Moving the Titanic: Reducing Readmissions Utilizing an Optimizing Transitions of Care Committee

Problem: Relative to our academic peers and internal data, we needed to reduce the amount of 7-, 14-, and 30-day readmissions. Work towards reducing readmissions was being performed but not utilizing the power of a multidisciplinary team and we were not making progress.

Measurement: Run charts, bar charts, pie charts, tables, CMS Star rating reports, HRRP data, rank charts, rank trend charts, strategy visualization charts, lists, filterable Excel reports, workflow visualization diagrams, dashboards, worklists.

Analysis: We are members  of Vizient. Thus, we pulled reports by FY for our own hospital and peers. We analyzed top three MS-DRGs and top three primary diagnoses, as well as utilized the Vizient Q&A Accountability scorecard efficiency domain and compared service lines to each other.

Implementation: We first implemented a multidisciplinary committee called Optimizing Transitions of Care Committee along with participation in a Vizient collaborative, created daily readmission list, pharmacy telehealth, Cipher Health, Qventus and Cerner Readmission Module. Obstacles included complexity of patients, timely data, and team dynamics.

Results/Discussion: Reducing readmissions is truly a multidisciplinary effort. Key is putting together a team with a central focus and creating a safe environment to constructively identify what is and what is not working. Timely data, service-line specific drilldowns, partnering with UR and CM, physician quality liaisons are all key.

Speakers
Associate Administrator
Associate Administrator – Keck Hospital of USC

Speaker Type: Poster Presentations On-Demand

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 Keck Medical Center of USC

Speaker Type: Poster Presentations On-Demand

  • Population Health and Care Transitions IconPopulation Health and Care Transitions
  • Patient Safety IconPatient Safety