DDBA 8561 Week 5 Care Transition Handoff Study Example

What Crosses, What Arrives Late and What Nobody Owns: A Handoff Study of Transfers From a Hospital Medical Unit to Skilled Nursing Facilities, Setting Relational Coordination Against Standardized Handoff Tools

Student Name

Walden University

DDBA 8561: Seminar in Managing Healthcare Delivery Systems

Instructor Name

Month Day, Year

What Crosses, What Arrives Late and What Nobody Owns: A Handoff Study of Transfers From a Hospital Medical Unit to Skilled Nursing Facilities, Setting Relational Coordination Against Standardized Handoff Tools

The Handoff

The handoff studied here is the moment responsibility for a patient's ongoing care passes from a medical unit at a composite 260-bed hospital in Wisconsin to the admitting team of one of four skilled nursing facilities that together receive about 80 percent of its post-acute transfers. The usual remedy proposed after a failed transfer is more information in the transfer packet. This study argues that the remedy misreads the gap: some failures come from information that crosses too late, and others from work that neither side owns.

The Sort

[after]

The sort draws on chart review of 40 transfers and interviews with six hospital nurses, three case managers and the admitting nurses at two receiving facilities.

Table 1

Work in Motion at Transfer, Sorted by What Happens to It

The Ownerless Items

Results pending at discharge are the clearest case. The hospitalist who ordered a test has discharged the patient and moved on to other patients; the facility's physician did not order it and may not know it exists. Roy et al. (2005) studied patients discharged from two academic hospitals and found that about 41 percent had test results pending at discharge, that some of those results were potentially actionable and that physicians were often unaware of them. In the 40 transfers reviewed here, 17 had a result pending, and in 9 of those the receiving facility's records showed no sign the result had been seen. Specialist follow-up appointments fall into the same gap: the hospital recommends them, but neither side schedules them.

Two Theories of the Gap

Thompson (1967) distinguished pooled, sequential and reciprocal interdependence and argued that reciprocal interdependence, where each party's work depends on the other's in both directions, requires coordination by mutual adjustment rather than by standard rules alone. A transfer looks sequential, hospital then facility, but pending results and medication changes make it reciprocal: the facility needs the hospital after discharge, and the hospital needs to know what the facility found.

Gittell (2002) proposed relational coordination, in which people across roles talk often, promptly, accurately and with a view to solving problems, grounded in common aims, an understanding of each other's work and respect for it, and found that it improved performance in surgical care, especially when patient conditions were uncertain. On her account, the late and ownerless items reflect weak relationships across the boundary as much as missing fields in a form.

The standardized handoff literature takes a different view. Starmer et al. (2014) found that introducing a structured handoff program among pediatric residents coincided with a drop in both medical errors and preventable harm to patients. Standardized tools work well for information that can be specified in advance. They do less for work that changes after the form is completed or that no one is assigned to carry.

What the Sort Implies

The items that cross intact are already well served by the packet. The late items call for a time-bound call between hospital and facility nurses within 24 hours of transfer. The ownerless items call for assignment: a named hospital clinician responsible for pending results until the facility acknowledges them, and a facility clinician responsible for scheduling recommended follow-up.

Why More Information Is Not Enough

Adding fields to the transfer packet would help the items that already cross intact, which are least in need of help. It would not help items that change after the packet is printed, such as an insulin dose adjusted on the morning of discharge, and it would not help items no one is assigned to act on, since a pending result listed on a form still needs someone to look for it when it returns. The sort shows that the handoff fails in three different ways and that each needs a different remedy. That is the managerial point of separating them: a single remedy, however well designed, addresses one column of the table and leaves the other two untouched.

Limits

Forty transfers to four facilities are a small sample. Interviews reached only two receiving facilities.

References

Gittell, J. H. (2002). Coordinating mechanisms in care provider groups: Relational coordination as a mediator and input uncertainty as a moderator of performance effects. Management Science, 48(11), 1408-1426. https://doi.org/10.1287/mnsc.48.11.1408.268

Roy, C. L., Poon, E. G., Karson, A. S., Ladak-Merchant, Z., Johnson, R. E., Maviglia, S. M., & Gandhi, T. K. (2005). Patient safety concerns arising from test results that return after hospital discharge. Annals of Internal Medicine, 143(2), 121-128. https://doi.org/10.7326/0003-4819-143-2-200507190-00011

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., ... Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556

Thompson, J. D. (1967). Organizations in action. McGraw-Hill.