1. Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH Colorado Foundation for Medical Care March 22nd, 2012
This material was prepared by CFMC PM CO 2012, the Medicare Quality Improvement Organization for Colorado under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

2. Root Cause Analysis (RCA) in ICPCA
Identify community-specific drivers/root causes of readmission
Customize the selection and targeting of interventions
Expressly part of Aim strategy
“Identify service patterns associated with readmission”

3. RCA in ICPCA Perform Root Cause Analysis
Identify Driver of Readmissions
Select and Implement Intervention
Track Process and Outcome Data
Determine Effectiveness

4. RCA in CCTP Application requirements
“Describe the results of the RCA that was performed.”
“Describe how the results informed the selection of the proposed intervention and target population.”
“Describe your implementation strategy.”

5. 9th SOW RCA: specific findings
Reasons for experiencing readmission
Unmanaged worsening of condition
Use of suboptimal medication regimens
Return to emergency department instead of accessing a different type of medical service

6. 9th SOW RCA: initiative-level
“Readmissions are a community problem.”
Poor patient-provider interface
Medication mis-management
No effective patient engagement strategies
Unreliable follow-up
Unreliable system support
Lack of standard and known processes
Unreliable information transfer
Unsupported patient activation during transfers
No community infrastructure for achieving common goals

7. RCA methods Medical record review Interview Focus group
Patient/family
Provider/care coordinator
Focus group
Process mapping
Cause-and-effect diagram
5 Whys

8. Medical record review
Review charts among a sample of patients who experienced readmission.
Sample size: small
Readmission and index admission charts
Structured review protocol
Narrative reflection
Types of information extracted
Commonalities, themes
Patient characteristics, behaviors
Provider and system factors
Underlying causes
Leverage points for intervention

9. Readmission-specific tools
NJ: Healthcare Quality Strategies, Inc.
30-day Readmission Chart Review Form
PA: Quality Insights of Pennsylvania
Readmission Review Form
IHI: STAAR Initiative
Readmissions Diagnostic Worksheet

10. HQSI (NJ) tool Claims-based fields Readmission chart review (21 items)
Diagnoses, hospitalization dates (LOS)
Readmission chart review (21 items)
MD office; ED visit; observation stays
Documentation
Reasons for readmission (i.e., patient/family, physician/nurse)
PHR, discharge plan
Discharge disposition
Patient education, instructions
Planned versus unplanned readmission
Open reflection
Potential hospital problems
Missed opportunities

11. HQSI (NJ) tool: comments
Comments from New Jersey team:
Despite everyone’s best efforts, documentation can still be lacking.
Requires clarification
May be unreliable (e.g., patient education)
Recommendations
Admission chart review to fill in holes
Patient/family interviews in conjunction with chart review
Pilot implementation of tool
Dial in setting-specific issues
Prompt a quality improvement process (improve documentation)
Caveat: targeted heart failure patients

12. Quality Insights (PA): 1-pager
Section 1
Dates, diagnoses, discharge disposition
Planned vs. unplanned readmission
Section 2 (13 items)
Post-discharge level of care
Physician follow-up
Referrals for home health, hospice, community resources (e.g. AAA)
Medication Reconciliation
Symptoms
Present on first admission
Discharge plan
Patient education
Admission
Unforeseen; avoidable; relation to first admission

13. Quality Insights (PA): 2-pager
Index admission
Dates, diagnoses, discharge disposition
Planned vs. unplanned
Readmission
Dates; planned vs. unplanned
Potential readmission factors (10 domains, 27 items)
Downstream provider issue
Patient/caregiver education
Patient activation
Medication management
Transitional care planning (services offered)
Discharge instructions
End of life
Discharge disposition
Unstable condition at discharge
Recurring possible triggers for readmission

14. Quality Insights (PA): comments
Comments from the Pennsylvania team:
Initial findings based on ~60 charts
15-20 charts reviewed per month, over 3 months
Process
Review readmission data submitted by providers
Generate a trending report and list of patients
Feedback to hospital
Random chart reviews with narrative
Issues
Get consistent information from reviewers across levels of clinical expertise
Results
Sustainable
High satisfaction, despite initial resistance
10 domains (readmission risk factors)
Evolution
7-day readmission review
Cross-setting chart review (downstream providers)

15. IHI STAAR worksheets In-depth review of 5 most recent readmissions
Identify opportunities for improvement
Chart review and interview components
Worksheet A: chart review
Details and documentation (9 items)
Reflective summary (7 prompts)
Worksheet B: interviews
Structured interviews (9 items): patient, family, and care team
Reflective summary (8 prompts)
Reference list of typical failures

16. IHI STAAR: Worksheet A Details and documentation
Days between discharge and readmission
Follow-up physician visit scheduled prior to discharge
Patient attended office visit
Urgent clinic/ED visit before readmission
Functional status on discharge
Clear discharge plan
Teach-back
Reasons for readmission
Social conditions contributing to readmission

17. IHI STAAR: Worksheet B Structured interviews Patient/family Care team
Reasons for symptom worsening and readmission
Physician follow up
Barriers
Medications
Behaviors
Barriers to adherence
Nutrition
Care team
Reason for readmission
Reflection on patient circumstances contributing to readmission

18. IHI STAAR: reflective summary
Worksheets A and B
What did you learn?
Most common failures? (Worksheet B only)
Trends or themes
What surprised you?
New questions
What are you curious about?
What to do next?
Challenged assumptions about readmissions

19. RCA challenges Don’t over-study. Remember these guiding principles.
Elegant, comprehensive demonstrations of the problem are not required.
Cumbersome, technically-detailed exercises enable you to avoid moving forward.
Remember these guiding principles.
The purpose is to inform the PDSA cycle, test interventions, and drive action on a larger scale.
Get just enough information to generate a reasonable set of priority actions.

20. RCA resources ICPCA Toolkit (NJ/PA tools)
IHI STAAR Readmissions Diagnostic Worksheet

21. Thank you! ICPCA National Coordinating Center
Tom Ventura