Background Reducing readmissions for heart failure (HF) patients is a national imperative, as prevalence and care costs for HF climb. Our multidisciplinary team utilized a programmatic, patient-centered, Lean approach to improve care processes and prepare patients for successful self-management at home. Processes included identification of the patient cohort, early assessment for readmission risk, enhanced patient education, accurate medication reconciliation, follow-up appointments and follow-up phone calls.

Objectives Reduce readmissions for HF patients by 30% within two years at an academic medical center.

Methods A core team of clinical stakeholders with cross-functional support staff used an A3-driven approach to assess current-state problems, understand root causes, and design, test, and stabilize countermeasures. Each intervention had its own workgroup led by a frontline staff member and supported by an improvement coach. EMR enhancements were created to support new workflows. A team-designed HF dashboard provided real-time, filterable process and outcome metrics that aided analysis. This helped identify opportunities for refinements and facilitated feedback to frontline staff.

Results 30-day readmission rate for primary diagnosis HF patients improved from 20% to 10% over the ensuing 10 months. 90-day readmission rates decreased to 27% from 31%. Improving process metric trends demonstrated hardwiring of new workflows, and patient responses to survey questions related to care transitions validated improved outcomes.

Conclusions Partnering with patients, multidisciplinary collaboration and timely feedback to frontline staff foster improved care transitions and patient outcomes. Tracking data for continuous improvement, we can refine care processes and inform innovative improvements in care across our organization.