INSIDE Reduce Readmissions with Better Data Analysis

INSIDE

Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Dana Spector, Nurse Planner Fameka Leonard, AHC Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.

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DECEMBER 2016 Vol. 41, No. 12; p. 133-144

Hospital uses real-time interviews for vetter data 136

Are lengthier interviews on readmission worth the time? . . . . . . . . . . . . . 138

Shorter data interval gives better readmission picture . . . . . . . . . . . . 139

AHA/HRET HEN 2 .0 yields useful tools, resources . . . . . . . . . . 140

Most Common Problems in TJC Surveys . . . . . 142

Program focuses on better transitions, warm handovers . . . . . . . . . 143

Also inside: Annual Index

THE PATIENT’S RESPONSE TO A BRIEF QUERY ON

READMISSION DIDN’T FIT ANY

OF THE OPTIONS LISTED ON THE

FORM.

Reduce Readmissions with Better Data Analysis

Readmissions can never be low enough, so hospitals are constantly looking for better

ways to reduce them. Some are find-ing that success depends on collecting good data, because you can’t reduce readmissions if you don’t know what’s bringing people back to your door.

Regions Hos-pital in St. Paul, MN, a 454-bed teaching hospital in the HealthPart-ners system, was concerned about readmissions two years ago and lead-ers there recognized that while they had a robust data collec-tion system, it was not capturing patient perceptions, says Rory P. Malloy, MPH, senior per-formance improvement manager. The hospital averages about 150 readmis-sions a month, and when a quality improvement team looked at how to

reduce those numbers, they found a weakness in their data collection.

Like many hospitals, Regions col-lects information on readmissions to help identify causes, but Regions found that for about two-thirds of their readmissions the reason was

listed as “other.” The patient’s response to a brief query on readmission didn’t fit any of the options listed on the form.

The hospital developed a process for in-depth inter-views at the time of readmission, delving much deeper than the usual list of rea-sons for the patient

returning. The results have been enlightening and revealed areas of concern, such as a high rate of patients not attending follow-up appointments and not following drug and nutrition recommendations.

“In 2017 we’re hoping to integrate

134 | HOSPITAL PEER REVIEW® / December 2016

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the feedback results directly into the electronic record and into the actual caregiver’s process,” Mal-loy says. “We want to integrate the information in team rounds and the discharge planning that the case manager might do at the patient level. As we start to see trends and themes emerge, that’s going to be what helps us drive our strategy for all patients.”

(For more on how Regions Hospital addressed readmissions, see the story in this issue. For more on the merits of real-time inter-views, see the story in this issue.)

Pursue Multiple

Strategies

The key to reducing readmis-sions is to operationalize several strategies and ensure account-ability for each strategy, says Donna Hopkins, MSN, RN, CMAC, vice president with Novia Strategies, a healthcare consult-ing firm based in Poway, CA.

One such strategy to reduce re-admissions focuses on the discharge plan — and specifically on the inclusion of the patient and their caregiver throughout the entire episode of care as part of the dis-charge planning process, she says.

“Too often, we see that the care team thinks the discharge plan is in place through daily rounds, only to discover at the time of discharge, the patient or their caregiver hasn’t been prepared or educated on what they need to do once they get home,” Hopkins says. “To reduce readmissions, we recommend proactively includ-ing the patient and their caregiver into daily conversation during their acute episode, so they know what they need to do after dis-

charge to foster full recovery.”Another strategy to reduce

readmissions focuses on discharge follow-up. Best practice is follow-ing up with the patient and their caregiver within 48 hours — ide-ally in person, and essentially by phone — to reinforce education and confirm the patient has the resources and support needed to follow the discharge plan, Hopkins says. Another best practice is to secure a home health agency screen for all patients discharged to home — not only the obvious ones.

“We see situations where a patient doesn’t appear to need a home health screen, yet that patient might have less optimal home conditions that may com-promise their recovery,” she says.

An emerging trend is the in-corporation of transition coaches or patient navigators within their care management models, Hop-kins says. The transition coach or patient navigator is a higher-level point person for the patient and family with the knowledge and skills to manage a patient’s care throughout the entire episode. This navigator takes care man-agement outside the four walls of the hospital, coordinating the patient’s care prior to admission, within the acute care setting, and post-discharge for 30 to 90 days.

“This approach ensures patients are ready for surgery, transition appropriately from one level of care to the next in a timely man-ner, receive appropriate discharge planning to that least restrictive environment, and are followed after discharge to minimize read-mission,” Hopkins says. “Early demonstration projects are show-ing positive results, as evidenced by such metrics as increases in patient satisfaction, decreases in surgi-

134 | HOSPITAL PEER REVIEW® / December 2016 HOSPITAL PEER REVIEW® / December 2016 | 135

cal cancellation rates, decreases in 30-90-day readmission rates, and increases in discharge to home.”

The optimal period for analyz-ing discharge data is being ques-tioned, with a recent study suggest-ing that a shorter interval will yield data that more accurately reflect hospital quality and factors that can be controlled. (See the story in this issue for more on that study.)

Don’t Restrict

Focus Too Much

Hospitals most often go wrong when studying and trying to reduce readmissions by focusing their efforts on a narrow patient population, says Patricia Hines, PhD, RN, a managing direc-tor with Novia Strategies. Many organizations have historically placed their readmission efforts on the high-risk, high-dollar patient populations targeted by CMS that are associated with financial penal-ties, such as pneumonia and, more recently, total joint replacement.

“They have not applied their readmission strategies to all of their patients, especially those at high risk who do not cleanly fall within those diagnoses. Patients don’t always fall into specific categories, and narrowing the focus tends to support a task-oriented approach to care delivery,” Hines says. “In our work with hospitals and healthcare systems across the country, we see more success when they adopt a comprehensive care planning ap-proach that includes all high-risk patients as well as their caregivers.”

