A Call for Leadership
She thinks problems with handoff have been ignored or invisible for a long time. Hospital leaders need to know what is at stake.
"If it is not recognized as a high-risk opportunity, it goes unaddressed," she says. "We are still working to educate leadership of the risks of hand-off communication"
One heralded approach to hand-offs is the I-PASS program. A 2013 pilot study at Boston Children's Hospital produced dramatic results. Medical errors declined from 33.8 per 100 admissions to 18.3 per 100 admissions after the I-PASS program was adopted.
Implementing the approach more broadly, however, may be difficult.
Across town, staff at the 1,000 bed-Massachusetts General Hospital more than 6,000 doctors, nurses and therapists have been trained to use the program. That was the easy part, according to a study on the first phase of their effort published in the journal BMJ Quality and Safety.
"I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows," the authors write.
McKee says that's not surprising; change is always difficult.
"That's the change management challenge," she said. "It has to be done artfully, strategically and in a way that it can be sustained."
Researchers at the University of Kentucky are part of a research project known as Project ACHIEVE, an acronym for "Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence."
In 2015, members of the project team traveled to 22 sites, including community hospitals and academic health systems, and talked to 810 people including management, transitional care teams, community partners, patients, and family caregivers.
They published some of their findings in the September edition of The Joint Commission Journal on Quality and Patient Safety.
Among those findings: In multiple hospitals, members of "leadership teams" reported that "making care transitions a strategic priority among the executive leadership team created an organizational culture focused on transitional care, which in turn improved the quality of transitional care services within the organization."
Tinker Ready is a contributing writer at HealthLeaders Media.