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How-to Guide:
Improving Transitions from the
Hospital to Skilled Nursing Facilities
to Reduce Avoidable
Rehospitalizations
Support for the How-to Guide was provided by a grant from The Commonwealth Fund.
Copyright © 2011 Institute for Healthcare Improvement
All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses,
provided that the contents are not altered in any way and that proper attribution is given to IHI as the
source of the content. These materials may not be reproduced for commercial, for-profit use in any form
or by any means, or republished under any circumstances, without the written permission of the Institute
for Healthcare Improvement.
How to cite this document:
Herndon L, Bones C, Kurapati S, Rutherford P, Vecchioni N. How-to Guide: Improving Transitions from
the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations. Cambridge, MA:
Institute for Healthcare Improvement. June 2011. Available at www.IHI.org.
Institute for Healthcare Improvement, 2011
Acknowledgements
The Comm onwealth Fund is a national, private foundation based in New York City that supports independent
research on health care issues and makes grants to improve health care practice and policy. The views presented
here are those of the author and not necessarily those of Th e Commonw ealth Fund, its directors, officers, or staff.
The Institute for Healthcare Im provement (IHI) is an independent not-for-profit organization helping to lead the
improvement of health care throughout the w orld. Founded in 1991 and based in Cambr idge, Massachusetts, IHI
works to accelerate improvement by building the w ill for change, cultivating promising concepts for improving patient
care, and helping health care systems put those ideas into action.
Co-Authors
Laurie Herndon, RN, MSN, GNP-BC, Director of Clinical Quality, Massachusetts Senior Care Foundation,
Senior Project Coordinator INTERA CT II
Catherine Bones, MSW, Director, Institute for Healthcare Improvement
Saranya Kurapati, MD, MPH, Director, Institute for Healthcare Improvement
Patricia Rutherford, MS, RN, Vice President, Institute for Healthcare Improvement
Nan cy Vecchioni, RN, MSN, CPHQ, Vice President of Medicare Operations, MPRO
Contributors and Reviewers
The w ork of several leading experts and organizations has informed the development of this guide. We thank the
follow ing for their contributions:
Joanne Lynn, MD, MA, MS, Director, Center for Elder Care and Advanced Illness, Altarum Institute
Jane Roessner, PhD, Writer, Institute for Healthcare Improvement
Rebecca Steinfield, Improvement Advisor, Institute for Healthcare Improvement
Val Weber, Editor, Institute for Healthcare Improvement
INTERA CT II Tools, educational materials, and implementation strategies developed by Drs. Joseph Ous lander, Gerri
Lamb, Alice Bonner, Ruth Tappen, and Laur ie Herndon, and colleagues in a project supported by The
Commonw ealth Fund based at Florida Atlantic University.
Initial versions of the INTERA CT Tools w ere developed by Dr. Ous lander and Mary Perloe, MS, GNP, and colleagues
at the Georgia Medical Care Foundation w ith the support of a special study contract from the Center for Medicare and
Medicaid Services. © 2010. Florida Atlantic University
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Note: Definition of “Skilled Nursing Facility”
For purposes of this guide and in IHI’s work to improve care transitions, ―skilled nursing facility‖
(SNF) is used as an umbrella term representing several different types of care settings to which
a patient is transferred after hospitalization, including the following:

Nursing home

Skilled nursing facility

Long-term care facility

Acute rehabilitation facility

Post-acute care facility
The term ―skilled nursing facility‖ was identified by past participants in IHI programs as the most
consistent and accurate way to describe these care settings, recognizing that these
organizations offer a variety of services in addition to skilled nursing care such as short - and
long-term care, palliative care, and acute rehabilitation.
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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce
Avoidable Rehospitalizations
Table of Contents
I. Introduction
p. 1
II. Getting Started
p. 7
Step 1. The SNF Administrator Serves as the Executive Sponsor and p. 7
Selects a Day-to-Day Leader
Step 2. The Executive Sponsor Convenes a Cross-Continuum Team
p. 8
Step 3. The Team Identifies Opportunities for Improvement
p. 10
Step 4. The Team Develops an Aim Statement
p. 12
III. Key Changes
p. 15
1. Ensure That SNF Staff Are Ready and Capable to Care for the
Resident
p. 16
2. Reconcile the Treatment Plan and Medication List
p. 21
3. Engage the Resident and Their Family or Caregiver in a
Partnership to Create an Overall Plan of Care
p. 26
4. Obtain a Timely Consultation when the Resident’s Condition
Changes
p. 29
IV. Testing, Implementing, and Spreading Changes
p. 32
Step 1. Based on your learning from the Getting Started activities,
select a place to start and identify the opportunities or failures in your
current processes.
p. 32
Step 2. Use the Model for Improvement; test changes.
p. 33
Step 3. Increase the reliability of your processes.
p. 35
Step 4. Use data, displayed over time, to assess progress.
p. 36
Step 5. Implement and spread successful practices.
p. 37
V. How-to Guide Resources
p. 44
VI. References
p. 55
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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce
Avoidable Rehospitalizations
I. Introduction
Delivering high-quality, patient-centered health care requires crucial contributions from many
parts of the care continuum, including the effective coordination of transitions between providers
and care settings. Poor coordination of care across settings too often results in
rehospitalizations, many of which are avoidable. Working to reduce avoidable rehospitalizations
is one tangible step toward achieving broader delivery system transformation.
The Institute for Healthcare Improvement (IHI) has a substantial track record of working with
clinicians and staff in a variety of health care settings to improve transitions in care after patients
are discharged from the hospital and to reduce avoidable rehospitalizations. IHI gained much of
its initial expertise by leading an ambitious, system-redesign initiative called Transforming Care
at the Bedside (TCAB). Funded by the Robert Wood Johnson Foundation, TCAB enabled IHI to
work initially with a few high-performing hospital teams to create, test, and implement changes
that dramatically improved teamwork and care processes in medical/surgical units. One of the
most promising TCAB innovations was improving discharge processes for patients with heart
failure (see the TCAB How-to Guide: Creating an Ideal Transition Home for Patients with Heart
Failure for a summary of the ―vital few‖ promising changes to improve transitions in care after
discharge from the hospital and additional guidance for front-line teams to reliably implement
these changes).
IHI is now leading the groundbreaking multi-state, multi-stakeholder initiative called STate
Action on Avoidable Rehospitalizations (STAAR). The aim is to dramatically reduce
rehospitalization rates in states or regions by supporting quality improvement efforts at the front
lines of care while simultaneously working with state leaders to initiate systemic reforms to
overcome barriers to improvement. Since 2009, STAAR's work in Massachusetts, Michigan, and
Washington has been funded through a generous grant provided by The Commonwealth Fund,
a private foundation supporting independent research on health policy reform and a highperformance health system. Additionally, the state of Ohio has funded its own participation in
STAAR beginning in 2010.
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Avoidable Rehospitalizations
The Case for Improving Transitions from the Hospital to Skilled Nursing Facilities
to Reduce Avoidable Rehospitalizations
Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the
United States.1,2 Experts estimate that 20 percent of Medicare hospitalizations are
rehospitalizations within 30 days of discharge. 3 According to an analysis conducted by the
Medicare Payment Advisory Committee (MedPAC), up to 76 percent of rehospitalizations
occurring within 30 days in the Medicare population are potentially avoidable.4 Avoidable
hospitalizations and rehospitalizations are frequent, potentially harmful and expensive, and
represent a significant area of waste and inefficiency in the current delivery system.
Approximately 20 percent of Medicare beneficiaries are discharged from the hospital to a skilled
nursing facility (SNF). Poorly executed care transitions negatively affect patients’ health, well
being, and family resources as well as unnecessarily increase health care system costs.
Continuity in patients' medical care is especially critical following a hospital discharge . Research
highlights that nearly one-fourth of Medicare beneficiaries discharged from the hospital to a SNF
are readmitted to the hospital within 30 days, costing Medicare $4.34 billion in 2006.5 Adding to
this problem is the financial environment within which rehospitalizations occur. Although
preventable rehospitalizations negatively impact the health of patients, current reimbursement
structures do not incentivize efforts to reduce these rehospitalizations. Payment reform is on the
horizon, however, and future changes, such as shared savings through Accountable Care
Organizations or financial penalities for high rehospitalization rates through Medicare, will likely
focus on realigning many incentives across the health care system to support optimal patient
care.
Avoidable rehospitalizations may signal a failure in hospital discharge processes, patients’
ability to manage self-care, and the quality of care in the next community settings (skilled
nursing facilities, home care, and office practices).
Interventions for Skilled Nursing Facilities to Reduce Rehospitalizations
In the course of the developmental work and further testing that informed this guide, IHI faculty
discovered that the failures in care coordination between the hospital and SNF that led to
rehospitalization within 30 days after discharge fell into two main categories: those related to
care provided within the skilled nursing facility and those related to care provided during the
transition from the hospital to the skilled nursing facility.
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Problems or failures leading to rehospitalizations that are related to care within the SNF:

