III.C. Transitions of Care

(Effective July 1, 2011)

Programs must design House Officer clinical assignments to optimize transitions in patient care, including safety, frequency, and structure. Programs, in partnership with the School of Medicine and participating institutions, must ensure and monitor effective, structured hand-off processes to facilitate both continuity of care and patient safety. Programs must ensure that House Officers are competent in communicating with team members in the hand-off process. Programs and clinical sites must maintain and communicate schedules of attending physicians and House Officers currently responsible for care. Programs will ensure continuity of patient care if a House Officer may be unable to perform their patient care responsibilities due to excessive fatigue or illness.
This transitions policy was created in response to multiple studies that have shown transitions of care result in medical errors or increased risk to patient safety ACGME Teleconference-August 2010. In addition to the policies outlined in this section, patient safety is further ensured by:

• Provision of complete and accurate rotational schedules in New Innovations
• Presence of a backup call schedule for those cases where a House Officer is unable to complete their duties
• The ability of any House Officer to, freely and without fear of retribution, report their inability to carry out their clinical responsibilities due to fatigue or other causes

House Officers receive educational material on Transitions at both orientation and as a core module of their AMA online training.
An adequate transition must be used whenever patient care is transferred to another member of the health care team. Although transitions may require additional reporting than outlined in this policy, the minimum standard of care includes the following:

• Demographics: name, medical record number, unit/room number, age, weight, gender, allergies attending physician phone numbers
• History and problem List: primary diagnosis(es) and chronic problems pertinent to this admission/shift
• Current condition status
• System based list: pertinent medications and treatments, oral and IV medications, IV fluids, blood products, oxygen, respiratory therapy interventions
• Pertinent lab data
• To do list: check x-ray, labs, wean treatments, etc. – and the rationale for each action
• Contingency planning: what may go wrong and what to do
• Anticipate what will happen to your patient: If this…then that…
• Code status/family situation
• Difficult family or psychosocial situations

Programs will periodically check transitions, including reviewing parts of a patient's chart and interviewing incoming teams, to ensure that key elements have been transmitted and understood.
This information is located on pocket cards available for each House Officer. The information is distributed to House Officers through AMA Core Modules and Orientation presentations, as well as through a Compliance Module for faculty. In addition, this information is presented in program/departmental meetings.
How monitored:
Faculty are required to answer a question on effectiveness of witnessed transitions on each House Officer evaluation. Programs must add the following language to the end of each monthly evaluation form in New Innovations: "I have witnessed effective transitions in person and attest the essential elements as defined in the Transitions Policy were transmitted to and understood by the receiving team." The process and effectiveness of each program's transition system is monitored by the Sponsoring Institution through the Annual Program Evaluation and Special Review process. The institution and program will monitor this by periodic review.