Heart Failure Readmissions: Pinpoint the Problem, Improve the Process

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Heart Failure Readmissions: Pinpoint the Problem, Improve the Process

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Reducing heart failure readmissions required an organized, comprehensive approach at Mary Washington Hospital.

The Issue

In 2008, Mary Washington Hospital (MWH) was ranked first in the state for having the worst 30-day Heart Failure (HF) All-Cause readmission rate. Inconsistent with our mission for improving the health status of the people in our community, MWH undertook efforts to reduce HF readmissions. With administrative support, a registered nurse (now the HF Program Coordinator) began taking steps to identify opportunities surrounding HF readmissions. From detailed chart review, it was discovered that the opportunities were multi-faceted and required an organized, comprehensive approach.

What We Tried

The strategy for reducing readmissions at MWH has evolved over the past several years and involved creating a formal HF Program that provides comprehensive, multidisciplinary inpatient and outpatient HF care.

Specific tactics implemented include:

  • — Creation of a formal, multidisciplinary HF team led by the HF Program Coordinator and Cardiology Medical Director.
  • — Implementation of a HF order set, protocols and processes based on ACC/AHA HF Guidelines, The Joint Commission Advanced HF Certification manual and the AHA Get with the Guidelines Program (GWTG).
  • — Development of HF patient education materials that are provided during hospitalization and used for continued education in the outpatient setting. Free scales are also provided to patients in need.
Heart Failure Patient Education and Self-Management Tools
Heart Failure Patient Education and Self-Management Tools
  • — Creation of the HF Navigator position to provide one-on-one patient education during hospitalization, identify barriers/risks with appropriate coordination of care and develop a transition of care plan.
  • — Engagement of palliative care and hospice teams to provider earlier consultation and home inotrope therapy (if indicated) during the terminal phase of life.
  • — Development of a transition of care plan that includes setting up follow-up appointments prior to discharge, home health if indicated and post-discharge callbacks within 24-48 hours.
  • — Establishment of a nurse practitioner-driven outpatient HF Clinic to provide disease management post-discharge.
  • — Performing in-depth review of every readmission to identify opportunities for improvement and developing focused action plans.


Using Midas Plus, our patient data management system, we collected 30-day readmission data for all payers. A HF readmission is defined as a readmission for any cause, within 30 days of discharge from a previous HF admission (based on the principal ICD diagnosis of HF). We achieved a 52.4% reduction in our 30-day HF All-Cause Readmission Rate from 2008 through 2014. This decrease in rate was realized by a 72.29% reduction in the actual number of readmissions in the same time period ranging from 296 readmissions per year to just 82.

In 2016, Midas Plus added an additional measure based on the requirements put forth by the CMS Readmission Reduction Program. The graph below represents readmission rates (from 2011– 2016) of patients who are 65 years or older and have Medicare. The patient volume is significantly lower, averaging 200 versus 500 per year which makes achieving lower rates more difficult. This measure also counts only one readmission per 30-day period and excludes patients who left against medical advice.

Additionally, in 2011, MWH was first in the state of Virginia to receive The Joint Commission’s (TJC) Advanced Certification in HF which has been maintained until 2015 when the decision was made to switch to TJC HF (non-advanced) Certification. MWH has also been recognized with Gold Plus status through the AHA GWTG program for the past 4 years.



“Remove blame. Be gentle on people, hard on processes.” One of our biggest discoveries was most opportunities are process, not people related. Performance improvement must be data-driven so use technology to your advantage. The importance of in-depth readmission analysis cannot be stressed enough. By pinpointing the underlying problem(s), the team can develop focused action plans to improve outcomes.

Have a process for provider accountability. Administration support is the key. Having a peer review process has been essential to addressing opportunities related to patient care and/or failure to comply with established processes/ protocols.

Be innovative. Pilot various processes until you find one that works. Engage outside resources and steal shamelessly! While an organization’s process may not work in your facility, don’t be afraid to use it as a jumping off point to develop your own version.

MWH HF Program’s work has changed the culture within our own organization. The navigator role, patient education tools, early palliative consultation, in-depth readmission analysis and peer review have all been implemented in other chronic diagnoses (i.e., pneumonia and COPD). The success of the HF Clinic also led to expansion of services to now include COPD patients.

Retrospectively, one of the greatest surprises has been how much we, as a hospital could do to reduce readmissions. Initially, it was assumed that the “problem” was mostly due to insufficient outpatient management/resources, but we realized that it truly takes a community to achieve these results.

Topics: Effective teamwork, Establishing a program, Identifying causes of readmission, Measuring and improving

Collaborator (Non-Members): Eileen Dohmann, Dr. Richard Lewis, Dr. Henry Clemo, Carol Cooke, Naynybet Ortiz, Teresa Grow, Carla Harding, Katherine (Ann) Latham, Louise Rollins, Shari Denecke, Susan O’Ferrell, Karen Randall, MaryJane Bowles, Carlos Valdez, Missi Cunningham, Christina Skinner, Teresa Walker, Stephanie Shea, Jennifer Reynolds, Renee Embrey, Lauren McKnight, Peggy Sue Collins

Organizational Background

Organization Name: Mary Washington Healthcare

Location: 1001 Sam Perry Boulevard, Fredericksburg, VA, United States

Organization Type: Hospital