USE RESTRICTED TO ABC Hospital READMISSION ROOT CAUSE ANALYSIS REPORT State: Community Name: YZ Cohort: Hospital: A ABC Hospital Reviewer: Jane Doe Abstraction Period: 1/1/2014 6/30/2014 Charts Abstracted: 20 Medicare FFS Focus: Any primary diagnosis Abstraction Date: Tuesday, March 17, 2015 Summary A total of 20 Medicare FFS patient charts from ABC Hospital were reviewed to identify the key drivers for readmission among patients with Any primary diagnosis. The RCA tool used to gather information included 23 best practices for preventing unnecessary readmission, all of which are related to one or more of four broad underlying drivers cited in Care Transitions research: (1) Low patient activation (2) Lack of standard or known process (3) Inadequate transfer of information between care settings (4) Medication Safety The five best practices topping the list for non compliance were rooted in 4 of the 4 drivers. They are, in order of decreasing non compliance: Best Practice ID Patient Activation Lack of Known Standard Process 11 Readmission Drivers Transfer of Information Medication Safety 2 Best Practice Instruct patient on a special plan of how to contact the PCP or back up by providing contact numbers for office hours and after hours communications. Post discharge appointments for physician office or lab are coordinated with the patient/family and set prior to discharge.
9c associated s: COPD and associated 21b High risk medication identified: Diabetes Drugs. 21c High risk medication identified: Opioids. The percentages of charts reviewed that did not conform to these best practices ranged between 35.0% and 80.0%. The total non conformance observed for these five best practices accounted for 50.0% of the non conformance observed across all best practices. This report was prepared by Quality Insights, the Quality Innovation Network serving DE, PA, WV, NJ, and LA, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
USE RESTRICTED TO ABC Hospital The RCA tool used by ABC Hospital is partially shown below. 20 Medicare FFS patient charts were reviewed (columns labeled 1 10), checking for conformance with 23 best practices. A "Y" (Yes), "N" (No), or "NA" (Not Applicable) was recorded for each chart based on findings. An "" in any of the four drivers columns indicates whether the best practice is associated with that driver. The best practices, IDs, and drivers were then copied from the tool to the ABC Hospital sheet (columns A F) in this report. Data (columns G I) For each best practice listed on the ABC Hospital sheet, column G shows the total number of non conforming charts (indicated by "N" on the tool), column H shows the total number of charts reviewed, and column I shows the total number of applicable charts (indicated by either "Y" or "N") Relevance (column J) Relevance measures how much a best practice pertains to the charts that were selected for review and is equal to column I divided by column H. In other words, of the total number of charts reviewed where conformance to that best practice was checked, what % were applicable. Non Conformancy (column K)
Non conformity measures how much non conformance was observed in charts where the best practice was applicable and is equal to the total number of non conforming charts (column G) divided by the total number of applicable charts (column I). % Charts Non Conforming (column L) The % Charts Non Conforming equals the number of non conforming charts (column G) divided by the total number of charts reviewed (column H), and can also be expressed as the product of Relevance and Non Conformity. For example, a best practice with a low relevance of 20% and a high non conformity of 100% yields a 20% overall non conformance (20% x 100%). Likewise, a best practice with a high relevance of 100% and a low nonconformity of 20% also yields a 20% overall non conformance (100% x 20%). Best practices are sorted by the value in column L in descending order, so that best practices where improvement may reduce readmission rate are at the top of the list. Cumulative % Non Conforming Charts (column M) Column M shows the cumulative % of non conformance observed. For example, if the cumulative % of non conforming charts for the first 3 best practices listed were 25%, then corrective action aimed at those best practices would potentially address roughly 25% of all non conformance observed. Choose best practices which top the list such that all 4 readmission drivers are covered among them. The hospital and Quality Insights can then work together to select appropriate interventions. Community Aggregate results from all participating community hospitals are shown on the Community sheet. Graphs The bar graphs on the Graphs sheet are Pareto style graphical representations of best practice non conformance at the hospital and community level.
