Executive Solution Overview
Tw week 7 – ## pdsa-form.PDF – ## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx **## pdsa-form.PDF** PLAN DO STUDY ACT (PDSA) FORM Cycle #: Start Date: End Date: Project Title: State: Project Lead: Task-related; Task: Internal Process Objective of this Cycle: Develop a Change Test a Change…
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Tw week 7
– ## pdsa-form.PDF
– ## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx
**## pdsa-form.PDF**
PLAN DO STUDY ACT (PDSA) FORM
Cycle #:
Start Date: End Date:
Project Title:
State:
Project Lead:
Task-related; Task:
Internal Process
Objective of this Cycle:
Develop a Change Test a Change Implement a Change
Aim Statement (WHAT YOU ARE TRYING TO ACCOMPLISH):
Specific- targeted population:
Measurable- what to measure and clearly stated goal:
Achievable- brief plan to accomplish it:
Relevant- why is it important to do now:
Time Specific- anticipated length of cycle:
PLAN
Test/Implementation Plan (THINK ABOUT WHAT CHANGES YOU CAN MAKE THAT WILL RESULT IN IMPROVEMENT):
What change will be tested or implemented? Include how change will be conducted, who will run it, where it will be
run and when it will be run unless already noted in Aim Statement above. (If needed, include specifics on tasks,
responsibilities and due dates.)
Prediction:
Data Collection Plan (THINK ABOUT HOW YOU WILL KNOW THE CHANGE IS AN IMPROVEMENT):
What data/measures will be collected?
Who will collect the data?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 1
When will the collection of data take place?
How will the data (measures or observations) be collected and displayed?
What decisions will be made based on data?
DO
Activities/Observations:
Record activities/observations that were done in addition to those listed in plan (above):
STUDY
Questions: Copy and paste Prediction from Plan above and evaluate learning. Complete analysis of the data. Insert
graphic analysis whenever possible.
Prediction:
Learning (Comparison of questions, predictions, and analysis of data):
Summary (Look at your data. Did the change lead to improvement? Why or why not?):
ACT
Describe next PDSA Cycle: Based on the learning in “Study,” what is your next test?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 2
01. Taskrelated Task: Off
02. Internal Process: Off
03. Develop a Change: Off
04. Test a Change: Off
05. Implement a Change: Off
06. Cycle #:
07. Start Date:
08. End Date:
09. Project Lead:
10. Task:
11. State:
12. Project Title:
13. Measurable:
14. Specific:
15. Achievable:
16. Relevant:
17. Time Specific:
18. The Plan:
19. Prediction:
20. What data/measures will be collected?:
21. Who will collect the data?:
22. When will the collection of data take place?:
23. How will the data be collected and displayed?:
24. What decisions will be made based on the data?:
25. Comparison of questions, predictions, and analysis of data:
26. Summary:
27. Activities/observations done in addition to those listed in the plan:
28. Describe next PDSA Cycle:
**## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx**
Closing the Discharge Education Gap in New Jersey:
Integrating a Digital Patient Education Platform with Telehealth Follow-Up
Tiffany Williams
NU725
8/10/2025
Objective of Proposed Technology Integration
Enhance discharge education and follow-up care in New Jersey hospitals through a secure, nurse-led digital platform.
Integrate telehealth visits to reduce 30-day hospital readmissions.
Improve patient comprehension, adherence, and satisfaction while meeting NJ-specific healthcare quality goals.
Current Practice State – New Jersey
New Jersey hospitals have among the highest 30-day readmission rates in the nation, ranking 50th for all readmissions.
Readmission rates for patients discharged to skilled nursing facilities reach 26.1% vs. 17.6% nationally.
Despite NJHA’s Readmissions Reduction Program reducing preventable readmissions by 30%, communication gaps remain.
Patients report confusion about discharge instructions, medications, and follow-up plans.
Technology adoption for discharge planning and patient engagement still lags behind the national average.
Desired Future State
Early initiation of discharge education during hospitalization.
Digital access to condition-specific education materials and videos.
Scheduled telehealth nurse check-ins within 48–72 hours post-discharge.
Consistent monitoring of patient understanding and adherence using technology.
Overview of the Identified Gap
Current discharge processes in New Jersey remain fragmented and paper-based.
Desired process is continuous, technology-supported, and interactive.
