Reducing Readmissions CQI+ Team-Implementing Change Through the IHA Project RED Collaborative

The all-cause, 30-day readmission rates for the hospital are higher than both the state and national average for all three quality indicators (AMI, CHF and community-acquired pneumonia). In January 2011, the hospital started a new CQI+ team to implement the Illinois Hospital Association Project Re-Engineering Discharge (RED) collaborative.

Working through the CQI process steps, sub-teams created process maps for each of the six target areas: medication reconciliation, patient/family education, internal and external communication, after-discharge follow-up, discharge instructions and RED implementation.

Patient follow-up included a minimum of five phone calls during the 30-day post-discharge period. Health coaches generally make one home visit and often attend physician appointments with the patient in order to create seamless care coordination and ensure that the discharge plan of care is carried out. As a result, readmission rates in all categories are trending downward.

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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.)