Topic: Quality Improvement vs Patient Readmission
Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.
This chat is about patient readmission.
Re-admissions within 30 days of discharge often result from patient harm, and may result in payment clawback from insurance providers, Medicare, Medicaid, etc. Readmission may reflect a quality issue, and as such, readmission often acts as a signal that something went wrong – something was missed, something caused harm, etc.
There are many different risks, issues, and opportunities related to patient readmission, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patient comorbidities and home/work environment.
This week the #MEQAPI topics relate to Physician’s Weekly articles related to readmission::
- Readmissions After Emergency General Surgery
- Surgery, Readmission Destinations, & Mortality
- Transitional Care Interventions to Prevent HF Readmissions
- Tackling Heart Failure Readmissions
- Total Joint Arthroplasty: Addressing Unplanned Readmissions
- Surgical Readmissions and Quality of Care
The period immediately following discharge is associated with several heightened risks, and has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm, resulting in readmission or even post-discharge mortality. Readmission may also be due to indirect issues, such as self-harm. The period immediately following discharge carries a high risk for suicidality.
Standardizing the patient discharge process and making it a “no interruption” activity can reduce readmission risk, but readmission may be due to a wide range of causes, including the patient or carer not having the knowledge or means to carry out ongoing care.
Quality Improvement approaches can greatly reduce readmission risk by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove risks.
We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.
Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:
- Policies: either unit, office, organization, or national policies
- Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps self-care, etc.
- Insurance Models
- Home visits
- Transportation option
- Machines (equipment, EHR)
- Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
- Home equipment specific to the patient condition
- Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
- Staffing: insufficient or unqualified staff
- Training: insufficient base training, incorrect training, insufficient CME, etc. or insufficient patient or carer training
- Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
- Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
- Supplies: medical or office, inferior fax paper, lack of coffee(!)
- Data? – sent to wrong recipient, not shared with pt or specialist, etc.
- Patient self-care materials including checklists and how-to instructions, contact information for questions, and slef-care consumables
- KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
- Poor quality and safety metrics
- Targets: improper or unachievable performance targets
- Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
- Monitoring of home-care
- Noise: distracting noises, sound levels too high, etc.
- Space: cramped, uncomfortable, slippery surfaces, etc.
- Time: Too little time per patient, too little time in a day, too many demands
- Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.
- Readiness of receiving point of care to cater to patient needs
The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.
- What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a readmission
- What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a readmission
- What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a readmission
- What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a readmission
- What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a readmission
- What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a readmission
MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.
To quote the IHI on what the Triple Aim encompasses:
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.
The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.