The Improving Medicare Post-Acute Care Transformation Act, or IMPACT Act, of 2014 is intended to improve many quality metrics, including readmissions and ED

re-visits from post-acute settings, Hines notes. The IMPACT Act is stimulating post-acute venues to ramp up efforts to identify pa-tients at risk and establish efforts to prevent readmissions, she says, and the risks imposed to hospi-tals for accountability for entire episodes of care, whether through bundled payments or Medicare Spending per beneficiary (MSPB), will affect readmission rates.

For hospitals, the threat of penalties better justifies their investment in initiatives to re-duce readmissions, Hines says. Thus, hospitals are becoming more motivated to coordinate care and reduce fragmentation not only within their own acute care setting, but also beyond to the post-acute services, she says.

Address Transition

Earlier than Discharge

Ideally, the healthcare team should position the patient for the next level of care along the course of the hospitalization and not in the last few hours prior to dis-charge, Hopkins says. As a safety measure, hospitals should adopt a “Discharge Time Out” process prior to a patient’s discharge, like a surgical procedure time out, where the healthcare team would reas-sess all the processes essential for a smooth transition of care have occurred. If not, the application of teach-back methods, medication reconciliation, and further patient education is best saved for the transition coach or navigator role to follow-through post-discharge.

“What is absolutely essential is what is termed ‘survival edu-cation,’ encompassing whom to contact for problems, medications

for the first 24-48 hours, and the expectations for follow-up by someone from the transition care team the day after discharge.”

Every readmission is a learn-ing opportunity, even if the cause was beyond your control, says Mathew Thomas, MD, a hospital-ist for 10 years and now CEO of Metrix Health, a healthcare data analytics company based in San Francisco. Good data will reveal information that can be applied to individual patient care, he says.

Healthcare professionals from many areas need to work together, and with community resources, to address readmissions rather than seeing the issue as primarily the hospital’s responsibility, he says.

“The financial penalties have us focused now not on just a 30-day risk period but the 90 days, and that pushes all the various provid-ers and environments where pa-tients journey over 90 days to start aligning a little bit differently,” Thomas says. “We can’t just say we’ll blame it on the home environ-ment and leave it at that. Let’s try to understand it because we’re all at financial risk, but it’s also about the quality of care in a community.”

Data collection should be wid-ened so that instead of a simple checklist, the provider asks open-ended questions such as, “what would have helped you avoid coming back to the hospital?” he suggests. Seeking information from the original treating clinician, ask-ing what could have been done to avoid the readmission, also yields valuable information, he says.

Readmission history also is not captured well during intake, Thomas says. Emergency physi-cians and others can add a ques-tion about readmission history to the standard history questionnaire,


he suggests, possibly identify-ing issues that can be addressed in the treatment process.

Significantly reducing read-missions will require a change in mindset across the entire health-care community, Thomas says.

“The new model says patients shouldn’t be managed in a silo but rather connected along an epi-sode of care, and that’s a strategy that will help align folks along the continuum to start align-ing their efforts more,” he says.

Telemedicine is a strategy with great potential for reduc-ing readmissions, says Richard Kimball, managing partner of HExL, a consulting company based in New York City.

Some of the most immediate benefits come when using tele-medicine to monitor patients with

congestive heart failure, which can begin with simply having the patient step on a scale every day. If the patient’s body mass goes up 5% in a short period, this is a warning for fluid retention, prob-ably caused by failing to take medications or manage diet.

“You can get an alert from that measurement and intervene im-mediately before the problem gets out of control and the pa-tient comes back to the hospital,” Kimball says. “The same can be done with glucose monitors and a number of other monitoring devices. The ability to get that heads-up before the patient starts spiraling down can make a sig-nificant difference in reducing readmissions, as long as you’re also prepared to provide the necessary intervention in a timely way.” n

SOURCES• Patricia Hines, PhD, RN, Managing

Director, Novia Strategies, Poway,

CA . Telephone: (858) 486-6030 .

Email: phines@novia-inc .com .

• Donna Hopkins, MSN, RN, CMAC,

Vice President, Novia Strategies,

Poway, CA . Telephone: (858) 486-

6030 .

Email: dhopkins@novia-inc .com .

• Richard Kimball, Managing Partner,

HExL, New York City . Telephone:

(646) 734-2486 .

Email: rick@jhexl .com

• Rory P. Malloy, MPH, Senior

Performance Improvement Manager,

Regions Hospital, St . Paul, MN .

Telephone: (651) 254-3542 . Email:

rory .p .malloy@healthpartners .com .

• Mathew Thomas, MD, CEO of

Metrix Health, San Francisco .

Telephone: (615) 577-5968 .

Email:jmathew@navihealth .us .

Hospital Uses Real-Time Interviews for Better DataWhen a quality improvement

committee at Regions Hospital in St. Paul, MN, sought to reduce readmissions, the members realized that they did not have sufficient data to identify the reasons patients returned. Forty percent of their readmission records indicated “other” as the reason, rather than the possible causes listed.

The hospital team decided to try drilling deeper with “real-time interviews” in which a staff mem-ber would take the time to ask the patient a series of questions intend-ed to collect more valuable data, explains Rory P. Malloy, MPH, senior performance improvement

manager. The quality improvement committee addressing the problem of readmissions drew on demo-graphic data and brainstormed all the possible reasons a patient may return to the hospital, then distilled that into a series of ques-tions to introduce on a trial basis.

Once the real-time interviews were implemented, the downside immediately became apparent. Staff were taking about an hour to sit down with patients and draw out all the answers to the list of questions. Even though the interviews were to be conducted on about four admissions per day, just a fraction of all readmis-sions, spending all that time was

too much for the hospital staff to work into their already busy days.

