Date of Graduation

Spring 5-17-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Mary Seed



The objectives during this project were to achieve by the end of 2018 an overall reduction of 25% in HF readmissions within 30 days. By identifying root causes of readmissions and using needs assessment within the microsystem, literature highlights the elements defining interventions that can be used to improve transitions of care and reduce avoidable HF hospital readmissions. A plan was developed for integrating an evidence-based practice, IDEAL Discharge Planning, along with engaging patients and families at bedside from the first day of admission until discharge to more effectively assist staff in providing patient-centered education and self-care skills. The results were a better care transition experience and prevention of avoidable readmissions in HF patient populations.

The microsystem consists of twenty-six telemetry beds and specializes in managing patients with a primary diagnosis of cardiovascular disease. Fifty patients’ charts were reviewed for 2 months prior to initiation of the project, and again 2 months later to collect data specific to HF patient 30-day readmission rates.

The CNL strives to identify quality measures that need improvement, incorporate new evidence into practice, implement new guidelines for patient care, track data on the project, and is able to show improved clinical outcomes that are immensely cost effective within the microsystem. Ultimately, this project should gain support and spread to other microsystems and other patient populations within the hospital organization.