Accreditation 2023 - Communication

Information Transfers at Care Transition by Kelly Malley and Discharge Planners Group

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Accreditation Canada has identified “Information Transfer at Care Transitions” as a required organizational practice, outlining how, what, and when information regarding a patient and their care is communicated between:

• Patient and provider

• Provider to provider

• Organization to Organization

Effective communication is the foundation for safe patient care and requires a timely and accurate exchange of information. Relevant transfer of care information depends on the nature of the care transition but always includes the patient or their care partner to ensure accuracy. This reduces the need for clients and families to repeat information and ensures they have the proper information to prepare for and improve care transitions. Click here to collect the Q-Tip.

Information shared at care transitions includes the following:

1. A minimum of two patient identifiers,
2. Contact information for the most responsible healthcare provider,
3. Reason for transition,
4. Safety concerns,
5. Patient goals,
6. Other relevant information may include allergies, medications, diagnoses; test results, procedures completed, and advanced directives.

To better understand how this safety practice applies to your work environment, consider the following questions:

• How do I receive information from patients and other providers?
• How do I share information with patients and their essential care partners?
• How do I share information with other providers in the circle of care both internally and externally?
• How do I escalate a safety concern regarding patients?

PRH demonstrates a commitment to optimizing communication via our policies, procedures, forms, and standardized tools and the following support strategies support safe information transfer at transitions of care:

• Standard referral forms and pathways, with auditing to ensure communication has been sent and received.
• Standardized documentation and communication tools: SBAR, checklists, discharge teaching materials, patient room whiteboards and follow-up instructions.
• The use of strategies such as “I Have a Safety Concern” and Read-Back/Teach-Back methods.
• Providers can pair verbal communication to patients or their care partners with written materials including educational handouts, and discharge checklists and GAP tools.
• Utilization of Interpreter Services and providing patient materials in multiple languages (when available) promotes equitable access to information.
• Community partners (Long Term Care Residences, Home and Community Care, Retirement Residences, behavioural supports) regularly attend family meetings and participate in a Transitional Care Working group along with our discharge planners.
• Patients can request their Hospital Record through our Release of Information Office
• LEAN Boards can be used to share safety concerns between health care disciplines and keep track of improvements to communication processes.
• Patient Advisors provide valuable feedback and identify improvements opportunities to transfer of information processes.

More information on Information at Care Transitions can be found in the policy and procedure manual by searching “Communication” and/or “Transition” and/or “Discharge” to find applicable policy documents.