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 requestthat 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.
  2. Population Data and current readmission rate:Look at population wide data related to patient transitions.
  3. Observational Work:Evaluate the current processes related to patient transitions
  4. Medical Record/Chart Reviews:Identify trends and patterns
  5. 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.

  1. Assess your current practices with the RARE Mental Health Collaborative Assessment. (Required Activity)
  1. 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:
  2. Reflective Summary Discussion Questions
  3. Typical Failures in Hospital Discharge
  4. SWOT Analysis Worksheet
  5. Identify key area(s) for improvement.Five key areas > (Required Activity)
  1. Set a goal for readmission reduction by the end of the collaborative. (Required Activity)
  2. 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
Population Data
Look at population wide data related to patient transitions. /
  • 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
Understanding PPR Data Reports (Coming in February)
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? /
  • 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)
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 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. /
  • 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
/ Chart Review of Patients Who Were Readmitted. A simple chart review tool with audit information for up to five patients. (1-page Word doc)
Individual and Group 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. /
  • Interview 4 to 5 patients or their families who have experienced an unplanned readmission within 30 days
  • Interview the care team about what they observe as the main causes of hospital readmissions
  • Complete a focus group with patients or care team
/ 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)
RARE Mental Health Collaborative Assessment
Determine how your current practices compare to the recommended practices for improved care transitions. /
  • Discuss with front line staff if these practices are consistently done for all patients.
  • 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 / Activities Completed / Key Findings
Population Data
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

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 canbetter assist and support your team’s efforts.

RARE Campaign