Getting Started and
Organizational Assessment
RARE Campaign Summary
• Campaign across the continuum of care to
reduce avoidable hospital readmissions across
Minnesota and surrounding areas
• Regional approach, supported by hospitals,
providers, health plans, other key stakeholders
– More than 60 participating hospitals to date
• Goals:
– Prevent 4,000 avoidable readmissions in 18 months
– Reduce the overall readmission rate by 20%—from
5.8% in 2009 to 4.6% by Dec. 31, 2012
Getting Started
1. CEO selects an executive
sponsor
2. CEO selects working team
leader
3. CEO and executive sponsor
communicate reasons for
engaging in the RARE
Campaign, PPR data and
specific readmission reduction
goals
4. CEO communicates with
community stakeholders
regarding the RARE Campaign
and engages them in the work
5. CEO selects physician
champion
6. Cross Continuum of Care
Guidance Team formed
7. Working Team formed
8. Organizational assessment
completed
9. RARE focus area selected for
improvement work
10.Organizational resources to
accomplish improvements
provided
RARE Hospital Requirements
– Commit to specific readmission reduction goals set
based on MHA analysis
– Conduct an organizational assessment of
readmissions; tools provided by RARE Operating
Partners
– Share organizational assessment results and
readmissions data with the RARE Operating
Partners
– Commit to improving performance in key areas
identified through the organizational assessment
– Agree to publicly disclose participation in campaign
Purpose of the Organizational Assessment
Organizational Assessment Steps
1. Create a plan to gather information and data
on your organization's current state of
processes and readmissions.
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.
3. Identify key area(s) for improvement.
4. Share summary information with your RARE
resource consultant.
Gather Information and Data Overview
• A complete assessment includes:
– 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
• Tools:
www.rarereadmissions.org/resources/assessment.html
Gather Information and Data Observation
• Evaluate the current processes related to patient
transitions, asking questions such as:
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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?
• Tools:
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5 Whys
Admission Assessment Observation
Cause and Effect Diagram (Fishbone)
Discharge Observation
Patient Teaching Observation
Process Mapping/Value Stream Mapping
Gather Information and Data 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.
• Tools:
– Interviews with Patients, Family Members, and Care Team
Members: questions for each audience
– Readmission Worksheet: combines interviews with chart review
for a fuller picture of individual readmissions
Discuss with Team - Tools
• Reflective summary discussion questions:
– What themes emerged?
– What, if anything, surprised you?
– What new questions do you have? What are you
curious about? Is there a way we can answer
these questions?
– What assumptions about readmissions that you
held previously are now challenged?
– What opportunities for improvement will add the
most value to your organization (value = (quality
+ safety)/cost)?
Discuss with Team - Tools
Typical Failures in Discharge Planning:
Medication Management
• Medication reconciliation does not align with medications patient is taking when patient arrives home
• New medications not available on discharge, patient may have difficulty filling in timely manner
Transition Care
• No follow-up appointment, or follow-up needed with additional provider expertise
• Inability to keep follow-up appointments because of illness or transportation issues
Patient and Family Engagement in Discharge Preparation
• Patient/family failure to ask clarifying questions on instructions and plan of care
• The care provided by the facility unravels as the patient leaves the hospital
Comprehensive Discharge Plan
• No advance directive or planning beyond do not resuscitate status
• Patient returns home without essential equipment
Transition Communication
• Poor communication of the care plan to the nursing home team, home health care team, primary care
physician, or family caregiver
• Current and baseline functional status of patient not described, making it difficult to assess progress
and prognosis for post-acute care providers
Strengths, Weaknesses, Opportunities, Threats
WEAKNESSES
Attributes that hinder the vision.
EXTERNAL
INTERNAL
STRENGTHS
Attributes that help achieve the vision.
OPPORTUNITIES
THREATS
External conditions that help achieve the vision.
External conditions that damage the vision.
Identify Key Area(s) for Improvement
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Comprehensive Discharge Planning
Medication Management
Patient and Family Engagement
Transition Care Support
Transition Communication
Organizational Assessment Summary
• Includes:
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Activities completed
Key findings
Describe areas identified for improvement
Prioritize improvement opportunities
• Share summary with RARE resource consultant
• Complete within 4 – 6 weeks of committing to
campaign
Next Steps
• Create an action plan for your priority area(s)
– Include multiple PDSA cycles
– Start small—but start!
• Tools and models available for each key area on
website starting late Sept.
• Action Day: Oct. 18—details coming soon!
• Webinars and other events at
www.rarereadmissions.org/resources/calendar.html
• Utilize your RARE resource consultant
Thank You For
Helping Everyone Sleep
More Peacefully.
Questions?
www.RAREreadmissions.org
Thank you!
Kathy Cummings: kathy.cummings@icsi.org
Karla Weng: kweng@stratishealth.org