AIM Statement Next Steps Run Chart

Readmission Reduction
Chino Valley Medical Center
Chino, CA
November, 2014
AIM Statement
Run Chart
Reduce all-cause Medicare Fee for
Service readmission rate by 20% from
2011 baseline of 23.4% to 18.4% by
December 2014.
• Update the “dialog” for both the Discharge
Office and the Call back process. Include the
floor nursing and unit managers in the call
back process to better connect the staff to
their patients post discharge.
Interventions
• Assess and improve the pharmacy’s role in
the discharge process and medication
reconciliation.
Test (T), Interventions (I), Spread (S)
• Standardized discharge instructions; available in
several languages; distributed to patient/care taker. (T,
I, S)
• Improve and expand the risk screening tool
to include bedside nursing.
• Discharge instructions are being built into the electronic
record. (T)
• Develop an “enhanced home health”
program.
• Initiated “discharge envelope” (with hospital logo and
contact information) to consolidate discharge
paperwork in one area so patient has hospital staff to
contact when questions arise post discharge. (T, I, S)
• Implemented teach back methodology to ensure patient
comprehension (T, I, S). Additional staff training of
teach back based on identified need. (S)
• Created ‘Discharge Office’ for patient stop during actual
discharge to ensure patient has discharge instructions
and follow-up appointment. (T, I)
• Developed script for ‘Discharge Office’ (T, I). Script
revised in 2014 to elicit more meaningful responses and
understand issues that still need to be resolved.
• Expanded ‘Discharge Office’ stop to 7 days per week.
(I)
• Adapted EMR to include documentation of patient
comprehension of education/preparation and
Incorporate all required elements of discharge
summary. (T, I)
• Engaged CMO in concurrent and retrospective review
of readmissions. (I)
• Coordinated with IT for electronic trigger of patients
readmitted within 30 days including in ER. (T, I, S)
• Follow-up appointments carefully monitored and a post
discharge process has been implemented for patients
who discharge without an appointment in place. (T, I,
S)
• Reviewed core measure patients to ensure all elements
of Evidence Based Practice are implemented. (T, I, S)
Next Steps
• Develop a partnership with local residential
programs to improve the hand-off process.
Data Source: Comprehensive Data System-HRET as of 09-09-2014
Lessons Learned
• Processes needs to be assessed on an ongoing basis.
• Focus group needed expansion to include key community
members i.e, Home Health and residential/assisted living
programs.
Team Members
• Case Management/Champion: Sue
Montoya-Bell, LCSW
• PI Director: Donna Young, RN
• MST Director: Angelica Silva, RN
• ICU Director: Sandra Moreno, RN
Resources
• ED Director: Cheryl Gilliatt, RN
• Clinical specialist with IT: Jean Arriaga, RN
• Director of HIM: Nancy Dukes
• HQI Readmission Elimination Toolkit is available on the
HQI website at hqinstitute.org < Tools and Resources.
• Pharmacy Director: Dr. Joseph Catalano,
RN, PharmD
• Questions: Contact Mahsa Farahani, Project Manager, HQI
at 916-552-7521, email mfarahani@hqinstitute.org.
• Chief Medical Officer: Dr. James Lally, MD