Person responsible for teaching regarding nutrition is not identified11 . Person responsible for teaching regarding equipment is not identified12. Person responsible for teaching regarding CPR is not identified13. Person responsible for teaching regarding car seat is not identified14. Person responsible for teaching regarding routine care is not identified15. Care giver does not understand teaching

1. Contact is not initiated2. Wrong person within specialty is contacted3. Consulting service can not be reaching for follow up4. Consulting service does not respond

1. Recommendations are missed by attending2. Conflicts between teams as to appropriateness of recommendations3. Recommendations are never documented in medical record4. Consultants never come5. Written recommendations are lost6. Written recommendations are illegible7. Follow up recommendations do not make sense8. Follow up recommendations can not be followed

2D

Baylor Clinical RN schedules

appointments

Contact primary care pediatrician done by

licensed care provider (NNP, resident, fellow)

2E

1. BC RN can not find insurance information2. Insurance is refused3. Provider is out-of-network4. Family is not involved in the appointment scheduling process5. Clinic does not allow BC RN to schedule appointment6. Recommended appointment times not available7. Patient is discharge don’t the weekend8. Appointment time not available in a timely manner9. Appointments can’t be clustered10. Failure to identify need for interpreter11 . BC RN not able to schedule appointment and family fails to follow through12. Primary care pediatrician doesn’t’ follow through13. BC RN not allowed to schedule appointments by central scheduling

1. Person responsible for making contact not identified2. Primary care pediatrician not identified3. Can not find a primary care pediatrician to accept patient4. Can not contact primary care pediatrician5. Can not get a timely appointment with the primary car pediatrician6. Patient information provided to primary care pediatrician but is lost7. Primary care pediatrician not provided with patient information8. Information is lost within the internal TCH system9. Licensed car provider does not make call

Our HFMEA™ Results

• Team identified 114 potential failure modes within the discharge process

• Final model included 40 high-failure modes and 75 high-risk causes

HFMEA™ Results• Common issues present across most failure

modes and causes: Clinicians act in isolation resulting in lack of

standardized, coordinated, comprehensive plan of care

Parents/caregivers inadequately prepared for home care and management of fragile infants

Community providers lack required knowledge and skills to manage medically complex infants

“Multiple Methods” to confirm the HFMEA• Self-reporting of events (using TCH reporting

system)• Electronic triggers for possible adverse events

ER visits within one month of discharge Readmissions within one month Missed appointments within one month

• Questionnaire for parents/caregivers the “Care Transitions Measure”

Retrospective Review• Charts reviewed using a trigger methodology to

confirm or add to HFMEA findings (N=88) Failures documented for 14 of 35 sub-steps predicted to

have errors, in 1-10 cases each

• Documentation in current medical records system inadequate to systematically collect reliable data

Documentation unavailable for majority of patients for 19 of the 35 sub-steps.

• A pediatric-adapted “care transitions measure” developed and validated.

Qualitative Analysis of the HFMEA Process• The team members felt that the group functioned

extremely well, with a high level of involvement and many new insights gained in the process.

• The team encountered difficulty applying the HFMEA scoring system to the identified failure modes

The severity descriptions did not seem to fit the types of failure modes identified

Frequency descriptions did not seem sufficiently granular The group modified both descriptions before it proceeded with

scoring.• Some group members were concerned that scoring

severity and frequency at the same time allowed for “gaming” of the scores

At the end of the process, the group scored one set of failure modes independently to determine whether this would significantly alter the scores (it did not).

Safe Passages• The final step of the HFMEA is the development

of a mitigation plan

• We addressed the three major themes that were identified in the HFMEA:

Lack of a standardized discharge plan Inadequate parent/caregiver preparation Lack of knowledge and skills by community-based

health care providers

Safe Passages• We based the intervention on the Care

Transitions Intervention (Coleman et. al.), adapted for a pediatric population.

• Enhanced Personal Health Record

• Health Coach

• Just In Time Information for community-based health care providers

Enhanced Personal Health Record

• Existing discharge plan is ad hoc

• Existing standard discharge information limited to a single sheet of paper with diagnoses, medications and appointments written in by hand.

Note that for many of our babies, the paper chart weighs more than the baby.

Enhanced Personal Health Record• Welcome, Helpful Information about the Newborn Center, and Important Numbers • Journaling and Care Pages • Tips for Choosing Insurance and Pediatrician for Your Baby • Resources and Support

Ronald McDonald House Key People, Equipment and Medical Terminology Glossary

• Your Baby’s Development, Nutrition, and Feeding Premature Babies Immunization Schedule Breastfeeding Your Baby Newborn Feeding- Bottle Feeding and Formula Preparation

• Safety and Education Medication Safety Giving Oral Medicines How to Give a Subcutaneous Injection Crib Safety Signs and Symptoms of Illness Crying Colic Preventing Infection RSV Synagis

• Planning for Discharge Checklist • Calendar with Follow-Up Appointments

Health Coach• A technically expert individual who takes the role

of sensitive coach, teacher and facilitator to foster the development of parents into competent caregivers for their fragile infants.

• Master’s prepared health educator, available at the hours parents are able to be present in the NICU.

• Available to staff as a resource person

Just-in-Time information for primary care providers

• Capitalized on new Evidence Based Guidelines program at Texas Children’s

• One page summaries of evidence based guidelines for common problems

Transition from premature formula, oxygen weaning, growth of premature infants, management of gastrostomy, management of tracheostomy, chronic lung disease… and much, much more.

• Sent home with infant and also faxed to provider at the time of discharge

Research Design• Concurrent Cohort Study over 1 year• NICU is divided into geographically distinct

“pods”• One NICU III pod and its usual step-down Level

II pod comprise the intervention group• Other pods comprise the control patients• IRB did not require patient/parent consent

beyond verbal consent at the time of enrollment• But did require written consent for the evaluation

of PCP compliance with JIT protocols

Progress to date• Recruitment of intervention babies is close to

on-schedule (n~50 at 6 months)

• Recruitment of control babies is behind (n~40) because 2 control units were closed for low census

• Very few refusals to participate, very high rate of response to phone surveys

• Moderate level of difficulty recruiting PCPs to the J-I-T intervention, so numbers are low.

Outcome Evaluation• Primary outcome is adverse events within 31

days of discharge (death, ER visit, readmission, missed appointments)

• Care Transitions Measure – Neo: administered by phone 2-3 days after discharge and again at 31 days

• Comfort level and satisfaction of PCPs with common post-NICU problems

• Adherence to guidelines by PCPs

Deliverables• Toolkit

Manual for the Health Coach Enhanced Discharge Binder (to be converted to

electronic format if and when our EMR implementation actually happens)

JIT information sheets (to be converted…)

• CTM-Neo - validated tool to evaluate the quality of the NICU discharge experience

ReferencesThe Care Transitions ProgramSM http://www.caretransitions.org accessed January 18, 2007.

Coleman EA, Berneson RA. Lost in transition: Challenges and Opportunities for improving the quality of transitional care. Ann Int Med. 2004 Oct 5; 141(7):533-536.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002 May;28(5):248-267, 209.

Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital.  CMAJ. 2004; 170:345-349.   

McPherson ML, Lairson DR, Smith EO, Brody BA, Jefferson LS. Noncompliance with medical follow-up after pediatric intensive care. Pediatrics 2002;109(6):94.

Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 Aug;18(8):646-51.

Philibert I. Leach DC. Re-framing continuity of care for this century. Qual Saf Health Care. 2005 Dec;14(6):394-396.

Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-8.

Questions?