Patients forget up to 80% of discharge information, contributing to preventable readmissions.
Lack of integrated technology and follow-up systems widens the gap.
Proposed Remedy
Adopt a HIPAA-compliant discharge education platform (e.g., GetWell Loop, MyChart modules).
Train NJ hospital staff on consistent patient onboarding to the system.
Schedule telehealth visits for medication review, symptom monitoring, and Q&A.
Evaluate results against NJ-specific readmission benchmarks.
Benefits of Proposed Integration
Improved patient comprehension and treatment adherence.
Reduction in 30-day hospital readmissions for NJ hospitals.
Increased patient satisfaction scores (HCAHPS).
Potential cost savings and improved quality metrics.
Implementation Plan (Who, What, When, Where, Why)
Who: Nurse educators, bedside nurses, IT support, case managers.
What: Platform setup, staff training, patient enrollment process.
When: 3-month pilot program, followed by 6-month evaluation.
Where: Medical-surgical units across NJ hospitals.
Why: To improve continuity of care, patient outcomes, and efficiency.
Full Spectrum Gap Analysis
Current State (High readmissions, fragmented education) → Gap (Lack of tech-supported discharge) → Desired State (Continuous, tech-integrated education) → Proposed Solution (Digital platform + Telehealth) → Expected Outcomes (Reduced readmissions, improved patient outcomes)
References
Alper, E., O’Malley, T. A., Greenwald, J., Umpierrez, G., & Aronson, M. D. (2021). Hospital discharge and readmission. Annals of Internal Medicine, 174(3), ITC33–ITC48.
Nejm, M., & Dykes, P. (2022). The impact of digital tools on patient comprehension of discharge instructions. Journal of Patient Experience, 9, 23743735221076142.
Vimalananda, V. G., et al. (2020). Electronic consultations (e-consults) to improve access to specialty care: A systematic review. Journal of Telemedicine and Telecare, 26(10), 583–595.
## image1.jpeg
**## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx**
Closing the Discharge Education Gap in New Jersey:
Integrating a Digital Patient Education Platform with Telehealth Follow-Up
Tiffany Williams
NU725
8/10/2025
Objective of Proposed Technology Integration
Enhance discharge education and follow-up care in New Jersey hospitals through a secure, nurse-led digital platform.
Integrate telehealth visits to reduce 30-day hospital readmissions.
Improve patient comprehension, adherence, and satisfaction while meeting NJ-specific healthcare quality goals.
Current Practice State – New Jersey
New Jersey hospitals have among the highest 30-day readmission rates in the nation, ranking 50th for all readmissions.
Readmission rates for patients discharged to skilled nursing facilities reach 26.1% vs. 17.6% nationally.
Despite NJHA’s Readmissions Reduction Program reducing preventable readmissions by 30%, communication gaps remain.
Patients report confusion about discharge instructions, medications, and follow-up plans.
Technology adoption for discharge planning and patient engagement still lags behind the national average.
Desired Future State
Early initiation of discharge education during hospitalization.
Digital access to condition-specific education materials and videos.
Scheduled telehealth nurse check-ins within 48–72 hours post-discharge.
Consistent monitoring of patient understanding and adherence using technology.
Overview of the Identified Gap
Current discharge processes in New Jersey remain fragmented and paper-based.
Desired process is continuous, technology-supported, and interactive.
Patients forget up to 80% of discharge information, contributing to preventable readmissions.
Lack of integrated technology and follow-up systems widens the gap.
Proposed Remedy
Adopt a HIPAA-compliant discharge education platform (e.g., GetWell Loop, MyChart modules).
Train NJ hospital staff on consistent patient onboarding to the system.
Schedule telehealth visits for medication review, symptom monitoring, and Q&A.
Evaluate results against NJ-specific readmission benchmarks.
Benefits of Proposed Integration
Improved patient comprehension and treatment adherence.
Reduction in 30-day hospital readmissions for NJ hospitals.
Increased patient satisfaction scores (HCAHPS).
Potential cost savings and improved quality metrics.
Implementation Plan (Who, What, When, Where, Why)
Who: Nurse educators, bedside nurses, IT support, case managers.
What: Platform setup, staff training, patient enrollment process.
When: 3-month pilot program, followed by 6-month evaluation.
