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Hospital Quality Improvement Projects

Project Name: Chronic Obstructive Pulmonary Disease (COPD) Hospital Readmissions Reduction Project

Time Frame: September 2013-present

Description: Hospital readmission rates are under close scrutiny by payers and policymakers including the federal government because of the high costs involved (and therefore high potential for savings). In addition to the costs, patient readmission rates are increasingly being used to measure quality of care, are being publicly reported, and are directly tied to some of the financial programs being put into place as part of national healthcare reform. Many patient re-admissions to hospitals represent good care such as those that are part of a course of treatment planned in advance by the patient and their physician, or those that are done in response to trauma or a sudden acute illness unrelated to the patient’s original hospital admission. However, sometimes hospital re-admissions are avoidable and that is the focus of this Team: to find ways to reduce avoidable hospital re-admissions for patients with chronic obstructive pulmonary disease within 30 days after their hospital stay. 

Background: According to the COPD Foundation, Chronic Obstructive Pulmonary Disease is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. This disease is characterized by increasing breathlessness.  Many people mistake their increased breathlessness and coughing as a normal part of aging. In the early stages of the disease, you may not notice the symptoms. COPD can develop for years without noticeable shortness of breath. You begin to see the symptoms in the more developed stages of the disease. That’s why it is important that you talk to your doctor as soon as you notice any of these symptoms. Ask your doctor about taking a spirometry test.

What are the symptoms?

  • Increased breathlessness
  • Frequent coughing (with and without sputum)
  • Wheezing
  • Tightness in the chest

How common is COPD?

COPD affects an estimated 24 million individuals in the U.S., and over half of them have symptoms of COPD and do not know it. Early screening can identify COPD before major loss of lung function occurs.

What are the risk factors?

Most cases of COPD are caused by inhaling pollutants; that includes smoking (cigarettes, pipes, cigars, etc.), and second-hand smoke.

Fumes, chemicals and dust found in many work environments are contributing factors for many individuals who develop COPD.

Genetics can also play a role in an individual’s development of COPD—even if the person has never smoked or has ever been exposed to strong lung irritants in the workplace.

Building on a recently completed successful effort to reduce readmission rates in patients with congestive heart failure (CHF) in 2013, we shifted our focus and efforts to COPD.  The primary structure used to do our work is a community-wide collaborative: A large group of providers and organizations that make up most of the healthcare in Rutland County for these patients.  This collaborative, of which there are approximately 30 members including the three local skilled nursing facilities, two home health agencies, Pulmonology, Primary Care Physicians, office coordinators, and others come together and work on this common goal of reducing 30 day hospital readmissions for COPD patients each month.  When the collaborative meets, the group shares ideas, information, best practices, and identifies the care redesign changes necessary to make improvements for COPD patients.   

At the beginning of this quality improvement project, Rutland Regional Medical Center’s 30-day readmission rate for COPD patients was averaging 20%.

Project Goals: 
1. Complete analysis of all COPD patient 30-day readmissions to identify opportunities for improvement to reduce avoidable admissions. 
2. To collaborate with other area health care providers and facilities to develop communication processes that cross organizational boundaries for the benefit of improving patient care and coordination. 
3. To implement evidence based best practices when evaluated as appropriate for our hospital, community and patient population. 
4. Overall measure to be used to gauge success on the project: Medicare 30-day all cause readmission rate. Current monthly rate averages 20%. 

1. Jointly develop standardized clinical protocols for managing COPD patients in the community setting and determining the clinical criteria to be used for sending a patient to the hospital. 
2. Improve the coordination and communication between the hospital, skilled nursing facilities, home health agencies, and physician practices so that when patients are admitted and then discharged from the hospital to another organization, we improve the ‘transitions of care’. 
3. Evaluate the potential for more patients to receive Home Health if they are eligible and would benefit from those services. 
4. Develop a standard of the clinical terms and advice given to patients as they are treated and cared for by/at the different facilities participating in this COPD collaborative. Develop a standard, effective patient journal to empower and encourage the patients to better self-manage. 
5. Provide a follow up telephone call to each COPD patient within 1-3 days after hospital discharge. This will be done to help answer any questions the patient may have, and to help ensure the patient understands and follows their discharge plans including getting prescriptions filled, dietary & other behavioral modifications, regular weight checks, follow up appointments with their physician and similar activities. 
6. Ensure the patient has a good understanding and an accurate list of the medications that he/she is taking. This list is also shared with others caring for the patients to ensure medication safety. 
7. For those patients with advanced stages of COPD, it may be beneficial to have palliative care discussion and advice with a nurse or patient’s doctor so that the patient’s wishes and best interests are known and factored into the care decision making practices. 

Measure: Chronic Obstructive Pulmonary Disorder 30-day Readmission Rate.

Results: In 2012-2013, the 30-day readmission rates for COPD patients over the age of 64 years averaged 20% each month. In 2014, the rate averaged 15.1%. In the first three months of 2015, the rate has averaged on 5.4%. From these results, we can determine that our interventions are proving to be effective in lowering the rate of hospital admissions.

Contact for Project: Darren Childs, Director, Quality Improvement Services, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone: 802.747.3704.

Project Name: Minimizing Surgical Site Infections through Pre-Operative Skin Preparation

Timeframe: September 2013-Ongoing 


Infection Prevention implemented a three phase program to standardize preoperative skin preparation for all patients going to the operating room.  (The Orthopaedic joint replacement program already had a strong pre-operative skin preparation program in place was not a part of this project.)  The multidisciplinary SSI prevention team led the effort in developing an evidenced-based process for pre operative skin preparation.

