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Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH Colorado Foundation for Medical Care

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Presentation on theme: "Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH Colorado Foundation for Medical Care"— Presentation transcript:

1 Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH Colorado Foundation for Medical Care March 22 nd, 2012 This material was prepared by CFMC PM CO 2012, the Medicare Quality Improvement Organization for Colorado under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

2 Identify community-specific drivers/root causes of readmission Customize the selection and targeting of interventions Expressly part of Aim strategy – “Identify service patterns associated with readmission” 2 Root Cause Analysis (RCA) in ICPCA

3 3 RCA in ICPCA Perform Root Cause Analysis Identify Driver of Readmissions Select and Implement Intervention Track Process and Outcome Data Determine Effectiveness

4 Application requirements “Describe the results of the RCA that was performed.” “Describe how the results informed the selection of the proposed intervention and target population.” “Describe your implementation strategy.” 4 RCA in CCTP

5 Reasons for experiencing readmission Unmanaged worsening of condition Use of suboptimal medication regimens Return to emergency department instead of accessing a different type of medical service 5 9 th SOW RCA: specific findings

6 9 th SOW RCA: initiative-level

7 Medical record review Interview – Patient/family – Provider/care coordinator Focus group Process mapping Cause-and-effect diagram 5 Whys 7 RCA methods

8 Review charts among a sample of patients who experienced readmission. – Sample size: small – Readmission and index admission charts – Structured review protocol – Narrative reflection – Types of information extracted Commonalities, themes Patient characteristics, behaviors Provider and system factors Underlying causes Leverage points for intervention 8 Medical record review

9 NJ: Healthcare Quality Strategies, Inc. – 30-day Readmission Chart Review Form PA: Quality Insights of Pennsylvania – Readmission Review Form IHI: STAAR Initiative – Readmissions Diagnostic Worksheet 9 Readmission-specific tools

10 Claims-based fields – Diagnoses, hospitalization dates (LOS) Readmission chart review (21 items) – MD office; ED visit; observation stays – Documentation Reasons for readmission (i.e., patient/family, physician/nurse) PHR, discharge plan – Discharge disposition – Patient education, instructions – Planned versus unplanned readmission – Open reflection Potential hospital problems Missed opportunities 10 HQSI (NJ) tool

11 Comments from New Jersey team: Despite everyone’s best efforts, documentation can still be lacking. – Requires clarification – May be unreliable (e.g., patient education) Recommendations – Admission chart review to fill in holes – Patient/family interviews in conjunction with chart review – Pilot implementation of tool Dial in setting-specific issues Prompt a quality improvement process (improve documentation) Caveat: targeted heart failure patients 11 HQSI (NJ) tool: comments

12 Section 1 – Dates, diagnoses, discharge disposition – Planned vs. unplanned readmission Section 2 (13 items) – Post-discharge level of care Physician follow-up Referrals for home health, hospice, community resources (e.g. AAA) – Medication Reconciliation – Symptoms Present on first admission – Discharge plan – Patient education – Admission Unforeseen; avoidable; relation to first admission 12 Quality Insights (PA): 1-pager

13 Index admission – Dates, diagnoses, discharge disposition – Planned vs. unplanned Readmission – Dates; planned vs. unplanned Potential readmission factors (10 domains, 27 items) – Downstream provider issue – Patient/caregiver education – Patient activation – Medication management – Transitional care planning (services offered) – Discharge instructions – End of life – Discharge disposition – Unstable condition at discharge – Recurring possible triggers for readmission 13 Quality Insights (PA): 2-pager

14 Comments from the Pennsylvania team: Initial findings based on ~60 charts – charts reviewed per month, over 3 months Process 1.Review readmission data submitted by providers 2.Generate a trending report and list of patients 3.Feedback to hospital 4.Random chart reviews with narrative Issues – Get consistent information from reviewers across levels of clinical expertise Results – Sustainable – High satisfaction, despite initial resistance – 10 domains (readmission risk factors) Evolution – 7-day readmission review – Cross-setting chart review (downstream providers) 14 Quality Insights (PA): comments

15 In-depth review of 5 most recent readmissions – Identify opportunities for improvement – Chart review and interview components Worksheet A: chart review – Details and documentation (9 items) – Reflective summary (7 prompts) Worksheet B: interviews – Structured interviews (9 items): patient, family, and care team – Reflective summary (8 prompts) Reference list of typical failures 15 IHI STAAR worksheets

16 Details and documentation Days between discharge and readmission Follow-up physician visit scheduled prior to discharge – Patient attended office visit Urgent clinic/ED visit before readmission Functional status on discharge Clear discharge plan Teach-back Reasons for readmission Social conditions contributing to readmission 16 IHI STAAR: Worksheet A

17 Structured interviews Patient/family – Reasons for symptom worsening and readmission – Physician follow up Barriers – Medications Behaviors Barriers to adherence – Nutrition Care team – Reason for readmission Reflection on patient circumstances contributing to readmission 17 IHI STAAR: Worksheet B

18 Worksheets A and B What did you learn? Most common failures? (Worksheet B only) Trends or themes What surprised you? New questions What are you curious about? What to do next? Challenged assumptions about readmissions 18 IHI STAAR: reflective summary

19 Don’t over-study. – Elegant, comprehensive demonstrations of the problem are not required. – Cumbersome, technically-detailed exercises enable you to avoid moving forward. Remember these guiding principles. – The purpose is to inform the PDSA cycle, test interventions, and drive action on a larger scale. – Get just enough information to generate a reasonable set of priority actions. 19 RCA challenges

20 ICPCA Toolkit (NJ/PA tools) – IHI STAAR Readmissions Diagnostic Worksheet – nsDiagnosticWorksheet.aspx nsDiagnosticWorksheet.aspx 20 RCA resources

21 ICPCA National Coordinating Center – – Tom Ventura 21 Thank you!


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