Quality Improvement

Hospital Best Practices and Recommended Strategies

Quality-Focused Culture

Implement the following best practices to develop an organization-wide quality-focused culture

  • CMS Conditions of Participation requires CAHs and PPS facilities to implement, maintain and evaluate their own Quality assurance / performance improvement (QAPI) program to monitor and improve patient care and incorporate quality indicator data related to hospital readmissions and hospital-acquired conditions. Best-practice rural hospitals ensure that all staff have a clear understanding of the hospital’s QAPI Plan
    • Share the hospital-wide QAPI Plan with staff
    • Provide ongoing staff education and relate staff responsibility to improve quality and drive PI.
  • Establish quality of care and patient-safety as a key strategy for the organization
  • Implement quality dashboards to monitor and communicate performance across the organization to include BOD, and medical and hospital staff
  • Track and trend quality metrics at the department level
  • Share results with all staff to drive performance across the organization
  • Post patient satisfaction and quality scores in all departments and publicly viewed areas of the hospital
  • Educate medical and hospital staff to build awareness and understanding of ways to engage the patients
  • Build accountability for all staff to provide quality patient care by establishing hospital-wide target goals for quality measures and patient satisfaction scores
  • Include quality scores and process improvement discussions in daily huddles
  • Hold quality / performance improvement meetings monthly and use dashboard to drive meetings and actions
  • Develop a “patient experience team” that reviews all scores and action plans

Provider Communication and Patient Engagement

Best practice hospitals establish a safe provider handoff method through effective communication and patient engagement. Adopt evidenced-based tools from Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ). These tools are designed as downloadable, easy to use templates that support leaders with quick adoption of best practices. These evidenced-based tools improve provider communications, engage patients and families, and support a smooth transition of care.

  • Use whiteboards and rounding to support ongoing communication with patients and family, and improve patient satisfaction.
    • Train nursing staff to perform hourly rounding to ensure patient safety and use whiteboards effectively
    • Perform daily leadership rounding and audit whiteboards for compliance (refer to Leadership)
  • Utilize IHI’s SBAR (Situation, Background, Assessment, Recommendation), Technique for Communication: Guidelines and Worksheet to standardize a method for effectively communicating the patient’s condition and issues among providers to ensure that appropriate information is transferred from one provider to another. IHI’s SBAR Toolkit includes Communication Tool, Generic Report to Physician, Scenarios, Lesson Plans, Report Competency Check Off, Poster Example, Phone Stickers Template, and Tips for Using SBAR. Access TeamSTEPPS “I Pass the Baton” for smoother communication during care transition. Utilize Ticket to Ride for procedural transfers.
  • AHRQ Strategy 1: Working with Patients and Families as Advisors helps hospitals to work with patients and families as advisors, which has shown to reduce medical errors and improve safety. This module provides hospitals with training materials and templates for ‘tell my story’ planning worksheet, confidential statements, sample letters, patient educational brochures, staff training materials, checklist and other templates such as Patient and Family Advisor Orientation Manual.
  • AHRQ Strategy 2: Communicating to Improve Quality teaches providers how to facilitate communication with patients and families. This module offers templates for patient handouts, brochures, posters to support patient communication tools and provides a checklist for clinician communication competencies, as well as PowerPoint presentation for training nursing staff on how to improve quality by adopting better communication techniques.
  • AHRQ Strategy 3: Nurse Bedside Shift Report helps clinicians to effectively perform the process to ensure a safe handoff of care between nurses by involving the patient and family, which further involves them in the care plan to support the transition from hospital to home. This model provides a sample report that the nursing staff can use and share with the family, a checklist and staff training presentation.

Quality and Patient Satisfaction Scores

Best practice hospitals track, monitor, benchmark and report quality measures and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores to improve the quality of care and patient satisfaction. To Improve Quality Scores and Reporting:

To Improve Patient Satisfaction Scores:

  • Implement the patient satisfaction committee to target improvements in patient satisfaction scores and survey response rates
  • Implement leadership patient rounds to proactively assess patient experience. Utilize Leadership Rounding Guidelines Studer for suggestions on effective rounding.
  • Educate all employees about patient perception of quality
  • Build staff awareness that the value of the organization is dependent upon improved quality and increased patient satisfaction relative to reduced utilization and costs in care
  • Train all employees on patient satisfaction by focusing on HCAHPS survey questions and applying communication techniques based on the concepts of the questions
  • Develop a script for employees with patient contact at the time of discharge to promote patient surveys (refer to AHRQ Re-Engineered Discharge (RED) Toolkit and Teach Back tools below for sample scripts)
  • Market high quality and patient satisfaction scores to build awareness of quality services
  • Access Hospital Compare to review your hospital’s patient satisfaction scores as compared to other regional facilities on a regular basis for strategy development

Care Management

  • Use admission criteria guidelines such as McKesson's InterQual Decision Support, Care Guidelines from MCG Health or equivalent to determine the appropriate level of care for the patient. Patients placed in the appropriate level of care at admission may improve patient satisfaction and reimbursement, and reduce denial rate.
  • Have case manager or clinical documentation specialist that is trained on admission criteria to review admissions and advise on the appropriateness of the level of care
  • Provide training to clinical staff on admission criteria to ensure patients are placed in the appropriate level of care after hours and on the weekends
  • Hold daily interdisciplinary team huddles to discuss patient treatment plans, referrals to community health care services and medication review
  • Access CMS document Care Management Services in RHCs and FQHCs-Frequently Asked Questions for information regarding covered services

Discharge Planning

Care Transitions and Readmissions

Quality Improvement Tools

Quality Indicators and Reporting Tools

Care Management and Discharge Planning Indicators

  • At a minimum, track the number of readmissions to inpatient (IP) in 30 days or less to and include:
    • Number of readmissions from an acute discharge
    • Number of readmissions from a swing bed discharge
    • Number of readmissions from a home discharge– no home health
    • Number of readmissions from a nursing home discharge (skilled nursing facility or long-term care) – total and by nursing facility
    • Number of readmissions from a Home Health discharge – total and by Home Health system
    • Number of patients discharged with palliative care or hospice

Utilization Review (UR) Indicators

  • Number of admissions and days for IP and Observation
  • Average Length of Stay (ALOS) for the fiscal year to date (FYTD) for all payors and Medicare only for both acute and Observation
  • Percentage of patients placed in the correct level of care at arrival
  • Number of patients changed from IP to Observations and vice versa
  • Number of patients and days not meeting any criteria
  • One day IP stays due to first MN being in the emergency department (ED) or Observation
  • One day IP stays that were admitted to IP and remained as IP until discharge the next day
  • Day in overage (past Geometric Mean Length of Stay (GMLOS))
  • Number of patients who were provided HINN letters for non-coverage
  • Percent of patients who did not receive the Important Medicare Message (IMM) for IP and Observation Status letter for others

SRHT Hospital Success Story

Delta Memorial Hospital in Arkansas shares ways they utilized the recommendations from their Small Rural Hospital Transition Project (SRHT) Quality Improvement Project.


This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,560,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.