The Successful Physician: Transition of Care

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Video Transcript

CAROLE: Hello and welcome to today's webinar. Cathy?

CATHERINE: Thank you and welcome. My name is Catherine Miller. I'm a Risk Management and Patient Safety Specialist with the Cooperative of American Physicians (CAP). I have a long history in healthcare, as does Carole. I worked as an RN and then moved into healthcare administration and worked for a major health maintenance organization as a risk management and patient safety officer. I'm happy to be here today. We have an important topic to discuss, but first, Carole.

CAROLE: I'm Carole Lambert. I'm the Vice President for Practice Optimization here at the Cooperative of American Physicians and like Cathy, I have spent most of my career working on quality and compliance primarily with physicians. I think of my work as really micro, working with one physician or a small group of physicians at a time. And today we're going to talk about what I think of and what people say to me is an “abyss” into which patients, families, physicians, and in fact organizations fall, and that is “Transitions of Care”. And what Cathy and I would like to share with you today and perhaps prompt some thinking on your part is about behaviors, information, and tools that can help us bridge that abyss and promote patient safety and physician safety as well.

CATHERINE: Absolutely. Healthcare as we know is so fragmented and when we take a moment to dig down deeper and drill down into the adverse events that occur within the hospital and across settings, maybe in the post discharge environment, what we often learn is that there's been a communication failure.

It’s in eighty percent of Sentinel Events involving transitions in care that you will find communication breakdown. What I think needs to happen, and we'll discuss this along the way, is there needs to be first, awareness that we work in high-risk environments and that these things happen, and secondly we need to pay very close attention to the way we manage information so that patient or that provider has whatever they need to be successful in that next setting. So it's managing information, how we communicate amongst ourselves as healthcare professionals, and how we educate and communicate with the patient and their family. That will take care of a lot.

CAROLE: It will, it will indeed.

So let's start with some with our objectives today which is to define transition of care. It takes many forms. We use a number of ways of talking about transitions of care. Who are at-risk populations? What things jump to mind? And what things do we need to pay attention to that perhaps are not so obvious to us? And then there are essential categories of intervention and they are recommended by national organizations who have done considerable work in this area.

First of all, Dr. Naylor and her Associates at the University of Pennsylvania talk about transition of care as “a broad range of time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.”

So, that's a fairly comprehensive definition. AHRQ and the patient safety network define hand-offs again as a transition of responsibility and accountability for patient care.

Now here's the thing. Cathy and I both know people who work at large medical centers, and I have a colleague who confided to me that they have everything in place but people don't use what they have consistently. So hand-offs in that setting are perhaps not as smooth or as effective as we wish. And then signouts.

Again, from AHRQ, signouts refer to the act of transmitting information about a patient during a hand-off or transition of care. And there are enormously effective signouts where one practitioner knows firsthand from another practitioner about the patient they're receiving--the patient they're agreeing to cover. And then there are terrifically and unfortunately ineffective signouts where not enough information is provided and the receiving physician, as well as the person signing out, can find themselves in a heap of trouble with not having appropriate information to take care of the patient they're accepting.

Now I mentioned at-risk populations. Certainly the bulk of the literature reflects a study of the elderly in the transition from nursing home to hospital and back again. From home to hospital to nursing home. But the elderly are only one part of the problem.

The very young in a multicultural society. Here in Los Angeles there are more than 200 identifiable dialects or languages and you have a very young child being cared for by a member of the extended family. So the child cannot tell you what's wrong or what they need and the person providing the care the responsible person may in fact not be able to understand. And Cathy will address that in more detail.

The critically ill. A critically ill person alone in the hospital terrifically at risk and cognitively impaired.

CATHERINE: Twenty percent increase risk of readmission rate right there.

CAROLE: Well, and you and I both know that people will nod and smile to practitioners and agree without truly understanding what's being said to them. And a person with cognitive impairment is terrifically at risk for that.

And then of course low in health literacy. We're used to our vocabulary when we talk to each other and we talk to people like us all the time. The general public does not necessarily share our vocabulary, our lexicon.

