Reducing Readmissions Through Follow-Up Appointment-RPI Project Charter

RPI Project Charter - Readmissions

Pdf Summary

This document is a project charter (created 2/24/2021 by Josee Gill, DNP, RN) to reduce 30-day Medicare/Medicaid readmissions for patients with COPD, CHF, pneumonia, and AMI across inpatient units. The problem is an elevated rolling readmission rate of 16.19% (Nov 2019–Oct 2020), above the CMS goal (≤15.5%). Readmissions negatively affect patient outcomes (including increased mortality risk), patient satisfaction, hospital reputation, CMS star ratings, and reimbursement. Finance estimates the facility’s 2020 readmission-related costs at about $193,034, with risk of denied claims contributing to lost revenue.<br /><br />The primary SMART goal is to decrease overall 30-day readmissions for COPD/pneumonia/AMI/CHF patients on all inpatient units from 16.19% to under 15% (a 1.9% improvement) by 7/01/2021. A secondary goal is a 20% relative reduction in reimbursement losses by 10/01/2021. The project emphasizes cost avoidance and must be budget neutral.<br /><br />Scope includes inpatient units, registered nurses, and case management on all shifts/days, beginning at inpatient admission and ending 30 days post-discharge. Exclusions are the Emergency Department, Women’s Services, and the observation unit. Key stakeholders include the CNO (sponsor), a Master Black Belt (mentor), a Green Belt financial leader, patient safety and patient-centric staff, and subject matter experts such as the Director of Case Management and Director of Quality (process owner).<br /><br />Milestones follow a DMAIC timeline: kickoff 2/25/21, define 3/26/21 (charter signed), measure 4/05/21 (baseline obtained), analyze 5/05/21 (root causes validated), improve 6/07/21 (pilot), and control 7/05/21 (sustainability plan). The primary metric is readmission rate (%), with a “defect” defined as readmission within 30 days despite discharge instructions.

Keywords

project charter

30-day readmissions

Medicare Medicaid

COPD

congestive heart failure (CHF)

pneumonia

acute myocardial infarction (AMI)

CMS readmission rate goal

DMAIC Six Sigma

case management and discharge planning