“Unfortunately, it’s one more additional process and you don’t have the people power to ac-complish something like that,” Malloy says. “We tried for about a year and we only got about 10 or 15 actual interviews. It was that burdensome for the staff.”

Staff Time Reduced to

13 Minutes

Regions addressed that issue by employing a handheld electronic medical communicator that Health-Partners was already piloting at oth-


er facilities in the system. The mul-tilingual device features a caregiver on screen who reads each question and then walks the patient through the possible answers, which Malloy says produces better data than sim-ply putting a written survey on a tablet for the patient to answer. The patient can complete the survey with little assistance, freeing up the staff. The device allowed Regions to cut the staff time needed for each readmission interview down from an hour to about 13 minutes.

The hospital completed 110 interviews over four months, representing 5.2% of the total expected readmission population. The average patient age was 61.

“We’ve gathered a lot of really valuable information from the patient telling us why they’re com-ing back,” Malloy says. “We set up the survey in a manner where we address key areas like the hospital stay, where they went after, then we focus on the medication ex-perience. After that, we address discharge and then the follow-up experience once they’re home.”

Regions found that one in three patients missed one or more medication doses after discharge, and 38.2% of patients were not confident taking their medications. Also, 39% were not confident in the treatments taught to them at discharge, with 32% saying the discharge process could have been improved. Forty percent of readmitted patients interviewed felt their questions were not ad-equately addressed at discharge.

Nearly half (41.67%) did not attend a follow-up appointment, even if it had been scheduled for them. Twenty percent of patients stated they did not follow their diet or nutritional plan scheduled for them, and 35% of that group

said it was because they could not find or afford food. A major-ity, 67.59%, said they received a discharge follow-up phone call.

Follow-up Visits

Missed Often

The lack of follow-up was somewhat surprising, Malloy says. Regions already recognized the importance of patients receiving follow-up care and so the hospital had taken steps to help patients contact a physician, and in many cases the hospital made the ap-pointment before the patient left.

“Half of the population not attending an actual appointment was kind of an eye-opening experi-ence for us,” Malloy says. “We also were surprised at the number of patients who did not follow nutri-tion recommendations or take their medications as instructed. In a lot of cases it was because they did not have transportation or access to the right food, so they ended up coming back to the hospital instead of outpatient care, because the hospital has mechanisms to get around those problems.”

Analyzing the data revealed that the hospital should put em-phasis on connecting patients with a pharmacist, so they un-derstand how and why to take their meds, Malloy says.

“Almost all patients remembered being told about their medica-tions and using teach back, but a third of them didn’t understand it. So, there’s that gap we’re start-ing to explore.” Malloy says.

In the same vein, it appeared that patients would benefit from contact-ing a primary care doctor for follow-up as part of their discharge plan-ning instead of just being told to

make an appointment or to appear at one already scheduled. That is particularly important, Malloy says, because research has indicated that a patient who does not have a follow-up visit within 10 days is signifi-cantly more likely to be readmitted.

“The interview data is allow-ing us to look at our processes and develop strategies that better serve our patients,” Malloy says. “We’re continuing with the survey, adding some new questions and address-ing some issues that were revealed as affecting readmission rates, such as homelessness and lack of access to resources in the community.”

Questions Delve Deep

for Causes

These are some of the ques-tions that Regions employed in the readmission interviews:

1. Disposition?a. Home addressb. Nursing home or TCUc. Family or friend’s homed. Other2. Noticed not feeling well?a. Day of readmissionb. A few days be-

fore readmissionc. More than a week ago3. Decided to re-

turn to hospital?a. Day of readmissionb. More than a day

before readmissionc. More than a week ago4. Know whom to contact

with change in condition? Yes/No5. Other treatment options

attempted before readmission?a. Urgent Careb. Emergency Departmentc. Home remediesd. Primary Care Providere. Called Nurse Care Line


f. Other6. Followed dietary in-

structions? Yes/No7. Reason dietary in-

structions not followed?a. Didn’t understand themb. Couldn’t get

right foods at storec. Couldn’t afford foodsd. Don’t want to follow diete. Was still hun-

gry while following dietf. Other8. Taught specific cares or

treatments upon discharge? Yes/No9. Confidence you under-

stood care or treatment education?a. Very confidentb. Pretty confidentc. Somewhat confidentd. Not confident10. Follow-up appoint-

ments scheduled? Yes/No11. How were follow-up

appointments scheduled?a. Patient made appointmentsb. Friend or family mem-

ber made appointmentsc. Primary Care Provider’s

office called to schedule

d. No one sched-uled appointments

12. Did you make it to fol-low-up appointments? Yes/No

13. Reason follow-up ap-pointments not adhered to?

a. No transportationb. Scheduling con-

flict (time didn’t work)c. Could not get off workd. Could not find childcaree. Forgot or didn’t know

about appointment(s)f. Other14. Received follow-

up phone call? Yes/No15. Who called?a. Regions Hospitalb. Primary Care

Provider’s officec. Health Insurance Companyd. Othere. Don’t know/remember16. How was the call helpful?a. Answered ques-

tions/addressed concernsb. Helped schedule

follow-up appointmentsc. Answered medi-

cation questions

d. Offered comfort, gave me confidence

e. Other17. Understood dis-

charge instructions? Yes/No18. Followed discharge

instructions? Yes/No19. Reason discharge in-

structions not followed?a. Didn’t understand themb. They were too long/

had too many pagesc. Lost themd. Didn’t want to

deal with theme. No one re-

viewed them with mef. Other20. Could discharge experi-

ence have been improved? Yes/No21. How could discharge

experience have been improved?a. Waited too longb. Felt too rushedc. Received too many papersd. My questions weren’t

answered well enoughe. Family members not

involved/included enoughf. Other n

Are Lengthier Interviews on Readmission Worth the Time?

