In a major three-year initiative, The Joint Commission puts transitions of care under scrutiny
New measures, requirements tied to care transitions planned for 2014
The Joint Commission (TJC) is in the process of developing new tools, solutions, and performance measures aimed at improving the processes used to transition patients from one health care setting to another. Studies show that this is where errors, omissions, or misunderstandings often lead to adverse outcomes or readmissions, so improvements have the potential to boost outcomes and reduce costs and inefficiencies.
• While the initiative will impact all of TJC's accredited programs, experts say transitions between hospitals and other health care settings are the most problematic.
• Developers intend to produce best practices, educational offerings, targeted solutions tools, and other products designed to help accredited organizations improve their transition processes.
• Also, TJC hopes to have new standards and performance measures related to care transitions in place by mid 2014. All such changes will undergo field testing before they are implemented.
With health reforms clearly moving toward a system that links reimbursements to patient outcomes, care transitions — or what happens when patients transfer from one care setting to another — are under increasing scrutiny. Why? Because this is where communication breakdowns can lead patients or their caregivers to misunderstand instructions, and where the ball is most often dropped with respect to follow-up care or referrals.
Recognizing the need for improvements in this area, TJC is in the midst of a three-year initiative aimed at defining methods for making care transitions more effective while also developing new standards and performance measures so that surveyors for TJC's accreditation programs can hold hospitals and other care settings accountable for the way they manage this important aspect of patient care.
The initiative involves all three components of the accrediting agency, including TJC, Joint Commission Resources, and the Center for Transforming Healthcare, and administrators say that the resources and interventions developed as a result of this work will apply to all accredited organizations, ranging from hospitals and long-term care facilities to ambulatory care settings and behavioral health care organizations.
While ineffective transitions can occur between any of these health care settings, experts note that the most problematic transitions typically occur when patients are leaving the hospital to go home or to receive care in another setting. In these cases, errors, oversights, or miscommunications can lead to readmissions and adverse events.
Timing is right
"We are all very well aware that this is not a new issue in health care; this has been around for decades," stresses Sophie Duco, RN, an associate project director specialist in the Department of Standards and Survey Methods at TJC. However, she explains that with new health reform provisions unfolding, TJC leaders felt the timing was right to assist the organization's accredited organizations in making improvements to ensure safe patient care transition practices.
The multidisciplinary project is focused squarely on the movement of patients from one care setting to another rather than transitions that take place within an organization, say from one unit to another within a hospital setting, explains Duco. There are, in fact, already many standards covering internal patient transitions.
"The leadership here at TJC realized that although we have quite a few standards that address discharge planning, education for patients, and those types of things, what we had in place was very siloed within each of the programs," observes Kathy Clark, RN, who is also an associate project director specialist with the Department of Standards and Survey Methods at TJC. "The leaders felt we needed to look at that space in between, or that gap in between one provider and another or one health care organization and another, to see what we could do to provide for better safety for our patients."
New standards and survey processes are not the only goals of the initiative. The enterprise-wide effort also aims to develop best practices, educational offerings, targeted solutions tools, and other products designed to help accredited organizations improve their processes with respect to transitioning and transferring patients to the next care setting, whether that is home or another health care organization, explains Duco.
The project will impact every program that we have, stresses Clark. "It isn't just going to be hospital-based, it is going to affect all of our accreditation programs that are in different health care settings," she says.
Engage patients, families
While the project is still in its early stages, the research phase has already been completed, so project developers have some key insights on problems and processes that need work. "What was interesting is that the broad issues [impacting transitions] remain the same across all health care settings," explains Duco.
For example, problems often crop up during the medication reconciliation process, observes Duco. An effective medication reconciliation process should go well beyond establishing what medicines a patient has been taking, she says. Health care organizations also need to determine whether or not patients have the financial resources to obtain their medicines, and this ties into completing a comprehensive psycho-social transitional planning process. "It's about educating the family and providing support for the patient," adds Duco.
