A



|Safe Transitions for Every Patient |

|(STEP): It’s PRIMARY |

|Workshop for Residents in Care Transition Communication |

Instructor Guide

Authors

Michael Weisgerber MD, MS, Heather Toth MD, David Klehm MD, Geoffrey Lamb, MD, Linda Meurer MD, MPH

Senior Editors

Deborah Simpson PhD, Karen Marcdante MD, Jeff Morzinski PhD

Contributors

Paul Koch MD, Kristin Guilonard MD, Nancy Havas MD, Emily Densmore MD, Angie Zikos MD, Laura Currey MS, Staci, Young, PhD, Karen Nelson MD,

Michael Radzienda MD, Ankur Segon MD

Abstract

This submission contains the materials and instructor’s guide for the highly rated Safe Transitions for Every Patient (STEP) Resident Workshop. Care transitions are a key component of good patient care and poor communication is known to be a major contributor to patient harm. Few educational materials are available for use to train residents in this important skill. To address this gap, the STEP Collaborative, composed of faculty from family medicine, medicine and pediatrics, systematically designed a resident-focused workshop on care transitions using the following steps:

• identified resident level objectives focused on transitions to/from the medical home,

• created a mnemonic to facilitate care transitions,

• designed, delivered and evaluated an interactive workshop to provide training and practice focused on care transitions.

This one hour workshop is composed of an introductory presentation, an interactive discussion of critical incidents involving care transitions, and a spirited Jeopardy-like game to reinforce key elements of the standardized care transition process. This workshop packet contains the PRIMARY care transition mnemonic, a critical incident worksheet, a quiz for assessing learner knowledge, and a workshop evaluation form. By using these materials, users can create a fun and valuable interactive care transition training experience for their residents easily adaptable to other audiences.

Table of Contents

Abstract 2

Table of Contents 3

Background/Overview- Safe Transitions For Every Patient 4

Learner Audience 4

Session Objectives 5

What this Packet contains: 5

Learner Assessment 6

Quality of the Workshop 6

The PRIMARY Care Transition Tool 8

Detailed Schedule of the Safe Transitions For Every Patient Resident Workshop 9

Facilitator and Present Qualifications and Responsibilities 10

Advanced Preparation: Materials, Resources, and Facilities, Checklist 11

Appendices: Worksheets and Handouts 12

Critical Incident Worksheet 13

Pre-Post Quiz 14

Pre-Post Quiz Instructor’s Copy with Answers 16

Session Evaluation Form 18

PRIMARY Tool 20

Jeopardy Game 21

References 22

Background/Overview- Safe Transitions for Every Patient (STEP)

Lack of quality communication at the time of transition of patient care from one health care provider to another results in medical errors, patient dissatisfaction, and inefficiencies. The Joint Commission (TJC) 1 has identified that 70% of errors leading to significant patient harm arise from poor communication, often at the time of a transition in care. Despite this, there is little formal education on the best methods of communicating necessary information at the time of a care transition. A search of existing peer reviewed medical education repositories using the key words of transitions, handoffs, care transitions, patient safety and quality revealed fewer than 5 available resources in the general topic area. Existing curricula have focused almost entirely on handoffs within the hospital setting, or on discharge from the hospital from the hospitalists’ perspective.2-6 Transitions to and from the medical home including referrals to specialists, admissions to hospitals, and alternative care settings have not been addressed. There is a need for curricula that emphasize the effective transition of patients to and from the medical home, including the communication of necessary information, incorporate a standardized approach and encourage bidirectional dialogue between providers.

The STEP Collaborative is a group of Medical College of Wisconsin faculty in internal medicine, pediatrics, and family medicine participating in a three year faculty development program designed to train faculty to study and develop methods to effectively teach various learners to conduct safer and more effective care transitions. This submission and Instructor’s Guide includes elements adapted with permission from the Safe Transitions for Every Patient (STEP): It’s PRIMARY Medical Student Workshop Instructor’s Guide.7 The methods of creation and style of the student and resident care transition workshop are different and therefore have been submitted as separate workshops. The resident subgroup of the STEP Collaborative has developed a workshop for training residents to effectively define care transitions, recognize the key elements of care transitions, and perform care transitions using a standardized tool. The subject matter of the workshop came from a systematic process including 1) a review of the care transition literature, 2) needs assessment using surveys and structured interviews, 3) faculty development group synthesis of the results of #1 and #2 to develop a standardized tool for care transitions (the PRIMARY tool) and 4) workshop creation and piloting during monthly faculty development sessions. The workshop resulting from this process has been used successfully with residents in medicine, pediatrics, and family medicine here at the Medical College of Wisconsin. This Instructor’s Guide contains all the materials necessary for others to use the methods we have developed to train residents at their institutions to engage in systematic and safe care transitions.

