primary drivers for reducing harm...use visual/audible cues, (e.g., colorful, easy to view alert...
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CAUTI Does the hospital avoid unnecessary urinary catheters? Are indwelling urinary catheters discontinued as soon as indications expire? Is the necessity of catheter continuation for all patients with a urinary catheter reviewed
on a frequent basis? Is aseptic technique maintained throughout the life of the catheter including insertion
and daily care and maintenance? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
CLABSI Has the hospital adopted guidelines for catheter insertion? Are there processes in place to remove catheters as soon as possible? Does the hospital have standardized policies or processes that ensure appropriate care
and maintenance of central line catheters? Are proper supplies/kits and equipment standardized and available for easy accessibility? In making changes to the hospital’s CLABSI approach, has there been adaptive changes? Has the hospital adopted guidelines for catheter insertion? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
CALHEN Hospital ChecklistPrimary Drivers for Reducing Harm
FALLS Does the hospital use a valid and reliable Falls Risk Assessment? Does the hospital conduct Falls Risk RE-Assessments at standard intervals? Does the hospital conduct Environmental Inventories? Are there interventions for all patients regardless of assessed risk? Are there individualized interventions for High Risk patients? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
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SSI Has the hospital adopted a Surgical Safety Checklist? Does the hospital have an Antimicrobial Prophylaxis protocol? Does the hospital have a preadmission skin cleansing protocol? Is there a standardized procedure for normothermia in the operating room? Does the hospital have a perioperative glucose control procedure or process? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
ADE Is there awareness, readiness & education on the ADE risks posed by high risk medication? Has the hospital integrated pharmacy standardized care processes throughout the facility? Are Pharmacists included in patient level Decision Support? Are processes in place to prevent failure? Are there processes in place for the identification and mitigation of failure of practices
including education real time? Has the hospital implemented smart use of technology? Does the facility involve patient and family in the administration and education of
pharmaceuticals? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
HAPU Does the hospital conduct standardized Skin/Risk Assessment & Reassessments? Are there standardized processes to manage moisture? Does the hospital optimize hydration and nutrition? Are there standardized processes to minimize pressure? Do improvement efforts include multidisciplinary approach to HAPU prevention? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
VAP (all questions allow for patient variation in standard practices based on patient condition)
Are all ventilated patient’s Head of the Bed raised between 30-45°? Are all ventilated patient’s placed on Peptic ulcer disease (PUD) prophylaxis? Does the hospital have standardized processes that include prophylaxis for
Venous Thromboembolism (VTE)? Does the hospital have standardized processes that include spontaneous
Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)? Do all ventilated patients receive standard Oral Care? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
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OB EED Has the hospital reduced demand for early elective deliveries
(prior to 39 weeks gestation)? Has the hospital reduced availability for early elective deliveries
(prior to 39 weeks gestation)? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
VTE Does the hospital perform effective VTE risk assessments? Has the hospital developed best practices for prophylaxis? Are there standardized care processes? Is there decision support for dosing and monitoring? Does the hospital involve the patient and family in VTE assessment and treatment? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
READMISSIONS Does the hospital identify patients at high-risk for readmission? Does the hospital confirm self-management skills? Does the hospital coordinate care across the continuum? Does the hospital ensure adequate follow-up and community resources? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?
