Patient Adherence is not about “Process Improvement!”

Quality Management and other process improvement programs typically show early progress… and then things return to the way they were.

What do weight-loss plans, unplanned readmission reduction programs and medication adherence-improvement programs have in common?

They typically start off well, generating excitement, but all too often fail to have a lasting impact as patients receive less and less reinforcement and return to their old habits that provide years of positive reinforcement.

Quality Management and other process improvement programs typically show early progress… and then things return to the way they were.

What do weight-loss plans, unplanned readmission reduction programs and medication adherence-improvement programs have in common?

They typically start off well, generating excitement, but all too often fail to have a lasting impact as patients receive less and less reinforcement and return to their old habits that provide years of positive reinforcement.

Many health services providers have embraced Teachback, a patient education program which aims to teach patients the things they need to do to improve their clinical outcomes. But many of those agencies have come away less than happy. Recent studies, for example, suggest that nearly 50% of all patient education initiatives fail to yield the desired results.  The Hospital Engagement Network (HEN 1.0) targeted a 20% reduction in readmissions over the two years of that program.  They fell short of their goal by at least 15%.

Behavioral Education and Research Services, Inc. (BEARS) has studied patient adherence programs over the past five-year period to gain insight into how and why so many of them fail.

We found that when confronted with the increasing pressures of nursing shortages, increases in the number of patients in the system, the addition of new tasks over the already overworked nursing staff, and the myriad of over reasons, that over time, these programs react in much the same way as any behavior does when it is not achieving the desired results.  The cries for doing something becomes louder and longer.  There are calls for having all nurses trained and certified in Teachback, even though the data is less than convincing as to the efficacy once the patient has left the hospital.

A closer look at the characteristics of patient education and adherence improvement programs offers lessons for health services and clinical executives seeking to avoid unplanned readmissions within 30-days post discharge.

The discussion that follows is based on what happens at any hospital that has implemented numerous quality improvement projects.  On review they often find, less than two years later, that many have failed to generate lasting improvement.


  1. In the last two years, since the implementation of HEN 1.0 and the Partnership for Patients Program, has your organization achieved lasting gains from readmission reduction and adherence-improvement programs such as Teachback or Motivational Interviewing?
  2. Do you pay attention to your patients once they have been discharged?
  3. Are you involved enough with patient adherence and readmission prevention plan to judge for yourself whether your program is worth continuing?
  4. Have you tied patient education and adherence coaching performance appraisals to 30-day readmission reductions?
  5. Do you plan on having an Adherence Management professional or other applied behavioral improvement experts on your patient education and coaching staff for the long-term?
  6. Are you providing continued reinforcement and ongoing behavior-based follow-up for your community based providers and your patients?

If you answered no to any of these questions, you should understand how and why many patient readmission reduction programs will fail.

Patient Education and Teachback Phase

When a staff nurse starts his or her shift, they stretch to accommodate the increasing workload pressure. In much the same way, the nurses involved in patient education generally find themselves stretching and willing to tackle all necessary tasks in the early hours of their shift.  Admissions, medications, treatments, patient rounding, and an endless list consumes large chunks of time.  Then comes the discharge order and a myriad of tasks that have to be seamlessly shuffled into the “to do” card deck.  Discharge planning and Teachback begins when the transportation tech shows up with the wheelchair at 2:30 as the nurse is preparing for shift change.  A harried review of the discharge plan is provided and placed in the “Patient Belongings” bag along with the disposable emesis basin, water pitcher, and wash basin.  Whether the change of shift report is dictated or given verbally, it is presented and concluded with, “Mr. X was discharged.”

Too often, after the patient educator or nursing staff expert moves on to the next patient and top management turns it focus to another group of quality management programs, implementation patient education starts to wobble. Understanding where the stress and strains are offers managers an opportunity to avoid them.

C-Suite Support – The Common Themes

In the health services arena, a patient education quality improvement project typically began with the formation of a team consisting of members from various departments. A patient educator or other quality improvement expert is assigned to the team to guide and train them. At this stage, teams are excited to learn and apply what they were being taught.  The educator may be exposed to some cognitive behavior texts or workshops to improve their Motivational Interviewing knowledge.  Keep in mind, the goal is to change patient behavior post discharge.  Reducing ambivalence has not been shown to have a long-term measureable effect.