Best Practice ID Patient Activation 1 Readmission Drivers Lack of Known Transfer of Standard Information Process Medication Safety 2 3 4 5 6 7a 7b 7c 7d 7e Best Practice Patient/family educated about the diagnosis throughout the in patient stay. Post discharge appointments for physician office or lab are coordinated with the patient/family and set prior to discharge. Patient/family is educated on importance of followup care and keeping appointments. Patient/family verbalizes ability to obtain transportation to appointments. Education on completed tests or studies and importance of follow up for future tests. Medication reconciliation occurs at admission and discharge. with review of medication purpose. with review of dosage. with review of adverse drug events. with review of other side effects. by reporting each side effect and untoward effects to providers. 8 Patient/family has a local pharmacy with ability to obtain medications in a timely manner. 9a associated s: CHF and associated 9b associated s: PNE and associated 9c associated s: COPD and associated
9d 10 associated s: DM and associated Educate patient on symptoms (Red Flags) of disease/condition to report to the physician. 11 Instruct patient on a special plan of how to contact the PCP or back up by providing contact numbers for office hours and after hours communications. 12 Educate patient/family on which symptoms constitute an emergency and what to do in this case. 13 Identification of end of life issues addressing advance care planning. 14 Need for community resources identified (HHA, AAA, Meals on Wheels, etc.). 15a 15b 15c 15d 15e following: Reason for hospitalization with specific principal diagnosis and other pertinent diagnoses. following: History and physical assessments. following: Procedures, treatments and care services provided. following: Patient physical and mental status at discharge. following: Medication list, which is comprehensive and reconciled and includes any current allergies or prior reactions.
15f 15g following: List of acute medical issues, tests, studies and labs for which confirmed results are pending at the time of discharge and require follow up. following: Consulting service information and evaluation including rehabilitation. 16 Assessment of degree of understanding of discharge plan (including medications) by the patient/family by asking patient/family to explain in their own words the details of the plan. (Teach Back on Plan of Care). 17 Interpreter utilized for patients/families with language and literacy barriers. 18 Family and or caregivers were included in patient education (I.e. cognitively impaired, non adherent, etc.). 19 Written discharge plan given to patient and family/caregiver at time of discharge. 20 Patient is assigned to a care transitions coach. 21a High risk medication identified: Anticoagulant. 21b High risk medication identified: Diabetes Drugs. 21c High risk medication identified: Opioids. 22 Education to prevent adverse drug events with high risk medication was provided. 23 Telephone call from professional staff or coach 2 or 3 days post discharge to provide reinforcement of the discharge plan and identify and resolve issues arising since discharge
USE RESTRICTED TO ABC Hospital Readmission Drivers YZ Community RCA Results Best Practice ID Patient Activation Lack of Known Standard Process Transfer of Information Medication Safety Best Practice Total Non Conforming Charts Total Charts Total Applicable Charts % Charts Applicable (RELEVANCE) % Applicable Charts Non Conforming (NON CONFORMITY) % Charts Non Conforming Cumulative % Non Conforming Charts 11 Instruct patient on a special plan of how to contact the PCP or back up by providing contact numbers for office hours and after hours communications. 72 90 77 85.6% 93.5% 80.0% 12.2% 23 Telephone call from professional staff or coach 2 or 3 days post discharge to provide reinforcement of the 47 90 77 85.6% 61.0% 52.2% 20.1% discharge plan and identify and resolve issues arising since discharge 2 Post discharge appointments for physician office or lab are coordinated with the patient/family and set prior to discharge. 44 90 82 91.1% 53.7% 48.9% 27.5% 21a High risk medication identified: Anticoagulant. 41 90 68 75.6% 60.3% 45.6% 34.5% 3 Patient/family is educated on importance of followup care and keeping appointments. 