Transcript Identifying the scale of readmissions

What is a
readmission?
Definitions
28 days -no exclusions
30 days PBr with exclusion maternity , under 4s , transplant and dialysis and chemotherapy patients
Why should we
look at
readmissions?
Patient Safety
Patient Experience
Efficiency and Effectiveness
Identifying
Readmissions
Reduction
Opportunities
Identifying the scale of readmissions
Readmission Rates
Peer Benchmarking ( Rates and Readmission Rations)
Review of Programme Matrix and previous specialty readmission work
Identifying the reasons for readmissions
Clinical audit including Patient Centred Reviews, planning and readmissions audit
Patient pathway process mapping
Staff surveys
Planning for a
change
Implementing
and Monitoring
Improvements
Review and
Revisit
Areas of change
Develop plans
Issues/Risk Log
Log projects onto Programme Matrix
Measuring Benefits
Baselines – readmissions
SPC charts
Review and revisit.
What is a readmission?
Readmissions Definitions
Spell
Emergency (GP Referral /ED)
Elective
Daycase
Readmission Spell
≤ 28 days
Emergency (GP Referral /ED)
NUH Readmissions
All patients who readmit to the hospital via an emergency code (GP referral/ED) within 28 days of discharge.
Reporting and extracts on Medway BI are based on this definition
PBR Definition
Payment by Results (PBR) who readmit to the hospital via an emergency code (GP Admission/ ED/ Consultant Clinic) within 30
days of discharge excluding some patient groups
•
•
•
•
•
•
maternity and childbirth
cancer, chemotherapy and radiotherapy
patients receiving renal dialysis
patients readmitted after an organ transplant
young children (under four years old at the time of readmission)
patients who are readmitted having self-discharged against clinical advice
https://www.gov.uk/government/publications/nhs-national-tariff-payment-system-201617
Why should we look at readmissions?
Patient Safety
In patient centred reviews carried out on readmitting patients 20% of patients responded that they did not feel confident leaving the hospital that either
their symptoms has resolved ,they knew who to contact , what to expect or that they had been given sufficient information .
Patient Experience
Patients and their families who are readmitted to the Trust may have lost confident in either the Trust or community support services.
Efficiency and Effectiveness
For 2013/14 the allocation of readmission penalty funds (£4.3m) was delegated to system implementation groups who administered a bidding process to
local health and social care providers including NUH. The panel agreed to assign a small proportion of these funds (£100k) to NUH to gain a better
understanding of the changes necessary to deliver a more coordinated approach to readmission reduction.
In 2014/15 commissioners supported the establishment of a NUH led Readmissions Reduction Programme and agreed to make the entire readmissions
fund (£4.3m) available to NUH based on the delivery of contract milestones. Two out of three contract milestones were delivered and £2.86m returned to
the Trust.
Following an improvement in the readmit rate during 2014/15, contract negotiations for 2015/16 agreed that the readmission penalty would continue to
be exclusively returned to the Trust contingent on meeting quarterly milestones. All milestones were met and the entire £4.3m penalty was returned to the
Trust.
For 2016/17 the full readmissions penalty of 3.6m will be reinvested in the Trust (£1.3m at baseline and the residual readmissions penalty valued at 2.3m
will be reinvested non-recurrently)
NUH and it’s commissioners have agreed to re-review the readmissions baseline in future years based on the same methodology as we agreed in 2016/17
and that any adjustments required will be made annually. The methodology for determining this can be found in a slide pack in the Appendix
No trajectory has been set by commissioners for readmissions reduction in 2016/17. However the rate will be monitored and reported within operations
(monthly ) and to QUAC (quarterly) any increasing risks or issues.
Identifying Readmissions Reduction Opportunities
Identifying the scale of readmissions.
•
•
•
Readmission Rates.
Peer Benchmarking ( Readmissions Rates and Readmissions Ratios
Review of Programme Matrix and previous specialty readmission work.
Identifying reasons for readmissions.
•
•
•
Clinical Audit including Patient Centred Reviews
Patient Pathway Process mapping
Staff Surveys
Identifying the scale of readmissions
Calculating Readmission Rates
Rates allow you to compare across time points/ specialties.
However but to identify the opportunity this may provide you should also look at absolute numbers e.g for a small specialty
discharging low numbers of patients one or two patients admitted will have a big effect.
150 patients
discharged from HCOP
in June 2016
≤ 28 days
15 of these patients
readmit within 28 days
(15/150) = 10% readmission Readmissions rate for HCOP in June 2016
Readmission Data Sets
Summary of all 28 Day Emergency Readmissions (without exclusion) since April 2012
•
•
•
•
This allows you to extract patient level data on all patients readmitted using an emergency pathway ( ED, GPAU etc) within
28 days following a spell of care which may have been inpatient or daycase.
