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Development and evaluation of a Continuity of Care Checklist for improving orthopaedic patient discharge from hospital
Journal of Orthopaedic Nursing (2009) 13, 183–193
Journal of Orthopaedic Nursing
www.elsevier.com/joon
Development and evaluation of a Continuity of Care Checklist for improving orthopaedic patient discharge from hospital q Heather D. Hadjistavropoulos PhD (Professor of Psychology and Director of Clinical Training) a,*, Sharon Garratt RN MBA (Director) b, Jennifer Amy Janzen MA (Doctoral Student) a, Michelle D. Bourgault-Fagnou MA (Doctoral Student) a, Kerry Spice BA (Master’s Student) c a
Department of Psychology, University of Regina, Regina, Canada S4S 0A2 System Wide Admission and Discharge Department, Regina Qu’Appelle Health Region, Regina, Canada S4S 0A2 c Educational Psychology Program, Faculty of Education, University of Regina, Regina, Canada S4S 0A2 b
KEYWORDS
In this study, we developed and evaluated a Continuity of Care Checklist (CCC) to assist nurses in comprehensively reviewing practices related to continuity of care for orthopaedic patients discharged from hospital to community. The CCC was designed to ensure nurses would attend to multiple dimensions of continuity including informational continuity, relational continuity and management continuity. To evaluate the CCC, patients discharged from an orthopaedic unit (n = 77) were interviewed about continuity of care. The CCC was then implemented and a second group of patients (n = 77) was interviewed to examine changes in care. Structured interviews were also conducted with nurses (n = 12) to learn about their experiences with the CCC. Interviews with patients revealed significant improvements in patient perceptions of information provision, involvement of informal caregivers in discharge, communication between hospital and community providers, consistency of information, and satisfaction with patient–provider relationships. Nurses who used the CCC found the tool improved standards for care and patient involvement
Summary
Continuity of care; Checklists; Discharge
q This study was made possible by a Grant (FRN 73183) funded by three partners: the Canadian Institute of Health Research, the Canada Health Services Research Foundation and Saskatchewan Learning. In-kind costs were also contributed by the Regina Qu’Appelle Health Region. * Corresponding author. Department of Psychology, University of Regina, Regina, Saskatchewan, Canada S4S 0A2. Tel.: +1 306 585 5133; fax: +1 306 585 5429. E-mail address: [email protected] (H.D. Hadjistavropoulos).
1361-3111/$ - see front matter c 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2009.05.006
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H.D. Hadjistavropoulos et al. in care. The CCC appears to be a practical tool for assisting nurses in systematically improving continuity of care among orthopaedic patients. Future directions for research and practice using the CCC are described. c 2009 Elsevier Ltd. All rights reserved.
Editor’s comments The needs of the orthopaedic patient do not end at the exit from the hospital. Orthopaedic care takes place in a wide range of settings and often continues for many weeks or even months after the hospital episode has ended. Achieving seamlessness at the boundaries of care settings is always a challenge. Ensuring that continuity of care is achieved when transferring the orthopaedic patient between hospital and community is an essential aspect of providing a quality experience for patients and their families and carers. This paper offers a tried and tested option for enhancing this process through good documentation and attention to detail. JS
Introduction Continuity of care refers to coherent care with seamless transitions over time between settings and providers through consistent communication and coordination (Jewell, 1993). Continuity of care is recognized as being multi-factorial in nature. Following a review of multidisciplinary research, Haggerty et al. (2003), for instance, distinguished among three essential types of continuity of care. Informational continuity refers to the use of information to provide appropriate client care over time. Relational continuity refers to the consistency and quality of relationships between clients and providers as a means of connecting care over time. Management continuity refers to the provision of timely, coordinated and complementary services responsive to client needs to connect care over time. The consensus in the literature is that continuity of care is essential to health care quality (Donaldson, 2001), and that there is a need for strategies to ensure that gaps in care are prevented (Cook et al., 2000). Like other areas of acute care, continuity of care poses a challenge for orthopaedic surgical patients, where multiple providers are involved in care, and pressures on hospital beds have resulted in reduced lengths of stay for orthopaedic patients (Fielden et al., 2003). Nurses, in particular, play a key role in facilitating continuity of care from hospital to community (Matt-Hensrud et al., 2001). Some nurse-led strategies that appear to improve continuity of care from hospital to home include involving post-acute coordinators in care (Lim et al., 2003), providing nurses with specific training in discharge planning (MattHensrud et al., 2001), using structured and standardized templates (Helleso, 2006), and implementing best practices that outline care requirements from admission through discharge (Bisaillon et al., 2004). In our review of the literature we noted that checklists designed to comprehensively improve
the varying dimensions of continuity of care (i.e., informational, relational and management) have not been studied in either orthopaedics or other areas of acute care. Checklists have been found to serve as a cognitive aid or organizational tool to ensure that tasks are completed (Hales et al., 2008). Standardized order checklists (Berenholtz et al., 2004) and best practice checklists as part of integrated care pathways (Wolff et al., 2004) are examples of common forms of checklists that have been found to improve patient care. The purpose of this study was to evaluate a Continuity of Care Checklist (CCC) was designed to assist nurses in systematically and comprehensively considering continuity of care for orthopaedic patients being discharged from hospital to community. The CCC was developed to be a reminder of tasks that should be completed prior to discharge (e.g., reminder of information that should be shared with patients, a reminder of existing forms that should be completed). The CCC was developed using Haggerty et al.’s (2003) conceptualization of continuity of care (i.e., informational, relational and management continuity of care) as a guide, as this conceptualization was developed based on a comprehensive multidisciplinary review of the literature. In Phase 1 of this research, we describe how we developed the CCC and examined patient perceptions of care before and after the CCC was implemented. In Phase 2, we describe nurse experiences with the CCC. Collecting information from both patients and nurses is important. As recipients of care, patients are in an ideal position to report on whether care is continuous and coordinated. They can report on whether they received essential information to prevent gaps in care, and share their observations about the quality of relationships with providers that would encourage them to continue with care. Patients can also report on consistency of care from hospital to community and the management of healthcare documents and follow-up
Development and evaluation of a Continuity of Care Checklist for improving appointments. Without garnering the patient’s perspective, provider attempts to connect care over time and prepare the patient for discharge may be incompletely understood. Nurse perceptions of the CCC, however, also provide valuable information about perceived strengths and challenges in using the CCC that are not necessarily gained from speaking with patients. Researchers who have developed past medical checklists have emphasized the importance of obtaining feedback from checklist users (Hales et al., 2008). It is quite possible that even if the CCC was perceived favorably by patients, the implementation of the CCC would be jeopordized if nurses also did not view the CCC positively. The research described below was approved by the ethics boards at both the University of Regina and the Regina Qu’Appelle Health Region.
Phase 1 Description of Continuity of Care Checklist To develop the CCC, we formed a Delphi panel made up of individuals from Saskatchewan (16), as well as individuals from other areas of Canada (five from Alberta, four from British Columbia, two from Ontario, one from Nova Scotia and one from Quebec). This team was formed to ensure that even though the CCC was developed in Saskatchewan it would have broader applicability. Our hope was that the CCC could not only be used in our health region, but also could be used in other health regions across the Country. The CCC was not designed to replace existing health care forms, but to complement existing forms and be a reminder of tasks that need to be completed to ensure continuity of care from hospital to community. The CCC lists essential tasks that need to be completed prior to discharge and nurses are required to initial these tasks as they are completed. In addition, a companion patient brochure was developed such that providers who used the CCC could give this brochure to patients, thus involving patients in the discharge process. This Delphi process is advantageous because it allows for group communication among experts who are geographically dispersed and permits participants to have input without bias (Landeta, 2006). Individuals were invited to be on the panel if they had published research on continuity of care, or were identified by a healthcare manager as having relevant expertise. Most participants had a nursing background (n = 21), but some physi-
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cians (n = 5) and individuals trained in health policy/administration/social sciences (n = 3) also participated. Through e-mail, participants reviewed information on Haggerty et al.’s (2003) conceptualization of continuity of care (i.e., informational, relational, and management continuity of care) and an initial draft of the CCC based on this framework. The CCC was divided into three parts corresponding to items that reflected informational continuity, relational continuity, and management continuity. The panel completed a questionnaire asking: (a) if they disagreed with any items; (b) whether any items were missing; (c) whether they would suggest wording changes; and (d) whether the tool had any particular strengths or weaknesses. The responses were anonymously collated and changes were made to the CCC based on these responses. Participants then reviewed the revised CCC, a summary of the comments/feedback from all of the participants in the first round, and a second questionnaire asking for further feedback and suggestions on how to resolve conflicting feedback. All but three participants responded at this stage and final changes were made to the CCC based on feedback. Participants again reviewed the CCC and rated the extent to which they felt their comments had been addressed. Ratings were made on a scale from 1 (not at all addressed) to 5 (completely addressed). All participants gave a rating of 4 or higher and therefore no further changes were made to the CCC. This entire process took four months to complete. After this initial development, the CCC was adapted for use on an orthopaedic unit in Regina, Saskatchewan. This involved meeting with the unit managers and staff members to discuss the CCC and further changes were made to the CCC to ensure that it was specific to the unit, as well as logical, appropriate, and attractive to users. Prior to implementation of the CCC, the CCC was trialed with several patients and additional changes were made to ensure it was user friendly. In reviewing the CCC, the staff noted that the CCC would complement their existing discharge form on which they documented the following information for patients: home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, and psychosocial recommendations. The CCC went beyond this form, however, and encouraged nursing staff to complete and review this discharge form with patients, and also to share additional information with patients and complete other tasks prior to discharge. The final implemented CCC for the orthopaedic unit appears in
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Appendix A and the companion brochure appears in Appendix B.
