Attachment B -- Component 1_Materials

Attachment B
Component 1:
Hospital-Stay Active
Involvement Materials

Component 1
Strategy 1:
Communication Packet:
Communicating to
Improve Quality

Guide to Patient and Family
Engagement

Strategy 1
Communicating to Improve Quality
Implementation Handbook

Implementation Handbook: Communicating to Improve Quality

Implementation Handbook:
Communicating to Improve Quality
Table of Contents
Overview of the Communicating to Improve Quality Strategy................................................ 1
What are the Communicating to Improve Quality tools?........................................................ 1
Why is communication important? ......................................................................................... 3
How does the Communicating to Improve Quality strategy facilitate communication? ........ 3
Implementing Communicating to Improve Quality .................................................................. 4
Step 1: Form a multi-disciplinary team to identify areas for improvement ........................... 4
Engage patients, families, and unit staff in the process: Establish a multi-disciplinary team 4
Assess family presence or visitation policies.......................................................................... 5
Assess existing admissions materials...................................................................................... 5
Assess communication between the patient, family and clinicians ........................................ 5
Set aims to improve communication....................................................................................... 7
Step 2: Decide how to implement the Communicating to Improve Quality strategy ............. 8
Decide how to use and adapt the tools for the patient and family .......................................... 8
Decide how to use and adapt the tools for clinicians .............................................................. 9
Step 3: Implement and evaluate the Communicating to Improve Quality strategy ............. 10
Inform staff of changes ......................................................................................................... 10
Train staff .............................................................................................................................. 10
Distribute tools and incorporate key principles into practice ............................................... 10
Assess implementation intensely during the initial two weeks and periodically after that .. 11
Get feedback from clinicians, hospital staff, patients and families ...................................... 11
Refine the process ................................................................................................................. 11
References .................................................................................................................................... 12

Implementation Handbook: Communicating to Improve Quality

Implementation Handbook:
Communicating to Improve Quality
The Guide to Patient and Family Engagement in Hospital Quality and Safety (the Guide) is a
resource to help hospitals develop effective partnerships with patients and family members, with
the ultimate goal of improving hospital quality and safety.1
Communication between the patient, family, and clinicians is a critical component of high
quality, safe care, and the foundation of partnerships between the patient, family, and clinicians.
The Communicating to Improve Quality strategy and its tools help facilitate this communication.
This handbook gives you an overview of and rationale for the strategy. It also provides step by
step guidance to help you put this strategy into place at your hospital.

Overview of the Communicating to Improve Quality
Strategy
The goal of the Communicating to Improve Quality strategy is to facilitate communication
between the patient, family, and clinicians to improve patient safety and the quality of care.
Hospitals distribute three tools to the patient and family upon admission or prior to admission to
help them understand opportunities that exist for engagement, how to be a partner in their care,
and the roles of the different members of their health care team. The bedside nurse will review
the materials with the patient and family on the first day of admission.
All clinicians reinforce the principles of effective communication throughout the patient’s
hospital stay. Tools are available to help hospitals train, observe, and provide feedback to
clinicians on core communication competencies that reinforce the principles of effective
partnerships.

What are the Communicating to Improve Quality tools?
This section provides an overview of the tools included in this strategy.
Tool

Use this tool to…

Description and formatting

Tool 1

Inform the patient and
family of scheduled
opportunities where they
can interact with the
health care team.

•

This handout gives information on routine
events and highlights tools the hospital uses
to talk with the patient and family (e.g.,
white boards).

•

Format: 1-page handout

Be a Partner in
Your Care

Implementation Handbook: Communicating to Improve Quality

1

Tool

Use this tool to…

Help the patient and
family know how to
Tips for Being a
interact with the health
Partner in Your
care team.
Care
Tool 2

Tool 3
Get to Know
Your Health
Care Team

Tool 4
We Are
Partners in
Your Care

Help the patient and
family understand the
roles of different members
of the health care team.

Establish a set of
behaviors to invite and
Communication
support the patient and
Competencies
family as members of the
for Clinicians
health care team.

Prepare clinicians to
support the efforts of
Communication
patient and family
Training
engagement related to
communication.

2

•

This handout describes four tips for being a
partner: (1) tell doctors and nurses about
their health, (2) check to see if they
understand what doctors and nurses say, (3)
ask questions until they understand the
answers, and (4) let health care staff know
which friends and family members should
be involved in their care.

•

Format: Tri-fold brochure

•

This handout gives information on the
different members of the health care team:
the patient, family, clinicians and hospital
staff.

•

Format: 2-page handout

Remind the patient,
•
family, and clinicians the
importance of being
partners and what they can
do.

Tool 5

Tool 6

Description and formatting

Designed to be posted in patient rooms or
elsewhere in the hospital, this flyer
summarizes the main action items from the
other handouts for the patient, family, and
clinicians.

•

Format: Poster/ flyer

•

Given to clinicians individually with verbal
description or as a handout during the
clinician training, this overview and
checklist highlight behaviors that invite and
support the patient and family to engage in
their care.

•

Format: 2-page overview with 1-page
observation form checklist

•

This training could be interprofessional,
coled by a physician, nurse, and patient and
family advisors to a group of clinicians,
who may also include other professionals
besides physicians and nurses.

•

Format: PowerPoint presentation slides and
talking points

Implementation Handbook: Communicating to Improve Quality

Rationale for the Communicating to Improve Quality
Strategy
The goal of patient and family engagement is to create an environment where patients, families,
clinicians, and hospital staff all work together as partners to improve the quality and safety of
hospital care. Patient and family engagement encompasses behaviors by patients, family
members, clinicians, and hospital staff as well as the organizational policies and procedures
that support these behaviors.

Why is communication important?
Communication is the foundation of partnerships between the patient, family, and clinicians, and
affects the safety and quality of care received during the hospital stay. Effective communication
can improve:
•

Patient outcomes. In a review of the literature, Roter found that patient-centered care,
realized through effective communication, had a positive effect on patient outcomes –
specifically, emotional health, symptom resolution, functioning, pain control, and
physiologic measures such as blood pressure and blood sugar levels.(1)

•

Patient safety. One study found that more than 70 percent of adverse events are caused by
breakdowns in communication among caregivers and between caregivers and patients.(2)
Studies show that patients who are informed and engaged can help improve safety through
“informed choices, safe medication use, infection control initiatives, observing care
processes, reporting complications, and practicing self-management.”(3, 4)

•

Perceptions of quality. Research has demonstrated that patient and family members’
perceptions of quality are influenced by their perceptions of their interpersonal interactions
with clinicians and hospital staff. Clinicians who are perceived to be responsive, empathetic,
and attuned to patients’ needs are judged to be of higher quality by patients than clinicians
who are perceived to be less responsive and empathetic, even if the clinical care provided is
the same.(5-7)

How does the Communicating to Improve Quality strategy facilitate
communication?
The Communicating to Improve Quality strategy identifies effective communication behaviors
for patients, families, and clinicians that are the foundation for partnerships throughout the
hospital stay. The strategy supports behavior change through individual tools. Specifically, the
tools in this strategy:
•

Invite the patient and family as full partners in their care at admission or prior to
admission, setting expectations for the entire hospital stay.

Implementation Handbook: Communicating to Improve Quality

3

•

Give the patient and family background information about the hospital environment.

•

Describe specific behaviors that the patient and family can do as a part of the team.

•

Describe specific communication competencies for clinicians to invite and support the
patient and family as partners of the health care team. These competencies are expected
of all clinicians at the hospital.

(Placeholder for examples from Task 7, Implementation and Evaluation in this section in the
form of patient/family/staff quotes or a case study.)

Implementing Communicating to Improve Quality
(NOTE: This is a section where we will want to incorporate information from the Task 7
Implementation and Evaluation. We will also be able to provide more specific guidance about
what worked and what did not work.)
The Communicating to Improve Quality strategy is designed to be flexible and adaptable to each
hospital’s environment and culture. As such, this guidance provides choices and questions for
hospital leaders about how to implement this strategy. It may be helpful to implement this
strategy initially on a small scale (for example, on a single unit). After identifying lessons
learned from the single-unit implementation, you can refine your approach and spread it to more
units. This allows you to build on your successes as a pathway to broader dissemination and
wider-scale change.

Step 1: Form a multi-disciplinary team to identify areas for
improvement
As with any new activity or quality improvement effort, planning and identifying areas of
improvement are important parts of the process. Below are some key considerations as you get
started implementing the Communicating to Improve Quality strategy.
Engage patients, families, and unit staff in the process: Establish a multidisciplinary team
A multi-disciplinary team includes hospital leaders, physicians, nurses, other key clinical and
management staff, and patient and family advisors.
Guide Resource

For more information about working with patient and
family advisors, see Component 2, Implementation
Handbook: Organizational Partnership Materials

Throughout the process of implementing the Communicating to Improve Quality strategy, patient
and family advisors can:
4

Implementation Handbook: Communicating to Improve Quality

•

Give feedback on what the current admission process, communication, and overall
hospital stay feel like as a patient or family member.

•

Help adapt the strategy and tools for your hospital.

•

Take part in training clinicians about the Communicating to Improve Quality strategy by
participating in role plays or other small group exercises or by describing how it feels to
be the patient or family in your hospital.

•

Observe clinicians throughout hospital stay and give feedback about how well they meet
the key elements of the communication competencies.

Assess family presence or visitation policies
The family cannot be partners of the health care team if they are not present. It is important for
patients to define who their family is and for the hospital to define policies that support the active
involvement of families.
Guide Resource

For more information about family presence policies, see
Supporting Patient and Family Engagement: Best Practices
for Hospital Leaders (in the Component 3 materials).

Assess existing admissions materials
Use the multi-disciplinary team to review information provided during current admission process
from the provider, patient, and family perspective. What, if anything, happens during admission
to engage patients and families in their care? How well does this process work? What
information is given? Who gives the information? What are potential barriers or challenges
within the unit when distributing these materials and expectations are set for the clinician
behaviors, including organizational infrastructure or staff attitudes? What are some ways to
overcome those challenges? What resources are available?
Assess communication between the patient, family, and clinicians
Use the multi-disciplinary team to review how things are going with respect to communication
from the clinician, patient, and family perspectives, using both formal survey measures and
people’s sense of what works or does not work. The team can identify strengths related to
communication –what is done well? The team can also identify areas for improvement – what
can be done better?
Improving communication may require new behaviors from each member of the health care team
– the patient, family, and clinicians. Each team member brings a different perspective to the
communication encounter, and understanding these perspectives is important for effective
communication.

