Editor's note: In Healthcare Transformation: A Guide for the Hospital Board Member, authors Maulik S. Joshi and Bernard J. Horak identify 10 "transformers," or action steps, to improve specific areas of health care. In this excerpt, the authors focus on coordinating care.
Care coordination is an emerging challenge in our health care system because of the increasing complexity of the number of providers, number of settings of care and the number of methods of delivering care.
Coordinating care across services within your hospital (such as between diagnostic imaging and your patient unit or lab and your patient unit), across settings (such as between the ICU and the medicine floor) or across people (such as between your primary doctor and specialist) is a challenge no matter who or where you are. Although we talk about "seamless care," the health care industry has failed miserably in achieving it and it is often recognized as a main driver for poor quality and medical error.
This article will use the specific example of coordination of care—handoffs and transitions in the hospital—to highlight care coordination issues. There are a number of interventions that hospitals are implementing today to address gaps in care coordination, including better systems of communication, personnel resourcing and information technology. Health care continues to change in terms of where care is delivered and by whom; thus care coordination becomes more vulnerable as a cause of poor care and service.
The importance of improving coordination of care and communication among health care providers and settings can be seen in the following issues:
- The Agency for Healthcare Research and Quality reported that poor coordination of care more than quadruples the odds of medical error.
- A recent report to Congress documented that 17.6 percent of Medicare patients were readmitted to the hospital within 30 days.
- A study at Massachusetts General Hospital found that 59 percent of residents said one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12 percent reported that this harm had been major.
- A study of malpractice claims in an emergency department showed that approximately 25 percent of missed diagnoses were caused by an inadequate handoff (e.g., failure to get a positive lab result back to the ordering physician).
- A study of veterans with one or more chronic illness found that 45 percent of patients with a chronic illness reported they received no help from their doctor or health plan in coordinating their medical services.
- In a literature review, researchers identified that poor communication was:
- The largest contributor to wrong site surgery and delays in treatment;
- The second most common cause for medication errors, patient falls and adverse events during and after an operation; and
- Responsible for 91 percent of mishaps involving medical residents.
- The results of an AHRQ hospital culture survey showed that hospital staff's perception about handoffs and transitions was positive at only 45 percent. For the following four statements, staff indicated a very poor rating:
- Things fall between the cracks when transferring patients from one unit to another;
- Important patient care information is often lost during shift changes;
- Problems often occur in the exchange of information across hospital units; and
- Shift changes are problematic for patients in this hospital.
The transformer opportunity includes:
Care coordinators/linking pins. These could be physicians (e.g., hospitalists), nurses or social workers (case managers), or an administrative staff member who coordinates referrals, follows up on test results, and ensures information transfers among settings or providers.
Interdisciplinary coordination. This includes joint rounding of patients, establishing procedures for coordination and building teams.
Structured communication. This includes read-backs of orders and instructions, briefings prior to a medical procedure, and a structured communication tool or checklist when handing off a patient to another provider.
Tracking and follow-up systems. This includes computer systems and programs that identify the treatment needs (protocol or plan) for a patient, track the patient's progress, and send reminders for needed follow-up care (e.g., exams, tests and procedures).
The following are practices in common with organizations that have successfully improved care coordination:
Team building. This usually consists of clarifying roles, establishing working relationships and interpersonal communication among providers, and setting ground rules for teamwork (e.g., question and participate, listen constructively, seek clarification and understanding, speak up when concerned about a patient).
Crew resource management training. Borrowed from the aviation industry and successfully applied in health care, this is interactive training and team building for the health care team in such areas as structured communication approaches, assertiveness, and ground rules for teamwork and collaboration.
Interdisciplinary problem-solving meetings. These are regular meetings of physicians, nurses, therapists, social workers and pharmacists to discuss coordination, quality, service and other issues on a patient care unit.
SBAR (Situation, Background, Assessment, Recommendation). This is a structured communication method to relay critical patient information or concerns about a patient. For example, a nurse would describe to a physician the Situation (e.g., trouble with breathing), the Background (e.g., 60-year-old with chronic lung disease), his or her Assessment (e.g., "I think he has a pneumothorax"), and Recommendation (e.g., "I think you should come in right now since I think he needs a chest tube").
"Touch base" meeting. This is a brief, daily meeting between a physician and nursing team leader or manager on the status of each patient prior to the physician leaving the unit.
Joint rounding. This ensures that all clearly know the current status and treatment plan for the patients. Rounds should include all who provide care to the patient, including nurses, therapists and house staff (e.g., residents, interns).