Some hospitals are implementing more in-depth

patient interviews on readmission, seeking to collect more and better data that can help identify quality issues that might be addressed. But these interviews are time- and resource-intensive, so do the results justify the investment?

They can be, if you make good

use of the resulting data, says Donna Hopkins, MSN, RN, CMAC, vice president with Novia Strategies, a healthcare consulting firm based in Poway, CA. His-torically, hospitals have looked at readmissions by diagnoses, with anecdotal reasons for readmis-sions and without patient-specific reasons as to why the readmis-

sion occurred. That produces data that is of limited value.

A better approach is for hos-pitals and health systems to de-velop and implement risk strati-fication checklists and in-depth patient questionnaires, she says. Readmission-risk criteria can be easily extracted by data in the electronic medical record such as


patient visit history, polyphar-macy, and comorbid diagnoses, she says. Those can trigger high-risk identification and flow into the daily census used by clinicians.

In addition, nursing and case management can use in-depth questionnaires for deeper dives and interviews to determine actual reasons for readmission. Many of those reasons will be not be clinical, Hopkins notes, related instead to issues such as having no electricity at home, unfilled pre-scriptions, or no transportation.

“Unfortunately, the operational flaw has been that hospitals are sometimes unsure what to do with the information, either for an individual patient or in the aggre-gate for a patient population, in order to ensure interventions and access to ambulatory or commu-nity connections are available,” she says. “Without an enterprise-wide strategy and available resources to employ outside of the acute care organization, it is not unusual to see a ‘so what?’ attitude about these tools and readmission data.”

With drivers, such as Medicare Spending per Beneficiary and the Quality Improvement Organi-zation renewing their focus on readmissions in the 11th Scope

of Work, Hopkins says hospitals are beginning to see an increase in collaborative efforts. Many healthcare systems are even proac-tively collaborating with needed resources such as transportation, home modifications, and access to nutritional food sources, she says.

Provided Detailed

Transition Data

Deep-diving into readmission interviews may not address the true problem, says Bryan R. Cote, managing director of the Berke-ley Research Group in New York City. There is nothing wrong with gathering more data, but there can be other problems no amount of interviewing will solve, he says.

“Often hospitals won’t even know that they’re dealing with a readmission, that the patient has been there in the past 30 or 60 days, unless a caregiver recognizes the patient and says so. And if they were at another hospital, that’s even harder to know,” Cote says. “The hospital doesn’t know until the patient has been there a while and that night they start looking at records and put the pieces together.”

Identifying the returning patients early should be a goal for any hospital, he says. Read-missions are most common and most costly with heart and lung patients, he notes, and intensive interviews with those patients are unlikely to yield better data.

“I don’t think real-time inter-views are the answer at all for that. They’re in a pattern and asking them more questions won’t help,” Cote says. “The real answer is in better documentation and clarity from the hospital to the skilled nursing facility that gives them more clarity, a better picture of this patient. They need to know as much as possible about medi-cations, history, comorbidities, everything under the sun, and they don’t feel like they’re getting that picture in most cases.” n

SOURCES• Bryan R. Cote, Managing Director,

Berkeley Research Group, New

York City . Telephone: (646) 862-

0952 . Email: bcote@thinkbrg .com

• Donna Hopkins, MSN, RN, CMAC,

Vice President, Novia Strategies,

Poway, CA . Telephone: (858) 486-

6030 .

Email: dhopkins@novia-inc .com .

Shorter Data Interval Gives Better Readmission Picture

The standard for studying readmissions, and what they

say about hospital quality, has long been 30 days. The 30-day window is used by the federal government to penalize hospitals believed to

provide lower-quality care because patients return to the hospital following discharge, but recent research suggests that window should be shortened.

Hospitals would get more

meaningful data if they studied readmissions in the first week — or even sooner — because that would isolate factors within a hospital’s control, says David Chin, PhD, a postdoctoral scholar at the UC


Davis Center for Healthcare Policy and Research and the Depart-ment of Public Health Sciences.

“When you look at the seven days following discharge, there are greater differences between hospital performance,” Chin says. “The 30-day implicitly ignores the fact that there are factors other than hospital quality that drive the patient back to hospital in that longer period.”

Chin and his colleagues recently published their study results in Health Affairs, recommending that CMS and other payers reconsider using the 30-day readmission rate as a basis for public reporting on hospital quality and reducing Medicare payments to hospitals. (An abstract of the study is available online at http://bit.ly/2d6ApWb.)

“Regulators should use mea-sures that push hospitals to provide excellent inpatient care and reduce avoidable hospitalizations,” Chin says. “Thirty-day readmission rates, however, don’t accurately reflect what happens within hospitals or clearly distinguish quality differenc-es from one hospital to another.”

Chin and the study team used information from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, a comprehensive resource for data on hospital encounters. The researchers focused on patients aged 65 or older who were hospi-talized for common medical and surgical conditions in four states with large, diverse populations: Ari-

zona, California, Florida, and New York. More than 66 million hos-pital discharges were evaluated for unplanned readmissions between one and 90 days. They looked for the day or days following discharge in which the true variation in hos-pital performance was the largest.

The results showed that a five- to seven-day post-discharge timeframe is when hospital-attributable factors have the greatest effect on readmissions. After that, readmissions are more heavily influenced by factors outside the hospital’s control.

Focusing on shorter post-hospital periods will better isolate the effect of hospital care from other drivers of readmissions such as a patient’s home, social, economic, and community cir-cumstances, Chin explains.

