2. Project RED: The ReEngineed Discharge Reducing 30 Day All Cause Rehospitalization Rates: A CQI Adventure
Heart Failure and Readmission Reduction Summit
August Maine, March 30, 2010
Charles Telfer Williams, MD
Vice Chair for Clinical Affairs and Quality
Division of Family Medicine – Boston Medical Center
Assistant Professor
Department of Family Medicine - Boston University School of Medicine

3. Basic quality improvement
Select an area for improvement.
Establish goal.
Describe current system (Process Map)
Select Measures
Standardize the process
Rapid Cycle improvement (PDSA)
AND then Spread it. (Today is that)

4. Plan for Today The Challenge How We Got Started - CQI
NQF ‘Safe Practice’
Is ‘Safe Practice’ Safer?
Risk Factors for Rehospitalization
Barriers to Implementation
Roll-out
Can Health IT Deliver?
This is what we will discuss today.

5. Case 1—Gloria
61 yo female admitted to hospital with cellulitis. She has a history of hypertension for which she takes Lisinopril at home. While in the hospital she was treated with antibiotics for her cellulitis. She was noted to have persistently high blood pressure and the decision was made to increase her blood pressure medicine. Her blood pressure responded appropriately to the new dose.
On the day of discharge she was given a prescription for clindamycin, motrin and a new prescription for lisinopril with a new dose.
She went home, got her new prescriptions filled and took them as instructed on her discharge papers and as well as what was written on the medication bottles. But also continued to take her old dose of Lisinopril as well.
Patient started to have problems of feeling light headed, family brought her back to ED and she was readmitted to the hospital with acute renal failure. 5 5

6. Case 2– Alex
80 yo male admitted to hospital to have his pacemaker adjusted. Was found to have new onset of atrial fibrillation and started on coumadin.
On the day of dc he was given prescription for coumadin and follow up appts to his PCP, cardiologist and Coumadin clinic. Teaching was done and he was given reading material on Coumadin.
Patient’s 79 yo wife was waiting in the car outside while their son came up to get his father. They were in the hospital room getting patient’s shoes on when the nurse came in and said, “the doctors decided you should be bridged with Lovenox while at home. Here is a box with all your information and there is a CD inside for you to watch on how to give yourself the medicine.” 6 6

7. Poor Quality & High Cost
The Challenges:
Poor Quality & High Cost
The ability of hospitals to safely discharge a patient in a reliable way is low (very low) and it costs a lot (too much!).
In 2006, there were 39.5 million hospital discharges with costs totaling $329.2 billion!
Hospital discharge is a time of high risk for adverse events and there a lot of discharges.

8. Major Changes in Hospital Payments
"Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period saving $26 billion over 10 years"
Obama Administration Budget Document
MedPAC recommends reducing payments to hospitals with high readmission rates MEDPAC Testimony before Congress March ‘09

9. Current Developments
All cause hospital readmission rates released this summer
CMS: 14 Quality Improvement Organizations “Safe Transitions” demonstration projects
AHA H2H - goal to reduce readmissions by 20% by 2012

10. Patients Are Not Prepared at Discharge
37% able to state the purpose of all their medications
42% able to state their diagnosis
Many patients are not ready for discahrge.
Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Amgad N. Makaryus, MD, Eli A. Friedman, MD. Mayo Clinic Proceedings. August 2005; 80(8):

11. Little Time Spent on Discharge
Audiotaped 97 discharge encounters
8 Elements - Roter Interactional Analysis
Nurse, Pharmacist, Physician, Nurse Case Manager
Averaged 8 minutes (range, 2 to 28.5 min)
No teachback 84% of the time
Patient is a passive participant
Two initiated questions
Not comprehensive
4 or fewer elements covered 50% of time
The discharge is not currently a priority for providers.

12. Documentation of Pending Tests in Discharge Summaries
668 pts
DC summaries mentioned only 16% of pending tests (482 of 2,927)
All pts had at least 1 pending result, but only 25% of dc summaries mentioned a pending result
Were, MC et al. J Gen Internal Med 24(9):1002-6

13. Pending Tests Not Followed
Annals of Internal Medicine. 2005; 143(2):121-8.
41% of inpatients discharged with a pending test result
37% actionable and 13% urgent
2/3 of physicians unaware of results
Tests done in the hospital the results of which are not back are often not tracked which could lead to many errors.

