Improvement Tools

The Discharge Patient Education Tool is a form that is completed by the provider and reviewed with patients prior to discharge to ensure they understand their discharge instructions. (Source: Society of Hospital Medicine)  — View Improvement Tool

This video reviews the four "stepping stones" to ensure good care transitions and avoid rehospitalizations. (Source: Qualis Health)  — View Improvement Tool

A free guide for health care leaders to help start the conversation about how to address avoidable hospital readmissions. It is designed to serve as a quick, simple resource by outlining four steps: 1) Examine your hospitals current state of readmissions; 2) Assess and prioritize your improvement opportunities; 3) Develop an action plan of strategies to implement; and 4) Monitor your hospital's progress (Source: Health Research & Educational Trust )  — View Improvement Tool

This site provides tools and educational resources designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities with the goal of improving care and reducing the frequency of potentially avoidable transfers to the hospital. (Source: Florida Atlantic University)  — View Improvement Tool

A DVD, "Putting Quality into Practice: Physicians in Their Own Voices," features the perspectives of physicians who have adopted quality measurement and improvement tools. The doctors speak candidly about why they decided to measure their performance, and how the information empowered them to improve the care they provide to patients. (Source: The Commonwealth Fund)  — View Improvement Tool

The PRHI Readmission Briefs seek to answer questions about the use of readmission rates as a measure of the quality and efficiency of care. They address: 1. What is the "right" time frame for defining a potentially avoidable readmission? For how many days past discharge is a readmission potentially preventable, and how does this vary by condition? 2. To what extent are readmissions likely to be related to an initial admission and to what extent does this vary across diagnoses? 3. To what extent are readmissions within the domain of hospital control? 4. Are there patterns of admissions and readmissions that can help clinicians flag, and then prevent, unnecessary hospitalizations? (Source: Pittsburgh Regional Health Initiative)  — View Improvement Tool

Section One highlights four key changes to create of an ideal transition home and specifies changes that can be tested. Key references and links to resources are included.Section Two outlines a practical step-by-step sequence of activities to assist staff in testing and adapting many of the proposed changes described in Section One. Section Three includes a bibliography, annotated list of resources, and worksheets. Section Four includes case studies of two hospitals that implemented many of the key changes highlighted in this guide. (Source: Institute for Healthcare Improvement and The Commonwealth Fund)  — View Improvement Tool

This document provides information regarding current best programs and practices to reduce rehospitalizations. (Source: Institute for Healthcare Improvement and The Commonwealth Fund)  — View Improvement Tool

This document is a survey of the published literature regarding the effective interventions to reduce avoidable rehospitalizations. (Source: Institute for Healthcare Improvement and The Commonwealth Fund)  — View Improvement Tool

This video describes an approach taken in Washington State's Whatcom County--involving a hospital, the state's QIO, and community providers--to improve care transitions and avoid rehospitalizations. (Source: Qualis Health)  — View Improvement Tool

You'd be hard pressed to find anyone working in a hospital who'd say, "Yes, we really want Mrs. Jones to be back here a few days after she's been discharged, running a fever, suffering complications from surgery, and now needing to be readmitted so we can run more tests." And yet, scratch the surface of even the most dedicated hospital these days, working hard on sending people home with appropriate information, support, and planning… and you'll find someone working late who's been asked to come up with the business model that's going to replace all the lost revenues when those "unwanted" readmissions are reduced! (Source: Institute for Healthcare Improvement)  — View Improvement Tool