Learner Audience

The session was designed for residents of all levels in General Internal Medicine, Family Medicine and Pediatrics.

The session would also be appropriate for residents in all specialties, and medical students involved in transitioning patients. It could also be used for CME purposes to improve skills in transitions/handoffs for attending physicians. All health care professionals (e.g. midlevel providers) who accept or receive patients from other providers may benefit from this workshop

Session Objectives

By the end of this session, each resident will learn a systematic approach to providing safe transitions for his/her patients through accomplishment of the following:

1) Define transitions in care and the roles patients and providers play in safe transitions.

2) Recognize the key elements of safe transitions

3) Describe the crucial role that effective transitions have on safe and high quality patient care as well as the effects of unsafe transitions.

4) Use a standardized communication tool (the PRIMARY mnemonic) to systematically prepare and convey a patient transition to a colleague.

What this Packet contains:

This 1-hour educational program was developed as an intervention to teach primary care residents how to effectively transition their patients to and from the medical home using a standardized tool for communication.

The materials for this program are listed in the table below.

|Item |Brief Description |

|Instructors’ guide |An all-inclusive guide to administer the session |

|Introduction Powerpoint Presentation |An introductory presentation, lasting approximately 10 minutes, that covers the significance of |

| |care transitions in the quality of care and the use of an original mnemonic “PRIMARY” to |

| |facilitate the communication of handoffs |

|Critical Incident Worksheet |A worksheet that is used for the interactive discussion of participants’ personal experiences |

| |with care transitions |

|PRIMARY Mnemonic Tool Summary |A one-page summary of the PRIMARY mnemonic describes and explains key communication components |

| |essential to safe transitions to/from the medical home. |

|Jeopardy-like Game |A “Jeopardy” type game, in PowerPoint format, to reinforce the concepts learned through the |

| |introduction, critical incident and PRIMARY mnemonic tool summary |

|Pre- and Post-Quiz |A brief (7 item) pre and post-quiz to reinforce concepts learned |

|Workshop evaluation form |An evaluation form to assess the session’s outcomes on residents’ reaction and learning |

Learner Assessment

The 7-item multiple choice quiz was developed to align with session objectives and written using case- based vignettes per NBME item format8. The items were reviewed first by two senior medical students, and then piloted by a group of 6 senior students unfamiliar with the curriculum. Based on the results and feedback, the items were revised to enhance examination quality.

Items were used as part of the curriculum with 35 family medicine residents immediately following instruction on care transitions.  Quiz statistics and item analyses were performed and overall the quiz had good psychometric results: Item standard quiz reliability (.79), mean item difficulty 0.81 and mean item discrimination 0 .35. After a detailed review of item analysis data selected item distracters were revised to enhance examination quality.  

The quiz was re-administered to 20 medicine and pediatrics residents and yielded a standard reliability of 0.93 and with a mean item difficulty of 0.66 and mean item discrimination of 0.47. Score range was 2-7.

Quality of the Workshop: Using Results for Continuous Improvement

Workshop #1: Family Practice Session

We first presented the workshop to 37 family practice residents of all levels of training. This residency has a standard evaluation form used for educational sessions. This group gave the session an overall mean rating of 5.16 (SD 1.14) [possible range 1-7 with 7 being the highest rating]. The content was given a mean rating of 5.32 (SD 1.23) and presenter rating was 5.32 (SD 1.25). Open ended comments revealed that some residents liked the jeopardy game, describing it as fun and interactive. Others gave feedback that the game needed improvements: noting it could have been run more effectively by explaining the rules clearly before the session, ensuring everyone could participate, and fixing the buzzer system. We learned that without a short time limit for giving an answer the game changed into a contest dependent on buzzer speed. Teams began to buzz in before they even knew the question and then took their time figuring out the answer. This frustrated other players. It was also noted some of the jeopardy questions were “poorly written” and “needed to get to the point.” The initial didactic lecture portion was criticized as “boring.”

Workshop Revisions

We then addressed these areas. The resident feedback confirmed the authors’ evaluation of areas needing improvements.

Jeopardy Game Improvements – The questions were revised or eliminated thereby decreasing the total number of questions resulting in a more concise and focused game with higher quality questions. Rules were clarified on the introductory slide for the game and highlighted by the facilitator prior to the beginning the jeopardy game. The timer was re-set on the buzzer for 5 seconds so that once a team buzzed in they needed to give their answer within 5 seconds or be marked as incorrect. To add more “competition” to the game, incorrect answers led to a loss of points similar to the game show rules.

Didactic lecture improvements – The lecture was reviewed and adapted to be more concise with added clinical examples and a better explanation of the PRIMARY mnemonic tool.

