Needs/Resource Assessment

Performing an Institutional Assessment of Current Care

One of the first steps to improve care is conducting a thorough survey of your current care environment, order sets, critical pathways and guidelines, and care processes central to the discharge transition process. This section contains a series of important headings under which are several questions related to that heading. You should first review the headings and determine whether these represent the critical areas of care delivery related to care transitions. Then, review the accompanying questions. Use the questions as a starting point for dialogue and discussion. You may find that some questions are more central to your organization's care transition issues than others. You may also find that there are other questions your team wants to include. These headings and questions should be used as a starting point for your team's work related to understanding your current discharge care transition processes.
Note: You might find it helpful to use process mapping when you do your assessment of selected areas of interest.

Assessment item 1: Institutional support

What is the institutional buy-in (from administration) and do you understand how your team fits into the organization’s clinical quality improvement structure and priorities? Do you have the resources available for forming a team and supporting its efforts in formulating order sets, protocols, educational programs, and metrics to optimize the discharge process?

A team working on an improvement effort this large is doomed to fail without recognition by hospital administration and medical staff committees of the importance of improving care transitions. If you haven’t already done so, First Steps, Obtaining Institutional Support, will assist you in enrolling the administration in your cause and in defining the medical staff entities to whom your team needs to report.

Assessment item 2: Presence of a multidisciplinary team to address issues

Have you formed a truly multidisciplinary team or steering committee that works on the front lines of health care delivery, as outlined in First Steps, Build a Team and Team Rules? If not, do so now! You won’t be able to complete the assessment without the knowledge of representatives from a variety of disciplines. However, you also want to be mindful of not waiting for every area to be represented prior to initiating your process. You can always add team members and review membership along the way. The key is to engage and include the key multidisciplinary stakeholders.

Assessment item 3: Reliable data flow and metrics

What is the dashboard of measures that your institution uses to assess the quality of its discharge processes?

Is the methodology for acquiring and recording discharge measures standardized and reliable (that is, are there any concerns about data integrity and accuracy)?

Are potential gaps in patient care identified in real time, or is the process retrospective?

Are the data communicated to the front-line caregivers, and if so, how? Help on data flow, formulating metrics, and presenting data is available in the Track Performance and BOOST Intervention Section.

The next assessment items relate to understanding the current status of your institution’s discharge transition processes.

Assessment item 4: Standardized discharge processes

What standardized processes for discharge transitions and monitoring already exist, particularly for older adults?

What elements of the discharge process can/should be standardized?

What elements of the discharge process need to be more customized to a specific patient population?

Visit the American Society for Quality (ASQ) website for information on process analysis tools.

Assessment item 5: Patient/family caregiver preparedness

How are patients/family/caregivers assessed regarding understanding of medical issues (ie, diagnoses, treatment, testing, and results) and follow-up plan/care?

Are there tools to assist in this process?

When does this process start?

Assessment item 6: Medication safety

How is medication reconciliation accomplished?

How are high-risk medications addressed? What kind of standardized monitoring is in place for medications that are high risk?

How is patient understanding of medication administration assessed?

How are issues related to medications and polypharmacy assessed and managed?

Assessment item 7: Follow-up care

What is the quality of the discharge communication to the outpatient follow-up clinician?

What is the timing of this communication?

How is quality assessed regularly?

Is follow-up standardized?

Are there any programs available for self-management after discharge?

How is care coordinated with the follow-up physician? What information is transmitted to the follow-up physician?

What are the most common reasons for readmission?

What is the relationship between readmission and the quality of the care transition?

Assessment item 8: Educational issues

What is the current discharge education process?

Is there a template in place for the discharge process?

Who is responsible for teaching?

Do you routinely assess the learner as part of the educational process?

Do you include information on community resources and further outpatient education if needed?

Is up-to-date and comprehensive written information provided as appropriate?

Do you have a reliable method for educating the patient whose primary language is not English?

Assessment item 9: General staff education and certification

What educational resources are routinely used to educate your staff about new topics or skills?

What resources are available to hospital staff to provide education regarding optimizing the hospital discharge transition.

Is it widely available via intra- or Internet access?

Is it interactive in the form of learner-based modules?

Are the modules tailored to nurses? Tailored to physicians and other providers?

If you are at a teaching institution, is education appropriately targeted at house staff?

Is there mandatory participation by key providers?

Is the educational program case based?

Is there any method for tracking participation or competence/understanding of the most important concepts?

How are pharmacists involved in medication safety?

Is the expertise of the pharmacist optimally used?

Have formulary issues between the inpatient and outpatient setting been identified and resolved?

Performing an institutional assessment can be daunting at first. Remember, you don’t have to fix or assess everything at once, and prioritizing an area of care is important and can narrow the scope of the initial assessment. An Institutional Assessment Tool can help you through this process.

Your team should reconvene to discuss the assessments as they become available, and review the assessments as you move to improve each of the focus areas. Some assessment assignments may require additional team member support and may need to be broken down into smaller assignments. For example, the assignment related to understanding the current discharge process will involve a variety of team members connected with different areas of the hospital.