Participants Participants included 154 patients from an orthopaedic unit, with 77 patients in a ‘Treatment as Usual’ (TAU) group interviewed before the CCC was implemented on the unit, and 77 patients in the CCC group interviewed after the CCC was implemented on the unit. Orthopaedic patients were admitted for diverse surgeries including: fractures (32.5%), knee replacement (31.8%), hip replacement (23.4%), back (5.2%), knee (3.9%), foot (1.9%), or elbow (1.3%) surgery. Table 1 provides information on patient demographics.
Procedure
Results
A pre-test post-design design was used. For patients in the TAU group care was provided as usual before the CCC was implemented on the unit. For patients in the CCC group, the CCC was used as a discharge audit checklist before patient discharge. Nurses initialled items after they were completed. Prior to discharge, nurses also went over the companion brochure with patients. To recruit both TAU and CCC patients, a staff member other than a nurse from the unit asked eligible patients to participate. Those who consented were interviewed about continuity of care in their homes approximately four weeks after discharge. In one case, a family member or personal guardian assisted in providing responses for a patient who desired such support. Table 1
Participant background. Mean
Age (years) Duration of hospital stay (days)
Female Male Never married Married/common law Separated/divorced Widowed Less than high school High school College/some university Retired Discharged home Discharged with home care
The Patient Continuity of Care Questionnaire (PCCQ; Hadjistavropoulos et al., 2008) was used to assess patient perceptions of continuity of care. Items address perceptions of transfer of critical information to the patient, relationships with providers in hospital and in the community, and management of forms, follow-up appointments, and communication among providers. All 36 items on this measure that are specific to nursing appear in Table 2 and are rated on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scale has been found to be a reliable and valid measure (Hadjistavropoulos et al., 2008). Items given a rating less than 4 (agree) represent areas where improvements could be made to facilitate continuity of care.
59.46 8.27
SD 15.71 5.15
Percentage (%)
n
58.00 42.00 14.90 63.63 7.10 14.30 28.50 26.60 43.50 45.50 91.50 20.10
91 63 23 98 11 22 44 41 67 70 141 31
Because assignment to TAU versus CCC groups was not random, we first began by examining potential differences between these groups on demographics and background measures. Chi-Square was used for categorical data and t-tests for continuous measures. No statistically significant differences were found between TAU and CCC groups. The groups were then compared on their responses to the PCCQ. Examination of items in the TAU group revealed 16 out of 36 items were given a rating below 4. In comparison, only seven items out of 36 were given a rating lower than 4 in the CCC group. Individual item analyses of the PCCQ were conducted using independent sample t-tests in order to examine whether TAU and CCC participants differed significantly in their perception of care. See Table 3 for PCCQ item analyses. CCC participants felt that they had been better informed of many aspects of their care compared to TAU patients, including being informed of non-urgent symptoms that may occur and how to cope with these, dietary instructions, and follow-up appointments. They were also more likely to perceive informal caregivers as having been more involved in care. Relational aspects of care were rated higher among CCC participants in that they were more likely to feel known by providers, have increased confidence in providers, and increased satisfaction with information and emotional support. Follow-up care was also rated better in many ways in that CCC participants felt that a well-developed and realistic follow-up plan had been developed, their family was involved in follow-up care, different health care providers in hospital communicated well with those in the community, and there had been consistency of information provided by all involved in care.
Development and evaluation of a Continuity of Care Checklist for improving Table 2
Patient Continuity of Care Questionnaire item analyses.
PCCQ item
I was provided with clear information on my diagnosis I was provided with clear information on my prognosis I was told about non-urgent symptoms that may occur and how I should cope with these I was given information on symptoms that may signal a need to seek urgent medical attention and whom to contact for these symptoms I was told about clinical findings that may impact my future health or care I was given complete information on my medications I was given dietary instructions I was provided with information on recommendations and restrictions in activities, exercises and aids I was given information on medical equipment and supplies I was given information on follow-up appointments that have been made for me and appointments I have to schedule myself I was given written information on recommended support services and target date for initial contact I was informed of ongoing treatment that may be required after discharge and whether I will have ongoing contact with providers of my care I was informed of patient resources/supports that may be available I was informed of different self-management tools and educational material that could be helpful to me My informal caregivers were given information on resources/support My informal caregivers had the necessary information about my health that they needed in order to help me out Providers understood my expectations, beliefs and preferences I felt ‘known’ by the providers involved in my care I had confidence in the providers involved in my care I was satisfied with the information from the providers involved in my care I was satisfied with the emotional support from the providers involved in my care I was satisfied with the opportunity to talk and raise questions with the providers involved in my care I feel ‘‘known’’ by my present providers who have taken over my care since discharge I have confidence in my present providers who have taken over my care since discharge The different providers appeared to communicate well with each other while I was in hospital/convalescent care A well-developed and realistic follow-up plan was prepared and explained to me I was involved in and agree with the follow-up plan My family was involved in the follow-up as appropriate I felt adequately prepared for discharge As far as I am aware, the different health care providers in hospital have communicated well with those in the community about my care As far as I am aware, my family physician or other key provider was contacted and informed about the important aspects of care that I received I was given consistent information by all providers about my care I was reminded about important appointments As far as I am aware, necessary forms were all completed As far as I am aware, necessary forms were sent to all appropriate places/ providers As far as I am aware. no forms or information were lost when I was discharged * ** ***
<.05. <.01. <.001.
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Treatment as Usual
Continuity of Care
Mean
SD
Mean
SD
4.43 4.06 3.58
1.18 1.37 1.61
4.61 4.23 4.08*
.87 1.18 1.40
3.64
1.69
4.05
1.41
3.33 4.27 2.36 4.38
1.74 1.24 1.59 1.14
3.86 4.62 4.19*** 4.29
1.56 1.04 1.53 1.31
4.55 4.54
.99 1.09
4.64 4.84*
.94 .61
3.43
1.75
3.86
1.59
3.96
1.50
4.15
1.41
2.30 2.64
1.69 1.76
2.83 2.76
1.85 1.93
2.61 3.71
1.84 1.66
2.80 4.50***
1.91 1.10
4.29 4.23 4.57 4.27 4.12 4.12
1.27 1.23 .88 1.29 1.33 1.33
4.56 4.68** 4.83* 4.66* 4.53* 4.41
.98 .73 .47 .78 .98 1.06
4.67
.83
4.77
.69
4.69
.83
4.84
.68
4.12
1.19
4.41
1.05
3.70 3.97 3.22 4.31 3.61
1.52 1.47 1.79 1.24 1.61
4.43*** 4.26 4.06** 4.56 4.15*
1.14 1.32 1.55 1.01 1.46
3.75
1.50
3.89
1.41
4.19 3.88 4.64 4.43
1.37 1.64 .86 1.12
4.59* 3.90 4.81 4.66
.95 1.60 .61 .85
4.55
1.02
4.81
.56
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Table 3 Significant differences between Treatment as Usual and Continuity of Care groups on the Patient Continuity of Care Questionnaire. df Informed of non-urgent symptoms and how to cope Informed of dietary instructions Informed of follow-up appointments Necessary information distributed to informal caregivers Felt ‘known’ by providers involved in my care Confidence in providers involved in my care Satisfaction with the information from providers Satisfaction with emotional support from providers Preparation of well-developed and realistic follow-up plan Family involvement in follow-up care Providers in hospital communicated well with community Consistency of information provided by all involved in care
Phase 2 Participants In this phase of the study, 12 registered nurses who used the CCC on a regular basis provided feedback on the CCC. On average, these nurses completed 4.75 (SD = 2.18) checklists.
