When some chronically ill patients are readmitted within 30 days at selected Kaiser Permanente hospitals, cameras start to roll.
"What do you think caused you to end up in the hospital again?" Kaiser staff ask, in words to that effect. "When you left the hospital, did you understand the purpose for taking each of the medications? Did you have any difficulty getting in to see the doctor after you left?" "How did you prepare your meals, and what did you eat?"
Some of the patients just sat there, not knowing how to answer. "I don't know. Ask my wife, she takes care of all that," said one.
Caregivers and social scientists, armed with handheld video cameras, are part of Kaiser's novel "video ethnography" team in California, an effort to understand the system's care process from beginning to end, with all its wrinkles, cracks, and failings, in order to improve care and prevent readmissions going forward.
They don't stop there. Team members interviews pharmacists, home care providers, nurses, and physicians as well.
They also visit patients' homes to see how medications were managed, and talk with home health aides and family members to get a sense of all the problems that brought patients back to the hospital (and probably would again and again unless the system's issues were resolved).
Then they shares the video and interviews with the care team, to show how those patients and caregivers experience the process, all along seeing ways to improve.
In the initial projects in California, Kaiser didn't learn just one lesson. It learned 42, explains Estee Neuwirth, director of field studies at Kaiser Permanente.
Neuwirth and Kaiser Permanente colleagues talked about their video ethnography efforts at last week's Institute for Healthcare Improvement forum in Orlando.
Neuwirth emphasizes that the projects have yielded a wealth of information that was impossible to obtain through chart review alone. In one project focused solely on Kaiser Permanente's South Bay Medical Center in Harbor City, near Los Angeles, video ethnography combined with other efforts was "key" to reducing readmissions from 15.7% to 9% in a recent six-month period.
Kaiser Permanente has a huge incentive to get this right. Although its readmission rate for patients over age 64 is 17.1%, far lower than the national average of 20% to 25%, the system manages nine million lives in eight states, and operates more than 30 acute care hospitals. "We saw an opportunity to strengthen the quality of our care even more by addressing gaps," Neuwirth says.
In addition to the desire to improve care, now that the age of federal penalties for excessively high risk-adjusted readmission rates in Medicare patients is near, there’s a lot of money at stake too.