CATHERINE: Wow very nice. Now I'd like to talk to you about why it's so hard. Why transitions are so difficult.

First, by introducing some survey statistics from the Agency for Health Research and Quality. They surveyed over a thousand hospitals and they administered a patient safety culture survey. And if you don't know about these surveys, they are hugely important to ferreting out or bringing to light the unexpressed concerns of staff when it comes to having the resources they need to do their job, having a culture that's supportive of patient safety, and other cultural dysfunction, such as a lack of reciprocal respect between departments or units. So there's an absence of teamwork.

So, as I said the AHRQ administered the survey and compiled the data and these are the results for the 2012 survey. They noted that “transitions in care” was the second lowest scoring area in the survey and more than fifty percent of staff agreed that there are definite problems where information is lost or there are huge communication failures. Here are some quotes, “Things ‘fall between the cracks’ when transferring patients from one unit to another.” Or, “Important patient care information is often lost during change of shift.” “Problems occur in the exchange of information across hospital units.” “Transitions in care are challenging and they are perilous for the patient.” Now why?

Well, the layperson is often shocked that errors could ever happen in a hospital where such competent people practice and interact. But we understand--those of us who have worked in the hospital understand that healthcare is not for the faint of heart and the atmosphere or the weather on any given day is what I like to call “Cloudy with a Chance of Chaos.”

You are in a meteor shower of activity. You are multi-tasking to the extreme, reflecting on the day in the life of a med-surg nurse. Patient in room one is getting blood. Patient in room two is spiking a temperature. Family's present. They have questions and concerns--you don't have the answers. Room three, you're prepping this patient for a procedure. Room four you have an elderly frail patient with cognitive-- or with dementia who's trying to get out of bed and is a fall risk.

CAROLE: And the doctors are looking for the lab results.

CATHY: There you go. So that is just a picture and what we do well in healthcare is we complete our to-do list. We are very successful at getting through our list of tasks for that day. Unfortunately, when we become so focused on our discrete tasks we lose the big picture and we often lose sight of the patient, and transitioning a patient is more like playing a game of hot potato than actually ensuring safe passage and working collaboratively with your colleague who is part of your team in radiology, right, to ensure that that person has everything they need to care for that patient in the next setting. We need to pay attention.

Then we also have variable communication styles amongst physicians and nurses. We are not thoroughly trained in how to communicate with each other. Patient factors can complicate things as Carol mentioned. You have patients of limited English proficiency. These patients are at a distinct disadvantage in the hospital, and they suffer more adverse events. They are readmitted in far greater percentages than the general population. Limited English proficiency and then limited health literacy.

One in three Medicare beneficiaries has low health literacy. That means they lack the basic skills to navigate through the healthcare maze and to understand what's being asked of them. There are strategies that we will discuss in a moment that can help you improve or compensate for a patient's low health literacy.

So I just want to make a few more comments about the importance of culture. Right. We Risk Managers in the hospital when we're doing a root cause analysis, we're always asking “why, why, why, why, why?” to get to the very root cause of whatever caused this catastrophic event. And invariably what we find is some sort of defect in culture.

Culture is considered the mother of all root causes in healthcare. Administering a survey annually to check in and to see what staff are saying about culture is absolutely huge because you can come up with the most elegant solutions and most beautifully drafted policies. But if people aren't working well together, and if they don't feel respected, and if they don't have the psychological safety to ask a question, we won't see any sustainable gains.

CAROLE: It won't be a safe place. If they won't ask a question, they don't feel safe.

CATHERINE: That's exactly it. A favorite quote of ours and sort of a healthcare universal truth. It's a quote from George Bernard Shaw who was a poet and playwright.

That is “the single greatest problem in communication is the illusion that it's taken place.” And this is an essential insight for anyone who works in healthcare. Because just because it’s said doesn't mean it's understood. Just because, as Carol said, your patient is smiling and nodding in agreement doesn't mean they understand. They might be thinking about going home. How exciting that will be. They want you to like them and they want to seem agreeable. They love their physicians right. Sort of enamored of them. Physicians and nurses.

