MHA Safe Transitions of Care
Tania Daniels, Vice President, Patient Safety, Minnesota Hospital Association
October 18, 2011
Karen MacDonald, Associate Administrator, HealthEast Care System
Barb Stricker, Group Director, Social Work Services, HealthEast Care System
Potential safety issue raised: communication issues that lead to unsafe transitions with hospital-to-hospital (and other) transfers
MHA Patient Safety Committee commissioned safe transition workgroup: Chaired by Karen MacDonald, HealthEast • Identified safety gaps and core elements of
information to address these gaps• Launched pilot project to test core elements, gap
analysis, and toolkit
MHA Safe Transitions of Care Workgroup
Purpose: Improve patient safety by standardizing transitions of
care between hospitals and across settings.
Timeline: Sept 2010: Webinar Kick-off Oct- Nov, 2010: Gap Analysis baseline completed Dec- March, 2010: Core element cross walk, tested
core elements of information, gap analysis roadmap, and other tools
April 2011: Final Gap Analysis, final meeting to evaluate/modify core elements, gap analysis, and toolkit based on pilot findings
MHA Safe Transitions of Care Pilot
MHA Safe
Transition Pilot Sites(13)
Essentia Fosston
Fairview UMC - Mesabi, Hibbing
GraniteFallsMunicip. Hosp
FairviewRed Wing
CentraCare St. Cloud Hospital
Mercy Hosp.Moose Lake
Fairview Northland, Princeton
Olmsted Med. Center,
Rochester
Sanford Jackson
Rice Memorial,Willmar
EssentiaSt. Joseph’s,Brainerd
HealthEast St. Joseph’s, St. Paul; St. John’s Maplewood
13 sites from across the state• Large rural hospitals• Small rural hospitals• Large urban hospitals
Across variety of settings, hospital to/from: - SNF - Assisted living - LTC - Community behavioral health - Home health - Adult Foster Care - Hospice - DME Agencies
MHA Safe Transitions of Care Pilot
Long Term Impact of Safe Transitions
Studies have shown poor communication during transitions leads to increased rates in hospital readmissions, medical errors (Epstein, AM, “Revisiting Readmissions-Changing Incentives for Shared Accountability,” New England Journal of Medicine, 2009:360(14)1457-1459)
Short term goal of improving transition communication will impact patient safety in long term
• Medication events/missed doses• Delayed care/redundant tests• Readmissions
Pilot sites beginning to measure: ER visits, overall readmissions or specific diagnosis readmissions
• Outcome measures will take more than 4 months to measure
HealthEast Final ReportJanuary to April 2011
Sites- Two of acute care hospitals: Saint Joseph’s and Saint Johns
Our Partners Cerenity Care Center-Marion Ramsey County Care Center
Pilot ran from January 21st to March 24th
N= 56
N= 56
HealthEast Receiving Facility Feedback
N= 55
Themes:•Unclear med orders•Needing narc scripts•Clarify wound care orders
Receiving Facility Feedback
N= 18
Receiving Facility Feedback
Receiving Facility Feedback
N= 5
Themes:• STACH does not return calls• Need more SW staff, especially on weekends• Make sure orders are clear• Complete Level I pre-adm screen at STACH before d/c
Receiving Facility Feedback
N= 12
N= 5
Q2: In your opinion, was staff at the STACH satisfied with the use of the core elements?
