MAPPING YOUR
DISCHARGE PROCESS
AND
HANDOFFS
Sara Butterfield RN, BSN, CPHQ, CCM
Christine Stegel RN, MS, CPHQ
Brenda Maynor, RN, MS
June 21, 2012
CMS
 Leads a national healthcare quality improvement
program, implemented locally by an independent network
of QIOs in each state and territory.
IPRO
 The federally funded Medicare Quality Improvement
Organization (QIO) for New York State, under contract
with the Centers for Medicare & Medicaid Services (CMS).
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Level of Importance of Safe Care Transition
 17.6% of Medicare beneficiaries are re-hospitalized within 30 days
of discharge, accounting for $15 billion in spending
 Estimates show that 76% of these readmissions may be
preventable
 Of Medicare beneficiaries re-admitted within 30 days, 64% receive
no post-acute care between discharge and re-admission
Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in
Medicare
Level of Importance of Safe Care Transition
 41% inpatients discharged w/ pending test results
 2/3 of physicians unaware of results
 37% actionable and 13% urgent
Annals of Internal Medicine. 2005; 143(2):121-8
 25% pts require additional outpatient work-ups
 More than 1/3 are not completed
Archives of Internal Medicine. 2007;167:1305-11
At Discharge:
 37% able to state purpose of all medications
 14% knew the common side effects
 42% able to state their diagnosis
Mayo Clinic Proceedings. August 2005; 80(8):991-994
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Investigation of Root Cause
Mapping Current To Desired Process
For Discharge Planning
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Root Cause Analysis
Definition
 A Root Cause Analysis (RCA) is a process for identifying
the basic or causal factors that underlie variations in
outcomes
 Allows you to identify the “root” of the problem in a
process, including how, where, and why a problem,
adverse event, or trend exists
 This analysis should focus on a process that has potential
for redesign to reduce risk
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Root Cause Analysis
 An RCA focuses primarily on systems and processes, not
individual performance
 To begin, identify the underlying functions leading to poor
outcomes. Then, determine the primary cause(s) and
contributing factors
 An RCA is generally broken down into the following steps:
● Collect data
● Analyze data
● Develop and evaluate corrective actions, using PDSA cycle
● Implement successful corrective actions
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Root Cause Analysis Purpose
 Identify causes of hospital 30-day readmissions within
your community
• Health care provider perspective (hospital, nursing
home, home health agency, hospice, etc)
• Community perspective (Office for Aging and other
community service providers)
• Patient/caregiver perspective
 Identify patterns of readmissions for your community
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Process Assessment
A picture of the steps in a process to gain a better
understanding of the existing process
Assessing a process in its current state
 Helpful to develop benchmarks
 Determine opportunities for improvement
 Direct observation of processes such as discharge and
admission
 Interviews with process owners
 Mapping of processes at a high level and/or a detailed level
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Process Assessment
Process Assessment Tools
 Cause & Effect Diagram
 Fault Tree Analysis
 Value Stream Mapping
 5-Whys
 Process Mapping
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Process Mapping
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Why Process Map?
Provides a picture of process – maps the patient’s journey
Helps to clarify a complex process
Establish commonalities
Identify all the process participants
Establish a baseline of what is current process
Identify delays, gaps, work-a-rounds
Identify factors that influence or impact the process
Provides a clear understanding of the processes of care so there
is no risk of changing parts of a process which will not result in
improvement
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Why Process Map?
Capture the reality of a process….. what is happening versus
what you think is happening)
Identify duplication, variation and unnecessary steps
Generates ideas and helps define where to start to make
improvements with the biggest impact
Helps all involved to understand the complete process
Allows for identification of problem areas such as bottlenecks
that cause unnecessary delays
Improve team building and promotes ownership of the process
Increases staff involvement in design of processes
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Process Mapping
Two stages to process mapping…
1. Understand what happens to the patient, where it happens and
who is involved
2. Examine the process map to determine where there are
problems



multiple hand-offs

waste, error and duplication of parts of the process which would
flow better if undertaken in a different order
parts of the process that are unnecessary
parts of the process that do not add value
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Process Mapping Steps
1. Define what you are trying to achieve
2. Identify the start and end point of the process
3. List what measures are you going to use to demonstrate
that changes actually do improve the process
4. Identify which staff need to be involved in mapping the
process – involve them at the start

Direct Care Staff of all disciplines involved in process

Senior leadership representative(s)

Community service providers

Patients

Caregivers

Stakeholders
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Process Mapping Steps
5. Select a facilitator (not someone involved in process being mapped)
6. Gather supplies
● Paper / Marker pens / Post-it notes / Flip charts / Tape
7. Set ground rules – safe environment to share
8.
Keep it simple
9.
Clearly define each step in the process
10. Start with a high level view
● 5-10 steps in the process
● 20 minutes or less to map
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Process Map Guidance
Keep the patient at the center of the process
Define the first and last steps in the process
Identify the steps that occur at the same time
Cross over departmental boundaries
Include what happens when there are problems
At decision points choose what occurs the majority of
the time
Identify branches or gaps as the map is developed
• At the end, go back to fill in branches
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Process Mapping Symbols
Shows the tasks and activities of process
Shows the start and end of the process
Shows where a question is asked or a decision is required
Shows where documentation is required
Shows the direction / flow of the process
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Alternatives Process Mapping Approaches
Walk through the patient journey yourself
● Interview staff on the who, what, where & how & record each step
Set up a mini process mapping session
● Use a staff meeting to discuss & record the process
Follow a patient through the process
● Best if external person not involved in process
Be a patient and travel through the process
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Redesigning the Process to the Desired State
Identify where the process can be improved by redesigning or removing elements of it
Consider impact of redesign on the rest of the
organization
Test ideas for improvement to show potential and any
unwanted side-effects of your changes
Key Components
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
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Application of Process Mapping
Discharge Planning
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Discharge Planning Process
 Process for planning the post-acute care for patients
prior to discharge