Subsequent Workshops: Internal Medicine and Pediatric Sessions

Nineteen first year internal medicine and eight pediatric residents completed the session. Evaluations were performed using the Session Evaluation Form (appendix). Results for the three sections of the evaluation are presented below.

|Section I Results: Baseline Resident Behavior- Mean |

|Scale: 1=strongly disagree, 2= disagree, 3=agree, 4= strongly agree) |

|Routinely initiate communication |Routinely initiate communication when|Failed to communicate important info |Use standard process for handoffs |

|with a physician I refer to |pt referred to me |during handoff | |

|Med |Peds |Med |Peds |Med |Peds |Med |Peds |

|2.9 |3.1 |2.9 |2.8 |2.4 |2.6 |2.8 |1.9 |

|Section II Results: Reaction to the Workshop - Mean |

|Scale:1= poor, 4= average, 7= excellent |

|Presenters Knowledge about the |Content was Highly relevant |Material clear and easy to follow |Program Enhanced Learning |

|Topic | | | |

|Med |Peds |Med |Peds |Med |Peds |Med |Peds |

|6.5 |5.3 |6.0 |5.6 |6.1 |3.4 |5.9 |4.5 |

|Section III Results: Post Session Resident Attitudes/Intended Behavior Change - Mean |

|Scale: 1=strongly disagree, 2= disagree, 3=agree, 4= strongly agree |

|Now feel more equipped to |Now intend to request input |Now intend to use standard |Can describe elements of a |Can apply the handoff mnemonic |

|elicit info during handoff |from Primary physician |process for handoff |handoff tool |tool to transition |

|Med |Peds |Med |Peds |Med |Peds |Med |Peds |Med |Peds |

|3.1 |3.1 |3.0 |3.1 |3.0 |3.3 |3.1 |3.4 |3.1 |3.3 |

|Can list consequences of poor |Communication between physicians at |Identify one or more thing that you can |Critical Incident enhanced learning|

|handoffs |the time of a handoff/care transition|do to enhance effective care transitions| |

| |is essential to pt care | | |

|Med |Peds |Med |Peds |Med |Peds |Med |Peds |

|3.2 |3.3 |3.3 |3.8 |3.2 |2.7 |3.2 |3.3 |

|Overall grade for this curriculum |

|High pass |Pass |

|87% |13% |

|What did you like the most? |What did you like the least? |

|The game/jeopardy |Lack of a final jeopardy question |

|Interactive |Buzzer malfunction/sound effects |

|Real examples |Double jeopardy role play |

The PRIMARY Care Transition Tool

This tool was developed by consensus methods of the STEP Collaborative using the most valuable elements found in other transition tools combined with two elements to reinforce the importance of two-way communication and receiver input. Primary was chosen as a mnemonic that contained these essential care transition elements, was memorable and reinforced the importance of the Primary Medical Home as a focus in the care transition. The Table below describes the elements included in the tool.

Safe Transitions for Every Patient (STEP): PRIMARY Care Transition Mnemonic

|PRIMARY |Explanation |How |Pearls |

|P=People |You/Patient/Person on phone |Identify caller, receiving provider and all patient ID |Establishes WHO is calling receiver |

| | |info | |

|R=Reason |What’s occurring with the patient and why the|Maximum of 1-2 sentence reason for transition and relevant|Gives CONTEXT for understanding |

| |transition is proposed |information | |

|I=Input/Inquire |Verify receiver knows and cares for patient |Ask how well receiver knows patient and what can add to |ENGAGES receiver and recognizes his/her |

| | |understanding of patient’s condition |EXPERTISE |

|M=Medical Course |Pertinent chronology |Include pertinent specifics of presentation, Dx & Tx. |THOROUGH yet CONCISE summary of patient’s |

| | |Answer questions |recent care |

|A=Assessment |Patient’s current status |Summarize active and resolved problems, immediate |Establishes CARE PRIORITIES |

| | |treatment plan, family and patient | |

| | |understanding/expectations | |

|R=Recommendations & Responsibilities |Explicit expectations of who will do |Explain next steps, what needs to be done in follow-up/ |“TAG, You’re It”; establishes accountability |

| |what/when |who will accept tasks | |

|Y=Your turn |Receiver’s further input and agreement with | Ensure shared understanding, agreement, and determine |ACTIVE LISTENING used |

| |plan |best means of further communication. | |

Detailed Schedule of the Safe Transitions for Every Patient Resident Workshop

The table below is a suggested timeline for pre-workshop preparation and the workshop itself.