Implementation Handbook: Communicating to Improve Quality

5

Keep in mind that taking on new behaviors will be challenging. Think about what challenges
might be present in your environment as you decide how to use the tools in this strategy. The
multi-disciplinary team can help identify challenges and facilitators for effective communication
at your hospital or unit. What factors seem to support good communication? How can you
replicate them? What are the challenges that need to be addressed from the clinician, patient, and
family perspectives?
Below, are some examples of communication challenges for the patient, family, and clinicians.
The tools in the Communicating to Improve Quality strategy were designed to help address these
challenges.
Examples of communication challenges for the patient and family. Some patients and family
members may already feel capable of being an active partner in their care. Other patients or
family members may:
•

Feel uncertain or intimidated about taking part in their care. Patients and family
members may be unsure how to be involved or may feel intimidated by clinicians,
hospital staff, and the health care system, overall.(8, 9) The patient and family especially
may feel intimidated if clinicians use professional language or medical jargon.(10, 11)

•

Need more information to be full partners in their care. Clinicians can help increase the
patient and family’s awareness and confidence in taking part in their care by giving them
information about their condition and steps in their care regularly throughout the hospital
stay. Information is most helpful when it addresses the patient and family’s individual
needs and concerns.(12)

•

Need an invitation and reinforcement from clinicians. Although information is
necessary, it is not sufficient to support behavioral change. The patient and family need
clinician support and reinforcement to engage in their care. Patients are more likely to
take part in their care when clinicians encourage them to ask questions, respond
positively to the patient’s needs and views, and give patients the information they
need.(13-15)

Examples of communication challenges for clinicians. The more difficult challenges
underlying this strategy are changing clinicians’ communication styles and behaviors to invite
and support the patient and family as full partners of the health care team. Some common
challenges are:
•

6

Clinicians may feel that their communications are already patient- and family-centered
or may not know how to incorporate new communication approaches into their care.
Clinicians may focus on the clinical aspects of quality of care, such as skills in
diagnosing, treating, and obtaining positive clinical outcomes. Although many clinicians
recognize the importance of communication as a component of quality, they tend to be
Implementation Handbook: Communicating to Improve Quality

overly positive in their perceptions of how effectively they communicate.(16) Even when
clinicians see the need for better communication and patient-centered care, it may be
difficult to operationalize those skills in practice.(17)
•

Professional culture and practice norms traditionally have emphasized technical skills
over communication skills. Professional culture and practice norms have traditionally
been based on individual autonomy, rather than teamwork and patient-centered
practices.(18) Clinicians lack experience with models that encourage collaboration with
the patient and family. Traditionally, professional schools (including medical schools and
academic programs that train health care leadership) have offered limited or no emphasis
on patient and family engagement.(19)

•

Clinicians may be concerned about interacting with the family. Concerns associated
with family presence include potential interference with treatment, medical risk (e.g.,
exposure to infections), or the emotional response of the family member.(20) Or,
clinicians may be uncertain how to act when the patient and family want different
approaches to treatment.

Identify ways to overcome these challenges at your hospital or unit. Are there particular units
where it might be wise to pilot this new approach, either because of staff attitudes or because
there is a pressing need to improve communication for a specific group of patients?
Set aims to improve communication
Once you have a strong understanding of the existing family presence policies, admissions
materials, and communication challenges and facilitators, you can identify what needs to be
improved and ways to measure that improvement.
For more information on setting aims and
identifying measures, see the Institute of
Healthcare Improvement’s Web site on
improvement methods. Available at:
http://www.ihi.org/IHI/Topics/Improvement
/ImprovementMethods/HowToImprove/.

Any quality improvement initiative requires setting
aims. The aim should be time-specific, measurable,
and define who will be affected. For example,
hospitals may want to improve patients’ experience
of care as measured by the CAHPS® Hospital
Survey. CAHPS® Hospital Survey questions related
to communication include:
•
•

Q1: During the hospital stay, how
often did nurses treat you with
courtesy and respect?
Q2: During this hospital stay, how
often did nurses listen carefully to
you?

Implementation Handbook: Communicating to Improve Quality

•
•

Q3: During this hospital stay, how
often did nurses explain things in a
way you could understand?
Q5: During this hospital stay, how
often did doctors treat you with
courtesy and respect?

7

•

Q6: During this hospital stay, how
often did doctors listen carefully to
you?
Q7: During this hospital stay, how
often did doctors explain things in way
you could understand?
Q14: During this hospital stay, how
often did the hospital staff do
everything they could to help you with
your pain?

•
•

•
•

Q16: Before giving you any new
medicine, how often did hospital staff
tell you what the medicine was for?
Q17: Before giving you any new
medicine, how often did the hospital
staff describe possible side effects in a
way you could understand?

If a hospital wants to improve their CAHPS® Hospital Survey scores related to physician
communication, an aim might be “to improve scores on CAHPS® Hospital Survey Questions 5,
6, and 7 by 5 percent within 1 year.”

Step 2: Decide how to implement the Communicating to Improve
Quality strategy
Once the team has set specific aims for improvement, it is helpful to identify a single point
person as the primary person staff would go to with questions. This person may not have the
answers to all questions, but would be able to facilitate the process of getting answers. This way,
people are clear about whom to go to, and that person will hear all the questions and concerns.
Then, the single point person can coordinate with the multi-disciplinary team to decide on how to
use and adapt each of the tools in this strategy.
Decide how to use and adapt the tools for the patient and family
As described above, the Communicating to Improve Quality strategy includes three tools to be
distributed to the patient and family at or prior to admission.
Guide Resources

Tool 1: Be a Partner in Your Care informs the patient and
family of scheduled opportunities where they can interact
with the health care team.
Tool 2: Tips for Being a Partner in Your Care helps the
patient and family know how to interact with the health
care team.
Tool 3: Get to Know Your Health Care Team helps the
patient and family understand the roles of different
members of the health care team.

8

Implementation Handbook: Communicating to Improve Quality

Answer the following questions to decide how to use and adapt the patient and family tools at
your hospital:
•

Adapt the patient and family tools to hospital needs. At a minimum, you will need to
insert your hospital name, logo, and tailored information into the patient and family tools.
Do clinicians, hospital staff, or patient and family advisors recommend additional
changes? If so, how will these changes be made? Who needs to review and approve the
final tools?

•

Determine how to distribute the patient and family tools. Can the tools be integrated into
current admissions process? If so, how? If not, how will the current process be changed?
How will interpreters be involved in the distribution process, if needed? What approvals
need to be sought?
Once ready, how will the tools be printed? Will they be distributed in a folder, online, or
another way? How can the messages from the tools be incorporated or distributed via
different communication methods such as video, social media such as Facebook, or cell
phone text messages?

•

Identify staff to go over tools with the patient and family. What staff will go over the
tools with patients and families? (We recommend that this be the bedside nurse on the
day of admission.) If applicable, how will temporary staff learn about the communication
competencies and distributing the tools to the patient and family?

Decide how to use and adapt the tools for clinicians
As described above, the Communicating to Improve Quality strategy includes two tools for
clinicians.
Guide Resources

Tool 5: Communication Competencies for Clinicians
establishes a set of behaviors to invite and support the
patient and family as members of the health care team.
Tool 6: Communication Training prepares clinicians to
support the efforts of patient and family engagement related
to communication.

Answer the following questions to decide how to use and adapt the clinician tools at your
hospital:
•

Adapt the clinician tools to hospital needs. What changes have been made to the patient
and family tools that impact the clinician communication competencies or clinician
communication training? Do clinicians, hospital staff, or patient and family advisors

Implementation Handbook: Communicating to Improve Quality

9

recommend changes to the clinician competencies or training? If so, how will these
changes be made? Who needs to review and approve the final tools?
•

Plan the clinician training. Which physician(s) and nurse(s) can conduct the training for
their colleagues? These training facilitators should be respected by their colleagues and
model the behaviors being asked of them. Which patient and family advisors can help to
conduct or facilitate the training? How many sessions are needed to train all staff? When
can the training be scheduled? Where can the training happen?
Recognize that communication is a skill that can be taught and learned, but not without
continual feedback and followup. A systematic review of randomized control trials found
that interventions that improved clinician communication behaviors often used three or
more different strategies to change behaviors, such as giving information, modeling
behavior, providing feedback, and practicing skills.(21)

Step 3: Implement and evaluate the Communicating to Improve
Quality strategy
Inform staff of changes
If not already involved, inform unit directors and managers what is coming and why it is
important. Inform staff at staff meetings and through posters in common rooms about the
changes and opportunities for training.
Train staff
Staff training can include physicians, nurses, and other clinical providers. Training includes a
mix of PowerPoint and role play. The main message to emphasize is: To improve safety and
quality, communication between clinicians, the patient, and family is critical. Nurses and doctors
need to invite and support the patient and family to engage in their care. After the training, it is
important to assess:
•

Did the training happen as planned? What happened during training that could challenge
or facilitate implementation?

•

How did staff react to training? What about the training could be improved?

Distribute tools and incorporate key principles into practice
As defined during Step 2, the unit staff will distribute and go over tools with the patient and
family. Clinicians should emphasize that the patient and family are important members of the
health care team and that we want to hear from you about your care.
Keep staff aware of communication expectations by posting flyers about expectations for the
patient, family, and clinicians. These flyers can be posted in all patient rooms and around staff
10

Implementation Handbook: Communicating to Improve Quality

areas, such as the nursing station, break room, or bathrooms, or in patient rooms. Consider
moving posters throughout implementation so hospital staff will continue to pay attention.
Guide Resource

Tool 4: We Are Partners in Your Care is a flyer that
reminds the patient, family, and clinicians the importance
of being partners and what they can do.

Assess implementation intensely during the initial two weeks and periodically
after that
Make sure that staff members have supports needed to effectively communicate and distribute
the patient and family tools. Have a nurse manager or other staff leader observe interactions with
the patient and family, and provide feedback to individual nurses and physicians for the first 2 to
4 weeks. Use a standardized form to keep track of the observations, such as the checklist that is a
part of Tool 5: Communication competencies for clinicians. Identify a way to analyze data
collected, such as in an Excel spreadsheet or other database.
Continue to conduct periodic observations for 2-months and 4-months after roll-out to ensure
consistency of implementation among staff. Continual feedback and monitoring is needed to
make sure behaviors become more natural.
Get feedback from clinicians, hospital staff, patients and families
Get informal feedback from clinicians, hospital staff, patients, and family members by asking
them about how communication and the tools can be improved. What worked well? What could
be improved? How could we change or adapt these tools for another unit? What was critical for
success? What was not successful and what could have made is better?
Incorporate formal feedback in mechanisms already in place at hospital such as patient and
family focus groups, patient and family satisfaction surveys, and staff surveys.
Refine the process
Share feedback with implementation team, problem solve, and adapt, as necessary. Using the
feedback received, refine process and tools before implementing in other units.

