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MHA “Safe Transitions of Care”
Pilot Project Final Report
May 2011
Overall Goal
Improve patient safety by standardizing and improving communication during transitions of care
between hospitals and across settings
Safe Transitions is a Priority Issue
Patient safety is a top priority for Minnesota hospitals and health care professionals. However,
communication failures between settings during transitions of care can compromise patient safety and
quality of care. A recent study of Medicare patients after hospital discharge found that nearly onequarter “experienced complicated care transitions.1 And an estimated 60 percent of medication errors
occur during times of transition: upon admission, transfer, or discharge of a patient.2
In efforts to address this safety issue, the Minnesota Hospital Association (MHA) Patient Safety
Committee commissioned a Safe Transitions of Care Workgroup to identify patient safety gaps due to
transitions of care and core elements to address these gaps. Appreciating a significant amount activity
to prevent readmissions both within organizations and throughout the Minnesota community, this
project is intended to be one component to further address hospital readmissions.
The Safety Committee commissioned a pilot to test the core elements, gap analysis, core element
cross walk and other tools.
Pilot Goals
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Evaluate appropriateness of and provide feedback for edits to safe transition elements
Utilize tools in toolkit (e.g. crosswalk, gap analysis) and recommend edits /additions
Evaluate metrics (facility specific, statewide, gap analysis assessment questions)
Identify mentor organizations
Pilot Learning: Successes
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Safe transition gap analysis is infrastructure for smooth, safe transitions- which is one
component of reducing readmissions
Significant value with engaging community/stakeholders across settings
Reduced follow-up calls required with use of MHA core elements of information
Increased satisfaction of patient/family, transferring and receiving facility staff
Operational champion for safe transitions is key
Process of nurse to nurse call/handoff is one of most successful pilot strategies
EA Coleman et al., Posthospital Care Transitions: Patterns, Complications, and Risk Identification, Health Serv. Res. 39(5): 1449–1466
(Oct. 2004).
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JD Rozich & RK Resar, Medication Safety: One Organization’s Approach to the Challenge, J. Clin. Outcomes Manag. 8:27-34 (2001).
Pilot Impact
Short Term Measurement
 Safe Transition Gap Analysis: Increased from 55% to 71%
 Transferring Facility Surveys indicated increased satisfaction
 Receiving Facility Surveys indicated increased satisfaction
 High level of perceived satisfaction of patient/families
 Decreased follow-up calls for clarification
 Pilot site transition of care teams: value of networking and developing new community
relationships
Long term Measurement
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)
The short term goal of improving transition communication will impact patient safety in long term,
including but not limited to the following:
o
Medication events/missed doses
o
Delayed care/redundant tests
o
Readmissions, overall readmissions or specific diagnosis readmissions
o
ER visits
Pilot Learning: Challenges
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It was beneficial for pilot sites to align safe transition of care work with existing infrastructures
(d/c committee) and/or process improvement work (e.g. readmission)
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Longer timeframe recommended, a lot of work for 4 months
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Many communication gaps were closed, but still more work is needed
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Addressing gaps in medication orders/medication reconciliation
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Defining metrics/audits
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Incorporating core elements into EHR
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Instituting a hard stop policy with safe transitions
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Provider education
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Patient education
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More work is needed to incorporate core elements with patients transferring to/from
emergency department
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Pilot Sites
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13 diverse hospitals from across the state
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Large rural hospitals
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Small rural hospitals
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Large urban hospitals
Transition pilot population varied across settings of care, hospital to/from:
 SNF
 LTC
 Assisted living
 Home health
 Community behavioral health
 Adult Foster Care
 Hospice
 DME Agencies
Timeline
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Sept 2010 – Initial webinar meeting of pilot sites/teams to kick-off pilot project
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Oct- Nov 2010 – Pilot sites measure baseline including gap analysis and complete cross walk
of core elements of information. Teams convened to develop pilot process forms/processes
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Dec-March 2011 – Pilot period to test core elements of information, gap analysis roadmap,
and other tools
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April 2011 –Gap Analysis re-measurement and final meeting of pilot sites to evaluate/modify
core elements, gap analysis, and toolkit based on pilot findings
Pilot Site Key Action Steps
 Senior leadership signed-off for facility to participate in pilot project.
 Transition pilot population specified.
 Completed baseline Safe Transition of Care Gap analysis.
 Convened team to complete core element crosswalk and develop pilot process.
 Met with key transition stakeholders from community.
 Revised transition documentation to incorporate all MHA core elements of information into first
1-2 pages of transition documentation.
 Tested core elements and tools from toolkit during 4 month pilot period.
 Revised/developed new tools such forms, policies, checklists, patient and staff education
 Surveyed transferring and receiving facilities regarding staff and patient/family satisfaction with
new process/use of core elements.
 At conclusion of pilot: re-measured gap analysis.
 Participated in final meeting to revise core elements, cross walk, gap analysis, and tools.
 Shared revised and new tools.
