Running head: LEADERSHIP STATEGY ANALYSIS1

Leadership Strategy Analysis-Quality Improvement Process

Venus Johnston, Cynthia Magirl, Kathy Vietti, and Carol Zinn

Ferris State University

LEADERSHIP STATEGY ANALYSIS 2

Abstract

Readmission to the hospital for Heart Disease and Pneumonia, within 30 days of discharge,

reflects poor patient care and an increased cost to the healthcare system. This paper sets forth a

strategic plan to decrease the readmission rate at Spectrum Health Kelsey Campus and improve

patient compliance through teamwork, research, and education. The implementation of a

collaborative team approach will increase the success of the overall plan and improve patient

outcomes.

Keywords: readmission, interdisciplinary team, heart disease, pneumonia, discharge

instructions, compliance

LEADERSHIP STATEGY ANALYSIS 3

Leadership Strategy Analysis-Quality Improvement Process

The delivery of health care has always focused on quality. Recently, clinical quality has

become a critical issue on both national and regional levels. Nurses must continue to improve

the quality and safety within the healthcare system and focus on the six competencies identified

by Quality and Safety Education for Nurses (QSEN): patient centered care, teamwork and

collaboration, evidence-based practice, quality improvement, safety, and informatics. (Yoder-

Wise, 2011). Some ways to measure the improvement of quality and safety include setting

quality and safety goals, and participating in national patient satisfaction reports.

Leadership Strategy

The problem identified in the clinical setting involves the readmissions of patients within

30 days of discharge for Heart Disease and Pneumonia. These are the top two readmissions at

Spectrum Health Kelsey Campus (SHKC) and are subject to comparison with the national

average for cost reimbursement adjustments (McHugh & Ma, 2013). This is an important

concern for all nurses because nurses are in frontline positions promote optimal care that could

reduce these readmissions. With the implementation of the Affordable Care Act, Medicare is

reviewing these readmissions and are denying or reducing payment for the patients hospital stay

(Centers for Medicare & Medicaid Services, (CMMS), 2013). Non-reimbursement can be very

costly beginning fiscal year 2013 as data compiled from 2012 will determine these penalties

(Hines & Barndt, 2012). It has been concluded that nurse education, staffing levels, and work

environment are the three main concerns for hospital readmissions and are often preventable

(McHugh & Ma, 2013).

LEADERSHIP STATEGY ANALYSIS 4

The leadership strategy is to decrease these readmissions by 10% in a six month period.

After six months, the interdisciplinary team will reevaluate the process and make necessary

changes.

Clinical Need

The readmission of patient’s within 30 days of discharge has become a large concern for

hospitals. Spectrum Health requires anyone readmitted within 30 days to have a Previous

Admission Criteria Evaluation (PACE) form filled out (Appendix A). This form immediately

identifies potential reasons why patients return for additional care. Medicare has started a penalty

program in which if a patient is readmitted within 30 days of discharge the hospital may not be

reimbursed for these charges (Centers for Medicare and Medicaid Services, 2013). It has

become a national priority to reduce hospital admission rates. Nationally, 18-20% of those

receiving Medicare benefits are readmitted within 30 days of discharge (Sirona Health, 2013). It

has been estimated this may cost the American public more than 15 million dollars each year

(Bradley, et al., 2013). After reviewing Spectrum Health Kelsey Campus (SHKC), acute care

department admission records, it was noted that approximately 10% of SHKC patients were

readmitted within 30 days of discharge over a six-month period (SHKC, 2013). “The Patient

Protection Affordable Care Act of 2010 has created new incentives to reduce readmissions, and

hospitals with high readmissions rates can lose ≤3% of their Medicare reimbursement by 2015”

(Bradley et al., 2013). These incentives provide hospitals more money for keeping patients

healthy.

LEADERSHIP STATEGY ANALYSIS 5

Interdisciplinary Team

Members of the interdisciplinary team would include physicians, nurses, pharmacist,

social worker, respiratory therapist, physical and occupational therapist, caregiver, and dietician.

The team will develop goals to decrease the rate of readmissions within the 30 day window by

strategizing a plan of care that will follow through with post discharge care.

The admitting and primary care physicians are discharging patients too early, and there is

a lack of follow up in the primary care office (Spectrum Health Kelsey Campus, 2013). This is

most often times dictated by the rate of reimbursement of the insurance companies (Askren-

Gonzales & Frater, 2013).

