A Quality Improvement-based Approach to Implementing a Remote Monitoring-Based Bundle in Transitional Care Patients for Heart Failure.

Background: Congestive heart failure (HF) is a leading cause of hospitalization and readmission, leading to increased health care utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients after discharge to optimize medication management and intervene to avoid rehospitalization.

Equity and Performance Improvement: A Novel Toolkit That Makes Using an Equity Lens the Default.

Performance improvement methodologies do not currently include any structures that encourage analysis of how bias, inequity, or social determinants of health (SDOH) contribute to outcomes. The Montefiore Center for Performance Improvement developed a novel quality improvement (QI) toolkit that ingrains issues of diversity, equity, and inclusion (DEI) and SDOH into the Institute for Healthcare Improvement's tools. The toolkit prompts QI teams to evaluate DEI and SDOH at each step of the journey, including an updated charter and stratified baseline tool, a new fishbone diagram for the discovery phase with a tail to include DEI and SDOH, and additions in the Study and Act sessions of the Plan-Do-Study-Act worksheet to address these issues.