Emergency Department (ED) Performance Improvement Project (PIP) 7/27/ PDF

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Emergency Department (ED) Performance Improvement Project (PIP) TCC Conference, August 2016 Amy Pulliam, MPH, Quality Improvement Coordinator Michelle Mason, LCSW, ACHP-SW, Compliance
Emergency Department (ED) Performance Improvement Project (PIP) TCC Conference, August 2016 Amy Pulliam, MPH, Quality Improvement Coordinator Michelle Mason, LCSW, ACHP-SW, Compliance Specialist Objectives Describe overall requirements of a Quality Assessment Performance Improvement (QAPI) Program Describe recommended elements of Performance Improvement Projects (PIPs) Describe the process of designing, developing, and measuring a PIP utilizing the example of the Emergency Department (ED) PIP by Hospice and Palliative Care of Greensboro (HPCG) What is QAPI? QAPI is a combination of two quality management systems: Quality Assurance (QA) and Performance Improvement (PI). QA focuses on standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. PI (also called Quality Improvement - QI) is the continuous study and improvement of processes with the intent to better services or outcomes, prevent or decrease the likelihood of problems, identify areas of opportunity, test new approaches to fix underlying causes of problems or barriers to improvement. 1 Why Do We Do QAPI? : Condition of Participation, added in 2008 The hospice must develop, implement, and maintain an effective, ongoing, hospice-wide data-drive QAPI program. The hospice s governing body must ensure that the program: reflects the complexity of its organization and services; involves all hospice services (including those under contract or arrangement); focuses on indicators related to improved palliative outcomes; and takes action to demonstrate improvement in hospice performance. The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. The 5 Elements of QAPI Design and Scope (a) Standard: Program scope Show measurable improvement in indicators related to improved palliative outcomes and hospice services Must measure, analyze, and track quality indicators, including adverse patient events, in order to assess care, services, and operations 2 Feedback, Data Systems, and Monitoring (b) Standard: Program data Must utilize quality indicators in the design of its program Must use data collected to monitor service effectiveness and safety and identify opportunities and priorities for improvement Frequency and detail of the data collection must be approved by the hospice s governing body Systemic Analysis and Systemic Action (c) Standard: Program activities The hospice s performance improvement activities must: Focus on high risk, high volume, problem prone areas Consider evidence, prevalence, and severity of problems in those areas Affect palliative outcomes, patient safety and quality of care The hospice s performance improvement activities must: Track adverse patient events, analyze their causes and implement preventive actions Take action aimed at performance improvement Measure/track success of action to ensure that improvements are sustained Performance Improvement Projects (PIPs) (d) Standard: Performance Improvement Projects (PIPs) Hospices must develop and document PIPs The number and scope of PIPs conducted annually must be based on the hospice s needs, scope, complexity, and past performance The documentation must include what PIPs are being conducted, the reasons, and the measurable progress. 3 Governance and Leadership (e) Standard: Executive responsibilities Governing body ensures: That an ongoing program for QI and patient safety is defined, implemented, and maintained, and is evaluated annually. The QAPI efforts address quality of care and patient safety, and all improvement actions are evaluated for effectiveness. That one or more individual(s) is designated to lead QAPI efforts. What is QAPI Really About? QAPI represents a continuous process of doing business with the expectation of achieving optimum results by involving all levels of the organization. Performance Improvement Projects (PIPs) Should contain: A description of the activities to be conducted The frequency of activities Person/s designated to conduct the activities Methods of data collection Acceptable limits for findings / threshold Plans to re-evaluate if findings fail to meet acceptable limits Any other activities required under state or federal laws or regulations 4 PIPs PIPs are identified areas in which improvement can be made, specifically: high risk, high volume, and problem prone. (Area of improvement: costs/service/staffing) Involve various team members that will be directly impacted by the change. (Encourage honest feedback with respect to opinion differences) Record and acknowledge outcomes to use as building blocks to achieving improvement. Respect time to not exhaust valuable opportunity. Be open to the unexpected happening.. PIP Action Plan HPCG utilizes Deming s PDSA Cycle. The PDSA cycle is a method for testing change by planning, trying, observing, and acting on what is learned. It frequently takes multiple PDSA cycles to achieve desired results. Prioritize activities by doing PDSA cycles. PDSAs Break the process down in cycles: Plan: Predict what will happen with the change. (who, what, when, why, data to be collected) Do: Test the change on a small scale. (Document any problems and unexpected observations.) Study: Compare the data to your predictions. (Summarize what was learned, good/bad.) Act: Make changes, based on what was learned from test. 5 Maintaining Focus (Plan) A key step to the planning process is establishing an Aim Statement. An Aim Statement is an clear description of a team's desired outcomes, which are expressed in a measurable and timespecific way. It answers the question: What are we trying to accomplish? Establishing an Aim is important to keep the focus. Testing the Change (Do) Why test change before implementing it? It involves less time, money and risk Is a powerful tool for learning; from both ideas that work and those that don't It is safer and less disruptive for patients and staff Getting people involved during the testing and developing phase can result in less resistance at implementation Analysis of Process (Study) Based on the AIM statement and data gathered determine if: The plan resulted in an improvement? By how much/little? Was the action worth the investment? Do you see trends? Were there unintended side effects? 