N= 0
N= 5
Themes:• Needed to refax orders to SNF
Joe's n=21
Mon Tue Wed Thu Fri Sat Sun TOTAL
RCCC 2 2 0 1 3 1 1 10
CCC-M 3 1 5 1 0 1 0 11
Total 5 3 5 2 3 2 1 21
John's n=32
Mon Tue Wed Thu Fri Sat Sun TOTAL
RCCC 5 3 1 7 2 3 1 22
CCC-M 3 0 2 2 2 0 1 10
Total 8 3 3 9 4 3 2 32
WW n=3
Mon Tue Wed Thu Fri Sat Sun TOTAL
RCCC 0 0 0 0 1 0 0 1
CCC-M 0 0 0 2 0 0 0 2
Total 0 0 0 2 1 0 0 3
Mon Tue Wed Thu Fri Sat Sun TOTAL
Total 13 6 8 13 8 5 3 56
Overall St Joseph's St John's Woodwinds Mon Tue Wed Thu Fri Sat Sun TOTAL % of Total
Very Dissatisfied 0 3 0 0 1 0 0 2 0 0 3 5%
Dissatisfied 4 6 0 1 1 3 1 1 2 1 10 18%
Neutral 0 1 0 0 0 0 0 0 1 0 1 2%
Satisfied 9 15 1 7 4 3 8 3 0 1 26 46%
Very Satisfied 8 7 2 5 0 2 4 2 2 1 16 29%
Total 21 32 3 13 6 8 13 8 5 3
Continue to regular meet with community partners. Bring communication on success/challenges
Work especially on areas where we still have gaps especially on areas of Medication discrepancies
Evaluate and add core members to the team to help with this initiative-bedside nurse and pharmacy as examples
Continue to survey outcomes using consistent data from inpatient and community partners
Incorporate Core Elements within the current discharge documents
Revise discharge policy to include hard stop
Provide system-wide education –Will be included in Annual Mandatory Education for 2012 under patient safety for direct care givers
Identify a dedicated physician champion who will lead this initiative into areas where we have physician related gaps.
Incorporate Safe Transitions Core Elements into HE Culture and Best Practice.
Every Patient at time of discharge will be kept safe and experience uninterrupted quality care because HealthEast and its community partners provided the next level of care with accurate and complete information.
Every Patient will get the right care, every time, in every setting.
Safe transition operational champion is key Process of nurse to nurse call/handoff
successful strategy Significant value with engaging
community/stakeholders across settings Safe transition gap analysis is infrastructure
for smooth, safe transitions- which is one component of reducing readmissions
Increased satisfaction of patient/family, transferring and receiving facility staff
Reduced follow-up calls required with use of MHA core elements of information
Beneficial to align safe transition of care work with existing infrastructures (d/c committee) and/or process improvement work (e.g. readmission)
Ongoing process Many communication gaps closed, but more
work to do Medication orders/medication reconciliation Defining metrics/audits Incorporating with EHR Instituting hard stop policy Provider and patient education Patients transferring to/from emergency
department
Lack of communicating: Falls or pressure ulcer risk Isolation precautions Critical care tests/results Continuation of care plan e.g., timing of care,
meds, rehab, drains/tubes Who is responsible for patient Patient’s readiness for transition
Example areas that need ‘safe’ communication
Do the following core elements of information exist? Are they in the 1st 1-2 pages of transfer documentation? • Falls risk
• Pressure ulcers/skin integrity
• Infection/isolation precautions
• Lab/test results and values from previous 24 hours and other results and values as appropriate to the patient’s condition, including any pending results (e.g. blood glucose; INR, radiology, others)
• Medication reconciliation list (includes diagnosis associated with medication and any sliding scales)
Example MHA Core Elements of Information to assure ‘Safe’ communication
Safe Transition RoadmapGap Analysis Infrastructure: “SAFE”
S= Safe transition teams• Interdisciplinary team (physician, senior executive,
Operational champion) • Engage key stakeholders
A=Access to information• Verify the completion of SAFE TRANSITIONS• Evaluate for learning opportunity
F=Facility expectations (hard stop) E=Educate staff and patients
Transitions of Care Consensus Policy Statement
Gap Analysis ‘Transition’ Principles
Accountability Responsibility Coordination of Care Patient/Family Involvement Communication Timeliness Standards and metrics
Next Steps
All resources and tools on-line
Learning Collaborative Timeline• October 31st – Participant agreement forms due • November/December 2011 – Participants measure
baseline with safe transition gap analysis• January 2012- Kick-off webinar • February, April, June 2012- Participant learning and
network webinars/conference calls • July 2012 –Final Gap Analysis measurement