®

RPI Project Charter (Belts)

Project Title: Improve Overall 30- day Medicare/Medicaid Readmissions with Created by: Josee Gill,DNP, RN
COPD/CHF/Pneumonia and AMI patients Date: 2/24/2021

Project Critical to Quality (CTQs) Factors Project Management Factors

1 Voice of the Customer 6 Project Scope
Problem Statement: (What is the problem? Where does this problem occur? How does it Process begins and ends: Begins: When patient is admitted as an inpatient to the hospital; Ends: When
impact the customer?) The hospital is seeing an increase in 30-day Medicare/Medicaid 30-day after patient is discharged
readmissions with COPD/CHF/Pneumonia and AMI patients. The cost of readmissions
in America is estimated at 41.3 billion dollars and affects 3.3 million adults. This affects Process includes and excludes: Includes: Inpatient units, registered nurses and case management, all
patient care, since readmission can cause an increase in mortality by 10% in America. shifts, all days; Excludes: Emergency Department, Women's services and observation unit.
Readmissions is impacting reimbursement with a risk of a loss of $193,034.09 in possible
denied claims for the fourth quarter of 2020.
We need to understand why we have so many patients readmitted sometimes
unnecessarily and find solutions to address the problem.
The overall readmissions rate for 30-day Medicare readmission is at 16.19% for rolling
calendar year of November 2019 to October 2020, the CMS goal is 15.5% or less.

Primary Customer: (Who is the key beneficiary of the improvement?) Hospital and Non-negotiables: Solutions implemented have to be budget neutral
secondary it is Henderson Hospital patients.
7 Goal Statements
2 Unit of Improvement: (What is being measured?) Readmission Rate (%) with a (SMART goals: specific, measurable, attainable, relevant, timebound)
numerator and a denominator Primary goal target: Decreased 30-day overall readmissions for COPD-Pneumonia/AMI/CHF on all
* inpatient units from 16.19% to less than 15%, a 1.9% improvement by 7/01/2021.

3 Defect: (What indicates it is not good enough?) Patients are readmitted within 30 days of Secondary goal target: A 20% relative reduction of reimbursement losses by 10/1/2021
discharge even after receiving discharge instructions

8 Project Plan - What & When

4 Voice of the Business What are Milestone Expectations:
Business Case Justification: (Quantify the problem. Ask 'so what?) Readmissions impacts Date When Project will be Completed:
CMS star rating and can decrease the number of stars for Henderson Hospital. 02/25/21_Kick Off-Project initiated. 5/5/21_Analyze-Root causes validated.
Readmissions also affects reputation of the hosptial. Assuring proper discharge 3/26/21 Define-Charter signed. 6/7/21 Improve-Improvement piloted.
instructions prior to patient being discharged is a significant step towards reducing 30-day 4/05/21 Measure-Baseline obtained. 7/5/21 Control-Sustainability planned.
readmissions. Increased 30 day readmissions have led to increases the risk of a loss in
revenue, patient dissatisfaction and can cause an increase in mortality. 9 Project Team - Who

Sponsor/Signature: CNO Date of signature:

Financial Opportunity: (List savings or returns if goal targets are met.) Cost avoidance
from the expenses occurred because of 30-day readmissions include increased in lost of Champion/Signature: Case Management Director , Date
revenue with reimbursements. Finance cites the total costs of readmissions for our facility
to be at $193,034.09.2.3 for 2020.
Mentor/Signature: Master Black Belt
5 Enterprise Strategic Alignment Process Owner (only if not Champion): Director of Quality
(indicate primary) Finance: CFO
_x__ Financial Project Leader(s): Green Belt
_x__patient Safety Core Team (list): Director of Medical Surgical, HUC, Case management, Hospitalist, Pharmacy staff
_x_ Patient -Centric staff, Clinical ladder nurse,
Subject Matter Experts (list): Director of Case Management