Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Selected References

Project RED (Re-Engineered Discharge) Training Program

Provides a four-module training program to help hospitals implement Project RED.

The publications on this page provide information on Project Re-Engineered Discharge (RED), readmissions, performance improvement, multidisciplinary rounds, patient education techniques, medication reconciliation, and health literacy.

Project RED

Anthony D, Chetty VK, Kartha A., et al. Re-engineering the hospital discharge: an example of a multifaceted process evaluation. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from research to implementation. Vol. 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005. p. 379-94.

Bickmore T, Pfeifer L, Jack B. Taking the time to care: empowering low literacy hospital patients with virtual nurse agents. CHI 2009, Apr 3-9, Boston.

Bickmore TW, Mitchell SE, Jack BW, et al. Response to a Relational Agent by Hospital Patients with Depressive Symptoms. Interact Comput. 2010 Jul 1;22(4):289-298.

Clancy C. Re-engineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual 2009 Jul-Aug;24:344-46.

Jack B, Greenwald J, Forsythe S, et al. Developing the tools to administer a comprehensive hospital discharge program: The reengineered discharge (RED) program. In: Henriksen K, Battles JB, Keyes MA, et al., eds. Advances in patient safety: new directions and alternative approaches. Vol. 3. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

Jack B, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009 Feb 3;150:178-87.

Jack B, Bickmore T. The re-engineered hospital discharge program to decrease rehospitalization. Care Management December 2010/January 2011;12-5.

Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf 2007 Jun;3:97-106.

Greenwald J, Jack B. Preventing the preventable: reducing rehospitalizations through coordinated, patient-centered discharge processes. Prof Case Manag 2009 May-Jun;14:135-40.

Kartha A, Anthony D, Manasseh CS, et al. Depression is a risk factor for rehospitalization in medical inpatients. Prim Care Companion J Clin Psychiatry 2007;9(4):256-62.

Mitchell SE, Paasche-Orlow MK, Forsythe SR, et al. Post-discharge hospital utilization among adult medical inpatients with depressive symptoms. J Hosp Med. 2010 Sep;5(7):378-84.

Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can the hospital discharge be modified to impact recurrent hospitalization. J Hosp Med 2007 Sep;2:297-304.

Performance Improvement

Arthur J. Lean six sigma demystified: a self teaching guide. New York: McGraw Hill, 2007.

Chen C, Roth H. The big book of six sigma training games: proven ways to teach basic DMAIC principles and quality improvement tools. New York: McGraw-Hill, 2005.

Dennis P. Lean production simplified: a plain-language guide to the world's most powerful production system. University Park, IL: Productivity Press, 2002.

George M, Rowlands D, Kastle B. What is lean six sigma? New York: McGraw-Hill, 2004.

George M, Rowlands D, Price M, et al. The lean six sigma pocket toolbook. New York: McGraw-Hill, 2005.

Jimmerson C. A3 problem solving for healthcare: a practical method for eliminating waste, New York: Healthcare Performance Press, 2007.

Mann D. Creating a lean culture: tools to sustain lean conversions. University Park, IL: Productivity Press, 2005.

iSix Sigma Magazine. Available at:

iSix Sigma Blog.

The six sigma memory jogger II: a pocket guide of tools for improvement teams 2002.

Multidisciplinary Rounds

Dutton RP, Cooper C, Jones A. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma 2003 Nov;55:913-9.

Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. Qual Saf Health Care 2005 Jun;14:207-11.

Lees L, Allen G, O'Brien D. Using post-take ward rounds to facilitate simple discharge. Nurs Times 2006 May 2-8;102:28-30.

Ouchida K, LoFaso VM, Capello CF, et al. Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings. J Am Geriatr Soc 2009 May;57:910-7.

Proactive discharge planning keeps LOS low. Hospital Case Management news feed 2009 Dec; University of Wisconsin-Madison.

Sen A, Xiao Y, Lee SA. Daily multidisciplinary discharge rounds in a trauma center: a little time, well spent. J Trauma 2009 Mar;66:880-7.

Setia N, Meade C. Bundling the value of discharge telephone calls and leader rounding. J Nurs Adm 2009 Mar;39:138-141.

Patient Education and Teach-Back Techniques

Conversation with Dean Schillinger. AHRQ Web Morbidity & Mortality Rounds on the Web. Available at: Accessed June 21, 2010.

Osborne H. In other words ... confirming understanding with the teach-back technique. Health Literacy Consulting. Available at: Accessed June 21, 2010.

“Teach back” technique improves patient safety. Patient Education Management 2007 April;44-5.

