Reference no: EM133038867

Melanie Stanford, MD, MPH, Director of Operations for Central Hospital sat quietly at her desk, in deep thought. She stared at the data summary sheet in front of her. The report showed that the overall 30-day readmission rate at Central Hospital rose considerably and steadily between 2015 and early 2020, from 25% to 39%. The high and increasing rate of readmissions is a major problem facing the Hospital. Not only does the readmission rate have considerable implications for quality of care ratings, it also has financial implications. Newly introduced payment models penalize hospitals for readmissions within 30 days of discharge. In addition, the hospital was in the process of implementing a new electronic medical records (EMR) system, which has garnered a considerable amount of disapproval from physicians. Physicians maintain that they have not been properly trained on the EMR, and that the administrative task of documenting in the EMR was interfering with service delivery. Nurses managers, nurses, and nurses' aides across the hospital were burned out and felt as though the culture of the hospital and work conditions did not promote staff wellbeing, or promote improvements to patient care. Staff, although always put patients first, they were increasing becoming frustrated and not motivated (i.e., less likely to go above and beyond). In particular, staff members who take initiative to improve the work environment and care practices are not incentivized. This was further compounded by issues of workplace diversity and fairness (e.g., demographic of managerial staff, choice of schedule, workload, etc.) among staff. Melanie's mandate from upper management is to improve work conditions and reduce the readmission problem across all units of the hospital. Several initiatives to reduce 30-day readmissions at Central have been unsuccessful. Nearly 45% of the nurse managers were keenly aware of the readmissions rate on their units or hospital-wide and implications. Approximately 20% of those aware of the situation had submitted strategies for how to improve the functioning of their units and reduce unit-level readmissions. The structure of the hospital and communication channels were such that these nurse managers did not coordinate or collaborate in meaningful ways. In fact, there were no systems in place, either formal or informal to facilitate cross-unit collaboration. Melanie knew that 40% of staff, both physician and nurses, could be linked with cases of readmission within 30 days. However, the leadership of the hospital had not been using this data in their improvement efforts. Melanie's inclination is that using this data to more carefully target efforts would be helpful. She was, however, not sure of how best to do so without staff feeling blamed for the readmissions rate and other quality of care-related concerns. Readmissions is estimated to be associated with 30% of deaths at Central, and 60% of these deaths were related to cardiovascular disease, especially among the underserved (women, African-Americans, Hispanics). Dr. Stanford knows from her experiences as an administrator, practicing physician, and the available research that addressing the main problem will require efforts at multiple levels, and integration of strategies. She was very aware that a siloed approach would not be effective. For example, addressing burnout alone would not be a long-term or sustainable approach to addressing the readmission problem. A strategy that cuts across the various dimensions of issues would be necessary. She also knows that readmissions are caused by a web of interacting factors: organizational, social, environmental, economic, psychological, and physiological. One particular factor is patient - provider concordance (gender, race/ethnicity) and how it has been associated with improvements in outcomes among underserved groups. She was keenly aware that staff demographic was not representative of their patient population, especially among those where readmissions presented the most challenge. These factors do not operate in isolation and that they interact with each other to influence one's likelihood of being readmitted. In essence, there are individual and societal factors that must be closely understood and taken into account in her strategy for reducing the readmissions rate. Melanie recalls that Central Hospital spent $15 million on community health workers and other post discharge support for patients, a few years ago (prior to 2015), to explore opportunities for collaboration and development of mutually beneficial strategies to address the problem. But the financial investment made in addressing the problem is subpar, given the magnitude of the problem. These budgetary constraints are one of the many challenges faced by Central Hospital. As Melanie pored over the data, she realized that she and her team needed a strategy that effectively addresses the problem, taking into account the various constraints operating within the hospital, more broadly, the health care system. Dr. Stanford pauses and ponders what is realistic, considering the characteristics of the population and the hospital system. She ponders several questions:

• What is the best strategy to facilitate and support improvement in 30-day readmission rates?
• How can Central Hospital successfully implement the strategy? 
• How will success be measured?
• What will be the implications of the strategy they choose for the functioning of the hospital? 
• How will the strategy impact population health, both positively and negatively? 
• What could be the unintended consequences of the strategy? 
• Notwithstanding these questions, she found it promising and felt confident that readmission, quality of care, and patient outcomes could be improved, and sustained in a cost-effective way.