Aug 082011

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction – all pulled from charts, with just the contact information that enables an interview if someone undertakes it.  Each has targeted a certain set of issues — clear plan, medications, teach-back, advance directives, social problems, and so on.  Although the two forms overlap on many targets, on others they do not.

NJ_Readmission Chart Review tool

NEW_GA ReadmissionWorksheet

The Institute for Healthcare Improvement (IHI) has developed another useful form, which can be found on page 88 at this URL:  It “feels” more succinct, because it is set up to do 5 readmissions at a time and to focus upon themes.  But it also requires a more insightful reviewer, one who has thought about what it is that makes for rapid readmissions and what might work to make transitions bette

One way to get started is to simply review just a few charts of people who were readmitted to the hospital with which you are most familiar, and see what you most wanted to learn. You might start with the IHI form and then try filling out the other two to see what additional elements you might consider. Call a few patients or families, or, if that is not appropriate, call the main attending physician in the community. Try to gain some insight from the perspectives of people involved.
Keep track of the time it takes to do this review.  If you can get someone to pull the charts, the work to this point will take about two or three hours. Of the time involved, what seemed most productive and what was most illuminating?

Then put together your own form, starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful.  Test that form on another two or three records, perhaps asking a colleague to do those (to learn what instructions are needed and whether another perspective identifies other things that are very important to include.
My prediction would be that you’ll find some remarkable stories–people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient’s situation and medications; people who could not afford the treatment prescribed; and people who simply greatly misunderstood what they were to do. (I recall the patient who told me about having to eat fresh vegetables for his heart – whereupon he opened a fresh can of peas every day!) Those stories will greatly help you galvanize the will to move ahead.  And you’ll have a process and form that you can persuade the quality improvement team at each hospital to do: Perhaps at large hospitals, five each week for four weeks and at small hospitals, five in the month.  Within a month, you’d have enough data and stories to build the endeavor, and continuing to collect the data provides rapid feedback about progress. Pick a lead intervention or two and get it tested and underway!

You are likely to find a certain sense of chaos– that there is a lot of “catch as catch can” processing with thorough unreliability on all sides. If this is the case, your coalition might well work on standardizing the process simply so that it is reliable.  You may find that the issues affecting the frail elders are different from those affecting younger populations– more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger.  Whatever you find, this is the “root cause analysis” that you’ll need to decide priorities and to apply for CCTP funds.

Key words: root cause analysis, reviewing readmissions, discharge record review, quality improvement tools, CCTP funding

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