Despite our industry’s focus on the need to better coordinate care and reduce costs, only slight progress was made in reducing 30-day readmissions between 2008 and 2010 according to a new report from the Robert Wood Johnson Foundation and the Dartmouth Atlas of Health Care. In “The Revolving Door: A Report on U.S. Hospital Readmissions”, researchers also document significant variability from market-to-market in readmission patterns, which cannot be explained by differences in underlying patient population characteristics.

The fact that there are significant discrepancies in practice patterns, utilization, and resultant cost of providing care in markets across the country is not new news. John E. Wennberg, M.D., M.P.H., the founder of the Dartmouth Atlas, pioneered the methodology of determining population-based rates of healthcare utilization. Dr. Wennberg’s small-area analysis methodology was first published in 1973, and it uncovered significant variations in health care usage among different areas and that the higher spending was not correlated with improved outcomes as measured by mortality rates. Over the years, the Dartmouth Atlas’ research has consistently corroborated these findings, and the project continues to release reports detailing the variations in care for Medicare patients.

While the quantitative findings of this study are interesting, in many ways it is the back half of the report that is most enlightening. “Hospital Readmissions from the Inside Out: Stories from Healthcare Patients and Providers” helps to uncover the why behind the disappointing results in readmissions trends nationwide. Conducted by PerryUndem Research & Communication, the patient and provider in-depth interviews studies in this report revealed a number of the root causes of unnecessary readmissions trace to what happens – or doesn’t happen – before patients are discharged from the hospital. Quoting from report, the major reasons patients cited for readmission were:

  • Patients did not necessarily see readmission as a problem
  • Many patients felt they were discharged too soon
  • Many patients did not understand their discharge instructions
  • Care instructions were too general
  • Patients and caregivers  both wished they had been more assertive (in other words, they wished they had asked more questions)
  • New diagnoses posed special challenges
  • Primary care physicians were missing from the picture
  • Some patients had only limited or no support at home
  • Some patients were not ready to change behaviors
  • A few patients had chronic health conditions for years but were not educated about their illnesses
  • If their doctor was affiliated with the hospital, their outcomes were better

Note that over one-half of the reasons (italicized above) cited by patients relate to ineffective, insufficient communication with patients and their families before they leave the hospital. Despite this finding, there is a tendency to immediately jump to solutions that rely primarily or exclusively on post-discharge intervention.

The temptation to jump to addressing downstream symptoms instead of the root cause of problems reminds me of the great story about the deteriorating granite on the Jefferson Memorial that has been told countless times at healthcare quality improvement seminars over the past couple of decades. The story appears in the Juran Institute’s Quality Minutes Video Collection. In case you haven’t heard the story, following is a brief recap.

The National Parks Service was having difficulty figuring out why the granite on the Jefferson Memorial was crumbling faster than at the other monuments in Washington, D.C.  At first glance, the solution to the problem seemed to be removal of the birds that were leaving droppings on the memorial – a process that would be expensive and likely inhumane. But digging deeper into the root cause revealed a simple, economical solution. Here is an abbreviated version of the root cause process that revealed the most effective solution:

Problem: The granite of the Jefferson Memorial is crumbling at an increased rate

Why? Because it is hosed off with corrosive detergent more frequently than other monuments

Why? Because it needs to be cleaned more often

Why? Because it attracts a larger bird population

Why? Because there are large numbers of spiders for the birds to eat

Why? Because there are large numbers of gnats for the spiders to eat

Why? Because gnats are most active at dusk and are attracted to the lights of the Jefferson Memorial

Solution: Turn on the lights after dusk and the number of gnats will decrease … leading to fewer spiders … then fewer birds, and ultimately decreasing the need for frequent washings


Are healthcare provider organizations missing one of the most important, straightforward solutions to reducing readmissions when they short-change efforts to improve patient/family communication? Using Juran’s root cause philosophy of asking, “Why? Why? Why?”, perhaps one of the primary solutions to the complex problem of excessive readmissions is more obvious than we think.