Where: Medical-surgical units across NJ hospitals.
Why: To improve continuity of care, patient outcomes, and efficiency.
Full Spectrum Gap Analysis
Current State (High readmissions, fragmented education) → Gap (Lack of tech-supported discharge) → Desired State (Continuous, tech-integrated education) → Proposed Solution (Digital platform + Telehealth) → Expected Outcomes (Reduced readmissions, improved patient outcomes)
References
Alper, E., O’Malley, T. A., Greenwald, J., Umpierrez, G., & Aronson, M. D. (2021). Hospital discharge and readmission. Annals of Internal Medicine, 174(3), ITC33–ITC48.
Nejm, M., & Dykes, P. (2022). The impact of digital tools on patient comprehension of discharge instructions. Journal of Patient Experience, 9, 23743735221076142.
Vimalananda, V. G., et al. (2020). Electronic consultations (e-consults) to improve access to specialty care: A systematic review. Journal of Telemedicine and Telecare, 26(10), 583–595.
## image1.jpeg
**## pdsa-form.PDF**
PLAN DO STUDY ACT (PDSA) FORM
Cycle #:
Start Date: End Date:
Project Title:
State:
Project Lead:
Task-related; Task:
Internal Process
Objective of this Cycle:
Develop a Change Test a Change Implement a Change
Aim Statement (WHAT YOU ARE TRYING TO ACCOMPLISH):
Specific- targeted population:
Measurable- what to measure and clearly stated goal:
Achievable- brief plan to accomplish it:
Relevant- why is it important to do now:
Time Specific- anticipated length of cycle:
PLAN
Test/Implementation Plan (THINK ABOUT WHAT CHANGES YOU CAN MAKE THAT WILL RESULT IN IMPROVEMENT):
What change will be tested or implemented? Include how change will be conducted, who will run it, where it will be
run and when it will be run unless already noted in Aim Statement above. (If needed, include specifics on tasks,
responsibilities and due dates.)
Prediction:
Data Collection Plan (THINK ABOUT HOW YOU WILL KNOW THE CHANGE IS AN IMPROVEMENT):
What data/measures will be collected?
Who will collect the data?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 1
When will the collection of data take place?
How will the data (measures or observations) be collected and displayed?
What decisions will be made based on data?
DO
Activities/Observations:
Record activities/observations that were done in addition to those listed in plan (above):
STUDY
Questions: Copy and paste Prediction from Plan above and evaluate learning. Complete analysis of the data. Insert
graphic analysis whenever possible.
Prediction:
Learning (Comparison of questions, predictions, and analysis of data):
Summary (Look at your data. Did the change lead to improvement? Why or why not?):
ACT
Describe next PDSA Cycle: Based on the learning in “Study,” what is your next test?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 2
01. Taskrelated Task: Off
02. Internal Process: Off
03. Develop a Change: Off
04. Test a Change: Off
05. Implement a Change: Off
06. Cycle #:
07. Start Date:
08. End Date:
09. Project Lead:
10. Task:
11. State:
12. Project Title:
13. Measurable:
14. Specific:
15. Achievable:
16. Relevant:
17. Time Specific:
18. The Plan:
19. Prediction:
20. What data/measures will be collected?:
21. Who will collect the data?:
22. When will the collection of data take place?:
23. How will the data be collected and displayed?:
24. What decisions will be made based on the data?:
25. Comparison of questions, predictions, and analysis of data:
26. Summary:
27. Activities/observations done in addition to those listed in the plan:
28. Describe next PDSA Cycle:
**## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx**
Closing the Discharge Education Gap in New Jersey:
Integrating a Digital Patient Education Platform with Telehealth Follow-Up
Tiffany Williams
NU725
8/10/2025
Objective of Proposed Technology Integration
Enhance discharge education and follow-up care in New Jersey hospitals through a secure, nurse-led digital platform.
Integrate telehealth visits to reduce 30-day hospital readmissions.
Improve patient comprehension, adherence, and satisfaction while meeting NJ-specific healthcare quality goals.
Current Practice State – New Jersey
New Jersey hospitals have among the highest 30-day readmission rates in the nation, ranking 50th for all readmissions.
Readmission rates for patients discharged to skilled nursing facilities reach 26.1% vs. 17.6% nationally.
