Presentation
Designing for Better Inter-Departmental Patient Transfers: Process Map of Permanent Transfer Activities Between the Emergency Department and Inpatient Medical Units
DescriptionTransfer of Accountability and Information (TOAI) refers to the effective communication of relevant patient information. This includes conveying information in a timely and accurate manner between healthcare workers during transitions of care to ensure continuity of patient-centred care, as well as patient safety. As part of the University Health Network’s (UHN’s) work to standardize patient transfers, the TOAI Steering Committee sought to understand the current state of the permanent transfer process completed by nurses in the emergency department (ED). Permanent transfers refer to when a patient is permanently moved from one clinical area to another or from one individual’s care to another; in this case, when a patient is admitted from the emergency department to an inpatient (IP) unit.
To understand the current state of permanent transfers from the ED to an IP unit and the factors contributing to the success or hindrance of this process, Healthcare Human Factors (HHF) conducted ethnographic research in one of UHN’s emergency departments. Prior to going onsite, HHF employees met with a member of the patient safety team to learn about the current processes and standards nurses use to transfer patients out of the ED. This preliminary work allowed HHF to focus on key areas during the observation and interview process such as the use of technology, teamwork, and the environment.
In-context observations and semi-structured interviews were conducted by two HHF employees within the ED over 5 days to develop an understanding and to document general processes associated with permanent transfers. Deviations from the expected workflow, factors associated with successful permanent transfer, and any pain-points or points of frustration were recorded for future analysis. Within the 5-day observation, 13 Nurses and one Patient Support Worker (PSW) were interviewed.
Findings from observations and interviews related to the permanent transfer process were coded by two independent human factors analysts and categorized into high-level themes and sub-themes. The main themes that were derived from the research centred around the ED environment, the use of technology such as an electronic medical record system, and teamwork. Associated processes, deviations, success measures, opportunities for improvement, and recommendations were derived for each finding.
To better understand the permanent transfer process, the HHF team used process mapping to visualize who and what was involved in a successful transfer. In collaboration with a human factors designer, an initial process map was developed based on discussions with members of the TOAI Steering Committee and an examination of existing UHN documentation describing permanent transfer policies and patient flow throughout the hospital. The initial map was organized by activities completed by the patient, activities completed by ED team members (such as nurses, managers, and coordinators within the ED), and activities completed outside the ED.
Observation and interview findings about the expected permanent transfer process, along with known or anticipated deviations, were integrated into a second iteration of the process map. The second iteration focused on highlighting the collaboration and actions performed by multi-disciplinary team members throughout the patient transfer process. It also identified technology and policies that have the potential to impact the permanent transfer process.
The HHF team conducted multiple working sessions to further refine the process map, resulting in two versions: one base map showing the current state of permanent transfer, and one annotated map intended to illuminate success measures and barriers or opportunities for improvement.
Recommendations were provided at both an individual/team and organizational level for the UHN hospital in which the observations occurred, as well as for the examination of other transfer types within the same hospital and across different UHN clinical locations. This was to create a holistic set of conditions that would make it easier for clinical teams to effectively capture and share key information about patients when transferring from one clinical location to another or from one provider’s care to another’s. These findings were presented to the TOAI Steering Committee, who would then independently review and determine which recommendations to implement.
Key Takeaways:
• Patient transfers are key areas in which there is a greater potential for miscommunication or information loss which may negatively impact patient safety. To combat this, all transfer processes – not just permanent transfers – must be carefully examined to ensure quality patient care.
• It is necessary to examine the content included in the patient transfer, the process by which the transfer is completed, and the role of the patient during the transfer process to ensure patient safety.
• Using a Human Factors approach to identify key areas of success and opportunities for improvement ensures that the needs of all end-users are considered and met.
• Consideration should be given to how information is presented to key stakeholders. The use of a process map allows stakeholders at various levels within the hospital, from front-line workers to upper-level management, to understand how permanent transfers take place and where in the process influential factors occur.
• Providing visualizations and clear recommendations allow stakeholders to translate end-user feedback into actionable items.
• Preliminary research into time-sensitive environments is important to identify key areas of interest for future investigation to ensure conversations with staff are successful and respectful of their time and space constraints, and to avoid disruption to patient care.
