Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Susan L. Dean-Baar, PhD, RN, CENP, FAAN


Tonya Haynes, DNP, RN

Ursula Wright, M.S.N, M.B.A, R.N., FNP-BC


The United States (U.S.) healthcare system journey for making improvements in the quality and value of healthcare continues. Hospital organizations are required to compose and make publically available their health quality outcome data. The publication transparency and increased availability of local, regional and national health quality metrics, including readmission and mortality rates, to governmental agencies, health plans, investors, other hospitals, providers and potential patient and families’ knowledge, creates a competitive pressure for a hospital to assure their quality outcomes data are the best. Despite breakthrough improvements using innovative care models that target vulnerable and potentially high cost of care areas such as individuals with chronic illnesses, complex health and social needs, children, and frail elders, have been seen, there remains a need for quality improvement (QI) initiatives to reduce particularly avoidable hospital readmissions and mortality.

A Midwest hospital system identified that their 30-day pneumonia (PNA) readmission rate for FY2017 was higher than the national median and the peer hospitals Centers for Medicare and Medicaid Services (CMS) benchmark percentage. The assumption was if there are more programs and resources available to the PNA patient then there should be better health outcomes. This project evaluated the differences in the PNA patient outcomes, mortality and readmission rates based on the number of hospital readmission reduction strategies (RRS) identified and available for the PNA Medicare patients among three of the Midwest hospital system acute care facilities.

The results of the Chi-square test of independence performed to examine differences between the total number of RRS in FY 2018 and FY 2019 and readmission and mortality rates was significant for readmissions, χ2 (3, N= 107) = 25.15, p < .001, and mortality χ2 (3, N= 58) = 34.93, p=