1. Reducing Avoidable Readmissions by Improving Transitions in Care
Pat Rutherford MS, RN
Vice President
Institute for Healthcare Improvement
July 13-14, 2011
Denver, CO

2. Welcome! Who is attending the seminar? Why are you here today?
What do you hope to learn?

3. IHI Background Founded by Don Berwick and colleagues
Current President and CEO: Maureen Bisognano
Grew out of National Demonstration Project on Quality Improvement in Health Care (NDP)
First National Forum was the NDP Summit
Incorporated in 1991
From 4 employees to now 114
Office in Cambridge, Massachusetts
Remote employees in many other locations
Work in North America, Europe, and Africa

4. IHI Staff

5. We Are…
The Institute for Healthcare Improvement ( is an independent not-for-profit organization that works with health care providers and leaders throughout the world to achieve safe and effective health care. IHI focuses on motivating and building the will for change, identifying and testing new models of care in partnership with both patients and health care professionals, and ensuring the broadest possible adoption of best practices and effective innovations. Based in Cambridge, Massachusetts, IHI mobilizes teams, organizations, and increasingly nations, through its staff of more than 100 people and partnerships with hundreds of faculty around the world.

6. Institute of Medicine, Crossing the Quality Chasm, 2001
We Exist Because…
“Between the health care we have and the care we could have lies not just a gap, but a chasm.”
Institute of Medicine, Crossing the Quality Chasm, 2001
IHI exists because. There is an enormous gap between the health care we have and the health care we should have – a quality gap so large that the Institute of Medicine refers to it as a “chasm.” The flaws in the current system are indisputable: best-known science is not reliably applied; widespread inefficiencies waste precious resources; and our system, which aims to heal, too often does just the opposite, leading to unintended patient harm and unnecessary deaths.

7. The IOM’s Six Aims for the Health Care System:
Our Goals Are…
The IOM’s Six Aims for the Health Care System:
Safe – no needless deaths
Effective – no needless pain or suffering
Patient-Centered – no helplessness in those served or serving
Timely – no unwanted waiting
Efficient – no waste
Equitable – for all
The IHI’s blueprint for its work – the goals we aspire to – come from the Institute of Medicine’s landmark 2001 report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. In it, the IOM identified six urgently needed “Aims for Improvement” of health care in America. IHI has translated these goals into what we call the “No Needless” list:
Safe – To reduce the harm done to patients by errors in care – defects which, according to the IOM, kill between 44,000 and 98,000 Americans each year in hospitals alone;
Effective – To promise patients that they will receive care faithfully according to science, and that they will not be subjected to care that cannot help them;
Patient-centered – To redesign care so as to restore dignity, self-esteem, and control to patients and families who too often feel helpless, forgotten, and unheard;
Timely – To reduce the waiting and delays that pervade health care for both patients and those who give the care;
Efficient – To recover a substantial portion of the money wasted in health care through administrative complexity, unnecessary procedures, and lack of coordination;
Equitable – To close the racial and socio-economic gaps in health status, access, and outcomes.

8. Our Mission Is…
To improve the lives of patients, the health of communities, and the joy of the health care workforce.
….and to close the Quality Gap as fast as possible
And that is where the Institute for Healthcare Improvement (IHI) comes in. Improving health care is IHI’s mission, its promise, and its daily work. IHI is here to help raise the bar on health care performance – ultimately improving the lives of patients, the health of communities, and the joy of the health care workforce – by translating innovative ideas into practical results that are truly meaningful in the lives of our patients.

9. We Do This By… Building the Will for Change
Cultivating Promising Improvement Ideas
Putting those ideas into action through effective Execution
We achieve this mission by:
1. Inspiring optimism for change. We call this “Building Will.”
2. The intent to change is empty optimism without novel ideas and new solutions. So, IHI finds, cultivates, or invents great improvement ideas.
3. Strong will and good ideas must then be channeled by a practical implementation model. IHI supports action by bringing organizations and individuals together to “all teach and all learn,” and by providing the tools and methods for rapidly achieving meaningful and sustainable results.
Tom Nolan, one of IHI’s senior leaders, taught us this model: improvement of any system requires WILL, IDEAS and EXECUTION. IHI’s strategy focuses on all three of these elements simultaneously.

