Reduction In 30-day Readmission Rates Research Articles

Early outcomes following implementation of ERAS for pancreas surgery

Introduction: Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative program to reduce postoperative morbidity. A number of European institutions reported improvements in short-term outcomes following ERAS implementation for pancreas surgery; however there are no similar data from the US. In this study, we examined early outcomes following ERAS implementation at a major US academic institution among patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy. Methods: Using institutional NSQIP outcomes from 2013-2017 we identified patients who underwent PD or distal pancreatectomy before and after implementation of ERAS (May 2016). Categorical variables were compared using Fischer exact test. LOS was compared using Mann-Whitney U test. Statistical significance was defined as p value < 0.05. Results: 247 patients underwent PD (164 before and 83 following ERAS) and 149 patients underwent distal pancreatectomy (111 before and 38 following ERAS). Of those undergoing PD, there was a trend towards reduced median LOS following ERAS implementation from 10 days (range 5–79 d; IQR 7) to 8 days (range 4–52 d; IQR 8)(p = 0.17). Additionally, there was a reduction in 30-day readmission rates (18.9% to 13.3%, p = 0.29). For patients undergoing distal pancreatectomy, there was no difference in median LOS (6 vs. 5d; p = 0.55). Conclusions: The early results following ERAS implementation for pancreas surgery demonstrate a reduced LOS for PD patients without increased readmission rates. Similar LOS improvements did not apply to distal pancreatectomy. Given that PD is a complex surgical procedure with persistently high morbidity, ERAS may have a more profound impact on short-term outcomes among these patients.

Noninvasive Remote Dielectric Sensing Vest Significantly Reduces Readmission Rate of Patients with Heart Failure

Introduction Hospital readmission rates remain persistently high in the modern era despite optimal medical management following prescribed guideline directed medical therapy. Few interventions or therapies have demonstrated a significant reduction in 30-day readmission rate due to heart failure complications. The remote dielectric sensing (ReDS) vest manufactured by Sensible Medical Technologies is a noninvasive wearable device that may assist in optimization of volume status in patients with heart failure. Hypothesis Given preliminary data, our hypothesis is that the ReDS vest significantly reduces 30-day readmission rates for patients admitted for acute heart failure exacerbations. Methods A retrospective review was performed of 163 consecutive patients admitted between September 2017 and December 2017 to a dedicated cardiac telemetry unit with a diagnosis of acute systolic or diastolic heart failure. All patients underwent the standard of care with the addition of a ReDS vest reading within 24 hours of predicted discharge. Patients served as their own control, by analyzing admissions data for the 12 months previous to initiation of the ReDS vest assessments. Readmission rates of the patients were compared pre- and post-ReDS vest introduction. Results Implementation of the ReDS vest significantly reduced 30-day readmission rate between the ReDS and control groups (14.1% vs. 33.3%, respectively; ARR 19.2%, RRR 57.7%, p Conclusions The ReDS vest offers a noninvasive, efficient, user-friendly approach to impart a significant beneficial impact on clinical decision making and meaningfully reduce the 30-day readmission rate of patients admitted with heart failure exacerbation. Further investigation, including prospective randomized trials, is warranted based on this study.

Pilot Randomized Controlled Trial to Reduce Readmission for Heart Failure Using Novel Tablet and Nurse Practitioner Education

Abstract Background Heart failure education programs are not standardized. The best form of education is unclear. We evaluated whether addition of a novel tablet application to nurse practitioner (NP) education was superior to NP education alone in reducing 30-day readmission after heart failure hospitalization. Methods From February 2015-March 2016, patients admitted to a quaternary academic center with primary diagnosis of heart failure were randomized to 1) treatment – NP education plus tablet application (interactive conditional logic program that flags patient questions to medical staff), or 2) control – NP education. The primary outcome was reduction in 30-day readmission rate. Secondary outcomes included satisfaction and education assessed via survey. Results Randomization included 60 patients to treatment and 66 to control. A total of 13 patients withdrew prior to intervention (treatment n = 4, control n = 1) or were lost to follow-up (treatment n = 3, control n = 5). The 30-day readmission rate trended lower for treatment compared with control, but results were not statistically significant (13.2% [7/53], 26.7% [16/60], respectively, P = .08). Similarly, satisfaction trended higher with treatment than control ( P = .08). Treatment patients rated explanations from their physicians higher than control (Always: 83.7%, 55.8%, respectively, P = .01). Conclusions NP education plus tablet use was not associated with significantly lower 30-day readmission rates in comparison with NP alone, but a positive trend was seen. Patient satisfaction trended higher and heart failure explanations were better with NP education plus tablet. A larger study is needed to determine if NP education plus tablet reduces readmission rates following heart failure admission.

