Chair Files

Mobilizing the Workforce to Reduce Readmissions

“Every staff member counts” and “every patient counts.” With this mantra, AllianceHealth Pryor in Pryor Creek, Okla., has reduced readmissions and improved responsiveness to patient needs. Goals for the hospital’s readmissions reduction project included improving collaboration between case managers, physicians and nurses to initiate best-practice readmission strategies; better engaging patients in discharge planning; and reducing arrival-to-exam wait times in the emergency department. The hospital focused on ensuring engagement and accountability by leadership, particularly for leadership rounding and interdisciplinary safety huddles, and increasing transparency and communication with all staff. The hospital used AHA/HRET Hospital Engagement Network (HEN) tools to educate physicians, case managers and nurses on best practices. Teams began conducting discharge planning and call-backs on 100 percent of inpatients. Three tools—adult high-risk screening tool, discharge planning evaluation, and patient information and choice form—were used to screen patients, upon admission, for high-risk readmissions. Hiring a navigator provided support to improve discharge planning and processes. The navigator assists patients after discharge, following up with physician offices, clinics, and rehabilitation, home health and other services, while maintaining communication with the patient, family and health care providers. The navigator also continually monitors patient satisfaction and the patient experience. Readmissions at AllianceHealth Pryor decreased from 8.16 percent in the fourth quarter of 2015 to zero in April and May 2016. Cost savings were approximately $132,000.

For more information, contact Beverly Pickett, facility compliance officer and director, quality-risk management, at A storyboard about this project is available on the AHA/HRET HEN website at


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