And you know I was thinking about even our assumption that because we have an electronic health record that enables access anywhere at any time by anyone that we've overcome our communication challenges. Not in any respect. Think of what happened to Mr. Duncan at Texas Presbyterian Hospital during the Ebola epidemic. Okay, this gentleman presented to the ER with a fever and recent travel history to Liberia--the epicenter of the epidemic. And the triage nurse entered that information, “recent travel to Liberia” in the electronic health record and the physician never learned of it, discharged this poor unfortunate gentleman, and he came into contact with hundreds of people when he was out in the public and was readmitted and sadly expired later in his hospitalization.

But we always need to verify that we've been successful and that means getting out of the silo here. Right? And become critical in our communications when it's super important, when it's of critical importance, it's absolutely necessary to have a direct hand off. Right?

We had a wrong site Nephrectomy case related to a copy and paste error that perpetuated the false information across multiple settings. But the genesis of the error was a radiologist who realized he had indicated the wrong kidney on the report and created an addendum and it was present in the electronic health record, but there was no direct communication with the surgeon or the ordering physician about the mistake. So, when it's of critical importance, we need to be very direct and always verify the success of our communications. And there's another quote. We have medicalized so many things but transitions are not medical events and it's about the team working together. It's a person event.

CAROLE: Well you know, let me just, to touch on something from the Joint Commission as well: the Office of Quality Monitoring publishes statistics annuallyvand one page in particular caught my attention because of the durability over time of four elements.

So, this has to do with the sources of reportable events from 2011 to 2013. What was the top cause when they dug deep? Well it was human factors. The next three, leadership, communication, and assessment prevailed in all three years. They changed positions sometimes. Leadership was one sometimes, Communication was one, but those four elements which are so much within our control, really so much within our control, contribute so much to reportable events.

But let's take a look, and we were indebted to the National Transition of Care Coalition for their work on identifying seven essential categories in a care transition bundle and I'm going to spend a little time on these because it will sound to some of us like we are really going over old ground and the basics, but the basics tend to be what trip us up. Because we are so confident that we have covered them that in fact we have taken for granted things that are not happening. Cloudy with the chance of chaos and an illusion.

CATHERINE: But what you mentioned about the basics--I think that's the greatest irony in healthcare. It's something seemingly so small can result in something so catastrophic, right?

CAROLE: And then the durability of medical error, before I start let me just say, when you were talking about electronic records. I was at a meeting in Washington several weeks ago, and I walked into the meeting and they were talking about electronic records and three hours later we were still talking about electronic records, and algorithms, and checklists, and boxes, and drop downs. And all of that is fine, but if you don't have an individual entering precise, accurate, and timely information, there is not an algorithm that's going to save you.

So let's look at some essential categories of intervention in developing an effective care transition bundle. First of all, medication management. Patients retain about forty percent of what you've told them. They get out of the office. Out of the hospital. Out of the emergency room. “Am I supposed to take one three times a day or three once a day?” If it's very expensive, “Can I break it in half to make it last longer?” “If I take it every other day will that be as good? I hate taking pills.” And does the family does understand what we're trying to achieve with medication administration?

Also, families love alternative medicine. Everybody goes to the health food store. People buy herbs and supplements. And have we understood what people are likely to be given at home? St. John's wort and digitalis for example. Fresh grapefruit and a statin excellent. So you know things that can really absolutely undermine any therapeutic approach. So what's the plan? How well does everyone understand it? What kind of reinforcement is there? So, medication management.

CATHERINE: Can I add one question I learned along the way? It’s that you shouldn't ask a patient “Are you taking your medications?”

CAROLE: They'll say yes.

CATHERINE: You should ask them “how they're taking their medications,” right? And that speaks to your point about breaking pills in half, making the medicine stretch, or not understanding taking two twice daily, which is confusing to anyone right? But you knew I wouldn't let you talk.