Pilot Randomized Controlled Trial to Reduce Readmission for Heart Failure Using Novel Tablet and Nurse Practitioner Education

BackgroundHeart failure education programs are not standardized. The best form of education is unclear. We evaluated whether addition of a novel tablet application to nurse practitioner (NP) education was superior to NP education alone in reducing 30-day readmission after heart failure hospitalization. MethodsFrom February 2015-March 2016, patients admitted to a quaternary academic center with primary diagnosis of heart failure were randomized to 1) treatment – NP education plus tablet application (interactive conditional logic program that flags patient questions to medical staff), or 2) control – NP education. The primary outcome was reduction in 30-day readmission rate. Secondary outcomes included satisfaction and education assessed via survey. ResultsRandomization included 60 patients to treatment and 66 to control. A total of 13 patients withdrew prior to intervention (treatment n = 4, control n = 1) or were lost to follow-up (treatment n = 3, control n = 5). The 30-day readmission rate trended lower for treatment compared with control, but results were not statistically significant (13.2% [7/53], 26.7% [16/60], respectively, P = .08). Similarly, satisfaction trended higher with treatment than control (P = .08). Treatment patients rated explanations from their physicians higher than control (Always: 83.7%, 55.8%, respectively, P = .01). ConclusionsNP education plus tablet use was not associated with significantly lower 30-day readmission rates in comparison with NP alone, but a positive trend was seen. Patient satisfaction trended higher and heart failure explanations were better with NP education plus tablet. A larger study is needed to determine if NP education plus tablet reduces readmission rates following heart failure admission.

Impact of pharmacist-led medication management in care transitions

BackgroundWhen patients are discharged from hospital to home, it is a highlighted vulnerable period for which medication - related problems are prevalent. Researchers have proposed a telephone follow-up intervention as a means to reduce hospital readmissions. However, the outcome of the intervention with the engagement of pharmacists in managing patients’ medicines after discharge has not been well explored. The objectives of this study were (1) to determine whether a pharmacist telephone follow-up intervention focusing on patients’ medicines management support is associated with a reduction in 30-day readmission rates and (2) to describe the number and types of pharmacist interventions in care transitions.MethodsThis was a case-cohort study conducted in two acute hospitals in the UK. Pharmacists performed a telephone follow-up intervention to discharged patients to provide medicines management support. Patients who received pharmacist telephone follow-up calls within 14 days of discharge formed the intervention group. A subset of medical patient population discharged in the month of May 2013 formed the comparison group. During a series of two-telephone follow-up, pharmacists identified post-discharge pharmaceutical problems and provided patient-tailored interventions accordingly. The impact of pharmacist interventions was assessed using a risk assessment matrix tool by two senior pharmacists. Overall 30-day readmission rates in the intervention group were measured and compared with the comparison group using a chi-square test.ResultsBetween 5th and 25th June 2013, a total of 62 medical patients participated in the study. Pharmacists provided 192 interventions as a result of pharmacist telephone follow-up intervention. The most prevalent type of interventions was the provision of drug information (n=40), followed by screening patient adherence (n=30) and advising on adverse drug reactions (n=27). The impact of interventions was assessed, and 49.3% of the identified risks intervened by pharmacists were associated with moderate risk. The 30-day readmission rates in the intervention group were 11.3% compared to 9.0% in the control group (p = 0.376); this was not statistically significant.ConclusionsA pharmacist TFU intervention did not show a benefit in 30-day hospital readmissions. However, a pharmacist TFU intervention was an effective method to solve or avoid critical pharmaceutical problems. A future study using a larger scale trial is warranted.

