KAISER PERMANENTE ALL-CAUSE READMISSION DIAGNOSTIC TOOL
Background
The Care Management Institute (CMI) of Kaiser Permanente (KP) developed the Kaiser Permanente
All-Cause Readmission Diagnostic Tool for use by operational teams to gain insight into why
readmissions occur and how we can further leverage our integrated delivery system to prevent
unnecessary readmissions. The Care Management Institute is a partnership between the Permanente
Medical Groups and the Kaiser Foundation Health Plan and promotes transformative health care
system-wide through care delivery analytics, evaluation and improvement work.
The diagnostic tool was first developed by Roger Resar, MD and others at the Institute for Health Care
Improvement (IHI) as part of the Transforming Care at the Bedside Project. CMI tailored the IHI tool to
meet the unique needs of KP’s integrated care delivery system. In partnership with multiple regional
teams across KP, CMI has designed, tested, and refined the tool itself and the process for
operationalizing it’s use. To-date over 700 readmissions have been reviewed and the findings are
informing operational teams locally and as well as system-side care delivery improvement strategy.
Application
Sample: The majority of applications of this tool within KP have been to conduct “all-cause”
readmission diagnostic reviews on 30 readmissions that had occurred within 30 days of the previous
hospitalization. Reviewers are nurses and physicians and/or other specialists (i.e. PharmD)
experienced in the clinical setting and in chart review. The majority of teams review the 30 most recent
readmissions at a given medical center that occurred within 30 days after the previous hospital
discharge from the same facility.
Tool Description: The review tool employs a triangulated approach including chart review,
patient/caregiver interview, and patient provider interview. Interviews with patients are conducted inperson (if the interviewee is on-site) or by phone. When the first three sections are complete, the
RN/MD reviewer team reviews the case together to identify any missed opportunities in the care of the
patient and to assess the likelihood that the readmission could have been prevented. The process
takes about two hours per case depending on the level of experience of the review team and the
complexity of the individual the case.
Approach: The KP approach to application of the tool has been to focus learning on how, as a system,
it can prevent readmissions that once were considered impossible to prevent. Multidisciplinary teams
put aside blame; look for systems issues; and consider the possibility that previously unpreventable
readmissions might be avoided with redesigned clinical and/or operational processes. RN and MD
review teams work collaboratively utilizing KP’s electronic medical record (KP Health Connect) to view
care delivery information across the care continuum. Most importantly, the patient’s voice is an integral
part of the review that adds to the richness and depth of each review.
Video Ethnography: At Kaiser Permanente, these reviews often include a video ethnography
component that provides an opportunity to capture and analyze patient /caregiver interviews on video in
order to leverage patient and caregiver voices to drive change and improvement,
Additional Resources or Information
For more information about the Care Management Institute, please go to kpcmi.org.
For more information about the KP Readmission Diagnostic Tool, please contact Estee Neuwirth, PhD
at Estee.Neuwirth@kp.org
Copyright © 2010 Kaiser Permanente
Page 1 of 13
ALL CAUSE HOSPITAL READMISSION DIAGNOSTIC TOOL
For more information, please contact estee.neuwirth@kp.org of the Care Management Institute.
