Tackling Pneumonia Readmissions through Standardizing Processes

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Tackling Pneumonia Readmissions through Standardizing Processes

< 1 minute read

Baptist Memorial Hospital focused on reducing pneumonia readmissions through Kata, a rapid cycle improvement process

The Issue

Baptist Memorial Hospital has been focusing on readmissions for quite some time but for the last two years, we received the readmissions penalty. We found out that we were higher than the national average for pneumonia readmissions rates so we decided to examine our processes to address this issue.

What We Tried

About a year ago, our health system took on the challenge to train all the directors, managers and staff to look at performance improvement at a different way. We were introduced to some aspects of the Toyota Production System and kata was a part of that. Kata is a way of learning a new habit utilizing rapid cycle improvement PSDA to guide deliberate thinking and problem solving locally instead of jumping to a solution.

We pulled a team together of some of our most experienced kata trained employees and kata coaches to focus on pneumonia (PN) readmissions. We asked ourselves, “Where do we want to be in nine months? What should our goal be?”

We created a three-day event, called Get Better Jump Start (GBJS). The GBJS team consisted of a case manager, educator, nursing, respiratory care, PT, quality, senior leaders and a physician champion.

We did a deep dive into the issue so we could understand the current condition and identify obstacles. We reviewed our PN readmission data for the past 12 months. We contacted and interviewed some of the post-acute care facilities and our primary care physicians and asked how we were doing and what we could learn from them. We had a lot of lessons learned and “ah-ha” moments from connecting the dots and conversations with the team. After the evaluation from this three-day event, we decided to pilot our improvements with the 47-bed Medical-Oncology unit because our data showed most PN readmissions came from that floor.

1. Developed hypothesis targeting obstacles. We decided to focus on discharge education and communication between caregivers internally.

2. Utilized Training Within Industry (TWI). This is a method to train staff to help reduce variation.

We developed a Job Instruction Breakdown (JIB) for all staff (nursing and ancillary) to standardize patient education specific to PN. When training staff, we would use a JIB to identify important steps in a process, key points about the step and rationale supporting the key points. We created Pneumonia talking points for our multi-disciplinary meetings (MDM) and standard work for patients with pneumonia. I think this was one of the most important things that came out of it the TWI. When patient is admitted, diagnosed or develops PN, one of the initial pieces during the standard work is to take that JIB and put it on the white board in the room and educate that the patient is diagnosed with PN. Then every staff member that goes into the room can references the JIB, and review all the important steps, key points, and reasons for key points with the patient and/or family.

3. Utilized TWI on patients. We’ve used TWI on other processes with staff but this was the first time we used it with patients. We emphasized important things related to the patient. We made sure the patient understood the following and more:

  • their diagnosis
  • PN is high risk for readmissions
  • length of recovery time
  • medication instructions
  • breathing treatments
  • reasoning for treatments
  • understanding follow up appointment importance
  • who specifically would be contacting them (e.g., home health follow-up and why home health was ordered)
  • their transportation to and from appointment


Get Better Jump Start Kata Boards

The board on the left focuses on the discharge process. On the right, the MDM process is displayed.


We completed the pilot on March 31, 2017. We implemented several things:

  • Improved existing daily multi-disciplinary meeting (MDM) with the RN, case manager and facilitator report flow using detailed checklists and PN talking points. We developed a checklist  to facilitate these meetings.
  • Incorporated EPIC – LACE+ score to trigger automatic referrals for PT, respiratory and home care. LACE+ tool in EPIC is a good predictor for readmission and there is a need to educate providers about it. If the score is higher than 59 then there is a higher risk for readmissions. We are hoping this impacts other patients that are high risk for readmission, not just PN.
  • Established PN standard work (see attachment above).
  • Developed and streamlined PN aftercare instructions.


We learned that the JIB is working. During leader rounding and case manager interviews, staff sees the JIB and mentions to the patients that they are a PN patient. Many patients respond, “Yes, I know that I am a PN patient, and why I need to take all my antibiotics, keep my follow up appointment, eat better, and why I need to let home health come and evaluate me.” From these types of statements we learned that we were teaching our patients a new way of thinking about their recovery.


Don’t go into any problem or opportunity for improvement with any preconceived notions, or jump to solutions without knowing your REAL current condition. Many improvement efforts failed because we didn’t really know the current condition, and what barriers/obstacles are faced by caregivers and patients. We initially thought perhaps some patients couldn’t afford follow up appointments and that the readmission was caused by financial stress. However, our data showed otherwise.

Feedback from post-acute care providers really shed light on opportunities we weren’t aware of, such as making sure patients have enough of their home respiratory meds, MDI’s until their follow-up appointment. This led us to add to our standard work for Respiratory Therapy to check the amount in home MDI canisters. We needed to be open minded and take a deep dive into the current condition to pull out the real issues.



The GBJS Kata team: Alicia Grant, Tiffany Johnson, Belinda Sanderson, Mary Ellen Sumrall, Ashley Perry, Pam Richardson, Brandy Waldrop, Kayla Pruitt, Bridgett Alexander, Leslie Albright, Sandy Holman, Lauri Sansing, Dawn Thomas, and Ben Hughes

Program Challenges: Building Commitment for Care Transitions, Coordinating Care Across the Whole Team

Topics: Identifying causes of readmission, Measuring and improving

Collaborator (Non-Members): Tiffany Johnson, Case Manager; Mary Ellen Sumrall, CNO

Organizational Background

Organization Name: Baptist Memorial Hospital-Golden Triangle

Location: 2520 N 5th St, Columbus, MS 39705

Organization Type: Hospital

Organization Model: Not Set