1. Identify high risk patients
Aim
Primary Driver
Secondary Driver
Tools/Change Ideas
Risk assessment
Identify high risk patients
Risk stratification
Patient/caregiver knowledge of medication, symptoms, self-care strategies
Self-management skills
Driver diagrams are a type of structured logic chart with three or more levels (see example above). These would include:
1. A Goal or Aim (Reduce Readmissions by 20%)
2. The high-level factors that you need to influence in order to achieve this goal (Primary Drivers)
3. Specific projects and activities that would act upon these factors (Secondary Drivers)
Attached to this Driver Diagram are some Tools/Change Ideas associated with the Secondary Drivers. These are tools shared by hospitals in a previous readmissions cohort or public tools which may be helpful to you.
We encourage you to create your own Driver Diagram to assist you in mapping out where your focus areas are once you have identified your aim and patient population that you will be focusing on. You can also imbed your tools and tests of change into this diagram to create a roadmap of your readmissions journey and the tools/change ideas you are implementing.
To access any of the Tools/Change Ideas please right click on them, go to “Document Object” and click open.
Reduce Readmissions by 20%
Use of Teach-Back to validate understanding
Create a patient-centered record
Coordination of information across the care continuum
Adequately communicate to members of the care team who are not hospital based
Use a concise, standardized discharge transfer form
Timely follow-up with PCP and other providers
Adequate follow-up and community resources
Post-discharge calls and visits
Consider medical home capabilities