Hospitals in pursuit of excellence

Reducing Readmissions: A Strategic Initiative to Look at All Preventable Readmissions and How the Hospital Can Make a Difference in the Health of the Community

Phase I consisted of developing and implementing protocols for cases presenting to the emergency department within 30 days of hospital discharge. Interventions included identifying potential readmissions during ED triage and paging key team members with every potential readmission. The teams and the ED physicians collaborated on most appropriate patient disposition, while community resources, home health and supportive services were arranged from the ED.

Phase II consisted of determining readmission risk and providing a detailed transition plan to every inpatient; contacting moderate to high-risk cases by phone post discharge to review transition plan; and promoting in-hospital pharmacy consults, referrals to home care and palliative care. A readmission flag was implemented on the computerized chart. A dashboard of metrics was developed to track progress.

Phase III featured a collaborative with key skilled nursing facilities to develop standard practice and processes. Interventions included rolling out best practice tools and reviewing handoff processes. Monthly scorecards were reviewed with all SNFs. Gatekeepers at each facility were identified. A capabilities checklist was made available for providers in the ED for the SNFs. Transfer documents were standardized and sent with each patient outlining key clinical information.

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This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)