CAROLE: How about transition planning? A clearly identified practitioner or team leader that is in charge of facilitating, and coordinating, and understanding. Cathy's talked about health literacy and the culture the patient and family’s context. The family is reluctant to give too much information. Is something not discussed? You know, do they not want the patient to lose hope so they don't want the patient to know too much.

So planning and having a formal tool. What's really interesting to me is the continued problem with giving someone a piece of paper that tells them what they need to know and do. And keeping a copy for the person sending the patient. And then sending a copy to the person receiving the patient. And that continues to be a challenge with electronic records with all of our sophistication.

So a plan, a document, a responsible person, and then a summary. And whether you use a complex or a simple formula, and I'll talk more about those in a few minutes, use something. Patient, and family engagement, and education, of the patient support staff. If the support staff network doesn't understand what we're trying to achieve, a lot of it's going to fall by the wayside. What does it mean? What do they have to watch for? What do they need to report on? And then how to make things go well. What are the steps you can take in your home? Moving the wastebasket that everyone trips over. Moving the kitchen chairs out of the flight path of the patient. Education, that knowledge, can support what we're trying to achieve with getting a person from one level of care to another.

Information transfer. Boy I mean to echo what Cathy said a few minutes ago. The illusion that we have actually shared information, right? That we know what we're talking about. And that the person that we're trying to help knows what we're talking about. Also practitioner to practitioner. If you're a primary care physician. Did you in fact receive a report back from the consultant? Did you ever see it?

CATHERINE: In many cases no.

CAROLE: In many cases no. So is there a formal way of cycling back and closing that communication loop?

Follow-up care, access, time, make an appointment, show up, understand the importance of the appointment. But how easy is it to make an appointment? As we discharge someone, as we move them from one level of care to another, even within the same organization from one building to another. How sure are we that they understand about showing up to your clinic and bringing their information with them? So follow-up care, access, timeliness, clarity, and the receiving staff understanding who the patient is and why they want to be in touch. Because, “Oh you can have an appointment in three months!” is not follow-up care.

CATHERINE: It's a golden window.

CAROLE: A golden window. So practitioner engagement, provider engagement, somebody has to care. Now that sounds so simple. Of course we care. But under production pressure, moving from one organization to another, signing out. So who's going to be engaged? Who's going to care enough to remember or to have a system for remembering? So really important, that open and timely communication.

And of course we always get to accountability. It ought to be possible among us as colleagues to say to one another, “Did we ever get?”, “Did we ever see?”, “Did we remember?” Without getting nuts and defensive and feeling bad or feeling like we're being attacked. Part of a successful transition is that we are confident in one another and in our work and that we are responsible for finding out and then being in touch to close the gap, to plug the leak, whatever it is. So we can improve transitions of care. Organizations have done it.

I have a wonderful picture that I love. It's a picture of a firing neuron because there's no substitute for thinking. There just isn't, and all your neurons have to be firing when you're working on achieving an effective transition of care.

CATHERINE: Mine do that after coffee.

CAROLE: FYI - Coffee to help your neurons fire.

Cathy managed to get us this still from a wonderful movie called Cool Hand Luke. And you'll see it in the deck of slides that we have for this program. And of course it is the warden of the work farm standing over Paul Newman's prone body saying, “What we've got here is a failure to communicate.” Classic right? So it is the ultimate expression of Shaw's comment that communication is illusory.

Let's talk briefly about tools, approaches, and behaviors. So Anne Arundel Medical Center down near Washington, D.C. came up with the SMART Discharge Protocol: “S” for symptoms, “M” for medication, “A” for appointments, “R” for results, and “T” for talk with me. You can go online and view the protocol and the associated tools. There's a journal, there's a logbook. A colleague of ours, in fact, is responsible for her mother's care and has a large loose-leaf with everything in it. So there's no mystery.

SBAR, Cathy you actually know the person who developed it? Yes, right.

CATHERINE: Yes, Doug Bonacum, Vice President of Safety at Kaiser. He was a Navy Submariner, an engineer, and when he transitioned into healthcare, one of the things that he recognized was just how disorganized our communication is. And, you know when you're in the military, he said there's communication protocols. You knock on the door “Permission to enter?” “Enter.” Right? And when you listen to physicians and nurses talking he realized that physicians have a very distinct style, bulleted, clipped the facts and nurses are more narrative.

