1. ACTION ITEMS AND OUTCOMES Updated- February 2017

2. St. Joseph’s Hospital State Hospital Action Item Outcome WV
Care Transition
Improve d/c Call Back process
Working on creating a discharge call back template. Using AHRQ RED toolkit.
Started using readmission risk assessment (LACE) in December.
Creating a new admission booklet.
Recently changed HCAHPS vendor. Now using Press Ganey mailed survey (Brenda Bauer)

3. Minnie Hamilton Health System
State
Hospital
Action Item
Outcome WV
Minnie Hamilton Health System
Care Transition
Implement a process, on the Acute Care Unit, to ensure that Patient Care Summaries are forwarded to the patient’s PCP upon discharge. This will include both internal and external PCP’s.
Staff will ensure that the patient’s PCP is documented in the EHR.
Staff will utilize the EHR to select the appropriate PCP which will then populate a name, telephone number and fax number.
Staff will utilize the EHR to export information; i.e. Discharge Summary to the patient’s PCP.
Staff will check that faxed summary was completed and EHR stores this information within the system for future reference as needed.
Monitoring of process will be performed for compliance.

4. Minnie Hamilton Health System
State
Hospital
Action Item
Outcome WV
Minnie Hamilton Health System
Care Transition
Implement a process, in the Emergency Department, to ensure that Patient Care Summaries are forwarded to the patient’s PCP upon discharge. This will include both internal and external PCP’s.
This process will be the same as the Acute Care Unit. Staff in the ER will be trained on this process by the Acute Care Unit Clerk and the IT Coordinator, as needed.
Efforts will be made by staff to aid patient in the selection of a PCP in the event that the patient does not currently have one documented.
If patient refuses to select a PCP, staff will document such in the EHR.
Monitoring of process will be performed for compliance.

5. War Memorial State Hospital Action Item Outcome WV War Memorial
Discharge information to the provider
Readmissions to acute care within 30 of d/c
CMS requires discharged patient information go to the patients PCP upon discharge. The electronic medical record automatically sends the information via fax to the PCP as long as the PCP is listed and the fax number is in the system. If the PCP does not have a fax number listed the HIM department gets the discharge information via fax to be sent to the PCP.
The goal is to reduce the number of readmissions within 30 days of discharge to the facility. A team will look at the readmissions and determine ways to decrease the readmission rate for The team consists of the VP, VPMA, Case Management/UR, Medical / Surgical Clinical Manager, NP, and Director PI/Quality. This is an ongoing project aligned with the hospital’s operations plan to have readmissions within 30 days to be less than 11.0%.

6. Grafton City Hospital State Hospital Action Item Outcome WV
Pharmacy – will be involved with medication education as part of the discharge planning process. Begin utilizing “M” on the white board to identify patient’s needing education on new medications
Pushback from Pharmacist- still working on it
Use M on the board but it didn’t go well because the nurses didn’t know which medicine was new. Starting new process with medication written on board.

7. Grant Memorial Hospital
State
Hospital
Action Item
Outcome WV
Grant Memorial Hospital
Care Transitions
Implementation of Nurse Leader Rounding. Every patient will be rounded on daily by the Nurse Manager to identify any concerns the patient may have regarding their diagnosis and care needs.
Post -discharge phone calls to all patients to ensure the patient understands how to manage their care in the home setting. The patient will be contacted no later than 72 hours following discharge.
Implementation of pharmacy consults . Pharmacists will be available to provide education to patients regarding their medications prior to discharge.
Implementation of AIDET

8. Roane General Hospital
State
Hospital
Action Item
Outcome WV
Roane General Hospital
EKG times <10 minutes. Check that ED equipment times match the time of care.
Have assigned a RN to check that equipment times are synchronized.
Capital budget includes clocks that are synchronized to network.
4th quarter avg time 7 min
Carrie, Jennifer, Heather 2-23

