Goals of Care Conversations as a Method of Coordinating Care

During 2011, the hospital joined the IHA Project Re-Engineering Discharge (RED) collaborative to reduce avoidable hospital readmissions. A Six Sigma level of 1.9 for the discharge process and medication reconciliation process showed that there was a lot of deviation. Process maps, swim-lane diagrams and numerous other continuous quality improvement plus tools were used to guide the team through a culture change.

During an 18-month project period, new processes were implemented and the hospital opened a new department, chronic disease management, to coordinate care for high risk patients to prevent readmissions for congestive heart failure, acute myocardial infarction, pneumonia and chronic obstructive pulmonary disease.

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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.)