|Time |Topic |Method/Who |

| Prior to |Prepare copies of handouts for each participant including: |Administrative assistant |

|session |Pre and post quizzes | |

| |Primary Mnemonic handout | |

| |Critical Incident worksheets | |

| |Evaluation forms | |

| |Obtain “prizes” for Jeopardy winners (Candy, books, etc) | |

| |Arrange for signaling system for Jeopardy game (buzzer system, noisemakers, etc) | |

|-10 min |Preparation: Immediately prior to session | |

| |Set up AV equipment for powerpoint presentation and Jeopardy game |Lecturer |

| |If using a buzzer system for jeopardy quiz set that up as well | |

| |Arrange room in format friendly to the number of teams (suggested 3-5 teams with |Jeopardy moderator |

| |a buzzer [or equivalent] at each table) | |

| | |All |

|5 min |Welcome and Pre-quiz |Lecturer |

| |Handout 7-item pre-quiz | |

| | | |

| |Collect after completion | |

|10 min |Powerpoint presentation – Safe Transitions for Every patient (STEP) |Lecturer |

| |Hand out PRIMARY mnemonic |Other facilitators |

|20 min |Critical Incident | |

| |Handout Critical Incident Worksheet: Individual work (5 minutes) |Critical Incident Facilitator |

| |Facilitate small group discussion of individual’s recording of a critical | |

| |incident that could have been improved by utilizing PRIMARY | |

|20 min |Jeopardy Game | |

| |Jeopardy Host describes format and rules |Jeopardy host |

| |Teams are set | |

| |Game begins | |

| |Score is kept by designated scorer |Jeopardy scorer |

| |One facilitator in charge of buzzer system or determining which team was first to|Jeopardy buzzer facilitator |

| |express desire to answer the question (can use buzzer, holding up signing, | |

| |banging table, etc.) | |

|5 min |Closing remarks |Lecturer |

| |Handout post-quiz and evaluation form | |

Facilitator and Presenter Qualifications and Responsibilities

o All facilitators and presenters (minimum of 3) must have an adequate background in clinical health care and be familiar with the literature on medical errors attributable to poor care transitions. Furthermore, all must be aware of the care transition concerns likely to face medical residents. Finally, all must be able to explain the reasons for the STEP curriculum and the elements of the PRIMARY mnemonic. At least one presenter should be an effective, experienced speaker with moderate to large-sized audiences of resident physicians.

o Facilitator(s) (one per six-to-eight learners) for the critical incidents component: should have clinical health care experience in transitions to or from the medical home (e.g., physician, nurse practitioner, etc). Facilitators should also have skills to engage a group of residents in discussion about their critical incidents. This includes skills to ask open-ended questions, seek input from the majority of the group, stay on time and on topic.

o Energetic game facilitator (one person): should have the ability to keep the audience engaged and participating in the Jeopardy style game.

o Scorer (one person): should have the ability to add and subtract Jeopardy game scores.

o Buzzer controller or observer of raised hands if no buzzer available (one person): should have the ability to watch which team has pressed the buzzer or raised their hand first, signaling the first team able to answer the Jeopardy game question.

Advanced Preparation: Materials, Resources, and Facilities, Checklist

o The checklist table below describes the required resources, facilities, materials in a checklist format to use as you prepare for the workshop.

o If you have administrative support, many of the tasks below can be delegated.

|Prior to Event |Tasks |( Complete |

|- 8 weeks |Reserve room/ facilities: | |

| |Room with tables set up for small groups of 8, PowerPoint projector and screen, flip chart or white | |

| |board for scoring, and Internet access for computer if possible. | |

| |Borrow (or purchase) Jeopardy like buzzers/game lights | |

|- 4-8 wks depending|Recruit facilitators and presenters | |

|on clinical |Send instructor guide | |

|schedules |Advise of room location, time | |

|-3-4 days |Practice Jeopardy | |

| |Set up computer with jeopardy game loaded/buzzer/timer system/ quiz to make sure it works | |

|- 1-2 days |Duplicate | |

| |Evaluation forms | |

| |Pre-post quiz | |

| |Handouts of PRIMARY mnemonic | |

| |Critical incident forms | |

|-1-2 days |Purchase and Bring Prizes (e.g. candy, books, bragging rights, cash) | |

|-1 day |Meet/Review Facilitator instruction | |

| |Review Objectives | |

| |Assign roles | |

| |Answer questions | |

|- 45 min |Set Up and Test | |

| |Jeopardy quiz hardware/software | |

| |Projector & laptop | |

| |Verify Handouts | |

| |Evaluation forms | |

| |Pre-post quiz | |

| |Handouts of PRIMARY pneumonic | |

| |Critical incident forms | |

|Appendices: |

|Worksheets & Handouts |

|Safe Transitions for Every Patient |

|(STEP): It’s PRIMARY |

|RESIDENT TRAINING MODULE |

1. Critical Incident Worksheet

2. Pre-Post Quiz

3. Evaluation Form

4. PRIMARY TOOL

|Safe Transitions for Every Patient [STEP] |

|Critical Incident |

DIRECTIONS: Identify a recent patient for whom a care transition occurred -- when a patient’s care was shifted from one provider to another. This could be any of an array of situations including:

• the patient “moved” from one setting of care to another (e.g., primary care clinic to a hospital, rehab unit, home care, hospice)

• the patient “stayed” and the providers changed (e.g.,. shift change)

If possible, please select a patient/care transition which evoked in you a strong emotional reaction (e.g., sense of accomplishment for a job well done, anger, frustration, annoyance, exasperation).