  • Phase I began September 2013 in our ambulatory care unit. All patients being prepared for surgery receive a 2% Chlorhexidine (CHG) skin prep if the surgical site involves an external skin incision.  
  • Phase II was implemented in October 2013 and focused on four hospital associated clinics, including general surgery, ENT, and OB GYN. Preparation for this phase included development of “Minimizing Surgical Site Infections” booklet. Three sets of instructions were also developed based on type of surgery and patient needs.  Each set provided directions for preparing one’s skin before surgery. The instructions, CHG product, and infection booklet were conveniently provided at the clinics when surgery was scheduled.
  • Phase III was initiated in November 2013 for inpatients. According to RRMC protocol all patients going to surgery are fully bathed with CHG wipes. When surgery is emergent, only the surgical site is wiped with CHG.
    Education for all phases was provided by the Infection Prevention Nurse, written policy, and e-learning.


Surgical site infections (SSI) continue to be a growing concern in healthcare.  SSI are known as hospital acquired infections (HAI).  These cases have a clean or clean contaminated wound class and occur within 30 days of an operation, or 90 days if surgery involves an implant. SSI increase morbidity, hospital length of stay, and healthcare costs. The most common cause of a surgical site infection is normal bacteria carried on one’s skin. Reducing the amount of skin bacteria, especially Staphylococcus, can minimize risk for these infections.  While investigating these infections we recognized an opportunity to improve care for our surgical patients by developing clear and concise instructions for pre operative skin prep.


  • Surgical site infections
  • Staphylococcal surgical site infections
  • Percent of Staphylococcal surgical site infections 

Minimizing Surgical Site Infections (SSI) October 2011 through March 2014


In April 2012, the SSI prevention team identified an opportunity to reduce Staphylococcal surgical site infections. The team developed a standard and effective skin preparation protocol for all patients undergoing surgery with external skin incisions. Working in collaboration with several physician practices, a process was established to educate patients and provide instructional material and 2% Chlorhexidine cloths. This allowed patients to successfully complete the pre-operative skin prep at home. Comparing the first half of fiscal year 2013 to 2014, we have seen a 33% reduction in Staphylococcal SSI.

Contact for Project: Nancy Meszaros, BSN, RN, CIC, Performance Improvement, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone: 802.772.2408.

Project Name: Patient Satisfaction — ED Physician Initiatives

Time Frame:   2012-Present

Description: With the never-ending list of challenges facing emergency departments, trying to increase patient satisfaction is more difficult than ever. However, because Emergency Departments are the “front door to the hospital” for many patients, high patient satisfaction scores are critical to a hospital's reputation and success. This project summary portrays our ED physicians' methods and approach to improving satisfaction. 

Background: According to the American College of Emergency Physicians (ACEP), understanding and responding to information received in patient satisfaction surveys is relevant to the delivery of quality care for emergency room patients. From a patient’s perspective, quality and value are inexplicitly linked. While quality is determined by objective measures of outcome, satisfaction surveys help determine the value of care. Value is not the same as quality. Value is subjectively reported by the patient. While value is typically determined in relation to price, in the US healthcare system, satisfaction is primarily driven by expectations of service. To point, patients who are most satisfied with care are more likely to be compliant with their plan of care and engaged with the health care community as they continue to receive care. This translates to improved quality and better outcomes. Thus, measures of perception such as patient satisfaction along with quality measures of clinical processes and outcomes create a value of care that influences a hospital’s reputation and contributes to the success of the organization when patients are highly satisfied.  

Project Goals:

  1. To establish a process to monitor and review patient satisfaction survey results with ED physicians.
  2. To implement evidence based best practices to improve the value of care for ED patients.  
  3. To collaborate with providers and staff to improve our patient satisfaction overall rank to greater than the 50th percentile.  


  1. Built a series of run charts to monitor and report Press Ganey ED Patient Satisfaction scores and ranks.
    • Measures are reported and evaluated on a monthly basis in the Section of Emergency Services, Medical Staff meeting.
  2. Implemented evidence based methods and tools
    • Business cards for physicians
    • Call Back
    • Direct Bedding
    • Feedback of Survey comments to physicians on an individual basis
    • Enhanced communication through the use of mobile headphones
  3. Established a partnership with the Studer Group and utilized its principles to improve patient satisfaction. 
    • AIDET (Acknowledge, Introduce, Duration, Explanation, Thanks)
    • Manage Up
    • Rounding for Outcomes

Measures: Press Ganey Patient Satisfaction mean scores and large database rank.


Results: RRMC’s 2013 patient satisfaction goal was to achieve an overall rank above the 50th percentile.  Over the course of the year, we met that goal and often surpassed it.  In the month of October, our rank in the large database report, was at the 98th percentile.  Our Press Ganey Patient Satisfaction standard mean scores improved by over 9% following implementation of evidenced based improvement methods in the ED.  During this time, rank scores for physicians rose from below the 10th percentile to an annual rank of 78 percent.
Emergency Department Press Ganey Patient Satisfaction Mean Scores

Emergency Department Press Ganey Patient Satisfaction Rank


American College of Emergency Physicians Advancing Emergency Care. (2014).

Press Ganey Associates, Inc. (2014).

Studer Group. (2014).

Contact for Project: Denise Simpson, MSA, CIC, CPHQ, Manager, Performance Improvement, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone: 802.747.1892.

phoneCall 802.775.7111 for more information about a service or to make an appointment.

Reducing Hospital Admissions for Congestive Heart Failure Patients

A collaborative of health care providers in Rutland, Vermont is working to help patients with Congestive Heart Failure (CHF) stay out of the hospital. 
Watch the Video >>

Rutland Regional Medical Center
160 Allen Street
Rutland, VT 05701

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