Information Transfer – ROP Compliance Medicine Accreditation 2016

Information relevant to the care of the client is communicated effectively during care transitions

Effective Communication Identified as a critical element in improving patient safety Accurate and timely exchange of information that minimizes misunderstanding Reduces the need for clients and families to repeat information.

Effective Communication Clients and families need information to prepare for and improve care transitions may include: written information or instructions Actions plans Goals Signs or symptoms of declining health status Contact information for the team

Major Tests for Compliance The information that is required to be shared at care transitions is defined and standardized for care transitions where clients experience a change in team membership or location: Admission Handover Transfer Discharge

Information Transfer @ Covenant Policy http://www.compassionnet.ca/Policies/vii-b-255.pdf All Covenant Health sites will ensure that they have mechanisms in place; Timely and accurate transfer of information at transition points Adherence to established mechanisms to transfer information and Safeguards are in place to protect the confidentiality of the information, and Only authorized individuals will have access to the information.

Clinical status criteria includes but is not limited to: • Patient label – demographics information • Diagnosis – why are they here; primary concern • Infection Prevention Control • Allergies • Current Assessment • Vital Signs – including pain status Falls Risk Assessment • Cognitive Status • Behavioral Issues • Goals of Care • Medication Reconciliation •Communication Barriers

Major Tests of Compliance Documentation tools and communication strategies are used to standardize information transfer at care transitions

Standardized Processes Communication SBAR (situation, background, assessment, recommendation) Tools checklists or forms Used to communicate clinical status that supports patient/resident safety during transition points

Admission Checklist Used by nursing staff to facilitate communication of pertinent admission information

Bedside Shift Report Used by nursing staff at changeover to improve communication

Transfer of Accountability Form used within hospital for transfer between units

Rapid Round Kardex And Medworxx Used to identify barriers to discharge and enhance communication within the interdisciplinary team

Kardex Used to facilitate communication of care needs prior to Nursing receiving patient into care

Major Tests of Compliance During Care transitions, clients and families are given information that they need to make decisions and support their own care

Information Transfer @ Covenant Nursing Perspective Admission Checklist White Boards for Communication with Patient and Families Kardex Discharge Checklist

Inter professional Discharge Checklist Tool used across team to facilitate discharge communication to patients And families

Short Stay Discharge Form Used by Physician's to facilitate communication with Family Physicians, clients and families

Major Tests of Compliance Information shared at care transitions is documented

Progress Notes Facilitates communication across the interdisciplinary team and handover

Minor Test of Compliance The effectiveness of communication is evaluated and improvements are made based on feedback received

Information transfer @ Covenant Audit tools (BSR, Path to Home) Asking clients, families and service providers if they received the information they needed Evaluation of Safety incidents related to information transfer (RLS)

Questions?