For more information, please refer to HRET’s change packagehttps://s3.amazonaws.com/CAUTI_Manuals_and_Toolkits/CAUTI+Implementation+Guide/CAUTI+Implementation+Guide+-+November+2012.doc
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CALHEN Hospital ChecklistSecondary for Reducing Harm
CAUTI: Catheter Associated Urinary Tract InfectionsPrimary Drivers Secondary Drivers Avoid unnecessary urinary catheters Identify conditions or situations that do not require a urinary catheter
Require the purpose for a urinary catheter when ordered by the physician or practitioner
Remove urinary catheters as soon as possible
Include daily review of catheter necessity into daily rounds, with prompt removal if catheter is no longer indicated
State the catheter day (e.g., “catheter day 6”) during daily rounds as a reminder of how long the catheter has been in place
Adopt a standard post-operative removal by the nurse unless certain conditions exist (24-48 hours post-operative)
Ensure appropriate care and maintenance
Ensure a standardized protocol for foley insertion, care and maintenance, and removal, including who can insert urinary catheters
Maintain a sterile, continuously closed drainage system
Keep catheter properly secured to prevent movement and uretheral traction
Keep the collection bag below the level of the bladder at all times
Maintain unobstructed urine flow
Empty the collection bag regularly using a separate collecting container for each patient and not allowing the draining spigot to touch the collecting container
Engage patients families and staff in the reduction of CAUTI
Include the patient and family in the care specifically in the avoidance of a urinary catheter
Provide patient education utilizing Teach Back and Ask Me 3 methodologies
Provide unit level information or feedback about patients that experience a catheter associated UTI to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
For more information, please refer to HRET’s change packagehttps://s3.amazonaws.com/CLABSI_Elimination_Toolkit/CLABSI+Elimination+Toolkit+Manual.doc
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CLABSI: Catheter Associated Blood Stream InfectionsPrimary Drivers Secondary Drivers Adopt guidelines for catheter insertion Use an insertion checklist that includes all bundle elements for central
line insertions
Avoid the use of the femoral vein for central venous access in adult patients
Establish a process to assure correct insertion technique by all individuals inserting catheter and identify who inserts central lines
Empower nurses to stop insertion if element(s) of the bundle are not being executed
Remove catheters as soon as possible Include daily review of line necessity into daily rounds with prompt removal if catheter is no longer indicated
State the line day (e.g., “line day 6”) during daily rounds as a reminder of how long the line has been in place
Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.)
Ensure appropriate care and maintenance
Standardize dressing change policies
Adopt a process for access into the central line (e.g., scrub the hub process)
Availability of supplies and equipment Develop a process to assure proper equipment is available – central line insertion kit, central line dressing kits, administration sets, needleless systems
Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions
Adaptive changes Adopt a senior leader as part of the improvement team
Engage frontline workers
Adopt team and communication skills
Engage Patients, Families, and Staff in the reduction of CLABSIs
When possible and as far in advance as possible, prepare the patient and family prior to insertion with what to expect information including appropriate line maintenance
Provide patient education utilizing Teach Back and Ask Me 3 methodologies
Provide unit level information or feedback about patients that experience a central line associated blood infection (CLABSI) to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/falls_final_508.pdf
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FALLSPrimary Drivers Secondary Drivers Fall and Injury Risk Assessment Conduct a fall risk assessment upon admission using a validated
risk assessment
Assess patient’s fall risk by asking the patient and family what they do outside the hospital to prevent falls
High-injury risk patients include ABCS – Age > 85, Bone, C anticoagulation, coagulopathies, and Surgical patients
Fall Risk Reassessment Conduct ongoing reassessments including new and/or changed medications that increase fall risks
Perform hourly or bi-hourly rounds to assess and address patient needs for Ps: pain, position, potty, personal belongings and safe pathway
Environmental Interventions Create a safe environment for patients by eliminating hazards and injury hazards (e.g., sharp edges, clear hallways etc.)
Develop an equipment safety checklist to include bathroom and shower safety devices
Consider flooring and lighting and the setup of the patient rooms (e.g., clutter free, furniture placement based on the assessment of the patient’s strongest side when getting out of bed, and floor mats)
Institute fall prevention alerts in the electronic medical record (EMR)
Interventions for All Patients Use visual/audible cues, (e.g., colorful, easy to view alert wristbands, bedside risk signs, non-skid footwear)
Medication review – avoid unnecessary hypnotic/sedative medications
Use of beds that are lower/closer to the floor
Involve family and care givers in the care of the patient to prevent falls (e.g., sit with the patient during vulnerable times)
Intermittent but regular observation through hourly “rounding” by staff
Patient education – emphasizing the positive benefits of interventions (enhancing independence and quality of life) rather than the negative (e.g., risk of falls)
Achieve interdisciplinary participation and include all staff in the reduction of falls including nursing, medical staff, pharmacy, therapy staff, environmental services and engineering/maintenance
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/falls_final_508.pdf
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Primary Drivers Secondary Drivers Individualized Interventions for High Risk Patients
Increase the frequency of rounding
Enhance environmental changes (e.g., move closer to nursing station)
Assistive devices (e.g., walking aids, transfer bars, bedside commodes) located on exit side of bed
Engage Patients, Families and Staff in the Reduction of Falls