1

The Guide was developed for the Agency for Healthcare Research and Quality (AHRQ), in the U.S. Department of
Health and Human Services, by a collaboration of partners with experience in and commitment to patient and family
engagement, hospital quality, and safety. Led by the American Institutes for Research (AIR), the team included the
Institute for Patient and Family-Centered Care (IPFCC), Consumers Advancing Patient Safety (CAPS), the Joint
Commission, and the Health Research and Educational Trust (HRET). Other organizations contributing to the
project included Planetree, the Maryland Patient Safety Center (MPSC), and Aurora Health Care.
Implementation Handbook: Communicating to Improve Quality

11

References
1.
Roter D. Which facets of communication have strong effects on outcome: a metaanalysis. In: Stewart M, Roter D, editors. Communicating with medical patients. Newbury Park,
CA: Sage; 1989.
2.
The Joint Commission. Improving America's hospitals: The Joint Commission's Annual
Report on quality and safety. 2007. Available from:
http://www.jointcommission.org/Improving_Americas_Hospitals_The_Joint_Commissions_Ann
ual_Report_on_Quality_and_Safety_-_2007/.
3.
Charmel PA, Frampton SB. Building the business case for patient-centered care. Healthc
Financ Manage. 2008;62(3):80-5.
4.
Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving
patients. BMJ. 2007;335(7609):24-7.
5.
Carman KL, Maurer M, Yegian JM, Dardess P, McGee J, Evers M, et al. Evidence that
consumers are skeptical about evidence-based health care. Health Aff(Millwood).
2010;29(7):1400-6.
6.
Attree M. Patients' and relatives' experiences and perspectives of 'Good' and 'Not so
Good' quality care. J Adv Nurs. 2001;33(4):456-66.
7.
Levine R, Shore K, Lubalin L, Garfinkel S, Hurtado M, Carman K. Comparing physician
and patient perceptions of quality [unpublished work]. 2010.
8.
Corlett J, Twycross A. Negotiation of parental roles within family-centred care: a review
of the research. J Clin Nurs. 2006;15(10):1308-16.
9.
MacKean GL, Thurston WE, Scott CM. Bridging the divide between families and health
professionals' perspectives on family-centred care. Health Expect. 2005;8(1):74-85.
10.
Carman K, Devers K, McGee J, Dardess P, Hibbard J. Ensuring positive physicianpatient communication about hospital quality information (presentation). 2006.
11.
Efraimsson E, Sandman PO, Rasmussen BH. "They were talking about me"--elderly
women's experiences of taking part in a discharge planning conference. Scand J Caring Sci.
2006;20(1):68-78.
12.
Eldh AC, Ekman I, Ehnfors M. Conditions for patient participation and non-participation
in health care. Nurs Ethics. 2006;13(5):503-14.
13.
Martin LR, DiMatteo MR, Lepper HS. Facilitation of patient involvement in care:
development and validation of a scale. Behav Med. 2001;27(3):111-20.
14.
Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff
on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf
Health Care. 2008;17(2):90-6.
15.
Davis RE, Jacklin R, Sevdalis N, Vincent CA. Patient involvement in patient safety: what
factors influence patient participation and engagement? Health Expect. 2007;10(3):259-67.
12

Implementation Handbook: Communicating to Improve Quality

16.
Makoul G, Arntson P, Schofield T. Health promotion in primary care: Physician-patient
communication and decision making about prescription medications. Soc Sci Med. 1995
Nov;41(9):1241-54.
17.
Bruce B, Letourneau N, Ritchie J, Larocque S, Dennis C, Elliot R. A multisite study of
health professionals' perceptions and practices of family-centered care. J Fam Nurs.
[10.1177/107484002237515]. 2002;8(4):408-29.
18.
Degeling P, Kennedy J, Hill M. Mediating the cultural boundaries between medicine,
nursing and management--the central challenge in hospital reform. Health Serv Manage Res.
2001;14(1):36-48.
19.
Johnson B, Abraham M, Edgman-Levitan S, Sodomka P, Schlucter J, Ford D. Partnering
with patients and families to design a patient-and-family-centered health care system. Bethesda,
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Duran CR, Oman KS, Abel JJ, Koziel VM, Szymanski D. Attitudes toward and beliefs
about family presence: a survey of healthcare providers, patients' families, and patients. Am J
Crit Care. 2007;16(3):270-9.
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Rao J, Anderson L, Inui T, Frankel R. Communication interventions make a difference in
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[0025-7079/07/4504-0340]. 2007;45(4):340-9.

Implementation Handbook: Communicating to Improve Quality

13

Be a Partner in Your Care
We work as a team to make sure you get the best care.
The health care team includes you, family or friends of your choice, doctors, nurses, other
clinical providers, and hospital staff. At [insert hospital name], our staff will:
•

Give you timely and complete information about your care.

•

Ask about and listen to your concerns.

•

Explain things in a way that you can understand.

•

Encourage and support your choices.

•

Involve family and friends in ways that you wish.

You are an important part of the health care team.
If anything has been less than perfect about your care, we want you to speak up.
Talk to any member of your health care team at any time. Also, there are times that hospital
staff are usually available:
•

Doctors will visit your room once or twice a day [insert time range if able]. This is
a good time to raise any questions you have. The time the doctor visits may vary
from day to day. If you or your family needs to talk to a doctor at any time, please
let your nurse know.

•

Nurse shift changes occur when nurses who are going off duty share information
about you with nurses coming on duty. Your nurses will change shifts between
7 and 7:30 am and 7 and 7:30 pm. At [insert hospital name] this happens right by
your bedside, so you can be involved. If you would like, you can invite family or
friends to take part as well.

•

When plans are being made for your care after the hospital stay, we will include
you, family, and your caregivers. We want to make sure you have what you need to
take care of yourself when you leave the hospital.

•

If you have questions at any time during your stay, you can also [write them down
on the notebook next to your bed or on the white board in your room].

We’re in this together!
Please ask questions, share what you know, and let your health care team know about your
needs and concerns. Remember, you are an essential member of your health care team!
Communication Tool 1: Be a Partner In Your Care

1

Be a Partner in Your Care
At [insert hospital name], we want you and
family or friends of your choice to be partners
in your care.
Doctors and nurses may know more
about medicine, but you and your family
or friends know more about you and your
body. That is why working together as
partners is so important.

Tip 1: Tell us information about
your health
We want you to share with us what you see,
think, and feel. If something is important to
you, we want to know it.
When you are in the hospital, doctors and
nurses will talk with you about:
•
•
•
•
•
•
•

Your health before this hospital stay.
Medicines, vitamins, and herbal
supplements you are taking.
Allergies to medicines or foods.
How you feel during and after
treatment.
Any pain you may feel.
Any changes in your health while you
are in the hospital.
Plans for you after you leave the
hospital.

Do not assume that your doctor or nurse
knows everything about you.

Tip 2: Check if you understand
what your doctors and nurses
tell you
To help make sense of all the information you
get while you are in the hospital:
Repeat what doctors and nurses say in your
own words. After your doctor or nurse tells
you something, try saying “Let’s make sure I
have this right” and then repeat the main
points back in your own words. This helps
your doctors and nurses know right away if
they did not explain something well. That
way, they can explain it again more clearly.
Take notes. It can be hard to remember all of
the information you get in the hospital. It is
helpful to write down what the doctors and
nurses tell you. Family or friends can help you
do this.
Visit the hospital resource center, patient
education center, or library. To get more
information on your own, these areas in the
hospital have information and materials that
are easy to read. Also, you can also always ask
your doctors and nurses about how to find
more information.

Tip 3: Ask questions until you
understand the answers
You and family or friends will probably have
questions about your care in the hospital.
Asking questions is not always easy. Use these
suggestions to help:
Be prepared. Keep a notebook in your room
and write down questions as you think of
them. Your family and friends can help with
this.
Speak up if something is unclear or
confusing. It is important to let doctors and
nurses know right away if there is something
you do not understand. You can say, “I’m not
sure I understand what you just said. Can you
tell me again?”
Keep asking until you understand. If you
got an answer, but still do not understand,
please ask again. You can say, “I still don’t
understand. Can you try explaining it to me in
a different way?”
Ask questions about your medicines. Ask
what each new medicine is for, how often you
need to take it, and if it is the right amount, or
dose. If you are worried about taking any
medicine for any reason, tell your doctor or
nurse before you take it.

Tip 4: Tell us who and how you
want your friends or family
members to be involved
Your family or friends are welcome at [insert
hospital name]. Family or friends can:
•
•
•
•
•

Give you comfort and support.
Help you keep track of and understand
information about your health.
Make sure your health care team is
aware of any concerns.
Tell a doctor or nurse if they notice a
change in your condition.
Find a nurse when help is needed
urgently.

Important contact information
If you have questions or concerns about
the quality or safety of your care during
your hospital stay, contact our [insert
Quality Coordinator name and title] at
[insert phone number].

For questions about cost, insurance, or
billing during your hospital stay, contact
our [insert Billing Specialist name and
title] at [insert phone number].

Tips for
Being a
Partner in
Your Care

It is up to you to say who you want to be
involved. If you do not want us to share
private information about your health with
them, let us know.

Remember—
You and your family or friends are a vital part
of your health care team.
We want you to ask questions, understand the
answers, share observations, and be an active
partner in your care.

Being a partner in your care helps you get
the best care possible while you are in the
hospital. It also helps you learn how to
care for yourself after you leave the
hospital.
This brochure has four tips to help you
and your family or friends work with
doctors, nurses, and other members of
your health care team while you are in the
hospital.

Communication Tool 2: Tips for Being a Partner in Your Care

Get to Know Your Health Care Team
Getting to know your health care team helps you get the best care possible. This handout tells
you about the different members of your health care team and what they do. The members of the
health care team include:
“Different people would come into my room
• You and family or friends of your choice.
at different times and for different reasons
• Different types of doctors and nurses.
while I was in the hospital. It helped that the
hospital staff all wore name badges large
• Other clinical providers and hospital staff.
When they enter your room, all hospital staff should
tell you their name, who they are, and what they do.
If you don’t know who someone is or why they are in
your room, ask them!

enough for me to read. The name badges
gave their name and their position in the
hospital.” -Jack, patient

You and family or friends of your choice
You and family or friends of your choice are part of the health care team. Doctors and
nurses may know more about medicine, but you are the expert on you! It is up to you to say who
is your family and how they are involved in your care. For us, families are not visitors, but a part
of the team. They can give you comfort and support. They also can tell your doctors and nurses
about your needs and concerns.