Impact of Contextual Factors on Interventions to Reduce Acute Care Transfers II Implementation and Hospital Readmission Rates

ObjectivesIdentify contextual and implementation factors impacting the effectiveness of an organizational-level intervention to reduce preventable hospital readmissions from affiliated skilled nursing facilities (SNFs). DesignObservational study of the implementation of Interventions to Reduce Acute Care Transfers tools in 3 different cohorts. SettingSNFs. ParticipantsSNFs belonging to 1 of 2 corporate entities and a group of independent SNFs that volunteered to participate in a Quality Improvement Organization (QIO) training program. InterventionTwo groups of SNFs received INTERACT II training and technical assistance from corporate staff, and 1 group of SNFs received training from QIO staff. MeasurementsThirty-day acute care hospital readmissions from Medicare fee-for-service claims, contextual factors using the Model for Understanding Success in Quality framework. ResultsAll 3 cohorts were able to deliver the INTERACT training program to their constituent facilities through regional events as well as onsite technical assistance, but the impact on readmission rates varied. Facilities supported by the QIO and corporation A were able to achieve statistically significant reductions in 30-day readmission rates. A review of contextual factors found that although all cohorts were challenged by staff turnover and workload, corporation B facilities struggled with a less mature quality improvement (QI) culture and infrastructure. ConclusionsBoth corporations demonstrated a strong corporate commitment to implementing INTERACT II, but differences in training strategies, QI culture, capacity, and competing pressures may have impacted the effectiveness of the training. Proactively addressing these factors may help long-term care organizations interested in reducing acute care readmission rates increase the likelihood of QI success.

Trends in 30-day readmission rates after COPD hospitalization, 2006-2012.

Reduction in 30-day readmission rate after chronic obstructive pulmonary disease (COPD)-related hospitalization is a national objective. However, little is known about trends in readmission rates in recent years, particularly in priority populations defined by the Agency for Healthcare Research and Quality (AHRQ)(e.g., the elderly, women, racial/ethnic minorities, low-income and rural populations, and populations with chronic illnesses). We conducted a retrospective cohort study using data from the State Inpatient Database of eight geographically-dispersed US states (Arkansas, California, Florida, Iowa, Nebraska, New York, Utah, and Washington) from 2006 through 2012. We identified all COPD-related hospitalizations by patients ?40 years old. The primary outcome was any-cause readmission within 30 days of discharge from the index hospitalization for COPD. From 2006 to 2012, a total of 845,465 hospitalizations at risk for 30-day readmissions were identified. Overall, 30-day readmission rate for COPD-related hospitalization decreased modestly from 20.0% in 2006 to 19.2% in 2012, an 0.8% absolute decrease (OR 0.991, 95%CI 0.989-0.995, Ptrend<0.001). This modest decline remained statistically significant after adjusting for patient demographics and comorbidities (adjusted OR 0.981, 95%CI 0.977-0.984, Ptrend<0.001). Similar to the overall population, the readmission rate over the 7-year period remained persistently high in most of AHRQ-defined priority populations. Our observations provide a benchmark for future investigation of the impact of Hospital Readmissions Reduction Program on readmissions after COPD hospitalization. Our findings encourage researchers and policymakers to develop effective strategies aimed at reducing readmissions among patients with COPD in an already-stressed healthcare system.

Return-on-Investment (ROI) Analyses of an Inpatient Lay Health Worker Model on 30-Day Readmission Rates in a Rural Community Hospital.

