Queensway Carleton Hospital identified a need to reduce its readmission rates – one strategy amongst several to address capacity challenges and occupancy rates that regularly exceed 100%.

The team examined available data and determined that the discharge process was a great place to start. Our patient survey data indicated that patients were not very satisfied with the discharge process.

We know that discharge can be a stressful time for patients — and often happens at the last minute.  The period following discharge is also a vulnerable time for patients.  An improvement in this area could help reduce readmissions – and increase patient satisfaction.

Each medicine unit discussed the issue at their Unit Leadership Team (ULT) meeting, which consists of nursing, allied health, physicians and patient/family advisors.  Each unit identified one area to work on – medication teaching, transportation, transition tools, MD appointments and Care Partner identification.

One key “aha moment” was the clarification of who the transition tools were for.  For the longest time, it was felt that the tools were intended to inform staff. However, the reality is that the tools and information are for the patient and family — so it must be tailored to them.  Transition tools transmit critical information from hospital to patient at the time of discharge.

We experienced across-the-board reduction in readmission rates and an increase in patient satisfaction with discharge since the implementation of the new process

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