gerri lamb, phd,rn, faan associate professor arizona state university
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Gerri Lamb, PhD,RN, FAANAssociate Professor
Arizona State UniversityCollege of Nursing and Health Innovation
Tracking Hospital Transfers and the Quality Improvement Review Tool
The development and evaluation of the INTERACT quality improvement program and Curriculum are supported by grants from the Retirement Research Foundation and The Commonwealth Fund
INTERACT Curriculum Session 2
If you are participating in a teleconference proceed to the next slide for instructions
If you are reviewing this session as a self-learning activity: Proceed to slide # 4 Click the speaker at the bottom of each
slide to listen to the audio If you do not have audio, click on “View” on the
toolbar, and select “Normal” to view the text below each slide – if necessary select “Zoom” to make all of the slide and text visible.
INTERACT Curriculum Session 2
Teleconference Instructions
Call in Number 1-888-808-6959
Conference Code 3588988 #During the call, please mute your line Press * 6
To un-mute your line Press # 6
If the leader is not on the call when you call in, please wait
INTERACT Curriculum Session 2
Welcome and Introductions
Tracking Hospital Transfers and the Quality Improvement Review Tool
This session is designed for the entire interdisciplinary team, including the:
• Project champion and co-champion• DON, key RNs, LPNs, and CNAs• Medical director, primary care MDs, and NPs/PAs• Social workers• Administrators
Tracking Hospital Transfers and the Quality Improvement Review Tool
Gerri Lamb, PhD, RN, FAAN is Associate Professor at the College of Nursing and Health Innovation at Arizona State University in Phoenix Arizona. She is a member of the team that developed and evaluated the INTERACT tools. She is well-known for her research on case management and transitional care for older adults
Dr. Lamb’s work is now focused on coordination of care for older adults across our health care system and assisting patients, families, and health care providers improve care transitions.
Gerri.Lamb@asu.edu
The INTERACT Interdisciplinary Team
Joseph Ouslander, MD Florida Atlantic UniversityLaurie Herndon, GNP Mass Senior Care FoundationRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAnnie Rahman, MSW Miami UniversityJo Taylor, RN, MPH Carolinas Center for Medical ExcellenceAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services
In collaboration with participating nursing homes
Tracking Hospital Transfers and the Quality Improvement Review Tool
Why track hospital transfers Factors linked to hospital transfers Asking the question: can we improve
what we’re doing to reduce hospital transfers?
Using the Quality Improvement (QI) Review Tool
What This Session Will Cover
Tracking Hospital Transfers and the Quality Improvement Review Tool
Please complete the Pre-Session Quiz If you take the Quiz in a paper and pencil format, please
make sure your facility champion or co-champion gets a copy If you are reviewing this session on-line, you can take the on-
line Quiz, or take the Quiz using a hard copy obtained from your facility champion or co-champion, and return it to them
Pre-Session #2 Quiz
Tracking Hospital Transfers and the Quality Improvement Review Tool
INTERACT and Hospital Transfers
The goal of the INTERACT program is to improve the care of nursing home residents by:
Identifying situations that commonly result in transfers to the hospital – and working together to manage them effectively and safely in the nursing home without transfer whenever possible
Tracking Hospital Transfers and The Quality Improvement Review Tool
Why track transfers? Tracking hospital transfers allows you to:
Identify situations that commonly result in
transfers of your residents to the hospital Determine which situations you can
potentially manage effectively and safely in your facility without transfer
Improve quality of care for your residents
Tracking Hospital Transfers and The Quality Improvement Review Tool
Look for patterns in clinical situations that result in transfers
Work together on strategies on situations you believe can be managed safely and effectively without transfers
Tracking Hospital Transfers
Tracking Hospital Transfers and the Quality Improvement Review Tool
Tracking Hospital Transfers and the Quality Improvement Review Tool
Some of the common reasons for transfer of residents to the hospital included: Change in medical status Family expectations Services available within the nursing home Availability and communication with primary
care providers Advance directives of lack of advance care
planning
Common Reasons for Transfers
Tracking Hospital Transfers and the Quality Improvement Review Tool
Lots of factors may be involved Staff involved in the decision may be
unsure and uncomfortable Discovering situations that might have
been safely treated in the facility may also be uncomfortable at first
Transfer Decisions are Complicated
Tracking Hospital Transfers and the Quality Improvement Review Tool
Early detection of signs Stop and Watch
and symptoms Communication with SBAR
primary care providers Early management of Care Paths, File Cards
clinical conditions Discussions with family Advance Care Planning
about hospitalization
Tracking Hospital Transfers and the Quality Improvement Review Tool
Think prevention and early intervention using the INTERACT tools
Early detection of signs Stop and Watch
and symptoms Communication with SBAR
primary care providers Early management of Care Paths, File Cards