14. Work-ups Not Completed
Archives of Internal Medicine. 2007;167:
25% of discharged patients require additional outpatient work-ups
More than 1/3 not completed

15. Communication Deficits at Hospital Discharge Are Common
Discharge summary not readily available:
12-34% at first post-discharge appt
51-77% at 4 weeks
Discharge summary lacking key components:
Hospital course (7-22%)
Discharge medications (2-40%)
Completed test results (33-63%)
Pending test results (65%)
Follow-up plans (2-43%)
Direct communication, 3-20%
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
JAMA 2007;297(8):

16. Discharges are Variable by Day of the Week
Days to Rehospitalization 20 40 60 80
0.4
0.6
0.8
1.0
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

17. Errors Lead to Adverse Events
Arch Intern Med 2003;138:pp.
19% of patients had a post-discharge AE
1/3 preventable and 1/3 ameliorable
CMAJ 2004;170(3):pp.
23% of patients had a post-discharge AE
28% preventable and 22% ameliorable

18. A Real Discharge Instruction Sheet
This is an example of an actual instructin sheet for a patient being discharges – how couudl anybody nderstand this. 18

19. “Perfect Storm" of Patient Safety
The hospital discharge is non-standardized and
frequently marked with poor quality.
Loose Ends
Communication
Poor Quality Info
Poor Preparation
Fragmentation
Great Variability
N summary – there is great room for improvement in the hospital discharge.
20% of Medicare patients readmitted within 30 days1
Only half had a visit in the 30 days after discharge1
Jenks NEJM 2009.

20. Quality goals Do the right thing (evidence-based care)
For this patient (individualized) and every patient (equal care)
Every time (consistency)

21. Basic quality improvement
Select an area for improvement.
Establish goal.
Describe current system (Process Map)
Select Measures
Standardize the process
Rapid Cycle improvement (PDSA)

22. Two Questions We asked:
Can improving the discharge process reduce adverse events and unplanned hospital utilization?
Grant reviewer asked:
What is the “discharge process”?

23. Approaches to improving reliability
Definition: Failure free performance over time.
Approaches to improving reliability
Method 1 -- Prevent errors
Method 2 -- Catch and correct errors

24. Method 1 Preventing Errors
Goal: Prevent system failure from occurring in the first place.
Method: Standardization of the system. There is good evidence that quality improves with standardization.
Simple test: Ask 5 people. Roger Resar suggests that one ask 5 people to describe the process or standard work of a system. If you do not get the same answer the process is not standardized.

25. Method 2 Catch and correct errors
Goal: To identify failures and minimize further harm.
Method: Redundancy in the process
Measure:
Track adherence to standard process AND
Number of failures identified and mitigated by redundancy in the process

26. Poka Yoke Error - proofing
Fit the system to the human not the other way around

27. Principles of the RED: Creating the Toolkit
Readmission Within
6 Months
Hospital
Discharge
Patient
Readmitted
Within
3 Months
Probabilistic
Risk
Assessment
Process
Mapping
Failure Mode
and Effects
Analysis
Qualitative
Root Cause
So we used theses methods to carefully look at the process 27

28. RED Component #1 Educate patient about their diagnosis throughout the hospital stay
RED intervention starts within 24 hours of the patient’s admission to the hospital
Continues daily until discharge
Before meeting the patient we view their EmR; Talk to their team of doctors; (so you can be as knowledgeable as possible)
Important to meet with the patient every day to reinforce previous teaching, update them on new information and answer any questions that may have arisen.
Discharge planning should start as close to admission as possible. Discharge planning on the day of discharge is very ineffective.
Like cramming for an exam on the day of the test.
NQF Safe Practice-15: “preparation for discharge occurring with documentation, throughout the hospitalization” 28 28

