Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.8 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.
To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach.
Change ideas are specific and practical changes by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.
Evidence-Informed |
How To Implement |
Toolbox |
Individualized Discharge Planning
Implementing personalized discharge planning and reduce length of stay, lower readmission rates, and may increase patient satisfaction. |
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Individualized Discharge Planning
REFERENCES:
Systematic Reviews
Gonçalves-Bradley D, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.
Supporting Research
Shen E, Koyama SY, Huynh DN, Watson HI, Mittman B, Kanter MH, Nguyen, HQ. 2016. Association of dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a medicare advantage population. Jama Internal Medicine. Published Online November 21, 2016.
Mekonnen AB, McLachlan AJ, Brien JA. 2016. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 6(2):e010003 2016 Feb. 23
Use Teach Back when Building Caregiver and Patient Capacity - Health Quality Ontario
Adopting a Common Approach to Transitional Care Planning - Health Quality Ontario
Re-Engineered Discharge (RED) Toolkit - Agency for Healthcare Research and Quality
Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) - Agency for Healthcare Research and Quality
Patient Oriented Discharge Summary - University Health Network Open Lab
SMART Discharge Protocol - Institute for Healthcare Improvement
Prevent Adverse Drug Events - Institute for Healthcare Improvement
LACE Tool - Health System Performance Research Network
Hospital Report Manager - OntarioMD
Medication Reconciliation Acute Care Getting Started - Safer Healthcare Now!
Evidence-Informed |
How To Implement |
Toolbox |
Post Transition Follow-up |
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REFERENCES:
Systematic Reviews
Gonçalves-Bradley D, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.
Supporting Research
Shen E, Koyama SY, Huynh DN, Watson HI, Mittman B, Kanter MH, Nguyen, HQ. 2016. Association of dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a medicare advantage population. Jama Internal Medicine. Published Online November 21, 2016.
Mekonnen AB, McLachlan AJ, Brien JA. 2016. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 6(2):e010003 2016 Feb. 23
Use Teach Back when Building Caregiver and Patient Capacity - Health Quality Ontario
Adopting a Common Approach to Transitional Care Planning - Health Quality Ontario
Re-Engineered Discharge (RED) Toolkit - Agency for Healthcare Research and Quality
Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) - Agency for Healthcare Research and Quality
Patient Oriented Discharge Summary - University Health Network Open Lab
SMART Discharge Protocol - Institute for Healthcare Improvement
Prevent Adverse Drug Events - Institute for Healthcare Improvement
LACE Tool - Health System Performance Research Network
Hospital Report Manager - OntarioMD
Medication Reconciliation Acute Care Getting Started - Safer Healthcare Now!
Evidence-Informed |
How To Implement |
Toolbox |
Promote Self-Management and Patient Education |
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Promote Self-Management and Patient Education
REFERENCES:
Systematic Reviews
Gonçalves-Bradley D, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.
Supporting Research
Shen E, Koyama SY, Huynh DN, Watson HI, Mittman B, Kanter MH, Nguyen, HQ. 2016. Association of dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a medicare advantage population. Jama Internal Medicine. Published Online November 21, 2016.
Mekonnen AB, McLachlan AJ, Brien JA. 2016. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 6(2):e010003 2016 Feb. 23
Use Teach Back when Building Caregiver and Patient Capacity - Health Quality Ontario
Adopting a Common Approach to Transitional Care Planning - Health Quality Ontario
Re-Engineered Discharge (RED) Toolkit - Agency for Healthcare Research and Quality
Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) - Agency for Healthcare Research and Quality
Patient Oriented Discharge Summary - University Health Network Open Lab
SMART Discharge Protocol - Institute for Healthcare Improvement
Prevent Adverse Drug Events - Institute for Healthcare Improvement
LACE Tool - Health System Performance Research Network
Hospital Report Manager - OntarioMD
Medication Reconciliation Acute Care Getting Started - Safer Healthcare Now!
Evidence-Informed |
How To Implement |
Toolbox |
Medication Reconciliation |
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REFERENCES:
Systematic Reviews
Gonçalves-Bradley D, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.
Supporting Research
Shen E, Koyama SY, Huynh DN, Watson HI, Mittman B, Kanter MH, Nguyen, HQ. 2016. Association of dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a medicare advantage population. Jama Internal Medicine. Published Online November 21, 2016.
