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.