Another issue that surfaces across all health care settings is the need for leadership support when it comes to developing more robust transitional planning processes, says Duco. This pertains to both the allocation of needed resources as well as holding people accountable for their roles in the transitional planning process, she says.
In some cases, Duco notes that improvements may require members of the health care team to assume new roles or to apply their skills in a different way. Additionally, she says that leaders may need to re-prioritize responsibilities. "In a multidisciplinary approach, everyone needs to be involved, including the patient and their support person," she says.
Further, patient and family engagement needs to begin much earlier on in the care process, stresses Clark. "Make sure that they are part of the process, not just on the day of discharge, but all the way along in whatever setting they are in, and wherever it is they are going," she says. Health care providers should not just assume that patients have the support they need to manage once they return home, adds Clark.
Collaborate with community resources
Accountability can be a tricky issue in the ED because EDs are typically part of a larger organization, but ED personnel often feel separated from the hospital setting — perhaps because they don't necessarily receive resources or collaboration from the inpatient setting, explains Duco. She also stresses that collaboration with community resources is critical to successful transition processes.
While there is no one-size-fits-all model for transitional planning, Duco recalls visiting one large, urban center where all the physicians in the ED did their own discharge planning. "They knew who their community support contacts were, what primary care organizations they could work with in the area, and they had contacts they could utilize any time of the day or night to arrange follow-up appointments for ED patients," she explains.
In another community, a large physician group clinic in the area worked closely with the main hospital in town, several skilled nursing facilities, their home health agency, and all the community organizations to which a patient might transition as part of their care to develop better transitional processes, explains Clark.
It took several years to hone these processes, but one of the tweaks that has worked particularly well for the ED is what developers refer to as the one-call admissions process. The way it works is if a physician in the clinic needs to admit a patient, he or she can directly call a hospitalist or an admissions nurse to explain why they are sending the patient over, explains Clark. The process enables patients to bypass the ED, thereby freeing up resources for urgent and emergent cases. "By doing this direct admit process, they are cutting down on the time and the costs, and they are facilitating a better transition to the hospital for the patient," observes Clark.
Another tweak worked out in the same type of collaborative process enables many patients to receive quick follow-up care rather than face admission to the hospital. "In the beginning, the process was just for deep-vein-thrombosis (DVT) patients," explains Clark. Whenever an ED physician diagnosed a patient with DVT, he would call the patient's primary care physician (PCP) and explain that the patient could either be admitted or sent to the DVT clinic, which was within the physician group, as long as the patient was seen in the next two days, she says.
"By doing this, the providers were able to cut down on their admissions for DVT patients, but the approach was so successful that they have instituted a similar process for other types of patients that end up coming into the ED," says Clark. "If a physician can see the patient the same day or the next day, or if the patient can follow up with a referral to home care or whatever type of care the patient needs, then admissions can be avoided in some cases."
New standards, measures coming
People are coming up with these types of fixes in different settings and regions, but it is clear that such solutions come with a fair amount of complexity. "There isn't going to be one fix for everybody because there is too much involved," explains Clark. "If it was that easy, this would have been fixed a long time ago."
The next step for TJC is to develop new products and tools that can help accredited organizations devise transition solutions that work in their communities. At the same time, planners are beginning to think about standards and performance measures that can capture the transitions aspect of care and drive improvement.
"The goal is to have requirements that would go into effect in July of 2014, but that is not a firm date," explains Clark. "Everything we do with standards and requirements is always first vetted internally and externally through field reviews that would go to different health care providers and customers to get their input and feedback."
With the Centers for Medicare and Medicaid Services clamping down on readmissions, there is already heightened awareness of problematic transitions of care. This is prompting health care organizations to take a look at how they can make transitions safer for patients, stresses Duco.
"There are no quick fixes or easy solutions to this decades-old issue, so our work will continue," she says. "But we want to be very thoughtful, considerate, and deliberate in our approach so that whatever solutions we put out are the best we can offer."
Editor's note: See tools, articles, guides, and other information developed by TJC on its Transitions of Care Portal at http://www.jointcommission.org/toc.aspx.