29. RED Component #2 Make appointments for clinician follow-up and post-discharge testing
Schedule PCP appt within 2 weeks after discharge
Review the provider, location, transportation and plan to get to appointment
Consult with patient regarding best day and time for appointments
Discuss reason for and importance of all follow up appointments and testing
From RED:
-Make appointments with input from the patient regarding the best time and date of the appointment. -Coordinate appointments with physicians, testing, and other services. -Discuss reason for and importance of physician appointments. -Confirm that the patient knows where to go, has a plan about how to get to the appointment; review transportation options and other barriers to keeping these appointments.
(1) “explicit delineation of roles and responsibilities in the discharge process”
If its not one person responsibility then its no ones responsibility
SP-15: “explicit delineation of roles and responsibilities
in the discharge process” 29 29

30. RED Component #3 Discuss tests/studies completed and who will follow up on results
Information listed in After Hospital Care Plan (AHCP), which is transmitted to PCP
Patient knows to discuss this with PCP at follow-up appointment and where to find it on their AHCP
(7) “coordination and planning for follow-up appointments that the patient can keep “follow-up of tests and studies for which confirmed results are not available at time of discharge”
From RED:
Be sure patient understands the importance of such services.
Make appointments that the patient can keep.
Discuss the details about how to receive each service.
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 30 30

31. RED Component #4 Organize post-discharge services
Communicate with case manager and social worker about post-discharge services that they schedule
Provide patient with contact information for these services (phone number, name of company, etc.)
SP-15: “explicit delineation of roles and responsibilities
in the discharge process”

32. RED Component #5 Confirm the Medication Plan
Reconcile the patient’s home medication list as close to admission as possible
Review each medication; make sure that the patient knows why they take it
Discuss new medications each day with medical team and with patient
“completion of discharge plan and discharge summaries before discharge”
This is definitely a challenge but is a current JACHO requirement
It is important to talk to the medical team early on in the admission to “fix or clean up med rec as soon as descrepancies are found
Don’t save it until discharge
SP-15 “completion of discharge plan and discharge summaries before discharge” 32 32

33. RED Component #6 Reconcile discharge plan with national guidelines and critical pathways
Communicate with medical team each day about the discharge plan
Recommend actions that should be taken for each patient under a given diagnosis
The DA looks at these to see that they are done and if not discusses them with the medical team.
Provides a starting point for conversation 33

34. RED Component #7 Review appropriate steps for what to do if a problem arises
What constitutes an emergency
What to do if a non-emergent problem arises
Where to find contact information for the discharge
advocate and PCP on the After Hospital Care Plan
From RED:
Instruct on a specific plan of how to contact the PCP (or coverage) by providing contact numbers for evenings and weekends.
Instruct on what constitutes an emergency and what to do in cases of emergency.
(14) “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.”
SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.” 34 34

35. RED Component #8 Expedite transmission of the discharge summary to the PCP
Fax the discharge summary and After Hospital Care
Plan to PCP within 24 hours after discharge
SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”
From RED:
Reason for hospitalization with specific principal diagnosis.
Significant findings. (When creating this document, the original source documents – e.g. laboratory, radiology, operative reports, and medication administration records – should be in the transcriber’s immediate possession and be visible when it is necessary to transcribe information from one document to another.)
Procedures performed and care, treatment, and services provided to the patient.
The patient’s condition at discharge.
A comprehensive and reconciled medication list (including allergies).
A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of discharge and require follow-up.
Information regarding input from consultative services, including rehabilitation therapy.
(3) “reliable information from the primary care physician (PCP) or referring primary care physician PCP or referring caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”
(8) “A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge. At a minimum, the discharge summary should include the following: reason for hospitalization; significant findings; procedures performed and care, treatment, and services provided to the patient; the patient’s condition at discharge; information provided to the patient and family; a comprehensive and reconciled medication list; a list of acute medical issues, tests, and studies for which confirmed results are unavailable at the time of discharge and require follow-up” (italicized text is part of the Safe Practice recommendation but not presented in the slide)
Calling the PCP, faxing PCP med list, faxing DC summary
Keeping DA in the loop of developments 35 35

