Engaging Front Line Staff in Readmission ReductionRegina Truong, RNTelemetry Charge NurseReadmission Reduction Team Lead

May 6, 2014

Staff LeadPerformance Improvement at Saint Francis - Model

Sustainable Improvement

Right careRight timeRight place

Evidence-Based Data-Driven Hands-On

Holistic

Lean/Six Sigma Methodology

Engages Community

Partners

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Hands On & Holistic….

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Staff LeadPerformance Improvement at Saint Francis - Process

• Identify problem, root cause & realistic, sustainable solution

• Select a single test site (small test of change)

• Communicate and educate

• Test

• Monitor/Assess/Adjust/Test Again/Repeat

• Spread the proven process

• Champion sustainment

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Staff LeadPerformance Improvement at Saint Francis - Opportunities

Improved Quality of

Care

Increased Patient

Satisfaction

Increased Staff

Satisfaction

More Collaborative

Culture

Improved Revenues

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Staff LeadPerformance Improvement at Saint Francis - Challenges

Keeping Teams

Focused

Integrating Solutions

Proving a Solution Has

Value

KeepingLeadership

Engaged

Continuously improving

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• 2010 – first Inpatient Discharge Team formed and laid the foundation for ongoing performance improvement

– Identified process inefficiencies and siloes

– Initiated improvements in discharge timing and patient throughput

• 2013 – Discharge Team becomes Readmission Reduction Team with renewed focus on interdisciplinary collaboration and effective patient discharge education

– Integrated 10am Discharge Rounds

– DRG-specific Discharge Patient Education Cards with Teach Back

Staff-Lead Readmission Reduction Efforts at Saint Francis

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Integrated Discharge Rounds

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Patient Discharge Education – Pilot Focus on COPD

15.03%

12.42%

9.15%

6.54%

4.58%

0%

2%

4%

6%

8%

10%

12%

14%

16%

COPD CHF Pneumonia RespiratoryInfection

Cellulitis

Top Readmissions by DRG% of Total

Notes -Source: Midas Readmit Toolpack, excludes Rehab & PsychDate Range: 1/2013 – 6/2013DRGs: COPD – 190,191,192, CHF – 291,292,293, Pneu – 193-194-195, Resp. Inf. – 177,178,181,189,204, Cellulitis – 602,603N = 153

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10

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Will support readmission reduction for high risk patients by:

• Planning, developing, implementing, coordinating and evaluating overall readmission reduction program

• Collaborating with multidisciplinary clinical team, Readmission Reduction Team and community partners

• Providing hands-on discharge education and follow up for patients and families

• Providing ongoing education for staff and leadership

Nurse Navigator

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30 Day All Cause Readmissions

Notes -Source: Midas Readmission ProfileDate Range: 1/2011 – 12/2013All Cause Readmissions

8.95%9.31%

7.29%7.52%

8.26%8.09%

7.53%

6.22% 6.11%

5.64%

6.94%

5.93%

5.00%

4%

5%

6%

7%

8%

9%

10%

Readmission RateJanuary 2011 - March 2014

Readmit Rate Target (6.4%)

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Thank You