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Pilot Implementation Support
 “SAFE Transitions of Care” form/core elements for use during all patient transitions of care
 Forum for sharing successes and challenges: monthly conference calls, in-person meetings,
list serve
 Infrastructure: 39 question Gap Analysis
 Web based Toolkit
o On-line gap analysis
o Core element crosswalk
o Transition form
o Model Policy
o Education Tools
o Pilot measurement
Core Elements of Information and Intent
MHA Core Element (Elements that
must be included)
Transferring Facility
Contact information for receiving facility questions
Transferring Facility Contact Name
Contact information for receiving facility questions
Intent
Transferring Facility Phone Number Contact information for receiving facility questions
Transferring Facility
Nurse giving report
Transferring Facility
Fax Number
Transferring from/ Coordinating
Physician contact information
Responsible Provider 1st 24 Hours
of Transfer
Contact information for receiving facility questions
Contact information for receiving facility questions
Who is accountable for patient? (e.g. ordering, attending,
primary care)
Who is accountable for patient? (e.g. ordering, attending,
primary care)
Responsible Person Telephone
Number
Primary and Secondary Diagnosis
Basic Information
Problem List
Basic Information
Allergies
Safety/High Risk Concern
Falls Risk and interventions
Safety/High Risk Concern
Infection/Isolation Precautions
Safety/High Risk Concern
Mental/Cognitive Status
Safety/High Risk Concern
Behavioral Status
Safety/High Risk Concern
Pain Assessment
Safety/High Risk Concern
Pressure Ulcer/Skin Integrity:
Assessment and Interventions
Communication Needs
Safety/High Risk Concern
Interpreter needs, hard of hearing, health literacy
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Health Care Directive
Timely continuation of plan of care/prevent delays in care
Code Status
Timely continuation of plan of care/prevent delays in care
Overall Goal for Patient/Prognosis
Timely continuation of plan of care/prevent delays in care
Plan of Care and Appropriate
Orders
Immediate Follow-up
Procedures/Labs/Tests
Timely continuation of plan of care/prevent delays in care
Nutrition/Diet
Timely continuation of plan of care/prevent delays in care
Medication Reconciliation List/D/C
Medication list
Medication errors or discrepancies in medication list
(and/or formulary changes) and delays in care/medication
Pertinent Labs and Test Results,
Including Pending Results (Last 24
hours)
Communicating 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)
Timely continuation of plan of care/prevent delays in care
Reduce duplication/redundant tests
Gap Analysis Infrastructure
SAFE
 S: Safe transition teams
o Interdisciplinary team (physician, senior executive, Operational champion)
o Engage key stakeholders
 A: Access to information
o Verify the completion of SAFE TRANSITIONS
o Evaluate for learning opportunity
 F: Facility expectations
 E: Educate staff and patients
Principles*
 Accountability: All transitions must include records that contain core elements
 Responsibility: At every point during care transition, patients and their families must know who
is responsible for care and how to contact the caregiver
 Coordination of Care
 Communication: Clinicians or institutions must provide a clear and direct communication
infrastructure, including transition records, treatment plans, and follow-up expectations
 Timeliness
 Standards and metrics
* Based on “Transitions of Care Consensus Policy Statement,” American College of Physicians-et al.
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Gaps Analysis: Areas of Improvement during Pilot
 Safe Transition Gap Analysis:
o Baseline implementation 55% of infrastructure best practices
o Post pilot implementation 71% of infrastructure best practices
 Senior Leadership identified a physician champion(s) and/or senior executive for SAFE
TRANSITIONS
 Senior Leadership defined roles, set expectations and provides support for the champion(s)
 Individual roles in SAFE TRANSITIONS are clearly defined
 Stakeholder representation on team includes all transition settings
 The facility has a process in place to audit the completion of SAFE TRANSITIONS through
audits
 The facility requires AND has a designated mechanism of communication to provide caregiver
contact information to patients and their family
Gap Analysis: Ongoing Gaps after Pilot
 Data is shared with the facility’s medical staff on a regular basis
 Expectations and supporting education have been incorporated into orientation for new
physicians and other practitioners involved in transitions
 Patient/family safe transition education tools are disseminated as appropriate
 The facility requires AND has a designated form that contains core elements for each
appropriate transition from Emergency Department to all settings
 The facility requires AND has a designated form that contains additional elements for each
appropriate transition from all settings to hospital
Contributors
We would like to thank the following MHA members for participating in the MHA Safe Transitions of
Care Workgroup: Karen MacDonald, HealthEast Care System (Chair); Cindy Cross, Granite Falls
Municipal Hospital and Manor; Dr. Ken Kephart, Fairview Southdale Hospital, Edina; Marilyn
Graftstrom, LifeCare Medical Center, Roseau; Kay Greenlee, St. Cloud Hospital; Barb Stricker,
HealthEast Bethesda Hospital, St. Paul; Pennie Viggiano, HealthEast Care System, St. Paul; Sherril
Zehr, Fairview Health Services, Minneapolis; Tania Daniels, MHA, Julie Apold, and Mark Sonneborn,
MHA.
MHA would also like to thank all team members from the pilot sites:
Essentia Fosston; Fairview University Medical Center – Mesabi; Granite Falls Municipal Hospital;
Fairview Red Wing Medical Center; St. Cloud Hospital; Mercy Hospital, Moose Lake; Fairview
Northland Medical Center; Olmsted Medical Cente; Sanford Jackson Medical Center; St Josephs
Hospital, St. Paul; St. John’s Hospital, Maplewood; Rice Memorial Hospital; St. Joseph's Medical
Center, Brainerd.
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
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