36. RED Component #9 Assess degree of patient understanding, ask patient to explain discharge plan
Deliver information to reach those with low health literacy level
Include caregivers when appropriate
Utilize professional interpreters as needed
From RED:
May require removal of language and literacy barriers by utilizing professional interpreters.
May require contacting family members who will share in the care-giving responsibilities.
(11) "Before discharge, present a clear explanation that the patient understands that addresses postdischarge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.”
(21) “Use the ‘teach back process’ to ensure pt understands transition-of-care planning.”
SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.”
"Use the 'teach back process' to ensure pt understands transition-of-care planning." 36 36

37. RED Component #10 Give the patient a written discharge plan at time of discharge
After Hospital Care Plan includes:
1) Principal discharge diagnosis
2) Discharge medication instructions
3) Follow-up appointments with contact information
4) Pending test results
5) Tests that require follow-up
From RED:
Reason for hospitalization.
Discharge medications including what medications to take, how to take them, and how to obtain the medication.
Instructions on what to do if their condition changes.
Coordination and planning for follow-up appointments that the patient can keep.
Coordination and planning for follow-up of tests and studies for which confirmed results are not available at the time of discharge. 
(7) “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 37 37

38. After Hospital Care Plan
Patient-centered discharge instruction booklet
Designed to reach patients with low health literacy
Individualized to each patient and hospital

39. COVER PAGE

40. MEDICATION PAGE (1 of 3)

41. MEDICATION PAGE (2 of 3)

42. MEDICATION PAGE (3 of 3)

43. APPOINTMENT PAGE

44. APPOINTMENT CALENDAR

45. PATIENT ACTIVATION PAGE

46. PRIMARY DIAGNOSIS PAGE

47. RED Component # 11 Provide telephone reinforcement of the discharge plan after discharge
Call patient within 72 hours after discharge
Assess patient status
Review medication plan
Review follow-up appointments
Take appropriate actions to resolve problems
(15) “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid postdischarge adverse events and unnecessary rehospitalizations"
SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations"  47 47

48. Components of RED Intervention
In Hospital – Nurse Discharge Advocate (DA)
Interacts with care team: medication reconciliation, appointments, and national guidelines
Prepares and teaches After Hospital Care Plan (AHCP)
After Discharge – Clinical Pharmacist
Calls for 72 hours post-dc
Reinforces dc plan and review medications
“Discharge” preparation begins at admission… and continues post discharge with a phone call. 48 48

49. Rapid Cycle Improvement
The random controlled trial

50. Testing the RED Process Randomized Controlled Trial
RED Intervention
N=375
30-day
Outcome Data
Enrollment
N=750
Randomization
Usual Care
N=375
Enrollment Criteria:
English speaking
Have telephone
Able to independently consent
Not admitted from institutionalized setting
Adult medical patients admitted to Boston Medical Center (urban academic safety-net hospital)
Usual care at BMC
No policy to make PCP appt for patients
Provided with dc summary, typed out sheet with dc info written
Little instruction, few minutes with nurse/doctor 50

51. How well did we deliver intervention
RED Component
Intervention Group (No,%)
(N=370) *
PCP appointment scheduled
346 (94%)
AHCP given to patient
306 (83%)
AHCP/DC Summary faxed to PCP
336 (91%)
PharmD telephone call completed
228 (62%)
* 3 subjects excluded from outcome analysis: subject request (n=2), died before index discharge (n=1)

52. What did we find?

53. Primary Outcome: Hospital Utilization within 30d after Discharge
Usual Care
(n=368)
Intervention (n=370)
NNT
P-value
Hospital Utilizations *
Total # of visits
Rate (visits/patient/month)
166
0.451
116
0.314
7.3
0.009
ED Visits 90
0.245 61
0.165
12.5
0.014
Readmissions 76
0.207 55
0.149
17.2
0.090
* Hospital utilization refers to ED + Readmissions

54. Cumulative Hazard Rate Time after Index Discharge (days)
Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge 5 10 15 20 25 30
0.0
0.1
0.2
0.3
Cumulative Hazard Rate
Time after Index Discharge (days)
Cumulative hazard curve – shows the cumulative hazard of hospital utilization over the 30 days after discharge from the index admission. For subjects with more than one event in that time period, all events were counted, with time-to-event measured from the date of index discharge for each one. The p-value, significant at 0.004, comes from a log-rank test, comparing the intervention subjects to control subjects.
Usual care
Intervention
p = 0.004