Doctors
Attending physicians are in charge of your care. The attending physician usually comes to see
you once or twice a day while you are in the hospital. The attending physician may be your
primary doctor, a specialist, or a doctor who works for the hospital. Ultimately, the attending
physician is the person responsible for the quality of care delivered to each patient. If you have
any questions about your care, the attending physician can answer them.
Name of attending physician: _______________________________________________
Contact information: ______________________________________________________
[If not a teaching hospital, delete this section] Doctors in training, called “house staff,” are
doctors supervised by the attending physician. These doctors have completed medical school
and are getting additional training. They will talk to you about your health history and
symptoms, work with you to find the right treatments, and help do routine procedures. There are
several different types of doctors in training:
• Fellows have completed their residency and have almost all responsibilities of the attending
physician. They have chosen to do an advanced training in a particular specialty, called a
“fellowship.”
• Residents have completed medical school and passed national and state board exams, but
they cannot work on their own without supervision. Most residents complete at least 3
years of training, but some doctors, especially surgeons, complete 6 or 8 years.
• Interns are first-year residents.

Communication Tool 3: Get to Know Your Health Care Team

1

Nurses
Registered Nurses (RNs) take care of you at the bedside. They spend the most time with you.
They can give you medicines, take care of your wounds, and make sure everything is going
okay. Registered nurses can help with any questions
“Nurses work with everyone in the
you have. If they don’t have the answers, they will find
hospital. They are often the best
out and get back to you.
Licensed Practical Nurses (LPNs) [or Licensed
Vocational Nurses (LVNs)] provide basic nursing
services. They can perform simple medical procedures
under the supervision of a doctor or a registered nurse.
They may give you medicines or take your blood
pressure, heart rate, and temperature.

people to ask when you have
questions. If nurses don’t know the
answers right away, they can find
out and get back to you quickly.”
–Emily, family member

Certified Nurses’ Aides help licensed nurses but do not have a license for patient care. Nurses’
aides help patients with their basic needs such as eating, drinking, walking, bathing, and going to
the bathroom.
Nurse supervisors are responsible for the nursing care on your unit. Nurse supervisors can
be charge nurses or nurse managers.
• Charge nurses supervise the bedside nurses on the unit. Charge nurses may also be called
shift leaders or clinical team leaders.
• Nurse managers supervise charge nurses. They help to make sure that the hospital meets
all standards and regulations.

Other clinical providers
Physician assistants are not doctors, but are licensed to provide care, and are supervised by
doctors. They help doctors by doing many things the doctor does. They may talk to you about
your health history and symptoms, order lab tests, help with surgery, and write prescriptions.
Advanced Practice Nurses can take greater responsibility for patient care than other
nurses. These nurses have completed school beyond nursing school. They can prescribe
medicine and help you make treatment decisions. They may also be called Clinical Nurse
Practitioners or Clinical Nurse Specialists.

Other members of your health care team
Other clinical providers are pharmacists, lab technicians, dieticians, phlebotomists (someone
who is trained to draw blood), physical therapists, occupational therapists, respiratory therapists,
and others.
Other staff members include social workers, case managers, interpreters, patient advocates,
patient safety officers, housekeeping staff, librarians, chaplains or clergy, volunteers, admissions
staff, and financial staff.
Other members of your health care team help with your care in different ways. Ask the nurse in
charge of your care if you want to talk with them.
2

Communication Tool 3: Get to Know Your Health Care Team

Partners Flyer/Poster

We are partners in your care!
We work to make sure you get the best
care possible. We will:
•
•
•
•
•

Give you timely and complete information.
Ask about and listen to your concerns.
Explain things in a way that you can understand.
Encourage and support your choices.
Involve family and friends in ways that you wish.

What can you do?
• Tell doctors and nurses about your health.
Tell us what you see and feel. Don’t assume we know
everything about you.
• Check if you understand what doctors and nurses
tell you. Repeat back what they say in your own
words.
• Ask questions. Ask questions until you understand
the answers. Make sure you get the information you
need.
• Tell us who you want involved in your care. You
get to decide if you want family or friends to take part
in conversations about your health.
Communication Tool 4: Partners Poster/Flyer

1

Communicating to Improve Quality:
Communication Competencies
Ove rvie w o f Co m m u n ic a tio n Co m p e te n c ie s
Effective communication between clinicians, patients, and families can lead to better health care
outcomes and improved quality and safety. The following list identifies behaviors to help
clinicians build partnerships with patients and families, leading to better health care quality and
safety.

Wh e n yo u e n te r th e ro o m ...
Read patient information before entering the room.
Make eye contact with the patient, not a machine or other medical professional in the room.
Smile, if appropriate. Your smile should be genuine and not forced.
Introduce yourself by name and your role in the patient’s care.
Hi, Mrs. Smith. It’s your nurse, Mary. Is there anything I can do for you now?
Introduce any new people in the room, their role, and what they will do.
I’d like you to meet Dr. Nancy Burns. She’s a specialist that is going to help manage your sugar.
If it’s okay with you, she is going to talk with you.
Have conversations at eye level.

Wh e n yo u a s s e s s th e p a tie n t...
Ask how the patient prefers to be addressed (for example, by first or last name).
Identify family that should be “team members” or “partners in care” and put their names on
the white board in the patient’s room. Let the patient define who family is. Family can give you
information that you don’t know about the patient. They also need to know about the patient’s
health so they can take care of the patient at home.
You may want family or friends to take part in conversations about your health or health care.
Who would you like to be involved?
Who is going to help you once you get home? Do you want that person/these people to take part
in this talk? How would you like these people to be involved in conversations about your care
while you’re in the hospital?
Make sure the patient has Communication Tools 1-3 and highlight the main points.
We are here to help you. I know the technical stuff, but I am not an expert about you. When it
comes to you, you’re the expert.
Please tell us what you want and need, ask questions, and share any concerns you have about
your health.
Invite the patient and family to use the white board as a communication tool.
The white board can help us talk with each other. Please feel free to write notes, questions, or
concerns on the white board. Here is the pen.

Communication Tool 5: Communication Competencies for Clinicians

1

Th ro u g h o u t th e h o s p ita l s ta y
Include the
patient and
family as
members of
the health
care team

Ask about
and listen to
the patient
and
family’s
needs and
concerns

Invitation behaviors:
Invite patients and families to engage
• Welcome the patient and family as partners of
the health care team. Acknowledge their
expertise.
− We may know more about medicine, but
you know more about you and your body.
We want you to share what you are feeling
and experiencing with us, so that we can
provide the best care possible.

Supportive behaviors:
Support patients and families
• React positively when people ask
questions, volunteer information,
share concerns, or want to
participate in treatment decisions.
− Don’t say: Don’t worry – we have
done this hundreds of times. Say:
This procedure takes a picture of
how your knee is looking after
surgery. It helps us follow your
progress. It does have a small
amount of radiation, but should
not hurt you.

• Use open-ended questions to encourage the
patient and family to share information about
their health.
− What is going well right now? What
problems are you having?
− What has been less than perfect in your
care?
− What questions do you have?

• Listen to, respect, and act on the
observations and values of the
patient and family.
− Thanks for letting us know about
that drug allergy, Mrs. Jackson.
Let me note this in your record.
We’ll find another medication.

• Try to see the experience through their eyes.
Curiosity and judgment cannot exist in the
same space.
Help the
patient and
family
understand
the
diagnosis,
condition,
and next
steps in
their care

• Give timely and complete information about
the patient’s condition. Review information
with the patient and family at every
opportunity - during rounds, shift report,
medication administration, and discharge
planning meetings.
• Check that patients really understand by using
“teach back”
− Don’t say: Do you understand? Say: I want
to make sure I explained that clearly. Do
you mind repeating what I just said in your
own words?
• Share as much information as they want; find
out how much they want to know:
− Is there anything else you would like to
know? Are you the kind of person who
wants the overall picture, or do you want to
get the details?

2

• Help people articulate their concerns
when needed.
− I see something is bothering you.
Please feel free to share it with me.
I may be able to help.
• Slow down.
• Use plain language. Use words
everyone can understand. Break
messages into shorter statements.
• Invite the patient or family to take
notes.
• When you can’t answer a question,
let them know you will find
someone with the answer. Also let
them know when to expect the
answer.
− I don’t have that information, but I
will talk with the pharmacist about
it and get back to you, or have him
come and talk to you by this
afternoon. Will that work?

Communication Tool 5: Communication Competencies for Clinicians

Building Partnerships for Safe Care: Observation Form and Checklist
Clinician Name: _____________________________________________________________________________________________
Entering the room

Initial assessment

Throughout encounter

_____Made eye
contact with
patient

_____Asked how patient
prefers to be
addressed

Invitation behaviors: Inviting patients and families to engage

_____Smiled, as
appropriate

_____Identified family or
friends who are team
members, names
written on white board

_____Used open-ended questions

_____Introduced self
by name and
role
_____Introduced new
people in the
room, their
role, and what
they will do
_____Had
conversations
at eye level

_____Welcomed patient and family as part of health care team

_____Gave complete information about the patient’s condition
_____Used “teach back”

_____Highlighted main
points of
Communication Tools
1-3

_____Found out how much the patient/family wanted to know
Supportive behaviors: Supporting patients and families as they engage
_____Reacted positively when people engaged
_____Listened to and respected observations and values of patient and
family
_____Helped people articulate their concerns when needed
_____Used plain language
_____Invited patient and family to take notes
_____Identified others to answer questions if needed

Notes:

Communication Tool 5: Communication Competencies for Clinicians

3

Insert hospital logo here

Communicating to Improve Quality:
Clinician Training

[Insert hospital name, presenter name and title, date
of presentation]
Communication Tool 6: Clinician Training Presentation

Today’s session

 What is patient and family engagement?
 What is the patient and family
experience in our hospital?
 Communicating to Improve Quality
♦ What are we asking patients and
families to do?
♦ What are we asking you to do?
 Practice exercises

What is patient and family
engagement?

