APPLICANT INFORMATION Hospital/Institution affiliation First Name Last Name Degree 1 Degree 2 Address Mailbox City State Postal Code Phone Phone Extension Are you or is key member of your team an SHM member in good standing? (A Hospitalist is preferred as a team lead, but not required) Years in practice Do you have training in quality improvement (QI)? If yes, please describe Are you now or have you been active in QI work, either within your hospital medicine group or at the hospital where the Discharge Transition Improvement effort will be implemented? (please check all that apply) Do you serve on or chair any medical staff committees at the hospital where the Discharge Transition Improvement effort will be implemented? (please check all that apply) QI leader for hospitalist/medical group QI leader for hospital Participant in QI projects led by others ne Quality Safety Pharmacy and Therapeutics ne
Who is your employer? How long have you worked at the hospital where the Discharge Transition Improvement program will be implemented? How much of your time do you spend working at the hospital where the Discharge Transition Improvement program will be implemented? (Include clinical and nonclinical work.) Please provide the name and specialty/discipline of additional members of your team (up to three) Please rate your interest in eventually submitting your Discharge Transition Improvement effort for publication in a peer reviewed journal Hospital or hospital corporation Academic institution Hospital medicine or multi-specialty group that contracts with hospital Independent hospitalist 1. Name Discipline/specialty 2. Name Discipline/specialty 3. Name Discipline/specialty interest Some interest Very interested Consider this a mandatory component of effort HOSPITAL INFORMATION Hospital Name: Address Mailbox City State State Type of facility (please check all that apply) Is the facility part of a system? If yes, system name Do you have medical or surgical housestaff at your hospital? Number of staffed beds University medical center Community teaching hospital Community hospital (non-teaching) County or Publicly-funded Safety Net Hospital Veterans Affairs (VA) hospital 2
Which types of units does the hospital have? (please check all that apply) Does the hospital have computerized physician order entry? Does the hospital have an electronic health (medical) record? Has Discharge Transition Improvement been recognized as a QI or safety priority by clinical or administrative leaders at your site? Please describe the status of Discharge Transition Improvement efforts at this site If no program is in place, have there been prior attempts to improve the discharge transition at the hospital? How/where did you first hear about Project BOOST? Acute care Skilled nursing facility Rehabilitation unit Behavioral health unit formal program in place Thinking of launching a QI project Active QI project, intervention not yet implemented Active QI project, intervention implemented SHM Web-site home page SHM Care Transitions Resource Room Email from SHM SHM Annual Meeting The Hospitalist Word of mouth/colleague NEEDS ASSESSMENT QUESTIONS Note: It is NOT required or expected that applicants will have completed the processes outlined in sections 1 through 8. However, please answer each question so we have an accurate description of your current program. Section 1: Institutional Support Are senior clinical/administrative leaders aware of your project? Is your project linked to the hospital s medical staff committee reporting structure? Is your project receiving support from any hospital departments (i.e., QI Department staff are assisting with development, implementation, and evaluation tasks)? Briefly summarize the institutional support that has been offered or provided to your project. Section 2: Project Team Have you assembled your project team? 3
If yes, please indicate which roles/disciplines are represented (please check all that apply) If Other please describe Briefly summarize the strengths and weaknesses of your project team Facilitator/QI expert Discharge Transition Expert Hospitalist (any in addition to team leader) Senior hospital administrator Pharmacist QI staff Informatics Nurse supervisor/manager Staff nurse Social work Case manager Section 3: Goals, Aims and Scope Has your team developed specific goals and aims? Do you have a goal that addresses rates of patient understanding? (i.e., "we will ensure X% of our patients are able to demonstrate understanding of their discharge diagnosis, follow-up plans, etc.")? Do you have a goal that addresses reduction in the rate of 30 day hospital readmission (i.e., "we will reduce by XX% the rate of 30 day hospital readmission among our target patients")? Are your goals time-specific (should be achieved by a specific date)? Have you defined the scope of your project (which hospital units or patient populations you will focus on)? Please indicate which hospital units you will focus on? Medical wards Surgical wards If Other please describe If you are focusing on surgical units, which patient populations are you targeting? (please check all that apply) If Other (please describe) Briefly summarize your project goals and the process used to develop them Cardio-thoracic surgery patients General surgery patients Neurosurgery patients Orthopedic patients Otolaryngology patients Transplant surgery patients Urology patients Vascular surgery patients Section 4: Process Mapping and Redesign 4
Have you mapped the current processes for discharging patients from your hospital? Have you redesigned any of those processes? Briefly summarize your process map findings, and any redesign work you have done. Be sure to mention any high-leverage points you identified (i.e. areas where you ll get the most bang for your buck from redesign). Section 5: Risk Assessment and Intervention Recommendations Have you selected a rehospitalization risk assessment model (a protocol or algorithm for identifying patients at increased risk for rehospitalization)? If yes, have you developed recommendations for different levels of risk? Briefly summarize any work you have done to develop a risk assessment model and recommendations. Section 6: Order Sets and Protocols Have you developed any specific discharge order sets or protocols that encourage initial assessment of patients risk for rehospitalization or adverse events post-discharge? Have you developed any specific discharge order sets for patient education? Have you piloted your order sets or protocols? Briefly summarize any work you have done to develop order sets or protocols related to the discharge process. Section 7: Measurement Have you collected baseline data describing any of the following (check all that apply)? Have you determined how all data of interest will be collected or accessed, where it will be stored, how it will be analyzed, and who will be responsible for those tasks? Patient Satisfaction with Discharge 30 day rehospitalization rates Length of stay Patient knowledge of discharge instructions Primary care provider access to discharge summaries 5
If you have implemented your project, are you monitoring any of the following? (please check all that apply) If you have implemented your project, are you using run charts or statistical process control charts to monitor process or clinical outcomes? Have you determined which stakeholders will want to see data describing project outcomes, and when and how you will report to them? Briefly summarize your data collection, management, analysis and reporting efforts. Patient satisfaction with discharge process 30 day rehospitalization rates Length of stay Patient knowledge of discharge instructions Nursing time involved with discharge process Primary care provider access to discharge summaries Section 8: Education and Outreach Have you measured baseline MD and hospital staff awareness of the need to assess patients risk of rehospitalization and provide appropriate interventions and follow up? Have you undertaken any educational efforts aimed at raising MD and hospital staff awareness of the need to improve the discharge transition process? If you are using new order sets or protocols, have you taken steps to orient MDs and hospital staff to your intervention(s)? Briefly summarize your education and outreach efforts, in particular efforts to promote awareness and buy-in from opinion leaders or skeptics. Section 9: Summary Assessment Strengths: List the attributes of your hospital or project team that will help you achieve your goals. These might be the personnel who are participating or leading the project, a culture that supports quality improvement, strong senior leader motivation to address this issue at this time, etc. Weaknesses: List the aspects of your hospital or project team that might impede or prevent your success. This might be lack of protected time to pursue the effort, a history of failed attempts to improve the discharge process, strong opposition from opinion leaders or other stakeholders, etc. What have been your successes to date? Please describe any significant barriers your project has encountered. Is there anything else you would like to tell us? 6
Please submit your final application online via the Project BOOST application site: www.hospitalmedicine.org/boostapplications Letter of support can be e-mailed or faxed to Lauren Valentino at the Society of Hospital Medicine: Lauren A. Valentino F: 215-351-2536 E: Lvalentino@hospitalmedicine.org 7