Performance Improvement Tip of the Day: Readmissions Assessment Tool

Systematically assessing high-risk patients who are readmitted to a hospital is one of the proven strategies to reducing readmissions. 

The keys to implementing this tool are: discipline and structure.

Staff tend to think that "we already address all of these issues with our patients". However, if it doesn't done with discipline, its not happening reliably, and that will allow for some vulnerable patients to fall through the cracks. This form can provide structure to the readmission assessment process, and increase confidence that any issues that can be acted upon are being identified.

Structure is provided through the actions indicated by the next steps listed next to each element of the assessment. The point here is simple but very important to grasp - assessment without intervention is meaningless. This is not a data collection task, but an opportunity for improvement. 

This form is a variant of a checklist integrated with a decision support tool: it reminds the user of specific issues that need to be addressed, and provides clarity as to the decisions that should be made if any items are "checked". Intelligent tool design is critical to getting a tool in use and for driving performance.

This Readmissions Assessment Tool was modified from a version being used by participants in the STAAR (State Action for Avoidable Readmissions) Initiative supported by IHI (Institute for Healthcare Improvement) and The Commonwealth Fund.

Performance Improvement Tip of the Day: Fix the Problem, and Not Just the Symptoms

Novartis CEO, Joseph Jimenez, in an interview by Adam Bryant of the New York Times talks about getting at the "root cause of a problem" rather than attempting to resolve the symptoms. This is an endeavor that needs to be pursued with greater discipline throughout healthcare. ITs tempting to think that we have identified the root cause, but we don't always exert the discipline to drive deep enough to find it. Too often we are satisfied to act - believing that action itself, or rapidity of action, or intensity of action, can suffice. Action may indeed be enough to keep regulators and overseers happy, but true improvement can only come from a deep understanding of the root issue.

One simple tool - ask "why?" five times - often helps us to persist in the diagnosis of the problem before we attempt to treat it. To illustrate:

Why1: Why did the patient with diabetic ketoacidosis die?

His condition was not recognized as severe in a timely manner.

Why2: Why was that?

Critical lab results were not called in to the right physician.

Why3: Why did that happen?

The lab followed its procedure, but there was confusion about which clinician was managing the case.

Why4: Why was there confusion?

There are no clear protocols for shared management of critically ill patients in the emergency room.

Why5: Why are there no protocols?

We haven't realized the significance of this issue before as an organization.

The inquiry can continue deeper, perhaps ultimately getting at issues of culture or leadership within an organization, however, the leaders conducting the analysis need to be clear that they are unearthing a "root cause" which if addressed will significantly reduce the likelihood of the problem recurring.

Fix the Problem, and Not Just the Symptoms

By ADAM BRYANT

Published: October 8, 2011

This interview with Joseph Jimenez, chief executive of Novartis, the pharmaceutical company, was conducted and condensed by Adam Bryant.

Marilynn K. Yee/The New York Times

Joseph Jimenez, C.E.O. of Novartis, the pharmaceutical maker, says he learned in a previous job that you can't solve a problem if you can't get to its roots.

Corner Office

Every Sunday, Adam Bryant talks with top executives about the challenges of leading and managing. In his new book, "The Corner Office" (Times Books), he analyzes the broader lessons that emerge from his interviews with more than 70 leaders. Excerpt »

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Q. What are the most important leadership lessons you’ve learned?

A. One occurred when I was a division president of another company. I was sent in to turn the division around after four years of underperformance. It was a declining business. And when I got there, I completely misdiagnosed the problem. I said: “Look. We’re missing our forecast every month. What’s wrong?” I brought in a consulting firm, and we looked at what was wrong. And the answer was that we had a bad sales and operations planning process, where salespeople, marketing people and operations people were supposed to come together and plan out the next 18 months and then forecast off of that. So I said: “O.K. We’re going to fix this. We’re going to have the consulting team come in and help us make that a better, more robust process, with more analytics.”

And it turned out it wasn’t at all about analytics. Because once we did that, and we put that new process in place, we still continued to miss forecasts. So I thought, “Something’s really wrong here.” I brought in a behavioral psychologist, and I said: “Look, either I’m misdiagnosing the problem or something’s fundamentally wrong in this organization. Come and help me figure it out.” She came in with her team and about four weeks later came back and said: “This isn’t about skills or about process. You have a fundamental behavioral issue in the organization. People aren’t telling the truth. So at all levels of the organization, they’ll come together, and they’ll say, ‘Here’s our forecast for the month.’ And they won’t believe it. They know they’re not going to hit it when they’re saying it.” The thing she taught me — and this sounds obvious — is that behavior is a function of consequence. We had to change the behavior in the organization so that people felt safe to bring bad news. And I looked in the mirror, and I realized I was part of the problem. I didn’t want to hear the bad news, either. So I had to change how I behaved, and start to thank people for bringing me bad news.

Q. That doesn’t mean letting them off the hook, though.

A. Right. It’s more a chance to say: “Hey, thank you for bringing me that news. Because you know what? There are nine months left in the year. Now we have time to do something about it. Let’s roll up our sleeves, and let’s figure out how we’re going to make it.” It was a total shift from where we had been previously. So after that experience, I always ask all of my people, and I always think to myself: “Are we really fixing the root cause of this problem, if there’s any problem? Or are we fixing the symptoms?”