The purpose of the study was to assess the return-on-investment (ROI) of an inpatient lay health worker (LHW) model in a rural Appalachian community hospital impacting 30-day readmission rates. The Bridges to Home (BTH) study completed an evaluation in 2015 of an inpatient LHW model in a rural Kentucky hospital that demonstrated a reduction in 30-day readmission rates by 47.7% compared to a baseline period. Using the hospital's utilization and financial data, a validated ROI calculator specific to care transition programs was used to assess the ROI of the BTH model comparing 3 types of payment models including Diagnosis Related Group (DRG)-only payments, pay-for-performance (P4P) contracts, and accountable care organizations (ACOs). The BTH program had a -$0.67 ROI if the hospital had only a DRG-based payment model. If the hospital had P4P contracts with payers and 0.1% of its annual operating revenue was at risk, the ROI increased to $7.03 for every $1 spent on the BTH program. However, if the hospital was an ACO as was the case for this study's community hospital, the ROI significantly increased to $38.48 for every $1 spent on the BTH program. The BTH model showed a viable ROI to be considered by community hospitals that are part of an ACO or P4P program. A LHW care transition model may be a cost-effective alternative for impacting excess 30-day readmissions and avoiding associated penalties for hospital systems with a value-based payment model.

Abstract WP374: Implementation of the Stroke Transition Discharge Center Improves 30-day Readmission Rate

Background: Stroke patients and their caregivers require formalized education, medications, testing and rehabilitation to assist in prevention of recurrence and of post-stroke complications for optimal outcomes. Objective: The purpose of this program was to evaluate the effect of the Stroke Transition Discharge Center (STDC) on stroke readmission. Methods: The Advanced Practice Nurses (APN) see all stroke and TIA patients one week after discharge from hospital to home or one week after discharge from rehab to home. During the hour encounter, the APN reviews medications, test results, signs and symptoms of stroke, complete education including patient specific risk factors and ensure appropriate follow up. The APN coordinates and facilitates multiple services and disciplines impacting the patient, assuring the most efficient and effective goal-directed activities are provided at the right time and in partnership with all other disciplines providing care. Results: Implementation of the STDC enhances patient outcomes and improves 30-day readmission rates. Prior to our intervention, the readmission rate was 15.3%. After the implementation of the STDC, there was a 61% reduction in 30-day readmission rates to 6%, which is significantly below the hospital system benchmark of 11%. There was an increase in the readmission rate in the first two quarters of 2016 noted. There is an inverse correlation with the number of patients seen in the STDC during the same time period. Further analysis demonstrates that only one readmission in this time period had been seen prior in the STDC. Conclusion: Implementing the Stroke Transition Discharge Center demonstrated a dramatic reduction in 30-day readmission rates. Our data suggests that utilization of the clinic and participation by the patients has a direct and inverse effect on readmissions. Further data will need to be collected to determine if this is a sustained response.

Reducing Inpatient Length of Stay Using a Multicollaborative Protocol for Management of Non-Intensive Care Unit Asthmatics.

Maximizing clinical efficiency through the reduction in inpatient length of stay (LOS) using standardized protocols has been a major objective among hospital administrators, most notably in the context of recent healthcare reimbursement changes at statewide levels. The objective of our project was to determine whether a synchronous change in an inpatient asthma protocol that relied on a respiratory therapist (RT)-driven bronchodilator weaning algorithm and bronchodilator therapy given through a metered dose inhaler (MDI) plus valved holding chamber (VHC) could impact clinical and financial outcomes. A pre-post study assessed patients aged 2-21 years of age admitted with a primary diagnosis of status asthmaticus. The effect of the protocol was measured from October 2014 to July 2015. Outcome variables included patient demographics, hospital LOS, all-patient refined diagnosis-related groups (APR-DRGs), and inpatient charges. Outcomes were compared between the preimplementation and postimplementation time periods. Statistical significance was measured using Wilcoxon signed-rank test and bootstrap logistic regression models. Protocol patients (n = 110) had a similar demographic and clinical profile compared with the matched population from the previous nonprotocol fiscal year (n = 150). Use of the protocol resulted in a significantly reduced LOS that maintained significance after adjusting for APR-DRGs weight (P < 0.05). The protocol did not alter the total hospital billing charges. A nonstatistically significant reduction in 30-day readmission rates was observed among those administered the protocol. An RT-led weaning protocol using a quantitative scoring system and MDI+VHC for bronchodilator administration resulted in a significantly reduced LOS.

