Measure Name: 30 Day Readmissions Modified Root Cause Analyses Measure Description: Once the hospital has identified potentially preventable readmissions, it is expected to conduct an in-depth review of the discharge planning process for a sample of such readmission (at least 10% of potentially preventable readmissions, or 15 cases/quarter, whichever is larger is suggested but not required), in order to determine whether there was an appropriate discharge planning evaluation, discharge plan, and implementation of the discharge plan. Having identified factors that contribute to preventable readmissions, hospitals are expected to revise their discharge planning and related processes to address these factors. Type of Measure: Quality Assurance Results Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD 100% 100% 100% 100% 100% Target FY2017 100% 100% 100% Actual Data Analysis: There were two 30 day readmissions in 1Q2018. One readmission was due to a patient needing medical hospitalization and was transferred to a medical hospital. She was discharged to the hospital on 7/19/17 and admitted back to DDPC on 7/25/17. Per social work discharge planning procedure 5-1: If the patient is not readmitted in the allowed time (72 hours), then the discharge order becomes permanent and a Release Plan will be required. The second readmission was on 7/5/17 when a patient refused to continue medication compliance after release back to Penobscot County Jail on 6/9/17. The medication prescribed was on the jail formulary and the only interruption within this discharge was reported by the jail administrator that the administration and medical departments were not notified that this inmate was returning. An internal review was done regarding this situation. It was established that contact was made by the Forensic Liaison with Penobscot County Jail Transport Department. That Transport Department did not notify administration or medical departments that they were doing so. Nothing was found stating that there was clinical hand-off by the hospital to the jail. Medications were given to corrections staff, but not passed on directly to the medical department at the jail. Action Plan: A procedure for Forensic Discharge Planning will be developed to address forensic patients returning to jail. Educating the that the Forensic Liaison is there to help facilitate discharge planning needs with jail departments as needed.
Measure Name: 30 Day Readmissions Modified Root Cause Analyses Measure Description: Once the hospital has identified potentially preventable readmissions, it is expected to conduct an in-depth review of the discharge planning process for a sample of such readmission (at least 10% of potentially preventable readmissions, or 15 cases/quarter, whichever is larger is suggested but not required), in order to determine whether there was an appropriate discharge planning evaluation, discharge plan, and implementation of the discharge plan. Having identified factors that contribute to preventable readmissions, hospitals are expected to revise their discharge planning and related processes to address these factors. Type of Measure: Quality Assurance Results Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target FY2017 100% 100% 100% 100% 100% 100% Actual 100% 100% Data Analysis: There were two 30 day readmissions in 1Q2018. One readmission was due to a patient needing medical hospitalization and was transferred to a medical hospital. She was discharged to the hospital on 7/19/17 and admitted back to DDPC on 7/25/17. Per social work discharge planning procedure 5-1: If the patient is not readmitted in the allowed time (72 hours), then the discharge order becomes permanent and a Release Plan will be required. The second readmission was on 7/5/17 when a patient refused to continue medication compliance after release back to Penobscot County Jail on 6/9/17. The medication prescribed was on the jail formulary and the only interruption within this discharge was reported by the jail administrator that the administration and medical departments were not notified that this inmate was returning. An internal review was done regarding this situation. It was established that contact was made by the Forensic Liaison with Penobscot County Jail Transport Department. That Transport Department did not notify administration or medical departments that they were doing so. Nothing was found stating that there was clinical hand-off by the hospital to the jail. Medications were given to corrections staff, but not passed on directly to the medical department at the jail. Action Plan: A procedure for Forensic Discharge Planning will be developed to address forensic patients returning to jail. Educating the that the Forensic Liaison is there to help facilitate discharge planning needs with jail departments as needed.
DDPCQuarterlyReport1Q2018.docx