Care – Communication/Coordination

Inadequacies in communication and coordination of care issues can lead to dissatisfied patients/families and patient safety issues. These can include but are not restricted to unclear hand-off protocols, inadequate discharge/transition planning and inadequate case management protocols. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls / Mitigation Strategies

• Emergency Department (ED):
  • Standardized triage criteria
  • Physical space designed to maximize visibility and patient flow
  • Standardized care pathways and medical order sets/directives for common conditions
  • Reassessment process for patients waiting to be seen to monitor status change
  • Standardized follow-up process for patients who leave ED without being seen by a physician
  • Surge plan for patient flow and staffing resources 
  • Clinical indicators at triage regarding infection control (i.e. Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), Clostridioides difficile (C-diff)
• Laboratory/Critical Test Results (CTRs):
  • CTR protocol/policy
  • CTR flags in Electronic Medical Record (EMR)
  • Clinical policies and procedures in place for certain clinical indicators
  • Physician accountability for daily review of lab/late results 
  • Standardized process for follow-up of results reported after patient discharge, to discharging and primary care physicians
  • Communication of CTRs recorded in lab Information Technology (I.T.) internal systems
  • Documentation to show attempts made to share results
  • Decision trees constructed in lab for whom to phone if MRP cannot be reached
  • In acute care, call the unit and if patient already discharged, protocol in place to contact the Most Responsible Physician (MRP)
  • Patients contacted about CTRs requesting they return to ED. Document.
  • ED Physician accountable to review late arriving lab results daily
  • ED Nurse Practitioners/Physician Assistants participate in family call-backs on late-arriving lab results 
  • Escalation strategies to support timely notification of late arriving lab results
  • Standardized process in place to follow up on positive microbiology culture results post-ED discharge
  • Occurrence reporting for lack of compliance
  • Daily logs of pending results for tests and critical results printed daily (organizations with EMRs)
  • Standardized handover utilized (includes test review as part of patient summary)
  • Information to patient on normal results process
  • Rapid response by team members to the situation to offer correct treatment, investigation, etc.
  • Staff members provided with targets for reporting wait times for results
• Diagnostic Imaging:
  • Process to inform MRP for requisitions requiring to be redone; missing clinical information
  • Request for legible requisitions and/or further clinical information (radiologist to physician)
  • EMR print requisition with direct link to patient demographics and electronically ordered tests
  • Any concerns that are flagged are escalated to the appropriate physician, and have the mechanism to escalate to the Chief, if required
• Medication:
  • High risk medication(s) protocol/policy
  • Intensive Care Unit (ICU)/floor medication reconciliation at admission, discharge and transfer
  • Electronic allergy management system (admitted patients)
  • Role clarity regarding the collection of allergy information (nursing/pharmacy/dietary)
  • Only clinical staff enters allergies into the EMR
  • Coloured armbands for allergies
  • Staff training and mandatory refresher e-learning for allergy identification
  • Procedures for inquiring about allergies before giving medications
  • Individual feedback when errors are made; patient disclosure process if error reaches patient 
  • Use of pharmacist on multidisciplinary rounds to lower adverse drug events caused by prescribing errors
  • Assistance with development of protocols or guidelines by pharmacists for safe and appropriate sedation
  • Goal-directed sedation with clear sedation targets to reduce the duration of intubation/total ICU length of stay
  • Staff education on sedation scale
  • Direct inbox messaging from pharmacies/labs etc.
  • Pharmacy triages medication orders
  • Pharmacy carries out independent double checks
  • Medication Safety Committee
  • Education to patient/family regarding the side effects of medication and communication protocol to let staff know if experiencing a side effect
• Obstetrics:
  • Escalation of fetal status protocol/policy
  • Regular staff education/simulations/fetal surveillance
  • Daily multidisciplinary huddles 
  • Quality/risk huddles if infant cord gas <7 mmol/L
  • Education rounds with case study/review
  • Managing Obstetrical Risk Effectively (moreOB) program
  • Standardized response (algorithm) to atypical fetal heart rate
  • Monitoring equipment ‘flags’ nurses’ station
• Discharge/Transitions:
  • Comprehensive interdisciplinary discharge process/checklist
  • Process for early identification of patients at high risk 
  • Critical information transmitted to family physician 
  • Patients/families included in discharge planning process 
  • Plain language discharge instructions for patients/caregiver or Substitute Decision Makers (SDMs)
  • Utilizing Accreditation Canada’s Required Organizational Practice (ROP) guidelines to implement new tools, procedures and improve practice
  • Discharge/aftercare planning protocols 
  • Annual patient safety training required by staff and volunteers
  • High level education on patient safety for new hires
  • Clinical pathways for discharge
  • Use of HIROC resources related to discharge/transitions
  • Transfer of accountability at patient discharge to appropriate health care provider(s)
  • ED chart faxed to family physician following ED visit and/or MRP receives notification of patient’s ED visit via electronic health record
  • Nurse Practitioner/Bed Manager/Unit Manager attends bed rounds for continuity of patient information
  • Interdisciplinary rounds in the ED and on nursing unit. 
  • Daily bullet rounds in acute care and multiple times a week in post-acute care
  • Include physicians in patient bullet rounds
  • Improved electronic communication with physicians
  • Instill the teach-back method so patients can demonstrate they have an understanding of their care expectations
  • Discharge follow-up phone call program
  • Communication has been provided to clinical areas regarding the fact that volunteers may only assist with discharges when family members are present
  • Volunteers and volunteer management have been advised not to accept assignment of assisting with discharges when family members are not present
  • Utilize various mechanisms for timely and accurate transfer of information at transition points (e.g. forms and communication tools)
  • Perform caregiver to caregiver information transfer at the end and start of every shift
  • Utilize SBAR (Situation, Background, Assessment, Recommendation) which is a communication tool that helps structure the transfer of information
  • Consistent process for hand off between physicians and nursing
  • Shift change meetings with standardized format
  • Weekly staff meetings with staff signing off minutes
  • Comprehensive interdisciplinary transfer form and transfer of accountability
  • Service Provider Transfer Form developed based on patient needs and key information
  • Transfer of most responsible physician designation
    • Discharge to Long-Term Care/Home Care:
      • Service provider submits required information to ensure long term care facilities have most up to date information
      • Home and Community Care Coordinators on-site to facilitate discharge planning
      • Critical information transmitted to home care providers
      • Patients/families included in discharge planning process and identification of homecare needs
      • Nurse Practitioner/Bed Manager/Unit Manager facilitates earlier discharges from hospital to long-term care facilities to decrease length of stay/enhance continuity of care and communication between acute care and long-term care sector
      • Nurse Practitioner/supporting teams averting transfers from long-term care facilities to EDs (avoiding hospital visits and admissions)
      • Discharge support meeting held with families, homecare
• Clinics:
  • Referral criteria, refreshed, and updated annually
  • Clear guidelines for referral triage
  • Appointments booked depending on urgency of care and appointment details communicated timely to patient
  • If no clinic appointment available within triaged timeframe, contact referral source to review potential options with the MRP, clinic or new referral reassigned to another MRP to be booked within agreed upon timeframe
• Oncology/Chemotherapy:
  • Senior Research Nurse provides a clinical trial orientation for all new nurses/presentation for treatment room nurses
  • A first treatment/new trial study overview and review of chemotherapy orders is conducted with treatment room nurses
  • A binder with drug information for all clinical trials is housed in the treatment room
  • The Nurse Managers for the treatment room have completed all research training and appear on the delegation of responsibilities log for all trials
  • Email distribution lists are maintained on an ongoing basis to ensure current 
  • A communication strategy for prioritizing emails with respect to importance has been introduced
  • Completing weekly peer review
• EMR/Hybrid Chart/Documentation:
  • Clinical panels to assist clinicians to identify key clinical information (between EMR and paper record)
  • Staff education including documentation of training
  • Structured interprofessional meetings/rounds
  • Standardization of physician documentation regarding plan of care
  • Documentation policies and training
  • Built-in alerts in EMR to notify providers of concerns
  • Implementation of EMR in Clinical Genetics
• Patient/Family-Centered Care:
  • Family forum
  • Patient/family engagement on committees and/or review of specific initiatives
  • Patient Experience Community Advisory Council
  • Indigenous Patient Manager role
  • Client/Patient Safety Handbook distributed to all new Clients/Patients at start of service
  • The Client Rights and Responsibilities is reviewed with Clients/caregivers
  • The Client Rights and Responsibilities is reviewed by key staff and Client and Family Service Advisory Committee every two years
  • Home Safety Risk Assessment completed in Client’s homes upon home care admission and every six months
  • Access to language and translation services
  • Medical escort translator service available
• Administrative/Policies and Procedures:
  • Participating in Teamwork and Communication project with Canadian Patient Safety Institute (CPSI)
  • Ongoing pursuit of Accreditation Canada accreditation and various mandatory licensing
  • Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS)
  • Incident Reporting Framework policy
  • Standardized care plans with associated policy
  • Education for staff on standardized care plans
  • Standard format during critical incident process (i.e. email communication, patient letter, etc.)
  • Disclosure Guide
  • Coverage for providers during absence/on-call services 
  • Organizational newsletter (i.e. Quality newsletter)
  • Awareness campaign regarding importance of accurate patient information on requisitions
  • Risk Management/Patient Safety Specialist consultation
  • Recruitment practices considering communication (i.e. competency profiles, weighted interview to assess emotional intelligence)

