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Safety and Medicare Requirements Essay


The first SMART goal is regarding the elevated re-hospitalization rates, and how as a team we can reduce these numbers by 10% within the next six months. I chose this goal because the Medicare requirements are changing for reimbursement rates and we are a non-for profit organization where cutting down on any costs are important for not only our organization but also for our patients. Secondly, the next SMART goal I chose was how we can increase the compliance of incident reports being filled out for patient injuries, falls and infections by 10% within the next 3 months. I chose this SMART goal because this is an area in which we have been falling behind and this is an lack in compliance. Case Managers and Triage Nurses are responsible for making sure these are completed and returned to our managers in a timely manner.

Goal 1: Leadership Development

The complete Hospice Team; Social worker, CNA, Pastoral Care, Bereavement Services, RN/ Case Manager and Volunteers will all work together to achieve this goal by beginning teaching at time of admission. The Hospice team will all work together in order to make sure that the patient will die comfortably in their home with their family by their side and will do this without returning to the hospital. .We will provide the family with all of the information and support they will need in order to feel comfortable in keeping their loved one at home without returning them to the hospital. They will have access to a nurse 24 hours a day/7 days a week through our Triage line and will be reminded at each visit to use this form of communication in order to prevent re-hospitalization.

Peer-Reviewed Articles

In the article, Hospital Readmission Rates in Medicare Advantage Plans, this article speaks about the changes that CMS (Centers for Medicare & Medicaid Services) put into effect this year (2013). The changes are to establish a hospital readmissions reduction program in Medicare, when implemented, the program reduces payments to hospitals based on their readmission rates by 20% and hospital-acquired conditions or adverse events among patients with Medicare by 40%. This was a good article to explain why as a non-for profit organization, we must drop the rehospitalization rates.

Credible Websites

The website, Agency for Healthcare Research and Quality, has several tools and articles speaking of how to avoid rehospitalizations. They have materials, documents and tools called, State Action on Avoidable Rehospitalizations or STAAR. This aims to reduce avoidable rehospitalizations and is focused on how to improve transitions of care and how to address systemic barriers to reducing avoidable rehospitalizations. This is helpful and useful information to use for our SMART goal, as it provides a lot of tools we could use in reducing our rehospitalization rates.

Informational Expert

Amy Suydam RN CPS (Clinical Practice Supervisor) is over the Hospice RN/ Case Managers at our office. Amy and I discussed the SMART goal about rehospitalization rates and how we are going to decrease these rates. Amy agrees with all of the teaching with the family from admission on and making them aware of all the assistance they have available from our services. One thing she also did mention is that we could do more in-services with our staff regarding this and make sure everyone does understand the decline in reimbursement rates that we are receiving at this time compared to the costs to the organization.


In searching information regarding the rehospitalization rates and the drop of Medicare reimbursements for those stays, I was surprised to have found there was so much information regarding this and the tools that are out there also to use. My direct supervisor, Amy Suydam RN CPS, was also helpful in bringing up some things not thought of that would assist in the success of our organization in achieving our goal of decreasing rehospitalizations by 10% within the next 6 months. Amy Suydam RN CPS did not feel this was an unreasonable timeframe and decline to be looking towards. This is something we have discussed many times as our organization is non-for profit and this is very important that we follow through with our teachings and get all the information put out there that we can regarding these changes.

Goal 2: Organizational Planning

The RN/ Case Managers and Triage Nurses will increase their compliance of filling out incident reports that are being filled out by 10% within the next 3 months. The nurses will fill these out for patient falls, infections and injuries in order to be compliant with our Quality Assurance Goals.

Peer-Reviewed Articles

In the article, Introducing incident reporting in primary care: a translation from safety science into medical practice, the authors speak of how most reported incidents were ones that caused little or no injury to the patient. They found those providing care were able to deal with these incidents more actively and taking less of their time away from their other work. This explains how important it is to report any and all incidents. This is what the organizational SMART goal pertains to is making sure we are compliant in reporting everything that should be reported.

Credible Websites

The website that related to the SMART goal is called, Quality and Safety. This website provides useful tools and different ways that may be effective in reporting incidents easier which may in turn provide increased compliance. On this website they say EHR’s are the best way and more people are compliant when using the electronic reporting.

Informational Expert

Amy Suydam RN, Clinical Practice Supervisor reviewed the SMART goal and while reading through the plan of action, she declines any further recommendations. She feels everything has been covered even compared it to our policy for incident reports for our organization, and found nothing further at this time.


In researching the SMART goal of increasing compliance of filling out incident reports, it is amazing how many people are non-compliant. This can lead to legal actions at times and other problems. This is a very important part of Quality Assurance within our organization. .Will hold in-services, cover the company’s policy and explain why incident reports are filled out for and how to properly fill them out and who they are turned in to. We will strive to meet our goal of decreasing non-compliance by 10% within the next 3 months.


Qual Saf Health Care 2004; 13: 281-286 doi:10.1136/qshc.2003.009100 Marieke, & Adriana. (2013). introducing incident reporting in primary care: a translation from safety science into medical practice. Health, Risk & Society, 15(3), 265-278 doi:10.1080/13698575.2013.776014

Lemieux, Jeff. (2012). Hospital Readmission Rates in Medicare Advantage Plans. American Journal of Managed Care,18(2), 96-104
N.A. (2009). U.S. Department of Health and Human Services. Agency for Healthcare and Research and Quality. Retrieved from

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