Evidence demonstrates that communication is one of the leading contributors to adverse events. Transitions of care epitomize this challenge. WATCH ON DEMAND: https://goo.gl/M1ovsS

1. Communication During
Transitions of Care:
Is there room for improvement?

2. Communication During Transitions of Care:
Is there room for improvement?
OBJECTIVES
1. Understand the complexity of challenges we face when
sharing care across teams and places
2. Be familiar with “I START‐END” ‐ a tool that facilitates
engagement and effective communication in various settings
3. “What we said is NOT what they heard” – appreciate the
human factors that make this true and how to manage this
reality

5. ...start with WHY...
• Every year, the average elderly patient sees 7
physicians (5 specialists and 2 primary care
physicians) across 4 different practices.
• Physicians in private practice caring for Medicare
patients interact with as many as 229 other
physicians at 117 different practices each year.
• The average surgery patient is seen by 27 different
healthcare providers while in the hospital.
Institute of Medicine (IOM) report 2012

8. “splat”
Stranded Patients Looking After Themselves

9. 9.5% of all deaths result from “unwanted
variations” endemic in healthcare.
Developing consensus protocols that streamline
the delivery of medicine and reduce variability can
improve quality & lower costs in healthcare.
BMJ 2016, 353; i 2-39

11. HIGH RELIABILITY
ORGANIZATIONS
TRANSITIONS OF RESPONSIBILITY MUST BE “HARDWIRED” INTO
THE SYSTEM
(process happens every time – not optional)
Face-to-face communication
Minimize non-essential tasks/distractions (prioritize)
Structured framework - documentation
Contingency plans discussed (what’s next)
READ-BACK

12. Who is everyone?
INTRODUCTIONS
Identify leader

13. STORY
What is happening?

14. What is the TREATMENT plan?
TASKS

15. Who will do what?
ASSIGNMENT +/- ADJUSTMENTS

16. What else do we need?
RESOURCES

17. What do you think is going on?
TIMELY UPDATES

18. Before EXITING
discuss the plan for NEXT
DOCUMENTATION & DEBRIEFING

19. HOW does the cognitive aid
“I START‐END”
work to improve transitions of care?
1. Standardization ‐ same language/shared mental maps
2. Creates the expectation & opportunity for speaking up
3. Hardwires iterative processes so complexity around
healthcare information transfers, care management plans &
relationship accountabilities are openly & actively reviewed in a
continuous way across the patient care journey

20. IDENTIFY leader, INTRODUCE patient,
 team members & ROLES (level of expertise)
Review the patient’s STORY
 what happened, why? what else? (co‐morbidities)
Leader sets out the TREATMENT plan/assigns TASKS
Team members ADJUST/ACCOMPLISH assigned tasks
 (judgment, experience)
Consider other RESOURCES needed ‐
 more help, monitors, equipment, other drugs,
investigations...
TIMELY UPDATES
 ask team members what their viewpoint of the patient’s
status is (“What do you think is happening?”)
Before EXITING – discuss NEXT
 determine WHO will do WHAT, by WHEN
DOCUMENT these details (include names & contact info) &
DEBRIEF with entire team‐what went well, what could be improved
H
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H A
C M
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21. IDENTIFY receiving care provider & the PATIENT (name band & ALLERGIES)
Patient STORY
 including medical history & language, hearing,
cognition, mobility issues...
TREATMENT
 describe what care was provided
ADDITIONAL INFORMATION
 detail any significant/unexpected events during care
RESOURCES – family/next of kin aware?
 need for other consults/investigations/special monitoring/
ongoing care
 including medication changes
TIMELY UPDATES
 review VITAL SIGNS & address other patient/provider concerns
Then, before EXITING ‐ what is NEXT?
 anticipate issues for follow‐up & SPECIFICALLY name
& contact info for MRP
DOCUMENT all this & DEBRIEF
 Ask patient & receiving care provider if they have any
QUESTIONS & confirm understanding (read back)
H
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22. INTRODUCTIONS
 I am “so & so” ‐ What is your ROLE in my care today?
STORY
 Could we go over my history to be sure its up to date?
TALK about your diagnosis & TREATMENT plan –
 Bring someone helpful along for support & scribing
ADJUSTMENTS/ALTERNATIVES
 What are other treatment choices? medication changes?
RESOURCES
 How will the treatment plan be operationalized?
 Will other care (rehab etc.) be needed?
TIMELY UPDATES
 How will I be updated? – by whom?
BEFORE EXITING
 Ask the team what’s NEXT and the plan for “next”
DOCUMENTATION
 Get electronic/hard copy of details & obtain specific
CONTACT INFORMATION (for unexpected events)
DEBRIEF
 summarize what you heard & understood (read back)
 ask QUESTIONS – “is there anything else I need to know?”
P
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23. I PASSSBAR

24. *
*
*
*
*

25. “Why what I said was NOT what you heard”

26. The “SENDER” is 100%
responsible for ensuring that
information is sent successfully
TRUE OR FALSE?

27. Who is receiving?

28. Know your receiver(s)
• ARE THEY READY? (right time, place)
• Minimize interruptions & distractions
• Standardize format
• Critical H/O information DOCUMENTED
• Sender leaves their CONTACT DETAILS
Ensure patient/family are
partners in care planning

30. “READ BACK”
(teach back, check back...)
“OK, ANY QUESTIONS?”
JUST TO MAKE SURE I HAVEN’T MISSED TELLING YOU SOMETHING ‐
“CAN YOU JUST SUMMARIZE THE KEY POINTS BACK TO ME ?”
(Give PROMPTS prn)
The main problems are...
The plan is...
Other special considerations are...
Follow up is...
MRP is...

31. “splat”
Smart Patients Looking After Themselves

32. QUESTIONNAIRE
ID
 Confirm any changes in your health card
 Confirm any changes in your home address
 Contact info – best way to reach me is …
 If it is urgent – next of kin/# is …
STORY
 summary of my health changes since the last time I saw you
 Treatment –bring current medication list, other therapies
 Allergies/additional information
 Resources –”how are you getting around?” exercise, ADLs, coping etc. ?
 Updates – what is important for us to talk about today?
BEFORE EXITING
 Know what will happen next, understand why
 Document – ask for name/ # for follow‐up
 Debrief ‐ Ask questions ‐ is there anything else I should know?

34. Disclosures
Funding
• The Ottawa Hospital IS/IT
• AHSC AFP Innovation Funds
• The Ottawa Hospital Department of Anesthesiology
• University of Ottawa PGME
No commercial ties or funding

37. Improve handover safety
Share information
Protect data security

40. Questions