“The bottom line is that when you look at hospitals in the 30-day interval, the hospitals all look pretty much the same,” Chin says. “When you contract that interval closer to seven days, you start to be able to tie individual hospitals to the readmission.”

Stronger Correlation in

Early Days

There is nothing magical about the seven-day mark, Chin explains, but the tie to hospital quality is higher the closer you get to the discharge. It’s like a

sliding scale, where readmissions in the first few days are more likely to be tied to hospital qual-ity and the correlation becomes weaker with each additional day.

There is some question that focusing on a shorter time will miss patients who were readmit-ted at 30 days, for instance, for a reason directly tied to hospital quality. Chin says that is possible but those instances probably would be uncommon and not skew overall data analysis on readmissions.

Even without changing from a 30-day analysis, early contact with the patient is critical to preventing readmission, says Patricia Hines, PhD, RN, Managing Director with Novia Strategies, a national healthcare consulting firm based in Ploway, CA. Readmission strategies will frequently focus on a follow-up call to the patient within 48 hours and a physician office visit within 5-7 days’ post-discharge

“A seven-day time frame is critical to ensure that the patient understands the discharge plan, the importance of medication adher-ence, compliance with follow-up appointments, and that there is an opportunity to intervene if the situ-ation warrants,” she says. “A seven-day time frame allows the health-care team to reassess the patient’s clinical situation and course, and to correct the plan of care to ensure the quality outcomes and goals are met on behalf of the patient.” n

AHA/HRET QI Project Cuts HACS 40%, Readmissions 20%Hospitals are continuing to

improve patient care, per results from the second round of the American Hospital Association/

Health Research & Educational Trust (HRET) Hospital


Engagement Network (HEN), part of the CMS’ Partnership for Patients initiative.

The AHA/HRET HEN initia-tive involved more than 1,500 hospitals seeking to improve care across 11 areas, including preven-tion of hospital infections, falls, early elective maternal deliveries, and preventable readmissions. Among other findings, the AHA/HRET HEN 2.0 helped hospitals reduce early elective deliveries by 44%, postoperative venous throm-boembolisms by 34%, and surgical site infections by 21% over the past year, preventing more than 34,000 incidents with an associated cost savings of nearly $300 million.

The project yielded many resources that are available for any hospital to use for free. The overall goal of the Partnership for Patients program was to reduce hospital-acquired conditions by 40% and readmissions by 20%.

HENs find best practices that reduce hospital-acquired conditions and share them with other provid-ers, explains Charisse Coulombe, MS, MBA, CPHQ, HRET’s vice president for clinical quality. The HEN 2.0 project built upon the success of the initial HEN proj-ect, which prevented more than 92,000 hospital-acquired condi-tions and saved nearly $1 billion in avoided healthcare costs over a three-year period from January 2012 through November 2014.

The original HEN project lasted three years, and HEN 2.0 was one year. A large part of the project involved putting clinicians together to discuss the topics and compare strategies, Coulombe says.

“There is no one answer for how to reduce harm. It’s very specific to each hospital and community,” Coulombe says. “We provide them

with multiple tools and resources, almost a one-stop shop where they can go for information about adverse drug events, for instance. That information might include ad-vice on how engage pharmacists in that discussion, and how to engage physicians and hospital leadership.”

The AHA/HRET HEN 2.0 relied on five core strategies to assist hospitals. It distributed evidence, tools, and best prac-tices to the field; offered coaching and technical assistance; spurred on peer-to-peer sharing; fostered increased capability and capac-ity in quality improvement; and deployed cross-cutting strategies.

Throughout the course of the project, AHA/HRET HEN 2.0 hospitals have prevented over 34,000 harms and have saved nearly $300 million in healthcare costs, Coulombe says. The AHA/HRET HEN 2.0 team supported hospitals across 34 states through hosting virtual and in-person educational events, maintaining a website with hundreds of resources and tools, providing intensive training to over 900 hospital staff who participated in Action Leader Fellowship and maintaining a data-base of nearly 400,000 data points collected to track and trend the improvement of patient care of all applicable topics for all hospitals.

AHA/HRET HEN 2.0 worked to prevent harm in 11 adverse event areas:

• Adverse Drug Events (ADE),

• Catheter Associated Uri-nary Tract Infections (CAUTI),

• Central Line Associated Bloodstream Infections (CLABSI),

• Falls With Injury,• Pressure Ulcers (PrU),• OB Harm,• Early Elec-

tive Delivery (EED,)• Surgical Site In-

fections (SSI),• Readmissions,• Venous Thrombo-

embolisms (VTE), and• Ventilator Associ-

ated Events (VAE).Additionally, the AHA/HRET

HEN 2.0 hospitals focused on sepsis and C. difficile, airway safety, culture of safety, failure to rescue, iatrogenic delirium, undue exposure to radiation, severe sepsis, and septic shock.

Hospitals interested in the AHA/HRET HEN 2.0 resources should start by assessing their own data to identify issues that might be ad-dressed, Coulombe says. If falls are a problem, for instance, the hos-pital quality director can go to the project site and find many strate-gies and tools that could be applied, along with information on the ex-periences of other hospitals address-ing the same problem, she says.

“The information should help the quality director ask the right questions and you’ll get a sense of what has worked in the past, and what hasn’t worked,” Coulombe says. “There’s a whole litany of information on each informa-tion, and the change package is the best place to start. Read all the ideas in there and you may see things you’ve tried in the past, but you’re almost certain to find new ideas that you can try.”

(The AHT/HRET HEN 2.0 final report is available online at http://bit.ly/2fbrnrK. Free re-sources and more information on the project are available at http://www.hret-hen.org/.) n


Most Common Problems in TJC Surveys

With The Joint Commission changing its scoring system

in 2017, it may be difficult for hospital quality leaders to an-ticipate what could go wrong on a survey. Experience will still yield some clues, but the first surveys may provide some insight into what hospitals should expect.