Inadequate level of services and staff to deal with the complexity of care (e.g., palliative
care needs, end-of-life care with supportive therapies, residents requiring IVs, failure to
recognize gradual or rapid deterioration of the resident’s condition)

Lack of advance directives, palliative care services, and other types of care that prevent
readmission to the hospital

Lack of laboratory and other diagnostic resources

Lack of interventions such as intravenous fluids

Inadequate availability and consistency of primary care providers for residents

Lack of prevention and/or early intervention (e.g., inadequate infection management)
Problems or failures leading to rehospitalizations that are related to the transition from hospital
to SNF:

Clinical instability of the resident at transfer

Lack of a shared care plan that:
o Includes the following essential care information: current status; ongoing and
future treatments; critical lab results; assessment data such as vital signs,
mobility level, and cognitive status; standard discharge information; medication
reconciliation forms that are consistent with transfer orders
o Is in a format that is useful and informative to all parties using it 6
o Is developed with input from the entire care team, including the resident and his
or her family
o Includes a mutual agreement about expectations regarding outcomes of care
(e.g., the resident and family may expect full recovery and a return to home while
care providers do not see that as a realistic outcome)
o Includes medication reconciliation and the availability of medications and other
needed services in the next care setting
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Avoidable Rehospitalizations
o Includes a discussion of advance directives and options for palliative or hospice
care needs as appropriate

Lack of an available primary provider who is familiar with the resident’s condition and
treatment

Lack of a cross-continuum team to address questions across organizational boundaries
regarding the quality of transfers (e.g., ―Who do I call when a transition did not go as
expected?‖)
Although it is helpful to consider these as two distinct categories, the problem areas are
interdependent. Certain factors, such as the preferences of the resident regarding advance
directives, influence care during the transition to and within the SNF. Conversely, addressing
issues in one setting may improve care in the other.
Through assessments in field learning sites, IHI faculty identified several defects in transitions
related to care within the hospital that directly contributed to rehospitalization within hours or
days of the transition to the SNF. These defects stem mainly from siloed care processes.
Caregivers within both settings strive to deliver the best possible care to patients, but they are
hindered by the lack of a patient-centered system that bridges care across settings. The focus
of this guide is the transition of residents from the hospital to the SNF setting and the associated
transfer of responsibility from the hospital to the SNF care team. Patients are most at risk for
experiencing gaps in care that lead to rehospitalization during the transition between care
settings. Based on a synthesis of the literature, interviews with experts, direct observations in
SNFs, and workgroups with clinicians at field sites, this How-to Guide highlights four promising
changes for an ideal transition and several other changes that merit further testing. The guide
reflects the developmental and groundbreaking work of many dedicated individuals on the quest
to better understand and address the underlying causes of rehospitalizations for residents
recently discharged to SNFs.
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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce
Avoidable Rehospitalizations
A Roadmap for Improving Transitions from the Hospital to Skilled Nursing
Facilities to Reduce Avoidable Rehospitalizations
Based on a growing body of evidence and IHI’s experience to date in improving transitions in
care after a hospitalization and in reducing avoidable rehospitalizations, IHI has developed a
conceptual roadmap (Figure 1) that depicts the cumulative effect of key interventions to improve
the care of patients throughout the 30 days after patients are discharged from a hospital or postacute care facility.
Figure 1: IHI’s Roadmap for Improving Transitions in Care after Hospitalization and Reducing
Avoidable Rehospitalizations
Key Changes
included in this
How-to Guide
The transition from the hospital to post-acute care settings has emerged as an important priority
in IHI’s work to reduce avoidable rehospitalizations. Transitions in care after hospitalization
involve both an improved transition out of the hospital (and from post-acute care and
rehabilitation facilities) as well as an activated (resident is ―actively received‖) and reliable
reception into the next setting of care such as a skilled nursing facility (SNF), home care, or
office practice. This How-to Guide is designed to support SNF-based teams and their
community partners to co-design and reliably implement improved care processes to ensure
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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce
Avoidable Rehospitalizations
that residents have an ideal transition into the SNF setting. IHI also provides separate How-to
Guides for hospitals, clinical office practices, and home care agencies:

How-to Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to
Reduce Avoidable Rehospitalizations, June 2011

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to
Reduce Avoidable Reshospitalizations, June 2011

How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce
Avoidable Rehospitalizations, June 2011
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II. Getting Started
This section lists steps to get started on creating an ideal transition for patients being transferred
to the SNF.
Step 1. The SNF Administrator Serves as the Executive Sponsor and Selects a
Day-to-Day Leader to Lead the Improvement Work
The role of the executive sponsor is to link the goals of improving transitions in care and
reducing readmissions to the strategic priorities of the organization as well as provide oversight
for their team’s work. The executive sponsor will also provide guidance for the quality
improvement initiative to achieve breakthrough levels of performance. Depending on the size
and organizational structure of the SNF, typical executive sponsors may include the SNF
administrator, director of nursing, or medical directors. When framing the improvement initiative,
executive sponsors should ask the following strategic questions for improving transitions and
reducing rehospitalizations:

Do you know the facility’s readmission rates for all residents?

Is reducing the readmission rate a strategic priority for the facility? Why?

Have you declared your improvement goals?

What will help you drive success in your quality improvement initiatives?

What initiatives to reduce readmissions are already under way or planned in your
organization, and how could they be better aligned?

How much experience do your executive leaders, mid-level managers, and front-line
teams have in process improvement? What resources (e.g., expertise in quality
improvement, data analysis) are available to support improvement efforts?

How will you provide oversight for the improvement projects, learn from the work, and
spread successes?

What other provider organizations should be engaged in this work?
An optional but highly recommended activity for the SNF administrator is to conduct a financial
analysis of the current impact of readmissions on the facility and the projected impact of
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Avoidable Rehospitalizations
reducing readmissions over the course of the initiative. Key issues to consider in this financial
analysis may include the following:
1. Financial and staffing implications of occupied versus empty beds and bed holds
2. Cost in terms of staff time, number of steps, and number of ancillary staff involved in
completing the entire discharge process as well as the entire admission process
3. Cost in terms of business staff time involved in preparing and submitting final bill(s)
4. Cost in losing rehospitalized resident to another SNF
5. Cost of unused medications and supplies that cannot be returned
6. Implications of poor patient and family satisfaction for reputation
The executive sponsor should also select a day-to-day leader who will coordinate project
activities, help to lead the cross-continuum team, and provide guidance to the front-line
improvement team(s) (see Step 4b). The day-to-day leader is often a nursing director or quality
improvement leader. Finally, the executive sponsor is responsible for eliminating or mitigating
barriers identified by the front-line/transistion teams to ensure success. A proposed system for a
strategic and successful quality improvement initiative as outlined in IHI’s white paper,
Execution of Strategic Improvement Initiatives to Produce System-Level Results, contains four
components:7
1. Setting priorities and breakthrough performance goals;
2. Developing a portfolio of projects to support the goals;
3. Deploying resources to the projects that are appropriate for the aim; and
4. Establishing an oversight and learning system to increase the chance of producing the
desired change.7
Step 2. The Executive Sponsor Convenes a Cross-Continuum Team
A multistakeholder team with representatives from across the care continuum, including
patients, family members, and caregivers, provides leadership and oversight for the initiative to
reduce readmissions and improve transitions in care after discharge from the SNF. By
understanding mutual interdependencies and identifying customer and supplier relationships at
each step of the patient journey across the care continuum, the team will codesign processes to
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improve transitions in care. Collectively, team members will explore the ideal flow of information
and patient encounters as the patient moves from one setting to the next and then home.
Recommendations for cross-continuum team members include:

Patients, family members, or other designated caregivers

Staff from the SNF, hospital, and other care settings, such as nurse managers, staff
nurses, case managers, pharmacists, or quality improvement leaders


SNF administrator
Director of Nursing from the SNF and the hospital

Physicians including the SNF Medical Director, hospitalist, and a primary care physician

Home care nurses

Palliative care or hospice nurses

Area agency on aging representatives and representatives from other social services
agencies

Staff from community-based organizations

Pharmacist (hospital and SNF pharmacist)