Method Each nurse participated in a 20- to 60-minute, open-ended audiotaped interview designed to capture strengths and challenges in using the CCC.
Analysis The audiotapes were transcribed verbatim and QSR N6 (QSR, 2002) facilitated qualitative analysis of the data (Bradley et al., 2007; Braun and Clarke, 2006). Units of analysis were defined as the smallest segment of text that conveyed a unitary, cohesive idea. Two researchers reviewed the transcripts to devise an initial thematic framework. Then they analyzed the transcripts line by line to allocate data to the framework. A third researcher reviewed the framework to combine duplicate items, and group similar themes. Further grouping was done until all three researchers agreed on the final themes.
144.04 94.00 117.26 123.45 124.09 116.85 124.65 134.18 139.01 127.67 142.54 135.44
t
p Value 2.02 5.68 2.13 3.38 2.75 2.26 2.24 2.11 3.37 2.89 2.14 2.06
<.05 <.001 <.05 =.001 <.01 <.05 <.05 <.05 =.001 <.01 <.05 <.05
there were barriers to discharge. It was also reflected in comments that the CCC was a good multidisciplinary tool encouraging nurses to communicate with other providers to ensure care was complete. Nurses also reported that it increased their confidence that patients could be discharged without significant gaps in care or risk to the patient. The second major theme that emerged was that the CCC improved patient knowledge. Nurses indicated that the CCC ensured patient knowledge by encouraging nurses to go through important aspects of the discharge with the patient/family using the companion brochure. Challenges fell into two primary areas. One theme that emerged was the time commitment necessary to complete the CCC. Two common examples of when it took increased time to complete the CCC were when nurses were discharging a patient that had not previously been under their care, and the difficulty of assessing relationship satisfaction between patients and their providers. The second theme that emerged was that nurses felt that resolving implementation issues prior to using the CCC was critical to its success. Nurses noted that it was important that the CCC was adapted and trialed in their unit prior to implementation, resolving where the CCC would be kept and when it would be completed.
Discussion Results Nurses identified numerous positive aspects of the CCC. In general, two broad themes emerged. One theme was that the CCC improved standards for ensuring continuity of care. This was seen in comments that the CCC served as a reminder to ensure that discharge duties were complete even when
Although checklists have been used to improve quality of health care (Hales et al., 2008), to date little research has directly examined the use of checklists to improve continuity of care. Although others have used strategies to improve patient discharge, a broader conceptual focus on continuity of care has not been used. It was relatively
Development and evaluation of a Continuity of Care Checklist for improving straightforward for our panel to reach consensus on items that should appear on the CCC. As had been found by others (Landeta, 2006), the Delphi approach was advantageous in this study, allowing for a diverse group of individuals to use an existing framework on continuity of care (Haggerty et al., 2003) to provide feedback on the CCC. A strength of this research is that input was obtained from individuals from more than one region of Canada who had clinical and/or research interests in continuity of care. This improves the potential applicability of the CCC to other regions. In Phase 1 of this study, we examined the impact of the CCC on patient perceptions of care. What was notable when examining the TAU ratings were the many positively rated items related to continuity of care. For example, by reviewing items in Table 1, it was clear that many items were given a rating of 4 or greater by patients in the TAU condition. That being said, there were many items where ratings were lower than desirable, especially items reflecting receipt of information and management of care. In comparison, items reflecting relationships with providers were rated positively even in the TAU group. In terms of improvements in patient perceptions, the CCC had a significant impact on several areas as demonstrated by significant changes in patient perceptions of their care when the CCC was used compared to TAU. The CCC participants were more satisfied with information they were provided, and were also more satisfied with relationships with providers compared to TAU participants. Furthermore, CCC participants had more positive perceptions that a well-developed and realistic follow-up plan had been prepared and explained. Lastly, CCC participants were also more likely than TAU participants to perceive information as consistent. It is notable that even though ratings of relationships were quite high in the TAU condition, the CCC patients provided even higher ratings in this regard. Despite improvements in patient perceptions with the CCC, there were some items that did not change with the CCC. In many cases, this reflects that ratings of care were high to begin with. In other cases, however, perceptions of care continued to be rated below a desirable level (e.g., a score of 4) despite the use of the CCC. These represent areas where further improvement may still be needed on this unit. For example, patients reported not necessarily being told about clinical findings that may impact on their future healthcare, or about recommended support services and self-management tools for themselves or informal caregivers. Discussions with nursing staff revealed
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that this information was not available to nurses to share with patients, thus representing areas where further improvements could be made in facilitating continuity of care. One potential limitation of this study is that a pretest (TAU) post-test (CCC) design was used rather than random assignment to groups. Random assignment was not used since it was not possible to provide both TAU and CCC at the same time, without TAU being changed by implementation of the CCC. Given that our TAU and checklist groups did not differ demographically and no other changes in care were implemented during the study period, we can be reasonably confident that the changes in patient perceptions that were observed were due to the CCC. The results overall support the use of the CCC as a practical tool that assists nurses in systematically identifying, documenting and improving care necessary for informational continuity, relational continuity, and management continuity. Finding these improvements in patient perceptions of care is important. It was especially promising that improvements in patient care were found in all three areas of continuity (informational, relational, management). As recipients of care, we believe that patients’ perceptions of care are an important way to evaluate if there have been gaps in information sharing, problems in relationships, or problems in the management of health care documents and followup appointments, and problems with consistency and quality of communication among various providers. Without speaking with patients, it is difficult to learn whether problems transpired. In Phase 2 of this study, our interest was in exploring perceptions of the CCC by those who used the CCC. This provided a greater understanding of its strengths and suggestions for implementation. Most apparent among nurses was the belief that the CCC served to set a standard of care by acting as a reminder to ensure that discharge duties were complete. It was noted that the CCC was more comprehensive and covered more information than simply completing the discharge form, which only required nurses to document information on home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, and psychosocial recommendations. Nurses indicated that the CCC ensured patient involvement and understanding by encouraging nurses to fully discuss care with the patient/family. The importance of having positive perceptions of the CCC from nurses cannot be understated. For a new form/procedure to be added to an already full schedule, nurses must see a benefit to this inclusion.
190 For those who may consider using the CCC, those who used the CCC felt that their commitment to the CCC was essential for implementation. Educating staff on the value of using the CCC was vital to ensure that the tool was used to its full potential. Also key to successful implementation was the provision of a detailed explanation of how the tool was to be used. Prior to implementation it was essential that nurses adapted the CCC to their needs and that nurses determined the best location for the CCC, setting standards for when and by whom it would be completed. The feedback we obtained about the implementation of the CCC is very similar to general considerations that have been noted in the use of other medical checklists. Hales et al. (2008) recently reviewed the literature on medical checklists and noted that for checklists to be successfully implemented, several factors need to be considered, including context (e.g., location), content (e.g., coverage), structure (e.g., logical order), appearance (e.g., visual appeal), and usability (e.g., straightforward). There are multiple directions for future research. Based on feedback from users of the CCC, it was suggested that future studies could explore using the CCC as a method of reviewing unit practices related to continuity of care, without it being implemented on a case by case basis. In this way, a working group could review the CCC and discuss each item on the CCC, identifying barriers and strategies in general for addressing the item. They might, for instance, identify a lack of sufficient educational materials for patients, or a need to find ways to improve communication with family physicians. Users of the CCC also suggested that it would be valuable to explore using the CCC as a method of training nurses about continuity of care. They noted that the CCC would aid new nurses in following best practices in continuity of care from hospital to community. Other directions for future research include examining the CCC on other units in other regions. In this study, the combined effect of the CCC and the accompanying patient brochure was evaluated, but it is possible that the patient brochure could be effective on its own and easily implemented by other acute care units. Research by Coleman et al. (2006), for instance, has found that supporting patients and caregivers in taking a more active role during care transitions through patient education and transition coordinators reduces rates of re-hospitalization. Further research is warranted to examine whether the patient brochure alone could reduce the burden of managing care transitions among vulnerable patients.