18 One Page User Friendly Proforma Delivers Dramatic Improvements in Heart Failure Management in a Busy District General Hospital

<h3>Background</h3> Heart failure affects almost one million people in the UK with survival rates comparable to or worse than many cancers. Recent publications of the NICOR National Heart Failure Audit have focused attention on the need for improvement. This challenge is particularly acute in busy district general hospitals in London such as Whipps Cross University Hospital. <h3>Objective</h3> We aimed to investigate if the implementation of a simple one-page user friendly Whipps Cross Heart Failure Improvement Proforma- the ‘WHIP form’ in all medical wards could help improve the management of patients admitted with heart failure against standard quality measures. <h3>Methods</h3> The ‘WHIP form’ was introduced and implemented in all medical wards supported with a one-day educational seminar and a new dedicated heart failure email service. <h3>Results</h3> Between June to September 2015, 106 patients with a primary admission diagnosis of heart failure were enrolled and managed using the ‘WHIP form’. Inpatient mortality remained stable at 11.3% with an average hospital stay of 13.5 days. The 30-day readmission rate halved from 14% to 7%. Patients with documented left ventricular systolic dysfunction on Echocardiogram had significant improvements in the prescription of prognostic medication on discharge: ACEi/ARBs prescription increased from 78% from 88% [10% improvement]. B-Blockers prescription increased from 68% to 95% [27% improvement]. <h3>Conclusion</h3> The initiation of an “easy to use” one page heart failure management proforma led to a dramatic reduction in 30-day readmission rates and significant increase in the prescription of prognostically important ACE inhibitors and B-blockers. If the reductions in 30-day readmissions are sustained, we estimate that our cost neutral intervention could translate to yearly savings of nearly £80K for Whipps Cross University Hospital alone.

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial.

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge. Randomized, controlled trial with concealed allocation and blinded outcome assessors Two tertiary care academic medical centers Adults hospitalized with a diagnosis of ACS and/or ADHF. Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported. A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition. A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

Evaluation of Pharmacist Medication Education and Post-discharge Follow-up in Reducing Readmissions in Patients With ST-Segment Elevation Myocardial Infarction (STEMI)

Hospital readmissions have been shown to contribute to both patient morbidity and rising health care expenditures across a number of disease processes. Adherence to a cardioprotective drug regimen is particularly important after ST-segment elevated myocardial infarction (STEMI) because it is an acute condition associated with high patient morbidity and mortality. The objective of this study was to evaluate the effectiveness of pharmacist intervention with regard to reduction in hospital readmissions and improvement in medication adherence and literacy. This was a prospective single-center study in which patients admitted with STEMI who received stents between January 2015 and April 2015 were included. Pharmacist intervention included medication reconciliation, medication education, facilitation of the delivery of discharge medications, and post-discharge telephone calls within 48 to 72 hours. A retrospective review of historical STEMI patients who did not have pharmacist transitions of care support was performed to compare readmission rates. All-cause readmission at 30 days decreased from 13% to 5% (P = 0.18). Twelve of 95 patients in the historical control group were readmitted, compared to 2 of 40 patients in the intervention group. In the historical group, 3 of 12 patients required subsequent stent placement upon readmission, compared to none in the intervention group., Medication adherence and literacy scores improved significantly from baseline to high adherence and literacy at 30 days post-discharge (P = 0.0005). Pharmacist involvement in medication education signficantly improved medication adherence and literacy. There was a reduction in 30-day readmission rates, but the results were not statistically significant.

Pharmacist Monitoring in an OPAT Program Can Lead to a Reduction in 30-Day Readmission Rates

Pharmacist Monitoring in an OPAT Program Can Lead to a Reduction in 30-Day Readmission Rates

Improving quality in a national intestinal failure unit: greater efficiency, improved access and reduced mortality

ProblemIn 2010, there was a significant waiting list for admission to the intestinal failure unit (IFU) at the Salford Royal National Health Service (NHS) Foundation Trust. There had been a...

OC-039 Improving Quality In A National Intestinal Failure Unit: Greater Efficiency, Improved Access, Reduced Mortality

IntroductionIn 2010, there was a significant waiting list for admission to the Intestinal Failure Unit (IFU) at Salford, one of two current nationally-accredited centres. There had also been a steady...

Abstract 292: Predictors Of Heart Failure Readmission Rates, A Stanford Experience.

