F.W. Huston is a 25 bed Critical Access Hospital in Winchester, in Northeast Kansas and is a member hospital in the Compass HQIC Network. When Nancy Martin, a former employee of F.W. Huston Medical Center, returned to the hospital as Director of Nursing in August of 2022, she noticed some trends in care transitions that were attributed to an increase in readmissions. Patients were returning to F.W. Huston or other hospitals after hospital discharge in cases where it seemed preventable. Nancy and the F.W. Huston Team would embark on a quality improvement project that after nearly one year has made strides in process improvements, yet admittedly is still under construction.