MHA Safe Transitions
of Care
October 18, 2011
Karen MacDonald, Associate
Administrator, HealthEast Care System
Barb Stricker, Group Director, Social
Work Services, HealthEast Care System
Tania Daniels, Vice President, Patient
Safety, Minnesota Hospital Association
MHA Safe Transitions of Care Workgroup
 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 Pilot
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
Transition
Pilot
Sites
(13)
Essentia
Fosston
Fairview UMC Mesabi, Hibbing
Essentia
St. Joseph’s,
Brainerd
Mercy Hosp.
Moose Lake
GraniteFalls
Municip. Hosp
CentraCare
St. Cloud
Hospital
Fairview
Northland,
Princeton
HealthEast St. Joseph’s,
St. Paul; St. John’s
Maplewood
Rice Memorial,
Willmar
Fairview
Red Wing
Sanford
Jackson
Olmsted
Med. Center,
Rochester
MHA Safe Transitions of Care Pilot
 13 sites from across the state
• Large rural hospitals
• Small rural hospitals
• Large urban hospitals
 Across variety of settings, hospital to/from:
- SNF
- LTC
- Home health
- Hospice
- Assisted living
- Community behavioral health
- Adult Foster Care
- DME Agencies
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 Report
January 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
Receiving Facility Feedback
N= 18
Themes:
•Unclear med orders
•Needing narc scripts
•Clarify wound care orders
Receiving Facility Feedback
Receiving Facility Feedback
N= 5
Receiving Facility Feedback
N= 12
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
Q1: Did you have to make any
follow-up phone calls
to the SNF for this patient?
0%
20%
N= 5
No phone calls
1-2 Phone Calls
3 or more Phone Calls
20%
60%
Unknown
Q2: In your opinion, was staff at the STACH
satisfied with the use of the core elements?
N= 0
Q3: In your opinion, was the staff at the
STACH satisfied with the information
communicated during the transition?
0% 0%
N= 5
20%
20%
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
60%
Themes:
• Needed to refax
orders to SNF
Q4: In your opinion was the
patient and family satisfied with the
transition process?
0%
0%
0%
20%
N= 5
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
80%
Very Satisfied
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
5
3
5
2
3
2
1
21
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
8
3
3
9
4
3
2
32
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
0
0
0
2
1
0
0
3
Mon
Tue
Wed
Thu
Fri
Sat
Sun
TOTAL
13
6
8
13
8
5
3
56
Total
John's
n=32
Total
WW
n=3
Total
Total
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%
21
32
3
13
6
8
13
8
5
3
Total

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
Example areas that need ‘safe’ communication
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 MHA Core Elements of Information to
assure ‘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)
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
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