H.D. Hadjistavropoulos et al. Future research could also explore if the outcome of the CCC would be improved if the patient were also to initial items on the CCC that were completed. In this study, only the nurse initialled items on the CCC, but to ensure that nurses are accurate in their perceptions of continuity of care, patients could also be asked to initial items on the CCC. A further potential change to the CCC would be to add a column whereby nurses would document variances in the completion of items. This could provide valuable information to managers to help understand when tasks are not completed as recommended by the CCC. In summary, we systematically developed and studied the use of a checklist as a strategy for improving continuity of care among orthopaedic patients. Our hope is that others who have similar concerns about continuity of care will consider using the CCC. It serves as a cognitive aid and organizational tool for improving continuity of care (Hales et al., 2008). The advantage of this approach over others approaches used to improve continuity of care is that it provides nurses with a conceptual framework for thinking about continuity of care and does not require extensive resources to have a significant impact. Given that both patients and nurses responded positively to the CCC, further research on other potential benefits (e.g., readmission rates) of the CCC is warranted.
Acknowledgements We are grateful to the guidance and direction of the Delphi Panel members. We also appreciate the patients and providers who participated and the numerous research assistants and volunteers who assisted with the project. In particular, we want to acknowledge several individuals from the Regina Qu’Appelle Health Region, who facilitated the completion of this study including Dawn McNeil, Executive Director, Family Medicine, Home Care, and Palliative Care; Jeannine Brown, Executive Director, Surgical Services; Gretta Lynn Ell, Director, Program Development and Performance Support, Restorative and Continuing Care; Debbie Kosabek, Nurse Manager, Orthopaedic Unit, Regina General Hospital; Drew Racette, Nurse Manager, Orthopaedic Unit, Regina General Hospital; Bev Molson, Case Coordinator, System Wide Admission and Discharge Department; Patricia Engel, Nurse Manager, Regina Pasqua Hospital; Cheryl Kelln, Case Coordinator, System Wide Admission and Discharge Department; and Gord Moyer, Case Coordinator, System Wide Admission and Discharge Department.
Development and evaluation of a Continuity of Care Checklist for improving
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Appendix A Orthopedics Continuity of Care Checklist Patient Name:
Health Number:
Indicate if patient/caregiver has and understands written or verbal information on: All components of the discharge care plan including information on home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, psychosocial recommendations Diagnosis and prognosis Non-urgent symptoms that may occur and how to cope with these Symptoms that may signal a need to seek urgent medical attention and whom to contact for these symptoms Clinical findings that may impact future health or care that patient should be aware of (e.g., allergies and blood pressure) Follow-up tests and appointments that have been made for patient and appointments patients have to schedule Patient resources/supports (e.g., support groups) consistent with patient education and literacy Patient self-management tools and patient education material (e.g., diaries, books, tapes, and videos) Informal caregiver resources/support (e.g., support groups) consistent with education and literacy Assess to the best of your knowledge based on your conversations with the patient: Nurses feel they know the patient’s expectations, beliefs, preferences Patient/informal caregivers: Feel ‘‘known’’ by present providers (e.g., current clinical condition and events, preferences) Have confidence in present providers Are satisfied with emotional support from present providers Are satisfied with the opportunity to raise questions and information provided by present providers If follow-up providers known to patient, patient/informal caregivers: Feel ‘‘known’’ by follow-up providers (e.g., current clinical condition and events, preferences) Have confidence in follow-up providers Are satisfied with emotional support received from follow-up providers Are satisfied with the opportunity to raise questions and information provided by follow-up providers Ensure the following items are complete: A case coordinator has been assigned to the case if appropriate Services that are recommended for patients are realistic and available Communication among providers has taken place (e.g., multidisciplinary meetings, conference calls, and letters) Patient specific coordination among providers has taken place (e.g., negotiation of follow-up care plan) Patient/informal caregivers are involved in and agree to follow-up plan Necessary forms have been completed to arrange follow-up care Necessary forms have been transferred to all relevant follow-up providers (this may be direct or by asking patient to transfer information) There is verification of transfer of information to providers (e.g., phone calls or letters to remind or prompt) Follow-up services have been scheduled (e.g., confirmation, date, time, and place) Follow-up appointments have been made and/or instructions given to make appointments with follow-up providers Relevant protocols/pathways/guidelines for specific diseases have been followed Relevant protocols/pathways/guidelines for specific diseases have been transferred to follow-up providers The TIPS for discharge brochure was given to patient/informal caregivers Nurse initial = Condition has been met; X = Item is of concern and could not be addressed; NA = Not applicable.
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Appendix B Patient brochure to accompany use of Continuity of Care Checklist Tips for when you are discharged It is important that your care is consistent from one setting to the next. For this to happen there needs to be good communication between you and all of your health care providers and between your health care providers who are working in the hospital and in the community. Good communication makes sure that your care is not ‘‘undone’’ when you are discharged, and that your needs continue to be met after discharge. Before leaving the hospital, it is important that you feel comfortable and ready for discharge. Make sure you have the following information: Diagnosis – name of your medical condition Prognosis – likely outcome of your condition Non-urgent symptoms that may occur
Where or how to get aids to help with activity
(e.g., wheelchair, cane) Medical equipment and supplies (e.g., what needed
& how to cope with these Symptoms that need urgent medical attention
& who to talk to about these symptoms (e.g., specialist, family physician, homecare nurse) Medical results that may affect future health or care (e.g., allergies, history of blood clots, cancer, high blood pressure) Medications (e.g., type, why you are taking, how to take, how much, when, how often, for how long, side effects, drug interactions) Diet (e.g., special needs or limitations) Recommendations for activity (e.g., exercises, limits on activity) Also, before you leave the hospital be sure you: Talk about your follow-up plans with
a provider or coordinator Name: ______________ Phone Number: ____________ Involve the people who will be helping you
on discharge in making follow-up plans (your family/friends)
and who to contact). Follow-up tests and appointments, both those made
for you and those you have to make yourself (preparation instructions) Support services (name, phone number) and date for first contact (e.g., home care, respite, convenience meals, transportation, adult day program) Ongoing treatment needed (why, how often, when) Resources/supports for you (e.g., peer support groups) Resources/supports for your caregiver (e.g., peer support groups, community organizations) Educational materials (e.g., diaries, books, tapes, videos)
Ask questions to ensure follow-up services
are available, practical and work for you Provide the name of your family doctor to hospital
providers Go through the discharge summary with your
provider and understand the information in it Get a copy of your discharge summary
to show to your family doctor
References Berenholtz, S.M., Milanovich, S., Faircloth, A., Prow, D.T., Earsing, K., Lipsett, P., et al., 2004. Improving care for the ventilated patient. Joint Commission Journal on Quality and Patient Safety 30 (4), 195–204. Bisaillon, S., Faraone, J., Eliott, K., Cuthbert, J., Doucette, C., Shaw, J., 2004. Improving care for orthopaedic patients undergoing surgery for hip fracture and total knee replacement through best practice. Journal of Orthopaedic Nursing 8, 215–220. Bradley, E.H., Curry, L.A., Devers, K.J., 2007. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Services Research 42, 1758– 1772.
Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101. Coleman, E.A., Smith, J.D., Frank, J.C., Min, S., Parry, C., Kramer, A.M., 2006. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. Journal of the American Geriatrics Society 52, 1817–1825. Cook, R.I., Render, M., Woods, D.D., 2000. Gaps in the continuity of care and progress on patient safety. British Medical Journal 320, 791–794. Donaldson, M.S., 2001. Continuity of care: a reconceptualization. Medical Care Research and Review 58, 255–290. Fielden, J.M., Scott, S., Horne, J.G., 2003. An investigation of patient satisfaction following discharge after total hip replacement surgery. Orthopaedic Nursing 22 (6), 429–436.
