Patient Safety Measures:
Ensuring Safer Transitions in Care
What are we measuring and why?
The transition out of the hospital can be a high-risk time for patients. Whether patients return home or are transferred to a post-acute facility such as a rehabilitation center or nursing home, the discharge process must be coordinated carefully to ensure patient safety. The sending hospital must document important medical information accurately so that it can be available to the staff at the receiving facility, and to the patient's outpatient providers such as their visiting nurse and / or primary care physician. Partners HealthCare experts have identified twelve key pieces of information that promote safer transitions, and we track how well we do in including these elements in the discharge paperwork. The list of the twelve key pieces of information includes:
- The reason for admission to the hospital
- A physician to contact for information related to the hospital stay, 24-hours a day, 7 days a week
- The patient's medical condition at the time of discharge
- Principal diagnosis at the time of discharge
- A list of tests that were still pending (results not back yet) at the time of discharge (if applicable)
- A provider to contact about tests that were still pending (results not back yet) at the time of discharge
- Detailed discharge medication instructions, including how the discharge medication regimen is different from the one taken before being admitted
- Major procedures and tests that were done in the hospital and a summary of those results (if applicable)
- Medication allergies
- Follow up plans after discharge
- Detailed information regarding use of any blood-thinning medications (if applicable)
- Information about patient's wishes for treatment near the end of life (if applicable)
We recently changed this list in order to include new key pieces of information that are important in safe transitions and "retired" others because we found that they were consistently being included in discharge paperwork and no longer needed to be tracked. Click here to view historical data for this measure, which shows our scores before we changed the key pieces of information that we include in this measure.
How are we doing and how do we compare to national best practice?
When we review our performance, we only give ourselves credit when all key elements are present, aiming for a defect-free discharge or perfect score of 100%. Our defect-free rates currently range from 76% to 92%. Since we have recently "raised the bar" for our hospitals by adding new information, we expect that our scores will get better over time as we address areas in need of improvement. There are no national best practices that define what information is needed for a safe hospital discharge. But, Partners HealthCare has asked our own experts to develop these guidelines, based on what makes sound clinical sense. Some of the newly included measures were added because of an emerging new standard for discharge documentation set by MassHealth.
What are we doing to improve?
Partners HealthCare has created hospital-based Transition Teams. We support them and their improvement efforts in many ways. We:
- Provide regular updates on their discharge documentation performance
- Share best practices among all our hospitals
- Standardize staff education
- Give discharge document feedback to individual caregivers and their supervisors
- Guide them in including key pieces of information in their electronic discharge systems
And, we are creating our own technology to support successful patient transitions.
Charts for Ensuring Safer Transitions in Care
- Current Scores
- Scores Over Time
- Current Scores
- Scores Over Time
Percent of Patients Transferred with All Recommended Information
Partners HealthCare Data Period: October 2012 - December 2012
On January 1, 2012 we changed this measure to include new elements that are important in safe transitions in care and "retired" other elements that were successfully implemented. Click the link below to view historical data for this measure, which shows our scores before we changed the elements that are included in this measure.
View Historical Charts for Ensuring Safer Transitions in Care
Partners HealthCare Source: Partners HealthCare
Reference Point Source: Partners-wide Goal
Percent of Patients Transferred with All Recommended Information
On January 1, 2012 we changed this measure to include new elements that are important in safe transitions in care and "retired" other elements that were successfully implemented. Click the link below to view historical data for this measure, which shows our scores before we changed the elements that are included in this measure.
View Historical Charts for Ensuring Safer Transitions in Care
Partners HealthCare Source: Partners HealthCare
Reference Point Source: Partners-wide Goal
Percent of Patients Transferred with All Recommended Information
Partners HealthCare Data Period: October 2012 - December 2012
On January 1, 2012 we changed this measure to include new elements that are important in safe transitions in care and "retired" other elements that were successfully implemented. Click the link below to view historical data for this measure, which shows our scores before we changed the elements that are included in this measure.
View Historical Charts for Ensuring Safer Transitions in Care
Partners HealthCare Source: Partners HealthCare
Reference Point Source: Partners-wide Goal
Percent of Patients Transferred with All Recommended Information
On January 1, 2012 we changed this measure to include new elements that are important in safe transitions in care and "retired" other elements that were successfully implemented. Click the link below to view historical data for this measure, which shows our scores before we changed the elements that are included in this measure.
View Historical Charts for Ensuring Safer Transitions in Care
Partners HealthCare Source: Partners HealthCare
Reference Point Source: Partners-wide Goal