Quality Improvement

Hospital Best Practices and Recommended Strategies

• Quality-Focused Culture
• Provider Communication and Patient Engagement
• Quality and Patient Satisfaction Scores
• Care Management
• Discharge Planning
• Care Transitions and Readmissions
• Quality Improvement Tools
• Quality Indicators and Reporting Tools
• Trainings and Examples
• SRHT Hospital Success Story

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.
  • Additional Bedside Reporting training videos

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:

• Refer to MBQIP (Medicare Beneficiary Quality Improvement Project) scores for updates on CAH data reporting
• Refer to the MBQIP Guide to understand reporting process for CAHs and use the Measure Fact Sheet to learn more about data collection
• Refer to Quality Net to learn more about inpatient and outpatient measures for PPS acute care hospitals
• Refer to CMS Hospital Value-Based Purchasing Program for more information on how payments to hospitals under the Inpatient Prospective Payment System (IPPS) are impacted based on the quality of care

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

• Utilize AHRQ and IHI evidenced-based tools to improve discharge planning and transitions of care. Use AHRQ Re-Engineered Discharge (RED) Toolkit to adopt best practice discharge planning processes. The Toolkit consists of ready to use downloadable templates to support providers in adopting best practices quickly and easily. The templates are comprehensive and include care plans, post-discharge follow-up phone call documentation and sample call scripts. Per AHRQ, hospitals that tested RED Toolkit reduced readmissions by 32%.
• Utilize Discharge Planning Process power point for a summary of CAH discharge planning requirements and proposed discharge planning rules  
• Access IHI SMART (Signs, Medications, Appointments, Results, and Talk with me) Discharge Protocol Toolkit to learn more about how to apply best practices that improve care and discharge processes
• Provide patients with discharge folders that include a discharge preparation checklist for the patient and comprehensive discharge instructions, as well as complete follow-up calls to patients within 24 to 48-hours following discharge to improve quality and patient satisfaction and reduce risk. 
• Barthel Index is a resource to assess a patient’s current activities for daily living. It can be used to assist in the decision making of needed resources in preparation for discharge.
• Use AHRQ Strategy 4: IDEAL Discharge Planning template to adopt key elements for patient and family engagement in discharge planning. Templates offer clinicians a Discharge Planning process that includes a ‘Go Home Checklist and Booklet’ to share information that patients and families need to know before discharge, and PowerPoint presentation to train staff on how to improve communication and patient and family engagement to support a smooth transition from hospital to home.
• Apply the AHRQ Teach Back technique tools to improve patient understanding and compliance and reduced readmissions. Sample scripts and templates are included.
  • Use the Teach-Back Method: Tool #5
  • Teach-Back: Intervention Patient and Family Engagement in Primary Care
  • The SHARE Approach—Using the Teach-Back Technique: A Reference Guide for Health Care Providers

Care Transitions and Readmissions

• Apply resources from the Quality Improvement Toolkit for the Emergency Department Transfer Communication (EDTC) Measure to support the transfer of critical patient information from the emergency department (ED) to other care settings
• Utilize the quick, downloadable EDTC Form
• Easily access the Readmission Tool for Data Tracking
  • Readmission Worksheet for Chart Reviews
  • Transfers/Readmissions Tracking
  • Care Management: Chronic Care/Transition Care Management CPT Codes
• Utilize evidenced-based tools discussed below to reduce readmissions and support smooth transitions of care along with the following actions:
  • Coordinate patient care with post-acute care and primary care services
  • Utilize a readmission risk assessment tool
  • Ensure that all transfers and readmissions are tracked and aggregated for trending analysis for performance improvement
  • Establish communications between hospital and home health for improved patient care transitions
  • Meet with patients prior to discharge to ensure patients understand their care plan and what services they will be receiving before they leave the hospital.
• Develop and market swing bed program to support transitions of care, drive inpatient rehabilitation services and generate increased reimbursement
• Promote swing bed program to area providers and case managers other local and regional hospitals
• Educate physicians and area providers on the appropriate use of swing bed program
• Review Partnership for Patients Readmissions and Care Transitions for evidenced-based models that reduce readmissions and improve the transition of care
• Implement the evidence-based strategies from AHRQ’s Designing and Delivering Whole-Person Transitional Care Guide to reduce readmissions and provide effective transitional care, particularly for the adult Medicaid population
• Use AHRQ’s Tool 2 Readmission Review for determining, from the patient’s perspective, issues that occurred, between discharge and readmission.
• Adopt AHRQ downloadable Taking Care of Myself: A Guide for When I Leave the Hospital Guide to your hospital to ensure staff provides patients the information they need to help them care for themselves when they leave the hospital. This ready to use guide assists staff by outlining key information that ensures a smooth transition of care, as well as communicates important information to the patient in an easy to understand manner.
• Use IHI’s Readmissions Diagnostic Worksheet to conduct chart reviews of patients readmitted to determine opportunities for improvements to reduce readmissions
• Prevent readmissions and reduce adverse events by using Modified LACE Tool (for more information on LACE and preventable readmissions, refer to MRH Performance Improvement Network)
• Apply IHI’s STate Action on Avoidable Rehospitalizations (STAAR) framework to reduce readmissions and improve quality of care processes and refer to the following guides for recommended best practices for transferring to home health, skilled nursing facilities and other community settings
  • How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
  • How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
  • How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
• Review HRET’s Readmission Change Package for evidenced-based methods and successful practices and actionable items to help hospitals reduce readmissions.

Quality Improvement Tools

• Use IHI’s Plan Do Study Act (PDSA) framework to support process improvements and use the worksheet to determine opportunities to improve processes
• IHI Model For Improvement Video Series
• Use Root Cause Analysis (RCA) tool to trace a problem to its origin and help determine the most appropriate action plan
• What is Root Cause Analysis and Why is it Valuable? (video by Stratis Health)
• Root Cause Analysis (video by HRET HIIN Hospital Improvement Innovation Network)
• Use Lean Process planning to improve performance and measures, and gain a better understanding of the issue(s). Apply Value-Stream Mapping and 5S worksite organization, and build a lean culture with measurements

Quality Indicators and Reporting Tools

• Use the Quality Dashboard Templates or the Hospital Quality Dashboard Example and Template (Excel and Word templates) to create a tracking and reporting system for your hospital.
• Use CMS Abstraction & Reporting Tool (CART) to collect and analyze inpatient and outpatient data. Use CART Training to educate staff on CART data collection
• Track and trend all transfers to evaluate transfers for appropriateness and determine if patients could potentially be treated at the facility
• Review EDTC form checklist to achieve success in EDTC overall scores. Use the Data Specifications Manual for EDTC Measure to access tools and definitions. Refer to EDTC Resources

• Emergency Department Performance Measures

  Emergency Department Performance Measures (PDF Document - 6 pages)

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.