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Hospital Report Card

  • Quality Improvement Projects

Hospital Quality Improvement Projects

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

Time Frame: September 2013-present

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. 

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. 

Chronic Obstructive Pulmonary Disorder 30-day Readmission Rate.

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: Emergency Department Left Without Being Seen

Timeframe: 2012-2014

Rutland Regional Medical Center has the 2nd largest Emergency Department in the State of Vermont with over 34,000 visits each year. Our Emergency Department (ED) consists of a 15-Bed unit that includes four acute resuscitation and two acute psychiatric or isolation rooms. Additionally, there are seven hall beds and four Fast Track beds. We provide 45 hours per day of Physician coverage which is supplemented by Physician Assistants who provide coverage in Fast Track for 13 hours each day. We have a high acuity level with an admission rate of approximately 20%. In 2012, Rutland Regional recognized the need to evaluate and improve ED throughput. At that time, our Left Without Being Seen (LWBS) rate was 4.9 and patient satisfaction was low.

The Institute of Medicine has defined 6 domains of quality of care: safety, timeliness, effectiveness, efficiency, equality, and patient- centered care. Timeliness and efficiency are core measures of emergency medicine and help us understand and address factors that contribute to workflow and ultimately impact quality and satisfaction for patients seeking emergent care.

The percentage of patients who leave without being seen in an emergency department is an outcome measure of impaired access and represents the failure of an emergency healthcare delivery system to meet its goal of providing care to those who need it most. Patients who leave without being seen is correlated with timeliness and can be thought of as an indirect marker for timeliness and efficiency. LWBS rates increase as emergency department capacity saturates. LWBS rates have also been shown to be associated with poorer patient care outcomes.

Patients leave without being seen for many reasons. In 2012, a study of our ED patients who left without being seen, identified long wait times as the most frequently stated reason. Rutland Regional undertook a study of crowding in the ED. According to this NEDOC analysis, our ED is overcrowded a third of the time.

Emergency physicians have historically viewed LWBS patients as those whose illnesses and injuries were not sufficient enough for them to feel they needed to wait. Administrators see these patients as lost revenue and increased potential liability. The benchmark is 1% but the average busy ED has 3% or more of their patients leaving without being seen by a doctor.

In order to decrease the number of patients who leave without being seen, we sought new models of ED intake and flow. Our initial measure is our LWBS rate. Length of stay, door-to-physician time, and left without being seen have been endorsed by the National Quality Forum as quality measures for ED services.

Project Goals: 
The Mission of our Emergency Department is to deliver high quality critical, emergent and urgent care while maintaining a safe, respectful and compassionate environment.

Our project goal was to reduce the number of patients who leave the Emergency Department without being seen.


  • Adoption of Direct Bedding
  • Introduction of Motorola radios
  • Staff Engagement (Studer)
  • Leader Rounding on Patients and Staff
  • AIDET training and coaching
  • ED Scribe Program


  • National Average: 2%
  • RRMC: 1.4% December 2014

Last fall, the ED was chosen to receive an Excellence in Patient Care Award, given by Studer Group. ED Director, Tom Rounds, RN said this about his team’s important achievement: “The Excellence in Patient Care Award represents an early win for both the Emergency Department staff and the community of Rutland. We have embraced change to respond to the external operating environment, and because adopting new evidence-based practice will deliver better clinical and quality outcomes for our patients! It was an incredible honor to walk the national stage with representatives of our physician and nursing leadership team. We have more hard work ahead and are all committed to Excellence in the Emergency Department.”

Jesse M. Pines, M. M. (2006). Left-without-being-seen: An Imperfect Measure of Emergency Department Crowding. Academic Emergency Medicine, 807.

Rennee Y. Hsia, M. M.-J. (2011 Jul; 58(1)). Hospital Determinants of Emergency Department Left Without Being Seen Rates. Ann Emerg Med, 24-32.e3.

S.Welch, M. B.-G. (2010). Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit. Ann Emerg Med.