The OR Brief (an expanded "timeout"). This is a meeting immediately before an operation commences where critical information is verified (e.g., correct patient, site, procedure, and administration of antibiotics) and potential risks (e.g., bleeding and fluid loss) and contingency plans are identified.
Patient information systems. As mentioned earlier, these are computer programs that use algorithms or protocols that lay out treatment needs, track the patient's progress, and send reminders for follow-up exams, tests and procedures.
Leadership. Most critical is the role of the leader who must ensure that coordinating mechanisms are in place. In addition, leaders and managers at all levels must emphasize ongoing and one-on-one communication and coordination (e.g., "just pick up the phone and call").
Case management and discharge planning. Many organizations use a case manager (usually a nurse or social worker) to arrange and follow up on referrals and other patient care needs among providers. In addition, interdisciplinary discharge planning meetings are held to ensure follow-up care and social services, if needed, are provided after discharge.
Patient liaison. Some health care organizations employ an administrative staff member or social worker to assist the patient and family in navigating the health system, particularly for patients with complex or chronic conditions. In addition, many organizations establish a formal relationship with a family member (e.g., an elderly patient's son) to ensure follow-up of referrals, procedures, etc.
Linking pins. These are hospital representatives who meet on a regular basis with office managers and providers who refer patients to the hospital. Critical to the discussions are the efficacy and timeliness of reports, patient information and follow-up care.
Clinical/nurse advocates. Catholic Healthcare Partners, Cincinnati, has trained and uses nurses, called "heart failure advocates," to educate patients about their disease, coordinate their care and follow up with them after discharge. These advocates go beyond the roles of the case managers, discharge planners, patient liaisons and linking pins described earlier. They have been charged to do "whatever it takes" to improve heart failure care and the patient's quality of life. They look for ways to improve systems of care, use evidence-based clinical guidelines, continually coordinate between outpatient providers and the patient, educate and follow up with patients on their diets, implement behavioral strategies to increase medication adherence, and address post-discharge barriers. For example, they assist low-income patients with obtaining medications through pharmaceutical company programs that offer free or low-cost prescription drugs. The results across the 22 CHP hospitals have been astounding. There was a 40 percent decline in inpatient heart failure mortality rates and these patients were five times less likely to be readmitted within 30 days.
Handoff system. Great Ormond Street Hospital in London used Ferrari Formula One pit crew team consultants to design a better system for handoffs between the operating room and the intensive care unit. GOSH learned that one of the important roles in pit crew coordination was that of the "Lollipop Man"—the member of the crew who holds up a large, round sign that resembles a lollipop and signals to the driver when to stop and leave. Hence, the Lollipop Man highlights the need for timely, accurate information and sequencing of activities. As in health care, this informational role is critical since crew members could be run over if coordination and information fails. The following were key redesign features to improve the OR-ICU handoff:
- Training each hospital staff member for a specific task set.
- Developing protocols for each member of the team.
- Having a "carer" (designated person) to ensure adequate information, equipment, supplies and other services.
- Sequencing of the steps.
- Using a Lollipop Man (an anesthesiologist) to monitor the sequence and to provide clear signals to every member of the care team.
The results were extremely positive. Errors per handoff to the ICU fell by 42 percent and the number of information omissions fell by 49 percent.
As a hospital board member, consider the following questions:
- What measures are we using to track care coordination within the hospital and with other providers and stakeholders in the community and how are we doing?
- Do I, as a board member, emphasize the importance of communication among providers within my organization and with referral providers and other entities that we interact with to ensure effective coordination and continuity of care?
- Specifically, how do we ensure effective transitions and handoffs of information and care across shifts within the hospital?
- Are there effective mechanisms in place for coordination within my organization such as joint rounding, OR briefings, case management and discharge planning?
- Are there effective mechanisms to help patients navigate the health care system such as use of patient liaisons?
- Am I advancing information management systems, particularly electronic health records, which would track and follow up on patient care needs?
- Are we tracking our hospital's readmission rates?
- Have we examined the main causes of avoidable readmissions and identified opportunities for improvement?
- For factors that are outside of the hospital's control, are we working with community stakeholders to reduce avoidable readmissions?
This excerpt was reprinted with permission from Healthcare Transformation: A Guide for the Hospital Board Member, published by Productivity Press, copyright 2009. To purchase, go to www.healthforumonlinestore.com.
Maulik S. Joshi, DR.P.H. (firstname.lastname@example.org), is president of the Health Research & Educational Trust, Chicago. Bernard J. Horak, PH.D. (email@example.com), is a professor and director of the Graduate Program in Health Systems Administration at Georgetown University.