Advance Practice Nurse Leader Rises to the Quality Challenge at UCLA Health

Added on Jul 18, 2019

iStock-157400797Advance Practice Nurse Leader Rises to the Quality Challenge at UCLA Health  

By Whitney Fishburn

Since joining UCLA Health’s quality team as the Neurology Department and Inpatient General Neurology Operation Quality Officer in early 2017, multidisciplinary nurse practitioner Melissa Reider-Demer has helped spearhead quality improvement initiatives for the system’s outpatient neurology service that have notably increased access to care, improved patient experience ratings, and saved millions of dollars by decreasing lengths of stay.

The first nonphysician member of the quality team, Reider-Demer, winner of Press Ganey’s 2018 Nurse of the Year Award, is proud of her contributions. “Until that time, there hadn’t been another person such as myself who’d said, ‘Hey, I have ideas. I can do this work. Let me show you what I can do,’” she said in a recent webinar.

Although she relies on a range of evidence-based quality improvement methodologies, Reider-Demer explained that her core approach begins with an analysis of all relevant performance data to spot trends in need of improvement. She then assembles a team of key stakeholders across the enterprise to help frame the root cause of the trend and discuss ways to improve it. As the solution is implemented, she clearly communicates what she is doing and why. She then measures outcomes and adjusts the program accordingly.

One of the first quality improvement challenges that Reider-Demer faced in her new role was to address lagging patient experience scores in one of the system’s outpatient neurology facilities. Because this site seemed to be struggling in the area of care transitions and access, Reider-Demer focused her attention on patient throughput and discharge protocols, where she discovered wide variation and which likely contributed to an inability to consistently meet patients’ needs and expectations.

To address the deficiencies, Reider-Demer prioritized effective and consistent inpatient education around the transition to post-acute outpatient care. She also proposed and helped modify the discharge protocol to include

  • Follow-up calls within 48 hours of discharge;
  • “Warm handoffs” between inpatient and continuity care providers during post-discharge outpatient evaluations, so the patient hears what is being discussed about the clinical problem and plan of care; and
  • Updated discharge instructions that include specific and clear guidance to minimize the potential for readmissions due to insufficient or unclear information.
During multidisciplinary discharge rounding, Reider-Demer began educating residents to think about how treatment might be delivered at home or at other outpatient facilities in the system, which supports more of a continuum-of-care mentality. “If, for example, a patient with MS is started on steroids [as an in-patient], and they improve, we can finish their steroids at home with home-care nursing. We don’t need to retain them in the hospital,” she said.

The changes have led to overall decreases in lengths of stay, readmissions, and emergency department visits for stroke and general neurology patients, Reider-Demer explained. Before the intervention, expected lengths of stay for this patient population had for years remained above the one-day mark. Since the intervention, the length-of-stay index for this group has consistently trended downward, usually falling below the one-day mark. Neurology unplanned readmissions have been variable by month but have consistently trended downward, and ED visit rates for this cohort have decreased dramatically. For example, monthly ED visit rates for general neurology and stroke patients from January 2016 through December 2018 typically dropped by half. Overall, ED visits dropped by one-third, from 602 visits in 2016 to 416 visits in 2018. Patient experience scores at the site increased from below the 50th percentile mark across several categories in April 2016 to consistently scoring in the 90th percentile by March 2019.

Leveraging Teamwork to Improve Care Access​​​

Reider-Demer’s inaugural quality improvement initiative led her to realize the importance of working across departments for optimal outcomes. “I encourage everyone to participate in committees as much as possible, because a lot of the ideas for improvement come from what is shared during these meetings,” she said. Since becoming a quality officer, she has joined four inpatient/outpatient committees, which allows her to create teams to drive more efficiency, either through protocol changes or integrated pilot programs, she said.

One of the committees Reider-Demer serves on provides oversight to a new joint acute rehabilitation facility between UCLA’s Neuro-Rehabilitation program and nearby Cedars-Sinai Medical Center’s Physical Medicine and Rehab program. Through her participation with this group, she learned UCLA’s neurology department was taking up to a week longer than Cedars-Sinai to refer patients to the facility, resulting in longer lengths of stay.

To streamline the referral process and improve patient access, Reider-Demer developed a pilot program based on a protocol she had previously helped develop for neurosurgery patients that predicted lengths of stay based on diagnosis. For the pilot, referrals to the acute rehab facility were standardized to occur within 24 hours for diagnoses in the ED that met certain criteria, such as ischemic stroke, traumatic brain injury, or spinal cord injury. These referrals then triggered an occupational/ physical therapy evaluation for the patient, also within 24 hours.

To reduce confusion about care transition plans and processes among these patients and their families, Reider-Demer created patient and family education scripts that provided clarity around the reasons for and benefits of referral to the acute rehab center. “These were very well-received by the patients and families. They actually were excited about it,” she said.

Between the first quarter of 2017 and the third quarter of 2019, after the pilot was in place, UCLA Health readmissions from the acute rehab joint venture trended downward significantly, from just over 22% to 4%, with a low of 2.7% in the second quarter of 2019. The overall savings to the hospital during the pilot program period totaled more than $2.5 million, according to Reider-Demer.

An outgrowth of Reider-Demer’s care transition quality improvement initiatives has been to reduce high ED utilization rates by established UCLA neurology patients. Working with the residents responsible for ED neurology admissions, ReiderDemer created a triage protocol that directs patients to the appropriate level of diagnostic testing and care within a 24-hour period. To help reduce ED visits for routine care in this patient population, Reider-Demer also partnered with a primary care group specializing in the treatment of high utilizers to ensure access to other services.

For the program, the team identified the 25 neurology patients with the highest utilization in the system, who had visited the ED 106 times collectively over the previous six months. At six and 12 months post-launch, respectively, the cohort’s collective ED visits totaled 21 and 26, and individual visits among the 25 patients went from an average of 3.52 visits to 0.44 per patient per year.

Because the expedited workups and lab requests required by the new system had created inpatient and outpatient workflow issues, certain process changes had to be initiated. The biggest “tweak” was having residents perform the patient evaluations after triage. This tweak meant that in the three months after the program was initiated, 47 patients were referred out of the UCLA ED and to the residents’ clinic. “These were patients who would have otherwise been waiting there, holding up the ED and preventing access for others,” Reider-Demer said. An unplanned advantage of this change has been residents’ increased exposure to a wider variety of neurological diagnoses without having to work additional hours, something survey results indicate they like, she said.

Reider-Demer is also leveraging UCLA’s role as a teaching hospital to help drive quality improvement in other ways. One example is the creation of custom templates in electronic medical records that prompt residents and attendings to enter the most thorough level of patient documentation possible to help boost hospital rankings in cost, length of stay, and mortality. “This also emphasizes to residents that they document how sick their patients are, because oftentimes this is easier said than done, as we all know,” she said.

Another pilot program uses technology to prompt, automate, and track palliative care and hospice referrals in order to avoid patient safety indicator demerits due to unplanned mortalities. “We realized that a lot of the residents really didn’t feel comfortable with this topic,” she said. To overcome this obstacle, she led the development of lectures and workshops designed to help residents discuss end-of-life care, and alert them to the depth of resources available. This work, she said, has led to a nascent pilot program for better identifying thrombectomy candidates in order to further avoid patient safety violations.

The key to staying on top of quality improvement is awareness, Reider-Demer said. “Some things I thought would work, and they did, but not as great as I thought. Other ideas I didn’t think would [be as promising], but they worked beautifully. You have to be willing to constantly assess and reassess.”