CASE REVIEW INFORMATION
RN Reviewer Name
RN Reviewer Case #
Index Hospitalization Dates
Readmission Hospitalization Dates
Chart Review - Section 1

Patient Interview - Section 2

Provider Interview - Section 3

Final MD Review - Section 4

CMI Data Validation

CHART REVIEW (Section 1)
General Information:
Patient Name (Last, First)
MRN:
Age:
Patient Preferred Language:
 English
Spanish
Mandarin
 Cantonese
 Tagalog
Korean
Russian
 Other
Vietnamese
Race/ Ethnicity:
 Caucasian  African American  Asian  Latino  Native American  Asian/Pacific Islander
 Other
Gender:
 male
 female
Index Hospitalization:
Index Hospitalization Admission Date
Type of service:
 Medical
 Surgical
Index Hospitalization Discharge Date
 Other
After index hospitalization, patient was discharged to:
 Home
 SNF
LT Care
Assisted Living
 Board & Care
 Other
If patient discharged home, the patient lives:
 Alone
 With Family (including spouse)
Copyright © 2010 Kaiser Permanente
 With other caregiver
CHART REVIEW Page 2 of 13
1. Copy and paste the index discharge diagnoses into the Excel tool:
1a. What chronic conditions does the patient have? (check up to three boxes)
 DM COPD
 HF CVD
CKD
Mental Illness
Cancer
Other______________________
Hypertension
1b. Categorize the principle discharge diagnoses for the index hospitalization (select max of 3):
Indicate which diagnosis of the ones you select is the most important
 Adverse reaction to meds
 Chest Pain
 Chemotherapy/Oncology
 Cirrhosis
 COPD/Respiratory condition
 Diabetes
 Dementia or Cognitive Impairment
 Injury
 Fluid overload
 Gastrointestinal problems
 Heart failure
 Infections
 Infections, hospital acquired
 Myocardial Infarction
 Seizure
 Hypertension
 Pneumonia
 Psychiatric illness
 Renal disease
 Shortness of breath
 Social issues
 Surgical complications
 Stroke
 Other
1c. Prior to index hospitalization, were there any of the following in the last 6 months?
Hospital admissions (not including index hospitalization).
If so, how many?________
Emergency room visits (those independent of hospitalizations only)
If so, how many?________
Is this a case with multiple hospital admissions close together within 90 days of index
admission?
Yes  No
Transitions Care Plan
2. Were there discharge instructions and/or a SNF/Board and Care discharge order form completed in the
chart at the time of index hospitalization discharge?
 Yes  No
(Note – to find these instructions, you may need to look both at the discharge instructions and/or the
physician discharge summary)
a. If yes to question above, which of the following items were included in the instructions or order?
Included
Not included
Not
applicable
1. Discharge diagnosis
2. List of discharge medications
3. Indication of any pending test/lab results
4. Instructions about what the patient or caregiver
should do if patient’s condition worsens
5. Key phone number for who to call if problems
arise after discharge (not including 911)
6. Date for scheduled follow-up appointment with
key outpatient provider (note—suggesting that the patient
make an appointment does not qualify as scheduled appointment)
7. Important information on diet, fluid intake, or
home equipment
Copyright © 2010 Kaiser Permanente
CHART REVIEW Page 3 of 13
b. What was the patient’s functional status at index hospitalization discharge (physical, psych and ADL)?
 Fully dependent
 Somewhat dependent
 Independent
 Unknown
3. Were any referrals made for post-acute care? If no, skip table below and go directly to question 4a.
(Note: If the discharge orders indicate MD intended for a referral but you see no evidence of visit/services
in chart then leave blank).  Yes
 No
Types of referrals made during index stay for
post acute care.
If yes, referrals were made, please enter:
1. The date that the visits/services took place
2. ’00 if you could not locate date
3. ‘99 if patient was readmitted prior to visit/service
4. Leave blank if no referral
1. Behavioral health (including
psychological/psychiatric treatment)
2. Chronic Conditions Disease Management
3. Community Services
4. Durable Medical Equipment
5. Home Health
6. Hospice
7. Outpatient Coagulation Clinic
8. Outpatient Palliative Care or AICC
9. Physical Therapy
10. Social Work
11. Specialist
12. Other
4a. At time of index hospitalization, had there been a palliative care consult?  Yes  No
4b. If yes, what was the most recent date of palliative care consult (Enter mmddyyyy):