Team members collect data on their current patient population and, with the help of the patient education expert, identify the changes they most needed to make to achieve their stated goal—say, a reduction in unplanned readmissions or hospital acquired illnesses or injuries. The experts develop a “to do” list that included action items, responsibilities and deadlines and ensure needed resources are available.

Because top executives are paying close attention to the project at this stage, nurse managers made clear to staff nurses that the initiative for reducing unplanned readmissions was their top priority. For example, Teachback might become more important than rounding on assigned patients in a timely manner.

While time nurses spent in direct patient care slipped initially when the team transitioned to the new way of working, it improved when the nursing staff grew accustomed to the new process. When the team reached its goal—say it increased Teachback training by a certain percentage—the improvement project was declared a success.

The nursing director who was spearheading the hospital’s patient education initiatives shared the teams’ achievements with others in the hospital. Nursing team members were given rewards such as gift certificates to restaurants, and their pictures appeared in the hospital newsletter. The Chief Nursing Officer reported on the team’s success to the hospital’s other vice presidents and to its top executives.

Yielding Phase – A Crystal Ball Look

Unfortunately, the story doesn’t end there.

If staff nurses continue to be stretched, there will come a point when the nursing care yields as it struggles to support the increase in patient teaching demands. Though still intact, the nurse becomes disillusioned—stretched out, for example—as the demands between old requirements are continued or even increased and new ones added.

Similarly, in the middle stage of a quality improvement project—when the readmissions reduction expert moves on to another project and top management turns it focus to another group of cost saving or quality improvement programs—implementation starts to wobble, and nursing teams may find themselves struggling to maintain the gains they achieved early on. With increased demands on the patient education and transitional care team, the patient loses their objective advocate in the discharge process and readmissions return to their previous high rates.

Some transitional care team members will start spending too much time on their preferred quality improvement project, which will certainly affect their ability to meet other quality management objectives and other daily responsibilities.

When reporting on the status of their patient readmission reduction projects, teams may try to make themselves look better by highlighting what they hoped to accomplish in the future, instead of what they were accomplishing now. Some team members may become discouraged and start to doubt the benefits of the readmission reduction strategies.

The Quality Improvement Director, whose salary and bonus depends on the success of the hospital’s readmission reduction initiatives, will highlight projects that show great progress and ignore those that don’t. As a result, hospital executives will be unaware that some patient education/readmission reduction improvement teams are slowly starting to crack under the pressure. While transitional care teams at this stage continue to look for the flaws in their current working environments, they will get bogged down trying to perform any additional duties.

Failing Stage – What Might Happen

We have all seen stress tests on television where materials are stretched.  Over time, as stress is increased material begins to narrow, creating an area that becomes smaller and smaller until it is unable to sustain any more pressure. At that point, it breaks.

Similarly, when deploying a readmission reduction program with minimally behaviorally trained staff, team members become stretched thin of resources and find themselves unable or unwilling to learn the new tasks of modifying patient behavior. At this stage the reduction levels are not achieved and the effort is abandoned.

Team members become increasingly discouraged by their failure to achieve numbers developed by an outside source. They eventually stop caring about the readmission improvement project, partly because it wasn’t tied to their performance reviews nor was it positively reinforced and gains were not celebrated. As morale sags, no one steps forward to assume leadership of the readmission reduction improvement project. The team loses interest in looking for ways to improve their current work environment.

Hospitals may even allow newly formed “Try Me, This Might Work” quality improvement teams to poach people and resources from older, more established patient education and readmissions reduction/transitional care teams.  However, the only improvements made under these quality improvement efforts were those related to reducing patient harm—and even then, only the bare minimum was done because the efforts were focused on the processes and not on the individual patient or staff behavior.

Team members will steadily return to their old ways of working, and the group’s performance will return to its previous levels before the project began.  Past performance is always the best indicator of future performance.

As quality improvement projects fail, teams will report their achievements incorrectly, giving a false sense of success. Because assistant directors of nursing communicate only about projects that are showing excellent results, it will take several months for the CNO to become aware of the widespread failures and reluctantly inform the hospital’s top executives.

There is a Better Way!

Lessons Learned

Four lessons from our research stand out.