Okay. And so to help healthcare workers and professionals structure their communications, he brought this into healthcare and it's called SBAR. It stands for “Situation, Background, Assessment, and Recommendations.” And it's a way of providing a brief summary to a colleague--to the physician to give them an update on the patient's current status. And what I love about it is it includes recommendations for the provider, where the nurse could say, “I would really like you to come to the unit and assess this patient. I'm concerned.” So there's that escalation component too that I really like.

CAROLE: And that also addresses the concern about being in a safe place, where the nurse is in a position and has the confidence in the environment to say, “I'm concerned, come and take a look.”

So AHRQ has developed team steps, a few more steps having to do with introducing ourselves and the patient information--that assessment which looms so large in the Joint Commission's evaluation of things. The situation, current status. Safety issues known and unknown. Fall risk is huge, absolutely huge. The patient's background, patient, and family history. There is that culture and literacy concern. Actions and procedures done or needing to be done. You know you send someone home without any note that there's a dressing to be changed and the family turns the patient over and discover this thing. What is it and what was it for?

CATHERINE: How often does this happen? That’s sad. That's when home health is dispatched.

CAROLE: So and timing, urgency. What is the urgency around this patient? How quickly do they need to come back? How quickly do you need to report on anything you observe?

Ownership of course. We've talked about taking responsibility. And then the treatment plan. Contingencies and expected changes are very important details, but it helps. It is absolutely a framework for making sure we've crossed all our T's and dotted all our I's.

Vidyarthi and colleagues out in the Pacific Northwest have come up with ANTIcipate. Administration data relayed accurately, new clinical information updated, tasks to be performed and clearly explained, illness severity communicated, and contingency plans for changes in clinical status outline.

So, I think that the message here is that barriers can be overcome when we talk about culture as Cathy has touched on. Another important thing to understand is how your hospital organization really works. Who's got the real authority? Okay, someone's got a title and someone's a go-to person--not necessarily the same person.

Standard processes, so we all are talking about the same thing.

CATHERINE: And what I'd like to see is when you're talking about improvement and standardized processes. It's really great in any improvement activity to involve front line staff. They are the true experts. They know where things are going wrong. They have come up with the simplest, most effective and sustainable solutions for any issue. Whether it's “let's improve our handoff between the O.R. and the med surg unit.” Right? Get staff involved, then they're part of the process. They tend to commit to it, right? Rather than if something's imposed from the outside.

CAROLE: And of course we haven't really hammered home “document, document, document.” First of all, appropriate documentation gives you bedrock to stand on. You can go back and refer to it and you refresh your memory and there it is on the page in the computer with the date, and the time, and the responsible person and boy does it give you a feeling of security when someone's in your face saying “Do you mean to tell me…” and we can say, “Yes, we mean to tell that. In fact, I did.”

CATHERINE: Carol I just want to take a few moments to talk about some tips for improving health literacy.

CAROLE: From a very interesting article written by Catherine Miller RN JD.

CATHERINE: Well I'm very surprised that you noted that. But thank you. Not interested in being self-promoting here. But the truth is it's a fascinating subject and I think that the onus is on us, as professionals, to understand that we not only have to be clinically competent, we have to work on our communication competencies. We have to become competent communicators. And that's the thing I don't think we really appreciate.

The Agency for Healthcare Research and Quality has some beautiful publications on the subject. They have a discharge tool that they have posted on their website that includes a lot of information on health literacy. These patients are more likely to suffer adverse events while they're in the hospital and they're more likely to be readmitted. We're working on reducing preventable re-admissions. Paying attention to health literacy is paramount.