5. At the time of index hospitalization, did the patient have an advance directive or POLST (prior to
discharge) in the chart?  Yes  No
6. What was the patient’s code status at index hospitalization prior to discharge?
 Full Code  Partial
 DNR
Readmission Hospitalization:
Readmission Date (Enter mmddyyyy):
Readmission Discharge Date (Enter mmddyyyy):
7. Was this a planned readmission? Yes
No
Unsure
8. If planned, describe the purpose for readmission: (Note: If planned, go directly to question 11b
9. Select the statement that best describes how the patient was admitted to the hospital:
a. Patient was seen by doctor and was referred to the hospital
b. Patient/caregiver/SNF contacted KP and was told to come to KP ED/hospital
c. Patient/caregiver/SNF tried to contact KP but could not reach or could not get authoritative advice
d. Patient/caregiver/SNF called 911 in emergency situation and was brought to KP ED by decision of
EMTs
e. Patient/caregiver/SNF decided on their own to come to KP ED/hospital
f. KP outreached to patient and then advised patient to come in
g. Could not assess from Health Connect
Copyright © 2010 Kaiser Permanente
CHART REVIEW Page 4 of 13
10. If someone from KP sent patient to the hospital, who was it?
PCP/NP Specialist Call Center/Advice Nurse SNF doc  Home Health Other:___________
11a. Copy and paste the chief patient complaint for the readmission (ie. difficulty breathing, pain):
11b. Categorize the principle admitting diagnoses for the hospital readmission:
Indicate which is the most important principle diagnosis of the ones you selected
 Adverse reaction to meds
 Chest Pain
 Chemotherapy/Oncology
 Cirrhosis
 COPD/Respiratory condition
 Diabetes
 Dementia or Cognitive Impairment
 Injury
 Fluid overload
 Gastrointestinal problems
 Heart failure
 Infections
 Infections, hospital acquired
 Myocardial Infarction
 Seizure
 Hypertension
 Pneumonia
 Psychiatric illness
 Renal disease
 Shortness of breath
 Social issues
 Surgical complications
 Stroke
 Other
12. Was the readmission diagnosis related to the index hospitalization?
 Yes
 No
13. Was the readmission a result of a complication from the index hospitalization (i.e. surgical error,
hospital acquired infection, etc)?
 Yes
 No
 Maybe
(Note: If yes or maybe please be sure to include explanation in Missed Opportunities Section 4.)
Accessing Kaiser Permanente between Index & Readmission:
14. Was there an in-person MD or Nurse Practitioner (NP) appointment between the index hospitalization
and readmission?
 Yes (can include SNF MD visit)
 Yes, but patient did not show
 Yes, but patient was readmitted prior to appointment
 No
a. If yes, what was the date of the first visit? (Enter mmddyyyy) __________________________
b. What type of provider was the appointment with?:  PCP/NP  Specialist SNF doc
15. Was there a MD or NP telephone encounter (TAV or other) and/or email between the index
hospitalization and readmission?
 Yes  No  n/a (SNF Only)
a. If yes, what was the date of the first call and/or email? (Enter mmddyyyy) __________________
16. Was there an outbound call to the patient between the index hospitalization and readmission (MD or
NP telephone encounter included)?
 Yes, call was attempted but didn’t reach patient
 Yes, call was completed
 No call attempted
 n/a (SNF Only)
a. If yes, what was the date of the first call? (Enter mmddyyyy) ________________________
b. If yes, who made that first call?
 Transitions Nurse  Other Nurse  Pharmacist
 Other:_____________
Copyright © 2010 Kaiser Permanente
PCP  Hospitalist  Specialist
CHART REVIEW Page 5 of 13
PATIENT/CAREGIVER INTERVIEW (Section 2)
Hi, my name is _____________ from Kaiser Permanente and I am calling about a study we are
conducting of how we can best support our members to stay safely at home after a hospital
visit. The interview takes only 10 minutes of your time. Is now a good time for us to talk?
Interviewee:

Patient
 Family Caregiver
 No interview
1. Was your hospital visit [on x readmission date] scheduled ahead of time?
 Yes  No
2. Can you tell me what happened that brought you back to the hospital this time?
___________________________________________________________________________
a. Why do you think this happened? Enter open text
b. Was there anything you think that KP could have been done to prevent this? Enter open text
c. How are things going at home/care at SNF? (Probe for psych/social/family/non-medical issues).