1. Briefly describe: (A) the patient (do not provide actual names or other identifying information); (B) the context/setting in which the care transition occurred; and (C) the process(es) and types of information exchanged during transition.

2. Describe the emotion(s) and what and why this situation evoked your emotional response.

3. How do you think the processes and types of information exchanged during the transition impacted the patient?

STEP: PRIMARY QUIZ

Please choose the single best answer:

1. Resident X is the outgoing resident on a general internal medicine team. He is signing out to resident Y who is the incoming resident. The patient is Andy Urisis, a 75 y/o male with past medical history of prosthetic (metallic) valve, atrial fibrillation and localized prostate cancer. Medications prior to admission include coumadin. Reason for this hospitalization is bilateral hydronephrosis secondary to obstruction from prostate cancer. Coumadin is held and bilateral nephrostomy tubes are placed with significant post-obstructive diuresis. Resident X communicates all the above information to resident Y as he addresses the patient's medical course.

To assure a safe hand off, what additional information must resident X convey to resident Y?

A. The levels of sarcosine (marker of aggressive prostatic cancer)

B. The patient’s next of kin who would serve as power of attorney if needed.

C. The reason the patient is not on digoxin

D. The plan for managing the patient's anticoagulation

E. The patient's family history of heart disease.

2. A 9 yo boy is referred by his PCP to the pediatric surgery clinic. The mother misplaced the referral slip that was given to her by the PCP. Mother states reason for visit is to follow-up after an ED visit for a “fender bender” where her son was found to have a grade I splenic laceration. You examine the patient and find mild left upper quadrant tenderness. You discharge the patient home with activity restrictions after staffing the patient with your surgery attending. You call the referring doctor and reiterate the plan. She states, “I know how to manage a grade I splenic laceration, but what about the incidental CT finding of the adrenal mass?

What action would have best prevented this disconnect in this patient’s care?

A. Entering the diagnosis of adrenal mass into the problem list in the electronic medical record.

B. Reinforcing to the mother how important the referral slip is and to make sure she had it.

C. Direct contact between the PCP and surgeon to determine the reason for the referral

D. Sending the CT scan report to the surgeon’s office, with “adrenal mass” highlighted.

E. Completion of a referral slip.

3. A student on your service calls a PCP regarding a discharge. The student begins, “Hi Dr. Jones, I am the M4 student and would like to notify you that your patient, Suzy Smart, will be discharged from the hospital today. Suzy Smart is a 4yo with moderate persistent asthma who was admitted to the PICU 3 days ago. Her asthma exacerbation was triggered by cigarette smoke exposure. She was initially intubated, given IV steroids, and continuous nebulizer treatments. She was extubated yesterday…”

As the supervising resident, what additional information would you encourage next in the medical history to concisely communicate a summary of the patient’s care?

A. Review of Systems

B. Current Medications

C. History of prior intubations.

D. Home treatment regimen.

E. Chest radiograph results.

4. Dan, a PGY1 resident, calls the PCP for an inpatient, a 70 year old male w/p AMI and CABG, being released to cardiac rehab today. The rehab facility has the full chart and a clear plan for rehab, with scheduled release to home and to his PCP’s care, in 2 weeks. Dan tells the PCP about the patient’s past medical history, social history, immunizations, habits, full physical exam on admission and discharge, current diet, all meds and complete hospital course, commenting on daily events throughout, nurses notes, daily labs, and full diagnostic reports. He completes the call by mentioning that the family was grateful for their loved one’s care, and by commenting that this was the first AMI patient he had managed and how exciting it was.

What basic principle was ignored in relaying the medical course?

