Narrowing the Scope of a QI Project
Using Root Cause Analysis
IDEAS Alumni event
October 13, 2015
Nicole Robinson and Rachel Stack
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Meet Bob
“patient with high care needs”
• Male patient in his 70s
• Lives alone in Elgin County
• History of CAD with stents, angina,
recurrent falls, GERD, rheumatoid
arthritis
• Had 28 visits to ER in 2014
• Was admitted/readmitted to St.
Thomas Elgin General Hospital 15
times in 2014
• Has substance abuse concerns
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Readmissions….It’s a BIG
Problem
The Cost of Inpatient Readmissions
Based on a recent study (September 2012), inpatient
readmissions within 30 days of discharge cost the
Canadian health care system an estimated $1.8 billion
during the study period
CMAJ September 4, 2012 vol. 184 no. 12 First published August
7, 2012, doi: 10.1503/cmaj.109-4245
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Readmissions…..it is complex!
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Ross Baker, November 2011
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The problem at a Hospital Level
St Thomas Elgin General hospital consistently
experienced higher than expected readmission rates
(~20% actual, compared to ~16% expected).
data reported as of September 2014
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Case Study (Part 1)
• At your table, please review the case scenario and divide
the team roles amongst the group.
• Step 1: Identify what happened - Start by process
mapping “Bob’s journey.” Begin at point of the team
identifying discharge at bullet rounds to readmission to
the hospital. (15 minutes)
• Step 2: Determine what should have happened - After
you have mapped the current state, discuss in the team
what the “ideal” or “future” state process should have
looked like. (10 minutes)
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Process Map with Key Data
Where are the greatest
opportunities?
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Case Study (Part 2)
• Step 3: Determine causes - At your table, apply the five
whys to determine the root cause of Bob’s readmission
to hospital.
• Step 4: Based on the five whys discussion, develop a
causal statement(s).
• Remember:
– A causal statement has three parts: the cause (“This
happened …”), the effect (“ … which led to something
else happening …”), and the event (“ … which caused
this undesirable outcome”).
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St. Thomas Elgin General
Hospital
• Step 5: Generate a list of recommended actions to
prevent the recurrence of the event – What could
STEGH do?
• Step 6: Write a summary and share it – How did STEGH
summarize and share?
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3
What will have the greatest
impact?....and would be the
easiest to implement?
2
1
Where to start? – What are
the key drivers/ contributors
to improving transitions of
care from hospital to primary
care…
…consider the literature and
/OR the data?
How can you scope/ focus?
Where are the GAPS?
-identification of top
problems - data driven? By
pareto?
-where is other work
happening that can be
leveraged? (complimentary)
-should you scope or focus
based on emerging or
4
planned disruptive
What can you learn from
technologies?
understanding the patient
experience?
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Understanding the Data
Audit on Medical Unit 4th
and 5th – (45 admit pt
charts reviewed, 41
correct (91%)) + (54 admits
49 correct (90%)) *only 3
with no family doctor
noted at all
Average summary dictation
time 25 hours, October,
11% or 25 patients had no
discharge summary
?
Proportion of patients
seeing primary care
provider within 7 days of
discharge?
Health Records – Not
meeting 24 hour turn around
time goal. Currently no
standard for priority
transcriptions, almost 36% in
October were flagged
priority
Scorecard Tracking – 31.6%
of (all) discharge
summaries were sent from
St. Thomas Hospital to
primary care providers in
48 hours (patient discharge
to sign off)
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Primary Care Physician
Audit result – 43% of
discharge summaries
received within 48 hours of
patient discharge
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Narrowing the Focus
• Focus on the transition to primary care
• Starting point is ‘improving communication between
hospital and primary care – discharge summary
timeliness’
• Process included 3 key steps: dictation, transcription,
and authentication/ send.
• New transcription system was implemented, the focus
narrowed further to include dictation and
authentication/send processes.
• Finally ensuring patients have timely follow ups with
primary care post discharge
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Using the Data to Narrow the
Scope
Early results that were used to drill down:
– Data for October (Cerner Report) shows an average dictation time of 25
hours. This average was influenced by some outliers. Follow up is
underway to understand the reasons for the outliers.
– An audit was conducted by an Elgin County primary care provider to
verify the proportion of discharge summaries for acute medical patients
discharged in October, that were received in 48 hours (total 43%).
– From this audit we found the following:
• The barrier/delay seemed to be with the ‘sign off’ or authentication
time for many of the summaries
– Next Steps include:
• Expanding the primary care audit to increase sample size from one
physician to a group,
• Confirm the number of patients that actually went for an
appointment within 7 days of discharge
• Establishing regular reporting for baseline capture and on-going
monitoring of discharge summary process measures
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Effort
Impact v Effort
Difficult to Do
Impact
Major
Improvement /
Benefit
• Primary Care to participate in LENs
notifier
• Use EDMS to predict discharge date
• Std for dictation complete within
24hrs
• Make it mandatory for primary care to
use SPIRE
Easy to Do
• Survey primary care re notification
preference + fax numbers
• Survey primary care fax numbers to
reduce mail distribution annual?