Monitoring / Indicators

• General:
  • Occurrence reports related to communication and coordination
  • Quality reviews related to communication
  • Audits of key communication processes (e.g. medication administration, CTRs)
  • Morbidity and mortality review related to communication and coordination
  • Ongoing issues identified and monitored through staff and physician feedback
  • Number of grievances
  • Audit respite packages
  • Audit residential charts
• Clinics:
  • Clinic referral data/volumes/efficiencies
  • Corporate Scorecard indicator to drive wait times and improve access to clinics
  • Standard Referral Management audit system in place for every clinic 
  • Audit of occurrence reports/Neonatal occurrences with harm
• ED:
  • ED patient flow and wait time indicators
• Diagnostic Imaging:
  • Tracking all changes made to head and neck cases
  • Monitoring wait times, volumes and KPIs
• Medication:
  • Number of adverse drug events from receiving a medication patient was allergic to
  • Number of near misses reported
• Laboratory/CTRs:
  • Quality review to monitor and review compliance with the CTR policy
  • Occurrence reports completed when significant test results are not followed up
  • Test result monitoring
  • Monitoring lab and DI incidents
• Discharge/Transitions:
  • Monitoring physician discharge summary compliance
  • Unit rounding and daily status sheet
  • Daily safety call
  • Feedback from follow-up calls
  • Volunteers and volunteer management reports any assignments to assist in discharges when family members not present
• Patient/Family-Centered Care:
  • Patient satisfaction surveys; patient/family complaints related to communication/access
  • How many times language translation service is accessed per month
• EMR/Hybrid Chart/Documentation:
  • EMR staff and physician group meetings to discuss issues and recommend strategies (short and long-term)