10. Some of Our Groundbreaking Initiatives Include…
100,000 and 5 Million Lives Campaigns
IHI Open School for Health Professions
The IHI Triple Aim
The Improvement Map & Passport
STAAR (STate Action on Avoidable Rehospitalizations)
TCAB (Transforming Care at the Bedside)
Safer Patients Initiative (UK)
Scottish Patient Safety Programme
Chronic Care Initiative (Indian Health Service)
WIHI

11. IHI Open School for Health Professions

12. The IHI Improvement Map

13. A 12-month membership program for hospitals, including:
Unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements
Training for middle managers to effectively lead quality improvement initiatives
Enhanced strategic planning for member organizations through customized whole systems data and selected benchmarking information
Exclusive access to On Demand tools and resources, including podcasts, videos, and presentations on a variety of topics
For details, visit call , or

14. IHI Conferences:
23rd Annual National Forum on Quality Improvement in Health Care December 4-7, 2011 Orlando, Florida
13th Annual International Summit on Improving Patient Care in the Office Practice and the Community March Washington, DC
IHI/BMJ International Forum on Quality and Safety in Health Care – April 17-20, 2012 in Paris, France

15. IHI’s Online Resources
Subscribe to This IHI, IHI’s free weekly e-newsletter
Listen to WIHI, a free audio program from IHI
Check out the great resources, tools, stories, and contacts available on
IHI Fan Page
IHI Group

16. Seminar Agenda (Day 1)
Wednesday, July 13, :00-8:20 Welcome, Introductions and Overview 8:20-9:20 Getting Started 9:20-9:40 Break 9:40-11:00 Overview of IHI’s Approach 11:00-12:00 Enhanced Assessment 12:00-12:40 Lunch 12:40-2:00 Effective Teaching and Enhanced Learning 2:00-2:20 Break 2:20-3:40 Post-Hospital Follow-Up Care 3:40-5:00 Real-Time Handover Communications 5:00-6:00 Networking Reception (optional)

17. Seminar Agenda (Day 2) Thursday, July 14, 2011 8:00-8:20 Debrief
8:20-9:00 Cross Continuum Teams
9:00-10:20 Transitions into Community Settings
(2 breakouts)
10:20-10:40 Break
10:40-11:40 Engaging Patients and Families
11:40-12:30 Lunch
12:30-1:30 Getting Results
1:30-2:15 Action Planning
2:15-2:30 Wrap-up and Evaluation
2:30–3:00 Faculty Consults (optional)

18. Kate Bones, MSW
Kate Bones, MSW, Project Director, has been with IHI for eleven years managing collaborative quality improvement programs, R&D initiatives, and strategic partnerships for the organization. Most recently, Ms. Bones has directed programs related to waste reduction and serves as IHI’s Operational Lead for the AHRQ ACTION II Partnership, and she will be serving as a Collaborative/Network Director in IHI’s State Action on Avoidable Rehospitalizations (STAAR) initiative. Ms. Bones has a background in community health and health policy.

19. Peg Bradke, RN, MA
Peg M. Bradke, RN, MA, Director of Heart Care Services, St. Luke's Hospital, coordinates services for two intensive care units, two step-down telemetry units, the Cardiac Catheter Lab, Electrophysiology Lab, Diagnostic Cardiology, Interventional/Vascular Lab, and Cardiopulmonary Rehabilitation. In her 25-year career, she has had various administrative roles in critical care areas. Ms. Bradke works with the Institute for Healthcare Improvement on the Transforming Care at the Bedside initiative and Transitions Home work. She is President-Elect of the Iowa Organization of Nurse Leaders.

20. Eric Coleman, MD, MPH
Eric A. Coleman, MD, MPH, is Professor of Medicine within the Divisions of Health Care Policy and Research at the University of Colorado at Denver and Health Sciences Center. He is the Director of the Care Transitions Program that aims to improve quality and safety during care "handoffs" across care settings.

21. Saranya Kurapati, MD, MPH
Saranya Kurapati, MD, MPH, recently joined IHI as its Director of Care Transitions Programs.  Saranya, who recently completed her master’s at the Harvard School of Public Health, will work closely with the STAAR team to align all of IHI’s current work on care transitions and to develop strategies to make the interventions in STAAR scalable.

22. Gail Nielsen, BSHCA, FAHRA, RTR
Gail A. Nielsen, BSHCA, FAHRA, RTR, Director of Learning and Innovation, Iowa Health System, building infrastructure and capability across the 26-hospital enterprise for innovation and process improvement to achieve ideal patient care delivery. She is a George W. Merck Fellow, Patient Safety Scholar and faculty of the Institute for Healthcare Improvement.

23. Cory Sevin, RN, MSN, NP
Cory Sevin, RN, MSN, NP is a Director with the Institute for Healthcare Improvement. She has 30 years of experience in supporting change for improvement-with individuals and healthcare organizations. She has experience working with adolescents and their families in health risk behavior change, adults with chronic conditions, and leading primary care practice transformation as Vice President of Operations at Clinica Campesina Family Health Services. With IHI, Ms. Sevin has lead work in Office Practice Transformation, Operational Excellence in the ED, Spread and Improving Transitions in Care.

24. Pat Rutherford MS, RN
Patricia A. Rutherford MS, RN is a Vice President at the Institute for Healthcare Improvement (IHI). She is leads innovations in the following areas: Transforming Care at the Bedside; Optimizing Care Coordination and Transitions in Care; Improving Efficiency and Flow in Hospitals, Office Practices and Outpatient Settings; and Innovations in Patient-Centered Care. She is currently the co-investigator for the STate Action on Avoidable Rehospitalizations (STAAR) initiative, funded by The Commonwealth Fund.