Operational Processes

Work with your Reducing Readmissions Committee to complete the following assessment. Each item relates to prevention elements that should be in place for a successful readmissions program in your facility. Select one of the implementation status options for each assessment item. Please complete your facility name and CMS Certification Number (CCN) at the end of this assessment.

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* 1. Do you track and trend transfers using a readmission dashboard?
Rationale: “A dashboard is an ideal way to prioritize the most important indicators for a nursing home and encourage regular monitoring of the results. Nursing homes should include readmission as one of the measures in your dashboard.”
Source: Instructions to Develop a Dashboard, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/InstrDevDshbddebedits.pdf.

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* 2. Do you discuss readmissions that occurred in the last 24 hours during daily stand-up meetings?
Rationale: Daily stand-up meetings provide an opportunity to review all patients readmitted from the previous day to determine root causes for the readmission and the plan to prevent them in the future.

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* 3. Do you conduct case reviews for residents who return to the hospital?
Rationale: Conducting case reviews on patients who return to the hospital is an important part of root cause analysis. This will provide nursing homes a comprehensive review of the resident’s condition and other factors that contributed to the transfer. See the INTERACT Quality Improvement Tool for Review of Acute Care Transfers (chart audit tool) at http://www.pathway-interact.com/.

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* 4. Do you use the INTERACT chart audit tools (or other evidence-based tools) for your readmission case reviews on residents that return to the hospital?
Rationale: Reviewing a small sample of readmitted patient charts aids in identifying patterns or trends in data and provides opportunities for improvement. Data analyzed include key clinical information, such as: change in condition, vital signs at time of transfer, new or worsening symptoms, etc. See the INTERACT Quality Improvement Tool for Review of Acute Care Transfers (chart audit tool) at http://www.pathway-interact.com/.

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* 5. Do you have more than one Performance Improvement Project (PIP) specific to readmission prevention?
Rationale: A project charter clearly establishes the goals, scope, timing, milestones, and team roles and responsibilities for an improvement project. Develop a PIP charter specific to readmission prevention. 
Source: Worksheet to Create a Performance Improvement Project Charter. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf.

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* 6. Do you have annual competencies with your nurses related to effective team communication?
Rationale: Adding standardized communication tools in the annual competencies is a method to validate that staff members know how to use the communication tools. Provide training for those that are not using the tools or using them inconsistently. Consider use of INTERACT Situation-Background-Assessment-Recommendation (SBAR) and “Stop and Watch” warning tool. See the INTERACT forms at http://www.pathway-interact.com/.

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* 7. Do you have a readmissions committee that meets monthly?
Rationale: A monthly readmission committee is a team that meets to review data, case studies, and improvements for current processes. The readmissions committee should include the administrator, director of nursing, medical director, pharmacist/consultant, case manager, and admissions coordinator. Having a dedicated review committee will assist in identifying system failures that exist, trends in data, and opportunities for improvement. See the Reducing Readmissions Preparation Program Committee Roster at http://www.hsag.com/az-rrpp.

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* 8. Do you report on readmissions, including data, to your Quality Assurance and Performance Improvement (QAPI) committee monthly?
Rationale: As part of feedback, data systems, and monitoring for QAPI, it is important to keep the QAPI leadership in your nursing home informed of readmission related issues and data, so that they can support and provide resources to drive improvement efforts.   

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