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Re-engineering project reduces hospital trips
Discharge process evaluated
The last place patients want to end up after a hospital stay is right back in the hospital. But millions of patients each year are readmitted to hospitals, and many of those stays could have been prevented. In fact, 4.4 million hospital stays each year are due to potentially preventable readmissions, according to Agency for Healthcare Research and Quality (AHRQ) estimates.
In 2006, Boston University Medical Center's Brian Jack, MD, an AHRQ grantee, decided to tackle the problem of these preventable readmissions. His focus was the hospital discharge process. By applying engineering methods such as probabilistic risk assessment, process mapping, failure mode and effects analysis (FMEA), qualitative analysis, and root cause analysis, he and his colleagues were able to get a clear picture of discharges.
It wasn't pretty. In fact, Jack calls the discharge process a "perfect storm" where adverse events can coalesce into patient safety problems. "There are loose ends, there are communication problems, there is poor quality information, there is poor preparation, there is fragmentation of care, and there is great variability," Jack said. "It is no surprise that there are many adverse events post discharge."
At the heart of many preventable readmissions lie poorly coordinated care, including unreconciled medications, still-pending test results and still-needed tests, poorly communicated discharge instructions, and rushed staff who don't have adequate time to spend with the patients who are leaving the hospital.
"The discharge process receives low priority in the work schedules of inpatient clinicians, and that is understandable in the sense that nurses and doctors are worried about the sick patients coming out from the emergency room, not so much about the relatively healthy ones who are going home that day," Jack said. His solution was to standardize the discharge process.
Funded by an AHRQ Partnerships in Implementing Patient Safety grant, his Re-Engineered Discharge Project, or Project RED, is based on basic principles that ensure patients are well prepared to leave the hospital: explicit delineation of roles and responsibilities among staff, patient education throughout the hospital stay, easy information flow from the community primary care physician (PCP) to the hospital team and back to the PCP, and an easy-to-read printed discharge plan for the patient. As part of the discharge plan, the patient receives contact information for staff members who can assist after the hospital stay ends. Hospital staff also take the additional step of following up with a phone call within three days after the patient is discharged to ensure he or she is able to comply with the personalized discharge plan.
When Project RED was put to the test in a randomized trial of 750 adult patients at Boston University Medical Center, Jack documented a 30% decrease in readmissions at the end of 30 days for the patients who received the standardized discharge process compared with patients in the control group who underwent a typical discharge. In fact, the National Quality Forum adopted the re-engineered discharge in 2007 as one of the national "Safe Practices for Better Healthcare." These safe practices are evidence-based, ready-to-use tools to improve safety that have been evaluated, assessed, and endorsed to guide health care systems in providing the safest care possible. Furthermore, of the 14 Safe Transition grants the Centers for Medicare & Medicaid Services awarded to quality improvement organizations around the country in 2008, many are using the re-engineered discharge methodology.
To help hospital staff stay on course for preparing patients for discharge, Jack created a checklist, much like the ones pilots and co-pilots work through before each flight. "They [pilots] don't go through that checklist only if it is a rainy day or a snowy day. It is done each and every time," Jack said.
The checklist ensures that the 11 components of Project RED are consistently applied for every patient. For example, it prompts staff to check if the patient's medications have been reconciled, treatment conforms to accepted guidelines, follow-up appointments are made, outstanding tests are tracked, and post-discharge services, such as physical therapy or nutritional counseling, are arranged.
The discharge advocate
The job of ensuring all these moving parts seamlessly come together falls to a staff member called the Discharge Advocate, or DA. "It became clear to us that preparing the patient for discharge wasn't clearly the responsibility of any one group within the hospital," Jack said. "In general, when responsibility is not clearly assigned, then it is nobody's responsibility, resulting in gaps and redundancies."
The DA is the central person responsible for coordinating the patient's discharge from the moment the patient is admitted. The DA's duties include educating the patient throughout the hospital stay, reconciling medications with the treatment team, and coordinating follow-up care with community-based providers, which includes ensuring the patient's primary care physician, receives the discharge summary.
Ultimately, the role of the DA is to reduce information gaps and redundancies that typically occur during discharge and can adversely affect patient care. In Jack's study, a nurse was designated the role of DA, but the duties can be filled by a trained patient advocate, social worker, or other support personnel. The DA or pharmacist calls the patient shortly after discharge to see how the patient is faring with new medications or to remind the patient of upcoming appointments.
