Organizational Assessment Guide and Tools
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 RARE Campaign, we request that your
facility complete an organizational assessment. We ask that you share summary information with your
RARE Resource Consultant so they can better assist in linking your organization to appropriate
resources and tools. The RARE Campaign also 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:
 Comprehensive discharge plan
 Transition care
 Medication management
 Transition communications
 Patient/family discharge preparation
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 at the end of this guide and share with us your key
findings and targeted areas for improvement.
Process
1. Gather information and data on the current state of processes and readmissions. A complete
assessment includes the following areas.
 Population Data: 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.
 Financial Review: Understand the financial impact of avoidable readmissions and
subsequent patient care.
The Organizational Assessment Tools table on the next page lists tools for gathering assessment
data in all of these categories. This information also is available on the RARE website at
http://rarereadmissions.org/resources/assessment.html.
2. 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:
 Reflective Summary Discussion Questions
 List of Typical Failures in Hospital Discharge
 SWOT Analysis Worksheet
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 it with your RARE Resource Consultant.
Organizational Assessment Tools
Component/Description
Examples
Population Data

Look at population wide data
related to patient transitions.
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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?

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Tools - Select tools that are most appropriate for
your facility
Admission/discharges per year
and day
Current hospital readmission rate
Patient diagnosis
Key characteristics of readmitted
patients
Length of stay
Source of readmissions
Common location of discharges
Population Health Worksheet
Complete a process map of
hospital experience
Observe an admission
Observe patient teaching in
preparation for discharge
Observe a discharge
Admission Assessment Observation Tool. Identify
patients for observation during admission assessment
and use this tool to discover the current process.
(1-page Word doc)
Understanding PPR Data Reports (Coming soon)
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)
Component/Description
Examples
Observational Work continued
Tools - Select tools that are most appropriate for
your facility
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)
5 Whys Worksheet. Identify the root cause of your initial
problem by completing this worksheet. (2-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.
Individual and Group Interviews

Review charts of at least 5
patients who were readmitted
within 30 days for an unplanned
readmission

Work with partner organizations to
review medical records of services
provided by skilled nursing, home
health or physician follow-up for
the readmitted patients

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.
Interview 4 to 5 patients or their
families who have experienced an
unplanned readmission within 30
days
Interview the care team about
what they observe as the main
causes of hospital readmissions
Complete a focus group with
patients or care team
Chart Review of Patients Who Were Readmitted. A
simple chart review tool with audit information for up to
five patients. (1-page Word doc)
Care Transitions Abstraction Template. This abstraction
helps review care transitions. (4-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)
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)
Component/Description
Financial Review
Understand the financial impact
of avoidable readmissions and
subsequent patient care.
Examples

Determine what would be the
consequences if your Medicare
reimbursement for all patients was
reduced by 0.5%, 1%, 2% or 3%
Tools - Select tools that are most appropriate for
your facility
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)
Organizational Assessment Summary
Organization:
Team Lead:
Team Members:
Component
Population Data
Activities Completed
Observational Work
Medical Record/
Chart Reviews
Individual and
Group Interviews
Financial Review
Describe your organization’s
priority areas for improvement
using key findings identified.
Tools:
Questions for Reflective Team
Discussion
Typical Failures in Hospital
Discharge Planning
SWOT Analysis Worksheet
Key Findings
Focus Areas for Your Hospital
Prioritize the five key areas of focus for your hospital (mark 1 through 5, with 1 being the highest
priority). Definitions of key areas >
____ Comprehensive discharge plan
____ Medication management
____ Patient/family discharge preparation
____ Transition care
____ Transition communications
Based on your organization’s priority areas, what types of tools and resources would be most
helpful to assist your improvement efforts:
Please share a copy of your completed RARE Organizational Assessment Summary with your
RARE Resource Consultant so they can better assist and support your team’s efforts.
RARE Campaign www.rarereadmissions.org