Development and evaluation of a Continuity of Care Checklist for improving Hadjistavropoulos, H.D., Biem, H.J., Sharpe, D., BourgaultFagnou, M., Janzen, J.A., 2008. Patient perceptions of hospital discharge: reliability and validity of a Patient Continuity of Care Questionnaire. International Journal for Quality in Health Care 20, 314–323. Haggerty, J., Reid, R., Freeman, G.K., Starfield, B.H., Adair, C.E., McKendry, R., 2003. Continuity of care: a multidisciplinary review. British Medical Journal 327, 1219–1221. Hales, B., Terblanche, M., Fowler, R., Sibbald, W., 2008. Development of medical checklists for improved quality of patient care. International Journal for Quality in Health Care 20 (1), 22–30. Helleso, R., 2006. Information handling in the nursing discharge note. Journal of Clinical Nursing 15, 11–21. Jewell, S.E., 1993. Discovery of the discharge process: a study of patient discharge from a care unit for elderly people. Journal of Advanced Nursing 18, 1288–1296.
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Landeta, J., 2006. Current validity of the Delphi method in social sciences. Technological Forecasting and Social Change 73, 467–482. Lim, W.K., Lambert, S.F., Gray, L.C., 2003. Effectiveness of case management and post-acute services in older people after hospital discharge. Medical Journal of Australia 178, 262–266. Matt-Hensrud, N., Severson, M., Hansen, D.C., Holland, D.E., 2001. A discharge planning program in orthopaedics: experiences in implementation and evaluation. Orthopaedic Nursing 20 (1), 59–66. QSR, 2002. QSR N6 Computer software. QSR International Pty Ltd., Melbourne, Australia. Wolff, A.M., Taylor, S.A., McCabe, J.F., 2004. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Medical Journal of Australia 181 (8), 428– 431.
Available online at www.sciencedirect.com
Journal of Orthopaedic Nursing
www.elsevier.com/joon
Development and evaluation of a Continuity of Care Checklist for improving orthopaedic patient discharge from hospital q Heather D. Hadjistavropoulos PhD (Professor of Psychology and Director of Clinical Training) a,*, Sharon Garratt RN MBA (Director) b, Jennifer Amy Janzen MA (Doctoral Student) a, Michelle D. Bourgault-Fagnou MA (Doctoral Student) a, Kerry Spice BA (Master’s Student) c a
Department of Psychology, University of Regina, Regina, Canada S4S 0A2 System Wide Admission and Discharge Department, Regina Qu’Appelle Health Region, Regina, Canada S4S 0A2 c Educational Psychology Program, Faculty of Education, University of Regina, Regina, Canada S4S 0A2 b
KEYWORDS
In this study, we developed and evaluated a Continuity of Care Checklist (CCC) to assist nurses in comprehensively reviewing practices related to continuity of care for orthopaedic patients discharged from hospital to community. The CCC was designed to ensure nurses would attend to multiple dimensions of continuity including informational continuity, relational continuity and management continuity. To evaluate the CCC, patients discharged from an orthopaedic unit (n = 77) were interviewed about continuity of care. The CCC was then implemented and a second group of patients (n = 77) was interviewed to examine changes in care. Structured interviews were also conducted with nurses (n = 12) to learn about their experiences with the CCC. Interviews with patients revealed significant improvements in patient perceptions of information provision, involvement of informal caregivers in discharge, communication between hospital and community providers, consistency of information, and satisfaction with patient–provider relationships. Nurses who used the CCC found the tool improved standards for care and patient involvement
Summary
Continuity of care; Checklists; Discharge
q This study was made possible by a Grant (FRN 73183) funded by three partners: the Canadian Institute of Health Research, the Canada Health Services Research Foundation and Saskatchewan Learning. In-kind costs were also contributed by the Regina Qu’Appelle Health Region. * Corresponding author. Department of Psychology, University of Regina, Regina, Saskatchewan, Canada S4S 0A2. Tel.: +1 306 585 5133; fax: +1 306 585 5429. E-mail address: [email protected] (H.D. Hadjistavropoulos).
1361-3111/$ - see front matter c 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2009.05.006
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H.D. Hadjistavropoulos et al. in care. The CCC appears to be a practical tool for assisting nurses in systematically improving continuity of care among orthopaedic patients. Future directions for research and practice using the CCC are described. c 2009 Elsevier Ltd. All rights reserved.
Editor’s comments The needs of the orthopaedic patient do not end at the exit from the hospital. Orthopaedic care takes place in a wide range of settings and often continues for many weeks or even months after the hospital episode has ended. Achieving seamlessness at the boundaries of care settings is always a challenge. Ensuring that continuity of care is achieved when transferring the orthopaedic patient between hospital and community is an essential aspect of providing a quality experience for patients and their families and carers. This paper offers a tried and tested option for enhancing this process through good documentation and attention to detail. JS
Introduction Continuity of care refers to coherent care with seamless transitions over time between settings and providers through consistent communication and coordination (Jewell, 1993). Continuity of care is recognized as being multi-factorial in nature. Following a review of multidisciplinary research, Haggerty et al. (2003), for instance, distinguished among three essential types of continuity of care. Informational continuity refers to the use of information to provide appropriate client care over time. Relational continuity refers to the consistency and quality of relationships between clients and providers as a means of connecting care over time. Management continuity refers to the provision of timely, coordinated and complementary services responsive to client needs to connect care over time. The consensus in the literature is that continuity of care is essential to health care quality (Donaldson, 2001), and that there is a need for strategies to ensure that gaps in care are prevented (Cook et al., 2000). Like other areas of acute care, continuity of care poses a challenge for orthopaedic surgical patients, where multiple providers are involved in care, and pressures on hospital beds have resulted in reduced lengths of stay for orthopaedic patients (Fielden et al., 2003). Nurses, in particular, play a key role in facilitating continuity of care from hospital to community (Matt-Hensrud et al., 2001). Some nurse-led strategies that appear to improve continuity of care from hospital to home include involving post-acute coordinators in care (Lim et al., 2003), providing nurses with specific training in discharge planning (MattHensrud et al., 2001), using structured and standardized templates (Helleso, 2006), and implementing best practices that outline care requirements from admission through discharge (Bisaillon et al., 2004). In our review of the literature we noted that checklists designed to comprehensively improve
the varying dimensions of continuity of care (i.e., informational, relational and management) have not been studied in either orthopaedics or other areas of acute care. Checklists have been found to serve as a cognitive aid or organizational tool to ensure that tasks are completed (Hales et al., 2008). Standardized order checklists (Berenholtz et al., 2004) and best practice checklists as part of integrated care pathways (Wolff et al., 2004) are examples of common forms of checklists that have been found to improve patient care. The purpose of this study was to evaluate a Continuity of Care Checklist (CCC) was designed to assist nurses in systematically and comprehensively considering continuity of care for orthopaedic patients being discharged from hospital to community. The CCC was developed to be a reminder of tasks that should be completed prior to discharge (e.g., reminder of information that should be shared with patients, a reminder of existing forms that should be completed). The CCC was developed using Haggerty et al.’s (2003) conceptualization of continuity of care (i.e., informational, relational and management continuity of care) as a guide, as this conceptualization was developed based on a comprehensive multidisciplinary review of the literature. In Phase 1 of this research, we describe how we developed the CCC and examined patient perceptions of care before and after the CCC was implemented. In Phase 2, we describe nurse experiences with the CCC. Collecting information from both patients and nurses is important. As recipients of care, patients are in an ideal position to report on whether care is continuous and coordinated. They can report on whether they received essential information to prevent gaps in care, and share their observations about the quality of relationships with providers that would encourage them to continue with care. Patients can also report on consistency of care from hospital to community and the management of healthcare documents and follow-up
Development and evaluation of a Continuity of Care Checklist for improving appointments. Without garnering the patient’s perspective, provider attempts to connect care over time and prepare the patient for discharge may be incompletely understood. Nurse perceptions of the CCC, however, also provide valuable information about perceived strengths and challenges in using the CCC that are not necessarily gained from speaking with patients. Researchers who have developed past medical checklists have emphasized the importance of obtaining feedback from checklist users (Hales et al., 2008). It is quite possible that even if the CCC was perceived favorably by patients, the implementation of the CCC would be jeopordized if nurses also did not view the CCC positively. The research described below was approved by the ethics boards at both the University of Regina and the Regina Qu’Appelle Health Region.
