Transitional Pearls

Transitional Pearls – Episode 1

We’re pleased to inaugurate our occasional series in which the patient safety community shares its work on improving safety during transitions.  If you would like to share your work, please contact us.

This information is shared by Elaine Lobdell RN, MS, CPHQ.  Elaine is Vice-President Quality Services at Valley Medical Center (VMC) in Renton.  She shared this information via an email interview process.

WPSC: I understand that a few months ago you looked at your patients who had been readmitted after recent discharges in order to learn more about the circumstances of their readmissions, and you used some innovative methods. What were you hoping to learn?  That is, why did you undertake this project?

VMC: Historically, VMC’s performance in readmissions had been comparatively favorable overall (that is, below expected), so reduction of readmissions had not risen to the threshold of a strategic performance improvement (PI) initiative.  However, with the intent to be proactive in identifying improvement opportunities and in anticipation of pay for performance, we began a more detailed analysis.  Previously, we had wanted to understand contributions to readmissions from a “quality of care” perspective and had conducted extensive medical record reviews.  In fact, we learned a lot from those reviews but they did not answer our specific questions regarding the factors contributing to readmissions.  If anything, those studies affirmed that “quality of care” (medical management) issues, in the traditional sense, were not driving readmissions.  This time, beyond the medical record, we believed there were “untold stories” that would better unveil those contributions, so we decided to explore patients’ experiences through their own eyes.  The specific tactic we used was patient interview upon readmission.

WPSC: Please describe the project – which patients did you look at? For example, did you look at everyone readmitted within a certain timeframe? Or those readmitted with a specific diagnosis?

VMC: This decision evoked much discussion among PI team members.  In order to avoid prejudice in data collection (regarding specific conditions), we decided to capture as many patients as possible who were readmitted (inpatient to inpatient) within 30 days, regardless of diagnoses.  We eliminated patients whose readmission was totally unrelated to the previous admission.

WPSC: Who was involved with this process, and what did they do?

VMC: The initial PI team consisted of representatives from nursing, rehabilitation, pharmacy, the primary care clinic network, case management, and quality management.  Spurred by a review of the literature, together, the team developed a combined patient interview/medical record review audit. Information Technology prepared a daily report of readmissions within 30 days that was delivered electronically to the PI team leader.  A case manager on the PI team with particular interest in this study volunteered to conduct all the interviews while the patient was in the hospital the second time.  She arbitrarily selected from the list the patient(s) she would interview that day.  Initially each interview took up to one hour to complete, but she was able to reduce that time to approximately 45 minutes consistently.  She also conducted the review of the medical record for the previous admission.  We recognized that such an approach would likely extend the data collection period but were committed to consistency in the data collection process.  We stopped once there were 47 completed interviews in our sample.

WPSC: What did you learn from this project?  What do you think others can learn from your work?

VMC: First of all, I would emphasize that we are still learning!  The critical findings included:

• Patients who are discharged to home—including those with home care services (which were sometimes delayed) are most at risk for readmission.  We think the reason was the delay in and/or lack of consistent medical/clinical oversight in the home, as opposed to other situations, where someone was at least charged with overseeing their care and assuring they received their medications as ordered.
• Contributions (breakdowns) were more about discharge “processes” than related to specific conditions:  aside from end-of-life stages of illness, contributions transcended diagnoses and even age.
• Primary contributions to readmissions can be distilled into two high-level processes:
  • Hand-over to the community provider (specifically the primary physician) and the follow-up appointment. For example, despite what directives were given or what preparations were made for the first follow-up appointment, the appointment, most often, did not occur for patients who were readmitted.  Either they “forgot to schedule it/forgot to keep it”; “didn’t understand the importance/felt too ill/felt too well” to keep the appointment; they “didn’t have transportation”; it “wasn’t a convenient time for their ride”; or sometimes they “didn’t know why they didn’t keep it.”
  • Medication management.  For example,  despite an excellent technological solution for the process of medication reconciliation, and the layperson-friendly document it yields, the KEY seems to be in taking the next step – namely, reconciling the “pill bottles” with that home medication list together with the patient…  and employing “teach-back” while doing so.  We have not yet implemented “teach-back” for this specific purpose.

Since we began our journey, these findings have been reflected in more recent literature as well.  Still, they underscored where we needed to focus our improvement efforts.

WPSC: What are your next steps, and what do you hope to learn?

VMC: We are implementing several strategies:

• We are resuming follow-up (clinical) phone calls to all discharged inpatients.
• For patients with complex/high-risk medication regimens, we are initiating a post-discharge follow-up discussion with a clinical pharmacist – we’re testing this with our heart failure population.
• We are redesigning hand-over processes with particular emphasis on communication and the first follow-up appointment.

WPSC: Is there anything else you’d like to add?

VMC: I would like to express my appreciation to the members of the PI team for their ongoing commitment of time and effort.  In particular, I would like to acknowledge our case manager for assuming the monumental task of data collection.  The work of this particular performance improvement team has coincided with the work of another team:  the Nurse Communication (HCAHPS- Hospital Consumer Assessment of Healthcare Providers and Systems) PI Team, which has been focusing on “teach-back.”  That particular communication/teaching technique is anticipated to augment our efforts while teaching patients about community provider follow-up and medication self-management.