Root Cause Analysis in Care Transitions: Chart Review Tools Tom Ventura, MS, MSPH [email protected] Colorado Foundation for Medical Care www.cfmc.org/integratingcare March 22 nd , 2012.
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Root Cause Analysis in Care Transitions: Chart Review ToolsTom Ventura, MS, [email protected] Colorado Foundation for Medical Carewww.cfmc.org/integratingcare March 22nd, 2012
This material was prepared by CFMC PM-4010-094 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.
“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.”
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
“Readmissions are a community problem.”
Poor patient-provider interface
No effective patient engagement strategies
Unreliable system support
Lack of standard and known processes
Unreliable information transfer
Unsupported patient activation during transfers
No community infrastructure for achieving common goals
Comments from New Jersey team:
Comments from the Pennsylvania team:
Details and documentation
Worksheets A and B