A. Reason for transition

B. Thoroughness including pertinent labs and imaging

C. Having a clear diagnosis

D. Having a clear treatment plan

E. Providing a concise summary of the patient’s care

5. Between 1995-2006, the leading cause of “Sentinel Events,” (per JCAHO, unexpected occurrences involving death or serious injury in medical/hospital care) was:

A. Medication errors

B. Poor handoffs

C. Patient falls

D. Wrong site surgery

E. Equipment failure

6. According to medical literature, a discharge summary was available by the first post-discharge visit:

A. Less than 20% of the time

B. 25% of the time

C. About half of the time

D. 75% of the time

E. 90% of the time

7. A PGY3 resident Lucy, chief resident and most talented of all the residents in her program, calls the Family Physician upon discharge of inpatient Mickey, a 2 y/o male admitted for an asthma exacerbation. The patient’s condition became quite critical, requiring intubation and transfer to PICU. The resident explained the hospital course with great precision and actually did a fabulous job in managing the patient, doing all procedures and returning the patient to good health by discharge. Resident Lucy was concise in her summary, but tended to talk over the Family doc, preempting his questions and continuing with the oral report. She hung up from the call feeling quite proud of herself because she gave a seamless report that required no interruptions or questions from the primary care doc on the phone. His only comment was “thank you, have a good day” before he hung up.

What principle was forgotten in Lucy’s discussion with the PMD?

A. Reason for transition

B. Medical course

C. Input from receiver

D. Assessment

E. Follow-up plan

STEP: PRIMARY QUIZ INSTRUCTOR COPY WITH ANSWERS

Correct Answers are bolded below: 1. D, 2. C, 3. B, 4. E, 5. B, 6. A, 7. C

Please choose the single best answer:

1. Resident X is the outgoing resident on a general internal medicine team. He is signing out to resident Y who is the incoming resident. The patient is Andy Urisis, a 75 y/o male with past medical history of prosthetic (metallic) valve, atrial fibrillation and localized prostate cancer. Medications prior to admission include coumadin. Reason for this hospitalization is bilateral hydronephrosis secondary to obstruction from prostate cancer. Coumadin is held and bilateral nephrostomy tubes are placed with significant post-obstructive diuresis. Resident X communicates all the above information to resident Y as he addresses the patient's medical course.

To assure a safe hand off, what additional information must resident X convey to resident Y?

A. The levels of sarcosine (marker of aggressive prostatic cancer)

B. The patient’s next of kin who would serve as power of attorney if needed.

C. The reason the patient is not on digoxin

D. The plan for managing the patient's anticoagulation

E. The patient's family history of heart disease.

2. A 9 yo boy is referred by his PCP to the pediatric surgery clinic. The mother misplaced the referral slip that was given to her by the PCP. Mother states reason for visit is to follow-up after an ED visit for a “fender bender” where her son was found to have a grade I splenic laceration. You examine the patient and find mild left upper quadrant tenderness. You discharge the patient home with activity restrictions after staffing the patient with your surgery attending. You call the referring doctor and reiterate the plan. She states, “I know how to manage a grade I splenic laceration, but what about the incidental CT finding of the adrenal mass?

What action would have best prevented this disconnect in this patient’s care?

A. Entering the diagnosis of adrenal mass into the problem list in the electronic medical record.

B. Reinforcing to the mother how important the referral slip is and to make sure she had it.

C. Direct contact between the PCP and surgeon to determine the reason for the referral

D. Sending the CT scan report to the surgeon’s office, with “adrenal mass” highlighted.

E. Completion of a referral slip.

3. A student on your service calls a PCP regarding a discharge. The student begins, “Hi Dr. Jones, I am the M4 student and would like to notify you that your patient, Suzy Smart, will be discharged from the hospital today. Suzy Smart is a 4yo with moderate persistent asthma who was admitted to the PICU 3 days ago. Her asthma exacerbation was triggered by cigarette smoke exposure. She was initially intubated, given IV steroids, and continuous nebulizer treatments. She was extubated yesterday…”

As the supervising resident, what additional information would you encourage next in the medical history to concisely communicate a summary of the patient’s care?

A. Review of Systems

B. Current Medications

C. History of prior intubations.

D. Home treatment regimen.

E. Chest radiograph results.

4. Dan, a PGY1 resident, calls the PCP for an inpatient, a 70 year old male w/p AMI and CABG, being released to cardiac rehab today. The rehab facility has the full chart and a clear plan for rehab, with scheduled release to home and to his PCP’s care, in 2 weeks. Dan tells the PCP about the patient’s past medical history, social history, immunizations, habits, full physical exam on admission and discharge, current diet, all meds and complete hospital course, commenting on daily events throughout, nurses notes, daily labs, and full diagnostic reports. He completes the call by mentioning that the family was grateful for their loved one’s care, and by commenting that this was the first AMI patient he had managed and how exciting it was.

What basic principle was ignored in relaying the medical course?

