Top five contributing factors that lead to care coordination events

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ECRI 'Deep Dive' digs into care coordination issues

Communication and handoffs play a key role in preventing errors tied to medication and laboratory tests

In July, doctors at the Children's Hospital of Philadelphia (CHOP) performed the first hand transplant on a child. The 10-hour surgery, performed on an eight-year-old boy who had lost his hands and feet following a serious infection at the age of two, included 40 different surgeons, doctors, and nurses.

Certainly, the first-of-a-kind surgery was a rare and special case, but for Elizabeth Drozd, MS, MT (ASCP)SBB, patient safety analyst at the ECRI Institute Patient Safety Organization in Plymouth Meeting, Pennsylvania, the overwhelming number of medical professionals involved in the surgery was emblematic of a shift toward a team-based approach throughout healthcare.

"I don't think it's necessarily new, but it is becoming very clearly associated with patient safety," she says.

Just about every inpatient stay relies heavily on a coordinated team approach. Gone are the days where one doctor would handle all of a patient's healthcare needs, from medications to follow-up diagnostic care. Now, patients are cared for by dozens of clinicians and specialists, all of whom have an important role in the plan of care. While this team-based approach has its advantages, it is also fraught with potentially risky gaps in care, as evidenced by ECRI's latest "Deep Dive" report, which identifies care coordination challenges that can lead to medical errors, diagnostic delays, and preventable patient errors.

Beyond just the number of clinicians involved in patient care, various provider settings—from hospitals, to skilled nursing facilities, to home health providers—are now working together in an effort to improve patient outcomes from start to finish.

"Coordinating a patient's care among various providers and across multiple care settings—from a hospital to a rehabilitation facility to the patient's home, or from a hospital to a skilled nursing facility—is a huge challenge," said William M. Marella, MBA, the ECRI Institute's executive director of PSO operations & analytics, in a press release. "Several events from the analysis were particularly compelling in illustrating the importance of ensuring that providers along the care continuum work together as a team and communicate among each other about the patients' care."

ECRI analyzed 223 events submitted by 38 facilities between September 2011 and January 2015, and found the following:

  • 62% of events involved care coordination during the hospital stay. The remainder occurred after discharge.
  • 38% of care coordination events in the hospital involved inadequate handoffs.
  • Of all the reported events, 51% could be traced back to medication errors, and 71% of those medication events were attributed to medication reconciliation failures.
  • Laboratory testing and diagnostic testing represented 20% of all events.


Based on these reports, ECRI also identified the top four contributing factors to care coordination events:

  • Human factors (59%)
  • Communication breakdowns (44%)
  • Unclear or missing policies and procedures (29%)
  • Staff limitations or qualifications (24%)


The report underscores the obstacles many hospitals still face in accurately identifying care coordination problems, while highlighting some of the key risk areas that can lead to patient harm.

Patient Safety Monitor Journal spoke to Drozd and Cynthia Wallace, CPHRM, senior risk management analyst at the ECRI Institute, about the key findings in the report and how hospitals can improve care coordination within their own facility. (Note: The following has been lightly edited for clarity.)


PSMJ: Was there anything about these findings that were particularly surprising or notable to either of you?

Drozd: The first thing that really surprised us was the lack of reports. As we were looking for these types of data in our database, we were really surprised at how underreported some of these events were. We would surmise that there are more events out there that just aren't being reported.

Wallace: With a lot of healthcare systems reporting programs, they might have specific event reports for medication errors, and falls, and pressure ulcers, but they don't have an event report for care coordination because care coordination can be part of a medication error or part of a fall, so it's not captured by the event reporting program.

Drozd: The other thing we saw is that it was a very common theme to find that often, care coordination events revolved around some kind of medication event. That was a very common theme that we saw in all the events we were reading early on.


PSMJ: Is that surprising, though? It seems as though medication management and medication errors are a frequent issue, generally.


Wallace: Patients are on a lot of medications. I don't know what the average is, but the average patient is certainly taking more than one or two or three medications.