Enter open text
3. Medications (referring to index hospitalization or “the first time you were in the hospital”)
a. Were changes made in your medications when you were in the hospital on [date of index
hospitalization]?  Yes  No
 Not sure
Explain:
Note: If no or not sure, please skip to question d
b. Did you understand the changes?  Yes  No
Explain:
c. Were you able to obtain your new medications right away?  Yes  No  n/a SNF only
Explain:
d. Were you able to take your medications like the doctor wanted you to?  Yes  No
Explain:
e. Did the hospital give you an accurate, easy to understand list of medications when you left?
 Yes  No  n/a SNF only
Explain:
4. From your perspective, who is in charge of your care at Kaiser Permanente?
 PCP
 specialist  case manager RN  Other RN
 Hospitalist
Other:____________________________
 SNF doc
5. How often are you in touch with this provider? How are things going with this provider?
_____________________________________________________________________________
6. Does it seem like this provider and others responsible for your care are talking to each other about
your care?
 Yes  No Explain:
Copyright © 2010 Kaiser Permanente
PATIENT INTERVIEW Page 6 of 13
Let's go back to the day you went home from the hospital on [refer to index discharge date].
Think about the concerns or challenges you and/or your family faced when you first returned
home. We’d like to know if there is anything Kaiser could have done better to support you
and/or your family. I am going to read a list of possible things. Please let me know if this is an
area we need to improve.
Note to reviewer: If you answer yes to any factors below, make sure to refer to columns to the right and
go over degree that this issue may have contributed to the readmission. If you are doing a phone
interview, remember that it’s the index hospitalization experience that we are interested in. So refer to
the index hospitalization as, “time before last, on [index date]”.
“Referring to your first hospital visit,
COULD WE HAVE….”
STEP 2 If YES, ask, to what degree did it
STEP 1
Y, N, NA?
lead you back to the hospital?
Definitely a
Somewhat
Not at all a
factor
a factor
factor




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3. Talked to you more about your medications and
the reason you take them?
4. Made it easier for you to get in touch with
someone at KP when you needed help?
5. Reduced the time it took to get an appointment?









6. Provided more written materials for you to look
over?
7. Provided additional support or information to
your caregiver or family members?
8. Discussed what you might expect to happen in
the future regarding your health and the
expected course of your illness and treatment?
9. Made sure you had the equipment and other
things you needed once you arrived home?
10. Anything else? (please specify)

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1. Explained things more clearly to you?
2. Checked in on you from time to time?
7. a. Did you receive a follow-up phone call after your hospitalization?
 Yes
 No  Do not remember  n/a
If no or do not remember, skip to #8.
b. If yes, who did you receive the call from?
 Transitions Nurse  Other Nurse  Pharmacist  PCP  Hospitalist  Specialist 
Social Worker  Surgeon  Don’t remember  Multiple calls  Other:_____________
c. On a scale from 1-10, with 1 being the least and 10 being the most, how helpful was the call?
8. In hindsight, how likely is it that Kaiser Permanente might have been able to keep you safely at
home, preventing the second hospital visit [on x date]?
 not at all likely
 slightly likely
 moderately likely
 very likely
 completely likely
Explain: ________________________________________________________________________
9. Is there anything else you’d like to share with us?
Copyright © 2010 Kaiser Permanente
Thank you very much for you time.
PATIENT INTERVIEW Page 7 of 13
PROVIDER INTERVIEW (Section 3)
Hi my name is ------- from Kaiser’s ------ department. We are doing a quality improvement
project and would appreciate your candid insights on what we as a system might do better to
keep our patients safely at home after hospitalization. This project is about understanding what
we can do better and NOT about individual physician practice or peer review. Do you have a
few moments?
Interviewee:
 PCP  Specialist
 Hospitalist
SNF doc other______ no interview
1. Was this readmission scheduled ahead of time? Yes No
1a. If not planned, what do you think led to this patient’s readmission?
____________________________________________________________________________
2. Might it have been possible to provide the necessary care for this patient in an outpatient setting
rather than in the hospital?