• Buy-in from key stakeholders, such as ED management and front-line staff, is key to gathering information; ensuring anonymity so staff can freely voice their feedback without fear of retaliation is helpful for gathering accurate data into the current state of activities.
To understand the current state of permanent transfers from the ED to an IP unit and the factors contributing to the success or hindrance of this process, Healthcare Human Factors (HHF) conducted ethnographic research in one of UHN’s emergency departments. Prior to going onsite, HHF employees met with a member of the patient safety team to learn about the current processes and standards nurses use to transfer patients out of the ED. This preliminary work allowed HHF to focus on key areas during the observation and interview process such as the use of technology, teamwork, and the environment.
In-context observations and semi-structured interviews were conducted by two HHF employees within the ED over 5 days to develop an understanding and to document general processes associated with permanent transfers. Deviations from the expected workflow, factors associated with successful permanent transfer, and any pain-points or points of frustration were recorded for future analysis. Within the 5-day observation, 13 Nurses and one Patient Support Worker (PSW) were interviewed.
Findings from observations and interviews related to the permanent transfer process were coded by two independent human factors analysts and categorized into high-level themes and sub-themes. The main themes that were derived from the research centred around the ED environment, the use of technology such as an electronic medical record system, and teamwork. Associated processes, deviations, success measures, opportunities for improvement, and recommendations were derived for each finding.
To better understand the permanent transfer process, the HHF team used process mapping to visualize who and what was involved in a successful transfer. In collaboration with a human factors designer, an initial process map was developed based on discussions with members of the TOAI Steering Committee and an examination of existing UHN documentation describing permanent transfer policies and patient flow throughout the hospital. The initial map was organized by activities completed by the patient, activities completed by ED team members (such as nurses, managers, and coordinators within the ED), and activities completed outside the ED.
Observation and interview findings about the expected permanent transfer process, along with known or anticipated deviations, were integrated into a second iteration of the process map. The second iteration focused on highlighting the collaboration and actions performed by multi-disciplinary team members throughout the patient transfer process. It also identified technology and policies that have the potential to impact the permanent transfer process.
The HHF team conducted multiple working sessions to further refine the process map, resulting in two versions: one base map showing the current state of permanent transfer, and one annotated map intended to illuminate success measures and barriers or opportunities for improvement.
Recommendations were provided at both an individual/team and organizational level for the UHN hospital in which the observations occurred, as well as for the examination of other transfer types within the same hospital and across different UHN clinical locations. This was to create a holistic set of conditions that would make it easier for clinical teams to effectively capture and share key information about patients when transferring from one clinical location to another or from one provider’s care to another’s. These findings were presented to the TOAI Steering Committee, who would then independently review and determine which recommendations to implement.
Key Takeaways:
• Patient transfers are key areas in which there is a greater potential for miscommunication or information loss which may negatively impact patient safety. To combat this, all transfer processes – not just permanent transfers – must be carefully examined to ensure quality patient care.
• It is necessary to examine the content included in the patient transfer, the process by which the transfer is completed, and the role of the patient during the transfer process to ensure patient safety.
• Using a Human Factors approach to identify key areas of success and opportunities for improvement ensures that the needs of all end-users are considered and met.
• Consideration should be given to how information is presented to key stakeholders. The use of a process map allows stakeholders at various levels within the hospital, from front-line workers to upper-level management, to understand how permanent transfers take place and where in the process influential factors occur.
• Providing visualizations and clear recommendations allow stakeholders to translate end-user feedback into actionable items.
• Preliminary research into time-sensitive environments is important to identify key areas of interest for future investigation to ensure conversations with staff are successful and respectful of their time and space constraints, and to avoid disruption to patient care.
• Buy-in from key stakeholders, such as ED management and front-line staff, is key to gathering information; ensuring anonymity so staff can freely voice their feedback without fear of retaliation is helpful for gathering accurate data into the current state of activities.
Authors
Patient Safety Specialist & TOAI Quality Lead
Planner & TOAI Project Manager
Event Type
Oral Presentations
TimeMonday, March 312:37pm - 3:00pm EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)