The nursing staff is responsible for discharge teaching, the teach back process, and to

ensure patient understand of the discharge instructions. Failure by the nurse to complete this

process would jeopardize patient understanding and compliance. Failure with the communication

process between physicians and the nursing staff would put patient at risk for readmission.

The pharmacist is responsible to oversee medicine reconciliation forms and determine

proper antibiotic therapy. Currently, at SHKC, the pharmacist does not educate physicians

during the rounding of patients regarding the affordability and alternative options for discharge

medications, thereby decreasing the probability of compliance.

The social worker’s lack of availability after business hours and on the weekends plays a

major role in providing adequate resources that are available to the patient. Often caregivers are

not able to meet during normal business hours and the information provided by the patient may

not be what is needed by the caregiver.

LEADERSHIP STATEGY ANALYSIS 6

The respiratory therapist is responsible for educating patients on the proper use of their

inhalers, breathing techniques, and oral care following treatment. Failure to properly educate

patients on equipment maintenance with return demonstration could result in bacterial growth.

The physical therapy/occupational therapy departments are responsible to determine safe

discharge. Failure to properly educate and work with patients on energy conservation techniques

could result in decreased activity and readmission related to rebound symptoms.

The patient caregiver is responsible to see that all discharge recommendations are

fulfilled and follow up appointments are made. Failure to keep follow up appointments and fill

medication prescriptions and follow discharge instructions puts the patient at risk for

readmission.

The dietician is responsible to educate the patient on proper dietary needs and meal

planning options. Failure to take into account the patients financial and learning ability could

lead to possible complications and noncompliance. These failures may indicate the need for

readmission.

Collection Method

The leadership strategy approach to evaluate data will be to utilize the PACE form for all

readmissions with the Diagnosis Related Group (DRG), regarding heart disease and pneumonia.

This form will identify the possible reasons why the patient was readmitted within 30 days of

discharge (Appendix A). The PACE form will identify weaknesses in the discharge process

between the facility and the patient/caregiver.

LEADERSHIP STATEGY ANALYSIS 7

Established Outcomes

The initial goal is to improve discharge compliance thereby decrease readmissions by 10

percent in six months.

Increase staff awareness and education regarding discharge instructions in relation to

readmissions.

Improve staff availability to perform and enhance the discharge process

Implementation Strategies

The initial leadership strategy is to establish a new position called Community Care

Manager (CCM). This position would be filled by a bachelor prepared registered nurse who is

willing to make home visits. This position would initially be utilized in the follow up care of

heart disease and pneumonia patients. The CCM would be following up three days post

discharge with the patient and caregiver to ensure all discharge instructions were understood,

medications obtained and appointments kept. The CCM will be a liaison between the primary

care physician’s office and the patient to reinforce compliance with follow up appointment

scheduling (Askren-Gonzales & Frater, 2013). The CCM will receive copies of the PACE form

and research problematic areas using evidence based practice.

Improved communications within the interdisciplinary team members ensure all members

are aware of their roles in the patient care experience. This will improve the work environment

and increase the collaboration within the team. The process of daily rounding by the

interdisciplinary team needs to incorporate the patient being discharged as a priority. Currently,

the practice is to omit this patient from the rounding schedule. The CCM will generate a report

that will produce data to reflect the reasons for readmission. This report will be given to the

LEADERSHIP STATEGY ANALYSIS 8

departmental managers to be utilized during staff meetings as learning opportunities based on the

data provided.

Adding a case manager to assist staff with the discharge process will improve the overall

process and decrease readmissions (Askren-Gonzales & Frater, 2013). The case manager (CM)

will be a bachelor prepared registered nurse and handle all teaching required throughout the

hospital stay and discharge. The CM will work closely with the CCM and social worker in

providing an exceptional patient care experience and educational understanding.

Evaluation

The admitting nurse will have 24 hours to complete a PACE form and submit to the

CCM. The CCM will review the PACE form and evaluate for potential causes for readmission.

Data will be compiled on a monthly basis and reports generated to departmental mangers for

educational opportunities on the front lines. The CCM will meet with the patient to review the

PACE form and determine what could have been improved upon to prevent the current

admission. The CCM and CM will collaborate a plan of care to improve the patients outcome

and compliance.

Data will be collected using the PACE form to determine the number of readmissions for

heart disease and pneumonia. If there is a greater or equal to 10 percent success rate in the

strategic plan the program will deemed a success. If data reflects an unfavorable readmission

rate, the plan will be subject to reevaluation and design.