The new scoring system raises many questions, says Ruth Ra-gusa, RN, vice president of organizational effectiveness at South Nassau Communities Hospital in Oceanside, NY.

“It’s going to be a learning op-portunity for all of us, including the surveyors,” Ragusa says. “It’s hard to speak about what was found in the past because there is going to be a whole new game plan. What-ever improvements you thought you had previously, there probably are still going to be more problems with your surveys than in the past.”

The Life Safety Code require-ments are one area that has been changed significantly. In the past, hospitals largely had control over how and when physical plant resources were tested and main-tained, but TJC now specifies what must be done in that regard. The Life Safety Code requirements were effective November 1, 2016, and include requirements that may be new to some facilities.

For instance, fire sprinkler

systems must be present in all high rises, and if a sprinkler system is non-functioning for more than 10 hours, the facility must evacuate or implement a fire watch op-eration. New construction must have patient room windowsills no higher than 36 inches, and medi-cal gas alarms can be centralized. Water flow alarms must be tested semi-annually and electric mother fire pumps can now be churned monthly instead of weekly.

Beginning January 1, 2017, TJC is introducing the Survey Analy-sis for Evaluating Risk (SAFER) matrix, which replaces the current scoring methodology by elimi-nating Category A and Category C findings, as well as direct and indirect effect Elements of Per-formance (EPs). TJC says that methodology has been confusing, so now surveyors will use their experience and expertise to assign levels of risk in the matrix based on the likelihood that a deficiency will cause harm to patients, staff, or visitors; and the scope of the issue — how widespread the is-sue is within the organization.

The actual 3×3 SAFER matrix is color-coded, which TJC says should enhance the visual effect of the information and help organiza-tions understand which issues are most critical. The new approach is intended to help hospitals set their

priorities for improvement based on the severity of risk for each find-ing. (For more on the SAFER matrix, go to http://bit.ly/2e4MhWP.)

Ragusa says the changes may be good in the end, but the in-troduction could be difficult.

“They’ve changed so many things that it’s going to be a really bumpy ride until everyone, includ-ing surveyors as well as hospitals, get used to this new process and how to manage it,” Ragusa says. “We’ve been reading all we can about the new process and try to determine where we stand with some things that were on the self-identified list. You want to look at those things that are now out of your hands and make sure you have them all cleaned up.”

TJC publishes a list of the most common problems identi-fied in surveys, and Ragusa says those are still useful in assessing compliance before a survey. But the survey changes make Ragusa and many in her position ner-vous about how they might fare when TJC surveyors knock on the door next time. (For more on the most challenging requirements for 2015, visit http://bit.ly/2dPNJJB.)

“You have confidence in what you’ve done, but there’s still con-cern when you don’t know what to expect,” Ragusa says. “My feeling is that there will be many more


n EDs for elderly only

n Reducing pressure ulcers

n Human factors in patient falls

n PA home visits after heart surgery

COMING IN FUTURE MONTHS

Program Focuses Nursing on Patient Care TransitionsA Massachusetts program has

developed a number of resources for improving transition of care that are now available for healthcare facilities to use at no cost.

The Care Transitions Educa-tion Project (CTEP) is a strategy that focuses on effective patient care transitions, explains Cherelyn Roberts, RN, manager of commu-nity navigation/transitional care at Holyoke (MA) Medical Center, one of the participating hospitals.

Holyoke focused on readmis-sions and improving transitions, encouraging warm handovers and the extra steps to make sure the patient gets connected with services and professionals after discharge.

“When people leave our hospital and go into any environment now, we want to see a warm handover. With our complex heart patients, we have a warm handover in 90% of those cases,” Roberts says. “To me, that’s the biggest benefit from CTEP that our hospital, and other hospitals in our are still imple-menting it and still teaching it. It’s a way to bring us all together and understand each other’s set-ting, how things are different and what we need to do to have a safe, effective, low cost transition.”

Nursing schools and other organizations in the community also focus on warm transitions, which helps when a professional moves from one school or facil-ity to another, Roberts says.

“This is a must, that we’re all speaking the same lan-guage,” she says.

The program was piloted with 350 nurses & nursing students, says Jena Bauman Adams, MPH, director of special projects at the Center for Health IMPACT in Worcester, MA.

Our evaluations showed that the most powerful parts of the program were bringing together nurses from different settings for some face-time training,” Adams says. “If we had developed it to be all online, they would have missed out on a lot of the learning opportunity and especially the attitude change.”

Roberts agrees, saying the interaction between nurses of different settings helped elimi-nate a lot of turf issues.

“It was helpful for them to speak

to each other as actual people and to realize that a hospital nurse, for instance, wasn’t only concerned about patients while they were in the hospital but actually did have interest and concern about the next facility or caregiver,” Rob-erts says. “Having people speak to each other face to face breaks down some barriers and signifi-cantly improves communication.”

Materials on the website are free to use. For more information, go to http://bit.ly/2efukTq. n

SOURCES• Cherelyn Roberts, RN, Manager

of Community Navigation/

Transitional Care, Holyoke (MA)

Medical Center . Telephone: (413)

534-2521 . Email: roberts_cherelyn@

holyokehealth .com .

• Jena Bauman Adams, MPH,

Director of Special Projects, Center

for Health IMPACT, Worcester,

MA . Telephone: (508) 756-6676,

ext . 20 . Email: jenabadams@

centerforhealthimpact .org .

areas identified than in the past. You may have had 10 or 20 areas identified for improvement in the past, but I believe those numbers are going to be much greater.”

