These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”