SF General collected readmission rates by department to get each group’s buy-in for the transitions program.
Collaborator (Non-Members)Larissa Thomas, Michelle Schneidermann
When we first began, we had to get permission from each of the services to work with their patients. It was either feast or famine for us in terms of getting their buy-in. Some departments welcomed our help, but others didn’t want outsiders coming in to work with their patients because they thought they were doing fine.
San Francisco General is a non-profit hospital and level 1 trauma center in San Francisco, CA. It has 598 beds and serves a diverse population, the majority of whom are lower income and do not speak English as their first language. Many are also illiterate in English as well as their preferred language. The hospital also serves individuals who may not have health coverage, housing or access to food. They enroll the most difficult to engage patients who have a history of substance abuse and poor health outcomes. Their transitions program began in 2009 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We pulled together readmission numbers by department and saw that some had rates way above the national average while others had much lower rates. We brought these numbers to each department so that they could have a clearer understanding of how they were doing.
Once the departments saw their numbers, they started to get competitive. How come the other services were doing better or worse than them? Ultimately they all agreed to let us coach their patients.
Since we’ve been so successful, doctors have started shadowing us to see how we do our coaching. It’s not about what you know, but how you share it, so we’ve been able to help the doctors in that way, too.