STAAR’s 4 Domains of Process Improvement to Enhance Patient Health

Tuesday, June 18th, 2013
This post was written by Jessica Fornarotto

Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, recommends hospitals follow the four domains of process improvement from the State Action on Avoidable Rehospitalizations (STAAR) in order to improve the standards of care for each patient to prevent future health woes.

During HIN’s webinar Readmission Penalties in 2013: A Cross-Continuum Approach To Lessen the Financial Impact, Boutwell listed STAAR’s four domains, which include enhanced assessments, enhanced teaching, real-time communication and timely follow-up care.

STAAR’s four general domains of process improvement do not constitute a cookbook. We recognize that hospitals need to adapt and implement these concepts in various ways to fit their settings, whether rural, urban, academic or community hospitals.

The four major domains are an invitation to reflect. If your hospital is not providing these four elements of care for every single patient leaving your care, regardless of risk, then I invite you to reflect upon why you wouldn’t do this for everyone. Why wouldn’t we make sure that we update our standard of care as people leave our hospital ‘sicker and quicker,’ and take upon themselves a greater burden and more responsibility for after-hospital care? Why wouldn’t we improve our standard of care for everyone in these four areas? The four domains are as follows:

1. Enhanced assessment. This means that we assess patients. That’s what we do in the hospitals; that’s what nurses, doctors and therapists do all the time. But this is the concept of expanding that view, especially of our frequent flyers or our frail patients to the big picture. What is the longitudinal care need beyond the acute episodic presenting need?

2. Enhanced teaching and learning. This is a change from putting packets of information on meal trays to using the three or four days of the hospitalization as a learning opportunity. Identify who is the right learner, because it’s not always the patient. Engage in that health literacy-appropriate teachback technique to convey the key elements — not the entire 85-page booklet on heart failure but the key elements of self-management as the patient transitions from our setting to the next setting.

3. Real-time communication. This is communication both to the receiving providers as well as better updates in communication to the patients and family members. It can’t be okay for us to have rounds at 7:00 or 8:00 in the morning and then tell the patient to call their daughter because they are being discharged at 2:00. This is the experience of many of our patients still. Keeping people updated as to their care plan and their after-hospital care needs is something that we identified as a major theme in many root cause analyses of early readmissions.

But even more to the point around real-time communication is that we’re still not doing a great job in letting the outpatient providers know that their patients are being admitted and discharged and defining the reasons for their hospital stay. What was their course treatment? What were the new results and what medicines were they prescribed? Root cause analyses from every community across the United States now find that real-time communication with their receiving providers is still lacking.

4. Ensuring that there is timely post-acute care follow-up. This will vary based on patient risk, but if your patient is moderate or high-risk, a call to their doctor’s office and an appointment in one to two weeks is not going to do it anymore. We have so much data. If you run your own hospital’s data as to the average time between discharge and readmission, you will find that 25 percent of your readmissions are coming back within three to four days, and 50 percent are coming back within seven to 10 days. We need to get touch points. It doesn’t need to be a follow-up appointment; there are many good models of phone calls, visiting nurses, lay-care providers, etc. We need to follow up with patients to make sure that when they get home, they understand their plan of care, they get their medications and they are not confused.

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