Mekonnen AB, McLachlan AJ, Brien JA. 2016. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 6(2):e010003 2016 Feb. 23
Use Teach Back when Building Caregiver and Patient Capacity - Health Quality Ontario
Adopting a Common Approach to Transitional Care Planning - Health Quality Ontario
Re-Engineered Discharge (RED) Toolkit - Agency for Healthcare Research and Quality
Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) - Agency for Healthcare Research and Quality
Patient Oriented Discharge Summary - University Health Network Open Lab
SMART Discharge Protocol - Institute for Healthcare Improvement
Prevent Adverse Drug Events - Institute for Healthcare Improvement
LACE Tool - Health System Performance Research Network
Hospital Report Manager - OntarioMD
Medication Reconciliation Acute Care Getting Started - Safer Healthcare Now!
Systematic Reviews
Gonçalves-Bradley D, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397-403.
Supporting Research
Shen E, Koyama SY, Huynh DN, Watson HI, Mittman B, Kanter MH, Nguyen, HQ. 2016. Association of dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a medicare advantage population. Jama Internal Medicine. Published Online November 21, 2016.
Mekonnen AB, McLachlan AJ, Brien JA. 2016. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 6(2):e010003 2016 Feb. 23
Use Teach Back when Building Caregiver and Patient Capacity - Health Quality Ontario
Adopting a Common Approach to Transitional Care Planning - Health Quality Ontario
Re-Engineered Discharge (RED) Toolkit - Agency for Healthcare Research and Quality
Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) - Agency for Healthcare Research and Quality
Patient Oriented Discharge Summary - University Health Network Open Lab
SMART Discharge Protocol - Institute for Healthcare Improvement
Prevent Adverse Drug Events - Institute for Healthcare Improvement
LACE Tool - Health System Performance Research Network
Hospital Report Manager - OntarioMD
Medication Reconciliation Acute Care Getting Started - Safer Healthcare Now!
How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).
Type of Indicator | Indicator of Quality Improvement | How to Calculate | Targets/ Benchmarks | How is This Indicator Used? |
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Outcome | Percentage of respondents who responded positively to the following question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? | See Indicator Library | Targets: As high as possible (set by individual hospitals) | QIP Priority Indicator |
Outcome | Risk-adjusted 30-day all-cause readmission rate for patients with chronic obstructive pulmonary disease | See Indicator Library | Targets: As low as possible (set by individual hospitals) | QIP Priority Indicator |
Outcome | Risk-adjusted 30-day all-cause readmission rate for patients with congestive heart failure | See Indicator Library | QIP Priority Indicator | |
Outcome | Risk-adjusted 30-day all-cause readmission rate for patients with stroke | See Indicator Library | QIP Priority Indicator | |
Outcome | Readmission within 30 days for selected Health Based Allocation Model Inpatient Grouper (HIG) | See Indicator Library | QIP Additional Indicator | |
Process | Total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital | See Indicator Library | Targets: As high as possible (set by individual hospitals) | QIP Priority Indicator |
Outcome | Total number of discharged patients for whom a best possible medication discharge plan was created as a proportion of the total number of patients discharged | See Indicator Library | QIP Priority Indicator |
For a more comprehensive list of tools and resources, visit the following links on our HQO website:
Creating smooth transitions between care providers is a key quality issue facing Ontario. Individuals with chronic conditions have complex care needs and require better coordination between the different levels of care. The primary quality indicator used to monitor care transitions from hospitals is the 30-day readmission rate. In 2014/15 the provincial hospital readmission rate for medical patients was 13.7 per 100 patient discharges while surgical patients was 7 per 100 patient discharges1. Patients treated for chronic obstructive pulmonary disease and heart failure had higher rates at 18.5 and 21.4 per 100 discharges respectively2. While readmissions are not always avoidable, they can indicate that the quality of care the patient received in the hospital or in the community after leaving the hospital was inadequate. Causes for a readmission within 30 days can occur due to3-6:
Addressing issues in transitional care will involve multiple health professionals in a number of health settings. Through it all, it is important that patients are kept educated about their condition and what they are responsible for.
The goal in Ontario is to reduce the number of unplanned hospital readmissions. This can be accomplished by developing personalized discharge plans, scheduling post-transition follow up appointments, facilitating patient education and self-management, and completing medication reconciliation. By implementing these practices, hospitals can improve the patient experience, enhance patient safety, and improve the overall quality of care provided. Establishing strong cross-sector collaborations will be important to implement and sustain these practices.
Available from: http://yourhealthsystem.cihi.ca/hsp/indepth?lang=en#/theme/C5001/2/N4IgKgFgpgtlDCAXATgGxALlAYwPatQEMAHAZygBNNQAGGgFkxQFcoBfDoA
Health Quality Ontario, 2016.
Available from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2016-en.pdf
J Am Geriatr Soc. 2003 Apr;51(4):549-55
Cochrane Syst Rev. 2010 Jan;20(1).
JAMA. 2004 Mar 17; 291(11): 1358-67.
Circ Cardiovasc Qual Outcomes. 2010 Mar;3(2):212-19.