Form #1 Form #1 Baseline Needs Assessment Guide

Avoiding Readmissions in Hospitals Serving Diverse Patients

Attachment C -- Baseline Needs Assessment Guide

Baseline needs assessment

OMB: 0935-0173

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ppendix C. Baseline needs assessment guide

Study hospital:

This questionnaire is to be completed by each study hospital. Please send to RED leadership team at least one week prior to the baseline key contact semi-structured interview. It will be reviewed during this call.

1. Discharge planning process review

  • Review the current discharge process at your hospital

  • Conduct a process mapping plan for hospital discharge

  • Conduct root cause analysis for readmission events

Process Mapping: Process maps are one of the most effective ways of gaining an understanding of existing processes. Process maps are intended to represent a process in such a way that it is easy to visualize and understand. A process map is considered to be an aid for picturing work processes that show how inputs, outputs and tasks are linked.1 It has been described as being one of the “most important and fundamental elements of business process re-engineering.”2 Process maps have several benefits:3 (1) they give a clearer explanation of a process than words; (2) the process of working on maps imparts understanding of the tasks and problems faced within the organization; (3) they rapidly allow participants in individual tasks to see the entire process and help clarify their interactions with others involved; and, (4) they prompt new thinking. It is important to be sure process maps are clearly understood.4 We used the American Society of Mechanical Engineers mapping standard that is widely used in manufacturing and increasingly popular in office and service environments.

Our goal was to map the entire discharge process at BMC to determine what the process actually looks like. From this, we then began to investigate what worked, what did not, and how we could improve the process. To map the hospital discharge process, we recommend utilizing time at your weekly working group meetings and monthly advisory committee meetings. Using an iterative group process, you will explore all elements of your hospital discharge. Then using ASME process mapping standards, each step in the process should be reviewed and modeled to document how that step is currently performed. It may be helpful to create a graphic of your Process Map on poster-sized paper to review with residents, nurses, and ancillary staff, then revise it based upon their feedback. Your final process map represents the usual care received by patients at your hospital.


Anjard, R.P. (1998) Process Mapping: a valuable tool for construction management and other professionals. MCB University Press. Vol. 16, No ¾, pp 79-81.

2 Soliman, F. (1998) Optimum level of process mapping and least cost business process re-engineering. International Journal of Operations & Production Management. Vol 18, No 9/10, pp 810-816 MCB University Press.

3 Peppard, J. & Rowland, P. (1995) The essence of business process re-engineering. Hemel Hempstead: Prentice Hall, Europe.

4 Curtis, B., Kellner, M. & Over, J. (1992) Process Modeling. Communications of the ACM, September 1992, vol 35, no 9


Root Cause Analysis: Root Cause Analysis provides in-depth insight into errors that have actually occurred, in this case, preventable readmission to the hospital. The focus is primarily on systems and processes, not individual performance. We recommend conducting two sessions of Advisory Committee meetings, two hours each, for root cause analysis. Discuss the admission history of one of your frequently admitted patients and do some further, in-depth analysis into the details of each admission. Review the systems and processes that are at work to further exacerbate the patients’ medical and psychosocial social status and the resulting contact and movement through the hospital system. The second session at a monthly Advisory meeting should include the presentation of four patient scenarios by various members of our study team. Each patient scenario should be presented to the group and, together, you will address the patient and their multiple admissions using standard root cause analysis procedures. These sessions should be useful and informative in helping to determine what systemic issues and processes could be adjusted and/or improved to improve patient health and management of medical care. It should also help to identify the specific failures of the hospital discharge system and help inform an improved discharge process.



2. Re-engineered Discharge project goals, deployment timeline, and planning

  • What are your project goals? Success criteria

  • What is your projected timeline?

  • Where in hospital to implement?

  • How many hospital beds?

  • Does your hospital use an EMR?

  • What are the existing readmission rates?
















3. IT Implementation plan

  • Describe current medical record system and, if EMR used, how RED workstation can be integrated into existing EMR.

  • What specific hospital branding is requested?















4. Identify your hospital project team

  • Identify implementation team, those people representing the various constituencies (nursing, case management, hospitalists, etc).

ReEngineered Discharge Executive Sponsor: [Insert Name]

ReEngineered Discharge Project Manager: [Insert Name]

QI and Safety Organization Contact: [Insert Name]

Nursing Contact: [Insert Name]

Social Worker Contact: [Insert Name]

Outpatient Care Management Contact: [Insert Name]

Trainee Representative Contact: [Insert Name]


Others:

5. Staff Training

  • Identify who will be conducting RED discharge process, both at hospital discharge and post-discharge phone call

  • Will your hospital use existing staff or hire new staff?

  • How many staff will be necessary to provide RED?

  • What is your training timeline for RED staff?

6. Information about who your patients are:

  • Do you collect data on the demographics of your patients in regard to their race, ethnicity and language?

  • Is this information available for each patient?

  • Do you have data on the ethnic diversity of your hospital staff?

  • Are there requirements for your staff to complete CLAS (Culturally and Linguistically Appropriate Services)?




Public reporting burden for this collection of information is estimated to average 8 hours per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAppendix C
Authorwilliam.carroll
File Modified0000-00-00
File Created2021-02-02

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