55. Hospital utilizations among people with acute MI, CHF, or pneumonia
Primary outcomes within 30
days after index hospitalization
Control group (n=49)
Intervention group
(n=45)
P value
No. of hospital utilizations,* (No.visits/patient/month)
36 (0.73)
14 (0.31)
0.004
Incidence rate ratio of hospital utilizations, IRR (95%CI)
REF
0.42 (0.23 , 0.79) - 55 55

56. Outcome Cost Analysis We saved $412 for each patient given RED
Cost (dollars)
Usual Care
(n=368)
Intervention (n=370)
Difference
Hospital visits
412,544
268,942
+143,602
ED visits
21,389
11,285
+10,104
PCP visits
8,906
12,617
-3,711
Total cost/group
442,839
292,844
+149,995
Total cost/subject
1,203
791
+412
We saved $412 for each patient given RED

57. Elderly: Outcomes For Ages >=65yrs (121/738 Total Participants)
Primary outcomes ≤30 days after index hospitalization
Control
n=60
Intervention
n=61
P value
Hospital utilizations, n (visits/patient/mo)
32 (0.53)
14 (0.23)
0.001
Emergency department visits, n (visits/patient/mo)
12 (0.20)
2 (0.03)
0.01
Readmissions, n (visits/patient/mo)
20 (0.33)
0.13
Secondary Outcomes
How well were your questions answered before you left the hospital?
15 (47%)
19 (76%)
0.03
How well did you understand your appointments after you left the hospital?
35 (73%)
44 (88%)
0.06

58. Self-Perceived Readiness for Discharge: 30 days post-discharge%

59. Median Clinical Time Required
DA: 90 minutes/subject *
Collect information from patient, teach AHCP
Communicate with medical team, enter data into AHCP**
* Some information collection redundant with existing hospital staff
** Can be expedited using workstation software and ECA character
PharmD: 30 minutes/subject
Prepare for call
Call patients
Conduct interventions post-call

60. Medication Errors (MEs)
Frequency, number (%)
Patient
did not fill
did not need prescription
money/financial barrier
intentional non-adherence
non-intentional non-adherence
did not fill, insurance issue
16 (3.5)
1 (0.2)
19 (4.1)
170 (36.7)
57 (12.3)
18 (3.9)
System
Rx given w/ known allergies
conflicting info from different sources
d/c instructions incomplete/inaccurate
duplication
incorrect dosage
incorrect quantity
pt needed to fill at special pharmacy
pt does not know how to use
no Rx given at d/c
3 (0.6)
111 (24.0)
13 (2.8)
14 (3.0)
8 (1.7)
2 (0.4)
28 (6.0)
Total errors
463 (100.0)
Numbers are how many times that particular error came up, not the number of people with that type of error (i.e. one person could have 4 of one type and they are all counted). 60

61. Should the NQF/RED be Done for Discharge at Every Hospital?
Hypotheses
A comprehensive discharge will:
Lower hospital utilization
Improve readiness for discharge
Increase PCP follow-up

62. Implications The components of the RED should be
provided to all patients as recommended
by the National Quality Forum,
Safe Practice.

63. Who is at risk of Rehospitalizations?
Frequent Fliers
Health Literacy
Depression
Men
Substance Abuse
Elderly
LOS
Co-morbidity

64. HEALTH LITERACY: Risk of hospital re-utilization60
Usual Care
Intervention 50 40 30
Risk of re-utilization 20
p=0.06
p=0.59
p=0.38
p=0.04 10
Grade 3 and below
Grade 4-6
Grade 7-8
Grade 9+
REALM category

