By Jennifer J. Salopek
Transitions and improving care for pediatric patients are the two overarching themes that unite the four initiatives recognized with Honorable Mentions in the AAMC 2012 Readiness for Reform Innovations Challenge. All provide inspiration for other health care institutions with proven processes, useful tools, and rigorous research findings.
The I-PASS Study: A Multi-Site Effort to Standardize the Handoff Process for Better Handoffs and Safer Care
On the care transitions front, the I-PASS Study, submitted by study leader Amy Starmer, MD, of Oregon Health and Science University and Boston Children’s Hospital, involved 10 study sites and more than 50 co-investigators. The simple, central goal of the project was to reduce the number of communication errors that occur during handoffs, thus reducing errors and increasing patient safety. “Handoffs are an important way of communicating but they’re not standardized,” Starmer explains. “There is also not much teaching time dedicated to them. We felt that it’s a step that’s calling out for strategies and curriculum.”
Starmer has worked with colleagues across the country for the past two years to develop and test I-PASS, a mnemonic device that serves as shorthand for the curriculum:
I Illness severity
P Patient summary
A Action list
S Situation awareness and contingency planning
S Synthesis by the receiving provider.
The I-PASS Faculty Development Resources contain all the necessary materials that an institution, division, or training program would need to educate and train faculty and Chief Residents to implement the I-PASS Handoff Curriculum at their site and to act as handoff champions: a Faculty Champions Guide which contains critical information needed to recruit faculty/handoff champions, deliver training and education, implement a handoff program, facilitate handoff observations, initiate a campaign, and effectively sustain the handoff program; an interactive faculty development training presentation with simulation videos that allow faculty the opportunity to practice observing and evaluating handoffs; comprehensive instructions on how to use the I-PASS Faculty Observation Tools to provide effective learner feedback; and speaker notes to assist presenters. All can be downloaded free of charge from www.ipasshandoffstudy.com.
To further encourage faculty participation, the I-PASS Study Group offers physicians credit for their efforts through an approved American Board of Pediatrics Maintenance of Certification Project. In implementing the I-PASS handoff curriculum and providing feedback to improve the handoff process, faculty effectively engage in quality improvement efforts.
“It’s a very thoughtful educational intervention,” says Starmer. “Handoffs can be complicated, so we wanted it to be comprehensive and rigorously studied.”
The success of I-PASS is being studied at nine sites; data collection and organization occurs at Brigham & Women’s Hospital in Boston. Although final results won’t be available until spring of 2013, a pilot study demonstrated encouraging results that suggested improved outcomes.
“Although much of the post-intervention data is still being collected, our study group has collected substantial data that suggests that the I-PASS Handoff Bundle has significant potential to improve communication practices and patient outcomes,” Starmer says. Her complete Innovation Challenge submission can be viewed here.
Montefiore Medical Center’s Regional Nursing Home Collaborative: Innovations in Post-Acute Care Transitions and Reductions in Readmissions
To reduce avoidable readmissions of patients discharge from the acute-care setting to a skilled nursing facility, Anne Meara, RN, associate vice president for Network Care Management, initiated a unique collaboration between University Hospital for Albert Einstein College of Medicine and five nearby facilities in the Bronx. Her goals? To improve communication between acute and post-acute providers to improve the quality of care and reduce preventable readmissions.
“Patients who go to skilled nursing facilities are sicker than they were five years ago, and require more complex care,” Meara explains.
The program uses three primary interventions to establish new evidence-based protocols and care pathways support the program objectives:
- Implementation of the core interventions encompassed by the INTERACT ™ program, including the Quality Improvement Tool for Review of Acute Care Transfers; the “Stop and Watch” pocket card and report early warning tool; and, the SBAR communication tool and progress note.
- Regular opportunities for knowledge transfer and improved communications between acute care and post-acute care environments through new relationships, monthly meetings among all SNFs and Montefiore’s program leads.
- Standardized protocols for discharge planning, including the development and staged implementation of standardized processes to consistently perform advanced care screening and planning.
Montefiore capitalized on its role as an accountable care organization: Montefiore is at risk for the quality of care and costs of its patients, as well as the new motivations among providers to improve discharge planning and care management. The most innovative element of the intervention, says Meara, was bringing representatives of the five local facilities together.
“They usually interact in a competitive mode, but bringing them together around a shared issue was transformational,” she says. “They became more comfortable discussing common challenges and sharing data—really putting their cards on the table. This type of information sharing on readmissions and related data among competitors in the community had never been done.” Plus, she adds, picking up on common themes becomes easier with five facilities rather than one.
