Critical Transitions

Areas for Improvement in Critical Transitions

Driver Diagram

Elements of a High Quality Transition

A critical transition is any change of site of care, care plan, or care team.

Our aim is to achieve transitions that are safe, timely, effective, efficient, equitable, patient- and family-centered, and socially and environmentally responsible (STEEEPS).

The key drivers of STEEEPS transitions are:

  • Teamwork
  • Communication
  • Families as Partners
  • Health Equity
  • QI Methods

Achieving STEEEPS Transitions

The Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century is the source of the STEEEP (safe, timely, effective, efficient, equitable, patient- and family-centered) components. VON added the “social and environmentally responsible” criteria to this collaborative’s global aim.

Potentially Better Practices for Critical Transitions

Teams identify their improvement project for critical transitions by analyzing their VON data and discussing department and institutional needs and goals with stakeholders and team members. Some potentially better practices related to key drivers of high quality critical transitions are listed here.

Teamwork

  • Establish a shared mental model (map current/pre-improvement process)
  • Incorporate briefs, huddles, and debriefs
  • Conduct team training
  • Utilize simulation
  • Ensure team member roles are clear, flexible, and cross-trained

Families as Partners

  • Apply Families as Partners vision or philosophy of care statement to policies, practices, and programs
  • Design care processes with attention to infant and family experience of care
  • Support families to participate in care to the level they desire
  • Evaluate care practices and site of care to identify unnecessary separation of mothers, infants, and families
  • Develop strategies to support QI participation by parents including economically challenged, non-traditional and racially and ethnically diverse families

Health Equity

  • Screen all families for social risks and social support using a standardized tool
  • Provide parenting & family support tailored to individual family strengths
  • Provide mental health services for families during the hospital stay
  • Assess eligibility for public benefits and early intervention programs
  • Begin discharge planning and teaching at admission
  • Facilitate parent support groups & peer counselling that extend beyond the stay
  • Name racism and ask, “How is racism operating here?”

QI Methods

  • Utilize the Sequence to Achieve Change
  • Analyze failures (cases not following desired process) in real time
  • Conduct root cause analyses
  • Build decision aids and reminders into the system
  • Develop order sets, checklists, and clinical pathways as a result of tests of change
Phases of Care

Potential Areas for Improvement within Phases of Care

Pre-admission Outborn

  • Transport handoff tools; checklists
  • Integration of families into handoff process
  • Simulation
  • Communication w birthing NICU
  • Preparation of family including remote communication
  • Initiate family Peer Support
  • Telemedicine
  • Screen family for social risk & support

Pre-admission Inborn

  • Handoff with maternal-fetal medicine
  • Briefs, huddles, debrief w Antenatal and Birthing teams
  • Processes (teamwork informing clinical care) for optimal transition to extrauterine life
  • Integrate family w informed consent; coach; documents
  • Screen family for social risk & support
  • Initiate family Peer Support

Golden Hours

  • Briefs, huddles, debriefs
  • Develop verbal, written & graphic modes of communication
  • Develop checklists, decision tools, pathways to optimize clinical outcomes (minimally invasive vent’n; dev care)
  • Simulation to strengthen teamwork
  • Family peer support

Acute

  • Integrate family members into bedside teams
  • briefs, huddles, and debriefs into transition points incl. pre-post surgical
  • Develop family-led rounds
  • Begin discharge planning and teaching at admission
  • Facilitate parent support groups & peer counselling
  • Optimize all physiologic systems

Growing Stronger

  • Optimize nutritional transitions
  • Maximize skin-to-skin (site of care)
  • Provide parenting & family support tailored to individual family strengths
  • checklists for transition points
  • Include family in developing and evaluating daily care plans
  • Collaboration to stabilize systems

Breathing/Feeding/Growing

  • Support family’s shared decision-making
  • Provide mental health services for families
  • Checklists and clinical pathways supporting family & staff expectations
  • Educate and support families as the primary caregivers
  • Build decision aids and reminders into the system

Transition Home or Transfer

  • Handoff tools
  • Checklists
  • Multi-modal communication for family
  • Provide post-discharge anticipatory guidance
  • Facilitate parent support groups & peer counselling that extend beyond the stay
  • Facilitate transition to peds, family practitioner, referrals to all relevant services

Follow-up and Follow-Through

  • Provide high risk infant follow up
  • Provide telehealth support after discharge
  • Provide mental health and addiction services for families after the stay
  • Utilize innovative approaches to medical visits
  • Handoff tools supporting communication with specialists and services

Palliative Care and Bereavement

  • Integrate family members into bedside teams; clear roles for team
  • Develop individualized shared communication plans with families
  • Educate and support families as partners in the care of their infant
  • Include family in developing and evaluating daily care plans
  • Standardize the expectation and mechanism to screen and address each family’s emotional and spiritual health/needs
  • Make the environment welcoming and comfortable for families
  • Provide peer-to-peer support
  • Provide communication and support that is cultural sensitivity
  • Pain identification & management
  • Interdisciplinary Palliative Care teams
  • Home based hospice care
  • Grief support for families including siblings
  • Collaboration with Bioethics

Evidence-Based Toolkits Support Improvement

To facilitate teams’ improvement work, VON provides toolkits with change ideas and potentially better practices rooted in evidence.

Faculty skilled in the clinical application of evidence through disciplined QI methods guide teams as they implement changes to policies and practices.

VON uses the term “potentially better practices” to indicate that no practice is better or best until adapted, tested, and shown to work in the local context. Measurement and reporting available through VON help teams understand how the changes are affecting care at their center.

How can we affect health outcomes at your center?

See examples and determine your improvement focus.

VON Quality Improvement Collaboratives

iNICQ for Critical Transitions: Online education and discussion supports improvement, included in Quality Circle membership.

NICQ: Two-year collaborative in small groups to support sharing and collaboration, includes all Quality Circle benefits.