Drozd: That's one of the issues that I would see quite commonly that patients would come into the hospital not just on one or two medications, but I would see patients with up to 20?30 meds, and with multiple different diseases and comorbidities, all of which are being managed by different practitioners.

Wallace: And what we would see in the events involving medications is the patients came in the hospital, and for various reasons, the doctor would order the patient to go off certain medications. Maybe it's because of surgery and they had to go off anticoagulants because of the risk for bleeding.

Then the concern that arises at discharge is: Has someone taken the appropriate steps to ensure that the doctors have evaluated the patient's need for that anticoagulant and whether they need to resume that medication?


PSMJ: When you're talking about patients that are on up to 30 medications, how do you manage that appropriately?

Drozd: This is where medication reconciliation comes in. That process is one hospitals are required to use to first determine what medication the patient is taking at the home setting. That can also be fraught with difficulty in that the patient may not be a good historian, or the patient may not bring all the medication to the hospital and forget they are taking one.

Once you get all the home medications, they decide what medication the patient should be on in the hospital during that time period. Usually that's when you get a very skilled pharmacist and the physician to partner together to make sure any new meds don't conflict with any current medications.

Then as the patient finalizes their admission and gets ready for discharge, there has to be a process of reconciling what the patient was on in the hospital, should any of those medications be stopped, and what medications should the patient be on when they return back to their home setting.

That's the ideal process, but in our report we found that wasn't always going on.


PSMJ: Why not?


Wallace: That's the $64 million question.

Drozd: As we mentioned, it's fraught with difficulty. Some of it is that is because the patient is not an accurate historian, or it may be that multiple providers with different specialties are involved.

Wallace: And multiple settings. The patient might be going from the hospital to the physician's office or the hospital to a skilled nursing facility, and does that information about medications and medications the patient is supposed to be on at discharge get communicated clearly to the next level of care?

Drozd: Other than the human aspects of all of this, we do look at systematic issues. We look at how systems in the healthcare setting really do not talk to each other. For instance, it's not always easy for the hospital to get information from the retail pharmacy about what medication the patient is currently getting. That entails generating a phone call where the pharmacists will identify the retail pharmacy and get the information that way. But that's not always easy and can be time-consuming.

Also, the primary care physician's office records don't always easily communicate with the hospital records. As much as we're in the dawn of the computer age in healthcare, we still have many systems that don't talk to each other easily.


PSMJ: What gaps exist with coordinating laboratory testing?


Drozd: One of the issues I frequently saw is often it takes time to complete lab tests and sometimes the patient is discharged before that lab test is reported out or completed. However, that lab test may have something significant to the patient. So that laboratory test then has to catch up with the patient and has to be reported to the patient's primary care physician. But the patient may not have a primary care physician. Then the lab has to seek a provider who will look at the laboratory test and provide the appropriate intervention for the patient.


PSMJ: Are there ways hospitals can navigate that in terms of coordinating those results?


Drozd: There are better systems now where some of the labs in hospitals provide primary care physicians with a discharge summary. Hospitals are taking a very close look at that, and sometimes in that discharge summary the physician dictates that there are pending tests. That's a good way to alert the primary care physician that he or she needs to make sure that they get the results on these studies that are still pending.


PSMJ: Communication was the biggest contributing factor to care coordination problems. How can hospitals improve communication and handoffs in particular?


Drozd: Handoffs and communication seems to be almost a global problem that really transitions throughout all types of different patient safety events.

There are very precise tools and processes for handoff communication. A clear process for handoff communication is also required by some regulatory agencies.

There are different processes that hospitals use. Most successful organizations have a process that is standardized throughout the hospital so everyone buys into this process. They know what they will say and they do it very quickly. And it's really on the hospital to ­standardize the process and make sure everyone uses it.