65. IRR = Incident Rate Ratio
Depression: # Hospital Utilizations, Hospital
Utilization Rate, and IRR at 30, 60 and 90 days
Hospital Utilization
Depression Screen*
Negative Positive
n=500 (68%) n=238 (32%)
p-value
IRR*
(CI)
No. of Hospital Utilizations†
30-day Hospital utilization rate
140
0.296
134
0.563
<0.001
1.90
(1.51,2.40)
60-day Hospital utilization rate
231
0.463
205
0.868
1.87
(1.55,2.26)
90-day Hospital utilization rate
324
0.648
275
1.165
1.79
(1.53,2.10)
*Depression screen determined by scoring of Patient Health Questionnaire-9 (PHQ9).
Depressive symptom score of 5 points or higher is designated as positive. (17)
† Number of hospital utilizations include all emergency department (ED) visits and hospital readmissions following discharge from Project RED index admission. ED visits leading to hospital admission are counted as one event. Sum reflects cumulative number of events over 30, 60 and 90 days.
IRR = Incident Rate Ratio

66. GENDER: Primary outcomes ≤30 days after index hospitalization
Males
Females
P value
Patients, n
367
370
Hospital utilizations,
n (visits/patient/mo) *
174 (0.474)
108 (0.292)
<0.001
IRR (95% CI)
1.62 (1.28, 2.06)
REF
Emergency department visits,
n (visits/patient/mo)
101 (0.275)
50 (0.135)
2.04 (1.45, 2.86)
Readmissions,
73 (0.199)
58 (0.157)
0.09
1.27 (0.90, 1.79)

67. GENDER: Outcome data collected at 30-day follow-up call by gender
Males
Females
P value
Able to identify PCP name
77%
88%
<0.001
How well did you understand your appointments?
78%
87%
0.005
Visited PCP
49%
57%
0.04
Able to identify discharge diagnosis
73%
0.24
How well did you understand how to take your medications after leaving the hospital?
84%
0.12

68. RED Effectiveness by Risk Stratified Groups
1. This graph shows that at the extremes (Risk Group 20 or lower or 70 and above) the intervention does not work. For groups 20 to 70 (mid-level risk), the intervention is very effective with the exception of a small significantly insignificant point.
2. The y axis is hospital reutilization rate, defined as TOTAL number of hospital readmissions + ER visits/person/30 days. This counts multiple admissions/ER visits per index discharge.
3. Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, “frequent flier” status, and homelessness
Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, high hospital utilization, and homelessness 68

69. Conclusions Hospital Discharge is low hanging fruit for improvement
RED is NQF Safe Practice
RED:
Can be delivered using AHCP tool
Can decreased hospital use
30% overall reduction
NNT = 7.3
Saves $412 per patient
Health IT Could Help
could improve delivery
further improve cost savings and build the business case

70. Using Health IT to implement RED

71. Can Health IT assist with providing a comprehensive discharge?

72. Software to print AHCP

73. Using Health IT to Overcome Challenge of RN Time
Embodied Conversational Agents
Emulate face-to-face communication
Therapeutic alliance using empathy, gaze, posture, gesture
Teaches RED AHCP
Determine Competency
Can drill down
Maps of CHCs
Characters: Louise (L) and Elizabeth (R)

74. Studies of Nurse-Patient Interaction74

75. Patient Interacting with Louise

76. Automated Discharge Workflow76

77. Who Would You Rather Receive Discharge Instructions From?
“I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.”
“It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains everything.” 77

78. Embodied Conversational Agent http://relationalagents.com/red.wmv78

79. Current Work: Online Louise
Post-discharge web-based system designed to emulate the post-hospital phone call
Multiple interactions in the days between discharge and first PCP appointment
Designed to
Enhance adherence
Monitor for adverse events
Prevent adverse events
Identifying post-dc “confusion” and rectify
Screening system for who needs 2 day phone call
Beginning a trial of this system

80. A moment for
reflection

81. RED Implementation

82. Why Hospitals Should Use RED
Volume
Opens beds by decreasing 30 day hospital utilization
Reduces diversion and creates greater capacity for higher revenue patients
Improves PCP follow-up
Satisfaction
Improves satisfaction of patients and their families
Improves community image
Brands the hospital with high quality
Safety
National Quality Forum Safe Practice (endorsed by IHI, Leapfrog, CMS)
Exceeds Joint Commission standards
Improves patient “readiness for discharge”
Documents the discharge teaching and preparation
Documents patient understanding of the plan
Cost - the business case
Saves $412 per subject enrolled
Allows physicians to bill higher discharge level
Improves relationships with ambulatory providers
Improves market share as “preferred provider”
Prepares for change in CMS rules regarding readmission reimbursement
How about dissemination – why should hospitals use RED 82 82

