Draft Project Charter Reduce Preventable Readmissions through ...

Draft Project Charter
Reduce Preventable Readmissions through Networking (PRN)
January 2011
Project Title:
Sponsor:
Preventable Readmissions Network (PRN)
Hospital Association of San Diego & Imperial Counties
Process Owner: Hospital, Case Management, HF team, Quality Dept.
Facilitator:
Cynthia Cadwell MS
Start Date: 21 January 2011 End Date: 31 December 2012
Problem Statement: There are approximately 20 % of readmissions, within 30 days of discharge
from an acute care facility, that are possibly preventable, and further burden our limited HC
resources. Often, these patients are within certain high risk groups, can be readily targeted, and
benefit from best practices known to improve care management.
Team Members:
• Alvarado Hospital
• El Centro Regional MC
• Fallbrook Hospital
• Hospital Association of San Diego & Imperial
Counties
• Naval Medical Center San Diego
• Palomar Pomerado Health
• Paradise Valley Hospital
• Pioneers Memorial Hospital
• Rady Children’s Hospital San Diego
• Scripps Health
• Sharp HealthCare
• Tri-City Medical Center
• UCSD Medical Center
• VA Healthcare San Diego
• Mental Health Services
• Community Clinics
• SNF’s
• Hospice
• Palliative Care
• Dialysis centers
• Durable Medical Equipment orgs.
• Pharmacies
• Home & Independent Health Services
Project Scope:
This project includes the following acute care
population, re-admitted within 30 days to any
hospital department:
• Adults (>18)
• Geriatrics (>65)
• Pediatrics (

Draft Project Charter
Reduce Preventable Readmissions through Networking (PRN)
January 2011
Deliverables:
• Best practices and guidelines of care
• Surveillance tool(s) – to evaluate for both
effective methods and readmissions tracking
• Order sets; Checklists
• Strategy Implementation plans
• Education on processes/methods
• Definitions – based on best practice
• Data gathering assistance
• Elevator speech
• Outcomes and tools to measure outcomes
Goal and Other Potential Benefits:
To collaborate, utilize HIE portals as available,
and apply evidenced-based project tools and
organization-specific methods to reduce percent
of All Cause 30 day Readmissions by at least
25% by 12/31/2012, with a stretch goal of 30%
by 3/31/2013 in the San Diego and Imperial
County region. Optional outcomes may include
percent of a significant selected population (e.g.
HF, Diabetes, Depression). Furthermore,
focused preventative measures with the high risk
patient being discharged from the hospital will
reduce healthcare costs associated with
preventable readmissions and complications,
and increase patient satisfaction with their care.
Customer(s) and Requirements:
Health care professionals and care coordinators need various tools they can adjust to their
populations, to consistently execute on methods to support care transition improvement, and
change acceleration strategies for rapid adoption of best practices.

Population
Preventing readmission in high risk patients is possible using certain established targeting and discharge
plan/transition of care modalities. Sharing implementation methods to achieve best practices among multiple
providers and healthcare systems has been shown to expedite improvement. These methods can improve
patient satisfaction, care quality and resource utilization.
Coding based on ICD-9 and discharge DRG diagnosis 30 day readmissions and/or CMS data
• May be able to track certain inter-facility readmits through SD Beacon HIE project
• Providers may not be aware of ‘non PCP patient’ readmissions
• Patient admitted into hospital without any accessible records
• N = all patients with ‘unplanned’ readmissions within 30 days
• D = all discharges
Goal
• Reduce the incidence of preventable readmissions into licensed care facilities across the region
• Need current number – administrative data – for baseline
• Each organization: 30 day ‘unplanned’ readmission rates for 2009 and 2010 as baseline; Can sort to
specific DRG’s if necessary to better target high risk and high volume patients
• Side goal: Reduce unnecessary resource utilization and increase bed and revenue capacity
How can this project help us at our facility?
• Implementation tools, ideas and methods sharing can accelerate change and impact; Improve bed and
revenue capacity; Improve patient satisfaction with care
Elevator Speech
Recommend producing an elevator speech for each target audience.
• What our project is about… improving our care ‘transition’ coordination, especially upon hospital
discharge, to prevent unnecessary readmissions in our region, as well as improve patient care outcomes.
• Why it is important to do… because many 30 day readmissions are preventable with appropriate
intervention, yet today it occurs in approximately 20% of all cases in our region, and we are frequently over
capacity at most facilities, causing patients to have care delayed.
• What success will look like… increased regional capacity for planned, revenue producing and emergency
hospital admissions, improved quality of care for our high risk populations, and improved resource
utilization. Improved patient satisfaction scores.
• What we need from you… a commitment to understand, support, and comply with best practices to
prevent unnecessary readmissions, including early identification of high-risk patients, collaborating with
multi-disciplinary colleagues, and providing accurate information on patient readmission rates from your
facility on a quarterly basis to the region, and a monthly basis to your onsite team.
Staging Project
Considering evidence available it’s clear what needs to be done… We need:
Timeline
Description
March 2011 • Readmissions baseline data 2009; 2010; Quarterly progress reports
• Readmission prevention campaigns
• Hospital discharge order sets available in most facilities
• Literature supported targets and methods
May 2011 • Currently available prevention and surveillance methods, tools and resources
• Facility team’s assembly and management support tools
July 2011 • Change management/Implementation tools
• SD Beacon’s Contribution/Alignment
Sept. 2011 • 2011 Readmissions Measurement and Analysis
• Stakeholder analysis
Nov. 2011 • Project status evaluation
• Review change management
• Readjust plan, goals, etc. as needed
Jan 2012 • Project plan for 2012 defined and 2011 progress report disseminated