Read the following instructions carefully

1. Select the root causes you think are impacting hospital admissions (multiple selections are allowed)
2. Describe any root cause(s) NOT listed by using the "Other" (comment) box
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY. SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 2. What are Facility Specific Barriers that you think are attributable to having a increased hospitalizations in your facility?

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* 3. What are Patient-Related Factors that you think are attributable to increased hospitalizations in your facility? Make sure to include your FPR to gather patients' perspective when completing this section. FPRs will be surveyed for participation throughout the course of project.

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* 4. What are Organizational Factors (operational, policies, systemic) that you think are attributable to increased hospitalizations in your facility?

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* 5. What are Hospital or Data Factors that you think are attributable to increased hospitalizations in your facility?

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* 6. Completion of this root cause analysis was effective and easy to do on-line.

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* 7. Did you obtain direct patient feedback to ensure patients' perspective was part of this activity?

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* 8. Any additional thoughts or comments you would like to provide about this process?

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* 9. I have printed a completed copy of this RCA survey with all the answers for my records (right-click over the survey and select "Print")

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