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RARE - Reducing Avoidable Readmissions Effectively

Mental Health Collaborative - Organizational Assessment

Organizational Assessment - Guide and Tools

As a participant in the RARE Mental Health Collaborative, 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 the summary information with your RARE Resource Consultant. The consultant will work with you to assist you in linking your organization to appropriate resources and tools. The RARE Collaborative will use the summary information provided to target tools and educational opportunities to best meet the needs of participating hospitals.

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.

Organizational Assessment ProcessProcess

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. Use the assessment tools below to complete your organizational assessment.

  1. Gather information and data on the current state of processes and readmissions. A complete assessment includes the following areas. 
    • Population Data and current readmission rate: Look at population wide 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.
  2. Assess your current practices with the RARE Mental Health Collaborative Assessment. (4-page Word doc) (Required Activity)
  3. Analyze and discuss data with your Cross Continuum of Care Guidance Team and Working Team to understand key findings related to primary causes(s) of readmissions in your organization. Tools available to help support the discussion include:
  4. Identify key area(s) for improvement. Five key areas (Required Activity)

  5. Set a goal for readmission reduction by the end of the collaborative. (3-page Word doc) (Required Activity)
  6. Share summary information with your RARE Resource Consultant. Please complete the Organizational Assessment Summary (2-page Word doc) and share it with your RARE Resource Consultant. (Required Activity)

Organizational Assessment Guide and Tools (print version, 5-page Word doc)

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. (1-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)

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.

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

Current Practices Assessment

Assess your current practices with the RARE Mental Health Collaborative Assessment. (4-page Word doc) (Required Activity)

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.