This post is the second in a series on improving transitions in care through the Quality Improvement Plans (QIPs). Click here to read Part 1.
In a recent Quorum post, we shared some key themes in addressing timely and efficient transitions that were reflected throughout the 2019/20 QIPs. Together, these themes – including proactive discharge planning, patient partnering, and collaboration and partnerships – capture the work organizations are doing to improve transitions in care.
Today we will be taking a closer look at the work one group of organizations is doing to show how transitions can be addressed using partnerships among organizations, as well as with patients.
Preventing Readmissions and ED Visits in Elgin through Novel Transitions
In June 2018, the Elgin Health Link Steering Committee recognized that readmission rates for chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) in the Elgin region were higher than provincial averages.
Five organizations in Elgin County came together to address the readmission rate for patients with these conditions: Elgin Health Link/Thames Valley Family Health Team, St Thomas Elgin General Hospital, East Elgin Family Health Team, South West LHIN Home and Community Care, and Central Community Health Centre.
Recognizing that higher readmission rates could indicate that patients need more support easing back into the community, the team aimed to create a novel approach to discharge, designed to facilitate communication among the patient, hospital, primary care, and home care providers and to improve continuity of care across sectors, called the PREVENT Project (Preventing Readmissions and ED Visits in Elgin through Novel Transitions).
This post will describe the QI approach that the PREVENT team followed to improve transitions for patients with COPD and CHF, beginning with the first step in the QI process: Understand the problem.
Understand the problem
Quality improvement begins with identifying and understanding the problem you are trying to solve. This requires partnering with patients, staff, and other organizations to identify a problem, understand the current state of the process, and identify the root causes of the problem.
Develop a problem statement
A good problem statement is one or two sentences that identify and summarize a condition, problem, or issue that a quality improvement team is seeking to address.
Let’s take a look at the PREVENT team’s problem statement:
Map the current state
To create a process map, assemble the right group, including people from various disciplines who have knowledge of the day-to-day workings of the process, as well as patients who have experienced it.
Agree on the scope (the first and last steps to be mapped) and focus on mapping the processes that account for 80% of what is happening (do not waste time on the exceptions). Be sure that your map reflects the actual (not the ideal) process.
Here is the PREVENT team’s process map related to readmissions for patients with CHF or COPD: The team found that the greatest opportunity for improvement was in the discharge and transition process.
Identify root causes
To identify root causes of a problem, gather input from staff and patients and observe processes in real time. An effective tool for helping teams create a common understanding of potential sources that most significantly contribute to the problem is the fishbone diagram.
The PREVENT team’s fishbone diagram started with their problem: Patients with COPD or CHF are frequently readmitted to hospital. Along each “bone” of the fishbone diagram, multiple causes were identified for why these patients are readmitted to hospital. The key categories they used to explore the causes of the problem included patients, process, materials, hospital resources, and community physicians.
The team also used the 5 Whys tool to dive even deeper. The “5 Whys” is a simple brainstorming tool that can help QI teams to move beyond the usual answers to identify root causes of a problem. During this exercise, a team continuously asks “Why is this happening?” to identify how components of a system may contribute to a problem.
The PREVENT team’s 5 Whys looks as follows:
Based on your problem statement and understanding of the root causes of the problem, you can develop an aim statement for your project.
Let’s review the PREVENT team’s aim statement:
At this stage, the PREVENT team was ready to create a driver diagram. This tool helps answer the question “what changes can we make that will result in an improvement?” by translating a high-level improvement goal, as captured in the aim statement, into a logical set of related goals.
Factors thought to have a direct impact on the overall aim are referred to as primary drivers because they drive achievement of the main outcome. To have an effect on primary drivers, we need to carry out clearly defined actions, called secondary drivers. As root causes of the problem become clear, you can also add change ideas in your driver diagram.
The PREVENT team’s driver diagram evolved over the course of the work; initially a planning tool, eventually the driver diagram shows a road map logically leading to the changes the team focused on for improvement.
Generate a measurement plan
The drivers in the driver diagram should form the foundation of your measurement framework. Measurement is a critical part of testing and implementing changes.
A measurement plan should define what will be measured, how often will it be measured, who will be responsible for measurement, and how will the measurements be shared with the team, leadership and the organization.
In improvement work, the team should use a balanced set of measures. The PREVENT team’s measurement plan included the following outcome, process, and balancing measures:
Data can be plotted for these measures over time using a run chart, a simple and effective way to determine whether the changes you are making are leading to improvement.
At this point, you have an understanding of the problem you are trying to solve and why it is happening. Now you will begin to design and test change ideas to address these root causes. Read more about the next steps in the QI process, including key activities for designing and testing change ideas here, and stay tuned for Part 3 of this series to learn about the Prevent Team's change ideas and progress to date.