Hospital quality





Patients get care that is safe



No differences in treatment based on race,
ethnicity, income, education, or social status



Care is patient- and family-centered

Patients get the right care for their condition
Patients get care they need when they need it
Patients get care that makes wise use of
resources

Patient- and family-centered care


Mutually beneficial partnerships among
clinicians, hospital staff, patients, and families



Core concepts:
♦

Dignity and respect

♦

Information sharing

♦

Participation

♦

Collaboration

What is patient and family engagement?


Critical component of patient- and familycentered care



Patient and family engagement means
involving patients and family members as:
♦

Members of the health care team

♦

Advisors working with clinicians and leaders
to improve policies and procedures

Goal of patient and family engagement


To create an environment where patients,
families, clinicians, and hospital staff all work
together as partners to improve the quality and
safety of hospital care

Why engage patients and families?


Research shows patient-centered
communication can improve:
♦

Patient safety
(Coulter and Ellins 2007, Charmel and Frampton 2008, Joint
Commission 2007)

♦

Patient outcomes, including emotional health,
functioning, and pain control
(Roter 1989)

♦

Patient experience
(Iacono 2001)

What is the patient and family
experience at our hospital?

What is it like being a patient?
Clinicians and hospital staff Patients and family
• Know how the hospital
• Are strangers in this environment
works and how to get things • Don’t understand the system or culture
done
• Know about their body and life situation better
than hospital staff
• Know who hospital staff are
and what they do

• Don’t know who different staff are and what they
do
• May want family or friends to support them

• Are busy and under a lot of
stress

• Are often in pain or uncomfortable, vulnerable or
afraid.
• Family members are worried and want to do what
they can for the patient
• Aware that hospital staff are busy and may not
want to bother you

• Want to provide high quality
and safe care

• Trust hospital staff to provide safe and high
quality care

What is it like being a patient?


[Insert 1 to 2 experiences from real patients or
family members:
♦

Live presentation / story

♦

Video

♦

Vignette or quote]

Communicating to Improve
Quality
Process and tools

What is the communication packet?

 Give three tools to the patient and
family prior to or at admission:
♦

Tool 1: Be a Partner in Your Care

♦

Tool 2: Tips for Being a Partner in Your Care

♦

Tool 3: Get to Know Your Health Care Team

What you will need to do?


When you enter the room:
♦

Read chart before entering

♦

Smile, if appropriate

♦

Introduce yourself by name and role

♦

Introduce new people in room by name,
role, and what they will do

♦

Have conversations at eye level

What you will need to do?


When you first assess the patient:
♦

Ask how patient prefers to be addressed

♦

Identify family that should be team
members

♦

Highlight main points of communication
tools

♦

Invite the patient and family to use the
white board to “talk” with clinicians

What you will need to do throughout the
hospital stay?
1. Include the patient and family as members
of the health care team:
♦

Welcome the patient and family

♦

Acknowledge their expertise

♦

React positively when people ask
questions, volunteer information, share
concerns, or want to take part in
treatment decisions

What you will need to do throughout the
hospital stay?
2. Ask about and listen to the patient and
family’s needs and concerns:
♦

Use open-ended questions

♦

Try to see the experience through their
eyes

♦

Listen to, respect, and act on what the
patient and family says

♦

Help people articulate their concerns
when needed

What you will need to do throughout the
hospital stay?
3. Help the patient and family understand the
diagnosis, condition, and next steps in their
care:
♦

Give timely and complete information

♦

Take every opportunity to educate patient
and family

♦

Use Teach Back to make sure you
explained clearly

♦

Find out how much information they want
to know

What you will need to do throughout the
hospital stay?
4. Help the patient and family understand the
diagnosis, condition, and next steps in their
care:
♦

Slow down

♦

Use plain language

♦

Invite the patient or family to take notes

♦

If you can’t answer a question, find
someone who can

How does this benefit you?
 Helps make sure your patients have

better outcomes
 Helps improve quality and safety by
making sure patients and families
share important information
 Ensures the patient and family have a
better transition from the hospital

Practice exercises

Vignette 1






Jack has just been wheeled into his room in the med-surg
unit, after having a TURP. He is very about happy finally
getting through the surgery and being on this unit, but he
is still in pain and uncomfortable and is anxious to see his
wife Emily as soon as possible.
The first person who comes into his room after his arrival
is his bedside nurse, Angela. In this exercise, Angela
comes in to do her initial nursing assessment, but Jack
interrupts to ask her who she is and what can she do
about his pain and discomfort; he also wants to know
when his wife can visit him. He is clearly a bit nervous.
Let’s form pairs to do this exercise. One person plays
Angela the nurse, the other plays Jack. Take about 5-8
minutes.

Vignette 1


Debrief “Angela” and “Jack”:
♦

How did you each feel during this
interaction?

♦

What really went well?

♦

What could have been done differently?

♦

Anything else?

Tips for effective engagement







Slow down
Use plain language
Reassure patient and family by giving
information
Thank patient or family for calling attention to
any issue they raise; don’t act annoyed
Invite them to continue asking questions
Remember non-verbal communication says
just as much as verbal communication

Vignette 2





The Attending Physician, John Gladstone, after
hearing from Angela about Jack’s pain and
discomfort, has just told Jack that he is putting
him on a stronger dose of a different pain
medication.
Jack expresses worry because he had bad side
effects of a similar medication in the past.
Emily, Jack’s wife, who is there at the time,
reinforces that experience.
This time we will break into groups of three.
One of the doctors should play Dr. Gladstone,
and two other people play Jack and Emily. Play
out this scene for 5-8 minutes.

Vignette 2


Debrief:
♦

How did each of you feel during this
interaction?

♦

What really went well?

♦

Did you use any of the tips? If so which
ones and how did they work?

♦

What could have been done differently?

♦

What’s your biggest “take home” from these
exercises?

Final thoughts




Our hospital is committed to patient and
family engagement – everyone plays a
critical part
Patients and families won’t engage if they
believe that you don’t want them to – it is
simply too risky for them
Your job is to make it safe for them to be
here, not just as patients, but as partners in
their care

Thank you!


For questions or more information
[Insert name, phone number, and email]

Component 1
Strategy 2:
Bedside Change of Shift
Report

Guide to Patient and Family
Engagement

Strategy 2
Nurse Bedside change of shift
Implementation Handbook

Implementation Handbook: Bedside change of shift

Implementation Handbook:
Nurse Bedside change of shift
Table of Contents
Overview of Nurse Bedside change of shift Strategy ................................................................. 1
What are the Nurse Bedside change of shift tools? ............................................................... 1
Rationale for Nurse Bedside change of shift............................................................................... 2
Why is bedside change of shift important? ............................................................................ 3
How does the Nurse Bedside change of shift strategy facilitate bedside change of shift? .... 3
Implementing Nurse Bedside change of shift ............................................................................. 4
Step 1: Form a multi-disciplinary team to identify areas of improvement ............................. 4
Engage patients and families and unit staff in the process: Establish a multi-disciplinary
team ......................................................................................................................................... 4
Assess family presence or visitation policies .......................................................................... 5
Assess current nurse shift change communication and processes ........................................... 5
Set aims to implement nurse bedside change of shift .............................................................. 6
Step 2: Decide how to implement the Nurse Bedside change of shift strategy ........................ 7
Identify the logistics of bedside shift for hospital ................................................................... 7
Decide how to use and adapt the tools in this strategy ............................................................ 8
Step 3: Implement and evaluate the Nurse Bedside change of shift strategy .......................... 9
Inform staff of changes ............................................................................................................ 9
Train staff ................................................................................................................................ 9
Conduct bedside change of shift .............................................................................................. 9
Assess implementation ............................................................................................................ 9
Get feedback from nurses, patients, and families .................................................................. 10
Refine the process .................................................................................................................. 10
References .................................................................................................................................... 13

Implementation Handbook: Bedside change of shift

Implementation Handbook:
Nurse Bedside change of shift
The Guide to Patient and Family Engagement in Hospital Quality and Safety (the Guide) is a
resource to help hospitals develop effective partnerships with patients and family members, with
the ultimate goal of improving multiple aspects of hospital quality and safety.1
Nurse shift changes require the successful transfer of information between nurses to prevent
adverse events and medical errors. Patients and families can play a role to make sure these
transitions in care are safe and effective.
This handbook gives you an overview of and rationale for nurse bedside change of shift. It also
provides step by step guidance to help you put this strategy into place.

Overview of Nurse Bedside change of shift Strategy
The goal of this strategy is to help ensure the safe handoff of care between nurses by involving
the patient and family. The patient defines who their family is and who can take part in bedside
change of shift.
Hospitals train nurses on how to conduct change of shift report at the patient’s bedside. Nurses or
another hospital staff member invite patients and families to be part of the bedside change of
shift process and hand out the brochure explanation to the patient on the day of admission.
At each shift change, shift report happens at the patient’s bedside, and the nurses invite the
patient and family or friends of their choice to take part in the report.

What are the Nurse Bedside change of shift tools?
This section provides an overview of the tools included in this strategy.
Tool

Use this tool to…

Tool 1

Inform the patient and family •
about what bedside change
of shift is and how they can
take part.

Nurse Shift
Changes at
Your Bedside:
How You Can
Get Involved

Implementation Handbook: Bedside change of shift

Description and formatting

•

Given to patients on the day of
admission, this handout explains what
bedside change of shift is, what patients
and family or friends should expect, and
what they need to do.
Format: Tri-fold brochure

1

Tool

Use this tool to…

Description and formatting

Tool 2

Remind nurses of the critical
elements of bedside change
of shift.

•

Made available at all shift changes and
at admission, this checklist highlights
the six elements required to complete
bedside change of shift. As they would
like, nurses can write on the form during
bedside change of shift.

•

Format: 1-page handout

•

Slides and talking points for a training
to prepare nurses to do bedside change
of shift and to help them understand
how to engage patients and family
members in the process.

•

Format: PowerPoint presentation, with
embedded video [video treatment
included as a separate document in this
draft]

Bedside change
of shift
Checklist and
Notes Sheet

Tool 3
Bedside change
of shift Nurse
Training

Prepare nurses to conduct
bedside change of shifts.

Rationale for Nurse Bedside change of shift
The goal of patient and family engagement is to create an environment where patients, families,
clinicians, and hospital staff all work together as partners to improve the quality and safety of
hospital care. Patient and family engagement encompasses behaviors by patients, family
members, clinicians, and hospital staff, as well the organizational policies and procedures that
support these behaviors.
Bedside change of shift is a clinical expression of engaging patients and families as essential
partners in the health care team.

