Evidence-based clinical practice guidelines for the care of heart failure patients guide providers, individual units, and hospitals in developing their own best practice measures [1]. Identifying best practice measures can integrate both administrative practices such as staffing, with clinical outcomes such as patient length of stay. Benchmarking is a method used to compare your own practice with those of like hospitals. Establishing best practice levels of performance is the goal of benchmarking.

Well-known organizations that have established guidelines also known as core measures for best practice include The Joint Commission, The American College of Cardiology, and The American Heart Association [2–4]. These organizations provide published data that can be used as a benchmark for establishing individualized patient outcome goals. The American Heart Association provides “Get with the Guidelines-Heart Failure” clinical tool-kits that are available free of charge online [5]. These guidelines are also accessible through the Quality Check website associated with The Joint Commission [6]. The Quality Check website allows public viewing of hospital outcome reporting for multiple conditions including heart failure. While some of these guidelines are intended for inpatient use, they reflect evidence-based standards of care for heart failure patients. Since these patients may become inpatient at anytime during their hospitalization, adherence to established inpatient standards is necessary. Ambulatory care guidelines can also contribute to the development of observation medicine management goals, which is considered outpatient care.

Performance improvement measures need to be established by each institution based on the overall mission of the observation unit. These measures are used by the unit to determine the effectiveness of the heart failure protocol. Length of stay and discharge rates are common indicators of success. If the standard for the observation unit is a length of stay of less than 24 h, then length of stays greater than 24 h would indicate inefficiency either with treatment protocols, patient selection, or patient response to treatment. Discharge rates assist in identifying appropriate patient selection. The patient may have comorbidities that would have precluded effective treatment in this time frame. Therefore, exclusion criteria can be established or modified based on this data. Other data that may assist in refining protocol and patient selection may be examining time of day of admission and length of stay. Considerations such as time of discharge for elderly patients may be a factor. Based on time of admission, you may not be able to achieve the desired outcome for discharge within a 24 h time frame.

All patients admitted for heart failure must have realistic goals defined at the time of admission. Patient selection is key to the process. Placing a patient in observation must have a high probability of success within the observation time frame. Patients with multiple goals and/or comorbidities most likely will not be ready for discharge in less than 24 h.

Valuable feedback of unit/staff performance can be obtained directly from patients. Patient telephone surveys by the unit staff have been shown to provide valuable information regarding the operations of the department. A simple standardized questionnaire can be developed by the staff and physicians related to key aspects of care. Telephone calls placed at a decided interval after discharge can obtain information that can guide the department in developing their own best practices based on their patients’ perspectives. This information can also be incorporated into the unit’s performance improvement plan.

Health-care organizations benchmark administrative measures in which common hospital characteristics are compared to like organizations. There are many organizations or consortiums that provide these services such as Press Ganey, well known for patient satisfaction measurements. According to Press Ganey, positive patient experiences have been linked with positive clinical and financial outcomes for the organization. Therefore, measurement of patient satisfaction done with standardized methodology can be used to reflect the hospital performance and areas that can be targeted for improving patient’s perception of quality [7].