Medication Reconciliation

Coleman EA, Smith JD, Frank JC, et al.: Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care 2002 Jun;2:e02. Epub.

Gardner B, Graner K. Pharmacists' medication reconciliation-related clinical interventions in a children's hospital. Jt Comm J Qual Patient Saf, 2009 May;35(5):278-83.

Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm 2004 Aug;61:1689-95.

Gleason KM, McDaniel MR, Feinglass J, et al. Results of the medications at transitions and clinical handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010 May;25(5):441-7.

Institute for Healthcare Improvement. 5 million lives getting started kit: preventing adverse drug events (medication reconciliation), how-to guide. Available at: Accessed July 26, 2010.

Jencks S, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program N Engl J Med 2009 Apr 2;360:1418-28.

Kripalani S., LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007 Feb 28;297:831-41.

Lesselroth B, Adams S, Felder R, et al. Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. Jt Comm J Qual Patient Saf, 2009 May;35(5):264-71.

Murphy EM, Oxencis CJ, Klauck JA, et al. Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. Am J Health Syst Pharm 2009;66(23):2126-31.

Naylor MD, Stephens C, Bowles KH, et al. Cognitively impaired older adults: from hospital to home. Am J Nurs 2005 Feb;105:52-61.

Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm 2007;64(8):850-4.

Health Literacy

Farrell MH, Kuruvilla P, Eskra KL, et al. A method to quantify and compare clinician's assessments of patient understanding during counseling of standardized patients. Patient Educ Couns 2009;77:128-35.

Kountz DS. Strategies for improving low health literacy. Postgrad Med 2009 September;121:171-7.

Mancuso JM. Assessment and measurement of health literacy: an integrative review of the literature. Nurs Health Sci 2009;11:77-89.

Mancuso JM. Health literacy: a concept/dimensional analysis. Nurs Health Sci 2008;10:248-55.

Ngho LN. Health literacy: a barrier to pharmacist-patient communication and medication adherence. J Am Pharm Assoc 2009 September/October;49:e132-e49.

Schaefer CT. Integrated review of health literacy interventions. Orthop Nurs 2008 September/October;27:302-17.

“What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety. The Joint Commission. Available at: Accessed July 1, 2011.

Villaire M, Mayer G. Low health literacy-the impact on chronic illness management. Prof Case Manag 2007;12:213-16.

Readmission Risk and Analysis

Allaudeen N, Vidyarthi A, Maselli J, et al. Redefining readmission risk factors for general medicine patients. J Hosp Med 2011 Feb;6(2):54-60.

Babayan ZV, McNamara RL, Nagajothi N, et al. Predictors of cause-specific hospital readmission in patients with heart failure. Clin Cardiol 2003 Sep;26(9):411-8.

Epstein CD, Tsaras G, Amoateng-Adjepong Y, et al. Does race affect readmission to hospital after critical illness? Heart Lung 2009 Jan-Feb;38(1):66-76.

Hasan O, Meltzer DO, Shavkevich SA, et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med 2010 March;25(3):211-9.

Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA 2011 Feb 16;305(7):675-81.

Lin HJ, Chang WL, Tseng MC. Readmission after stroke in a hospital-based registry: risk, etiologies, and risk factors. Neurology 2011 Feb 1;76(5):438-43.

Mudge AM, Kasper K, Clair A, et al. Recurrent readmission in medical patients: a prospective study. J Hosp Med 2011 Feb;6(2):61-7.

Sharma G, Kuo YF, Freeman JL, et al. Outpatient follow-visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med 2010 Oct 11;170(18):1664-70.

Silverstein MD, Qin H, Mercer Q, et al. Risk factors for 30-day hospital readmission in patients > 65years of age. Bayl Univ Med Cnt 2008 Oct;21(4):363-72.

Syed S, Cohen KR, Sarij H, et al. Examination of the factors leading to readmission on the hospitalist service of an acute care hospital. SHM 2005 annual meeting abstract. Available at:

Yam CH, Wong EL, Chan FW, et al. Measuring and preventing potentially avoidable hospital readmissions: a review of the literature. Hong Kong Med J. 2010 Oct;16(5):383-9.


Osie-Anto A, Joshi M, Audet AM, et al. Health Care Leader Action Guide to Reduce Avoidable Readmissions. Health Research & Educational Trust, Chicago, IL. January 2010. Available at:

Swanson J, Koch L. The role of the oncology nurse navigator in distress management of adult inpatients with cancer: a retrospective study. Onc Nurse Forum 2010 Jan;37(1);68-76.

Return to Contents

Page last reviewed August 2011
Internet Citation: Selected References: Project RED (Re-Engineered Discharge) Training Program. August 2011. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care