Introduction: The prevalence of heart failure (HF) is approximately 5.8 million, one in every five Medicare patients with HF are readmitted within 30 days. Heart failure readmissions cost 17.4 billion dollars annually. A major focus of health policy reform has been to contain costs by preventing readmission. Medicare has proposed criteria for HF reimbursement among which are readmissions within a 30-day period after the index hospitalization will not be reimbursed. The Medicare core measure aggregate has been sparsely validated in the literature and such validation of the core measures is essential. The aim of our study was to evaluate the predictive value of the Medicare core measure aggregate and if this aggregate is an effective proposed benchmark in reduction of HF readmission. Methods: A database was developed using RedCap (Research Electronic Data Capture), to study all patients admitted to Stanford Hospital and Clinics from September 2011 through January 2012. Inclusion criteria included those with a primary or secondary diagnosis of heart failure. Cardiac variables of interest beyond the core measures included among others, demographics, length of stay, and past medical history. Aggregate data from the Redcap database was analyzed by standard methods. Results: 101 patients were indexed during the retrospective cohort analysis. 100 were discharged alive. The overall 30-day readmission rate was 14%. There was no difference in readmission rates between patients who had core measures completed versus those who did not (13.8% vs. 14.3%; p= 0.944). In univariate Chi-square analyses, a phone call to the patient by a nurse within 24-48 hours post discharge was associated with significant reduction in rehospitalization rates (7.1% vs. 22.7%; p=0.026). Patients who were readmitted were found to have significantly more prior hospital admissions (3.0 +/- 2 vs. 1.7 +/- 2; p = 0.011) and prior ED visits (1.6 +/- 2 vs. 3.1 +/- 2; p=0.008). In multivariate logistic regression analysis, the phone call was associated with a 75% reduction in readmission (adjusted odds ratio = 0.254, 95% CI 0.066-0.981; p= 0.047). The predictor variable, systolic dysfunction (EF &lt; 55%) approached significance, with an adjusted odds ratio of 6.962, 95% CI 0.979-49.5; p 0.052. Conclusions: High readmission rates for HF are present despite advances in its management. The achievement of Medicare core measure variables was not associated with a reduction in 30-day HF readmission. The reasons for this finding are still unclear, perhaps hospitalizations are in need to meet Medicare core measure guidelines rather then tailor the discharge care of each patient. It is unexpected and noteworthy that a phone call made by a nurse to the patient post discharge was associated with a 75% reduction in 30-day readmission rates. Predictors of HF readmission remain complex and an ideal aggregate for predictors in readmission have yet to be defined.

Listeriosis probe identifies multiple deficiencies

<h3>Problem</h3> In 2010, there was a significant waiting list for admission to the intestinal failure unit (IFU) at the Salford Royal National Health Service (NHS) Foundation Trust. There had been a steady increase in the number of new patients referred to the IFU (89 patients 2005; 152 patients 2012) and the number of established patients requiring home parenteral nutrition (HPN) (135 patients 2005; 206 patients 2012) over the last decade. The impact of the resulting long waiting list for these complex patients was that patient deaths occurred in those awaiting admission. <h3>Design</h3> Continuous improvement methodology using the model for improvement and sequential plan–do–study–act cycles. <h3>Setting</h3> Salford Royal NHS Foundation Trust IFU; a large NHS teaching hospital in Northwest England. <h3>Key measures for improvement</h3> The primary outcome measures were inpatient length of stay and time spent on waiting list prior to admission. <h3>Strategies for change</h3> A continuous improvement programme, supported by a project manager. <h3>Results</h3> There has been a 21% reduction in average length of stay on the IFU from 55.7 to 44.0 days and a reduction of 72% in the average length of time new patients spent on the waiting list for admission from 65.7 to 18.5 days. These changes were associated with concomitant reduction in 30-day readmission rate from 12.1% to 4.5% and early suggestions of reduced inpatient and waiting list mortality. <h3>Conclusions</h3> It is possible to improve the efficiency of a large national service for complex patients using quality improvement methodology, resulting in improved access and reduced waiting list mortality.