Accreditation Q-Tip: Information Transfer at Care Transitions

By Chandra Farrer and Jacqueline Follis

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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:

  1. Patient and provider
  2. Provider to provider
  3. Organization to Organization

Women’s College Hospital (WCH) demonstrates a commitment to optimizing communication in the ambulatory environment via our policies, procedures, forms, and standardized tools.

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. In recent years, WCH has undertaken a number of projects with extensive patient engagement including efforts to optimize the After Visit Summary (AVS) and access to myHealthRecord. Click here to collect the QTip.

“This tool is an integral part of keeping patients safe at home by providing comprehensive plain language instruction. I was a full partner at the table, and this is a testament that inclusion of Experience Advisors in safe patient-centred care is a WCH living value. Knowing that patient safety is a priority both within WCH and at home affirms for me that patient-centred care and safety is a priority and seamless commitment. – Vinceza, Experience Advisor since 2018 who provided valuable input on the After Visit Summary project

Information shared at care transitions should include a minimum of two patient identifiers, contact information for the most responsible healthcare provider, reason for transition, safety concerns, and patient goals. 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:

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

The following WCH tools, procedures, and processes support safe information transfer at transitions of care:

  1. Standard referral forms and pathways, with auditing to ensure communication has been sent and received
  2. Standardized documentation utilizing smart phrases in Epic or stamps in PS Suite (PSS)
  3. The use of Communication Safety Tools such as “I Have a Safety Concern”, SBAR , Teach Back
  4. Clinics and providers can pair verbal communication to patients or their care partners with written materials including educational handouts, the Epic After Visit Summary (AVS) or Ocean platform in PSS
  5. Utilization of Interpreter Services and providing patient materials in multiple languages promotes equitable access to information
  6. Quality and Safety Boards can be used to share safety concerns between health care disciplines and keep track of improvements to communication processes
  7. Experience Advisors provide valuable feedback and identify improvements opportunities to transfer of information processes, especially as the healthcare environment rapidly changes with technological advancements

For more information on Information at Care Transitions visit the Accreditation Intranet Hub at the Required Organizational Practice and the Information Transfer at Care Transitions Accreditation Blurb.