Case managers from health plans

Residents and families
At its first meeting, the cross-continuum team should discuss the purpose and goals of the
improvement initiatives and the team’s role in providing guidance and oversight. A suggested
initial activity for the cross-continuum team includes participation in an in-depth review of the
last five rehospitalizations (see Step 3).
Residents and families bring invaluable contributions to the cross-continuum team.8,9 For more
information on including patients and families in your cross-continuum team, please refer to the
following resources:
Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care
System: A Roadmap for the Future. Institute for Healthcare Improvement. Available at
http://preview.ihi.org/knowledge/Pages/Publications/PartneringwithPatientsandFamilies.aspx
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Tools for Advancing the Practice of Patient- and Family-Centered Care. Institute for Patientand Family-Centered Care Downloads. Available at www.ipfcc.org/tools/downloads.html .
Step 3. The Team Identifies Opportunities for Improvement
Step 3a. Perform an in-depth review of the last five residents that have been readmitted
to the hospital within 30 days to identify opportunities for improvement.
Conduct chart reviews on the last five residents that have been readmitted to the hospital
within 30 days, transcribing key information. It is recommended that SNFs utilize the
INTERACT II Quality Improvement Tool (Figure 2) for their review.
In addition, the SNF should interview the resident, family, or caregiver to identify the reasons
for readmission from their perspective. Information from the interviews should be transcribed
onto a data collection sheet; we recommend that SNFs use Worksheet B of the Diagnostic
Tool (Figure 3).
SNFs should coordinate with the hospital to obtain additional information on the readmissions
reviewed.
Figure 2: INTERACT II Quality Improvement Tool (How-to Guide Resources, page 45)
Figure 3: Diagnostic Worksheet (How-to Guide Resources, page 47)
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Step 3b. Review your organization’s resident experience data to identify opportunities
for improvement.
Evaluate trends in your organization’s resident experience data, with a focus on the informal
feedback and any survey data obtained over the last year. If your organization does not
survey residents for this information, work with your executive sponsor to develop and institute
a resident experience survey tool or other mechanisam to obtain this feedback and track this
data over time.
Step 3c. Review 30-day all-cause readmission rates to identify opportunities for
improvement.
Collect historical data and display monthly 30-day all-cause readmission rates (Figure 4) for
the SNF over time; include at least 12 months of data, preferably more. In addition to tracking
the 30-day all-cause readmission rate, SNFs may choose to also look at various segments of
the population (e.g., residents readmitted to the hospital within the first five days, residents
readmitted due to infection, residents with emergency vs. planned readmission to the
hospital).
Figure 4: Readmissions Outcome Measure: 30-Day All-Cause SNF Readmissions
Measure Name
Description
Numerator
Denominator
30-Day All-Cause
SNF Readmissions
Percent of all SNF
residents admitted
to the SNF from the
hospital who are
then readmitted to
the hospital within
30 days
Number of residents admitted
to the SNF from the hospital
who are then readmitted to the
hospital within 30 days
Total number of
residents admitted
to the SNF from
the hospital in the
measurement
month
Exclusion: planned
readmissions, hospice,
palliative care, DNRs and do
not hospitalize
See Figure 5 for a sample graph of monthly 30-day all-cause readmissions data tracked over
time.
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Figure 5: Sample Display of Baseline Readmissions Data
Step 4. The Team Develops an Aim State ment
Step 4a. Report findings from Step 3 to the entire cross-continuum team.
In the report, include the following:

Summary of chart reviews for readmitted patients (use INTERACT II Quality
Improvement Tool, How-to Guide Resources, page 45)

Summary of interviews with readmitted patients, their families, and clinicians in the
community (Diagnostic Worksheet, How-to Guide Resources, page 47)

Patient stories (summary of what was learned from the Diagnostic Review): Share the
stories of patients, families, and/or caregivers and their struggles to navigate transitions
in care between participating facilities. Such stories will resonate more deeply than
statistics and will engage the ―hearts and minds‖ of front-line clinicians and staff.

Trending data related to patient experience

Trending data for 30-day all-cause readmission rates
Step 4b. Select at least one unit or a pilot population.
Based on the review of your facility’s readmission rate(s), the front-line improvement team
selects one or more units where readmissions are most likely to occur. If there is a particular
patient population within one or more of these units that accounts for a large percentage of the
readmissions (e.g., patients with infections), then the team may want to focus its testing
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initially on this patient segment within the unit(s). Process improvements can then be further
tested and implemented for all patients on the selected unit(s).
The composition of the front-line improvement team(s) will vary from facility to facility, but
should ideally involve individuals who are actively engaged in admitting and assessing
patients, teaching and facilitating patient education, communicating essential information
during handovers, and arranging follow-up. Front-line improvement team(s) will be the
group(s) of people who initially test changes in care delivery processes on the unit. A typical
front-line improvement team includes:

A day-to-day leader for each pilot unit who will drive the work on their respective unit(s)

Patients, family members, and care givers

Physician or nurse champion

Nurse practitioner or physician assistant (if applicable)

Nurse manager/supervisor, staff nurses, case manager, certified nursing assistant,
nurse educators

Dietician

Physical therapist/occupational therapist

Social workers and/or discharge planners

Clinicians and staff from other care settings and/or community-based organizations,
e.g., home health, area agency on aging, other SNFs
Step 4c. Write an aim statement.
Aim statements communicate to all stakeholders the magnitude of the change and the time by
which the change will happen. Aim statements help teams commit to the improveme nt work.
The cross-continuum team develops a clear aim statement for reducing readmissions in the
selected units. Effective aim statements include five pieces of information:

What to improve for residents and families

Where (specific unit or entire SNF)

For which residents
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
By when (date specific deadline)

Measurable goal
Sample aim statements:
1) By December 2011, Maryfree Skilled Nursing Facility will reduce readmissions for all
residents as measured by a decrease in 30-day all-cause readmission rate from 17
percent to 13 percent or less. The Facility will focus on identifying early changes in
patients’ condition, standardized communication, and teamwork .
2) General Nursing Home will improve transitions for patients discharged from the
hospital and admitted to the nursing home as measured by a reduction in unplanned
30-day readmissions of patients from 25 percent to 15 percent or less by December
31, 2011. We will focus on coordination with hospital and assessment of changes in
the patients’ condition.
For more on setting aims, see
http://preview.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSettingAims.
aspx.
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III. Key Changes
The How-to Guide: Improving Transitions from the Hospital to Skilled Nursing and Long -term
Care Facilities to Reduce Avoidable Rehospitalizations outlines four recommendations (Figure
6): 1) ensure that SNF staff are ready and capable to care for the resident; 2) reconcile the
treatment plan and medication list; 3) engage the resident and their family or caregiver in a
partnership to create an overall plan of care; and 4) obtain a timely consultation when the
resident’s condition changes.
Figure 6: Key Changes to Complete the Transition to Skilled Nursing Facilities
1. Ensure That SNF Staff Are Ready and Capable to Care for the Resident
A.
Develop mutually agreed-upon standardized transfer criteria.
B.
Receive and confirm understanding of resident’s care needs from hospital
staff.
C.
Resolve any questions regarding the resident’s status to ensure fit between
resident needs and SNF resources and capabilities.
D.
Identify an emergency clinician contact for the resident.
2. Reconcile the Treatment Plan and Medication List
A.
Re-evaluate resident’s clinical status since transfer.
B.
Reconcile the treatment plan and medication list based on an assessment of
the resident’s clinical status, information from the hospital, and past
knowledge of the resident (if he or she was previously a resident).
3. Engage the Resident and Their Family or Caregiver in a Partnership to Create
an Overall Plan of Care
A.
Assess the resident’s and family members’ desires and understanding of the
current plan of care as well as any possible next care settings.
B.
Develop the care plan collaboratively with the resident and family.
4. Obtain a Timely Consultation when the Resident’s Condition Changes
A.
Use protocols to guide immediate interventions for conditions and
complications that commonly occur in the SNF.
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1. Ensure That SNF Staff Are Ready and Capable to Care for the
Resident
Recommended Changes:
1A. Develop mutually agreed upon standardized transfer criteria.
1B. Receive and confirm understanding of resident care needs
from hospital staff.
1C. Resolve any questions regarding resident transition status to
ensure fit between resident needs and SNF resources and
capabilities.
1D. Identify an emergency provider contact for the resident.
Flawless transitions across care settings require that all care providers share a common
understanding of the resident’s condition. Prior to transfer, an accurate and thorough
assessment of a resident’s needs based on standard criteria contributes to an effective
transition plan. This crucial step reduces the likelihood of a rehospitalization within hours or
days.
The crux of this intervention is to clearly specify what information SNF providers need in order to
care for a resident who is transitioning from hospital care to the SNF setting. Providers at the
SNF need a complete view of the resident’s clinical and functional status to assume
responsibility for the resident and appropriately plan his or her care.
Typical failures associated with ensuring that SNF staff are ready and capable to care for the
resident include:

Lack of adherence to or confusion about the transfer criteria specified by hospital staff;

Lack of complete clinical information – medications, labs, orders, additional treatments
requiring transportation (e.g., radiation therapy);

Lack of understanding of the resident’s functional health status and a failure to assess
the resident’s physical and cognitive needs (e.g., identifying underlying depression),
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which may result in transfer to a SNF facility that does not meet the resident’s needs;
and

Premature discharge from the hospital with unstable clinical condition.
How to identify your typical failures and opportunities for improvement:

INTERACT II Quality Improvement Tool (How-to Guide Resources, page 45) - Use this
tool to understand opportunities for improvement associated with acute care transfers.
Recommended Changes
1A. Develop mutually agreed upon standardized transfer criteria.
Clinicians in both settings – hospitals and SNFs – frequently work in isolation, unaware of the
information required by providers in each setting to coordinate a successful transfer. Employing
a cross-continuum team to co-design and test transfer criteria to guide the transfer process
provides a means to optimize care across settings. Form a cross-continuum team (see Section
II, Step 2: The Executive Sponsor Convenes a Cross-Continuum Team) if one does not yet
exist; commit to regular meetings and a means to efficiently address barriers. Follow these
steps to develop a standardized transfer process and standardized transfer criteria:

If possible, shadow one another in each care setting to observe the transfer process in
real time.

