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MHA Safe Transitions of Care Tania Daniels, Vice President, Patient Safety, Minnesota Hospital Association October 18, 2011 Karen MacDonald, Associate.

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Presentation on theme: "MHA Safe Transitions of Care Tania Daniels, Vice President, Patient Safety, Minnesota Hospital Association October 18, 2011 Karen MacDonald, Associate."— Presentation transcript:

1 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

2 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

3 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

4 MHA Safe Transition Pilot Sites (13) Essentia Fosston Fairview UMC - Mesabi, Hibbing GraniteFalls Municip. Hosp Fairview Red Wing CentraCare St. Cloud Hospital Mercy Hosp. Moose Lake Fairview Northland, Princeton Olmsted Med. Center, Rochester Sanford Jackson Rice Memorial, Willmar Essentia St. Josephs, Brainerd HealthEast St. Josephs, St. Paul; St. Johns Maplewood

5 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

6 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) ) 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

7 HealthEast Final Report January to April 2011

8 Sites- Two of acute care hospitals: Saint Josephs and Saint Johns Our Partners Cerenity Care Center-Marion Ramsey County Care Center Pilot ran from January 21 st to March 24 th

9 N= 56


11 HealthEast Receiving Facility Feedback N= 55

12 Themes: Unclear med orders Needing narc scripts Clarify wound care orders Receiving Facility Feedback N= 18

13 Receiving Facility Feedback

14 N= 5

15 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

16 N= 5

17 Q2: In your opinion, was staff at the STACH satisfied with the use of the core elements? N= 0

18 N= 5 Themes: Needed to refax orders to SNF



21 Joe'sn=21 MonTueWedThuFriSatSunTOTAL RCCC CCC-M Total John'sn=32 MonTueWedThuFriSatSunTOTAL RCCC CCC-M Total WWn=3 MonTueWedThuFriSatSunTOTAL RCCC CCC-M Total MonTueWedThuFriSatSunTOTAL Total

22 OverallSt Joseph'sSt John'sWoodwinds MonTueWedThuFriSatSunTOTAL% of Total Very Dissatisfied % Dissatisfied % Neutral % Satisfied % Very Satisfied % Total

23 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

24 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.

25 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.

26 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

27 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

28 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 Patients readiness for transition Example areas that need safe communication

29 Do the following core elements of information exist? Are they in the 1 st 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 patients 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


31 Safe Transition Roadmap Gap 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

32 Transitions of Care Consensus Policy Statement

33 Gap Analysis Transition Principles Accountability Responsibility Coordination of Care Patient/Family Involvement Communication Timeliness Standards and metrics

34 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 Kick-off webinar February, April, June Participant learning and network webinars/conference calls July 2012 –Final Gap Analysis measurement

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