Question

Planning for our patients during times of transitions (for example: hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:

• How does your facility promote interprofessional collaboration during times of patient transitions?
• What is the role of the nurse in patient transitions?
• What gaps can you identify in this process related to quality of care? (If you are not currently in practice, please use a previous role or clinical experience in your answers.)

Answer 1

1

• By developing a common goal and working towards that goal.
• Assigning roles and responsibilities to each member and each member understanding the role of other members.
• Have a mechanism to oversee carrying out the plans,assess outcomes and adjust based on results of the outcomes.

2 Nurses are the eyes and ears of the health-care team members. Nurses role include

• use SBAR.
• Ask questions.
• call for sepsis screens,blood,wound cultures.
• ticket to ride communication,pre-surgical check lists.
• transfer packet list.
• provide patient education.
• utilize resources.
• develop medication list.
• call and verify with pharmacy.
• collaborate with pharmacist.
• get most current medications list.

3 The factors which could make a gap in the quality of care are the limitations within the interprofessional collaboration which involves

• Process of team formation is time consuming and requires matching of schedules of all team members.
• Collaboration requires communication between team members.
• Comprehensive approach may lead to increased use of limited resources/services.
• Successful team requires on-going conflict resolution and goal re-assessment.

Ineffective transition to care leads to poor patient outcomes,wrong treatment,delay in diagnosis,severe adverse events,patient complaints,increased health care costs and increased length of stay