40 90 83 92.2% 48.2% 44.4% 41.2% 21c High risk medication identified: Opioids. 38 90 67 74.4% 56.7% 42.2% 47.6% 21b High risk medication identified: Diabetes Drugs. 37 90 66 73.3% 56.1% 41.1% 53.9% 22 Education to prevent adverse drug events with high risk medication was provided. 31 90 60 66.7% 51.7% 34.4% 59.1% 16 Assessment of degree of understanding of discharge plan (including medications) by the patient/family by asking patient/family to explain in their own words the details of the plan. (Teach Back on Plan of Care). 29 90 79 87.8% 36.7% 32.2% 64.0% 12 Educate patient/family on which symptoms constitute an emergency and what to do in this case. 10 Educate patient on symptoms (Red Flags) of disease/condition to report to the physician. 14 Need for community resources identified (HHA, AAA, Meals on Wheels, etc.). 4 Patient/family verbalizes ability to obtain transportation to appointments. 25 90 82 91.1% 30.5% 27.8% 68.2% 24 90 79 87.8% 30.4% 26.7% 72.3% 18 90 81 90.0% 22.2% 20.0% 75.3% 16 90 84 93.3% 19.0% 17.8% 78.0% 8 Patient/family has a local pharmacy with ability to obtain medications in a timely manner. 12 90 85 94.4% 14.1% 13.3% 80.1% 13 Identification of end of life issues addressing advance care planning. 11 90 90 100.0% 12.2% 12.2% 81.9% 17 Interpreter utilized for patients/families with language and literacy barriers. 10 90 12 13.3% 83.3% 11.1% 83.6% 20 Patient is assigned to a care transitions coach. 10 90 12 13.3% 83.3% 11.1% 85.3% 9c associated s: COPD and associated 8 90 13 14.4% 61.5% 8.9% 86.7% 15e following: Medication list, which is comprehensive and reconciled and includes any current allergies or prior reactions. 8 90 87 96.7% 9.2% 8.9% 88.0%
15f 5 15b 15g 9b 15c 15d 9d 15a 7a 7b 7c 7d 7e 18 6 1 following: List of acute medical issues, tests, studies and labs for which confirmed results are pending at the time of discharge and require follow up. Education on completed tests or studies and importance of follow up for future tests. following: History and physical assessments. following: Consulting service information and evaluation including rehabilitation. associated s: PNE and associated following: Procedures, treatments and care services provided. following: Patient physical and mental status at discharge. associated s: DM and associated following: Reason for hospitalization with specific principal diagnosis and other pertinent diagnoses. with review of medication purpose. with review of dosage. with review of adverse drug events. with review of other side effects. by reporting each side effect and untoward effects to providers. Family and or caregivers were included in patient education (I.e. cognitively impaired, non adherent, etc.). Medication reconciliation occurs at admission and discharge. Patient/family educated about the diagnosis throughout the in patient stay. 8 90 87 96.7% 9.2% 8.9% 89.4% 7 90 70 77.8% 10.0% 7.8% 90.5% 6 90 87 96.7% 6.9% 6.7% 91.6% 6 90 46 51.1% 13.0% 6.7% 92.6% 5 90 7 7.8% 71.4% 5.6% 93.4% 5 90 87 96.7% 5.7% 5.6% 94.3% 5 90 87 96.7% 5.7% 5.6% 95.1% 4 90 9 10.0% 44.4% 4.4% 95.8% 4 90 87 96.7% 4.6% 4.4% 96.5% 3 90 87 96.7% 3.4% 3.3% 97.0% 3 90 87 96.7% 3.4% 3.3% 97.5% 3 90 87 96.7% 3.4% 3.3% 98.0% 3 90 87 96.7% 3.4% 3.3% 98.5% 3 90 87 96.7% 3.4% 3.3% 99.0% 3 90 86 95.6% 3.5% 3.3% 99.5% 2 90 88 97.8% 2.3% 2.2% 99.8% 1 90 89 98.9% 1.1% 1.1% 100.0%
9a 19 associated s: CHF and associated Written discharge plan given to patient and family/caregiver at time of discharge. 0 90 10 11.1% 0.0% 0.0% 100.0% 0 90 82 91.1% 0.0% 0.0% 100.0%
USE RESTRICTED TO ABC Hospital Readmission Drivers ABC Hospital RCA Results Best Practice ID Patient Activation Lack of Known Standard Process Transfer of Information Medication Safety Best Practice Total Non Conforming Charts Total Charts Total Applicable Charts % Charts Applicable (RELEVANCE) % Applicable Charts Non Conforming (NON CONFORMITY) % Charts Non Conforming Cumulative % Non Conforming Charts 11 2 9c Instruct patient on a special plan of how to contact the PCP or back up by providing contact numbers for office hours and after hours communications. Post discharge appointments for physician office or lab are coordinated with the patient/family and set prior to discharge. associated s: COPD and associated 16 20 18 90.0% 88.9% 80.0% 17.0% 8 20 19 95.0% 42.1% 40.0% 25.5% 8 20 8 40.0% 100.0% 40.0% 34.0% 21b High risk medication identified: Diabetes Drugs. 