Mental Health Collaborative 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 Mental Health Collaborative, we
request that your facility complete an organizational assessment. We ask that you share summary
information with your Resource Consultant so they can better assist in linking your organization to
appropriate resources and tools. The Collaborative will also 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.
Process
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.
The Organizational Assessment Tools table on the next page lists tools for gathering assessment
data in all of these categories.
2. Assess your current practices with the RARE Mental Health Collaborative Assessment. (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:
 Reflective Summary Discussion Questions
 Typical Failures in Hospital Discharge
 SWOT Analysis Worksheet
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. (Required Activity)
6. Share summary information with your RARE Resource Consultant. Please complete the
Organizational Assessment Summary and share it with your RARE Resource Consultant. (
Required Activity)
Organizational Assessment Tools
Component/Description
Examples
Tools - Select tools that are most
appropriate for your facility
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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
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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
Complete a process map of hospital
experience
Observe an admission
Observe patient teaching in preparation for
discharge – Strongly Recommended
Assessment
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)
Population Data
Look at population wide data related
to patient transitions.

Understanding PPR Data Reports (Coming in
February)
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)
Observational Work continued
5 Whys Worksheet. Identify the root cause of
Component/Description
Examples
Tools - Select tools that are most
appropriate for your facility
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
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Interview 4 to 5 patients or their families
who have experienced an unplanned
readmission within 30 days
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.
RARE Mental Health Collaborative
Assessment
Determine how your current practices
compare to the recommended
practices for improved care
transitions.
Interview the care team about what they
observe as the main causes of hospital
readmissions
Chart Review of Patients Who Were
Readmitted. A simple chart review tool with
audit information for up to five patients. (1page 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)
Complete a focus group with patients or
care team

Discuss with front line staff if these
practices are consistently done for all
patients.
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Ask patients if they have experienced these
practices in their care.
RARE Mental Health Collaborative
Assessment
Mental Health Collaborative Organizational Assessment Summary
Organization:
Team Lead:
Team Members:
Component
Population Data
Activities Completed
Observational Work
Medical Record/
Chart Reviews
Individual and
Group Interviews
RARE Mental
Health
Collaborative
Assessment
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 and identifies your area to work on first). Definitions of key areas >
____ Comprehensive discharge plan
____ Medication management
____ Patient/family discharge preparation
____ Transition care support
____ Transition communications
Action Plan:
Please identify your team’s next steps to work on your priority area
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