Fostering Safe, Effective Care Transitions

Transcription

1 Fostering Safe, Effective Care Transitions Margherita Labson, MSHSA Executive Director Kathy Clark, MSN, RN, APD, Dept. Standards & Survey Methods Pat Quackenbush, RN-BC, MBA, Virtua Susan Wade-Murphy, MSN, RN, CCH Medical Center Klaus Nether, MBB Center for Transforming HealthCare Deatrice Greathouse, RN, MSHA, AD, Standards Interpretation Group 1

2 Objectives: At the conclusion of the program participants will be able to - Identify two key issues challenging safe transitions of care Describe how The Joint Commission accreditation process supports organizations efforts to promote safe care transitions Explore how accredited organizations are using the accreditation process to foster safe, effective care transitions 2

3 Issues Challenging Care Transitions Health care consumer s today Evolution of professional practice Impact of Affordable Care Act Issues specific to home care providers 3

4 The Joint Commission s Transitions of Care Project Goal: Utilize the research to develop standards/ NPSG, measures, and solutions to assist our accredited organizations to provide safe transitions of care from one setting to the next Background Key findings from research: Seven Foundations (next slide) Next steps 4

5 Foundations of Safe Transitions LEADERSHIP MULTIDISCIPLINARY PATIENTS AT MEDICATION TRANSITIONAL PATIENT/FAMILY TRANSFER OF SUPPORT COLLABORATION RISK MANAGEMENT PLANNING ACTION INFORMATION 5

6 ToC Portal Web-page 6

7 Transitions in Care Program Transitional Care Model Dr. Mary Naylor Home Care Hybrid Transitions in Care Program 7

8 Key Challenges Transitioning the patient safely across the gap : many challenges Medication Reconciliation Hand-off Communication/ Transfer of Information 8

9 Key Challenge #1 Medication Reconciliation- Policy should reflect actual practice(ld EP 1, 2) List from referral organization(npsg ) Prescription bottle to list (NPSG ) Assess the patient history for allergies, sensitivities, (PC , EP 6) 9

10 Medication Reconciliation (cont) Plan the patient care based on need (PC ) Separate historical medication ( Pt refuses to discard) (PC ) Provision of Care, Treatment and Services, Administration (PC ) Pt/Family education in terms they can understand (PC ) 10

11 Medication Reconciliation Focus on Medication Management Developing a SOP for Medication Reconciliation Lessons Learned Partnering with PCP 11

12 Medication Reconciliation Integrated EMR Inpatient Discharge Medication Profile Initial Nurse Home Visit Discrepancy Resolution EMR Medication Profile updated 12

13 Key Challenge #2 Hand-off Communication/Transfer of Information Use a consistent communication process during each transition of care. Communication between the sender and receiver prior to the transition Established methods and timelines for communication and information exchange Active collaboration between sender and receiver Patient-specific and service-specific 13

14 Hand-off Communication Strategies Review of your hand off process for compliance with PC Review of transfer/discharge process PC Process should include: PC Patient needs and education Reason for transfer/discharge Summary of care and progress 14

15 Safe and Effective Hand-off of Care New Jersey Universal Transfer Form Physician Access to Home Care EMR SBAR 15

16 Hand-off Communication Integrated EMR Employ Liaison Resource RN Utilize a Standard Transfer Communication Template New Patient Note Resumption of Care Note 16

17 Powered by RPI TM Hand-off Communications (HOC) Targeted Solutions Tool (TST) 17

18 Mission Transform Health Care into a high-reliability industry by Leadership High reliability industries such as airlines, nuclear power plants, amusement parks and even zoos have zero room for error 18

19 The Way We Do Improvement Usual approach: best practices, toolkits, protocols, checklists, bundles Typical best practice is one-size-fits-all Can produce modest improvement Difficult to get to zero Difficult to sustain The one-size-fits-all approach works well only for simple problems that do not vary Toughest problems are not simple 19

20 A New Way of Delivering Results Complex processes require more sophisticated problem-solving methods Three crucial and consistent findings: Many causes of the same problem Each cause requires a different strategy Key causes differ from place to place RPI = lean, six sigma, change management Producing next generation best practices Solutions customized to your causes 20

21 Causes differ by health care organization so solutions for each organization should be targeted Org. A should not spend additional time or resources on causes that were not identified 21

22 Powered by RPI TM The TST is an innovative online application that guides health care organizations through a step-by-step process to: Accurately measure their organization s actual performance Identify their barriers to excellent performance Direct them to proven solutions that are customized to address their particular barriers 22

23 Getting Started 23

24 Training Data Collectors 24

25 Getting Your Data Results 25

26 Viewing Your Contributing Factors 26

27 Selecting Your Solutions 27

28 How to Access the TST 28

29 Summary Effective Care Transitions are critical to safe patient care Two of the challenging issues include Medication Reconciliation and Hand-off Communication Resources available to guide organizations include Accreditation Standards, ToC, TSTs and processes developed by Accredited Organizations 29

30 Time for Your Questions! 30

31 The Joint Commission Team Contacts Joint Commission Home Care Program Help Desk: or Margherita Labson RN, MSHSA, CPHQ, CCM Executive Director or g Kathy Clark, MSN, RN Associate Project Director Home Care Department of Standards and Survey Methods Julia Finken, MBA Associate Director or Deatrice Greathouse RN, MSHA Associate Director Standards Standards Interpretation Help Desk: Joint Commission Resources: or Center for Transforming Health Care: 31