A. Reason for transition

B. Thoroughness including pertinent labs and imaging

C. Having a clear diagnosis

D. Having a clear treatment plan

E. Providing a concise summary of the patient’s care

5. Between 1995-2006, the leading cause of “Sentinel Events,” (per JCAHO, unexpected occurrences involving death or serious injury in medical/hospital care) was:

A. Medication errors

B. Poor handoffs

C. Patient falls

D. Wrong site surgery

E. Equipment failure

6. According to medical literature, a discharge summary was available by the first post-discharge visit:

A. Less than 20% of the time

B. 25% of the time

C. About half of the time

D. 75% of the time

E. 90% of the time

7. A PGY3 resident Lucy, chief resident and most talented of all the residents in her program, calls the Family Physician upon discharge of inpatient Mickey, a 2 y/o male admitted for an asthma exacerbation. The patient’s condition became quite critical, requiring intubation and transfer to PICU. The resident explained the hospital course with great precision and actually did a fabulous job in managing the patient, doing all procedures and returning the patient to good health by discharge. Resident Lucy was concise in her summary, but tended to talk over the Family doc, preempting his questions and continuing with the oral report. She hung up from the call feeling quite proud of herself because she gave a seamless report that required no interruptions or questions from the primary care doc on the phone. His only comment was “thank you, have a good day” before he hung up.

What principle was forgotten in Lucy’s discussion with the PMD?

A. Reason for transition

B. Medical course

C. Input from receiver

D. Assessment

E. Follow-up plan

STEP Core Objective Evaluation Form

Please check your position:

Faculty Student Resident – PGY 1 2 3 (circle) – Program: ____________________

Section I:

Consider your patient care prior to today’s program & indicate your level of agreement:

|Statements |Strongly |Disagree |Agree |Strongly Agree |

| |Disagree | | | |

|I routinely initiate communication with a physician I refer a patient | | | | |

|to. | | | | |

|I routinely initiate communication when a physician refers a patient to | | | | |

|me | | | | |

|I have failed to communicate important information at a time of patient | | | | |

|handoff. | | | | |

|I use a standardized process for communicating all patient transitions/ | | | | |

|handoffs to/from the medical home with the clinician accountable for | | | | |

|follow-up. | | | | |

Section II: Reaction 9

Use this scale to answer questions about the Care Transitions & Jeopardy Game session

| | | | | | | |

|1 |2 |3 |4 |5 |6 |7 |

|Poor | | |Average | | |Excellent |

1 . Were presenters knowledgeable about the topic?............................ 1 2 3 4 5 6 7

2. Content was highly relevant to my [M3/resident] curriculum………1 2 3 4 5 6 7

3. Material presented in a clear and easy to follow manner……………1 2 3 4 5 6 7

4. The amount of information was just about right……………………1 2 3 4 5 6 7

5. The game (program component) enhanced learning………………. 1 2 3 4 5 6 7

What did you like most?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What did you like least?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What did you learn?

_________________________________________________________________________________

Was there something you hoped to learn but did not?

Section III

Now, after today’s Care Transitions and Jeopardy Game session, check the box that corresponds to your agreement with the following statements.

|Statements |Strongly |Disagree |Agree |Strongly Agree |

| |Disagree | | | |

|I feel more equipped to elicit information at the time of handoff or | | | | |

|transition of care | | | | |

|I intend to routinely request input from a patient’s Primary Care | | | | |

|Practitioner related to a care transition. | | | | |

|I intend to use a standardized process for communicating all patient | | | | |

|transitions/ handoffs to/from the medical home with the clinician | | | | |

|accountable for follow-up. | | | | |

|I can describe the elements of a handoff tool | | | | |

|I can apply the handoff mnemonic tool to transition a patient | | | | |

|I can list consequences of poor handoffs on patient care, health care | | | | |

|teams and public health. | | | | |

|Communication between physicians at the time of a handoff/ care | | | | |

|transition is essential to patient care | | | | |

|Identify ≥1 thing that you can do to enhance effective care transitions.| | | | |

|Critical Incident enhanced learning (helped to personalize the care | | | | |

|transition) | | | | |

|Overall Grade for this |Fail |Low Pass |Pass |High Pass |Honors |

|Curriculum: (circle one) | | | | | |

Other comments:

| |

| |

Thank you!

The PRIMARY Care Transition Tool

Safe Transitions for Every Patient (STEP): PRIMARY Care Transition Mnemonic

|PRIMARY |Explanation |How |Pearls |

|P=People |You/Patient/Person on phone |Identify caller, receiving provider and all patient ID |Establishes WHO is calling receiver |

| | |info | |

|R=Reason |What’s occurring with the patient and why the|Maximum of 1-2 sentence reason for transition and relevant|Gives CONTEXT for understanding |

| |transition is proposed |information | |

|I=Input/Inquire |Verify receiver knows and cares for patient |Ask how well receiver knows patient and what can add to |ENGAGES receiver and recognizes his/her |

| | |understanding of patient’s condition |EXPERTISE |

|M=Medical Course |Pertinent chronology |Include pertinent specifics of presentation, Dx & Tx. |THOROUGH yet CONCISE summary of patient’s |

