Date of Graduation

Summer 8-11-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Cathy Coleman, DNP, RN, MSN, CNL, CPHQ



There are multiple layers of oversight across the healthcare delivery system. Measuring acute hospital readmissions has been identified as an important outcome measure of quality care. Our patients are one of the major stakeholders in the healthcare system. One role of a clinical nurse leader is to integrate evidence-based leadership practices that identify and assess outcomes, mitigate risk, enhance health promotion, deliver highly effective patient care, and ensure transparent relationships with stakeholders. Rationales for examining and re-designing the readmission analysis workflow based on the customer’s experience are discussed in this paper. The global aim of the project is to reduce skilled nursing facility (SNF) readmissions from home from 13% in 2020 to 10% in 2021. The specific aim is to increase utilization of the Voice-of-the-Customer template in readmission analysis for all SNF readmissions from home from 0% to 90% by July 15, 2021.

A telephone or face-to-face contact is initiated by a nurse case manager utilizing a script designed for this study. A Microsoft Forms template was used to document the survey details of the Voice-of-the-Customer as part of the readmission analysis. There were a total of 29 readmissions from home for the timeframe April 5, 2021, to July 15, 2021. Twenty-two met the inclusion criteria for the process improvement project. The team completed post-readmission contact and documentation on all 22 readmissions (100%), thereby meeting the outcomes measure goal. The process measure target was also met, as all but one, or 95%, of the patients/ caregivers participated.

Key opportunities identified for preventing hospital readmissions include improving patient and caregiver education with timely follow-up post SNF discharge and formalizing and routinely sharing best practices with SNF partners.