You can use the report to specify the time period ( not before Jan 2010) , the discharging specialty/ directorate and the
readmitting specialty/directorate.
The data contains details of the previous and current spell including specialty , diagnosis and specialty as well as
demographic detail
Data can be extracted and it is recommended this is done in .csv format to assist in analysis. Please note this contains
patient identifiable data as is therefore confidential.
Current Inpatients
•
•
•
•
This allow you to extract patient level data on all current in-patients who have readmitted using an emergency pathway ( ED,
GPAU etc) within 28 days following a spell of care which may have been inpatient or daycase.
You can then filter the report by ward, a full list of patients will be produced including details of the previous care spell and
days from discharge to readmission
Data can be extracted and it is recommended this is done in .csv format to assist in analysis. Please note this contains
patient identifiable data as is therefore confidential.
Full screenshots guides to the are available in the Appendix
Readmissions rates
•
This requires an extract of both readmissions and discharges. Data can be extctracted from Medway BI using an SQL query
by a Business Analysts a query is shown in the Appendix
Identifying the scale of readmissions
Reviewing Readmission Rates
Readmissions should be looked at over time to identify whether there is an increasing or decreasing trend in readmissions
as well as to identify any seasonal variation
The use of SPC charts further reviewed within the improvement section of this guide will assist in identifying the impact of
any variation
NUH Monthly 28 Day Emergency Readmit Rate
01/04/13 onwards
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
10.0%
9.5%
9.0%
8.5%
8.0%
7.5%
7.0%
6.5%
6.0%
Readmit Rate
2014/15 Baseline Mean - 8.4%
Maximum NUH Improvement Opportunity
Maximum System Improvement Opportunity
Identifying the scale of readmissions
Peer Benchmarking
Readmissions rates
(From Healthcare Evaluation Data https://www.hed.nhs.uk/
Operational Efficiency – Readmissions Report 84)
Standard Relative Risk of Readmissions (SRRR)
From Healthcare Evaluation Data https://www.hed.nhs.uk/
Clinical Quality –Relative risk of readmission- Report 117)
Identifying the scale of readmissions
Previous Readmissions Work
NUH Programme Matrix
Programmes or Projects within the hospital are recorded on the Trusts Programme Matrix including outcomes for access contact
the Trust Programme Management Office TPMO
Better for You
Better for You - Hospital's Improvement Team should be able to provide advice on improvement projects to date
Audit
The Hospital Audit Team will be able to advise on any readmissions audits carried out registered through them.
Identifying the reasons for readmissions
Methods to identify the reasons for readmissions
•
•
•
•
Readmissions Data Review
Readmissions Audit including Patient Centred Reviews
Patient pathway process mapping
Staff surveys
Readmission Data – Areas to Review
For some areas data on readmissions can provide insight into the potential areas for readmissions
•
•
•
•
•
What is the trend of readmission rates , increasing or decreasing ?
Discharge to readmission times 0-2 days – Are patients readmitting but staying a short time
Are their correlations between short spell LOS and readmissions?
Are there variations in Ward /Consultant ?
Are patients readmitting with the same diagnosis ?
For other areas the data alone does not provide sufficient information on the reasons for readmissions and an
notes audit or patient centred review can provide further information e.g
•
•
Reasons for readmission from the patients perspective , did the patient self refer or were they referred by
a GP
Do they think anything could prevent their readmissions?
Readmissions Audit
Readmission Audit
A standard form has been produced based on reviews carried out in the hospital a link can be found in the Appendix
Audit Data
This include demographic details as well as data on the first and readmitting spell which can be extracted using reports on Medway BI links
in the Appendix.
Sampling and Confidence intervals using Medway BI it should be possible to review all readmissions where patient are discharged prior to
review , a notes review might suffice to identify the reasons for readmissions
Patient Centred Review
Patients and their carers are often the one people who can describe what happened between discharge and readmissions. For contact
with GP or other services patient consent should be obtained and recorded. The following are useful questions to help elicit information
from patients
•
•
•
•
•
•
Did you feel ready to be discharged?
What would have helped you feel more prepared?
Were you comfortable taking existing/ new medications prescribed and understood possible side effects?
Did you know what follow up was planned and who to contact if you became more unwell?
Did anyone refer you back to hospital ?
Is there anything that you think could have prevented your readmission?
Who should carry out audits
Clinical staff should carry out audits as they are best placed for conversations with patients/carers as well as being able to provide clinical
judgement on the reasons for readmission.