So there are a few simple techniques to use. But the first thing we need to do is adopt an approach of universal health literacy precautions. Because health literacy is not something you can always discern. You might see someone who's nicely dressed, who is articulate, who can't read. Who is dysnumeric. Who you know you just don't want to make those assumptions and even the stress of a hospitalization can adversely impact how you receive and process information. So universal health literacy precautions because everybody benefits from plain spoken English and that's language that can be immediately understood. That's your heart condition versus your cardiac condition. Granted at some point your patient with diabetes will need to understand the benefits of having their hemoglobin A1C, but that lexicon will evolve, but initially keeping it simple. Please pass the salt, not the sodium, right? So plain spoken English for everyone.

I’m reminded of a case where a pediatrician was a patient and he was told that he had an elevated PSA. Now you would think a pediatrician of all people would have extraordinarily high health literacy but not in this context. It didn't occur to him what that acronym meant and there was a delay in diagnosing cancer. So we cannot make assumptions. So plain spoken English.

Avoiding information overload. You remember when we implemented the electronic health record. We're at a hospital where I worked. We were jubilant because we could print out all kinds of patient education, but patients don't need six pages on the pathophysiology of heart failure. What they need: They need to know what they need to do. Why they need to do it. And what will happen if they don't and that's called the “Teach Me Three.” “What do I need to do?” “Mrs. Smith you need to take this Lasix. It's your water pill. If you don't take it this will…” You know just unpacking that concept. Just the minimum necessary so as not to confuse and also providing that patient with something nice that they can take with them, a nicely prepared discharge summary with lots of white space, bulleting over narrative, with a list of pending tests or follow-up information right there. Something that's easy to refer to.

When we're covering medication non-adherence, here's a tip that I shared with you earlier. Asking patients how they're taking the medication, right? But you can learn a lot and if it's going to go wrong it invariably involves medications in the post discharge. It's almost always in the post discharge environment.

It's also really important to evaluate and simplify your written materials. While the average American adult reads at the eighth or ninth grade reading level, twenty percent of the population reads at the fifth grade level. And also we have patients who are illiterate and in those cases the use of iconography can help, right? Right. So we have to get creative and that’s something that definitely needs to be addressed.

Moving into discharge. When Carol mentioned the chasms, transitions that are like chasms. I think of discharge as like the Grand Canyon. I do. That's the mental image I have and back in the day when I was on the on the floor, we spent an average of eight minutes discharging a patient and discharge began on the day of discharge. That's when we started thinking about everything we needed to assemble to get this patient out the door, and we weren't thinking about the post-discharge environment.

I read a great article from The Journal of American Heart Association that was so brilliant. Because we know that twenty-five percent of Medicare beneficiaries are readmitted within 30 days, right? And these are those re-admissions actually are preventable. So we're spending a lot of money. We are inconveniencing and imperiling the patient with another hospitalization. We want to do our best to help them be successful in that next setting which is usually home, often home, and this article made this beautiful comment. It said, “Really, heart failure readmission is an event that occurs in the post discharge environment.” That might seem self-evident but that's where we have to shift our focus and they said, we know some things about readmission risk--we had your list of the elderly the cognitively impaired absolutely.

We also know that ten percent of the Medicare population accounts for fifty percent of the re-admissions and those ten percent are patients with 10 or more comorbidities. So we know the burden of disease, right, and those are the folks who are easy to spot. But the other determinant in this article that they identified was this concept of social instability, right? And that makes perfect sense. Does this patient have the support, have the economic stability, have the access to care, a safe environment, caregivers they need to be successful? Are they able to self-care? Right? To what degree? So, the more we look at the post-discharge environment, the better. And it's not that we can change the socio-economic conditions that make these populations vulnerable.

But we can identify resources. Make sure that the discharge process, or the point of discharge, is a well-coordinated event with a caregiver or a friend--someone there who can advocate on behalf of that patient. It takes a village. It takes an entire community to keep these people healthy and out of the hospital.

Some of the things that they should start. I also include this, because this is what we're currently doing, not because we're not well intended, but this is what's currently happening with our discharge process:

· Twenty percent of patients experience an adverse event post-discharge

· Forty percent are discharged with test results pending and no clear accountability for follow-up

· Fifteen percent of patients have a medications discrepancy at the point of discharge

We're discharging them without the information they need to govern their own health, with un-reconciled medications, with insufficient instruction, with tests pending, and no follow-up appointments.