83. Dissemination Website diagnostics - Thousands of worldwide contacts
PR - AHRQ webinar - 2,200 hospitals signed up
AHRQ Roll –out
6 hospital beta sites across country
Studying the process of implementation
Joint Commission, AMA, State Hospital Assns, KP etc.
Office of Tech Transfer at BU
132 hospitals now actively engaged
AHA - H2H
CMS: 14 QIO - “Safe Transitions”
IHI Commonwealth Fund - STARS
Society Hospital Medicine - BOOST

84. RED TOOLBOX After Hospital Care Plan (AHCP)
How to create it (paper or IT)
How to teach it
Discharge Advocate Training Manual
How to provide RED in other languages
In English to non-English speakers
In Spanish and Chinese language AHCPs
How to conduct post-discharge telephone call
How to implement Project RED
How to evaluate/benchmark progress

85. Discharge Advocate Training
Principles of RED
Roles and division of responsibilities
Hire as new role or use existing staff
Use of workstation to enter patient data and print AHCP
Medication reconciliation review
Patient teaching and activation
Cultural and linguistic competency

86. DA Workbook Used to collect patient information: Allergies
Appointments and Transportation
Substance Use
Medications
Medical Equipment
Diet
Exercise

87. Post-dc call manual Review with patient: Medical condition
Any new or existing medical issues
Medications
Acquisition, Adherence, Side Effects
Appointments
Communication with patient and with medical providers

88. How to implement RED
Process mapping to understand discharge process at your hospital
Choose appropriate staff for each task
Use IT capabilities
Pilot
Evaluate

89. Process Mapping-1 Ready for Discharge?
1 measure of discharge
Complex communication that happens 89 89

90. Process Mapping - 2 Discharge Summaries90 90

91. Process Mapping-3 Appointments91 91

92. Process Mapping – 4 Patient Education
If its not anyones responsibility then its no ones responsibility 92 92

93. Delineation of Roles
Where does usual hospital care end and Project RED begin?
What is usual care?
Getting the word out:
Inservice the floor nurses
Inservice the pharmacists
Inservice the medical teams
Send letters to attendings each month 93 93

94. Understanding the risk factors for rehospitalization
High hospital use
Limited health literacy
Depression
Male
Substance Abuse
Elderly
Longer LOS
Co-morbidities

95. How to evaluate RED Staff feedback
Process outcomes: success of delivery
Patient outcomes: satisfaction, 30-day rehospitalization

96. Barriers to Providing a Comprehensive Discharge
Discharge receives low priority for inpatient clinicians
Financial pressure to fill beds as soon as possible 
Often unclear about who is responsible for discharge
Medical team too busy
Many errors in the discharge summary
If done, it is often rushed and incomplete
Relegated to least experienced team members
Discharge papers are standardized and not personalized
RE Bullet #6-One problem we have encountered here at BMC is that the intern (ie least experienced) is frequently the clinician to do the discharge med rec. Often they are stressed, in a hurry, work overloaded & sleep deprived. Many discrepancies are noted by the DA. It has been suggested that the supervising resident oversee ALL med recs. It may be worthwhile to note the average # of d/c’s in a typical weekday and weekend day to see if this is feasible. 96 96

97. Barriers to Implementation
Discharges often occur in the late afternoon and evening
Patients are anxious to leave after waiting all day for final word; teaching is less effective
Lack of communication between hospital physicians and PCPs
No designation about who will follow up on pending tests from hospital and post hospital tests

98. Barriers to Implementation: Medication Reconciliation
Medication plan is regularly changed late in the hospitalization and not always complete/reconciled
Frequent inaccuracies in medication reconciliation (between admission and discharge)
Medication list not reconciled with ambulatory EMR
Team not sure if medication will be added/changed…need to wait for a decision by someone else
Team trained to do med reconciliation at time of discharge or after 98 98

