Streaming Media

Name of Corresponding Author

Keith Bakken

Name of Faculty Advisor

Dr. Audrey Klopp

Theoretical/Conceptual framework

This DNP Project has a Systems Leadership approach. The author has created a Conceptual Model inclusive of a bundle of 5 Interventions to address potentially avoidable SNF readmissions. The project will implement one of the 5 interventions.

Nature and scope of the project

The project aim is to implement a Structured Bi-Directional Apparent Cause Analysis (BDACA) tool, post readmission of qualifying 30-day Skilled Nursing Facility (SNF) readmissions to acute inpatient care at Weiss Hospital in Chicago.

Synthesis and analysis of supporting literature

Hospital readmissions from Skilled Nursing Facilities (SNF’s) are common & costly. Medicare patients discharged to a SNF have a 25% likelihood of readmission within 30 days costing more than 14.3 billion. The Center for Medicare/Medicaid Services (CMS) was deeply concerned about this problem and in 2012, it developed a financial penalty called the Hospital Readmission Reduction Program (HRRP). Many readmissions are preventable. Readmissions are also nurse-sensitive.

Project implementation

The tool to be used for this project is the INTERACT version 4.5 Quality Improvement Tool for Review of Acute Care Transfers. The INTERACT tool has been validated in previous research. Both the hospital and the SNF will complete the tool after each readmission during the implementation period. Bidirectional Side by side analysis will take place which will lead to lessons learned.

Evaluation criteria

Evaluation Criteria

30-day All Cause SNF readmission rate compared to baseline and compared to regional and national averages. Pre and Post project.

% of readmissions determined to be potentially avoidable

Total number of BDACA forms completed

End-user satisfaction with the tool: Knowledge, Skills, Attitudes (KSA’s) of end-users.


Since the project is beginning January 2022, the outcomes are yet to be determined. The hope is to reduce or prevent potentially avoidable SNF readmissions which will result in safer, more cost effective and reliable patient-centered care.


Once SNF and hospital leaders capture the apparent cause(s), of readmissions, they can determine contributing factors, and discern preventability and then communicate lessons learned in order to prevent unnecessary SNF readmissions in the future.



Reducing Readmissions: Implementing a Bi-Directional Apparent Cause Analysis to reduce SNF Rehospitalizations