Your Resource for HQIC Highlights and Learning Opportunities | April 2021
Readmission Prevention
A readmission is an unplanned return to the hospital within 30 days of the initial hospital discharge date. Readmissions are tracked and measured by Medicare to give hospitals a readmission rate.

Readmissions are disruptive for patients and family members and very often are preventable. In addition to quality concerns, readmissions are very costly for the healthcare system and patients. Hospitals are financially penalized by Medicare through the Hospital Readmissions Reduction Program for higher-than-expected readmission rates.1

Readmission reduction strategies frequently include:
  • Improving patient and family education.
  • Identifying patients at risk of readmission.
  • Assisting with provider follow-up appointments, including assuring transportation is available.
  • Improving hand-off communication to post-acute care, such as skilled nursing facilities (SNFs) or home health agencies.
  • Contacting/visiting high-risk patients within 72 hours post-discharge.
  • Maintaining frequent communication with SNFs and home health agencies to promote wellness outside the acute care hospital.

Patients discharged due to an admission for heart failure or sepsis often account for the highest readmitted patient populations. HSAG HQIC developed a Heart Failure Zone Tool and Sepsis Zone Tool to assist these patients in managing their own care after discharge.
The Flash: Resources
Readmission Roadmap to Success
Use the Readmission Roadmap to Success, developed by HSAG HQIC, to prevent readmissions. The roadmap includes evidence-based tools and resources for each step of your journey, including instructions to:
  • Review your data and know your high utilizers.
  • Charter a multidisciplinary team to focus on care transitions.
  • Identify high-risk patients.
  • Create a discharge plan.
  • Follow up with patients after discharge.
Teach-back can help prevent readmissions and engage patients and families by communicating in ways they can understand well enough to teach back to you. This includes using words patients understand in the language they prefer. When patients understand their discharge and self-management plan, they are more likely to not be readmitted.

You can find links to teach-back resources at View this short video about how a patient with asthma exemplifies the “show-me” method of teach-back,
Critical Communication
HSAG HQIC Culture of Safety and the Institute for Healthcare Improvement (IHI) National Action Plan to Advance Patient Safety Assessment
Once finished with your onboarding tasks of completing the Data Use Agreement; completing the Quality Improvement Innovation Portal Administrator form for the secure data portal; and conferring rights to HSAG HQIC for the National Healthcare Safety Network (NHSN), if you report into NHSN, it’s time to complete your Safety Assessment.

The Safety Assessment was developed by IHI to establish a baseline for the culture of safety infrastructure in your hospital, simultaneously reduce all-cause harm, incorporate Safety Across the Board and High Reliability, measure progress in overall safety, and identify potential correlations between a culture of safety and harm reduction.

The Safety Assessment contains four sections:
  1. Culture, leadership, and governance
  2. Patient and family engagement (PFE)
  3. Workforce safety
  4. Learning systems

HSAG HQIC is providing the Safety Assessment in a online format with the incorporation of the Centers for Medicare & Medicaid Services (CMS) PFE five focus measures. A short, how-to video on navigating the Safety Assessment is available at To access and complete the Safety Assessment, go to using the de-identified username provided to you by your Quality Advisor. 
Events and Education
Increasing the Use of ICD-10 Z Codes for Social Determinants
Wednesday, May 5, 2021
2–3 p.m. ET (1 p.m. CT, 12 noon MT, 11 a.m. PT)
  • Discuss the importance of identifying social determinants of health in the population you serve.
  • Identify the Z Codes that will enable your hospital to collect social determinants of health in administrative claims data.
  • Review how hospitals can leverage Z Codes to identify and address disparities of care. 

Diana Zona, Executive Director, South Carolina Hospital Association Foundation
This material was prepared by Health Services Advisory Group (HSAG) Hospital Quality Improvement Contractor (HQIC), under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. XS-HQIC-XT-03302021-01