Acute Care Hospital
Short-term Rehab
Skilled Nursing Facility
Home Health
Includes several HANDOFFS (the passing of a
patient’s care from one clinician to another clinician)
• To referring agencies/facilities
• Nurse to nurse
• Hospitalist to community physician
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Common Discharge Planning Gaps
Communication related:
- transfer of patient information
- pending lab values
- caregiver involvement
- patient’s discharge plan
- discharge medications
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Common Discharge Planning Gaps
Care Coordination related:
- primary care physician
- community services
- home health agency/SNF
- outpatient services
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The Desired Process for Discharge Planning





Explicit delineation of roles and responsibilities
Discharge process initiation upon admission
Patient education throughout hospitalization
Timely accurate information flow:
From PCP ► Among hospital team ► Back to
PCP
Complete patient discharge summary prior to
discharge
Source: Project RED Principles of the Re-Engineered Hospital Discharge
The Desired Process for Discharge Planning





Comprehensive written discharge plan provided to
patient prior to discharge
Discharge information in patient’s language and
literacy level
Reinforcement of plan with patient after discharge
Availability of case management staff outside of
limited daytime hours
Continuous quality improvement of discharge
processes
Source: Project RED Principles of the Re-Engineered Hospital Discharge
The Reality……
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Process Mapping
Examples
High Level View
Detail Level View
Institute for Innovation & Improvement:
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping__a_conventional_model.html
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Example: Current State Patient Discharge
Source: Project RED Principles of the Re-Engineered Hospital Discharge
Example: Desired Patient Discharge Process Map
Physician
Nurse
Discharge
Advocate
Pharmacist
Source: Project RED Principles of the Re-Engineered Hospital Discharge
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Brenda L. Maynor, MS, RN
Director, Clinical Resource Management
St. Mary's Healthcare
Amsterdam, New York
St. Mary’s Healthcare High Level Process Map
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Barriers to Process
 Identifying which MD to sign home care orders. (The
hospitalist sees patient in hospital)
 Missing parts of referral/discharge orders
 A clear understanding of Home Health care and what the
agency is able to provide
 Lack of assessment of home supports and ability to
manage basic necessities at home prior to discharge
 Skilled Nursing needs/therapy needs
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All patients are seen by a
discharge planner to determine
if home care services are
indicated after hospitalization.
Patients/families are given their
choice of agency based on their
home location and contracted
agency through their private
insurance companies.
Once a homecare agency is
established, contact is made to the
agency with the pending home care
referral. Face to Face
documentation is also obtained.
St. Mary’s Healthcare
Desired Referral Process
Hospital to Home Health
If the agency has computer access, this is given to
the agency to begin the formal communication
process. Those agencies without access either visit
the pt in person or documentation is faxed to the
agency for review.
Once a patient is discharged, the home care agency will
visit the pt within 24 hours of discharge unless a greater
time is mutually agreed upon with the patient, agency
and physician.
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Patients sent to ER by home care
nurse
1. The home care nurses contacts the ER
to speak to the charge nurse to give report
as to why the pt is being sent to the ER.
Community physician is also called.
2. ER staff note in the triage section the
conversation as part of complaint for
coming to ER.
St. Mary’s Healthcare
Desired Process
Home Health to Hospital
3. If the patient is evaluated and discharged,
the charge nurse will refer the pt back to the
agency and/or contact the nurse regarding
the course of treatment/evaluation in the
ER.
4. If the patient is admitted, the discharge plan is
facilitated by the inpatient discharge planners and
coordinated with the home care agency post acute
stay.
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St. Mary’s Healthcare
Desired Process
Patient comes to the ER who does not have
home care services. Is not admitted, but
needs home care after their ER visit.
1. The ER nurse is able to initiate a home
care referral using the Physicians Home
Care Referral form. These forms are
located in the ER & signed by the ER
physician. They are faxed to the agency.
2. If necessary, the next day the home care agency
can contact Clinical Resource Management for
additional information.
Initiating Home Health
Referral for ED Patients
RCA Process Improvement:
•Identify during triage if a pt currently has home
care services in the home. Currently this is not
addressed during the ER visit
•Sent message to ER Manager to inquire
adding this to interview screen
•If the pt currently has services, refer back to
that same agency
•If the pt does not have services, initiate a new
referral
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Questions
Comments
Plans for Next Week?
Resources
Agency for Healthcare Research & Quality
http://www.ahrq.gov/qual/projectred/swimlane.htm
Colorado Foundation for Medical Care National
Coordinating Center
http://www.cfmc.org/integratingcare/toolkit.htm
Institute for Innovation & Improvement
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvem
ent_tools/process_mapping_-_a_conventional_model.html
Project RED (Re-engineering Discharge)
https://www.bu.edu/fammed/projectred/index.html
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For more information
Sara Butterfield, RN, BSN, CPHQ
IPRO
Senior Director
(518)426-3300 ext. 104
sbutterfield@nyqio.sdps.org
Brenda L. Maynor, MS, RN
St. Mary’s Healthcare
Director, Clinical Resource Management
(518)-841-3896
Brenda.Maynor@smha.org
Christine Stegel, RN, MS, CPHQ
IPRO
Senior Quality improvement Specialist
(518)426-3300 ext. 113
cstegel@nyqio.sdps.org
IPRO CORPORATE HEADQUARTERS
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.ipro.org
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers
for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not
necessarily reflect CMS policy. 10SOW-NY-AIM8-N-12-07
Template 1/13/2012