Provide verbal and written patient and family education related to falls reduction in their preferred language
Provide patient and family education utilizing Teach Back and Ask Me 3 methodology
Engage the patient and family in reducing falls
Include falls risk status or concerns during shift handoffs and patient transfers and document this communication
Provide unit level information or feedback about patients that experience a fall to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussion)
FALLS (continued)
For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ssi_change%20package_508.pdf
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SSI: Surgical Site InfectionsPrimary Drivers Secondary Drivers Adopt Surgical Safety Checklist Conduct three pauses with surgical team at critical points:
• Before induction of anesthesia• Before skin incision• Before patient leaves the operating room
Verbally confirm all items on the surgical checklist at each pause with appropriate surgical team members
Ensure the use of a standard tool so as not to rely on memory for items in the surgical checklist
Antimicrobial Prophylaxis Develop standardized order sets for each procedure that include antibiotic, timing, dose and discontinuation
Develop pharmacist and nurse-driven protocols that ensure correct antibiotic selection based on type of surgery and patient characteristics (e.g., age, weight)
Create a process to review all exceptions to protocols
Ensure that antibiotics are re-dosed appropriately in surgeries (longer than four hours)
Perioperative Skin Antisepsis Develop standardized practices for application of skin antiseptic agents
Educate perioperative personnel on the safe application of selective skin antiseptic agents
Preadmission Skin Cleansing Develop standardized order sets for preadmission skin cleansing
Develop a strategy for distribution of skin antiseptic agent to the patients
Educate patients as to how to apply the skin antiseptic agent prior to hospital admission
Normothermia in the Operating Room Develop standardized procedure for pre-warming for every surgical patient without a contraindication
Develop standardized procedure for active warming in the operating room that could include warming blankets under patients on the operating table
Perioperative Glucose Control Obtain glucometers for every anesthesia station
Develop a perioperative glycemic control team that includes surgeons, anesthesiologists, endocrinologists and nurses to ensure that responsibility and accountability is assigned for blood glucose monitoring and control
For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ssi_change%20package_508.pdf
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Primary Drivers Secondary Drivers Engage Patients, Families and staff in the Reduction of SSIs
Provide verbal and written patient and family education prior to surgery in their preferred language
Utilize standardized patient and family education when possible including checklists
Provide patient education utilizing Teach Back and Ask Me 3 methodologies
Provide unit level information or feedback about patients that experience a surgical site infection to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
SSI (continued)
For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ade_changepackage_508.pdf
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ADE: Adverse Drug EventsPrimary Drivers Secondary Drivers Awareness, Readiness & Education Assess organizational capacity, readiness and willingness to implement
systems to prevent ADEs
Create awareness of high alert medications most likely to cause ADEs
Identify patients at high risk for ADEs
Standardize Care Processes Implement ISMP quarterly action agendas where appropriate
Develop standard order sets using safety principles
Allow nurses to administer rescue drugs based on protocol
Minimize interruptions during the process of medication distribution and administration
Standardize concentrations and minimize or eliminate multiple drug strengths where possible
Allow pharmacists to change anticoagulant doses based on lab values per protocol
Include a pharmacist in direct clinical activities (e.g., ICU rounds, ambulatory medication decision making)
Decision Support Include pharmacists on rounds
Monitor overlapping medications prescribed for a patient
Prevent Failure Minimize or eliminate nurse distraction during the medication administration process
Standardize concentrations and minimize dosing options where feasible
Timely lab results with effective systems to ensure review and action
Use non-pharmacological methods of pain and anxiety management where appropriate
Identification and Mitigation of Failure Analyze dispensing unit override patterns
Prompt real time learning from each failure
For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ade_changepackage_508.pdf
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Primary Drivers Secondary Drivers Smart Use of Technology Use “smart pumps” with up-to-date library or double check all IV infusions
for high alert medications
Understand errors that can occur from Patient Controlled Analgesic devices (PCAs)
Use bar coding
Use alerts wisely
Use data/information from alerts and overrides to redesign standards
Link order sets to recent lab values
Involve the Patient and Family Allow patient management of insulin where possible
Provide patient education at a literacy level understandable by all
Provide patient education at a literacy level that is understandable and in their preferred language
Utilize techniques like Teach Back and Ask Me 3 to ensure patient and family understanding of home management of medication and labs related to the management of pharmaceuticals at home
ADE (continued)
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/hapu_final_508.pdf
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HAPU: Hospital Acquired Pressure UlcersPrimary Drivers Secondary Drivers Conduct Skin/Risk Assessment & Reassessment
Use a head-to-toe skin and risk assessment as soon as possible, within 4 hours upon admission to the hospital
Utilize a validated standard tool for the skin and risk assessment
The risk and skin assessment should be age appropriate Pediatric versus adult
Skin Assessment and reassessment of risk daily or more frequently for high-risk patients
Engage a multidisciplinary team in the assessment and prevention of pressure ulcers (Medical Staff, licensed and unlicensed Nursing Staff, Nutritionists, Physical Therapy, Transporters etc.)
