lean healthcare - oahhs · lean healthcare: readmission pioneer ... jean mccalmont, rn care ... •...

Purdue Research Foundation© 1

LEAN HEALTHCARE: Readmission

Pioneer Memorial Hospital


About Us

Pioneer Memorial Hospital

• Prineville, Oregon

• Critical Access Hospital

• Part of St. Charles Health System

Prineville

Madras

Bend

Redmond

St. Charles Health System


Our Lean Project

Readmission What: Create a standard Readmission Risk Assessment tool Why: Evidence Based Best Practice Aim: By June 30, 2014, all patients hospitalized at PMH will be assessed for their social and medical risk for readmission during their hospitalization. Outcome Measure: All patients hospitalized at PMH will have their risk for readmission assessed on admission. Original Process Measures:

1) Number of patients discharged that had their medical and social risk for readmission assessed during hospitalization.

2) Number of patients that had their risk for readmission re-assessed daily


Project Team

Team Members & Roles

Holli Holland, Director Home Health Angie Taylor, Case Manager Redmond

Claudia McDonald, Case Manager

IMCU Bend

Emily Salmon, Program Manager

Medical Home

Janice Pendroy, Clinical Education

Coordinator

Jen Laughlin, DO; Hospitalist Medical

Director

Marian Morris-Fox, Case Manager

Madras

Teresa Parsons, RN Care Coordinator

SCMG Prineville

Verneene Fox, Case Manager

Prineville

Jean McCalmont, RN Care

Coordinator, Mosiac Medical,

Prineville

Darlene Henderson, Quality

Improvement Coordinator, Prineville

and Madras


Define

• Current SCHS standard for planning post-hospital care is to schedule a follow-up office visit prior to discharge

• One “Top Ten” action to reduce preventable readmissions is a formal assessment of readmission risk followed by aligning the post-hospital care interventions to the readmission risk

• This approach to planning care after hospitalization is expected to mitigate a patients risk for readmission and improve their transition to home or a community setting

Baseline Data

total number of readmissions 7

number of patients that had follow-

up apointment scheduled before

discharge

4

number of patients hospitalized

day of or before planned follow-

up visit

3

October and November 2013


Measure Voice of Customer • Reason for follow-up office visit not always clear – this leads to “guessing” reason when making the appointment • Primary Care providers not always aware of hospitalization • “Next available appointment” may not be within desired parameters for follow-up visit • Patient, family and caregivers not included in scheduling • Current process for planning care after discharge is a “one size fits all” • No process to schedule appointments for evening, weekend or holiday discharges


Analyze

Evidence Based Best Practice


Improve

Main point

Test of change #1

Test of change #9

Test of Change Summary: •Gap analysis of 6 different Readmission Risk Assessments • Decided on IHI Risk of Re-hospitalization from How-to Guide as starting point •Replaced teach back with assessment of health / disease state as teach back not commonly used at SCHS •Added section to annotate daily re-assessment •Added section to identify Primary Care Provider •Added section to include patient specific notes


Control

Weekly Measurement Monthly Measurement

Monthly updates and status reports:

• Med Surg Caregivers

• Readmission Improvement team

• PMH Leadership


Spread of project

The SCHS Readmission Team continues to meet to: • Track completion of Readmission Risk Assessment at time of admission and daily • Spread Readmission Risk Assessment to Madras, Redmond and Bend • Plan, test and implement post-hospital care specific for each level of risk • Plan, test and implement a standard workflow to:

1. Communicate Readmission Risk to primary care provider at time of admission

2. Include Community Providers in planning post-hospital care

3. Include patients, family and caregivers in planning post-hospital care


Sustainability of project

Test of Change #11 Second page added that outlines the recommended follow-up care for each level of risk

Test of Change #12 Testing flow that will “pull” patient into Community Provider’s care


Advice to Others & Lessons Learned

• Improving across a “system” of 4 unique campuses can be slow but yields good results

• Including the Community Provider voice at the table was important

• Need the right team members and access to decision makers


QUESTIONS?


Contact Information

[email protected]

Darlene Henderson Quality Improvement Coordinator

Pioneer Memorial Hospital and St. Charles - Madras

mailto:[email protected]

lean healthcare - oahhs · lean healthcare: readmission pioneer ... jean mccalmont, rn care ... •...

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