Preventing Unplanned
Readmissions – The Dell
Children’s Medical Center
Experience
Terry Stanley, DNP, RN, NE-BC
Director of Quality and Operational Effectiveness
The Evolution
• Alignment with Seton Network LEM goals for FY17
• PHIS database revealed our biggest opportunity was APR DRG 137 – Major
Respiratory Infection/Inflammation (36% readmission rate)
• Characteristics of the patients who were readmitted
– Chronically ill with multiple healthcare problems
– Index diagnosis frequently associated with aspiration
– Readmissions usually not related to the index admission; seizures was most common reason for
readmission
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©2015 Seton
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Gaps in structures and processes – the barriers
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Patient education resources and Teach Back
Lack of resources to manage transitions for complex care patients
Med rec challenges from admission to discharge
PHIS reports 6 month delay make it difficult to measure impact of interventions
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©2015 Seton
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Facilitators to improving performance
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Post Discharge Call Transition Program
REDCap survey to all parents of readmitted patients
Strong physician engagement
Network priority
Avoidance of monetary penalties from State
Acquisition of Health Intent Data Warehouse & Tableau visualization software along
with the right people to leverage these resources; we now have monthly metrics for
all APR DRGs in a Dashboard.
CONFIDENTIAL
©2015 Seton
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The journey
• Established interdisciplinary team with first meeting in September, 2016; initially
met X1/month, now X2/month.
– Physicians
– Social Work
– Care Management
– IS/EHR
– Nurses
– Pharmacists
– RT
– Education
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©2015 Seton
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The journey
• Thorough search & appraisal of readmission literature including SPS Readmission
Pioneer work
• Deep dive to identify characteristics of APR DRG 137 patients
• Examined data from post discharge phone calls and surveys from parents of
readmitted patients
• What we learned:
– No single or cluster of causative factors for our readmissions
– Numerous “best practices” to address all cause readmissions
– Removing identified barriers would benefit all patients, including APR DRG 137
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©2015 Seton
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The decision
• Focused on 3 possible pathways:
– Proceed with finding solutions specific to our target population (APR DRG 137)
– Proceed with finding solutions specific to complex care patients
– Proceed with solutions for all cause readmissions
• We decided to focus our initial efforts (2017) on all cause readmissions and then
begin to drill down for specific populations such as complex care and others once we
have addressed the all cause readmissions in 2018.
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Next steps
• From a list of best practices taken from studies in our lit review and the SPS
readmission bundle, we have identified 4 primary interventions/improvement
efforts:
• Provide discharging physician(s) notice their patient was readmitted
• Improve the congruence/accuracy between admission med rec and discharge med/rec (therefore
discharge instructions)
• Assure discharge instructions contain a plan for parents to address common problems including
an escalation plan (e.g. fever, pain, wound issues, etc.)
• Implement Teach Back throughout the hospital for all disciplines that provide patient education
• Concurrently we are also addressing our chaotic process for developing and maintaining patient
education resources, including health literacy principles
CONFIDENTIAL
©2015 Seton
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