Conduct regular skin prevalence studies and share the findings with staff
Manage Moisture Keep the patient dry and moisturize the skin only if necessary
When necessary, use under-pads that wick moisture away from skin and provide a quick-drying surface
Set specific time frames to remind staff to reposition, offer toileting often, check PO fluids, reassess for wet skin, (i.e. P’s – Pain/Potty/Position/Pressure)
Keep supplies handy at the bedside in the event the patient is incontinent
Optimize Hydration and Nutrition Give patients preferences to encourage hydration and nutrition
Provide at risk patients with a different color water container so all staff and families will know to encourage hydration
Provide nutritional supplements if not contraindicated
Consult a registered dietician if the patient is at a high risk
Assess weight status, food and fluid intake, hydration status and laboratory data
Minimize Pressure Turn and reposition patients every two hours using visual or musical cues, bells and alarms at the nurses’ station
Use special beds, mattresses, pillows and blankets to redistribute the potential pressure areas
Use the NPUAP guidelines for alignment
Use lifting devices to prevent shearing or friction
Evaluate and investigate on a regular basis new products that are evidence-based to prevent or treat pressure ulcers
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/hapu_final_508.pdf
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Primary Drivers Secondary Drivers Engage Patients, Families, and staff in the reduction of Pressure Ulcers
Provide patient education utilizing Teach Back and Ask Me 3 methodologies
Include pressure ulcer findings or risk status or concerns during shift handoffs and patient transfers and document this communication
Provide unit level information or feedback about patients that acquire a hospital acquired pressure ulcer to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
HAPU (continued)
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vap_final_508.pdf
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VAP: Ventilator Acquired PneumoniaPrimary Drivers Secondary Drivers Standardize processes and care reminders
Institute a standardized protocol or bundle for the care of a ventilated patient
Include bundle reminders and checklists on a flow sheet or EMR checklist
Elevate Head of Bed raised between 30-45 degrees
Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle
Include the clues on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care
Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation
Peptic ulcer disease (PUD) prophylaxis Evaluate the use of medications (H2 blockers are preferred over sucralfate). Proton pump inhibitors may be efficacious and an alternative to sucralfate or H2 antagonist
Include PUD on the ICU order admission set and ventilator order set
Incorporate review of PUD into daily multidisciplinary rounds
Engage pharmacy in daily multidisciplinary rounds to ensure ICU patients have some form of PUD and VTE prophylaxis
Venous Thromboembolism (VTE) prophylaxis
Initiate VTE prophylaxis on all mechanically ventilated patients unless contraindicated
Include VTE prophylaxis as part of your ICU order admission set and ventilator order set
Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
Develop protocols, order sets, and standard work for spontaneous awakening trials (SAT) and spontaneous breathing trial (SBT)
Perform daily assessments of readiness to wean and extubate
Create an environment where respiratory therapists work collaboratively with nursing to facilitate a daily “sedative interruption” in coordination to “weaning trials”
Implement a protocol to lighten sedation daily to assess for readiness to extubation. Include precautions to prevent self-extubation such as increased monitoring during the trial
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vap_final_508.pdf
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Primary Drivers Secondary Drivers Oral Care Perform regular oral care with an antiseptic solution (e.g., chlorhexidine)
in accordance with the manufacturer’s product guidelines
Include daily oral care with chlorhexidine as part of your ICU order admission set and ventilator order set
Educate the RN staff about the rationale for supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia
Patient and Family Engagement Standard practice includes patient and family preparation for intubation (both conscious and unconscious)
Include the patient and family in daily care activities or expectations
Provide patient and family education in their preferred language
Provide unit level information or feedback about patients that experience a ventilator acquired pneumonia to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
VAP (continued)
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/ChangePackages/perinatalharm_final_508.pdf
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OB EED: OB Early Elective DeliveriesPrimary Drivers Secondary Drivers Reduction in DEMAND for elective deliveries at prior to 39 weeks gestation