Phase 1 Description of Continuity of Care Checklist To develop the CCC, we formed a Delphi panel made up of individuals from Saskatchewan (16), as well as individuals from other areas of Canada (five from Alberta, four from British Columbia, two from Ontario, one from Nova Scotia and one from Quebec). This team was formed to ensure that even though the CCC was developed in Saskatchewan it would have broader applicability. Our hope was that the CCC could not only be used in our health region, but also could be used in other health regions across the Country. The CCC was not designed to replace existing health care forms, but to complement existing forms and be a reminder of tasks that need to be completed to ensure continuity of care from hospital to community. The CCC lists essential tasks that need to be completed prior to discharge and nurses are required to initial these tasks as they are completed. In addition, a companion patient brochure was developed such that providers who used the CCC could give this brochure to patients, thus involving patients in the discharge process. This Delphi process is advantageous because it allows for group communication among experts who are geographically dispersed and permits participants to have input without bias (Landeta, 2006). Individuals were invited to be on the panel if they had published research on continuity of care, or were identified by a healthcare manager as having relevant expertise. Most participants had a nursing background (n = 21), but some physi-
185
cians (n = 5) and individuals trained in health policy/administration/social sciences (n = 3) also participated. Through e-mail, participants reviewed information on Haggerty et al.’s (2003) conceptualization of continuity of care (i.e., informational, relational, and management continuity of care) and an initial draft of the CCC based on this framework. The CCC was divided into three parts corresponding to items that reflected informational continuity, relational continuity, and management continuity. The panel completed a questionnaire asking: (a) if they disagreed with any items; (b) whether any items were missing; (c) whether they would suggest wording changes; and (d) whether the tool had any particular strengths or weaknesses. The responses were anonymously collated and changes were made to the CCC based on these responses. Participants then reviewed the revised CCC, a summary of the comments/feedback from all of the participants in the first round, and a second questionnaire asking for further feedback and suggestions on how to resolve conflicting feedback. All but three participants responded at this stage and final changes were made to the CCC based on feedback. Participants again reviewed the CCC and rated the extent to which they felt their comments had been addressed. Ratings were made on a scale from 1 (not at all addressed) to 5 (completely addressed). All participants gave a rating of 4 or higher and therefore no further changes were made to the CCC. This entire process took four months to complete. After this initial development, the CCC was adapted for use on an orthopaedic unit in Regina, Saskatchewan. This involved meeting with the unit managers and staff members to discuss the CCC and further changes were made to the CCC to ensure that it was specific to the unit, as well as logical, appropriate, and attractive to users. Prior to implementation of the CCC, the CCC was trialed with several patients and additional changes were made to ensure it was user friendly. In reviewing the CCC, the staff noted that the CCC would complement their existing discharge form on which they documented the following information for patients: home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, and psychosocial recommendations. The CCC went beyond this form, however, and encouraged nursing staff to complete and review this discharge form with patients, and also to share additional information with patients and complete other tasks prior to discharge. The final implemented CCC for the orthopaedic unit appears in
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Appendix A and the companion brochure appears in Appendix B.
Participants Participants included 154 patients from an orthopaedic unit, with 77 patients in a ‘Treatment as Usual’ (TAU) group interviewed before the CCC was implemented on the unit, and 77 patients in the CCC group interviewed after the CCC was implemented on the unit. Orthopaedic patients were admitted for diverse surgeries including: fractures (32.5%), knee replacement (31.8%), hip replacement (23.4%), back (5.2%), knee (3.9%), foot (1.9%), or elbow (1.3%) surgery. Table 1 provides information on patient demographics.
Procedure
Results
A pre-test post-design design was used. For patients in the TAU group care was provided as usual before the CCC was implemented on the unit. For patients in the CCC group, the CCC was used as a discharge audit checklist before patient discharge. Nurses initialled items after they were completed. Prior to discharge, nurses also went over the companion brochure with patients. To recruit both TAU and CCC patients, a staff member other than a nurse from the unit asked eligible patients to participate. Those who consented were interviewed about continuity of care in their homes approximately four weeks after discharge. In one case, a family member or personal guardian assisted in providing responses for a patient who desired such support. Table 1
Participant background. Mean
Age (years) Duration of hospital stay (days)
Female Male Never married Married/common law Separated/divorced Widowed Less than high school High school College/some university Retired Discharged home Discharged with home care
The Patient Continuity of Care Questionnaire (PCCQ; Hadjistavropoulos et al., 2008) was used to assess patient perceptions of continuity of care. Items address perceptions of transfer of critical information to the patient, relationships with providers in hospital and in the community, and management of forms, follow-up appointments, and communication among providers. All 36 items on this measure that are specific to nursing appear in Table 2 and are rated on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scale has been found to be a reliable and valid measure (Hadjistavropoulos et al., 2008). Items given a rating less than 4 (agree) represent areas where improvements could be made to facilitate continuity of care.
59.46 8.27
SD 15.71 5.15
Percentage (%)
n
58.00 42.00 14.90 63.63 7.10 14.30 28.50 26.60 43.50 45.50 91.50 20.10
91 63 23 98 11 22 44 41 67 70 141 31
Because assignment to TAU versus CCC groups was not random, we first began by examining potential differences between these groups on demographics and background measures. Chi-Square was used for categorical data and t-tests for continuous measures. No statistically significant differences were found between TAU and CCC groups. The groups were then compared on their responses to the PCCQ. Examination of items in the TAU group revealed 16 out of 36 items were given a rating below 4. In comparison, only seven items out of 36 were given a rating lower than 4 in the CCC group. Individual item analyses of the PCCQ were conducted using independent sample t-tests in order to examine whether TAU and CCC participants differed significantly in their perception of care. See Table 3 for PCCQ item analyses. CCC participants felt that they had been better informed of many aspects of their care compared to TAU patients, including being informed of non-urgent symptoms that may occur and how to cope with these, dietary instructions, and follow-up appointments. They were also more likely to perceive informal caregivers as having been more involved in care. Relational aspects of care were rated higher among CCC participants in that they were more likely to feel known by providers, have increased confidence in providers, and increased satisfaction with information and emotional support. Follow-up care was also rated better in many ways in that CCC participants felt that a well-developed and realistic follow-up plan had been developed, their family was involved in follow-up care, different health care providers in hospital communicated well with those in the community, and there had been consistency of information provided by all involved in care.
Development and evaluation of a Continuity of Care Checklist for improving Table 2
Patient Continuity of Care Questionnaire item analyses.
PCCQ item
I was provided with clear information on my diagnosis I was provided with clear information on my prognosis I was told about non-urgent symptoms that may occur and how I should cope with these I was given information on symptoms that may signal a need to seek urgent medical attention and whom to contact for these symptoms I was told about clinical findings that may impact my future health or care I was given complete information on my medications I was given dietary instructions I was provided with information on recommendations and restrictions in activities, exercises and aids I was given information on medical equipment and supplies I was given information on follow-up appointments that have been made for me and appointments I have to schedule myself I was given written information on recommended support services and target date for initial contact I was informed of ongoing treatment that may be required after discharge and whether I will have ongoing contact with providers of my care I was informed of patient resources/supports that may be available I was informed of different self-management tools and educational material that could be helpful to me My informal caregivers were given information on resources/support My informal caregivers had the necessary information about my health that they needed in order to help me out Providers understood my expectations, beliefs and preferences I felt ‘known’ by the providers involved in my care I had confidence in the providers involved in my care I was satisfied with the information from the providers involved in my care I was satisfied with the emotional support from the providers involved in my care I was satisfied with the opportunity to talk and raise questions with the providers involved in my care I feel ‘‘known’’ by my present providers who have taken over my care since discharge I have confidence in my present providers who have taken over my care since discharge The different providers appeared to communicate well with each other while I was in hospital/convalescent care A well-developed and realistic follow-up plan was prepared and explained to me I was involved in and agree with the follow-up plan My family was involved in the follow-up as appropriate I felt adequately prepared for discharge As far as I am aware, the different health care providers in hospital have communicated well with those in the community about my care As far as I am aware, my family physician or other key provider was contacted and informed about the important aspects of care that I received I was given consistent information by all providers about my care I was reminded about important appointments As far as I am aware, necessary forms were all completed As far as I am aware, necessary forms were sent to all appropriate places/ providers As far as I am aware. no forms or information were lost when I was discharged * ** ***
<.05. <.01. <.001.
