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Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”
Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”
Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”