The program has been successful, reducing preventable readmissions and unnecessary costs in the system from 33 percent in 2010 to an average of 15 to 20 percent currently. “In our community, this is huge,” Meara says. But there are other positive outcomes as well: stronger relationships with community partners, new opportunities for shared learning, and improved quality of life for patients.
Montefiore’s full Innovation Challenge submission is available here.
Look before You LEAPP: An Interprofessional Team Approach to Inpatient Bedside Pediatric Procedures
Our next two honorable mention winners focus on improving care for pediatric patients. At SUNY Upstate Medical University, Ann S. Botash, MD, FAAP, and her colleagues noted that kids in their hospital were being subjected to what amounted to sneak attacks. Botash, who is associate dean for education and vice chair for education in the department of pediatrics, says that the opening of a new state-of-the-art children’s hospital, Upstate Golisano Children’s Hospital, provided the occasion to reexamine how care was delivered.
“It had become ingrained in our culture to conduct bedside procedures at the convenience of the provider rather than the patient,” Botash says. “There was no coordination or preparation.” When Botash and her colleagues investigated how children perceived what was happening, “It was eye-opening for me and the chief resident. The examples were really compelling.” Many patients expressed feeling anxiety, distress, and/or pain.
Interprofessionalism is the cornerstone of the innovative protocol Botash and her team developed, and its success depends on the involvement of nurses and child life specialists. LEAPP is a mnemonic for Listen, Evaluate, Anticipate, Plan, and Proceed. A frog logo was developed and a plastic cling sticker is placed on patient doors to remind staff of the patient’s potential need for a procedure. Nurses identified LEAPP champions for each floor.
An educational intervention was designed for residents, students, and nurses to introduce them to the new protocol, which is introduced via an online education module and reinforced in a YouTube video, pocket cards, and pens. Residents must watch the video and complete a five-question quiz. Multiple in-service sessions were offered for all subspecialties, and grand rounds in nursing and pediatrics were conducted.
Prior to the initiative, only 55 percent of caregivers and 60 percent of staff thought that pain and anxiety were well controlled during studied bedside procedures. Post implementation, 84 percent of caregivers and 93 percent of staff thought so.
“By developing methods to study the approach, reviewing current literature, and tapping the minds of people on the front lines while using the skills of academicians, we were able to develop an educational module that addressed the issue through specific objectives,” Botash says. “The most valuable aspect of the process was its simplicity; it can be easily replicated at other institutions.”
SUNY Upstate Medical University’s complete Innovation Challenge submission can be viewed here.
Reducing Missed Opportunities for EPSDT Well-Child Care at Acute Visits in an Academic Pediatric Practice
As a resident continuity clinic for 72 pediatrics residents, Children’s Hospital Primary Care Clinic at Vanderbilt University has worked steadily to move from an urgent care paradigm to a comprehensive, medical-home model of care for largely underserved populations. In late 2009, staff realized that 51 percent of the clinic’s 15,000 patients lacked up-to-date well-child care (defined as Early and Periodic Screening, Diagnosis and Treatment [EPSDT] screening visits).
“We knew intuitively that there were many missed opportunities, but we were shocked by the data,” says Barron Patterson, MD, the clinic’s medical director. “This is probably endemic across primary care.”
Although clinic staff could easily check immunization status by scrolling through the EMR, immunization status alone is a poor indicator of the status of a patient’s overall well-child care. To provide that status at a glance, clinic staff partnered with colleagues in Biomedical Informatics to develop a color-coded electronic indicator within the EMR. Because there are no standard definitions of EPSDT status, “We had to create definitions that made sense for us,” Patterson explains. Patients are flagged as up-to-date, due, overdue, or no EPSDT.
Process improvements were created that allowed clinic staff and providers to triage patients quickly and efficiently based on the status indicator, and to schedule same-day visits for patients who needed acute and well-child visits. The clinic also hired a full-time nurse practitioner who can convert an acute visit to incorporate EPSDT, and now spends 50 percent of her time doing so.
Using this simple framework that incorporates people, process, and technology, more than 1,000 acute visits were converted to comprehensive EPSDT well-child visits in the first year of the program, an improvement of 840 percent from baseline.
Adjustments have been made along the way. Patterson reports that while the intervention did not initially engage front desk staff, relying on triage nurses and technicians to convert the visits, “We realized that paperwork largely drives the nature of the visit.” To encourage cooperation with the new process, the clinic now holds a monthly competition for front desk staff; the member who catches the most walk-in patients who need EPSDT services wins a cash award.
“We are successful in converting the visits about 50 percent of the time. Sometimes we are still too busy or the child is too sick. But families are very grateful that we take the time, and our efforts are really meaningful for this underserved population,” Patterson says.
Vanderbilt’s complete Innovation Challenge submission is available here.