6 Implementation (Act) Standardize the improvement and begin to use it regularly OR Develop a new and different plan that might result in success. What is HPCG s ED PIP About? Finding ways to ensure the patient receives the right care to meet their needs, and reduce the number of unnecessary ED visits and transportation costs. What Was the Problem/Need? High costs of transportation High costs of ED visits Many of the patients going to the hospital have goals that indicate they don t want further hospitalizations HPCG tracking hospitalizations since 2011 (already had a lot of data) ED PIP formed in October of 2014 to address these issues 7 PIP Members Quality & Compliance Finance Clinical Staff Inpatient facility On-call Home Care Long-term Care (LTC) MD RN Social Worker Aide What Were the Numbers? October 2013-September 2014 # of patients who went to ED: 320 # of ED visits: 457 (199 were not admitted) (4.18 visits per 1000 days) Oct 2013-April 2014 Transport costs: $109, ($1,767 per 1000 days) Time of Day ED Visits On-Call ED Visit Hours Reasons for ED Visits Symptom Management ED Visits Top 3 Diagnoses of HPCG Patients Using ED Heart/CHF/Cardiac Alzheimer's/Dementia COPD/Respiratory Who Sent Patient to Hospital Unknown 2% HPCG 8% MD Office 15% Patient/Family 57% Facility 18% Disposition Other 9% Died 14% Beacon Place (Inpatient Facility) 8% Home (Facility or Residence) 69% 10 Other Things to Consider A higher percentage of full or limited codes go to the hospital (8% of HPCG hospice patients are full/limited codes vs. 22% of HPCG hospitalized patients). There is a seasonal effect fall and spring have more admissions than winter and summer. HPCG s average length of stay continues to decrease over time. Falls are a big issue for Long Term Care patients. On average, there is 1 day contact between HPCG visit and ED visit. There are a number of patients that have repeat hospitalizations ( frequent flyers ) ED PIP AIM To Reduce Emergency Department Visits by 10% per patients served in a 3 month time span. Timeline of Activities October st ED PIP meeting May 2015 Surveyed facilities to get feedback on improving collaboration and communication July 2015 Presented at team meetings the change results to increase awareness and sustain change. November 2014 Gathered feedback and increased awareness with staff January 2015 Met with Guilford County EMS to discuss collaboration April 2015 Piloted Personal Emergency Plan form in Assisted Living Facility (HG) (start date 5/1/15) March 2015 Implemented Personal Emergency Plan form usage in home setting August 2015 Met with Guilford County EMS to continue discussion of collaboration September 2015 Put HPCG stickers on DNR and MOST forms to help EMS identify as our patient 11 Timeline of Activities October 2015 Met with staff at AL Facility (CH) to begin piloted Personal Emergency Plan forms (start date 11/1/15) EMS shadowed Admission Nurse to get a better understanding of our process. November 2015 HPCG Counselors attended EMS trainings to educate staff about hospice June 2016 Identification of LTC facilities / staff to expand program April 2016 Met with LTC to discuss including more facilities in pilots January 2016 Paramedic attended clinical staff meeting to educate about EMS February 2016 Sharing frequent flyer information with Cone Health (hospital) Example of My Personal Emergency Plan Form Label on DNR/MOST Forms 12 1000 Patient Days # of ED Visits 7/27/2016 What Has Been Accomplished? 7.00 EMS Shadowing 6.00 Visit FY 14 / 15 / 16 ED Visits Per 1000 Patient Days HPCG Educates EMS RN/SW Personal Emergency Plan Reminder CH Facility Pilot EMS Educates HPCG Sharing Frequent Flyer Info with Cone Meeting with LTC to discuss moving forward Identification of Facilities / Staff to expand program 0.00 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep FY FY FY Another Look: Accomplishments Pilot Facility Accomplishments 12 Personal Emergency Plan in Pilot Facilities HG Pilot Begins CH Pilot Begins 0 4th Q st Q nd Q rd Q th Q st Q nd Q 2016 HG Pilot CH Pilot HG Facility CH Facility Fiscal Year # ED Visits 1000 Days # ED Visits 1000 Days FY FY 15-16* % Change -66% -73% * To June 30, Percentage 7/27/2016 What are the Numbers Now? The 15/16 FY thus far has resulted in a 27% decrease from the 14/15 FY and a 33% decrease from FY 13/14. Fiscal Year ED Visits Visits per 1000 patient days Patients using ED % Change from Previous Year 10/15 6/16* % 10/14-9/ % 10/13-9/ NA * Only 9 months of data Transportation Cost per 1000 patient days Jan 2016-May 2016 $1, June 2015-December 2015 $1, Jan 2015-May 2015 $2, Did We Meet Our AIM? AIM: To Reduce Emergency Department Visits by 10% per patients served in a 3 month time span. Some considerations: While the PIP began in October, our first intervention was in late November, so the earliest the PIP would have an impact would be December 2014 Thus, we compared January 2015 March 2015 to the same 3 months the year before using the old metric, per patients served, and calculated a 12% decrease, thus meeting our AIM January March 2014 January March % per patients served 7.6% per patients served 12% decrease Other Considerations In studying the data, we also found some correlation between Personal Emergency Plan Completion Rates and ED rates as follows: 120.0% PEP Completion Compared to ED Rates 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% -20.0% -40.0% -60.0% Month % Change from Previous FY PEP Completion Rate 14 What is Next? Partnering with Guilford County EMS on coordinating care for HPCG patients that call 911. Implementing Personal Emergency Plans in Assisted Living facilities and possibly Skilled Nursing Facilities. Continuing to educate staff about ED PIP and the effectiveness of the Personal Emergency Plan. Updating our AIM statement. Sustaining the Change There is a correlational relationship between reducing patient ED visits and transportation costs. Continuous education is imperative to maintaining staff involvement and their understanding of the need to make changes. Highlighting the different outcomes of each small change (numerous PDSA cycles) improves awareness and new opportunities. Encouraging improved care coordination with outside agencies (EMS and Long Term Care Facilities) will improve quality of life outcomes for HPCG patients. Questions? 15
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