Raise awareness of risks of EED for physicians, nurses, and hospital staff
Raise the awareness of risks of EED for patients/families and the community
Reduction in AVAILABILITY of elective deliveries at prior to 39 weeks gestation
Create a hospital policy and procedure that guides scheduling and oversight for elective deliveries
Develop mechanisms to support the appropriate implementation and enforcement of policies and procedures
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vte_final_508.pdf
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VTE: Venous ThromboembolismPrimary Drivers Secondary Drivers Effective risk assessment Adopt a VTE risk-assessment screening tool; simplify as much as possible
Assess every patient upon admission of his/her risk for VTE using the VTE risk assessment screening tool
Develop best practices for prophylaxis Review key resources and identify best practices
Adopt a standardized risk-stratified menu of choices for prophylaxis; simplify as much as possible
Standardize care processes Develop standard written order sets which link the risk assessment to the choice of prophylaxis
Identify contraindications and include them in order sets
Allow for ‘opt-out’ as clinically indicated
Institute hard stop alerts in the Electronic Medical Record (EMR)
Institute medication alerts within EMR
Decision support Use protocols for dosing and monitoring
Allow pharmacists to change anticoagulant doses based on lab values per protocol
Include a pharmacist in direct clinical activities (e.g., rounds, ambulatory medication decision making)
Engage the Patient, Family, and Staff in the Reduction of VTEs
Alert patients and families to early signs and symptoms of VTE
Give clearly written and well explained VTE discharge instructions to patients and families in their preferred language
Institute a standardized teaching tool for warfarin therapy
Utilize Teach Back and Ask Me 3 methodologies to ensure patients and families have thorough understanding of dosing and physician and lab follow-up appointments
Provide unit level information or feedback about patients that experience a venous thromboembolism to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/presentations/readmission_chg_pkg_final_2013.pdf
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READMISSIONSPrimary Drivers Secondary Drivers Identify patients at high-risk for readmission
Use a risk of readmission assessment tool and validate it using your own data
Develop a method to stratify patients at higher risk of readmission
Adopt an enhanced admission assessment
Assess the patient’s engagement and assertiveness in managing their own care
Engage the patient and family early in the discharge process
Self-management skills Assign clear accountability for medication reconciliation
Educate patient regarding medication, need for medication, method of obtaining and taking medication once discharged
Utilize Teach Back and Ask Me 3 techniques to assess the patient and family’s understanding of their condition and discharge instructions
Educate patient on their condition, symptoms, and what to do if symptoms worsen
Provide clearly written medication instructions using health literacy concepts in their preferred language
Coordination of care across the continuum
Identify a person or role that is responsible for assuring discharge planning activities are executed (can be phased in with the highest risk populations targeted first)
Obtain accurate information about primary care physician at the time of admission and create a patient centered record
Include routine interdisciplinary rounding in standard daily processes
Ensure effective communication to non-hospital based care team members
Perform medication reconciliation at each transition of care
Send discharge summary to primary care physician with 48 hours of discharge
Call the patient within 24 to 48 hours after discharge
For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/presentations/readmission_chg_pkg_final_2013.pdf
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Primary Drivers Secondary Drivers Adequate follow-up and community resources
Prior to leaving the hospital, determine what after-hospital resources and appointments are needed and ensure appropriate planning
Work with patient and care provider to identify and address any barriers to making and attending follow-up appointment(s) and other follow-up needs such as medications, special diet, etc.
Work with collaboratives and community organizations for a sustainable readmission solution. Some suggested programs are:• The Focus on Readmissions Reduction• Community-Based Care Transitions Program (CMS Partnership
for Patients)• Care Transitions Program (Eric Coleman)• Project RED (Brian Jack)• Transitional Care Model (Mary Naylor)• Project BOOST (Society of Hospital Medicine)• The PAVE Project (Health Care Improvement Foundation)
READMISSIONS (continued)