Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH tventura@cfmc.org Colorado Foundation for Medical Care www.cfmc.org/integratingcare March 22nd, 2012 This material was prepared by CFMC PM-4010-094 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.

Root Cause Analysis (RCA) in ICPCA 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”

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

RCA in CCTP 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.”

9th SOW RCA: specific findings 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

9th SOW RCA: initiative-level “Readmissions are a community problem.” Poor patient-provider interface Medication mis-management No effective patient engagement strategies Unreliable follow-up Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No community infrastructure for achieving common goals

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

Medical record review 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

Readmission-specific tools 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

HQSI (NJ) tool Claims-based fields Readmission chart review (21 items) 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

HQSI (NJ) tool: comments 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

Quality Insights (PA): 1-pager 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

Quality Insights (PA): 2-pager 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

Quality Insights (PA): comments Comments from the Pennsylvania team: Initial findings based on ~60 charts 15-20 charts reviewed per month, over 3 months Process Review readmission data submitted by providers Generate a trending report and list of patients Feedback to hospital 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)

IHI STAAR worksheets 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

IHI STAAR: Worksheet A 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

IHI STAAR: Worksheet B Structured interviews Patient/family Care team 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

IHI STAAR: reflective summary 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

RCA challenges Don’t over-study. Remember these guiding principles. 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.

RCA resources ICPCA Toolkit (NJ/PA tools) http://www.cfmc.org/integratingcare/toolkit_rca.htm IHI STAAR Readmissions Diagnostic Worksheet http://www.ihi.org/knowledge/Pages/Tools/ReadmissionsDiagnosticWorksheet.aspx

Thank you! ICPCA National Coordinating Center www.cfmc.org/integratingcare Tom Ventura (tventura@cfmc.org)