8 20 12 60.0% 66.7% 40.0% 42.6% 21c High risk medication identified: Opioids. 7 20 14 70.0% 50.0% 35.0% 50.0% 3 Patient/family is educated on importance of followup care and keeping appointments. 6 20 19 95.0% 31.6% 30.0% 56.4% 10 Educate patient on symptoms (Red Flags) of disease/condition to report to the physician. 6 20 18 90.0% 33.3% 30.0% 62.8% 12 Educate patient/family on which symptoms constitute an emergency and what to do in this case. 6 20 18 90.0% 33.3% 30.0% 69.1% 21a High risk medication identified: Anticoagulant. 6 20 14 70.0% 42.9% 30.0% 75.5% 9b associated s: PNE and associated 5 20 5 25.0% 100.0% 25.0% 80.9% 9d associated s: DM and associated 4 20 4 20.0% 100.0% 20.0% 85.1% 4 Patient/family verbalizes ability to obtain transportation to appointments. 1 20 19 95.0% 5.3% 5.0% 86.2% 6 Medication reconciliation occurs at admission and discharge. 1 20 18 90.0% 5.6% 5.0% 87.2% 7a with review of medication purpose. 1 20 18 90.0% 5.6% 5.0% 88.3% 7b with review of dosage. 1 20 18 90.0% 5.6% 5.0% 89.4% 7c with review of adverse drug events. 1 20 18 90.0% 5.6% 5.0% 90.4% 7d with review of other side effects. 1 20 18 90.0% 5.6% 5.0% 91.5% 7e by reporting each side effect and untoward effects to providers. 1 20 18 90.0% 5.6% 5.0% 92.6% 15a 15b following: Reason for hospitalization with specific principal diagnosis and other pertinent diagnoses. following: History and physical assessments. 1 20 20 100.0% 5.0% 5.0% 93.6% 1 20 20 100.0% 5.0% 5.0% 94.7%
15c 15d 15e 15f 22 1 5 following: Procedures, treatments and care services provided. following: Patient physical and mental status at discharge. following: Medication list, which is comprehensive and reconciled and includes any current allergies or prior reactions. following: List of acute medical issues, tests, studies and labs for which confirmed results are pending at the time of discharge and require follow up. Education to prevent adverse drug events with high risk medication was provided. Patient/family educated about the diagnosis throughout the in patient stay. Education on completed tests or studies and importance of follow up for future tests. 1 20 20 100.0% 5.0% 5.0% 95.7% 1 20 20 100.0% 5.0% 5.0% 96.8% 1 20 20 100.0% 5.0% 5.0% 97.9% 1 20 20 100.0% 5.0% 5.0% 98.9% 1 20 11 55.0% 9.1% 5.0% 100.0% 0 20 20 100.0% 0.0% 0.0% 100.0% 0 20 18 90.0% 0.0% 0.0% 100.0% 8 Patient/family has a local pharmacy with ability to obtain medications in a timely manner. 9a associated s: CHF and associated 13 Identification of end of life issues addressing advance care planning. 14 Need for community resources identified (HHA, AAA, Meals on Wheels, etc.). 0 20 20 100.0% 0.0% 0.0% 100.0% 0 20 4 20.0% 0.0% 0.0% 100.0% 0 20 20 100.0% 0.0% 0.0% 100.0% 0 20 20 100.0% 0.0% 0.0% 100.0% 15g following: Consulting service information and evaluation including rehabilitation. 0 20 9 45.0% 0.0% 0.0% 100.0% 16 Assessment of degree of understanding of discharge plan (including medications) by the patient/family by 0 20 18 90.0% 0.0% 0.0% 100.0% asking patient/family to explain in their own words the details of the plan. (Teach Back on Plan of Care). 17 Interpreter utilized for patients/families with language and literacy barriers. 0 20 0 0.0% N/A 0.0% 100.0% 18 Family and or caregivers were included in patient education (I.e. cognitively impaired, non adherent, 0 20 18 90.0% 0.0% 0.0% 100.0% etc.). 19 Written discharge plan given to patient and family/caregiver at time of discharge. 0 20 18 90.0% 0.0% 0.0% 100.0% 20 Patient is assigned to a care transitions coach. 0 20 0 0.0% N/A 0.0% 100.0% 23 Telephone call from professional staff or coach 2 or 3 days post discharge to provide reinforcement of the discharge plan and identify and resolve issues arising since discharge 0 20 18 90.0% 0.0% 0.0% 100.0%
USE RESTRICTED TO ABC Hospital 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% YZ Community Readmission Root Cause 11 23 2 21a 3 21c 21b 22 16 12 10 14 4 8 13 17 20 9c 15e 15f 5 15b 15g 9b 15c 15d 9d 15a 7a 7b 7c 7d 7e 18 6 1 9a 19 % Non-Compliance Best Practice ID 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ABC Hospital Readmission Root Cause 11 2 9c 21b 21c 3 10 12 21a 9b 9d 4 6 7a 7b 7c 7d 7e 15a 15b 15c 15d 15e 15f 22 1 5 8 9a 13 14 15g 16 17 18 19 20 23 % Non-Compliance Best Practice ID