The culmination of the DA's work is a document named the After Hospital Care Plan that the patient receives at discharge. The plan contains a wealth of information, in plain language, including the diagnosis, telephone numbers to call with questions, a detailed medication list and schedule, and a list of follow-up appointments that are plotted on a 30-day calendar. Before the patient leaves the hospital, the DA walks the patient through the document, asks the patient questions to ensure he or she knows where to find information, and provides any additional patient education material that may be useful. "Overall, patients really love it when you give them an After Hospital Care Plan that they can understand," Jack said. "They feel more ready and more prepared to go home." Having all the information in one document also helps family members participate in the patient's care. Additionally, patients are encouraged to bring the plan to all follow-up appointments so it can serve as a companion to the discharge summary the patient's community physicians are supposed to receive.
Putting RED into practice
In late 2009, AHRQ contracted with Joint Commission Resources to provide technical assistance for hospitals that want to implement Project RED. More than 135 hospitals across the United States have signed up for the opportunity to learn how to improve their discharge process.
Because this initiative isn't a research study, hospitals are free to implement Project RED however it best fits their needs. After completing three online training modules, the hospitals can choose to implement Project RED, for instance, in a certain unit or for a specific group of patients at high risk for readmission. Hospitals also have the flexibility to adapt Project RED to fit their systems. For example, some have had their information technology teams program computer prompts for different departments to remind them to perform tasks. Others use colored binders in the patient room to let team members communicate what's been done and by whom.
What quickly becomes evident to all of the hospitals is that re-engineering discharge is a team effort. The research study found that it is not only important for the providers, nurses, and other hospital staff to support the new process, but also that they significantly commit to making the process successful.
Nancy Carrier of Tift Regional Medical Center in Tifton, GA, says, "It's been a huge learning curve for all of us. We do quite an extensive discharge process...but the communication could be much improved." Carrier adds that team communication has improved since implementing Project RED.
Before deploying Project RED, Tift staff members underwent a team-building session to help them better understand each other's roles. "We stepped back and decided we need to bring the team together to make it more cohesive," Carrier said. "I don't think any of us could have pulled this together without pulling together as a team." Participating in patient rounds, a Project RED principle for improving team communication can also help DAs get to know their patients early on.
Katie Hall, a DA who works in an oncology unit at Rose Medical Center in Denver., said, "It provides an opportunity for me to get to know the patient, to identify what the learning needs are, and to start working on the care plan from day one. I can sit down and spend the time with the patient and review the new diagnosis, if that's the case, or review chemotherapy."
The experience has been enlightening for some of the hospitals. Leaders at one hospital discovered that although they thought they communicated well with their patients' community physicians, that wasn't necessarily the case. They also learned that their medication reconciliation process wasn't running as smoothly as they'd believed.
The follow-up phone calls have also reaped benefits for patients. These calls can serve to remind patients of appointments that might have slipped their minds, or they can pinpoint a larger problem. For example, during one call, Linda Hollan, a DA from Integris Baptist Regional Hospital in Miami, OK, learned that although a patient filled her prescription, she couldn't open the pill bottle. "I called the pharmacy, and they actually sent someone to her home to open the bottle for her," she said.
Because teaching the After-Hospital Care Plan can be time- and resource-intensive, Tim Bickmore, PhD, of Northeastern University worked with Jack to create a virtual DA named Louise that can review the After Hospital Care Plan at the patient's bedside. With a paper copy of the plan in hand and a touch-screen computer in front of them, the patient walks through the plan in about 40 minutes at Louise's prompts. When it is the patient's turn to speak to or ask a question of Louise, he or she touches one of the on-screen options. "We find that patients can very readily use the system, even if they have no computer experience whatsoever, and they seem to have high levels of satisfaction with it," Bickmore said.
Louise also checks the patient's comprehension of key information, such as information about medications. If the patient doesn't understand something, Louise reviews the information again, alerting a human DA if the second attempt at relaying the information is unsuccessful. "The information [Louise provides] is tailored to each patient's particular discharge information and to their particular needs," Bickmore said. "It takes as much time as the patient needs."
Additional AHRQ grants are being used to test Louise with medically underserved patients in an urban safety-net hospital and to create and test a culturally competent version of the After Hospital Care Plan for varied patient populations. With one in five Medicare patients returning for a hospital stay within one month of being released, Project RED is certain to continue gaining traction in hospitals across the nation, sources said. Jack said, "When you think about it, a lot of complex things are happening during the hospitalization in terms of pharmacology and medications and treatment and discussions. Then we send patients home with maybe eight minutes of discussion about how to care for themselves when they go home, so it is no surprise that patients are having a lot of trouble caring for themselves once they go home." Through Project RED, "we transition that information from the hospital environment to home where the patient cares for themselves and then to the community environment where the primary care physician knows about what happened."
[For more information on improving patient discharge, visit http://www.ahrq.gov/qual/impptdis.htm. Hospitals interested in learning about the AHRQ project for re-engineering hospital discharge can contact Deborah Morris Nadzam, PhD, FAAN, Joint Commission Resources, at 630-261-5048 or firstname.lastname@example.org.]