RESPONDING TO POST WEEK6 NR-536
Respond to the classmate post.
Preventable hospital readmissions are a quality indicator reflecting acute and transitional care. Pre- and post-discharge interventions require healthcare team collaboration and patient (and caregiver) engagement. If my organization were to experience a 25% increase in readmissions, as a nurse executive, I would convene an ad-hoc task force. This task force would include the following key stakeholders: the inpatient nursing manager (appointed as task force leader), the chief of hospitalists, the nurse case manager, the informatics nurse, the clinical nurse specialist (that abstracts patient data), and a frontline nurse, respiratory therapist, physical therapist, patient care tech and unit clerk. Each of these team members play an important role in the patient’s individualized plan of care throughout the care continuum, and with collaboration will implement best practice measures to reduce preventable hospital readmissions.
To guide practice to deliver safe and quality care, our task force would review and stratify one year of Centers for Medicare & Medicaid Services (CMS) abstracted data from patient readmissions (from all payers) to identify opportunities for process improvement, education, resources, etc. These audits measure readmissions within 30 days of discharge, and include discharge diagnoses, services at discharge, discharging providers, care practices, and patient specific information. Our team would also audit condition-specific (i.e., heart failure, chronic obstructive pulmonary disease, etc.) patient charts for patient (and caregiver) engagement and education provided during their hospital stay, discharge, and follow-up telephone call to identify what is working well. Another measure we would audit is patient experience, to determine if patients felt there was effective care provider communication of their plan of care and discharge, and if they felt they had a good understanding of managing their health when they left the hospital. After implementation of the new proposed intervention, our task force would audit our new process for compliance to ensure staff understanding and identify areas in need of further education. The measurement of these outcomes and subsequent follow-up will assist with quality control, thus positively contributing to the delivery of quality care.
The previous fiscal year data would serve as a baseline. The upcoming monthly and fiscal year target would be set at a percentage below the baseline, as this has been achievable within the last fiscal year, with an ultimate goal of achieving no preventable readmissions (best outcome). The specific outcome we want to achieve is reducing the readmission rate at or better than our established targets. Benchmarking helps measure operational performance in comparison to best practice. The benchmark our task force selects would reflect the national readmission average set by CMS and averages of top-performing like-sized regional hospitals, reflective of the population served. The current CMS national rate of readmissions after hospital discharge is 15% (Centers for Centers for Medicare & Medicaid Services, 2022). My organization uses the national observed readmission rates as a benchmark. Meeting set targets will require leadership support and appropriate time and resources allocated to implement change and assist our organization to meet and exceed the practice standard.
To achieve a reduction in readmissions, our task force would initially focus on a discharge diagnosis that contributed to a higher number of readmissions, such as heart failure. The intervention we would use would be nurse-led condition-specific education with electronic health record (EHR) redesign (Oliver et al., 2022). According to Oliver et al. (2022), the development and implementation of a nurse-led educational curriculum, designed to advance the healthcare team’s knowledge on managing heart failure, with EHR support to ensure appropriate management has occurred (i.e., alerts), has resulted in an immediate reduction and steady reduction of heart failure readmissions over three-years. This intervention supports a best practice approach, involving bedside nurses to educate and prepare patients and their caregivers for discharge (Oliver et al., 2022). Our task force would reach out to subject matter experts to develop a curriculum, educate, and support informatics. Our task force would engage the healthcare team and seek feedback on workflow efficiency, patient receptiveness, and patient experience.
PICOT Statement: For CMS patients readmitted within 30 days of discharge within the acute care setting (P), does nurse-led heart failure management education with EHR care plan alignment (I), compared to the current process of follow-up phone calls seven days post discharge (C), reduce the readmission rate of CMS patients from 18.75% to 15% (O), within a six-month period (T).