• Ward clerk to schedule an apt for pt
prior to pt leaving hospital
• Criteria for priority transcript
• Send discharge summary to CCAC for
pt’s
• Contact primary care to notify of admitted
pt (ward clerk, Dr to Dr communication)
• Ward clerk notify primary care provider
(phone) that pt admitted (same day or in
am)
• Dr to Dr conversation discuss plan would
be helpful in some cases? (criteria)
• Criteria for follow up apt with primary
care 7 days (i.e. med changes select
CMG’s etc)
Minor
Improvement /
Benefit
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Our Aim Statement
High level Aim (goal) – To optimize transitions
of care for acute medical patients (hospital to
community post discharge)
Aim – To increase the proportion of acute medical
patients with select CMGs (as appropriate) discharged
from St Thomas Elgin General Hospital seeing primary
care provider within 7 days of discharge from ~23% to
30% by March 31, 2015
Aim – To increase the proportion of discharge
summaries sent within 48 hours from St. Thomas
hospital to primary care or community provider for
acute medical patients from 41% to 80% by March
2015
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Reduce
Readmissions
Increase
percent post
discharge with
follow up
Timeliness of
Discharge
Summaries
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Change Idea Categories
A P
S D
Eat dinner
Partnership
earlier
with CHC
Schedule follow
up appointments
prior to discharge
Reduce
Readmissions
Patient
Try new
Education
(BPMH,blinds on
windows
standard)
Physician Scorecards/
Discharge
Summaries/
Auto-send
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RESULTS
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Snapshot Impact Summary
• Dictation turn around times were reduced from ~24 hours to 9
hours (mean)
• Transcription turn around times were reduced from ~48 hours
to 2 hours (based on new system implantation)
• Discharge summary process streamlined to eliminate report
authentication – auto send
• Overall percent of discharge summaries sent from hospital to
primary care within 48 hours – increased from 41% (august
2014 to 87% (September 2015)
• Improved patients having a scheduled following up
appointment to 100%
• Over the past 8 months, a significant reduction in
readmissions was demonstrated – this translates into an
actual cost avoidance of $325,699 (based on net
reduction of 47 readmissions in 8 months)
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Impact at the Patient Level
‘Bob ‘s Experience’ January – April 2015
2. Emergency
Department
Reduced visits to ER
2014 - 28 visits to ER
2015 – 7 visits to ER (so
far)
1. Living in
Community
ACTION - Connecting to
supports in the
community
Discharge summary sent to
primary care on Feb 14
(21:32)
On Feb 19 patient had a
follow up appointment with
primary care provider. He has
not had another ER visit since
22the follow up.
3. Acute Care/
Sub-Acute Care
Admissions to Hospital
2014 – 15 admissions
2015 – 3 admissions
Feb 12, discharged on Feb 14
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*Baselines established between 2007 - 2011
Impact at the Patient Level
‘Bob ‘s Experience’ April - September 2015
2. Emergency
Department
Reduced visits to ER
2014 - 28 visits to ER
2015 – 17 visits to ER
(10 more visits since
Feb)
1. Living in
Community
ACTION - Connecting to
supports in the
community
3. Acute Care/
Sub-Acute Care
Discharge summary sent to
primary care on Feb 14
Admissions to Hospital
On Feb 19 patient had a
follow up appointment with
primary care provider. He has
not had another ER visit since
the follow up.
23Next ER visit was May 5
2014 – 15 admissions
2015 – 6 admissions
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*Baselines established between 2007 - 2011
SPREAD
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Quality Improvement Plans
Identified Cross Sector Focus Areas
1
Targeting an improvement in readmissions
Key Focus for 2016-17 (cross sector) is aligned to the following key strategies:
1. Support reduced readmissions to hospital within 30 days by spreading
implementation of the following change ideas:
a. Increasing the timeliness of discharge summaries sent within 48 hours
from hospital to primary care providers (Hospital)
b. Increasing the proportion of patients with a post discharge follow up
appointment scheduled with primary care (Hospital)
c. Increasing the percent of patients seeing their family health care
provider within 7 days of discharge (Community Health Centres, Family
Health Teams)
d. Increasing the percent of unattached patients connected to a primary
care provider post discharge (Community Health Centres, Family
Health Teams)
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QIP Spread Strategy
Facilitating on-going collaborative
sessions between LHIN, St Thomas;
and London Hospitals
Spread and sustainability plan
implemented
through……. the Health Links
Learning Collaborative (standard
change ideas for teams on the
ground)
……Leadership Steering
Committees across South West reflected in key QIPs across sectors
(Primary Care, CHC, and Hospital)
Partnership and referral process to
refer unattached ‘orphan’ patients
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Further Improvement
Opportunities
• Survey primary care providers in Elgin County to
understand their perspective on progress and further
improvement opportunities
• Improve accuracy of discharge summary communication
to CCAC and Long-term Care and Retirement Homes
• Consider risk of readmission in determining best follow
up approach
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