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VA Palo Alto uses a large calendar to visually track readmissions, find patterns, and adjust their program as needed.
We were tracking readmission rates based on whether enrolled patients were readmitted after 30, 60, and 90 days. There are two challenges with that. One is that the readmissions were just numbers and we learned about them after the fact so we couldn’t dig into what really happened with the patient. The second is that we were too focused on our enrolled patients and would miss opportunities to reduce readmissions with patients outside our purview.
VA Palo Alto is a government-affiliated teaching hospital in Palo Alto, CA. It has 885 beds and serves primarily English-speaking US veterans with comorbidities requiring both acute and chronic care. Their transitions program began in 2012 and is influenced by Project RED.
We started tracking readmissions across the whole hospital on a daily basis. We ran reports every day to see whether any admitted patients from the previous day were readmissions. Then we’d put either a red or green dot on a large calendar to visually track readmissions. We had dots for every department and were tracking readmissions regardless of whether they were enrolled in our program.
The calendars have helped us be more nimble. They’re a visual way of noticing patterns and doing something about them in a timely manner. For example, we noticed that the IICU had readmissions multiple days in a row and none of them were patients that we had worked with. We caught the pattern right away and decided to enroll all of the IICU patients in our program to learn more about what was causing the readmissions.
It sounds simple, but we have to keep reminding ourselves that we need to act on the data. It’s not enough to pull it and put it up on the wall. How are we changing our practices based on what we see in the data?
Program Challenges: Identify Which Patients Need Extra Help
Topics: Identifying causes of readmission, Measuring and improving
Organization Name: VA Palo Alto
Location: 3801 Miranda Avenue, Palo Alto, CA, United States
Organization Type: Hospital