 Yes  Maybe, but not right now the way things are organized in our system No
3. Would you have predicted this readmission?  Yes
 No
Explain:_________________________________________________________________________
4. Did you discuss with the patient and/or their caregiver what they could expect to happen in the
future regarding their health and the expected course of their treatment?  Yes
 No
5. With the benefit of hindsight, is there anything that KP could have done to keep this patient safely at
home, potentially preventing a readmission? Note to reviewer: Prompt them to think about events
prior to and during the index hospital stay and prior to and after the index discharge.
_______________________________________________________________________________
6. Prior to readmission, do you think the patient would have benefited from a referral to an advanced
care planning program like palliative care or hospice?
 Yes  No
a. If YES, did you refer the patient to PC or hospice?
 Yes PC  Yes Hospice  Yes Both
 No
b. Did you have a conversation about advanced care planning with the patient and/or family? 
Yes  No
c. If NO to 6b, please explain why not:
7. Would you be surprised if this patient died in the next year?
 Yes  No Explain:
8. In hindsight, how likely is it that we could have kept this patient safely at home (in the SNF),
preventing this readmission?
 not at all likely
 slightly likely
Copyright © 2010 Kaiser Permanente
 moderately likely
 very likely
 completely likely
PROVIDOR INTERVIEW Page 8 of 13
If interview is with a hospitalist, please skip question 9-12.
9. Were you responsible for this patient’s care prior to the readmission?  Yes  No
10. Were you aware of this patient’s worsening condition prior to this readmission?  Yes  No
11. Do you feel you are the physician in charge of managing and coordinating the care for the patient?
Yes
No
If no, who do you think is in charge?
 PCP
 Hospitalist
 SNF MD  Surgeon
 Specialist
 RN
 Other_________
12. Did you receive accurate and timely information from the hospital regarding the patient?
Yes
No
For all respondents:
Is there anything else you’d like to share?
Thank you very much for your time.
Copyright © 2010 Kaiser Permanente
PROVIDOR INTERVIEW Page 9 of 13
FINAL ASSESSMENT & MD REVIEW (Section 4)
This section is intended to identify missed opportunities/gaps in the system
To complete the following table, assess the likelihood that each gap contributed to the readmission,
using the scale provided. Once you have completed this section, please discuss and collaboratively
confirm with MD reviewer and the review support team.
Potential Gap
Prior to index hospitalization
1. Not enough monitoring of chronic condition
prior to index hospitalization
2. Not enough monitoring of other medical
condition(s) prior to index hospitalization
3. Pre-op instructions were inadequate
4. Unmet psych/social needs
5. Needed more attention to palliative
care/hospice
During Index Hospitalization
6. Did not optimally manage chronic condition
7. Did not diagnose or misdiagnosed
8. Medication management issue (wrong
dose, wrong med, etc):_______
9. Did not recognize worsening condition
10. Surgical / procedural complication
11. Did not teach patient or family member
how and why to take meds
12. Transitions care plan not developed or
inadequate
13. Patient could have benefited from
additional referrals (list which ones):
_________________
14. Too unstable at discharge
15. Discharged too soon (i.e. prior to lab work
being completed)
16. Patient/caregiver left hospital without
written documentation or understanding of
the transition care plan. Skip to 16 if “n/a”
is chosen.
Specifically regarding,
a. Who to contact
b. Self-care instructions
c. Discharge meds
d. Other, please
explain:______________
17. Did not adequately coordinate patient care
18. Did not adequately assess patients
understanding or ability to follow through
on the transitions care plan
Copyright © 2010 Kaiser Permanente
In hindsight, how likely is it that this factor
contributed to the readmission?
