This paper will explore the importance of preventing acute hospital readmissions in the heart failure adult population. Prevention of re-hospitalization is aimed at improving patient care and outcomes as well as reducing the financial stress caused by readmissions. Recurrent hospitalizations are expensive and unnecessarily overutilize resources (Donzé, Lipsitz, Bates, & Schnipper, 2013). Research shows that improving transitions of care during hospitalization and developing specific heart failure interventions healthcare providers can assist in reducing readmissions. For this project the Plan Do Check Act (PDCA) tool combined with the lean methodology. The PDCA cycle consist of planning, to identify the problems, do to create solutions and implement, check to evaluate and assess progress, and to act to document and review for permanent implementation. Specific interventions will be discussed throughout this paper; the main interventions that were implemented during this capstone project are; progression of care rounds with physician attendance, dedicated care coordinator and social worker, dedicated transitions of care nurse, geo-localization of patients, and a medication program. Thus the clinical intervention question asked is: post-acute heart failure hospitalized patients (P) who receive specific inpatient and outpatient services (I) compared to those that do not receive specific inpatient and outpatient services (C) reduce hospital readmissions (O) within 30 days (T)?

Date of publication

Spring 4-26-2020

Document Type

MSN Capstone Project



Persistent identifier



Masters of Science in Nursing Administration