Planning a Readmissions Audit
Plan the type of audit
•
Prospective – while patients are currently readmissions
•
Retrospective – notes reviews of patients identified as readmissions
•
Sampling and confidence intervals
Plan the scope of the audit
•
All readmissions in a given period
•
All wards
•
All admissions areas
•
Specific patient cohorts
Resource and Planning
•
Identify the time and resources required for the audit
•
Access to patient notes and electronic systems
Carrying out the audit
•
Formatting the audit form ( sample available in the appendix)
•
Providing a consent /information letter if a patient centred review is to be carried out ( sample available in
the appendix)
•
Generating patients lists via Medway BI Information in the Appendix.
Analysis
•
Reasons for readmissions and process issues identified.
Patient Pathway Process Mapping
Process Mapping
•
•
•
•
•
Develop a shared understanding of readmissions
can identify the any of the current discharge or admission pathways
Identify and understand variations in clinical practice
Gain an in-depth understanding of a patient's perspective
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement
_tools/process_mapping_-_an_overview.html
Sample Process Mapping
Old Process
New Process
5
Transfer to another ward
Emergency
Department
10
GP
20
30
Discharged
15
C31 for review
Discharge and
Readmitted
5
Discharged and Planned
Elective
5
Transfer to C31
Emergency
Department
GP
5
10
30
Discharged
15
Triage
20
Planned Emergency
Procedures
4
Discharged and Planned
Elective
4
Signposting to other
4
service
Consultant Clinics
Issue : High volumes of short stay admissions/readmissions
Key
Admission
Location
No of patients
Issue: Change in Process -> Reduction in admissions & readmissions
2
Staff Survey
Some areas have found that staff have provided information on the reasons for readmissions and to identify
any new of useful approaches asking staff about the following areas.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Do they use any tools to assess the likelihood of a patient readmitting to NUH? Target interventions to
known readmissions under your care?
Do they provide diagnosis specific information to patients on discharge - i.e: falls/arthritis/dementia etc.
Provide patients information about what they should do if their condition worsens... If a) go and see your
pharmacist, if b) Arrange to see GP, If c) call 111 etc
Complete standardised discharge documents - GPs/district nurses/nursing homes etc
Verbally hand over high risk readmission patients direct to GPs ?
Provide all patients/carer with a discharge summary ?
Provide all patients with a simple medications list on discharge with clear direction on use
Provide simple tips on how to safely refill a dosette box for patients/carers on discharge (if applicable)
Ensure patients/carers can tell you of any medication changes?
Ensure patients/carers can describe any follow-up arrangements - GP follow up/ Outpatient appointments
etc
Provide telephone follow up calls to discharge patients
Is there anything you think your areas could do to prevent readmissions
Is there anything you think community partners could do to prevent readmissions?
Setting up and implementing a change
Setting up and implementing a change
•
•
•
Develop a plan of the change (action plan) and the proposed impact.
Issue and Risk Log record any potential issues and risk
Governance process
Potential areas of development
•
•
•
•
Pathway redesign – where significant numbers of patients are readmitted under an
emergency code is this known e.g. Trial of Discharge.
Improved Assessment and Triage e.g. creating dedicated areas pre-admissions.
Improved Discharge Information to patient/carers and effective management of
transfers of care to community providers.
Links to community services and pathways to reduce variation of service between
localities
Implementing and Monitoring Improvements
Baselines
These should be identified before implementing any change these measures could
include
– Readmissions rates/ overall numbers – within certain patient cohorts
– Audit outcomes
– Discharge to readmit time profiles
Monitoring Improvement
- Ensuring baseline data is recorded and collection of data is at intervals that are
sufficient to monitor change -Statistical Process Control (SPC) to monitor the
impact of interventions further detail on the next page
- Record dates of any interventions
- Monitoring and respond to any increasing issues or risks
SPC Charts
Implementation of Cancer
Assessment Triage Team
•
These are used both to identify baselines and to demonstrate where an implementation has demonstrated change
via special cause variation
•
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/s
tatistical_process_control.html
•
SPC template is shown below this can be used to generate charts as shown
Review and Revisit
Review and Revisit
Review the finding and embed any change
Generate a lessons learnt log
Appendix
•
Readmissions Audit Form
•
Readmissions Letter for Patient Information
Links to Medway Business Information
•
https://bireports.nuh.local/HDMSQL_Reports/Pages/Folder.aspx?ItemPath=%2f1.+Inpatient+Activity%2fReadmissions&ViewMode=List
•
Guide to using the data sets
•
Links to Healthcare Evaluation Data (HED)
•
SQL Query ( the date marked in yellow will need to be amended)
•
Methodology for determining PBR Tariff 2015/16
•
Full summary for Readmissions Reduction Programme 2013-2016