LEADERSHIP STATEGY ANALYSIS 9

Conclusion

By adding a CCM position we will have a dedicated staff member to track discharges and

make home visits as needed to further assist the patient on any unmet discharge needs and

education. The CCM will facilitate and collaborate with the primary care physician’s office to

ensure all appointments were made and or kept. The CM will work alongside the CCM to

facilitate inpatient educational needs for the patient and caregiver. These positions will work side

by side to ensure a seamless transition from admission through discharge to ensure a successful

patient recovery.

Utilizing the PACE form, an already a valued method of data recovery, will save time

and resources as staff are acclimated to its value. The rounding process is another valuable tool

already in place that the Leadership strategy has opted to keep in place. Changes to this process

will place greater emphasis on the pharmacist role to ensure the patient’s medications are

appropriate and affordable at discharge. The team will now make it a priority to see all

discharging patients whereas they were omitted in the past. By increasing the education of staff

members and patients, the goal of decreased readmissions is obtainable.

LEADERSHIP STATEGY ANALYSIS 10

Appendix A

LEADERSHIP STATEGY ANALYSIS 11

Appendix A (cont.)

LEADERSHIP STATEGY ANALYSIS 12

References

Askren-Gonzalez, A. & Frater, J. (2012). Case management programs for hospital readmission

prevention. Professional Case Management, 17(5), 221-239. Retrieved from: http://0-

ovidsp.tx.ovid.com.libcat.ferris.edu

Bradley, E. H., Curry, L., Horwitz, L. I., Sipsma, H., Wang, Y., Walsh, M. N., Goldmann, D.,

White, N., Pina, I. L., Krumholz, H. M. (January 11, 2013). Hospital strategies

associated with 30-Day reamission rates for patients with heart failure. Circulation:

Cardiovascular Quality and Outcomes Journal of the American Heart Association.

doi:10.1161/circoutcomes.111.000101

Centers for Medicare & Medicaid Services (2013). Retrieved from

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/

Readmissions-Reduction-Program.html

Hines, P. & Barndt-Maglio, B. (February, 2012). Reducing hospital readmissions. H & HN

Daily. Retrieved from

http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8620007299

McHugh, M., & Ma, C. (2013, January). Hospital Nursing and 30-Day Readmissions Among

Medicare patient With Heart Failure, Acute Myocardial Infarction, and Pneumonia.

Research & Publications. Retrieved from

http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/hospital-nursing-

and-30-day-readmissions-among-medicare-patients.html

LEADERSHIP STATEGY ANALYSIS 13

Reference (cont.)

Sirona Health. (2013). How to prevent avoidable hospital readmissions. Retrieved from

http://offers.sironahealth.com/how-to-prevent-unnecessary-hospital-readmissions-pd-

lander?utm_source=AdWords&utm_medium=PPC&utm_term=

%23readmissions&utm_content=21557684543&utm_campaign=Readmissions&Networ

k=Search&SiteTarget=&MatchType=p&Device=c

Spectrum Health Kelsey Campus. (2013). PACE (pp. January-June). Lakeview, MI: Kathy

Vietti.

Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St Louis, Missouri:

Elsevier Mosby

LEADERSHIP STATEGY ANALYSIS 14

Grading Rubric forLeadership Strategy Analysis – Quality Improvement Process

POINTSPOSSIBLE

POINTSAWARDED

Comments

Introduction: Background and purpose for quality and safety initiatives. Discusses the leadership strategy to be performed.

55

Identify Clinical Need: Identifies a clinical activity for review. Provides an analysis of the problem using current nursing literature.

1010

Designs an Interdisciplinary Team: Identifies and analyzes the inclusion of team members involved with the problem.

1010

Data Collection Method: Chooses and designs a method of data collection. Provides support for collection method as a leadership strategy.

10

10

Establishes Outcomes: Identifies a standard of care (goal for improvement) that reflects evidence-based practice.

55

Implementation Strategies: Selects and describes a process for implementing change. Integrates theory and EBP to support the identified process.

10

10

Evaluation: Identifies and designs a method for measuring improvement. Integrates theory and EBP in analyzing improvement.

1010

Scholarship: Integrates evidence of theory, current evidence-based research and information management resources to support decisions.

10

10

Sentence structure, spelling, grammar & punctuation; APA Format

3024

Title page (-1), spacing issues (-2), heading levels (-2), misc writing errors (-1)

TOTAL POINTS 100 94