2

Implementation Handbook: Bedside change of shift

Why is bedside change of shift important?
Communication during transitions in care, such as nurse shift changes, is extremely important for
ensuring that the handoff is safe and effective. Allowing the patient and family to be involved in
the change of shift report gives them the opportunity to hear what has occurred throughout the
shift and the next steps in their care. It also gives them the chance to ask questions and provide
input into the care process. Bedside change of shifts can improve:
•

Patient safety and quality. One study found that more than 70 percent of adverse events are
caused by breakdowns in communication among caregivers and between caregivers and
patients.(2) Bedside change of shift is another opportunity to make sure there is effective
communication between patients and families and nursing staff. Studies have shown that
bedside change of shift improves patient safety and service delivery (3, 4) as well as the
nurse-patient relationship.(5)

•

Patient experience of care. After implementing
bedside change of shift, hospitals reported an increase
in patient satisfaction scores.(1)

•

Nursing staff satisfaction. Bedside change of shift has
improved nursing staff and physician satisfaction.(1, 3,
4)

•

Time management and accountability between
nurses. After implementing bedside change of shift,
nurses have reported better ability to prioritize their
work or cases during their shift and an overall decrease
in staff time. One study noted a decrease in overshift
time by 100 hours in the first two pay periods on a 32bed general surgical unit.(1)

Bedside change of shift and patient
satisfaction
Increased patient satisfaction was seen
with the implementation of bedside
change of shift. By involving the
patients in their plan of care and
keeping all caregivers updated on that
plan, patients feel more secure, and
are more likely to participate in their
own care and follow recommended
healthcare options.
Cherri Anderson and Ruthie Mangino,
Banner Desert Medical Center,
Arizona, 2006 (1)

How does the Nurse Bedside change of shift strategy facilitate
bedside change of shift?
The Nurse Bedside change of shift strategy identifies critical elements of bedside change of shift
and supports the patient, family, and nurse in taking part in bedside change of shift through
individual tools. Specifically, the tools in this strategy:
•

Give the patient and family an opportunity and an invitation to take part in their care.

•

Explain to the patient and family what bedside change of shift is and what they can
expect.

•

List the critical elements of bedside change of shift that nurses should carry out.

•

Address nurse concerns about doing bedside change of shift.

Implementation Handbook: Bedside change of shift

3

•

Standardize the process of bedside change of shift.

(Placeholder for examples from Task 7, Implementation and Evaluation in this section in the
form of patient/family/staff quotes or a case study.)

Implementing Nurse Bedside change of shift
(NOTE: This is a section where we will want to incorporate information from the Task 7
Implementation and Evaluation. We will also be able to provide more specific guidance about
what worked and what did not work.)
The Nurse Bedside change of shift strategy is designed to be flexible and adaptable to each
hospital’s environment and culture. As such, this guidance provides choices and questions for
hospital leaders about how to implement this strategy. It may be helpful to implement this
strategy initially on a small scale (e.g., a single unit). Identify lessons learned from the singleunit pilot implementation, refine your approach, and then spread to more units. In this way, you
can build on your successes as a pathway to broader dissemination and wider-scale change.

Step 1: Form a multi-disciplinary team to identify areas of
improvement
As with any new activity or quality improvement effort, planning and identifying areas of
improvement are important parts of the process. Below lists some key considerations as you get
started implementing the Nurse Bedside change of shift strategy.
Engage patients and families and unit staff in the process: Establish a multidisciplinary team
This team should include hospital leaders, nurses, other key clinical and management staff, and
patient and family advisors.
Guide Resource

For more information about working with patient and
family advisors, see Component 2, Implementation
Handbook: Organizational Partnership Materials

Throughout the process of implementing the bedside change of shift strategy, patient and family
advisors can:
•

Give feedback on what the current process of shift report feels like as the patient or
family.

•

Can help adapt the patient and family tool, Tool 1: Nurse Shift Changes at Your Bedside:
How You Can Get Involved, for your hospital.

•

Can help adapt the standardized handoff tool, Tool 2: Bedside change of shift checklist
and notes sheet, for your hospital.

4

Implementation Handbook: Bedside change of shift

•

Take part in training nurses about bedside change of shift – by participating in role plays
or other small group exercises or by describing how the old way and new ways of shift
report feel like to the patient or family.

•

Observe nurses doing bedside change of shift and give feedback.

Assess family presence or visitation policies
The family cannot be partners of the health care team if they are not present. It is important that
the patient can define who their family is and that these members of the health care team are
encouraged and supported.
Guide Resource

For more information about family presence policies, see
Supporting Patient and Family Engagement: Best Practices
for Hospital Leaders in Component 3

Assess current nurse shift change communication and processes
Use the multi-disciplinary team to review the process of shift change report and how
communication occurs between nurses and from nurse to patient. The team can identify strengths
related to shift report – what is done well in terms of involving the patient and family, giving
information between nurses and from the nurse to the patient and family. The team can also
identify areas for improvement.
As with any change, some nursing staff members may be resistant to doing bedside change of
shift. Keep in mind that taking on new behaviors can be challenging. Some examples of
challenges and ways to address them are:
•

Acknowledging the “other” meanings of shift report for nurses. The official purpose of
nursing report is to transfer the accountability and responsibility of the patient between
nurses. But, shift report may also serve as a way for nurses to connect to other staff, share
emotional issues over the course of a shift, take a “break” from the family to focus on the
patient, and socialize. When shift report is done at the bedside, it will be important to
acknowledge the “other” meanings of shift report for nurses and identify alternative
methods or outlets for nurses to talk with one another.

•

Violating HIPAA or patient privacy. Nurses may be concerned about violating HIPAA –
especially when family members are present at shift report or if they work in semi-private
rooms. Using examples from the Office of Civil Rights’ Web site, the Tool 3: Bedside
change of shift Nurse Training PowerPoint Slides describe how bedside change of shift is
not a violation of HIPAA because it is part of treatment and normal operations.

•

Taking longer to do shift report. Although nurses may voice concerns about it “taking
too long,” bedside change of shift should be quick – about 3 to 5 minutes. As noted in the
previous section, after doing bedside change of shift, nurses have reported less time spent

Implementation Handbook: Bedside change of shift

5

on shift report and better time management because they have seen all of their patients at
the start of the shift and can prioritize patient needs and concerns.
•

Negotiating interactions with family members. Families are complicated, and it may be
difficult for nurses to know which family members should be present at bedside change
of shift and how to interact with those family members. As part of shift report, it will be
important for nurses to ask patients which family or friends would they like to participate.

•

Dealing with sensitive information. Sometimes, the patient or family may not be aware
of certain information or diagnosis. Bedside change of shift is not an appropriate venue
for discussing “bad news.” For example, the doctor may not have had a chance to
communicate a test result with the patient, or a mother may not know that her son has
HIV. This type of sensitive information may not need to be discussed at shift change.
When it does, the information can be exchanged between nurses before entering the
room, or nurses can point to relevant information on the chart during the bedside change
of shift.

•

Fearing change. Some nurses may fear losing control of the shift report process or may
not feel confident in doing shift report at the bedside. Often, if consistent use of bedside
change of shift is not monitored, nurses may revert back to familiar habits and ways of
doing things. It is important to let nurses know that bedside change of shift is not
optional. Acknowledge that change is hard, but stress the importance of adhering to the
new processes and procedures.

It is important for hospitals to identify the challenges that are most likely to arise in your
environment and to identify ways to overcome these challenges. For example, are there
particular units where it might be wise to “pilot” this new approach, either because of staff
attitudes or because there is a pressing need to improve nurse communication or transitions in
care?
Set aims to implement nurse bedside change of shift
Any quality improvement initiative requires setting aims.
The aim should be time-specific, measurable, and define
who will be affected. For example, an aim related to
implementing nurse bedside change of shift could be “to
have 95 percent of nurses implementing bedside change of
shift within 6 months.”

6

For more information on
setting aims and identifying
measures, see the Institute of
Healthcare Improvement’s
Web site on improvement
methods, available at:
http://www.ihi.org/IHI/Topics/I
mprovement/ImprovementMet
hods/HowToImprove/.

Implementation Handbook: Bedside change of shift

As another example, hospitals may want to improve patients’ experience of care as measured by
the CAHPS® Hospital Survey. CAHPS® Hospital Survey questions related to nursing shift
report include:
•

Q1: During the hospital stay, how often did nurses treat you with courtesy and respect?

•

Q2: During this hospital stay, how often did nurses listen carefully to you?

•

Q3: During this hospital stay, how often did nurses explain things in a way you could
understand?

If a hospital wants to improve their CAHPS® Hospital Survey scores related to nurse
communication, an aim might be “to improve scores on CAHPS® Hospital Survey Questions 1,
2, and 3 by 5 percent within 1 year.”

Step 2: Decide how to implement the Nurse Bedside change of shift
strategy
Once the team has set specific aims for improvement, it may be helpful to identify a single point
person as the primary person staff would go through with any kind of question. This person may
not have the answers to all questions, but can facilitate the process of getting answers. This way,
people are clear about whom to go to, and that person will hear all the questions and concerns.
Then, the single point person can coordinate with the multi-disciplinary team to decide how to
use and adapt each of the tools in this strategy.
Identify the logistics of bedside shift for hospital
What would nurse bedside change of shift look like at your hospital? Several hospitals that have
implemented bedside change of shift do a 10 minute overview or safety briefing on all patients
before going to individual rooms and bedside. Would this be important to include on your unit?
Also, consider how work flows to make sure that bedside change of shift is an efficient process.

Implementation Handbook: Bedside change of shift

7

Decide how to use and adapt the tools in this strategy
As described above, the Nurse Bedside change of shift strategy includes three tools.
Guide Resources

Tool 1: Nurse Shift Changes at Your Bedside: How You
Can Get Involved informs the patient and family about
what bedside change of shift is and how they can take part.
Tool 2: Bedside change of shift Checklist and Notes Sheet
reminds nurses of the critical elements of bedside change of
shift.
Tool 3: Bedside change of shift Nurse Training prepares
nurses to conduct bedside change of shifts.

Answer the following questions to decide how to use and adapt the tools in this strategy at your
hospital:
•

Decide how to use and adapt the bedside change of shift checklist. First, decide which
elements of bedside change of shift are important for your unit or hospital to make sure
that bedside change of shift is implemented in a standard way. Ask nurses and patient and
family advisors about possible changes. Adapt Tool 2: Bedside change of shift Checklist
and Notes Sheet to fit your hospital environment. Once this tool is adapted, who will
review it? What approvals are needed?