Together, draft a process map of an ideal transfer from the perspective of each care
setting.

Make the expectations of each care site explicit rather than assumed. The key is to ban
assumptions – if needs and requests are not specified, process failures will likely occur.

Develop ―standardized transfer criteria‖ with your colleagues in the other setting to help
guide the transfer process; ensure that each is able to provide the information
requested. For example, the staff of one SNF initially identified that they wanted to know
whether the resident they were receiving was stable when he or she left the hospital.
When pressed to specify the meaning of ―stable,‖ the director of nursing was able to
easily generate a list: no unassessed or untreated fever, no signs of recent deterioration,
oxygenation levels unchanged or improving in previous 24 hours, etc.
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
Test the criteria with the next transfer, and review what worked and what did not.
Implement a disciplined means of debriefing – such as an in-person or virtual (by phone)
huddle immediately aftewards – to capture learning in real time. For example, a debrief
may address a major frustration frequently reported by SNFs: who to call to problemsolve when a transfer goes poorly? Waiting until the next meeting sacrifices the
immediate rich learning that can take place.
Tips for Testing
In developing the transfer criteria and process, keep in mind that the transfer may need to be
timed to the availability of certain special skills within the SNF. For example, the transfer may
need to occur on a day/time when the physician will be in attendance or when the wound care
nurse is in the building.
1B. Receive and confirm understanding of resident care needs from hospital staff.
Clinicians in the SNF, who are accountable for the execution of the care plan following the
resident’s transfer from the hospital, should be involved when the inpatient care team formulates
the transfer and transportation plan. When the transfer plan is being formulated, and based
upon the standardized transfer criteria, providers at both the hospital and SNF should complete
the following steps:

Collaboratively plan and communicate the details of the resident’s transfer via phone or
in person, including the expected time of transition.

Review the resident’s current clinical and functional status.

Ensure understanding of care needs and details required to implement immediate care
needs (e.g., some SNFs cannot access new medication orders after 7 PM) :
o Have SNF and hospital staff use common transfer communication techniques,
such as SBAR or read-back-and-confirm, to confirm mutual understanding.

Compare the resident’s current status to the transfer criteria and resolve discrepancies
and questions (e.g., the transfer criteria require a stable oxygenation status, but the
resident’s oxygenation levels have decreased over the past six hours) .

Revise the standardized transfer criteria and transfer process as needed, as clinicians
from both the hospital and SNF learn improved transfer processes.
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Tips for Testing:

Treat each transfer as an opportunity to learn new ways to care for residents. After each
transfer, the SNF nurse should debrief (either via live conversation or virtually) with the
transferring nurse from the hospital to identify the elements of the transfer that worked
well and those that did not. The cross-continuum team can then test changes to address
problems identified during the debrief on the next transition.

SNF staff may use the INTERACT II Acute Care Transfer Log (Figure 7) to promptly
understand the resident’s situation in detail as close to the rehospitalization as possible.
Figure 7: INTERACT II Acute Care Transfer Log (How-to Guide Resources, page 48)




1C. Resolve any questions regarding the resident’s clinical status to ensure fit between
resident needs and the SNF resources and capabilities.
Gaps between the resident’s anticipated clinical status at the time of transfer and the resident’s
actual status places the resident at risk for incomplete care at the SNF. When such
discrepancies occur, SNF leaders may be unsure of whom to contact in the hospital to
understand the root cause of the discrepancy and propose solutions. An effective crosscontinuum team can mitigate this barrier. Open communication ensures a productive long-term
relationship between care settings and better patient outcomes.
Avoiding such gaps requires providers to:

Identify and discuss any concerns regarding the resident’s clinical status prior to transfer
to avoid care concerns that the SNF may not be equipped to address.

Identify gaps between the resident’s clinical status and the transfer criteria:
o Collaboratively determine whether the resident’s clinical status places that
resident at risk for complications after transfer.
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o Resolve any concerns about the resident’s status prior to transfer or defer
transfer if a stable, safe transfer cannot be ensured.
o Ensure that needed medication, treatment, and equipment (e.g., access to
dialysis, wound care, or rehabilitation) are available at the SNF .
Tips for Testing:
Start small. With the next resident to be transferred, identify problems or surprises that occur
with the transfer (e.g., missing information that would have fostered better care). Determine
whether the problems are due to gaps in the transfer criteria or gaps in the information provided
by hospital providers. Convey information about problems or surprises immediately to the
identified contact and to cross-continuum team members so they can learn about the issues and
use the resulting information to redesign the transfer process.
1D. Identify an emergency provider contact for the resident.
Residents transferred to skilled nursing care are often in fragile health with conditions that
require a well communicated plan of care. Frequently, hospital and SNF staff struggle with the
lack of an available emergency provider contact who can assist with changes in the plan of care
in a timely manner. Therefore, the team should work collaboratively to identify the name and
telephone number of an emergency clinician contact who will be available for the 24 to 48 hours
after transition to the SNF to revise the treatment plan, if needed.
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2. Reconcile the Treatment Plan and Medication List
Recommended Changes:
2A. Re-evaluate the resident’s clinical status since transfer.
2B. Reconcile the treatment plan and medication list based on an
assessment of the resident’s status, information from the hospital,
and past knowledge of the resident (if applicable).
When the resident arrives at the SNF, the care team’s attention should shift from needs
associated with the immediate transfer to updating the overall care plan, including clinical
treatment as well as plans to address functional, social, and emotional needs. An essential
component of updating the care plan should be reconciling previous acute care interventions
with the resident’s ongoing care needs. Once these needs are reconciled, the SNF staff must
ensure that all members of the care team are adequately educated, enabled, and confident to
carry out their part of the care plan.
Typical failures associated with the lack of a reconciled treatment plan and medication list
include:

Lack of a clear picture of the resident’s entire history, including the severity of the
resident’s condition and complications during hospitalization (e.g., C. difficile infection,
pressure ulcers, urinary tract infection, delirium);

Medication errors due to lack of clarity about the type, dose, and frequency of
medications or failure to resume pre-hospitalization medications;

Lack of timely delivery of medications;

Variability of insulin protocols and blood glucose trigger points for alerting physicians;

Incomplete coumadin management, delayed access to required lab results, and lack of
follow-up plans or protocol to follow;

Lack of key information from social workers, nursing staff, hospitalists, and house staff;

Lack of clear advance directives (i.e., information beyond the basic Do Not Resuscitate
[DNR] status) or inadequate use of palliative or hospice care;
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
Lack of experience of hospital staff with SNFs, and thus an inaccurate perception of the
assets and limitations of a particular SNF; and

Incomplete information sharing due to inaccurate interpretation of HIPAA regulations
limiting transfer of crucial information.
How to identify your typical failures and opportunities for improvement:

Use the MassPRO Safe Medication Practices Workbook. Pages 168-174 are dedicated
to medication reconciliation in long-term care facilities. Available at
www.masspro.org/NH/docs/tools/SafeMedPrac06_8-07Upd.pdf.

Use the INTERACT II Advance Care Planning Tracking Form (Figure 8) tool to
understand how SNF staff discuss advance care planning with the resident and their
family or caregiver.
Figure 8: INTERACT II Advance Care Planning Tracking Form (How-to Guide Resources, page 49)
Available at: http://interact2.net/tools.html

Use the INTERACT II Acute Care Transfer Log (How-to Guide Resources, page 48) to
track the SNF acute care transfers.

Use the INTERACT II Quality Improvement Tool (How-to Guide Resources, page 45) to
understand opportunities for improvement associated with acute care transfers.
Recommended Changes:
2A. Re-evaluate resident’s clinical status since transfer.
Re-evaluate the resident’s clinical status based on information from the hospital and use of a
standard treatment plan. Use a standard SNF assessment process and incorporate changes
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in the resident’s plan of care. The treatment and overall care plan should address the
following:10-12

Resident’s expected clinical course throughout their stay

Resident and family members’ values and priorities relative to their care

Medication and dietary restrictions

Cognitive status

Skin and wound care

Recommended activity level and limitations

Treatment

Provider follow-up with clear identification of the appropriate physicians for follow-up

Psychological state

Cultural background

Access to social and financial resources
2B. Reconcile the treatment plan and medication list based on an assessment of the
resident’s clinical status, information from the hospital, and past knowledge of the
resident (if applicable).