clinical conditions Discussions with family Advance Care Planning
about hospitalization
Tracking Hospital Transfers and the Quality Improvement Review Tool
Think prevention and early intervention using the INTERACT tools
The different INTERACT tools are meant to be used together in your daily work in the nursing home
The Quality Improvement Review Tool is meant to identify opportunities to improve management of changes in condition
Consider integrating review of hospital transfers into your regular quality process The same principles apply as you review
hospital transfers Look for common situations that you can
work on together Avoid blaming individuals
Quality Review of Hospital Transfers
Tracking Hospital Transfers and the Quality Improvement Review Tool
Retrospective Designed to assist you to review
situations that commonly result in transfers in your facility
The Quality Improvement Review Tool
Tracking Hospital Transfers and the Quality Improvement Review Tool
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Goal
Helpful for: Identifying situations that commonly
result in hospital transfers Determining situations that may be
managed effectively in your facility Improving quality and reducing
preventable transfers
The Quality Improvement Review Tool
Tracking Hospital Transfers and the Quality Improvement Review Tool
1. Background Information
2. Change in Condition
3. Evaluation and Management
4. Transfer Information
5. Opportunities for Improvement
The QI Review Tool: 5 Sections
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Section 1: Background Info
Tracking Hospital Transfers and the Quality Improvement Review Tool
Looking for Patterns in: Section 1: Background Info
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Section 2: Change in Condition
Tracking Hospital Transfers and the Quality Improvement Review Tool
Looking for Patterns in: Section 2: Change in Condition
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Section 3: Evaluation and Management
Tracking Hospital Transfers and the Quality Improvement Review Tool
Looking for Patterns in: Section 3: Evaluation and Management
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Section 4: Transfer Information
Tracking Hospital Transfers and the Quality Improvement Review Tool
Looking for Patterns in: Section 4: Transfer Information
Tracking Hospital Transfers and the Quality Improvement Review Tool
The Quality Improvement Review Tool Section 5: Opportunities for Improvement
Tracking Hospital Transfers and the Quality Improvement Review Tool
Does this situation offer an opportunity to improve care?
Tracking Hospital Transfers
Tracking Hospital Transfers and the Quality Improvement Review Tool
Tracking hospital transfers allows you to study situations that commonly result in hospital transfers in your facility
There are many factors including clinical, family, and nursing home issues that influence transfers and staff attitudes about them
Having a standard tracking and quality improvement process for hospital transfers keep the focus on improving patient care
Key Points of Session 2
Tracking Hospital Transfers and the Quality Improvement Review Tool
The INTERACT QI Review Tool is designed to help your team identify opportunities to improve your transfers and quality of care.
Prevention, early detection and management are central to improving care – once a resident is acutely ill, it is difficult to prevent a transfer.
Each of the INTERACT tools you will learn about in upcoming sessions is designed to help staff identify and manage situations that commonly lead to hospital transfers.
Key Points of Session 2 (continued)
Tracking Hospital Transfers and the Quality Improvement Review Tool
Your facility’s project champion is responsible for coordinating INTERACT implementation. She or he may ask you to complete specific activities before the next teleconference or before you review the next session on-line.
Suggested implementation activities before the next session: Go to the INTERACT website (http://Interact2.net) and print a copy
of the QI Review Tool. Complete the QI Review Tool for a resident who was transferred to
the hospital Talk with other members of your team about factors they think might
have contributed to the hospital transfer Discuss your answers to the question about whether the transfer
might have been prevented.
INTERACT Implementation Activities
Tracking Hospital Transfers and the Quality Improvement Review Tool
For teleconference participants please un-mute the line: Press # 6Please re-mute your line after talking: Press * 6
Questions and suggestions on Session 2 can also be directed to Dr. Lamb by email at:
Gerri.lamb@asu.edu
Please insert in the Subject Line: “Question about the INTERACT Curriculum”
Questions, Suggestions, Comments?
Tracking Hospital Transfers and the Quality Improvement Review Tool
Session 3:
The Early Warning Tool:Stop and Watch
Champion DON Key RNs and
LPNs Lead CNAs
The Next Session The next teleconference will be held at the same time next week
The topic and participants are listed below
Tracking Hospital Transfers and the Quality Improvement Review Tool
Please complete the Post-Session Quiz and Evaluation If you take the Quiz and complete the Evaluation in a paper and
pencil format, please make sure your facility champion or co-champion gets a copy
If you are reviewing this session on-line, you can take the on-line Quiz and complete the evaluation on-line.
Post-Session #2 Quiz and Evaluation
Tracking Hospital Transfers and the Quality Improvement Review Tool
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