•

Decide how to use and adapt the brochure for the patient and family. Next, adapt the
patient and family brochure, Tool 1: Nurse Shift Changes at Your Bedside: How You Can
Get Involved. Ask nurses and patient and family advisors about possible changes and
make the changes consistent with the elements of bedside change of shift. At a minimum,
it is important to insert your hospital name, logo, and tailored information into the
brochure. Who will review it? What approvals are needed?
Once adapted, determine how the brochure be distributed. How will the brochure be
printed? Who will distribute? How will interpreters be involved in the distribution
process, if needed? Can the brochure be integrated into current admissions materials (or
with the tools distribute in Component 2, Organizational Partnership Materials)? If so,
how? What approvals need to be sought? Who will go over the brochure with the patient
and family and invite the patient and family to participate? (We recommend that this be
the bedside nurse on the day of admission, but any hospital staff can do this at any time.)
If applicable, how will temporary nursing staff learn about how to distribute the bedside
change of shift brochure?

•
8

Plan the bedside change of shift training for nurses. Who can conduct the training for
their colleagues? Training facilitators should be respected by their colleagues and model
Implementation Handbook: Bedside change of shift

the behaviors being asked of them. Which patient and family advisors can help to
conduct or facilitate the training? How many sessions are needed to train all staff? When
can the training be scheduled? Where can the training happen? How should the Tool 3:
Bedside change of shift Nurse Training be adapted? Who needs to approve the training
materials?
Recognize that individuals have different learning styles. To be most effective, use three
or more different learning strategies during the training, such as giving information,
modeling behavior, providing feedback, and practicing skills.

Step 3: Implement and evaluate the Nurse Bedside change of shift
strategy
Inform staff of changes
If not already involved, inform unit directors and managers about what is coming and why it is
important. Inform staff at staff meetings and through posters in common rooms about the
changes and opportunities for training.
Train staff
The training tools for this strategy include a mix of PowerPoint slides, video, and role play. The
main message to emphasize: Conducting bedside change of shift can improve quality and safety.
After the training, it is important to assess:
•

Did the training happen as planned? What happened during training that could challenge
or facilitate implementation?

•

How did staff react to training?

Conduct bedside change of shift
As defined during planning, the unit staff will distribute and go over the brochure with patients
and families on the day of admission. At each shift change, nurses will conduct bedside change
of shifts, using the checklist to make sure they go over the key elements.
Keep staff aware of bedside change of shift by making sure Tool 2: Bedside change of shift
Checklist and Notes Sheet is available throughout the unit.
Assess implementation intensely during the initial first 2 weeks and periodically
after that
Make sure that nurses have the support needed to do bedside change of shift. Have a nurse
manager or other staff leader observe shift report and provide feedback to individual nurses. Use
a standardized form to keep track of the observations, such as the checklist that is a part of Tool
2: Bedside change of shift Checklist and Notes Sheet. Identify a way to collect and analyze data
collected, such as an Excel Spreadsheet or other database.
Implementation Handbook: Bedside change of shift

9

Continue to conduct periodic observations at (e.g., at 2 and 4 months after roll out) to ensure
consistency of implementation among staff. Continual feedback and monitoring is needed to
make sure behaviors become more natural.
Get feedback from nurses, patients, and families
Get informal feedback from nurses, patients, and families by asking them how bedside change of
shift can be improved. What worked well? What could be improved? How could the process or
tools be changed or adapted to work on other units? What was critical for success? What was not
successful and what could be made better?
Incorporate formal feedback by using mechanisms already in place at your hospital, including
patient and family focus groups, patient and family satisfaction surveys, and staff surveys.
Refine the process
Share feedback with the implementation team, problem solve, and adapt as necessary. Using the
feedback received, refine the process and tools before implementing in other units.

10

Implementation Handbook: Bedside change of shift

Case Study on Nurse Bedside change of shift: Emory Healthcare
Emory Healthcare recently reached 100 percent implementation of bedside change of shift report
across four hospitals and 73 inpatient units on every shift, including the night shift.
Approximately 1800 nurses participate.
In response to bedside change of shift, patients and
families report feeling more knowledgeable about
their care. Patient satisfaction scores reflect this
change in nursing practice. In August 2010, Emory
achieved a 98 percent on patient satisfaction scores,
with “nurse kept you informed” as the highest rated
question. In fact, this question achieved the highest
score of all hospitals nationwide.
Creating this new culture of bedside report for
nurses was a process, and a challenging one at that.

Keys to success
• Senior leaders, and especially the Chief
Nursing Officer, provided resources and
support for implementing BSR.
• Dedicated nurse leaders continued to
pursue BSR, even when there were
challenges.
• A standardized process for BSR made
sure that everyone knew what to do.
• Training and observation increased
buy-in because nurses immediately saw
the benefits of BSR and knew that
hospital leaders supported BSR.
• Committed nurse champions at the unit
and floor levels make sure that BSR
continues to happen.

Bedside change of shift began with a test of
change. In November 2007, a nurse champion at
Wesley Woods, a 100-bed geriatric hospital,
brought the idea of bedside change of shift to
Emory’s Unit Practice Council (UPC), a governance structure where clinical staff give input into
care on the floor. Using a “test of change” approach, one UPC member did bedside report,
followed by another. Because the process worked well, the pilot was expanded to nurses on two
units. After 2 weeks, the decision was made to implement bedside change of shift across the
hospital.
The first system-wide roll out did not go as planned. With the success at Wesley Woods, the
idea of bedside change of shift was brought to Emory Healthcare’s system council to implement
bedside report system-wide, across the three existing hospitals. In February 2008, three nurse
champions, one at each major hospital within the system (Wesley Woods, Emory Midtown,
Emory University), began planning for system-wide implementation between May and August
2008. These three champions created teaching points for each unit. Nurses were asked to read
about bedside change of shift and then do it. Unfortunately, the larger hospitals did not show
much interest in bedside report. Because there was limited buy-in, bedside change of shift did
not catch on.
Standardization was the key to effective system-wide roll out. In March 2009, the three nurse
champions attended a Quality Academy Practical Methods course, focusing on quality
improvement methods and Six Sigma. Most importantly, they learned that standardization was
the only way to assess effectiveness. The course included a small project or test of change. The
three champions got permission from the Chief Nursing Officer to work on bedside change of
shift.
The three nurse champions created a standard process for bedside report, called the bedside
bundle, and a process for educating staff. The bedside bundle included six components that were
essential for completing bedside report. They designated a training and observation team that
included the three leaders, plus one to two nurses who were not able to do clinical care.
Implementation Handbook: Bedside change of shift

11

In spring and summer of 2009, the team went to each unit in the hospital system. They spent 1
week educating nurses on the unit about bedside change of shift, both in group trainings and oneon-one. The team stayed on the unit to observe and provide feedback at every shift change for 2
more weeks, or longer if needed. The team observed individual nurses doing bedside report,
checked off items in the bedside bundle, and provided real-time feedback to nurses before
observing the next bedside report. After completing the initial education and observation process,
the team identified two to three nurses as floor champions, who would foster an environment that
supports bedside change of shift.
Support, monitoring, and education ensure continued success. Nursing Unit Directors ensure
that 16 random audits are performed during different shifts. With the Director of Care
Transformations and two patient and family advisors, the champions also developed a 4-hour
bedside change of shift seminar. As of September 2010, they have held six seminars and have
trained over 400 staff from across the four hospitals.

1

The Guide was developed for the Agency for Healthcare Research and Quality (AHRQ), in the U.S. Department of
Health and Human Services, by a collaboration of partners with experience in and commitment to patient and family
engagement, hospital quality, and safety. Led by the American Institutes for Research (AIR), the team included the
Institute for Patient and Family-Centered Care (IPFCC), Consumers Advancing Patient Safety (CAPS), the Joint
Commission, and the Health Research and Educational Trust (HRET). Other organizations contributing to the
project included Planetree, the Maryland Patient Safety Center (MPSC), and Aurora Health Care.
12

Implementation Handbook: Bedside change of shift

References
1.
Anderson CD, Mangino RR. Nurse shift report: who says you can't talk in front of the
patient? Nurs Adm Q. 2006;30(2):112-22.
2.
The Joint Commission. Improving America's hospitals: The Joint Commission's Annual
Report on quality and safety. 2007. Available from:
http://www.jointcommission.org/Improving_Americas_Hospitals_The_Joint_Commissions_Ann
ual_Report_on_Quality_and_Safety_-_2007/.
3.
Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: a case study. Int J Nurs
Pract. 2010;16(1):27-34.
4.
Chaboyer W, McMurray A, Johnson J, Hardy L, Wallis M, Sylvia Chu FY. Bedside
handover: quality improvement strategy to "transform care at the bedside". J Nurs Care Qual.
2009;24(2):136-42.
5.
Kelly M. Change from an office-based to a walk-around handover system. Nurs Times.
2005;101(10):34-5.

Implementation Handbook: Bedside change of shift

13

What is bedside change of shift?

What should I expect?

Nurse shift changes occur when nurses who
are going off duty share information about
your care with nurses coming on duty.

During the bedside change of shift, the nurses
going off and coming on duty will:

At [insert hospital name], this happens right
by your bedside so you can be involved. This
bedside change of shift gives you a chance to
meet the nurse taking over your care, ask
questions, and share information.
Bedside change of shifts happen every day
between 7 and 7:30 am and 7 and 7:30 pm.
Shift report at your bedside usually lasts 5
minutes.
Invite a family member or friend to stay
during bedside change of shift, if you want
them to. We will only talk about your health
with others when you say it’s okay.

•

Introduce themselves to you and
anyone with you. The oncoming nurse
will write his or her name and phone
number on the white board in your
room.

•

Invite you to take part in the bedside
change of shift. It is up to you to decide
who else can take part with you.

•

Talk with you about your health,
including the reason you are in the
hospital and what is going on with your
care. The nurses will look at your
medical chart.

•

Check the medicines you are taking.
The nurses will look at your IVs,
injuries, and cuts. They will also follow
up on any tests or labs that were done or
ordered.

•

Ask you what could have gone better
during the last shift and what you hope
to do during the next shift. For example,
you may want to get out of bed or just
sleep. The nurse will see how they can
help you meet this goal.

•

Encourage you to ask questions and
share your concerns. If needed, the
oncoming nurse may come back after
bedside change of shift to spend more
time discussing your concerns.

What should I do?
•

Listen. You are an important part of the
health care team. We want to make sure
you have complete and timely
information about your care.

•

Speak up. If you have questions or
concerns, bedside change of shifts are
the perfect times to raise them.

•

Ask if something is confusing. If the
nurses use any words or share any
information you don’t understand, feel
free to ask them to explain it.