187
Treatment as Usual
Continuity of Care
Mean
SD
Mean
SD
4.43 4.06 3.58
1.18 1.37 1.61
4.61 4.23 4.08*
.87 1.18 1.40
3.64
1.69
4.05
1.41
3.33 4.27 2.36 4.38
1.74 1.24 1.59 1.14
3.86 4.62 4.19*** 4.29
1.56 1.04 1.53 1.31
4.55 4.54
.99 1.09
4.64 4.84*
.94 .61
3.43
1.75
3.86
1.59
3.96
1.50
4.15
1.41
2.30 2.64
1.69 1.76
2.83 2.76
1.85 1.93
2.61 3.71
1.84 1.66
2.80 4.50***
1.91 1.10
4.29 4.23 4.57 4.27 4.12 4.12
1.27 1.23 .88 1.29 1.33 1.33
4.56 4.68** 4.83* 4.66* 4.53* 4.41
.98 .73 .47 .78 .98 1.06
4.67
.83
4.77
.69
4.69
.83
4.84
.68
4.12
1.19
4.41
1.05
3.70 3.97 3.22 4.31 3.61
1.52 1.47 1.79 1.24 1.61
4.43*** 4.26 4.06** 4.56 4.15*
1.14 1.32 1.55 1.01 1.46
3.75
1.50
3.89
1.41
4.19 3.88 4.64 4.43
1.37 1.64 .86 1.12
4.59* 3.90 4.81 4.66
.95 1.60 .61 .85
4.55
1.02
4.81
.56
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H.D. Hadjistavropoulos et al.
Table 3 Significant differences between Treatment as Usual and Continuity of Care groups on the Patient Continuity of Care Questionnaire. df Informed of non-urgent symptoms and how to cope Informed of dietary instructions Informed of follow-up appointments Necessary information distributed to informal caregivers Felt ‘known’ by providers involved in my care Confidence in providers involved in my care Satisfaction with the information from providers Satisfaction with emotional support from providers Preparation of well-developed and realistic follow-up plan Family involvement in follow-up care Providers in hospital communicated well with community Consistency of information provided by all involved in care
Phase 2 Participants In this phase of the study, 12 registered nurses who used the CCC on a regular basis provided feedback on the CCC. On average, these nurses completed 4.75 (SD = 2.18) checklists.
Method Each nurse participated in a 20- to 60-minute, open-ended audiotaped interview designed to capture strengths and challenges in using the CCC.
Analysis The audiotapes were transcribed verbatim and QSR N6 (QSR, 2002) facilitated qualitative analysis of the data (Bradley et al., 2007; Braun and Clarke, 2006). Units of analysis were defined as the smallest segment of text that conveyed a unitary, cohesive idea. Two researchers reviewed the transcripts to devise an initial thematic framework. Then they analyzed the transcripts line by line to allocate data to the framework. A third researcher reviewed the framework to combine duplicate items, and group similar themes. Further grouping was done until all three researchers agreed on the final themes.
144.04 94.00 117.26 123.45 124.09 116.85 124.65 134.18 139.01 127.67 142.54 135.44
t
p Value 2.02 5.68 2.13 3.38 2.75 2.26 2.24 2.11 3.37 2.89 2.14 2.06
<.05 <.001 <.05 =.001 <.01 <.05 <.05 <.05 =.001 <.01 <.05 <.05
there were barriers to discharge. It was also reflected in comments that the CCC was a good multidisciplinary tool encouraging nurses to communicate with other providers to ensure care was complete. Nurses also reported that it increased their confidence that patients could be discharged without significant gaps in care or risk to the patient. The second major theme that emerged was that the CCC improved patient knowledge. Nurses indicated that the CCC ensured patient knowledge by encouraging nurses to go through important aspects of the discharge with the patient/family using the companion brochure. Challenges fell into two primary areas. One theme that emerged was the time commitment necessary to complete the CCC. Two common examples of when it took increased time to complete the CCC were when nurses were discharging a patient that had not previously been under their care, and the difficulty of assessing relationship satisfaction between patients and their providers. The second theme that emerged was that nurses felt that resolving implementation issues prior to using the CCC was critical to its success. Nurses noted that it was important that the CCC was adapted and trialed in their unit prior to implementation, resolving where the CCC would be kept and when it would be completed.
Discussion Results Nurses identified numerous positive aspects of the CCC. In general, two broad themes emerged. One theme was that the CCC improved standards for ensuring continuity of care. This was seen in comments that the CCC served as a reminder to ensure that discharge duties were complete even when
Although checklists have been used to improve quality of health care (Hales et al., 2008), to date little research has directly examined the use of checklists to improve continuity of care. Although others have used strategies to improve patient discharge, a broader conceptual focus on continuity of care has not been used. It was relatively
Development and evaluation of a Continuity of Care Checklist for improving straightforward for our panel to reach consensus on items that should appear on the CCC. As had been found by others (Landeta, 2006), the Delphi approach was advantageous in this study, allowing for a diverse group of individuals to use an existing framework on continuity of care (Haggerty et al., 2003) to provide feedback on the CCC. A strength of this research is that input was obtained from individuals from more than one region of Canada who had clinical and/or research interests in continuity of care. This improves the potential applicability of the CCC to other regions. In Phase 1 of this study, we examined the impact of the CCC on patient perceptions of care. What was notable when examining the TAU ratings were the many positively rated items related to continuity of care. For example, by reviewing items in Table 1, it was clear that many items were given a rating of 4 or greater by patients in the TAU condition. That being said, there were many items where ratings were lower than desirable, especially items reflecting receipt of information and management of care. In comparison, items reflecting relationships with providers were rated positively even in the TAU group. In terms of improvements in patient perceptions, the CCC had a significant impact on several areas as demonstrated by significant changes in patient perceptions of their care when the CCC was used compared to TAU. The CCC participants were more satisfied with information they were provided, and were also more satisfied with relationships with providers compared to TAU participants. Furthermore, CCC participants had more positive perceptions that a well-developed and realistic follow-up plan had been prepared and explained. Lastly, CCC participants were also more likely than TAU participants to perceive information as consistent. It is notable that even though ratings of relationships were quite high in the TAU condition, the CCC patients provided even higher ratings in this regard. Despite improvements in patient perceptions with the CCC, there were some items that did not change with the CCC. In many cases, this reflects that ratings of care were high to begin with. In other cases, however, perceptions of care continued to be rated below a desirable level (e.g., a score of 4) despite the use of the CCC. These represent areas where further improvement may still be needed on this unit. For example, patients reported not necessarily being told about clinical findings that may impact on their future healthcare, or about recommended support services and self-management tools for themselves or informal caregivers. Discussions with nursing staff revealed
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that this information was not available to nurses to share with patients, thus representing areas where further improvements could be made in facilitating continuity of care. One potential limitation of this study is that a pretest (TAU) post-test (CCC) design was used rather than random assignment to groups. Random assignment was not used since it was not possible to provide both TAU and CCC at the same time, without TAU being changed by implementation of the CCC. Given that our TAU and checklist groups did not differ demographically and no other changes in care were implemented during the study period, we can be reasonably confident that the changes in patient perceptions that were observed were due to the CCC. The results overall support the use of the CCC as a practical tool that assists nurses in systematically identifying, documenting and improving care necessary for informational continuity, relational continuity, and management continuity. Finding these improvements in patient perceptions of care is important. It was especially promising that improvements in patient care were found in all three areas of continuity (informational, relational, management). As recipients of care, we believe that patients’ perceptions of care are an important way to evaluate if there have been gaps in information sharing, problems in relationships, or problems in the management of health care documents and followup appointments, and problems with consistency and quality of communication among various providers. Without speaking with patients, it is difficult to learn whether problems transpired. In Phase 2 of this study, our interest was in exploring perceptions of the CCC by those who used the CCC. This provided a greater understanding of its strengths and suggestions for implementation. Most apparent among nurses was the belief that the CCC served to set a standard of care by acting as a reminder to ensure that discharge duties were complete. It was noted that the CCC was more comprehensive and covered more information than simply completing the discharge form, which only required nurses to document information on home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, and psychosocial recommendations. Nurses indicated that the CCC ensured patient involvement and understanding by encouraging nurses to fully discuss care with the patient/family. The importance of having positive perceptions of the CCC from nurses cannot be understated. For a new form/procedure to be added to an already full schedule, nurses must see a benefit to this inclusion.
