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