The turnaround time to improve those issues also has been short-ened, so Ragusa also wonders if large organizations will be able to change quickly enough. She ad-vises quality leaders to study TJC

requirements more than ever before and be ready to discuss them dur-ing the survey process. The ability to discuss and address issues after the survey has been sharply cur-tailed in the new process, she notes.

“It behooves us to be well informed and aware of the new process so we can have meaningful conversations, because everything is going to be decided in the survey

process,” Ragusa says. “There’s not going to be a lot of opportunity, as in the past, where you could clarify or challenge things afterward.” n

SOURCE• Ruth Ragusa, RN, Vice President of

Organizational Effectiveness, South

Nassau Communities Hospital,

Oceanside, NY . Telephone: (516)

632-3999 . Email: rragusa@snch .org .

CONSULTING EDITOR

Patrice L. Spath MA, RHIT Consultant in Health Care Quality and Resource Management Brown-Spath & Associates Forest Grove, OR

EDITORIAL BOARD

Kay Ball RN, PhD, CNOR, FAAN Associate Professor of Nursing Otterbein University Westerville, OH

Claire M. DavisRN, MHA, CPHQ, FNAHQDirector of QualityMiddlesex HospitalMiddletown, CT

Susan MellottPhD, RN, CPHQ, FNAHQ CEO/Healthcare Consultant Mellott & Associates Houston, TX

NURSE PLANNER

Fameka Barron Leonard RN, MSN Administrative Director Quality Management University of Alabama Birmingham Hospital Birmingham, AL

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1 . Read and study the activity, using the provided references for further research .

2 . Log onto AHCMedia .com, go to “My Account” to view your available continuing education activities . First-time users must register on the site.

3 . Pass the online tests with a score of 100%; you will be allowed to answer the questions as many times as needed to achieve a score of 100% .

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CE INSTRUCTIONS

CE OBJECTIVES

CE QUESTIONS

Upon completion of this educational activity, participants should be able to:

1. Identify a particular clinical, legal, or educational issue related to quality improvement and performance outcomes.

2. Describe how clinical, legal, or educational issues related to quality improvement and performance outcomes affect nurses, healthcare workers, hospitals, or the healthcare industry in general.

3. Cite solutions to the problems associated with quality improvement and performance outcomes based on guidelines from relevant authorities and/or independent recommendations from clinicians at individual institutions.

1. Per Donna Hopkins, MSN,

RN, CMAC, which discharged

patients should be provided a

home health agency screen?

a . All discharged patients .

b . Only those most obviously

in need of home healthcare .

c . Only the elderly and those

known to have family difficulties .

d . All discharged pa-

tients except surgical .

2. When Regions Hospital in

St. Paul, MN, implemented

“real-time” readmission in-

terviews, what was the effect

of using technology for the

patient to enter information

instead of a staff member

conducting an interview?

a . The average staff time increased

from 20 minutes to 90 minutes .

b . The average staff time decreased

from one hour to 13 minutes .

c . The data entered was found

to be more accurate .

d . The most common reason

for readmission was different .

3. What did David Chin’s,

PhD, research conclude?

a . Hospitals should study re-

admissions for a longer period

than the typical 30 days .

b . Hospitals should study read-

missions for a shorter period

than the typical 30 days .

c . Hospitals should focus on

surgical readmissions .

d . Hospitals should study data

only from 30-day readmissions .

4. What is one way TJC

surveys will change under

the new SAFER matrix?

a . It eliminates Category A and

Category C findings, as well as

direct and indirect impact Ele-

ments of Performance (EPs) .

b . It eliminates Category A and

Category C findings, but retains

direct and indirect impact EPs .

c . It adds additional direct

and indirect impact EPs .

d . It creates a new Cat-

egory M finding that replaces

Categories A and C .

1 Supplement to HOSPITAL PEER REVIEW ® / December 2016

Hospital Peer Review 2016 Index

CMSCMS Finalizes Two-Midnight

Rule, SEP:87CMS Proposes Access to infor-

mation for Quality, Patient Care Improvement, MAR:34

CMS Releases Guide to Preventing Readmissions Among Diverse Beneficiaries, MAR:35