Contact for Project:
Denise Simpson, Manager, Performance Improvement, Rutland Regional Medical Center, 160 Allen Street, Rutland, VT 05701. Telephone: 802.772.2408.

Project Name: Core Measures Improvement

Time Frame: January 2013-December 2014

In setting the organizational goals for FY13, leadership at Rutland Regional Medical Center recognized that improvement was needed in our Core Measure results. In November of 2012, a steering committee was formed to initiate improvement projects and assist in selecting multidisciplinary staff members to the improvement teams. Results of our monthly quarterly Core Measures were to be reported on the Organizational Scorecard and incorporated into the Clinical Leaders evaluations. Surgical Care (SCIP) was selected for the project based on the assessment of the current data and identified opportunities. (SCIP is an acronym for Surgical Care Improvement Project, original name for the Surgical Care Core Measure).

Core Measures were to be reported on the Organizational Scorecard and incorporated into the Clinical Leaders evaluations. Core Measures are evidenced-based national standards of care shown to improve patient outcomes and the best treatment options for certain conditions including heart attack, heart failure, pneumonia, surgical care, children’s asthma, inpatient psychiatric services, stroke, venous thromboembolism, immunization, and perinatal care. Developed by The Joint Commission, Core Measures are an important way to measure the quality of care that a hospital is providing to its patients. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Several also include Prevention Measures. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care. These measures also provide a way for a hospital to identify areas of improvement and to take the action steps needed to provide the best care possible. Hospitals across the country, including Rutland Regional, are measured and compared by The Joint Commission against all other accredited institutions on their performance in these Core Measures.

Core Measure performance is critical to Rutland Regional for several reasons:

  • Rutland Regional is committed to provide our patients with the best quality care. Excellent performance is one measure of our Vision to be the Best Community Health System in New England.
  • Performance is reported to The Joint Commission and CMS and is tied to Medicare reimbursement.
  • Is publicly reported information.

Project Goals:
Goal #1 is to increase nursing and surgeon awareness of the SCIP measures, foster collaborative communication between nurse and MD on these specific care items and to improve overall necessary documentation when needed.

Goal #2 is to improve consistency with overall scores (that fluctuated quarter to quarter) to greater than 50th percentile when compared to the national database.

Our ultimate goal is to achieve 100% compliance with all measures.


  • SCIP Improvement Project Teams met to retrospectively review the opportunities for improvement. Each of the identified opportunities was screened for documentation and reasons for not meeting the measure via Root Cause Analysis. Low volumes in specific care sets can sometimes account for the variation in data.
  • Decision to implement a specific “SCIP” Physician Progress note: Surgical progress notes are handwritten and scanned into the Electronic Medical Record. The progress note has a section with a brief definition of each of the SCIP elements in which the surgeon can then address in the note. This progress note will address the elements that are not specifically captured in electronic documentation. 


  • Concurrent Review: Daily monitoring by Performance Improvement department and immediate feedback provided to physicians and nursing units when needed.
  • Monthly results reporting to Steering Committee, Medical Staff and Nurse Directors.
  • Results shared at Town Meetings and displayed on Organizational Scorecard.

With initial education and information to staff on the SCIP improvement project, our scores improved even before the SCIP progress note went “live”. RRMC met the goal and sustained consistency on our monthly results.

Core Measurements

Excellence Chart
The Joint Commission has recognized Rutland Regional Medical Center as a 2013 Top Performer on Key Quality Measures®. Rutland Regional has been recognized for its excellence in accountability measure performance shown to improve care for certain conditions, specifically its outcomes around Heart Failure, Pneumonia and Surgical Care. Rutland Regional was one of only two hospitals in Vermont and one of only 1,224 hospitals in the United States to achieve the distinction as a 2013 Top Performer.


Contact for Project: 
Denise Simpson, MSA, CIC, CPHQ, Manager, Performance Improvement

Ann Irons, BSN, RN-BC, Performance Improvement Clinical Specialist
Telephone: 802.747.1892, 802.747.3773

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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