n/a
No Gap
Not at
all
likely
Slightly
likely
Moderately
likely
Very
likely
Completely
likely
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FINAL ASSESSMENT AND MD REVIEW Page 10 of 13
Potential Gap
19. Did not adequately assess patient post
discharge risk and tailor care
20. Did not adequately address psychological
needs
21. Did not adequately address social needs
22. Did not adequately address end of life care
planning needs
23. Equipment, oxygen, or other necessary
supplies were not ordered
24. Hospital did not provide timely or accurate
information to PCP, SNF, or other key
provider
25. Other________________________
Post Index Discharge
26. Patients condition not monitored closely
enough
27. Pending lab/procedure results not followed
up
28. Did not have timely MD follow up in clinic
or SNF
29. Patient and/or caregiver did not know
enough about how or when to contact
Kaiser Permanente
30. Surgical/procedural complication
31. Did not recognize worsening condition
32. Did not optimally manage condition from
index hospitalization
33. Did not optimally manage chronic condition
34. Did not diagnose or misdiagnosed
35. Patient instructions were inadequate (i.e.
outpatient provider missed opportunity to
instruct patient/caregiver)
36. Medication management issue (wrong
dose, wrong med, etc): ____________
37. Did not adjust plan of care to meet patient
support needs post discharge
38. Did not adequately address psychological
needs post discharge
39. Did not adequately address social needs
40. Patient would have benefited from
additional referrals post discharge (list
which ones)
41. Referrals were made, but no one at KP
followed up on them post discharge
42. Poor coordination between inpatient and
outpatient providers post discharge
43. Other:____________________________
Copyright © 2010 Kaiser Permanente
In hindsight, how likely is it that this factor
contributed to the readmission?
n/a
No Gap
Not at
all
likely
Slightly
likely
Moderately
likely
Very
likely
Completely
likely
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FINAL ASSESSMENT AND MD REVIEW Page 11 of 13
Comments:_________________________________________________________________________
2. If there was not a completed in-person MD or NP appointment between the index and readmission
hospitalizations, could an appointment have potentially prevented the readmission?  Yes  No
Note: reference answer to Chart Review section, question 14.
3. Based on interviews and the chart review you conducted, did it seem that there was clear physician
accountability for the patient after the index hospitalization?  Yes  No
a. If yes, who was in charge?
PCP
 Specialist  Surgeon
 SNF MD
 Multiple physicians in charge  Other
b. If no, might clear physician accountability have made a difference in preventing this readmission?
 Yes  No
4. In hindsight, if all missed opportunities had been resolved, how likely is it that Kaiser Permanente
might have been able to keep this patient safely at home (or in the SNF) potentially preventing this
readmission?
 not at all likely
 slightly likely
 moderately likely
 very likely
 completely likely
5. How would you categorize this readmission? Circle one statement that best applies.
a. planned
b. unplanned; readmission was for an acute medical problem resulting from a clinical
complication or intervention that occurred during the index hospitalization that may have
contributed to the readmission (e.g. surgical infection)
c. unplanned; care could have been provided in alternative care setting such as clinic or SNF
d. unplanned; there were missed opportunities identified in the previous sections of this tool
that may have contributed to the readmission (e.g. closer monitoring, discharge too soon )
e. unplanned; related to index hospitalization but no opportunities identified that may have
prevented readmission
f. unplanned; unrelated to index hospitalization and no prevention opportunities identified
g. could not determine
6a. Was this a case in which reviewers had a particularly hard time reaching agreement on how to
answer above questions 4 or 5.  Yes  No
6b. Was this a case in which patient likely would have had a different perspective than the reviewers on
how to answer questions 4 or 5?  Yes  No
7. Were there any specific interventions that would have made a difference in preventing this
readmission? Explain and describe.
___________________________________________________________________________
Copyright © 2010 Kaiser Permanente
FINAL ASSESSMENT AND MD REVIEW Page 12 of 13
8. Write a detailed summary of this case review, including key insights from chart review and all
interviews. We encourage you to include important direct quotations to capture the voices of people
interviewed.
Summary of Case
Reason for readmission…
Opportunities to have prevented
readmission…..
Copyright © 2010 Kaiser Permanente
Important Patient
Direct Quotations
Important Provider
Direct Quotations
FINAL ASSESSMENT AND MD REVIEW Page 13 of 13