190 For those who may consider using the CCC, those who used the CCC felt that their commitment to the CCC was essential for implementation. Educating staff on the value of using the CCC was vital to ensure that the tool was used to its full potential. Also key to successful implementation was the provision of a detailed explanation of how the tool was to be used. Prior to implementation it was essential that nurses adapted the CCC to their needs and that nurses determined the best location for the CCC, setting standards for when and by whom it would be completed. The feedback we obtained about the implementation of the CCC is very similar to general considerations that have been noted in the use of other medical checklists. Hales et al. (2008) recently reviewed the literature on medical checklists and noted that for checklists to be successfully implemented, several factors need to be considered, including context (e.g., location), content (e.g., coverage), structure (e.g., logical order), appearance (e.g., visual appeal), and usability (e.g., straightforward). There are multiple directions for future research. Based on feedback from users of the CCC, it was suggested that future studies could explore using the CCC as a method of reviewing unit practices related to continuity of care, without it being implemented on a case by case basis. In this way, a working group could review the CCC and discuss each item on the CCC, identifying barriers and strategies in general for addressing the item. They might, for instance, identify a lack of sufficient educational materials for patients, or a need to find ways to improve communication with family physicians. Users of the CCC also suggested that it would be valuable to explore using the CCC as a method of training nurses about continuity of care. They noted that the CCC would aid new nurses in following best practices in continuity of care from hospital to community. Other directions for future research include examining the CCC on other units in other regions. In this study, the combined effect of the CCC and the accompanying patient brochure was evaluated, but it is possible that the patient brochure could be effective on its own and easily implemented by other acute care units. Research by Coleman et al. (2006), for instance, has found that supporting patients and caregivers in taking a more active role during care transitions through patient education and transition coordinators reduces rates of re-hospitalization. Further research is warranted to examine whether the patient brochure alone could reduce the burden of managing care transitions among vulnerable patients.
H.D. Hadjistavropoulos et al. Future research could also explore if the outcome of the CCC would be improved if the patient were also to initial items on the CCC that were completed. In this study, only the nurse initialled items on the CCC, but to ensure that nurses are accurate in their perceptions of continuity of care, patients could also be asked to initial items on the CCC. A further potential change to the CCC would be to add a column whereby nurses would document variances in the completion of items. This could provide valuable information to managers to help understand when tasks are not completed as recommended by the CCC. In summary, we systematically developed and studied the use of a checklist as a strategy for improving continuity of care among orthopaedic patients. Our hope is that others who have similar concerns about continuity of care will consider using the CCC. It serves as a cognitive aid and organizational tool for improving continuity of care (Hales et al., 2008). The advantage of this approach over others approaches used to improve continuity of care is that it provides nurses with a conceptual framework for thinking about continuity of care and does not require extensive resources to have a significant impact. Given that both patients and nurses responded positively to the CCC, further research on other potential benefits (e.g., readmission rates) of the CCC is warranted.
Acknowledgements We are grateful to the guidance and direction of the Delphi Panel members. We also appreciate the patients and providers who participated and the numerous research assistants and volunteers who assisted with the project. In particular, we want to acknowledge several individuals from the Regina Qu’Appelle Health Region, who facilitated the completion of this study including Dawn McNeil, Executive Director, Family Medicine, Home Care, and Palliative Care; Jeannine Brown, Executive Director, Surgical Services; Gretta Lynn Ell, Director, Program Development and Performance Support, Restorative and Continuing Care; Debbie Kosabek, Nurse Manager, Orthopaedic Unit, Regina General Hospital; Drew Racette, Nurse Manager, Orthopaedic Unit, Regina General Hospital; Bev Molson, Case Coordinator, System Wide Admission and Discharge Department; Patricia Engel, Nurse Manager, Regina Pasqua Hospital; Cheryl Kelln, Case Coordinator, System Wide Admission and Discharge Department; and Gord Moyer, Case Coordinator, System Wide Admission and Discharge Department.
Development and evaluation of a Continuity of Care Checklist for improving
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Appendix A Orthopedics Continuity of Care Checklist Patient Name:
Health Number:
Indicate if patient/caregiver has and understands written or verbal information on: All components of the discharge care plan including information on home care services, personal hygiene, mobility, elimination, medications, safety, appointments, nutrition, treatment and procedures, psychosocial recommendations Diagnosis and prognosis Non-urgent symptoms that may occur and how to cope with these Symptoms that may signal a need to seek urgent medical attention and whom to contact for these symptoms Clinical findings that may impact future health or care that patient should be aware of (e.g., allergies and blood pressure) Follow-up tests and appointments that have been made for patient and appointments patients have to schedule Patient resources/supports (e.g., support groups) consistent with patient education and literacy Patient self-management tools and patient education material (e.g., diaries, books, tapes, and videos) Informal caregiver resources/support (e.g., support groups) consistent with education and literacy Assess to the best of your knowledge based on your conversations with the patient: Nurses feel they know the patient’s expectations, beliefs, preferences Patient/informal caregivers: Feel ‘‘known’’ by present providers (e.g., current clinical condition and events, preferences) Have confidence in present providers Are satisfied with emotional support from present providers Are satisfied with the opportunity to raise questions and information provided by present providers If follow-up providers known to patient, patient/informal caregivers: Feel ‘‘known’’ by follow-up providers (e.g., current clinical condition and events, preferences) Have confidence in follow-up providers Are satisfied with emotional support received from follow-up providers Are satisfied with the opportunity to raise questions and information provided by follow-up providers Ensure the following items are complete: A case coordinator has been assigned to the case if appropriate Services that are recommended for patients are realistic and available Communication among providers has taken place (e.g., multidisciplinary meetings, conference calls, and letters) Patient specific coordination among providers has taken place (e.g., negotiation of follow-up care plan) Patient/informal caregivers are involved in and agree to follow-up plan Necessary forms have been completed to arrange follow-up care Necessary forms have been transferred to all relevant follow-up providers (this may be direct or by asking patient to transfer information) There is verification of transfer of information to providers (e.g., phone calls or letters to remind or prompt) Follow-up services have been scheduled (e.g., confirmation, date, time, and place) Follow-up appointments have been made and/or instructions given to make appointments with follow-up providers Relevant protocols/pathways/guidelines for specific diseases have been followed Relevant protocols/pathways/guidelines for specific diseases have been transferred to follow-up providers The TIPS for discharge brochure was given to patient/informal caregivers Nurse initial = Condition has been met; X = Item is of concern and could not be addressed; NA = Not applicable.
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H.D. Hadjistavropoulos et al.
Appendix B Patient brochure to accompany use of Continuity of Care Checklist Tips for when you are discharged It is important that your care is consistent from one setting to the next. For this to happen there needs to be good communication between you and all of your health care providers and between your health care providers who are working in the hospital and in the community. Good communication makes sure that your care is not ‘‘undone’’ when you are discharged, and that your needs continue to be met after discharge. Before leaving the hospital, it is important that you feel comfortable and ready for discharge. Make sure you have the following information: Diagnosis – name of your medical condition Prognosis – likely outcome of your condition Non-urgent symptoms that may occur
Where or how to get aids to help with activity
(e.g., wheelchair, cane) Medical equipment and supplies (e.g., what needed
& how to cope with these Symptoms that need urgent medical attention
& who to talk to about these symptoms (e.g., specialist, family physician, homecare nurse) Medical results that may affect future health or care (e.g., allergies, history of blood clots, cancer, high blood pressure) Medications (e.g., type, why you are taking, how to take, how much, when, how often, for how long, side effects, drug interactions) Diet (e.g., special needs or limitations) Recommendations for activity (e.g., exercises, limits on activity) Also, before you leave the hospital be sure you: Talk about your follow-up plans with
a provider or coordinator Name: ______________ Phone Number: ____________ Involve the people who will be helping you
on discharge in making follow-up plans (your family/friends)
and who to contact). Follow-up tests and appointments, both those made
for you and those you have to make yourself (preparation instructions) Support services (name, phone number) and date for first contact (e.g., home care, respite, convenience meals, transportation, adult day program) Ongoing treatment needed (why, how often, when) Resources/supports for you (e.g., peer support groups) Resources/supports for your caregiver (e.g., peer support groups, community organizations) Educational materials (e.g., diaries, books, tapes, videos)
Ask questions to ensure follow-up services
are available, practical and work for you Provide the name of your family doctor to hospital
providers Go through the discharge summary with your
provider and understand the information in it Get a copy of your discharge summary
to show to your family doctor
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