improving coordination of care to build teams & reduce ... · •gets people on the same page...

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.



3

Agenda

• Break at 10 a.m.

• Lunch at 11:45 a.m.



4

Community Collaborations and Resources

Kevin Cleary, MetaStarMicki Hill, DHS

Robert Kellerman, GWAAR

5

Wisconsin Care Communities



Coming soon:

Sheboygan!

And maybe…

Juneau!

6

Questions?

Natalie Friess, Project Specialist

[email protected]

Kevin Cleary, Project Specialist

[email protected]

Ross Gatzke, Project Specialist

[email protected]

mailto:[email protected]



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



8

Wisconsin at a glance



9

Wisconsin at a glance



10


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



11


What is an Aging and Disability Resource Center?



12


What is an Aging Unit?



13

ADRCs and Aging Units in Wisconsin



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





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.



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.



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.



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



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



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



21


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



22


In 2015, the JCAHO released the following

statement.

Speak Up Campaign

https://www.jointcommission.org/topics/speakup_a

void_return_trip_hospital.aspx



https://www.jointcommission.org/topics/speakup_avoid_return_trip_hospital.aspx

23

Resources

Michele (Micki) Hill, Department of Health Services

[email protected]

State of Wisconsin, Department of Health Services

https://www.dhs.wisconsin.gov

Robert (Bob) Kellerman, Greater Wisconsin Area on Aging Resources,Inc.

[email protected]

Greater Wisconsin Area on Aging Resources & Wisconsin Aging Network:

http://www.gwaar.org/


https://www.dhs.wisconsin.gov/


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



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?”


Consume leftovers within 3 days of original meal Achieve 90% June 1st

Buy food only at grocery stores Achieve 75% July 1st



Consume leftovers within 3 days of original meal Achieve 90% June 1st

Buy food only at grocery stores Achieve 75% July 1st

HOW?


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.


Consume leftovers within 3 days of original meal Achieve 90% June 15

Buy food only at grocery stores Achieve 75% July 1


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

improving coordination of care to build teams & reduce ... · •gets people on the same page...

Documents