Reconcile the medication list, including medications taken prior to hospitalization but
subsequently discontinued. Note: In a recent study, one of every five hospitalized
patients experienced adverse events due to inadequate medical care after leaving the
hospital. This gap is likely to also apply to patients transferring to SNFs. Confusion about
medication administration, follow-through, and access are the largest contributors to
rehospitalizations.13-16

Reconcile any other aspects of the treatment plan, including mobility assistance,
therapies, and advance directives, specifying which interventions are to be added,
deleted, or modified in the SNF.
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Tips for Testing:

Involve the resident and their family or caregiver when gathering information about the
resident’s medication and care history.

Ensure that the correct medications have been ordered and that their dose, frequency,
and route are clearly specified in the care plan and are consistent with the resident’s
post-acute treatment needs.

Consider the use of a tool or document, such as a personalized medication list, that
does not require the resident or caregiver to rely on memory.

Identify the essential aspects of care required and ensure that these are listed in the
care plan, for example:
o Daily weights and ranges triggering intervention for residents with heart failure
o Diabetes management and glucose alert levels that signal the need for a change
in medication management
o Diet
o Test results follow-up
o Pressure ulcer presence, staging of ulcers, and required supplies
o End-of-life wishes across settings
o Scheduling of timely follow-up with appropriate providers and services (e.g.,
dialysis, physical therapy, cardiologist, and surgeon) and associated
transportation
Learn from leading programs about advance care planning systems. ―Respecting Choices‖ is a
community-wide effort spearheaded by Gundersen Lutheran Medical Foundation to stimulate
and support constructive ongoing conversations. The intent is a process of communication that
helps individuals and their families understand their choices for future health care; reflect on
personal goals, values, and religious or cultural beliefs; and talk to physicians, health care
agents, and other loved ones as needed. The program has resulted in a significant number of
community members who are clear about their advance care plan, thus relieving the burden of
any one provider or care setting to address these complicated issues. Respecting Choices is
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now a statewide model in Wisconsin, Kansas, Ohio, North Carolina, South Carolina, and
Wisconsin, and is the end-of-life model for Australia. 17 More information is available at
http://respectingchoices.org.
INTERACT also has a number of tools to help facilitate conversations about advanced care
planning and to reliably document the resident’s wishes. More information is available at
http://interact2.net/tools.html.
MOLST/POLST (Medical or Physician Orders for Life-Sustaining Treatment) protocols ensure
consistent action on the resident’s end-of-life care wishes across settings 18,19
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3. Engage the Resident and Their Family or Caregiver in a Partnership
to Create an Overall Plan of Care
Recommended Changes:
3A. Assess the resident’s and family or caregiver’s desires and
understanding of the plan of care.
3B. Reconcile the care plan developed collaboratively with the
resident and their family or caregiver.
Rather than being passive participants, residents and their family or caregiver are key partners
in ensuring optimal transitions from sites of care. The experiences of care teams working to
improve transitions from hospitals to home demonstrate that active partnerships can lead to
better care and outcomes. (For more information on improving transitions to home, see
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Creating an Ideal
Transition Home to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for
Healthcare Improvement. May 2011. Available at www.IHI.org.) Experts in the SNF field affirm
that a cooperative partnership between providers and residents along with their family or
caregiver can create a trust-based relationship and improve understanding of the care goals,
which can help avoid rehospitalization. Common understanding between SNF staff and
residents and their family or caregivers regarding expected outcomes, especially those related
to end-of-life care, can help avoid the situation in which SNF staff must resort to
rehospitalization because of a lack of resident-determined care guidelines.
Experience shows that when SNF staff interview the resident and their family/caregiver prior to
transfer to clarify expectations, it helps build relationships and reduces confusion regarding care
outcomes. SNF staff note that skillful conversations to ensure clarity about palliative or hospice
care and the use of detailed advance directives are key success factors. Enlisting residents and
families as a consistent part of the care team helps to create clear care plans and support
improved outcomes.
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Typical failures in engaging the resident and their family or caregiver in a partnership for care
planning include:

Different expectations between the staff and the resident and his or her family members
or caregivers regarding the short-term and long-term outcomes for SNF care, leading to
gaps in care (e.g., family members and/or caregivers expect the resident to return home
at some point, but the clinical providers do not).

Lack of end-of-life conversations, including the options of palliative and hospice care.

Assumption by the resident and their family or caregiver that a single individual (e.g.
physician or nurse practictioner) is in charge of all of the resident’s care and sees the big
picture of his or her needs.

Failure to actively include the resident/family and/or caregivers in identifying needs,
resources, and planning for the SNF, leading to poor understanding of the resident’s
capacity to achieve care goals.
How to identify your typical failures and opportunities for improvement:

Use the INTERACT II Quality Improvement Tool (How-to Guide Resources, page 45) to
review resident transfers and determine the frequency of involving the resident and their
family or caregiver in care planning .

Use the INTERACT II Advance Care Planning Tracking Form (How-to Guide Resources,
page 49) to document that advance care planning discussions are taking place with
residents and their family or caregiver.
Recommended Changes:
3A. Assess the resident’s and their family’s or caregiver’s desires and understanding of
the plan of care.
Include the following in the assessment:

Expectations about short- and long-term clinical outcomes at the SNF. Review options
for care beyond the immediate post-acute time frame, including long-term care and
return to home.
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
Desires regarding detailed advance directives beyond Do Not Resuscitate (DNR) and
―do not hospitalize‖ status, including end-of-life care determination and the use of lifesustaining efforts.

Understanding of the overall care plan;.

Providing the resident and their family or caregiver with the name of a care team
member with whom they can easily follow up if questions or concerns arise.
Tips for Testing:

Use effective communication techniques such as Teach Back 20 to assess clarity and
understanding during conversations with the resident and family members.

When indicated, partner with palliative care and hospice care team members for family
care plan conversations.

Use a tool to assist with the end-of-life portion of the care plan such as the
MOLST/POLST tool.18,19
3B. Reconcile the care plan developed collaboratively with the resident and their family
or caregiver.
Revise the overall care plan with the appropriate provider(s), including providers of primary
care, specialty care, palliative care, and hospice care (when indicated), based on a partnership
with the resident and their family or caregiver.

Communicate with the appropriate provider(s) to revise the clinical treatment plan.

If appropriate, partner with staff from palliative care and hospice services to ensure
thorough reconciliation of a care plan that complements SNF care.
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4. Obtain a Timely Consultation when the Resident’s Condition
Changes
Recommended Changes:
4A. Use protocols to guide immediate interventions for conditions
and complications that commonly occur in the SNF.
Timely access to providers who can respond to changes in the resident’s condition is a
challenge for most SNFs. Lack of access to providers often leads to reliance on the emergency
department for immediate care, which often ultimately results in admission to the hospital.
However, clinical teams have tested alternatives that contribute to better care without
unnecessary transfer to the ED or hospitalization.
Typical failures in timely consultation when the resident’s condition changes include:

Transfer to the emergency department to avoid the risk of inadequate treatment when
the usual provider is unavailable;

Limited daily availability of providers, leading to a lack of timely modifications to the care
plan;

Lack of an emergency plan other than transfer to the ED if providers are not available;
and

Lack of protocols to guide care within the SNF and provide advice to on-call providers
who lack familiarity with the SNF or with the resident.
How to identify your typical failures and opportunities for improvement:

Use the INTERACT II Acute Care Transfer Log (How-to Guide Resources, page 48) to
understand patient conditions and complications that may result in readmission to the
hospital.
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Recommended Changes
4A. Use protocols to guide immediate interventions to address conditions and
complications that commonly occur in the SNF.

Use INTERACT II tools to aid in early recognition and intervention. All of the INTERACT
II tools referenced below are available at http://interact2.net/tools.html.
o Care Paths are protocols that help nurses think through common diagnoses that
lead to hospital transfer: dehydration, CHF, fever, pneumonia, abnormal glucose
levels, and UTI.21
o The Early Warning Tool is used by CNAs to promote recognition of change in
condition.21 Available in English, Spanish, and Creole.
o Change in condition protocols assist nurses in identifying conditions that require
immediate notification of the primary care physician, nurse practitioner, or
physician assistant.
o The SBAR Communication Tool and Progress Note guides nurses through a
comprehensive assessment when a change has taken place, assists in clearly
communicating, and aids in documenting the results.21

Use the American Medical Directors Association (AMDA) clinical tools such as the
―Know-It-All Before You Call‖ Data Collection Cards to evaluate the resident and collect
data before notifying a practictioner of changes in condition or the Clinical Practice
Guidelines to guide care given in long-term care settings. Available at
www.amda.com/resources/print.cfm.