Despite NJHA’s Readmissions Reduction Program reducing preventable readmissions by 30%, communication gaps remain.
Patients report confusion about discharge instructions, medications, and follow-up plans.
Technology adoption for discharge planning and patient engagement still lags behind the national average.
Desired Future State
Early initiation of discharge education during hospitalization.
Digital access to condition-specific education materials and videos.
Scheduled telehealth nurse check-ins within 48–72 hours post-discharge.
Consistent monitoring of patient understanding and adherence using technology.
Overview of the Identified Gap
Current discharge processes in New Jersey remain fragmented and paper-based.
Desired process is continuous, technology-supported, and interactive.
Patients forget up to 80% of discharge information, contributing to preventable readmissions.
Lack of integrated technology and follow-up systems widens the gap.
Proposed Remedy
Adopt a HIPAA-compliant discharge education platform (e.g., GetWell Loop, MyChart modules).
Train NJ hospital staff on consistent patient onboarding to the system.
Schedule telehealth visits for medication review, symptom monitoring, and Q&A.
Evaluate results against NJ-specific readmission benchmarks.
Benefits of Proposed Integration
Improved patient comprehension and treatment adherence.
Reduction in 30-day hospital readmissions for NJ hospitals.
Increased patient satisfaction scores (HCAHPS).
Potential cost savings and improved quality metrics.
Implementation Plan (Who, What, When, Where, Why)
Who: Nurse educators, bedside nurses, IT support, case managers.
What: Platform setup, staff training, patient enrollment process.
When: 3-month pilot program, followed by 6-month evaluation.
Where: Medical-surgical units across NJ hospitals.
Why: To improve continuity of care, patient outcomes, and efficiency.
Full Spectrum Gap Analysis
Current State (High readmissions, fragmented education) → Gap (Lack of tech-supported discharge) → Desired State (Continuous, tech-integrated education) → Proposed Solution (Digital platform + Telehealth) → Expected Outcomes (Reduced readmissions, improved patient outcomes)
References
Alper, E., O’Malley, T. A., Greenwald, J., Umpierrez, G., & Aronson, M. D. (2021). Hospital discharge and readmission. Annals of Internal Medicine, 174(3), ITC33–ITC48.
Nejm, M., & Dykes, P. (2022). The impact of digital tools on patient comprehension of discharge instructions. Journal of Patient Experience, 9, 23743735221076142.
Vimalananda, V. G., et al. (2020). Electronic consultations (e-consults) to improve access to specialty care: A systematic review. Journal of Telemedicine and Telecare, 26(10), 583–595.
## image1.jpeg
**## pdsa-form.PDF**
PLAN DO STUDY ACT (PDSA) FORM
Cycle #:
Start Date: End Date:
Project Title:
State:
Project Lead:
Task-related; Task:
Internal Process
Objective of this Cycle:
Develop a Change Test a Change Implement a Change
Aim Statement (WHAT YOU ARE TRYING TO ACCOMPLISH):
Specific- targeted population:
Measurable- what to measure and clearly stated goal:
Achievable- brief plan to accomplish it:
Relevant- why is it important to do now:
Time Specific- anticipated length of cycle:
PLAN
Test/Implementation Plan (THINK ABOUT WHAT CHANGES YOU CAN MAKE THAT WILL RESULT IN IMPROVEMENT):
What change will be tested or implemented? Include how change will be conducted, who will run it, where it will be
run and when it will be run unless already noted in Aim Statement above. (If needed, include specifics on tasks,
responsibilities and due dates.)
Prediction:
Data Collection Plan (THINK ABOUT HOW YOU WILL KNOW THE CHANGE IS AN IMPROVEMENT):
What data/measures will be collected?
Who will collect the data?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 1
When will the collection of data take place?
How will the data (measures or observations) be collected and displayed?
What decisions will be made based on data?
DO
Activities/Observations:
Record activities/observations that were done in addition to those listed in plan (above):
STUDY
Questions: Copy and paste Prediction from Plan above and evaluate learning. Complete analysis of the data. Insert
graphic analysis whenever possible.
Prediction:
Learning (Comparison of questions, predictions, and analysis of data):
Summary (Look at your data. Did the change lead to improvement? Why or why not?):
ACT
Describe next PDSA Cycle: Based on the learning in “Study,” what is your next test?