First, senior executives need to directly participate in Adherence Management/Patient Education/Readmission Reduction/Transitional Care projects, not just “support” them with the occasional wink and nod. Because it is in their best interest, directors in charge of quality improvement projects must observe firsthand the successes and failures of readmission reduction programs through objective data and feedback, rather than relying on someone else’s (CMS) after-the-facts interpretation.  Senior executives can make more accurate assessments as to the programs that are worth continuing. It is also, extremely counter-productive to penalize the provider, for the “Sins of the Patient.” The penalty “quality withholds” by CMS for high readmission rates do nothing to change the behavior of the patients who are being readmitted. It simply changes the behavior of the top management to find a better way to solve the problem.

Second, an Adherence Management (AdM) Coach is needed who can administer the Consequence Analysis™ to evaluate, from the patient’s perspective, the positive and negative consequences of the transition care/discharge plan, and who can developed the Adherence Improvement Plan™ that allows the transition team to prioritize the behavior based tasks that most affect the patient’s performance. Without the AdM Coach™ to manage and maintain the transition process (including the positive reinforcement and feedback from the patient’s behavior), some transition team members might begin pushing other agendas that benefit themselves and their departments rather than the patient. This makes it harder for the patient care team to agree on new directions and goals.

Also, the extended involvement of a trained Adherence Management (AdM) Master Coach is required if patient education and transitional care teams are to remain motivated, continue learning and maintain improvements in patient outcomes with the reduction of readmission rates. If the cost of assigning an Adherence Management Master Coach to each team on a full-time basis is prohibitive, one Master Coach should be assigned to several Adherence Management (AdM) coaches with basic training. Later, nurse managers could receive advanced training to take over the role of the Master Coach.

Third, performance appraisals of C-Suite down to the floor level providers need to be tied to successful implementation of readmission reduction and transitional care outcomes. Studies point out that positive reinforcers, even in small amounts, can motivate team members to embrace new and better work practices. Without such incentives, employees often regress to their old previously reinforced ways of working, once the initial enthusiasm for Adherence Improvement/Readmission Reduction/Transitional Care Management dies down.

Fourth, Improvement Teams should have no more than six to nine members who are trained as Adherence Management (AdM) Master Trainers per hospital. The timeline for training and launching an Adherence Management/Readmissions Reduction project should be no longer than four to six weeks. The bigger the team, the greater the chance team members will have competing interests and the harder it will be to agree on the aims and goals of the adherence mission. Adherence Management Master Coaches can move through a department, unit, or nursing division to teach nurses, nurse educators, pharmacy, and other members of the transition care team in the use of the Consequence Analysis™, Reinforcement Survey™, and Adherence Improvement Plan™.

Looking for the Unplanned Readmission Reduction Miracle

Understanding why most of our patients should follow their plan of care, for them, is not an “AHA!” moment.  Patients do not suddenly “see the light” following a Teachback session.  They just want to go home and resume their lives.  A fifteen to thirty minute Teachback session will almost never change the two or three or four decades of the patient’s self-injurious behaviors (e.g., smoking, over eating, etc.) which ARE positively reinforcing to them every time they light up or take a bite.

Following HEN 1.0, there was an almost universal cry from all of the HEN Partners and hospitals to require all nurses to “Be Certified in Teachback…  Every patient should have Teachback before discharge.”

I don’t disagree with this sentiment.  Universal Teachback alone, however, even if every nurse in America is certified, will not achieve the targeted 20% reduction in all-cause 30-day readmissions.  Behavior change, for both professionals and patients, takes training and time.  Providing Adherence Management Coach Certification will instruct direct-care professionals how to recognize “at-risk” patients, how to evaluate the negative consequences in the discharge plan of care, from the patient’s perspective, and how to develop and implement an Adherence Improvement Plan.  However, as with most hospital based patient education programs, if the Adherence Improvement Plan stops at the front door of the hospital, there may be some improvement in adherence, but as Dr. Ivar Lovass pointed out a half-century ago, “All behavior returns to baseline.”  New habit such as taking medications as prescribed, maintaining a salt restricted diet, exercise, etc., requires positive reinforcement as long as you want the new habit to continue.

We have to rethink the post-discharge period and what US lawmakers and the Center for Medicare and Medicaid meant when they wrote, “Improving readmission rates is the joint responsibility of hospitals and other clinicians…”  Changing patient behavior is the responsibility of health services professionals.  The most appropriate tool for doing that is a clear understanding of why people do the things they do and how to shape, reinforce and change behavior.  We do that through Adherence Management (AdM™) Coaches.

For more information on Adherence Management (AdM) Coach training programs, visit our website at or call 1-888-955-5591.

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