The relationship between transitions of care and medical errors is so clear, that leadership teams should be aware of what's required to protect patient safety.
What happens at a hospital when a patient is transferred among care teams, treatment facilities, or from hospital to home?
If the process doesn't go much beyond white boards or wheelchairs, it is time for an update.
That's essentially the advice of The Joint Commission, which has released a sentinel event alert on communications during transitions of care.
"While it sounds simple, a high-quality hand-off is complex," says the document. "Failed hand-offs are a longstanding, common problem in healthcare. Nevertheless, gaps in communication during hand-off processes continue to exist, thereby increasing patient safety risk."
The relationship between transitions of care and medical errors is so clear, that some of the key statistics in the document come from the research arm of a malpractice insurer.
The sentinel event alert is not a notice of a new standard hospitals will have to meet as part of the commission's accreditation process. Instead, it is designed to give providers and hospital administrators a heads-up on potential problem areas.
Ana McKee, MD, is the executive vice president and chief medical officer of The Joint Commission. The organization decided to issue the alert, in part, because the number of handoffs has increased dramatically, she says, and because communication during hand-offs can be a challenge for hospitals.
A Call for Leadership
She thinks problems with handoff have been ignored or invisible for a long time. Hospital leaders need to know what is at stake.
"If it is not recognized as a high-risk opportunity, it goes unaddressed," she says. "We are still working to educate leadership of the risks of hand-off communication"
One heralded approach to hand-offs is the I-PASS program. A 2013 pilot study at Boston Children's Hospital produced dramatic results. Medical errors declined from 33.8 per 100 admissions to 18.3 per 100 admissions after the I-PASS program was adopted.
Implementing the approach more broadly, however, may be difficult.
Across town, staff at the 1,000 bed-Massachusetts General Hospital more than 6,000 doctors, nurses and therapists have been trained to use the program. That was the easy part, according to a study on the first phase of their effort published in the journal BMJ Quality and Safety.
"I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows," the authors write.
McKee says that's not surprising; change is always difficult.
"That's the change management challenge," she said. "It has to be done artfully, strategically and in a way that it can be sustained."
Researchers at the University of Kentucky are part of a research project known as Project ACHIEVE, an acronym for "Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence."
In 2015, members of the project team traveled to 22 sites, including community hospitals and academic health systems, and talked to 810 people including management, transitional care teams, community partners, patients, and family caregivers.
They published some of their findings in the September edition of The Joint Commission Journal on Quality and Patient Safety.
Leadership Awareness
Among those findings: In multiple hospitals, members of "leadership teams" reported that "making care transitions a strategic priority among the executive leadership team created an organizational culture focused on transitional care, which in turn improved the quality of transitional care services within the organization."
Mark Williams, MD, one of the study authors, suggests that administrators learn how transition are handled in their institution if they don't already know. He suggests they find out whether staff are engaged in the practice of "teach back" with patients and with each other.
Clinicians explaining discharge instructions should be follow up with something like this, he says. "'Teach it back to me. Tell me, what you are supposed to do when you leave the hospital.'"
Williams thinks getting confirmation of understanding, a skill called "readback," is critical. He notes that some hospitals have made it a core competency for nurses.
It also happens to be the skill that providers at Mass General have found to be the most challenging feature of the I-PASS approach to implement.
Many clinician "find it awkward," and unworkable in discharges that don't occur face-to-face methods, according to the study.
McKee at The Joint Commission says, "there is a lot of opportunity for improvement" in the way the C-suite addresses this issue. They should be overseeing the process.
Tinker Ready is a contributing writer at HealthLeaders Media.