- Kathy Clark, RN, Associate Project Director Specialist, Department of Standards and Survey Methods, The Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5000.
- Sophie Duco, RN, Associate Project Director Specialist, Department of Standards and Survey Methods, The Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5000.
The Joint Commission: Hospitals struggle to comply with these five standards
A number of familiar standards proved most challenging for hospitals in the first half of 2012, according to reports from The Joint Commission (TJC). At the top of the list, the accrediting agency notes that surveyors found a 61% non-compliance rate with RC.01.01.01, the standard that calls on hospitals to maintain complete and accurate medical records for each individual patient.
Maintaining accurate medical records can be particularly problematic when patients are boarded in the ED, but there can be other issues involved as well, specifically with respect to documentation. "If a patient comes to the ED from a nursing home, and he has an existing pressure sore, but the nurse is so busy that she neglects to document that pressure sore, then when the patient is ultimately admitted, the hospital will be financially responsible for the pressure sore," explains Jeannie Kelly, RN, BA, MHA, LHRM, an expert on risk management and quality assurance at Soyring Consulting in St. Petersburg, FL.
Confusion can also arise if a provider's orders for a patient are not clearly spelled out. "If the doctor writes 'admit,' but he is not more specific about the timing, ED staff may keep the patient in observation for another 24-48 hours when what the physician really wanted was for that individual to be an inpatient," explains Kelly. This type of incident, where the care delivered doesn't match the physician's orders, can leave you vulnerable to an audit by the Centers for Medicare and Medicaid Services (CMS), she adds.
To make improvements in this area, everyone in the ED needs to take responsibility, and leaders need to be vigilant about making accurate record-keeping a priority, says Kelly. She also advises EDs to conduct chart reviews on a routine basis so that any problems can be identified and addressed.
Keep hallways clear
Another standard that hospitals regularly struggle with is LS.02.01.20, the requirement that hospitals maintain the integrity of the means of egress. In the first half of 2012, TJC surveyors found a 52% non-compliance rate with this standard. Kelly explains that in a setting as busy as an ED, providers and staff are often in a hurry and under stress, so keeping the hallways clear may not be uppermost on their minds, but it is important to regulators.
"If gurneys, wheelchairs, linen carts, or computers-on-wheels are blocking access, then that is going to be an issue," she says. "If surveyors come in and see a gurney in the hallway for more than a half hour, then they are going to cite you."
Further, if patients are in the ED hallway, the hospital may also be cited for lack of patient privacy as well as patient safety because the patients don't have access to a call light, adds Kelly. This is another area where the entire ED staff need to be made aware of the standard and held accountable for keeping the hallways clear, she says.
Hospitals often fall short with respect to certain fire and safety requirements. In particular, TJC notes that there was a 47% non-compliance rate with respect to LS.02.01.10, a requirement that building and fire protection features be designed and maintained to minimize the effects of fire, smoke, and heat. Typically, ED staff run afoul of this provision when they prop open doors so that they can travel from place to place more quickly without impediments, explains Kelly. Fixing the problem requires staff awareness and continual reminders, she says.
This year, hospitals also had trouble complying with EC.02.03.05, a provision that requires hospitals to maintain fire safety equipment and fire safety building features. The accrediting agency reports there was a 40% non-compliance rate with this provision in the first half of 2012.
Emphasize personal responsibility
The fifth most commonly cited hospital provision by TJC surveyors this year was IC.02.02.01, a requirement that hospitals reduce the risk of infections associated with medical equipment, devices, and supplies. There was a 39% non-compliance rate associated with this provision, according to TJC.
Typically, problems with this provision relate to stethoscopes, glucometers, and other mobile devices that are used routinely in the ED, observes Kelly. Providers and staff need to remember to cleanse these devices after each and every use, she says. "It's everybody's responsibility to take care of this," adds Kelly.
• Jeannie Kelly, RN, MHA, LHRM, Health Care Consultant, Soyring Consulting, St. Petersburg, FL. Phone: 866-345-3887.