Explore the use of alternative providers to offer timely primary care consultation for SNF
residents, for example:
o Evercare Model: This model presupposes that providing more intensive primary
care will reduce the use of more expensive services such as hospitalizations.
Advanced Nurse Practitioners (ANP) work in partnership with the resident’s
primary care provider, seeing the resident regularly and responding to concerns
early in the clinical course. ANPs also provide training and support to SNF staff
to improve care for residents. The ANP’s time is allocated to communication with
families, primary care providers, and SNF staff; direct care; and administrative
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duties. One study showed that the incidence of hospitalizations was twice as high
among control group residents than for residents in the intervention group, which
was cost effective because NPs were used to provide additional care support. 22 A
specific example includes an ANP who focuses on managing residents by
working directly with ED physicians when a resident needs to be assessed (e.g. ,
a resident on Coumadin falls). The ANP works with the ED physician to develop
a plan of care to return the resident to the SNF rather than admit the resident.
The ANP has found that ED physicians want to avoid hospitalizations but are not
clear on the capabilities of a SNF; therefore, they often admit the resident due to
a lack of information.
o Geisinger Model: The availability and cost of nurse practitioners may limit the
ability of SNFs to access providers for additional care support for residents.
Geisinger Health Plan is testing an alternative model in which nurse care
managers provide care for SNF residents in partnership with SNF providers. The
care managers provide regular review of the residents’ care plans, conduct
medication reconciliation at transitions, and communicate with the primary
providers either in person or via telephone. The model:

Provides a form of medical home for the SNF resident through daily
assessments and focus on ―whole person‖ needs in partnership with SNF
care teams;

Aims to avoid unnecessary rehospitalizations thus averting the personal
toll on the resident and family, loss of trust in the SNF care by the family,
and increased costs;

Includes ongoing medication reconciliation both during transitions and
across the multiple providers involved in the resident’s care (especially
pertinent for residents with several chronic conditions); and

Fosters close partnership and communication with the designated primary
care provider.
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IV. Testing, Implementing, and Spreading Changes
Step 1. Based on your learning from the Getting Started activities (Section II),
select a place to start and identify the opportunities or failures in your current
processes.
All four key changes (as outlined in Section
III) are strongly recommended for improving
Tips for Fixing Problems , from The High Velocity
Edge by Steve Spear
 ―Start s mall. Find a process or system that is
a patient’s transition to the SNF after
reasonably tightly bounded so that the number of
discharge from the hospital. These four
people learning together is relatively s mall. That
way the chance for shared reflection w ill be
changes are depicted in the flow chart
below (Figure 9). Many teams start their
relatively high.‖
 ―Solve a problem that really matters…When you
efforts with a focus on ensuring a flawless
start to score gains, you w ant people to sit up and
transition, but there are merits to allowing
take notice.‖
the front-line team’s interests to determine
 ―…Although you should start w ith a fairly small
group and a fairly w ell-defined problem…make
where to start improvement. If there are two
sure that every layer of management is involved.
pilot units, the teams on these units may
After all, w hat you are trying to master is a
want to begin testing different process
fundamentally different set of roles and
improvements and share what they are
relationships.‖
learning to accelerate overall progress.

―Don’t w ait.‖
Figure 9: Flow Chart of Key Changes to Create an Ideal Transition to the SNF
.
Key Change 1:
Ensure That SNF
Staff Are Ready
and Capable to
Care for the
Resident
Key Change 2:
Reconcile the
Treatment Plan
and Medication
List
Key Change 3:
Eng age the
Resident and Their
Fam ily or Caregiver
in a Partnership to
Create an Overall
Plan of Care
Key Change 4:
Obtain a Tim ely
Consultation When
the Resident’s
Condition
Changes
Each key change to improve transitions contains several processes. Choose which processes
you want to investigate, and use observation to gain a deeper understanding of the current
processes and to assess your own opportunities for improvement. Many quality improvement
and innovation strategies include observation as an essential foundation to inform process
improvements.23-26
The tool depicted below (Figure 10) is an example of an Observation Guide to assist front-line
teams in making observations about current processes for intake assessments.
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Figure 10: Observation Guide: Observing Current Processes for an Intake Assessment (How-to
Guide Resources, page 51)
Step 2. Use the Model for Improvement; test changes.
Developed by Associates in Process Improvement, the Model for Improvement (Figure 11) is a
simple yet powerful tool for accelerating improvement. It has been used successfully by
hundreds of health care organizations to improve many different health care processes and
outcomes.
The model has two parts:

Three fundamental questions that guide improvement teams to 1) set clear aims, 2)
establish measures that will tell if changes are leading to improvement, and 3) identify
changes that are likely to lead to improvement.

The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real
work settings — by planning a test, trying it, observing the results, and acting on what is
learned. This is the scientific method, used for action-oriented process improvement.
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Figure 11: The Model for Improvement
Reasons to Test Changes, from The
Improvement Guide by Langley et al .
 To increase your belief that the change will
result in improvement.
 To decide which of several proposed changes
will lead to the desired improvement.
 To evaluate how much improvement can be
expected from the change.
 To decide whether the proposed change will
work in the actual environment of interest.
 To decide which combinations of changes will
have the desired effects on the important
measures of quality.
 To evaluate costs, social impact, and side
effects from a proposed change.
 To minimize resistance upon implementation.
First Test of Change: A first test of change should involve a very small sample size (typically
one care provider or one patient) and should be described ahead of time in a Plan-Do-StudyAct format so that the team can easily predict what they think will happen, observe the results,
learn from them, and continue to the next test.
Use iterative PDSA cycles to design and redesign processes to make them effective and
reliable.
Figure 12 is a blank PDSA Worksheet that outlines guidance for each of the steps: Plan, Do,
Study, and Act.
Figure 12: PDSA Worksheet (How-to Guide Resources, page 53)
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Suggestions for Conducting PDSA Cycles
 Remember that one test of change informs and builds upon the next.
 Keep tests small; be specific.
 Refine the next test based on learning from the previous one.
 Expand test conditions to determine whether a change will work under a variety of
conditions like different times of day (e.g., day and night shifts, weekends, holidays, when
the unit is adequately staffed, in times of staffing challenges) or different types of
patients, those with lower health literacy, non-English speaking patients, short stay or
long stay patients.
 Collect sufficient data to evaluate whether a test has promise, was successful, or needs
adjustment.
 Continue PDSA cycles of learning and testing to improve process reliability.
Step 3. Increase the reliability of your processes.
The Plan (P) step of each PDSA cycle should include a high level of detail on the change being
tested: who, what, when, where, and the specifics of how. Adapt and build out this detail as you
conduct iterative PDSA cycles and learn about what works in your organization. The aim is to
end up with a process that can be executed as designed, every time, for every appropriate
patient, with the desired results.
The following is an example of how to plan for testing based upon the recommended Key
Change 4A: ―Use protocols to guide immediate interventions for conditions and complications
that commonly occur in the SNF.‖
Example: When redesigning your process for assessing changes in the resident’s condition
in order to ensure appropriate provision of care, work with people who conduct the tests to
precisely describe the work, including information regarding the following:
 Who will do it? (Specify: e.g., include the name of the nurse assigned to the
resident.)

What will they do? (Specify: e.g., use the INTERACT Stop and Watch Tool and the
Change in Condition Card File to assess changes in the resident’s condition; use
the INTERACT II SBAR Communication Tool and Progress Note to communicate
changes to the nurse practictioner, physician’s assistant, or physician.)
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
When will they do it?

Where will they do it? (Specify: e.g., in the resident’s room.)

How will they do it? (Include tools that are used – e.g., INTERACT II Stop and
Watch Tool and SBAR Communication Tool and Progress Note.)

How often will they do it? (Specify: e.g., when a change in condition is identified.)

Why should they do it? (Specify: e.g., to ensure effective communication of changes
in resident’s condition.)
Continue to test the process under a variety of conditions (e.g., different nurses, different
kinds of patients). Adapt the change until it optimally meets the needs of both residents and
staff.
When testing a change, you will learn from your failures as well as from your successes.
Understanding common failures (situations when a process is not executed as expected) helps
the team to (re)design the new processes to eliminate those failures.
Here is an example of a team learning from a failed test and applying that learning to
improve the process:

The process being tested required nurses to use the SBAR Communication Tool
and Progress Note for any resident whose condition had changed, requiring
communication of the change to the NP/PA/MD. During testing, a nurse responsible
for a resident was unsure of the early warning signs of an important change in
condition. Nurses, physicians, and social workers met to review the relevant early
warning signs, and a regular refresher training was put in place.
After successful testing under varying conditions with desired results, document the process so
there is no ambiguity: all involved can articulate the exact same steps in the process.
Step 4. Use data, displayed over time, to assess progress.
The Getting Started activities (Section II) include collecting baseline data on readmissions and
patient experience, and displaying the data in time series graphs. Continue to collect and
display this data in order to see whether your changes result in improvement for your residents.
We recommend looking at data both for your pilot population(s) and your facility as a whole.
Augment quantitative readmissions data with information you gather from asking readmitted
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patients about their experience (consider using the Diagnostic Worksheet, page 47, and the
INTERACT Quality Improvement Tool, page 45). Annotate run charts to indicate when specific
changes were implemented.
In addition to tracking the outcome measures for readmissions and patient experience, it is
valuable to track whether your new and improved processes are being executed as expected.
These ―process‖ measures tell us whether the specific changes we make are working as
planned, and they provide information on the relationship between our theory (the changes we
are making) and the outcomes for our residents. Plotting process data over time uncovers
signals of improvement (increased reliability of the process) or opportunities (proble ms with the
execution of the process). These signals show us when to investigate and apply the resulting
learning to redesign the process to make it work better.
When the data suggest we are not performing a process reliably, we want to go to the people
who should be executing the process and ask them what barriers they face. Use the data to
identify opportunities to make the new processes easier to execute, not to blame the staff.
Assume the problem is the design of the process or the system in which it is embedded, and
work with the team to fix it. For example, if the team observes that nurses are not using the
INTERACT Quality Improvement Tool, the team should consider how to improve the process by
getting input from the nurses about what barriers they are encountering with the process.
Collecting and reviewing data, over time, through implementation, helps you see when new
problems arise with the execution of your desired interventions. Share data with unit staff,
physicians, and senior leaders. Reflect on lessons learned from both successful and
unsuccessful tests of change. Develop the habit of challenging assumptions.
Step 5. Imple ment and spread successful practices.
Imple mentation
After testing a change on a small scale, learning from each test, and refining the change
through several PDSA cycles, the team can implement the change on a broader scale — for
example, for an entire pilot population. Implementation is the process of making an
improvement part of the day-to-day operation of the system in your pilot population. Unlike the
testing that you’ve done to develop your new processes, implementation is a permanent change
to the way work is done and, as such, involves building the change into the organization. It may
affect written policies/protocols, hiring, training, compensation, equipment, and other aspects of
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the organization's infrastructure that are not heavily engaged in the testing phase. Attention
should be paid to communication (i.e., publicizing the benefits of the change), documenting
improvement, as well as keeping in contact with the pilot team so that they are supported during
the implementation phase. The team can and should use PDSA cycles to enhance learning and
accelerate the process of hard-wiring the changes so they become an integral part of the
system.
Example: During the testing process, a few nurses may be trained in the redesigned
hand-off processes like using a phone call with the discharging hospital nurse to
confirm understanding of the resident’s care needs. Once the processes and support
materials have been adapted so that this hand-off involving SNF and hospital nurses
occurs effectively over 90 percent of the time, the process should be implemented
across the unit. Making this process the default system (i.e., the way the work is done
rather than the way a few nurses do the work from time to time) requires a training
system for all nurses currently on the unit, and changes to orientation programs for new
nurses. It might also require changes to an IT system where information about the
resident is documented and shared. Communication to all staff about the revised
expectations for teaching and learning might be developed to start to generate interest
in implementing the redesigned process in other parts of the SNF/s (e.g., in other units
or other facilities within the system or community) or with other disciplines (e.g.,
physicians or pharmacists) in preparation for spread.
During implementation, attend to the social aspects of the change as well as the technical
infrastructure. Leaders need to communicate the why as well as the how of the change, and
address questions and concerns. It is common for processes that seem to be working well (i.e.,
being executed reliably) during testing to get less reliable, temporarily, when you move to
implementation.27 During implementation, a group that may be unfamiliar and/or unsympathetic
with the purpose is now expected to make the change and there may be resistance, or simply
confusion. It may take some cycles of testing to put in place an effective infrastruc ture to
support the change(s). Continue to monitor whether your processes are being executed as
planned and to act on that information to adapt the processes and the related infrastructure to
support the change. Make it easy to do the right thing, and hard to do the wrong thing.
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Tips for Sustaining Improvements
 Communicate aims and successful changes that achieved the desired results (e.g.,
newsletters, storyboards, patient stories, etc.).
 ―Hard-wire‖ processes so that the new processes are difficult to reverse (e.g., IT
template, yearly competencies, role descriptions, policies and procedures).
 For processes that are sequential, create an impossibility of proceeding with
another desired step (e.g., signing out) until the process is complete.
 Assign ownership for oversight and ongoing quality control to ―hold the gains.‖
 Assign responsibility for ongoing measurement of processes and outcomes.
Spreading Changes
Leaders should begin making plans for spreading the improvement developed in the pilot
population or unit during the early stages of the initiative. After successful implementation of a
change or package of changes for a pilot population or an entire unit, leaders will be prepared to
lead the spread of the changes to other parts of the organization or to other organizations. Even
though the changes have been tested and implemented in the pilot population or unit, spread
efforts will benefit from testing and adaptation (using PDSA cycles) in the new patient
populations or additional units. Units adopting the change may need to adapt it to their own
setting and to build confidence that the change will result in the predicted improvement.
Some considerations for leaders as they plan for spread of the changes to improve transitions
include the following:

If the initial population of focus was a specific patient population (e.g., residents with a
particular disease type), consider adaptations to the process that may be necessary for
spread to all residents. For example, if you have developed an assessment strategy and
materials for patients with hip replacement, what tools and strategies will your nurses
need to apply to teaching all residents?

