Draft Project Charter Reduce Preventable Readmissions through ...

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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
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Draft Project Charter Reduce Preventable Readmissions through ...

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