Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations

Journal of the American Medical Directors Association
Joseph G OuslanderDavid Newman

Abstract

Performing root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions. To describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers. SNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period. SNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial. Sixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers. SNFs received education and technical assistance in INTERACT implementation. Data were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. A total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipita...Continue Reading

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Citations

Jun 29, 2016·Journal of the American Medical Directors Association·Joseph G OuslanderDavid Newman
Sep 7, 2016·Journal of the American Medical Directors Association·Mehmet Ilkin Naharci, Huseyin Doruk
Feb 29, 2016·Journal of the American Medical Directors Association·John E Morley
Nov 7, 2016·Journal of the American Medical Directors Association·Christine D JonesHeidi L Wald
Dec 17, 2016·Journal of the American Geriatrics Society·Eduard E VasilevskisJohn F Schnelle
Nov 12, 2016·Journal of Applied Gerontology : the Official Journal of the Southern Gerontological Society·Diane E BerishJane K Straker
May 17, 2017·The Journal of Nursing Administration·Lauran HardinElizabeth Murphy
Jul 7, 2017·Journal of the American Geriatrics Society·Robert E BurkeJacqueline Jones
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Mar 4, 2018·Journal of the American Geriatrics Society·Robert E BurkeJacques D Donzé
Nov 20, 2018·Journal of the American Geriatrics Society·Joseph G OuslanderDeanna Gray-Miceli
Jan 25, 2019·Journal of the American Geriatrics Society·Soo Borson
Apr 24, 2019·Journal of the American Geriatrics Society·Susan E HickmanGreg A Sachs
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