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Readmission root cause analysis tool - in-patient facility readmissions work sheet 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the facility name and reviewer details at the top of the worksheet. This sets the context for your analysis.
  3. For each best practice listed, mark 'Y' for compliance, 'N' for non-compliance, or 'NA' if not applicable. Be thorough in your assessment to ensure accurate data.
  4. In the section regarding patient education, ensure you check off items where patients and families are informed about their diagnosis and follow-up care.
  5. Continue through the form, documenting medication reconciliation and discharge planning details. Each entry contributes to a comprehensive understanding of readmission factors.
  6. Finally, review your entries for accuracy before saving or sharing the completed worksheet with relevant stakeholders.

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What counts as a readmission under the Hospital Readmissions Reduction Program? The Hospital Readmissions Reduction Program 30-day risk standardized unplanned readmission measures capture unplanned readmissions that happen within 30 days of discharge from the index (that is, initial) admission.
Dividing the number of readmissions by the number of index admissions and multiplying by 100 gives the readmission rate as a percentage. This rate is called an observed readmission rate because it is derived directly from what was observed during the study period.
The Hospital-wide, 30-Day, All-cause Unplanned Readmission (HWR) Measure for the Meritbased Incentive Payment System (MIPS) Groups is a risk-standardized readmission rate for Medicare Fee-for-Service (FFS) beneficiaries aged 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a
This measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days for members 18 years of age and older in the following categories: Count of Index Hospital Stays (denominator).
Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.

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