Eliminating Long Term Care Re-Admissions Tools & Resources

Working to improve the quality of care delivery to nursing home residents.


  • INTERACT Hospitalization Tracking Tool webinar 9/24/2013
  •  INTERACT Collaborative Webinar 6/11/2013

Readmission Root Cause Analysis

A root cause analysis (RCA) is a process for identifying the causes that underlie variations in outcomes. The analysis focuses on a process that has a potential for redesign. The RCA allows for an organization to identify the “root” of the problem including how, why, and where a problem, adverse event, or trend exists. It is a discovery process that identifies issues that are not readily apparent, so involving everyone who is affected by the process being investigated is important to identifying all the underlying factors contributing to the problem. Setting a timeframe for completion of the RCA is critical because a team can get stuck in this first step and never begins testing a change.

The methods for completing a RCA are:

  • Retrospective review of patient records
  • Process assessment through interviews and direct observation. Creating a pictorial representation of the process through mapping or flowcharting the process is helpful. Direct observation can be accomplished by shadowing a person for a period of time.
  • Focus groups of people/patients/staff who are experiencing the process
  • Analysis of the data

The first step in investigating an organization’s 30-day hospital readmissions is to perform a RCA. Including patient interviews is a key component to exploring all factors that are influencing readmissions. Below are examples of RCA tools that can be used by organizations when investigating the "root" causes of their 30-day readmissions.

  • Institute for Healthcare Improvement (IHI) STAAR diagnostic tool (includes patient interview tool)
  • Readmission Root Cause Analysis


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Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
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Maureen Valvo, RN, BSN, RAC-CT
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