9. Preston Memorial Hospital
State
Hospital
Action Item
Outcome WV
Preston Memorial Hospital
Care Transition
HCAHPS-Room cleanliness
Policy/Procedure to identify ED patients needing discharge planning and process for same
Monitoring ED returns within 72 hours
SBAR implementation in all clinical areas. With ticket to ride for ancillary departments.
Cleanliness scores:
Last quarter 83.3% (85th percentile)
Rolling 3 months 86.4% (95th percentile)
Discharge planning policy supports case management consult for ED physician .
Currently doing manual data collection for this measure

10. Jackson General Hospital
State
Hospital
Action Item
Outcome WV
Jackson General Hospital
ED Throughput
D/C
HCAHPS – increase
Times trending down
Failure Modes Effects Analysis
ED Steering Committee
New Discharge Planning standards implemented
Started with OP surgery patients
Hourly rounding
Setting expectations/using key words
Ask before leaving
Answering at the desk
No pass zone

11. Jackson General Hospital
State
Hospital
Action Item
Outcome WV
Jackson General Hospital
Amp up multidisciplinary rounds
Care transition
Pharmacist helps with worklist
RN and Case Management rounding with docs
MDR on how for now
Still an isssue
Looking at how the patient might be perceiving these questions
Considering addition of “custom” questions to further identify what the reasons for how the patients are responding

12. Hampshire Memorial Hospital
State
Hospital
Action Item
Outcome WV
Hampshire Memorial Hospital
Care Transition
Valley Health System-wide LEAN project was developed and continues.
Care Transition continues to be a part of the facility LEAN project on Discharge Planning.
Discharge Binders implemented
Rounding process redefined
One nurse has been designated to take care of discharges and follow-up phone calls to offer consistency in process.

13. Broaddus State Hospital Action Item Outcome WV Broaddus
Readability of discharge instructions
Acute care nurse manager reviewed as well as staff to make recommendations as to what should be updated/removed, etc. on discharge (electronic) instructions . Waiting on follow-up from IT.
Patients receive admission folders; throughout stay any disease or medication specific education is placed; very nice color-coded instructions supplied.
Daily interdisciplinary huddles working well; sense of engagement and ownership from staff; good participation
Encouragement and strong focus for nurse rounding with physician not only on inpatient units but also ED; physicians made aware of expectation

14. Boone Memorial Hospital
State
Hospital
Action Item
Outcome WV
Boone Memorial Hospital
Discharge follow-up phone calls
2. Whiteboard utilization
Form has been created. Unable to be consistent due to staff turnover, high census near or at capacity.
Positive feedback when calls
are completed.
Going well. Updated daily and at shift change.

15. Pocahontas Memorial State Hospital Action Item Outcome WV
Utilize white boards
Discharge Risk assessment
Pharmacy education on discharge and with new meds
Staff in process of designing a more useful whiteboard.
Sending information RE: whiteboard
Improved discharge summaries including assessment. Completed on all discharges for the month.
Kyna 2-23

16. Sistersville General Hospital
State
Hospital
Action Item
Outcome WV
Sistersville General Hospital
Improve IMM-2 by using visual management, re-education of data entry in CPSI to ensure all immunizations are documented/verified at each admission.
Our immunization rate was 38% for 1st quarter 2016, 2nd quarter %. 3rd quarter 2016 there were zero applicable cases to report. 4th quarter 2016 we were at 91.7%.
Trish 2-17

17. Potomac Valley Hospital
State
Hospital
Action Item
Outcome WV
Potomac Valley Hospital
Care Transition
Chosen to participate in “Achieve Project” through University of Kentucky. And “pcori”- Patient Centered Outcomes Research Institute.
Project goals are:
Identify which transitional care services and outcomes matter most to patients and caregivers.
2. Evaluate the comparative effectiveness of ongoing multi-component efforts focused on improving care transitions.
Develop recommendations on best practices for the design, implementation and large-scale national spread of highly effective, patient-centered care transition programs.
An essential component of the project is surveying patients and caregivers as they go through care transitions from the hospital to home or other post-acute setting and analyzing their healthcare utilization.