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RARE - Reducing Avoidable Readmissions Effectively

Organizational Assessment - Guide and Tools

Once your hospital has signed on to the RARE Campaign, you will need to complete an organizational assessment to help maximize your organization's resources and target improvement efforts to be the most efficient and effective to achieve your readmissions goals through the campaign. We request facilities to complete an organizational assessment and share summary information with your RARE Resource Consultant. The consultant will work with you to maximize your resources, target the improvement efforts that will most efficiently and effectively help you achieve your goals, and assist in linking your organization to appropriate resources and tools. The RARE Campaign use the summary information provided to target tools and educational opportunities to best meet the needs of participating hospitals.

If your organization has completed an organizational assessment in the last six to 12 months, please share the summary information with your RARE Resource Consultant. No additional assessment is needed.

RARE Hospitals' Organizational Assessments: What Are We Learning? In February 2012, the RARE Partners compiled a summary of the findings from the all the assessments completed by participating hospitals.

Focus Improvement Efforts for Readmissions - Getting Started and Organizational Assessment. This webinar describes the purpose, process and tools for completing the organizational assessment, and then how to analyze the findings. (Recorded September 8, 2011) (42-minute podcast) Handout (17-slide PPT)

Getting started >

Assessment Goals

The goals of the assessment are to identify the primary causes of avoidable readmissions at your facility and identify which of the five key areas to focus on to begin improvement efforts.


This guide will support your facility and provides the tools to complete a comprehensive organizational assessment to lay the groundwork for reducing avoidable hospital readmissions. If your hospital has already completed much of this assessment work in the last 12 to 18 months, use that information to complete the Organizational Assessment Summary and share with us your key findings and targeted areas for improvement.

Use the assessment tools below to complete your organizational assessment.

  1. Gather information and data on your organization's current state of processes and readmissions. A complete assessment includes the following:
    • Population Data: Data related to patient transitions
    • Observational Work: Evaluate the current processes related to patient transitions
    • Medical Record/Chart Reviews: Identify trends and patterns
    • Individual and Group Interviews: Understand the voice of your patients and staff
    • Financial Review: Understand the financial impact of avoidable readmissions and subsequent patient care
  2. Analyze and discuss data with working team and guidance team to understand key findings related to primary causes(s) of readmissions in your organization. Tools available to help support the discussion include:
  3. Identify key area(s) for improvement. Five key areas >
  4. Share summary information with your RARE Resource Consultant. Please complete the Organizational Assessment Summary and share with your RARE Resource Consultant.

Organizational Assessment Guide and Tools (print version) >

Assessment Tools

Population Health Data

Look at population wide data related to patient transitions.

Population Health Worksheet. Use this tool to understand your admissions, discharges, and readmissions. (1-page Word doc)

Observational Work

Evaluate the current processes related to patient transitions, asking questions such as: When are discharge summaries available to the next caregiver? How does that information get shared with the next caregiver? What is your process for medication reconciliation? How is it done? When is it done?

5 Whys Worksheet. Identify the root cause of your initial problem by completing this worksheet. (2-page PDF)

Admission Assessment Observation Tool. Identify patients for observation during admission assessment and use this tool to discover the current process. (1-page Word doc)

Cause and Effect Diagram (Fishbone). Includes a blank form for diagramming causes for readmissions, includes an example for preventing heart failure readmissions. (2-page PDF)

Discharge Observation. Spend time observing a patient on the last day of stay. Discover what went well and what didn't work as planned and predicted. (1-page Word doc)

Patient Teaching Observation Tool. Observe patient discharge teaching as it exists today. Honor the existing work and discover what went well. (1-page Word doc)

Process Mapping/Value Stream Mapping. Understand how to use process mapping  for quality improvement work. (19-page PDF)

Medical Record/Chart Reviews

Identify trends and patterns. These reviews might include randomly sampled hospital discharges, reviews of 30-day readmissions, as well as reviews of other services provided such as skilled nursing, home health, or physician follow-up services.

Care Transitions Abstraction Template. This abstraction helps review care transitions. (4-page Word doc)

Chart Review of Patients Who Were Readmitted. A simple chart review tool with audit information for up to five patients. (1-page Word doc)

Hospital Readmission Review. This review worksheet helps identify potential readmission factors, covering nine categories of potential readmission factors. (2-page Word doc)

Individual and Group Interviews

Understand the voice of your patients and staff. Individual interviews can help identify patterns, trends, and opportunities for improvement from the staff member and patient perspective. Group discussion and interviews allow for reflection and brainstorming of challenges and opportunities.

Interviews with Patients, Family Members, and Care Team Members. Use this form to gather input from patients, family members and care team members then outline the circumstances that contributed to the readmission. (2-page Word doc)

Readmission Worksheet. Use to identify gaps in care. Divided into several sections obtaining feedback from the patient and the provider as well as minimal chart review. (3-page Word doc)

Financial Review

Understand the financial impact of avoidable readmissions and subsequent patient care.

Return On Investment (ROI) Analysis and Calculator. The Project BOOST calculator helps you understand the financial impact of reducing readmissions at your hospital. The analysis document explains how to use the calculator and the algorithm behind the calculations, taking into account the hospital data, existing conditions, and actual or expected results from your project. Enter information specific to your hospital to compute the financial impact for your hospital. (7-page PDF and an Excel file)

STAAR Financial Impact Diagnostic Tool. A 10-step tool to assess financial impact of readmissions. (1-page Word doc)

Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.