Wallace: Another method to improve communication that we talked about besides standardized handoffs was also a change of shift report where the person coming on is at the bedside with the patient and the person going off shift, and they are talking directly with each other in front of the patient about pending test results or changes in the patient's condition. And the patient, if they are able, is listening and can pipe in, or family members can pipe in too, about changes they've seen or information that they think is important to the providers.

Drozd: We know that patient and family engagement really promotes better care, so engaging the patient and if possible, engaging the family members, has been very useful because then the family, who will take the patient home and care for them, is very much aware of things and aware of the importance of treatments that have to continue after the patient leaves the hospital.


PSMJ: What human factors contribute to care coordination?


Drozd: In the report, we list things like fatigue. Physicians that are coming off a third shift or a nurse that has a very intense patient load. Stress can be a real distractor. You just have a lot of things on your plate, which can lead to inattention. And then also just cognitive factors and cognitive overload all contributed to the types of events we're looking at.

Wallace: Also, distractions. I know that in some of the events at discharge, the physician didn't sign off on certain orders. It's likely that provider had other demands and just got distracted.


PSMJ: Over the past several years, patient care has transitioned much more towards a team-based approach. In that sense, are these care coordination issues representative of some of the growing pains of that transition?


Wallace: I welcome team coordination healthcare. It's helpful to have all the providers on the same page knowing what is going on with that patient. We see team care as a real asset for care coordination, and some of these initiatives with the feds and within accountable care organizations (ACO) are really emphasizing team ­coordination, not just amongst the physicians, but amongst different settings, like hospitals, physician practices, and skilled nursing facilities.

We say this at the outset of the report, but I remember when I was a kid, my pediatrician came to my home to take care of me. Those days of [TV doctor] Marcus ­Welby taking care of the patient are just not here anymore, and because of that you really do need a team approach.

Drozd: I think it's something that has really been associated with keeping patients safe, but most physicians have always recognized the necessity to maintain a healthy team atmosphere.


PSMJ: Overall, what do you hope hospitals take away from this deep dive? How can they take this information and apply it to their own facility?


Wallace: It takes a village. It takes all the providers working together to improve care coordination. What we would like to do with this report is to get the attention of the senior leaders in healthcare facilities because to really improve care coordination amongst providers, you have to have support of senior leaders to devote the resources and the staff to the initiatives we're talking about.

So in short, the message we want to send is that this is a topic that deserves the attention of senior leaders and the board. We'd like them to be aware that these are issues that affect patient safety and patient care in their facilities, and there are strategies they can adopt to improve care for patients.

ECRI's key recommendations

In ECRI's Care Coordination Deep Dive report, the key recommendations include:



  • Provide support for the organization's care coordination improvement initiatives to mobilize stakeholders who contribute to the efforts and to provide the necessary resources and staff to support the initiatives
  • Solicit feedback from patients and family members about their care experiences
  • Consider the business case for care coordination initiatives
  • Assign a multidisciplinary team to identify improvement projects, led by a project champion to oversee daily activities
  • Support care coordination improvement strategies that incorporate error reduction techniques


Event reporting, identification, and analysis

  • Develop a safety culture, supported by nonpunitive event reporting policies, in which frontline staff, clinicians, and others recognize the value of reporting events and near misses
  • Learn to evaluate events from a care coordination perspective and consider how different event types can involve care coordination
  • Look beyond the data in event reporting programs to other data sources (e.g., case management reports, patient surveys and complaints, etc.) to evaluate care coordination processes
  • Consider ways to encourage reporting and feedback about the discharge process from physician practices and other ambulatory settings and from postacute care facilities
  • Consider using the Agency for Healthcare Research and Quality's readmissions Common Format to evaluate readmissions and identify prevention strategies

Source: ECRI Institute PSO Deep Dive Executive Summary.


Top five contributing factors that lead to care coordination events

The following are the top five reasons behind care coordination events in the inpatient setting, according to the ECRI Institute's Deep Dive report:

  • Communication
  • Human factors
  • Policies/procedures
  • Staff qualifications
  • Supervision/support


Source: ECRI Institute PSO Deep Dive: Care Coordination.