July 24, 2014 Credit to IHI Open School for Health Professionals for original form. Modified for Telligen Use.
Revised: 02/11/2015
Page 2
01. Taskrelated Task: Off
02. Internal Process: Off
03. Develop a Change: Off
04. Test a Change: Off
05. Implement a Change: Off
06. Cycle #:
07. Start Date:
08. End Date:
09. Project Lead:
10. Task:
11. State:
12. Project Title:
13. Measurable:
14. Specific:
15. Achievable:
16. Relevant:
17. Time Specific:
18. The Plan:
19. Prediction:
20. What data/measures will be collected?:
21. Who will collect the data?:
22. When will the collection of data take place?:
23. How will the data be collected and displayed?:
24. What decisions will be made based on the data?:
25. Comparison of questions, predictions, and analysis of data:
26. Summary:
27. Activities/observations done in addition to those listed in the plan:
28. Describe next PDSA Cycle:
**## 1NJ_Gap_Analysis_Digital_Discharge_Telehealth.pptx**
Closing the Discharge Education Gap in New Jersey:
Integrating a Digital Patient Education Platform with Telehealth Follow-Up
Tiffany Williams
NU725
8/10/2025
Objective of Proposed Technology Integration
Enhance discharge education and follow-up care in New Jersey hospitals through a secure, nurse-led digital platform.
Integrate telehealth visits to reduce 30-day hospital readmissions.
Improve patient comprehension, adherence, and satisfaction while meeting NJ-specific healthcare quality goals.
Current Practice State – New Jersey
New Jersey hospitals have among the highest 30-day readmission rates in the nation, ranking 50th for all readmissions.
Readmission rates for patients discharged to skilled nursing facilities reach 26.1% vs. 17.6% nationally.
Despite NJHA’s Readmissions Reduction Program reducing preventable readmissions by 30%, communication gaps remain.
Patients report confusion about discharge instructions, medications, and follow-up plans.
Technology adoption for discharge planning and patient engagement still lags behind the national average.
Desired Future State
Early initiation of discharge education during hospitalization.
Digital access to condition-specific education materials and videos.
Scheduled telehealth nurse check-ins within 48–72 hours post-discharge.
Consistent monitoring of patient understanding and adherence using technology.
Overview of the Identified Gap
Current discharge processes in New Jersey remain fragmented and paper-based.
Desired process is continuous, technology-supported, and interactive.
Patients forget up to 80% of discharge information, contributing to preventable readmissions.
Lack of integrated technology and follow-up systems widens the gap.
Proposed Remedy
Adopt a HIPAA-compliant discharge education platform (e.g., GetWell Loop, MyChart modules).
Train NJ hospital staff on consistent patient onboarding to the system.
Schedule telehealth visits for medication review, symptom monitoring, and Q&A.
Evaluate results against NJ-specific readmission benchmarks.
Benefits of Proposed Integration
Improved patient comprehension and treatment adherence.
Reduction in 30-day hospital readmissions for NJ hospitals.
Increased patient satisfaction scores (HCAHPS).
Potential cost savings and improved quality metrics.
Implementation Plan (Who, What, When, Where, Why)
Who: Nurse educators, bedside nurses, IT support, case managers.
What: Platform setup, staff training, patient enrollment process.
When: 3-month pilot program, followed by 6-month evaluation.
Where: Medical-surgical units across NJ hospitals.
Why: To improve continuity of care, patient outcomes, and efficiency.
Full Spectrum Gap Analysis
Current State (High readmissions, fragmented education) → Gap (Lack of tech-supported discharge) → Desired State (Continuous, tech-integrated education) → Proposed Solution (Digital platform + Telehealth) → Expected Outcomes (Reduced readmissions, improved patient outcomes)
References
Alper, E., O’Malley, T. A., Greenwald, J., Umpierrez, G., & Aronson, M. D. (2021). Hospital discharge and readmission. Annals of Internal Medicine, 174(3), ITC33–ITC48.
Nejm, M., & Dykes, P. (2022). The impact of digital tools on patient comprehension of discharge instructions. Journal of Patient Experience, 9, 23743735221076142.
Vimalananda, V. G., et al. (2020). Electronic consultations (e-consults) to improve access to specialty care: A systematic review. Journal of Telemedicine and Telecare, 26(10), 583–595.
## image1.jpeg
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