Even from that position, we can do a lot and the really successful programs have done the following. There's been some clear early success in doing this. Starting discharge on the day of admission. That's when you really assess that patient and you identify their supports and you start thinking about how they're going to be successful in the next setting. Asking the patient the question, “What are your concerns if any about going home?” You'll get a lot of information.. And then helping coordinate care for that patient by scheduling the follow-up appointment with the PCP or the specialist before they leave the hospital, right? Getting their medications in order. Identifying the social supports that are there for that patient. Dispatching home health or a traditionalist right to help bridge that gap.

CAROLE: And if I can just interrupt for a second. This is where the input from all staff, from everyone who touches the patient is so important, because we all know the patients behave differently with the physician than they behave with other staff. And then the professional staff is not always with the patients. Sometimes the housekeeping staff is in the room or the dietary staff and patients will say things or that those people will observe things that can really contribute to our comprehensive picture of the social determinants of the patient situation.

CATHERINE: Absolutely. That's why a discharge team should be a multidisciplinary team and involve the CNA, the RN, right? And then okay, so what if your patient ends up being readmitted? Well one of the things that I think is really lovely and a really great tool for understanding the cause of readmission is this IHI questionnaire and it's on their website. It's a chart to review patients who were readmitted and really I think that warrants a mini root cause analysis.

Asking “why?” Asking “were you able to schedule or keep your follow-up appointment?” “Was there a clear discharge plan documented?” “Was evidence of teach-back documented?” Remember teach-back is that tool where you ask the patient to repeat in their own words the information that you've shared. You can cover a lot of, you know, misunderstanding that way. But using a tool like this to dig down deeper and to uncover the causes of readmission is a huge benefit to structuring your new discharge.

CAROLE: Well if you don't do it you're going to have another readmission. You fix the problem. If you send the problem out and then the problem will be back on your doorstep.

CATHERINE: So I think that's covered most of it.

CAROLE: Okay for discharge. Okay I think what Cathy and I have been eager to share with you and to prompt your thinking and your evaluation of your situation is transitions of care and how much they matter. How they can be improved. These are not insoluble problems and they don't have to have complex solutions. But they do need thinking. They do need planning. They do need understanding. They do need the assembly as Joe Grenier and his folks talk about in crucial conversations. They need the assembling of all the relevant information so the best decisions can be made.

And we spoke before about understanding how your organization really works. Whether it's a moderate practice or a very complex medical institution. Using standardized processes and having a plan. Training and modeling. You know it's so tempting to say to staff, “You don't really need to attend that class, you just attended class. This is just a way of getting an hour away from work.” No, the ongoing training education modeling of behaviors and sharing of information because the dynamics of care change all the time. The dynamics of organizations and of teams.

And measuring. You know we've talked more and more about managing metrics and we feel sometimes very beaten up by the need to measure and report. Metric fatigue. The metrics help us both guide improvement and justify our demand for more help or clarify why we think we're doing well.

So managing to metrics is a good thing and Cathy's talked and shared with us important ideas about the social determinants and cultural competence. But we come in the end to accountability and to documentation. To the concrete sharing of information and the willingness to say “I'll do it.” “Here's how I'll do it.” “Here's how I'll let you know.” Or, “Here's how we will know.” “Here's how we will know we've accomplished it.”

I want to close with a quote from Dr. Michael Leonard. Dr. Leonard was for many years the National Patient Safety Officer for Kaiser and he gave a wonderful presentation at one point which is really the topic for another whole webinar called The Normalization of Deviance and the Danger to Patient Safety. But Dr. Leonard said, “Never assume, assure.” And when it comes to transitions of care and marshaling information and changing behavior and providing tools, never assume. Don't submit to the illusion. Never assume, but assure. Thank you again for being with us today. Cathy?

CATHERINE: Thank you. Wonderful. Great.

CAROLE: Thank you so much.