| | |Answer questions |recent care |

|A=Assessment |Patient’s current status |Summarize active and resolved problems, immediate |Establishes CARE PRIORITIES |

| | |treatment plan, family and patient | |

| | |understanding/expectations | |

|R=Recommendations & Responsibilities |Explicit expectations of who will do |Explain next steps, what needs to be done in follow-up/ |“TAG, You’re It”; establishes accountability |

| |what/when |who will accept tasks | |

|Y=Your turn |Receiver’s further input and agreement with | Ensure shared understanding, agreement, and determine |ACTIVE LISTENING used |

| |plan |best means of further communication. | |

Jeopardy Game

We downloaded a PowerPoint jeopardy game template and added questions pertinent to the PRIMARY mnemonic and care transitions. We obtained permission to use the template and disseminate our version for care transitions from Elaine Fitzgerald (Teacher/Facilitator of Technology, St. Charles Parish Schools, Luling, LA,).

The actual PowerPoint slideshow is contained in the submission materials. Simply load the file on the computer you will using and run in the usual manner for a PowerPoint slideshow.

Rules of the game

1. There are 3 categories with 5 questions in each category. The questions are viewable in the attached PowerPoint file. The correct answers are listed in the Table below.

|Category 1 |Category 2 |Category 3 |

|Facts and figures |What am I |What went wrong |

|100 |100 |100 |

|What is a handoff? |What is person? |What is no input (I) or your turn (Y) part of|

| | |handoff? |

|200 |200 |200 |

|What is notification of discharge? |What is input (I) or your turn (Y)? |daily double |

| | |Role play Joe with recurrent bacterial |

| | |infections and pending immunodeficiency |

| | |workup |

|300 |300 |300 |

|What are sentinel events? |What is medical course (M)? |What is no responsible party (R)? |

|400 |400 |400 |

|What are primary car providers? |What is assessment (A)? |What is incomplete patient identification |

| | |(P)? |

|500 |500 |500 |

|daily double |What is responsible party (R)? |What is no reason for transition (R) |

|Role play 83 year old with uti and confusion | |explained? |

2. The facilitator (be sure to have a dedicated facilitator running the game) chooses a team to begin the game. The team then picks a category and dollar amount for the first question.

3. When a team chooses a category and point value click on the dollar amount and the question appears.

4. Begin reading the question and stop reading when a team buzzes in to guess the answer. (Be sure to have a dedicated buzzer operator managing the buzzer.) If you don’t have a buzzer consider having the teams hit the table or raise a flag to be recognized and have the dedicated buzzer operator decide who was first)

5. Once the team buzzes in we recommend having a 5 second time limit for giving the answer (Longer timeframes may lead to teams buzzing in and taking their time reading the question after signaling. This leads to everyone buzzing in immediately without reading the question.)

6. If the team does not answer correctly within 5 seconds they lose the dollar amount from their score. (Have a dedicated scorer keeping track)

7. If they answer correctly add the dollar amount to their score. The team that answers correctly has control of the board and chooses the next category and dollar amount until another team answers correctly. If a team buzzes in and answers incorrectly another team has a chance to buzz in and answer.

8. In the daily double question the team has to perform a role play of a care transition. They get to wager an amount up to $500 and to earn it their role play must successfully include all the correct elements of PRIMARY.

9. After all questions are completed the team with the highest amount wins. If you want to make up a final jeopardy scenario that is another option for ending the game. We did not do this because of time constraints but it could be fun.

References

1. Joint Commission Perspectives on Patient Safety 2007: 27(7)1-13

2. Vidyarthi AR, Baron RB. The Role of Graduate Medical Education (GME) in Improving Patient Safety (Agency for Healthcare Research and Quality – web M&M)

3. Project Red – Jack BW, Chetty VK. A Re-engineered Hospital Discharge Program to Decrease Re-hospitalization, Annals of Internal Medicine, Feb 3,2009, Vol. 150 no.3, 178-187.

4. Project Boost (University of Colorado): Seek to Improve Care Transitions, Medical Ethics Advisor, July 1,2009.

5. Monson SP. Physician Transitions Within the Medical Home: Applied Strategies to Safeguard Continuous Care, Family Medicine Digital Resources Library (FMDRL), modified 5/12/2009.

6. Atallah H. Interprofessional Team Training Scenario, Emory University School of Medicine, MedEdPORTAL ID# 1713.

7. Safe Transitions for Every Patient (STEP): It’s PRIMARY Medical Student Workshop

8. Case SM, Swanson DB. Constructing Written Quiz Questions for the Basic and Clinical Sciences. 3rd Edition. National Board of Medical Examiners. January 1998.

9. Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels (3rd Ed). San Francisco: Berrett Koehler. 2006

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