If the initial population of focus was a particular unit, what do you need to do to spread to
other units? What adaptations might be needed? Who are the stakeholders who need to
be engaged in the process? How might you involve them early on to build will and
excitement in the units to which the changes will be spread?
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Successful spread of reliable processes requires that leadership take responsibility for spread
and commit sufficient resources to support spread. Pilot unit staff also play an importan t role in
spread activities by 1) making the case that the changes contribute to better transitions for
patients and reduced readmissions, and 2) generating information and materials that leaders
can package to make it easier for others to adapt the changes they made. They may also be
involved in teaching and mentoring others, although the responsibility for developing the overall
training and support system lies with leadership.
An important consideration for leaders in preparing for spread is whether sta ff outside of the
pilot unit(s) or those caring for the pilot population will have the time and resources to make the
same changes that have been made at the pilot level. In other words, are the changes
developed at the pilot level scalable to the rest of the organization? Take, for example, changes
such as providing input into the hospital’s enhanced assessment of patients’ post-hospital
needs, using Teach Back for all patients, or ensuring that there is an active hand-off of
information regarding a patient being transferred from hospital to SNF. These changes may
mean that nurses and other staff will need to rethink and redesign their activities and
responsibilities to free up time to reliably carry out these as well as the other steps needed for
an ideal transition.
One way that leaders together with the SNF nurses can begin the redesign effort is to use
structured observation methods to evaluate their current workflows and processes, identify
areas of waste (e.g., time spent trying to identify the appropriate person to contact at the
hospital), and then test new ways of carrying out work more efficiently so they have more time
to spend with residents, providing care as well as ensuring appropriate follow-up after the
transition from the hospital. Information about how to engage front-line staff in the redesign of
patient care can be found in the IHI materials on Transforming Care at the Bedside (see the
web resources list below).
A key responsibility of leaders is to develop a plan and timetable for spread and then to
measure and monitor progress as the spread unfolds. This oversight process involves two parts:
1) measuring and monitoring the rate of spread of the changes, and 2) tracking improvement in
outcomes (e.g., reductions in readmission rates.) Figure 13 shows an example of a tool that
leaders can use to monitor the spread of a package of changes (the changes are listed in rows,
and the units designated for spread are listed in columns). This tool allows a leader to
understand the progress of the spread of each change and the spread of changes across the
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locations designated for spread (in this example, units within a SNF, but it could also be service
lines or facilities in a larger system). Use the Spread Tracker Template to monitor spread.
Figure 13: Spread Tracker Template (How-to Guide Resources, page 54)
Data about readmission rates or other outcome measures as identified by the leaders can be
used in conjunction with information about the rate of adoption of the changes. For example, if a
unit is not seeing a reduction in its readmission rates, then a leader could check their progress
in implementing each of the recommended changes. Leaders would want to determine if further
guidance and support are needed in the unit in order to accelerate progress and results. It is
recommended that outcome measures be reported and tracked at the SNF or system level as
well as at the unit level in order to provide leaders, unit managers, and front-line staff with
regular feedback on their progress.
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Recommended Resources on Quality Improvement
Books and articles:
Ohno T. Toyota production system: Beyond large-scale production: Productivity Press;
1988.
Womack JP, Jones DT, Simon, Audio S. Lean Thinking. Simon & Schuster Audio;
1996.
Kenagy J. Designed to Adapt: Leading Healthcare in Challenging Times. Second River
Healthcare Press, Bozeman MT; 2009.
Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL. The Improvement Guide: A
Practical Approach to Enhancing Organizational Performance: Jossey-Bass; 2009.
Massoud, MR, Nielsen, GA, Nolan, K., Schall, MW, Sevin, C. A Framework for Spread:
From Local Improvements to System-Wide Change. IHI Innovation Series white paper.
Institute for Healthcare Improvement; 2006. (Available on www.IHI.org)
Nolan KM, Schall MW (editors). Spreading Improvement Across Your Health Care
Organization. Joint Commission Resources and the Institute for Healthcare
Improvement; 2007:1-24.
Spear S. The High Velocity Edge (released in its first edition as: Chasing the Rabbit:
How Market Leaders Outdistance the Competition. McGraw Hill; 2009.
Web tools and resources:
Spreading Changes. Institute for Healthcare Improvement. Available at
http://preview.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSpreadin
gChanges.aspx.
On Demand Presentation: An Introduction to the Model for Improvement. Institute for
Healthcare Improvement. Available at
http://preview.ihi.org/offerings/VirtualPrograms/Individuals/ImprovementModelIntro/Pag
es/default.aspx.
Transforming Care at the Bedside (TCAB). Institute for Healthcare Improvement.
Available at
www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.
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Transforming Care at the Bedside How-to Guide: Engaging Front-Line Staff in
Innovation and Quality Improvement. Institute for Healthcare Improvement. Available at
http://preview.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.as
px.
How to Improve. Institute for Healthcare Improvement. Available at
http://preview.ihi.org/knowledge/Pages/HowtoImprove/default.aspx.
Quality Improvement 101-106. IHI Open School for Health Professions. Available at
http://preview.ihi.org/offerings/Pages/openschool.aspx.The Institute for Healthcare
Improvement offers online courses, through the IHI Open School for Health
Professions, that are available free to medical students and residents and for a
subscription fee for health care professionals.
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V. How-to Guide Resources
Return to:
INTERACT Quality Improvement Tool
p. 45 p. 10, 12, 17, 22, 27, 37
Diagnostic Worksheet
p. 47 p. 10, 12, 37
INTERACT Acute Care Transfer Log
p. 48 p. 19, 22, 29
INTERACT Advance Care Planning Tracking Form
p. 49 p. 22, 27
Observation Guide: Observing Current Processes for an
Intake Assessment
p. 51 p. 33
PDSA Worksheet
p. 53 p. 34
Spread Tracker Template
p. 54 p. 41
Note: All INTERACT II tools may also be accessed at http://interact2.net/tools.html.
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Diagnostic Worksheet: In-depth Review of Patients Who Were Readmitted
Summary of Interview Findings
What did you learn?
What themes emerged?
What, if anything, surprised you?
What new questions do you have?
What are you curious about?
What assumptions about readmissions that you held previously are now challenged?
What do you think you should do next?
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Observation Guide: Observing Current Processes for an Intake Assessment
Observe three intake assessments as they are currently done by nurses and physicians. Reflect upon what
you observed to discover what went well and where there are opportunities for improvement.
What do you predict you will observe?
Did the care team member(s)…
Patient # 1
Patient # 2
Patient # 3
______________
______________ ______________
Yes
Yes
No
No
Yes
No
Ask the resident and family members aboutY
their goals and concerns during their stay at
this facility?
Ask community caregivers about their
assessment of the resident’s ongoing care
needs during their stay and when they go
home?
Complete the medication reconciliation
processes?
Assess the resident’s cognitive and
psychological status?
Assess the resident’s current functional
status?
Assess the resident’s values, needs, and
preferences?
Assess the resident’s ability to perform selfcare and monitor health status (e.g., weight,
blood pressure, blood glucose levels)?
Assess the resident’s ability to pay for
medications and supplies or equipment?
Engage the resident and caregiver in
developing the overall plan of care?
Create an individualized plan of care based
on the assessment of the resident’s needs?
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Observation Guide: Observing Current Processes for an Intake Assessment
Reflections after observations are completed (to be shared with the entire team):
What did you learn?
How did your observations compare to the predictions?
What, if anything, surprised you?
What new questions do you have? What are you curious about?
As a result of the findings from these observations, what do you plan to test and by when?
1.
2.
3.
4.
5.
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Act
Plan
Study
Do
PDSA Worksheet
DATE __________
Change or idea evaluated:
Objective for this PDSA Cycle:
What question(s) do we want to answer on this PDSA cycle?
Plan:
Plan to answer questions (test the change or evaluate the idea): Who, What, When,
Where
Plan for collection of data needed to answer questions: Who, What, When, Where
Predictions (for each question listed, what will happen if plan is carried out? Discuss theories)
Do:
Carry out the Plan; document problems and unexpected observations; collect data and
begin analysis.
Study:
Complete analysis of data; What were the answers to the questions in the plan
(compare to predictions)? Summarize what was learned.
Act:
What changes are to be made? Plan for the next cycle.
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Spread Tracker Template
A=Planning B=Start C=In Progress D=Fully Implemented
Change 1
Pilot Unit
1
D
Pilot Unit
2
C
Spread Unit
1
A
Spread Unit
2
B
Spread Unit
3
C
Change 2
D
C
B
B
C
Change 3
D
C
A
A
C
Change 4
D
C
B
A
B
Change 5
C
C
C
A
Change 6
C
D
C
C
A
Change 7
C
D
A
C
A
Change 8
C
A
C
A
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D
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VI. References
1.
Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National Quality
Improvement/Hospitalization Reduction Study. Caring: National Association for Home
Care magazine. 2006;25(2):70.
2.
Alliance for Health Reform. Covering Health Issues 2006-2007:
http://www.allhealth.org/sourcebooktoc.asp?sbid=1. Accessed April 5, 2011.
3.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. Apr 2 2009;360(14):1418-1428.
4.
Hackbarth G, Reischauer R, Miller M. Report to Congress: Medicare Payment Policy.
Washington, DC: Medicare Payment Advisory Committee;March 2007.
5.
Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from
skilled nursing facilities. Health Affairs. 2010;29(1):57.
6.
Gandara E, Moniz T, Ungar J, et al. Communication and information deficits in patients
discharged to rehabilitation facilities: an evaluation of five acute care hospitals. J Hosp
Med. Oct 2009;4(8):E28-33.
7.
Nolan T. Execution of Strategic Improvement Initiatives to Produce System-Level
Results. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare
Improvement; 2007.
8.
Conway J, Johnson BG, Edgman-Levitan S, et al. Partnering with Patients and Families
to Design a Patient- and Family-Centered Health Care System: A Roadmap for the
future. A Work in Progress: Institute for Healthcare Improvement;unpublished
manuscript June 2006.
9.
Institute for Patient- and Family-Centered Care. Free Downloads: Reports/Roadmaps.
http://www.ipfcc.org/tools/downloads.html. Accessed May 2, 2011.
10.
Adams K, Lindenfeld J, Arnold JMO, et al. HFSA 2006 comprehensive heart failure
practice guideline. J Card Fail 2006;
http://www.heartfailureguide.org/document/hfsa_2006_comprehensive_heart_failure_gui
delines.pdf
Accessed April 5, 2011.
11.
Zwicker D, P icariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T,
Abraham I , Zwicker DA, eds. Geriatric Nursing Protocols for Best Practice. 2nd ed.
New York: Springer Publishing Company, Inc; 2003:292.
12.
Safe Practices for Better Healthcare-2006 Update: A Consensus Report. Washington,
DC: National Quality Forum;2006.
13.
Forster A, Murff H, Peterson J, Ghandi T, Bates D. The incidence and severity of adverse
events affecting patients after discharge from the hospital. Annals of Internal Medicine.
2003;138:161-167.
14.
Happ MB, Naylor MD, Roe-Prior P. Factors contributing to rehospitalization of elderly
patients with heart failure. J Cardiovasc Nurs. Jul 1997;11(4):75-84.
15.
Coleman EA, Smith JD, Raha D, Min S. Posthospital medication discrepancies. Arch
Intern Med. 2005;165(16):1842-1847.
16.
Forster AJ. Prescription medications affected 66% of 400 patients. Annals of Internal
Medicine. 2003;138:161-167.
17.
Gundersen Lutheran Medical Foundation. Respecting Choices. 2011;
http://respectingchoices.org/. Accessed 2011, June 10.
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18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Centers for Ethics in Health Care. Oregon Health & Science University. Physician Orders
for Life-Sustaining Treatment Paradigm (POLST). 2008; http://www.ohsu.edu/polst/.
Accessed June 10, 2011.
Compassion and Support. Medical Orders for Life-Sustaining Treatment (MOLST).
2009; http://www.compassionandsupport.org/index.php/for_patients_families/molst.
Accessed June 10, 2011.
American Medical Association Foundation. Health Literacy Kit http://www.amaassn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacyprogram/health-literacy-kit.page.
INTERACT II. INTERACT II Tools. http://interact2.net/. Accessed June 10, 2011.
Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The effect of Evercare on
hospital use. Journal of the American Geriatrics Society. 2003;51(10):1427-1434.
Ohno T. Toyota production system: beyond large-scale production: Productivity Press;
1988.
Womack JP, Jones DT, Simon, Audio S. Lean thinking: Simon & Schuster Audio; 1996.
Spear SJ, Graw-Hill M. Chasing the rabbit. Target. 2009;25(1).
Kenagy J. Adaptive Design. http://kenagyassociates.com/adaptive.what.php. Accessed
April 12, 2011.
Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL. The Improvement Guide: A
Practical Approach to Enhancing Organizational Performance: Jossey-Bass; 2009.
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