University of Cincinnati Medical Center reduced healthcare costs by $250,000 per year.
Leaders at University of Cincinnati Medical Center (UCMC), have developed a care bundle for COPD patients that has cut the hospital’s COPD readmission rate from 22.7 percent to 14.7 percent (Zafar, M.A., Panos, R.J., Ko, J., et al., “Reliable Adherence to a COPD Care Bundle Mitigates System-Level Failures and Reduces COPD Readmissions: A System Redesign Using Improvement Science,” BMJ Quality & Safety, Vol. 26, Issue 11).Beyond patient care benefits, such a reduction could save 120 bed days and avoid $250,000 in costs annually.
In recent years, inclusion of COPD in the Hospital Readmissions Reduction Program has made COPD care improvement a hospital priority, says Muhammad Ahsan Zafar, MD, lead author of the study and quality improvement lead for pulmonary and critical care. He is also medical director of UCMC pulmonary rehabilitation.
“Linking COPD readmissions to financial incentives has caught the attention of finance leaders to start programs to reduce readmissions and find better ways to deliver care,” Zafar says. “And while we may not be able to prevent every readmission, there is certainly a push to reduce readmissions that would have occurred because of poor care.”
Understanding the Factors
Several patient factors, such as the severity of COPD and socioeconomic conditions, contribute to hospital readmissions after COPD exacerbation. “Once patients have a flare-up, they are much more susceptible to another flare-up in subsequent days,” Zafar says. In addition, other conditions can make COPD patients more likely to be readmitted. “On average, a COPD patient has three to five comorbid conditions,” Zahar says.
System factors, such as hospital coordination of care (e.g., inhaler education, follow-up after discharge, medication adherence) and following evidence-based treatment play major roles. Unfortunately, there is a lack of standardization in COPD care across the industry. “There is clear evidence to suggest that if two similar patients go to two different hospitals, their outcomes will be different,” Zahar says.
Designing and Implementing the Bundle
In 2015, Zafar and a team of hospitalists, nurses, respiratory therapists, pharmacists, and care coordinators set out to create a care bundle that would address system failures within UCMC’s control and, in turn, reduce COPD readmissions.
To help identify which components to include in the bundle, the UCMC team reviewed six months of COPD readmissions data. The team identified 42 system failures that made COPD patients more likely to return to the hospital within 30 days. These included suboptimal discharge instructions and late or nonexistent follow-up visits.
The team also interviewed individuals who were readmitted to understand patient needs and found that inhaler use was a common cause of confusion.
As a result of their initial research and reviewing the available literature, the team decided to include the following five components in the care bundle:
- Prescribing patients an appropriate inhaler regimen
- Providing a 30-day supply of inhaler brands that are compatible with patients’ insurance
- Providing personalized inhaler education (developed in-house)
- Giving standardized education and discharge instructions (developed in-house)
- Arranging a follow-up appointment within 15 days of discharge
Once the bundle was designed, the team conducted “plan, do, study, act” (PDSA) cycles to test their approaches. These cycles—a fixture of improvement science—provide a four-step model for changing processes and improving performance. “Trials are really important before implementation because they identify your barriers and, most importantly, increase staff buy-in,” he says.
The team strove to make the new workflows efficient so they would not burden staff. “If there was a process added, we tried to make it as Lean as possible,” Zafar says. This also meant distributing the work evenly across stakeholders, including physicians, pharmacy, nursing, and respiratory therapy.
Realizing the Results
The cost of an average COPD readmission lasting three to five days ranges from approximately $6,000 to $9,000. Each month, UCMC receives nearly 30 COPD admissions. By reducing its 30-day COPD readmission rate by 8 percent (from 22.7 percent at baseline to 14.7 percent six months after implementation of the bundle), the hospital eliminated one COPD readmission every 10-12 days. This translates to approximately 120 bed days saved, as well as $250,000 in healthcare costs avoided each year, Zafar says.
In addition to avoiding costs, reducing COPD readmissions allows a high-volume hospital like UCMC to improve access to care for other patients.
Not all COPD patients at UCMC received all five bundle components, but those that did had an even lower readmission rate, 10.9 percent. “There is clearly a dose effect—the more bundle elements that are delivered to a patient, the lower the risk of readmission,” he says. “They have to be given together to have a maximal effect.”
For example, providing patients with 30-day supplies of insurance-compatible inhalers did not make much of a difference on its own but helped reduce readmissions when combined with other elements, such as personalized inhaler education. In general, no single component of the care bundle stood out as the most important factor to reduce readmissions, Zafar says.
Leveraging Continuous Improvement
Having an existing continuous improvement (CI) infrastructure can help organizations implement a COPD bundle by giving frontline staff a familiarity with the tools needed to change care processes, Zafar says. This includes a quality improvement vocabulary as well as databases to help monitor performance. By using improvement strategies aimed at redesigning care delivery, UCMC achieved 90 percent bundle adherence in five months.
“The success of the bundle depends on how well it is implemented,” Zafar says. “That requires leaders and the frontline staff who are familiar with process design to look at the problems and design a more reliable system.”
However, CI expertise is not a prerequisite. Zafar says most of his organization’s frontline staff had not been trained in CI approaches like LEAN. However, as long as physician leads have CI skillsets and are able to develop execution plans, programs can gain traction. “If the culture supports it, that’s well and good, but if not, it’s still doable,” he says.
Heeding Lessons Learned
Zafar suggests the following strategies to reduce COPD readmissions.
Focus on patients, rather than financial benefits. When embarking on CI projects, leaders should not get distracted by quests for financial gains, as these rewards typically follow improved outcomes. “We should always be patient-centric in our approach,” Zafar says. “I find that talking about ‘dollars saved’ never motivates frontline staff, but patient outcomes motivate them.”
He suggests using compelling patient stories of COPD readmissions and performance data to motivate staff to adopt new processes and change behaviors.
Give physician leaders protected time to work on these projects. The COPD care team at UCMC did not add any FTEs to implement the care bundle, although Zafar was allotted time to develop the approach. “Most quality improvement champions are intrinsically motivated to do the right thing and get the right outcomes, but they still need the time and space to do the project,” he says.
Equip teams with accurate and timely performance and outcomes data. Data collection systems are particularly useful in the early stages of implementation to help teams refine their strategies, if necessary. However, access to actionable data can be a hurdle for many improvement teams, Zafar says. “Most of the data that we get from our finance offices is at least one or two months old, which does not allow us to see the changes from our efforts last week,” he says.
UCMC has formed a sustainability team that monitors 30-day COPD readmission rates. The team monitors bundle adherence and COPD readmissions each month. If adherence drops or readmissions rise, leaders can adjust strategies.
Being a Partner for Quality
Financial leaders can support clinicians’ quality improvement efforts by offering project management templates, storyboards, team-building resources, and other tools that improve performance.
Assistance with project management is especially valuable. “Most clinicians and frontline staff are not as good at project management as finance leaders are,” Zafar says. “Using these skills—not just sharing finance reports—also could help the team succeed.”
Interviewed for this article:
Muhammad Ahsan Zafar, MD, FCCP, is an assistant professor, quality improvement lead for pulmonary and critical care, and medical director of pulmonary rehabilitation, University of Cincinnati Medical Center, Cincinnati.