CMS Standardizing Some Quality Measures, APR:37

Final Rule Changes Quality Initiatives, and More, OCT:114

Financial Stakes Rise as Auditors Set Their Sights on Providers, APR:45

Five Things to Know About MACRA, OCT:111

Journal Outlines Issues of Contention in HAC Program, SEP:95

Is CMS Penalizing Top Performers? SEP:85

MACRA Coming Soon, and Many Hospitals Not Ready. OCT:109

Meaningful Use Experience Can Help, OCT:113

Nursing Home Five-Star Quality Ratings Updated, OCT:119

Step Toward Bundled Payments, OCT:114

ComplianceAHA Continues Fight Against

OIG Reviews, JUL:83

Data Collection and Reporting

Data from NSQIP Better than Others, SEP: 94

Meaningful Use Presents Opportunity for Measuring Quality, FEB: 13

Moving from Data to Action – Finding Meaning in Numbers, JAN:1

Quality Reporting Costs $15 Billion Annually, MAY:59

Self-Reported Data May Be Inaccurate, JUL:78

Discharcge PlanningDischarge Planning Proposed

Rule Focuses on Patient Preferences, FEB:21

Infection ControlQuality Department Evolution

to Deeper Data, More Efficient Action, JAN:7

The Best Catheter Is One That’s Out; SEP:91

Patient SafetyCANDOR Toolkit Helps After

Adverse Events, AUG:94Health System Screens All

Patients for Suicide Risk, FEB:15

Hospital-Acquired Conditions Decreasing, Says HHS Report, FEB:23

Hospital Explains Errors with Duplicate Dose, Clonidine, MAY:55

Hospital Tries Reporting Project, but Few Takers, NOV:127

Include Patients, Family in Reporting Patient Safety Events, NOV:125

Lessons Learned from Patient Safety Hotline, NOV:127

Medical Errors: Third Leading Cause of Death, JUN:71

Nearly All Wrong-Patient Errors Preventable, NOV:130

NPSF says patient safety still a

serious concern, FEB:20Patients and Families Can Teach

Safety, OCT:118Quality and Safety Promoted by

Disclosing Errors to All Staff, MAY:54

Safety Culture Proven to Improve Quality, Must be Monitored and Measured, MAY:49

Study Shows Safety Culture Affects Hospital Quality, MAY:53

Patient SatisfactionApp Lets Patients Check ED

Wait Times Before Leaving Home, FEB:19

Assess Anesthesia Patient Satisfaction Correctly, AUG:92

Money-Back Guarantee Aimed at Patient Satisfaction, FEB:17

Patient Satisfaction vs. Quality Scores: What They Really Mean, NOV:121

Patient Secretly Records Disparaging Remarks in Surgery, JUN:68

Recommended Questions from the American Society of Anesthesiologists, AUG:94

Research Shows Disparity with Quality, Satisfaction, NOV:124

Uniformity of Uniforms One Way to Improve Patient Experience, FEB:19

What Do Satisfaction Scores Really Mean? NOV:123

Video Visits Aim to Improve Patient Satisfaction, APR:42

Peer ReviewDon’t Overreach, and Argue for

Broad Interpretation in Court, MAR:32

Follow Peer Review Procedures Rigorously to Protect Privilege, MAR:32

Protect Your Peer Review Privilege or Lose Major Protection, MAR:29

Strategies for Recruiting Peer Review Physicians, MAY:56

Quality Improvement/Evidence-based practice

AHA/HRET QI Project Cuts HACS 40%, Readmissions 20%, DEC:140

Best Practices Lead to Better Cardiac Survival, APR:43

CAUTI Nearly Eliminated, Major Savings from Nurse Project, JUN:65

Case Study 2: LWBS Rates Drop, AUG:88

Create Culture of Confidentiality Through Education, MAR:31

Enhanced Recovery Comes to America. SEP:88

Health System Focuses on Education Outreach, JUN:69

Help Wanted: CBO to Screen Patients for Benefits, APR:47

Health Organization’s PI Program Speeds Up Multiple EDs, JAN:9

Hospital Culture Must Be Measured, Not Just Improved, MAR:33

Hospital LOS Confirmed to Worsen Hip Fracture Outcomes, APR:44

Hospital Overcomes Us-vs.-Them with Doctors, OCT:115

Hospitals and Physicians Benefit from Collaboration, OCT:117

Magnet Status Improves Outcomes, SEP:92

Nurses Take the Lead with Improvement Projects, JUN:64

PAs Rapidly Growing in Number and Influence, AUG:89

Physician Assistants Help Drive Quality Improvement, AUG:85

Quality Department Evolution to Deeper Data, More Efficient Action, JAN:5

Quality Management’s Role Evolves as Hospitals Shift to Population Health, JAN:3

Senior Patients: Unique Expectations, Needs, MAY:58

STAR, CUSS, Secret Shoppers Promote Reliability, MAR:28

Quality MeasureHigh Reliability Organizations

Aim High, Strive for Zero, MAR:25

Philadelphia Hospital First Certified for Total Hip and Knee, JUN:70

Precise Coding Is Best Defense with Quality Measures, JUL:79

Preoccupied with Failure, HROs Constantly Ask Why, MAR:28

Rely More on Risk-Adjusted Rates for Accuracy, JUL:76

Study Finds Only 1 in 21 Quality Measures Valid, JUL:77

Usefulness of Quality Measures Questioned, May Be Misleading, JUL:73

ReadmissionsAre Lengthier Interviews on

Readmission Worth the Time?, DEC:138

Case Study 1: PAs Central to Reducing

Hospital Readmissions, AUG:87Hospital Uses Real-Time

Interviews for Better Data, DEC:136

PA Home Visits Sharply Reduce Hospital Readmissions After Heart Surgery, AUG:89

Readmissions Are Focus of Joint Commission Resources, FEB:22

Reduce Readmissions with Better Data Analysis, DEC:133

Shorter Data Interval Gives Better Readmission Picture, DEC:139

Reports and StudiesMedicare Star Ratings Correlate

with Patient Experience, Outcomes, JUN:70

Study Shows a Data Route Tying Quality to VBP, JAN:11

TechnologyCopy-and-Paste Should Be Used

Carefully, AUG:90EHRs, Devices Threaten Quality

and Patient Satisfaction, JUN:61

Research Shows EHRs Distract Clinicians, JUN:64

Transitions of CareNurses’ Project Improves

Handoffs, NOV:128Program Focuses Nursing on

Patient Care Transitions, DEC:143

Survey and Checklist Help Improve Handoffs, NOV:129

“Warm Handoffs” Can Reduce Hospitals’ Readmission Rates, JAN:10

The Joint CommissionConcurrent Monitoring Helps

Hospital Be a TJC Top Performer, APR:41

Looking at the In-Between Moments of Care, SEP:89

Most Common Problems in TJC Surveys, DEC:142

TJC Allows Docs to Text Orders, Still Use Caution, JUL:80

TJC Denies Accreditation for Deficiencies. AUG:90

TJC Launches New SAFER Scoring Matrix, JUL:82

TJC to Survey Fire Life Safety Code, AUG:95

2 Supplement to HOSPITAL PEER REVIEW ® / December 2016

INSIDE Reduce Readmissions with Better Data Analysis

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Transcript of INSIDE Reduce Readmissions with Better Data Analysis