99. Barriers to Implementation: Appointments
Difficult to obtain PCP appointments within two weeks
Patient has no PCP
PCP not accepting new pts
Insurance
Long time to wait on phone
Team not sure of follow up/consults 99 99

100. Health Outcomes – the bottom line
“The ultimate test of the quality of a health care system is whether is helps the people it intends to help.”
“Crossing the Quality Chasm: A New Health System for the 21st Century”. Committee on Quality of Health Care in America –Institute of Medicine National Academy Press. p44

101. What have we learned
Getting quality right in healthcare is a GREAT challenge. Healthcare systems are very complex and the improvement work is hard. The honesty and humility necessary require significant courage.
Yet I feel it is a worthy and even noble challenge and to shy away from it is immoral.

102. Conclusions Project RED: Can be delivered using AHCP tool
Can decrease all-cause 30 day rehospitalization
30% overall reduction
NNT = 7.3
Saves $412 per patient
Hospital Discharge is low hanging fruit for improvement
RED should be provided to all patients as recommended by the National Quality Forum, Safe Practice #15 (2009).

103. Thank you Thank you for being here.
Charles T. Williams, MD

104. For more information: Project RED Toolkit: Research questions:
Research questions:
(Dr. Brian Jack, PI)
Commercial software and implementation
support:

105. BREAK!
Please take a few minutes to stretch and refresh yourselves 

106. An diversion 5 min.

107. Guiding principles for quality efforts
Must be:
sustainable
evidence based
focus on high impact items
feedback must be timely
systems focus
measures should derive from core values

108. Guidelines for implementation of changes
Must be time neutral or saving for each individual user.
Must be cost neutral or saving to the system
Should be piloted first
No new staff added unless mandatory for …
Insist on standard work and data
Enter information once and only once
Automate where ever possible.

109. Muda -- Waste
Inventory: documents, forms, supplies, storage space, waiting
Overproduction: space, care (churning), over-prescribing
Correction: apologizing for delays, retaking vitals or H&P, reentry, duplicate entry
Material & Info Movement: charts, labs slips & samples
Processing: Turning an encounter in to a viable bill for HCFA
Waiting: waiting, waiting waiting…
Motion: leaving the exam room, looking for charts

110. Review of key points Use Improvement science Keep it simple
Must address people’s concerns
Look for “Triple aim”; WIN – WIN – WIN items

111. Resources IHI – www.ihi.org Measurement – www.qualityhealthcare.org
Lean Enterprise Institute –
AAFP Quality Site –
Future of Family Medicine --

112. --Sidebar-- How good is your system
Assume that you audit these 20 and find 1 who did not get appropriate follow up. How big is your problem?

113. Estimation of error rate for rare events.
It is difficult to calculate error rates for rare events in most systems.
The rule of 3 can give an estimate of error rates in such cases.

114. Observed event (errors) = y
Rule of 3/n
If “y” is the number of error (events) in “n” patients, then the upper limit of the 95% confidence interval (CI) can be estimated by the formula x/n.
Observed event (errors) = y
x = Numerator for calculating the approximate upper limit of the 95% CI 3 1 5 2 7 9 4 10

115. Our example. 1 in 20 defect/error rate
For a numerator of 1 the table says use a numerator of 5
5/n, n=20: 5/20 = 0.25
You found a 5% defect rate (1 in 20) but it may be as high as 25%.
For a high risk issue is this good enough?

116. Rule of 3 example
If you find no errors in an audit of 100 charts, then upper limit of 95% CI is 3/100 (0.03 or 3%). You are fairly sure that your error rate is < 3%.
However if you do a random sample of 10 charts and find 1 error, then the error rate may be as high as 50%. (numerator = 1; then use 5/n  5/10 = 0.5 or 50%).

117. --Sidebar-- SMART Goals
A SMART objective is one that is specific, measurable, achievable, relevant and time-bound.
George T. Doran, There's a S. M. A. R. T. Way to Write Management Goals and Objectives, Management Review (AMA Forum), November 1981, pps
For additional information in this area search “SMART goals” and you will get much information.
E.g.,