Provider Interventions & Strategies
The first step toward ensuring patient safety in a physician practice is creating an environment that supports teamwork and good communication. The information, strategies and tools presented in the Working as a Team Module, are designed to improve teamwork and communication attitudes, knowledge and skills for you and your fellow staff members.
An easily customizable outreach letter to other providers, caregivers and potential partners in efforts to improve care transitions will give you a head start on communicating effectively in your local community.
The IPRO Universal Transfer Tool is designed to provide a standardized method to communicate critical patient information during patient transition between health care provider settings. There are two versions of the tool available. The Emergency Department (ED) Universal Transfer Tool is used only when a patient is transferred to the emergency department and is currently being utilized with transitions for emergent cases transferred from the skilled nursing facility to the ED. The Full Version Universal Transfer Tool is to be utilized when a patient is being transferred between two health care settings non-emergently. This tool does not take the place of a verbal "hand-off" communication report from clinician to clinician. Both Universal Transfer Tools were created with input from a cross-setting representation of providers, including Emergency Department physicians and staff members.
The Physician Communication Needs Assessment is a tool used during an onsite visit to a physician office practice or over the telephone to gain information on the methods used to communicate with other health care providers.
The Transitional Care Partnership Survey is an interview tool used to assess an organization's communication and care coordination of patient information with its referral sources.
Discharge Planning Tools
IPRO's High Risk Patient Discharge Flyer #1 provides a series of checklists to determine a patient's risk level for hospital readmission and communicates that to hospital staff in advance of their discharge.
High Risk Patient Discharge Flyer #2 provides a reference list of important definitions and considerations for high risk patients being discharged, as well as a list of critical patient information to include as they transition to a new setting of care.
For information on HIPAA regulations specific to transitions of care, IPRO offers a summary document touching on these issues and offering links to complete HIPAA language on the topic.
IPRO offers a Partnership Assessment Tool that can be used by hospital staff to survey their referral sources to identify opportunities for improvement in patient information, communication and care coordination This will enable more clear communication between organizations and help to ensure the proper steps are being taken in the transition process.
Provider Monitoring Tools
IPRO's Progress Measurement Tracking Tool is a setting specific Excel-based document that was created to track and trend your organization's progress on improving:
- All cause 30 day Readmission Rates
- Medication Discrepancies
- Follow-up Physician Evaluation within 7 days of acute care/rehab discharge
The instructions document will walk you through how to enter data into the Tool.
Download the appropriate Progress Measurement Tracking Tool for your setting of care below:
Skilled Nursing Facility (SNF) Progress Measurement Tracking Tool
SNF Readmission Tracking Tool
Home Health Agency Progress Measurement Tracking Tool **Hospices and Dialysis Centers Can Also Use This Tool**
Rehab SNF Progress Measurement Tracking Tool
Hospital Progress Measurement Tracking Tool
Record Review Tools
The Institute for Healthcare Improvement's (IHI) STAAR Diagnostic Worksheet is a record review and patient interview tool that is used by hospitals to investigate their last five hospital readmissions to identify opportunities for improvement.
This series of record review tools will allow healthcare providers to monitor important aspects of the patient's care and note where system and process changes may be needed.
The Blank Record Review Tool is a template offering space to note what care a patient is receiving and what aspects of that care may need adjustment.
The Care Management Tracking Calendar Sample shows an example of how a patient's transitions of care can be charted over a daily calendar to best track primary care events that may trigger or prevent an avoidable acute care hospitalization.
The Calendar Template Instructions describes how best to use the calendar tool to enable rapid overview and observation of patterns and trends within both the individual care and in the case of multiple patients.
The Clinical Record Review for Congestive Heart Failure is formatted like the Blank Record Review, but with fields populated with prompts specific to heart failure patients.
The Nursing Home Transfer Clinical Audit Worksheet covers patients being unexpectedly readmitted to the hospital from a skilled nursing facility setting and tracks their condition and key points about their care prior to readmission.
The Quality Improvement Tool for Review of Acute Care Transfers is used to review transfers of residents to an acute care hospital. The questions on the Tool guide you through: What was going on when the resident was transferred? Would this transfer have been avoided? Consistent use of this tool will help your nursing home understand the reasons for acute care transfers of your residents and identify opportunities to prevent avoidable transfers. The tool is accompanied by an Instructional Guide.
Tools for Use with Patients and Caregivers
Teach-back is a simple mechanism by which a patient's understanding of a concept or topic may be assessed. This teach-back overview presents the basic structure of the process.
"Managing Your Congestive Heart Failure" is a comprehensive look at the important facts of heart failure for patients to understand.
A Personal Health Record is a tool for patients to use to better self-manage important health information, including health history, medical conditions, medications, allergies and recent hospital and doctor visits. The tool is available for customization with your organization's logo or other information in Microsoft Word and in ready-to-use in PDF format in Spanish.
Ask Me 3 is a program developed by the National Patient Safety Institute to prompt better patient communication with their physicians. A patient-focused article easily usable in office newsletters or other patient-targeted publications (or as a stand-alone piece), an office poster and a patient brochure handout are all useful tools to help patients remember to ask the three key questions promoted by this initiative.
Partnering in Self-Management Support: A Toolkit for Clinicians, an initiative of the Institute for Health Care Improvement (IHI), is intended to give busy primary care physician practices practical and tested tools that can be utilized to empower patients to better self-manage their chronic conditions and to improve health-related behaviors, clinical outcomes and patient satisfaction regarding care.