Quality Improvement

Hospital Best Practices and Recommended Strategies

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Develop a culture of excellence for quality of care and patient safety:

• Educate medical and hospital staff to build awareness and understanding of how to engage the patients
• Post patient satisfaction scores and core measures and/or Medicare Beneficiary Quality Improvement Program (MBQIP) scores in all departments and a publicly viewed area of the hospital on a weekly or monthly basis
• 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 weekly manager and department meetings and daily huddles
• Develop a “patient experience team” that reviews all scores and action plans
• Support increased IT system training and integration of IT resources into clinical operations

Improve quality of care through adoption of best practices:

• Use white boards to improve patient communication and satisfaction
• Enforce no pass zones
• Perform hourly rounding to include CEO rounding for all new admissions and CNO documenting on daily rounds. Refer to Massachusetts General Hospital’s (MGH) Understanding the P’s (2013) with sample scripts from MGH’s Hourly Safety Rounds Toolkit (2011). Also see Henry Ford Health System’s 6 P’s Fall Prevention Program.

Improve patient safety, communications and satisfaction, as well as educate patients about medications and how to manage their disease and care at home by using the IHI teach back method and tools:

• 10 Elements of Competence for Using Teach Back Effectively
• Always Use Teach Back Coaching
• Always Use Teach Back Conviction and Confidence Scale
• Making Teach-Back an Always Event
• Teach Back Observation Tool
• Engage pharmacists to visit patients to discuss medication and side effects

Improve patient and family engagement and satisfaction:

• Use Agency for Healthcare Research and Quality (AHRQ) guides to Get Started with Engaging Patients and Families to implement the transitions of care best practices, learn suggestions on how to create a supportive environment for patients and family, and understand benefits to your hospital and patients. Download AHRQ Patient Family Engagement Guide Zip File to obtain guides and a PowerPoint template that can be adopted to your hospital for staff training.
• Adopt AHRQ Patient and family engagement strategies:
• Strategy 1: Working with Patients and Families as Advisors. Download AHRQ Strategy 1 Zip File Tools to obtain sample letters, patient educational brochures, staff training materials, check list, and other templates that can be adopted to your hospital.
• Strategy 2: Communicating to Improve Quality. Download the AHRQ Strategy 2 Zip File for staff and patient communication tools.
• Strategy 3: Nurse Bedside Shift Report supports the safe handoff of care between nurses by involving the patient and family in the change of shift report for nurses. Download the AHRQ Strategy 3 Zip File tools.
• Strategy 4: IDEAL Discharge Planning provides tools to implement processes to reduce preventable readmissions by engaging patients and family members in the transition from hospital to home. Download the AHRQ Strategy 4 Zip File tools that may be adopted to your hospital to support your staff in implementing new processes.

Improve Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and quality scores:

• Participate in the AHA Hospital Engagement Network and utilize the Rural / CAH Data Collection Tool and the HEN Calculator
• Track, monitor, benchmark and report MBQIP measures, if you're a CAH, to improve quality of care and scores. Refer to the MBQIP Guide for more information.
• Track, monitor, benchmark and report Core Measures and HCAHPS to improve quality of care and scores and patient satisfaction
• Compare your hospital’s results to nearby facilities through online resources such as Hospital Compare
• Target core measures at 100% and patient satisfaction scores to being the highest score amongst competitors within the region
• Develop a script for employees with patient contact at time of discharge to promote patient surveys

Improve discharge planning and reduce readmissions by using:

• Admission criteria such as InterQual or equivalent to place patients in the appropriate level of care
• IHI SMART Discharge Protocol toolkit
• AHRQ Re-Engineered Discharge (RED) Toolkit
• AHRQ Whole-Person Assessment

Improve transitions of care:

• Create a discharge plan and transition of care process that is multi-departmental
• Provide patients the information they need to help them care for themselves when they leave the hospital by using the AHRQ Taking Care of Myself Tool and Taking Care of Myself: A Guide for When I Leave the Hospital
• Apply best practices outlined in IHI How-to Guide: Improving transition from hospital to community setting to reduce avoidable re-hospitalizations – developed as part of STAAR initiative

To reduce readmissions:

• Perform patient follow up calls within 24 - 48 hours of discharge
• Identify opportunities for improvement with IHI’s STAAR Readmissions Diagnostic Worksheet
• Prevent admissions and reduce adverse events by using Modified LACE Tool (for more information on LACE and preventable readmissions, refer to MRH Performance Improvement Network)
• Improve processes by applying tools provided in Implementation Guide to Reduce Avoidable Readmissions. Refer to the Hospital Engagement Network 2.0 (HEN2)
• Review Partnership for Patients resources and tools on readmissions and care transitions

Utilize tools to improve care management processes:

• Use CMS Abstraction & Reporting Tool (CART) to collect and analyze inpatient and outpatient data
• Use CART Training to educate staff on CART data collection 
• Use IHI Plan Do Check Act (PDCA) process to determine opportunities to improve processes
• Use Root Cause Analysis (RCA) tool to trace a problem to its origin and help determine the most appropriate action plan
• 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
• Use AHRQ’s  teamSTEPPS to optimize patient care by improving communication and teamwork skills among health care professionals to include frontline staff

Improve care management and discharge planning processes by monitoring and benchmarking key indicators:

• Number of readmissions to inpatient (IP) in 30 days or less to 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 (SNF or LTC) – 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

Improve utilization review (UR) processes by monitoring and benchmarking key 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 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 a 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