[Insert hospital name] wants to make sure that
you get the best care possible.
If you have any concerns about the quality or
safety of your care during your hospital stay,
please let your nurse or doctor know.
If you are still concerned, contact our [insert
Quality Coordinator name and title] at [insert
phone number].

You Are Invited!

You are invited to take part in bedside
shift report. You can also invite a family
member or friend to take part with you.
Bedside shift reports happen every day
between 7 and 7:30 am and
7 and 7:30 pm.
Let us know if you have any questions.
You are valuable members of the health
care team!

Nurse Shift
Changes
at Your
Bedside
How You Can
Get Involved

Being a partner in your care helps you to get
the best care possible in the hospital. Taking
part in bedside change of shift is one way you
can be a partner. This brochure explains what
bedside change of shift is and how you get
involved.

Bedside Shift Report Tool 1: Nurse Shift Changes at Your Bedside:
How You Can Get Involved

Bedside change of shift:
Checklist and Notes Sheet
Introduce nursing staff, the patient, and family. Invite the patient and family to take
part.
Open medical record to patient information / electronic work station in patient room.
Conduct Verbal SBAR report with patient / family.
Use words that patient and family can understand.
S=Situation (What is going on with patient? What are the current vital signs?)
B=Background (What is the pertinent patient history?)
A=Assessment (What is the patient’s problem now?)
R=Recommendation (What does the patient need?)
Do focused assessment.
Visually inspect all wounds, incisions, drains, IV sites, IV tubings, catheters, etc.
Review tasks that need to be done such as:
o Labs or tests needed.
o Medications administered.
o Forms that need to be completed– admission, patient intake, vaccination, allergy review.
o Other tasks _________________________________________________
Identify the patient and family’s needs or concerns.
o Ask the patient and family:
- What could have gone better during the last 12 hours?
- Tell us how your pain is. Tell us how much you walked today.
- Are there any concerns about safety?
-Any worries you would like to share? We want to work together to make certain you
have what you need.
o Ask the patient and family what their goal is for the next shift. “What do you want to do
during the next 12 hours?” Remember, this is the patient’s goal - not our goal for the
patient! Follow up to see if this was addressed at the next shift report.
Adapted from the Emory University Bedside change of shiftBedside change of shiftBedside change of
shiftBedside change of shift Bundle.

Bedside change of shift Tool 2: Checklist and Notes

1

Insert hospital logo here

Nurse Bedside Change of Shift
Training
[Insert hospital name, presenter name and title, date
of presentation]

Bedside Change of Shift Tool 3: Nurse Training Presentation

Today’s session

 What is patient and family engagement?
 What are the components of bedside
change of shift?
 What are the benefits and challenges of
bedside change of shift?
 What does HIPAA say about bedside
change of shift?
 Practice exercises

What is patient and family
engagement?

Hospital quality





Patients get care that is safe



No differences in treatment based on race,
ethnicity, income, education, or social status



Care is patient- and family-centered

Patients get the right care for their condition
Patients get care they need when they need it
Patients get care that makes wise use of
resources

Patient- and family-centered care


Mutually beneficial partnerships among
clinicians, hospital staff, patients, and families



Core concepts:
♦

Dignity and respect

♦

Information sharing

♦

Participation

♦

Collaboration

What is patient and family engagement?


Critical component of patient- and familycentered care



Patient and family engagement means
involving patients and family members as:
♦

Members of the health care team

♦

Advisors working with clinicians and leaders
to improve policies and procedures

Goal of patient and family engagement


To create an environment where patients,
families, clinicians, and hospital staff all work
together as partners to improve the quality and
safety of hospital care

Why engage patients and families?



Research shows patient-centered
communication can improve:
♦

Patient safety
(Coulter and Ellins 2007, Charmel and Frampton 2008, Joint
Commission 2007)

♦

Patient outcomes, including emotional
health, functioning, and pain control
(Roter 1989)

♦

Patient experience
(Iacono 2001)

What is the patient and family
experience at our hospital?

What is it like being a patient?
Clinicians and hospital staff Patients and family
• Know how the hospital
• Are strangers in this environment
works and how to get things • Don’t understand the system or culture
done
• Know about their body and life situation better
than hospital staff
• Know who hospital staff are
and what they do

• Don’t know who different staff are and what they
do
• May want family or friends to support them

• Are busy and under a lot of
stress

• Are often in pain or uncomfortable, vulnerable or
afraid
• Family members are worried and want to do what
they can for the patient
• Aware that hospital staff are busy and may not
want to bother you

• Want to provide high quality
and safe care

• Trust hospital staff to provide safe and quality
care

What is it like being a patient?


[Insert 1 to 2 experiences from real patients or
family members, focus on what shift change
feels like to the patient or family member:
♦

Live presentation / story

♦

Video

♦

Vignette or quote]

Bedside change of shift
Critical elements
Benefits
Challenges

What is bedside change of shift?


Nursing staff conducts shift change reports at
the patient’s bedside



Patient can identify a family member or close
friend to participate




Report should take 3-5 minutes per patient
Purpose is:
♦

To engage the patient and family in their care

♦

To share accurate and useful information
between nurses, patients, and families

Critical elements of bedside change of shift



Introduce nursing staff, patient and family. Invite
patient and family to participate



Open medical record / electronic health station in
patient room



Verbal SBAR with patient / family – use words
they can understand



Focused assessment – visually inspect all
wounds, IVs, and so forth




Review tasks needed to be done
Identify needs and concerns from patient/family

Benefits of bedside change of shift for
patients



Demonstrates value of patient perspective as
most important



Shows the patient how much nurses know / do
for their care



Reassures the patient that everyone knows
what is going on with them



Reminds the patient and family that they can
ask questions and that nurses are available
and usually have answers

Benefits of bedside change of shift for
patients





Shows teamwork among nursing staff



Increases patient satisfaction with their
experience of care

Builds trust in the care process
Informs patient and family members about the
patient’s care – less anxiety

Benefits of bedside change of shift report for
nurses






Better information about the patient’s condition
Accountability
Time management
Patient safety

Video of bedside change of shift


[To be added: Video of real example of bedside
change of shift from Emory University]



Discussion questions:
♦

What are the overall impressions of the
bedside change of shift?

♦

What went well?

♦

What could have been done differently?

♦

What questions or concerns do you have
about bedside change of shift?

Tips for bedside change of shift


Invite patients and loved ones to participate
using bedside change of shift brochure (Tool
1)



Use checklist to facilitate bedside change of
shift (Tool 2)



If problem with room or situation, don’t
confront the outgoing nurse in front of the
patient



Don’t forget to thank the outgoing nurse if
everything is in good shape

Potential challenges



Unknown visitors / family in the room




Patient is asleep



Patient or family has complex question or
lengthy clarification



Semi-private rooms / HIPAA concerns

New diagnosis / information patient is not yet
aware of (e.g., waiting for doctor to discuss)
Patient is noncompliant and you need to share
information with oncoming nurse

HIPAA and Bedside Change of
Shift

Addressing HIPAA concerns




Health information can be disclosed for:
♦

Treatment

♦

Health care operations

♦

Payment

HIPAA acknowledges incidental disclosures
may occur. Not a HIPAA violation as long as...
♦

Take reasonable safeguards to protect
privacy

♦

Only disclose or use the minimum
necessary information

Addressing HIPAA concerns


Is a covered entity required to prevent any
incidental use or disclosure of protected health
information?
Answer: No. The HIPAA Privacy Rule does not
require that all risk of incidental use or
disclosure be eliminated to satisfy its standards.
Rather, the Rule requires only that covered
entities implement reasonable safeguards to
limit incidental uses or disclosures. See 45 CFR
164.530(c)(2).

Addressing HIPAA Concerns


Can physicians and nurses engage in
confidential conversations with other providers
or with patients, even if there is a possibility
that they could be overheard?
Answer: Yes. HIPAA does not prohibit
providers from talking to each other and to
their patients. Providers primary consideration
is the appropriate treatment of their patients.

Addressing HIPAA Concerns


Oral communications often must occur freely
and quickly. Covered entities are free to
engage in communications as required for
quick, effective, and high quality health care.
For example:
♦

Coordinate services at nursing stations

♦

Discuss a patient’s condition or treatment
regimen in the patient’s semi-private room

♦

Discuss a patient’s condition during training
rounds in an academic or training institution

Practice exercises

Option 1: Role play vignette





Jack, a 64 year old male with a history of chronic
obstructive pulmonary disease, hypertension, and Type II
diabetes, was admitted to the unit this afternoon from the
ED. His symptoms were severe morning headache with
occasional vomiting for 3 days, chest pain, and shortness
of breath. He received a dose of Zofran for vomiting before
being brought up to the unit. During the initial nursing
assessment, the nurse noticed a large bruise on the elbow
and hip related to a recent fall.
It is time for evening shift change. During shift change,
Jack notes he is slightly disoriented and drowsy and his
headache has returned.
Let’s form groups of three for this exercise. Take about 5-8
minutes.

Option 1: Role play vignette


Debrief :
♦

How did you each feel during this
interaction?

♦

What really went well?

♦

What could have been done differently?

♦

Anything else?

Option 2: Small group discussion


Break into groups of X with one patient / family
advisor in each group



Each person should discuss experience with
bedside change of shift – what went well, what
did not go well



Report back to large group

Final thoughts




Our hospital is committed to patient and family
engagement – everyone plays a critical part
Patients and families won’t engage if they
believe that you don’t want them to – it is
simply too risky for them
Your job is to make it safe for them to be
involved, not just as patients, but as partners
in their care

Thank you!


For questions or more information
[Insert name, phone number, and email]

Bedside change of shift:
Treatment for Nurse Training Video
Draft Treatment for Bedside change of shift Nurse
Training Video
The video will be included in the nurse training PowerPoint materials for Component 1Working with patients and families at the bedside, Nurse Bedside change of shift.
The goal of the Bedside change of shift strategy is to help ensure the safe handoff of care
between nurses by involving the patient and family and to involve patients and families in the
change of shift report for nurses. Hospitals will train nurses on how to conduct change of shift
report at the patient’s bedside. The primary focus of the training is to prepare nurses to do shift
report at the bedside, and to help them understand how to engage patients and family members in
the process. The training will include a video that shows the process of a bedside change of shift
report.
This treatment describes the video, what will happen and when. It describes why certain actions
will take place, i.e., the intended effect on the audience. Because we plan to video an actual
bedside change of shift at Emory University Hospital, this treatment does not contain the full
narration or dialogue. The video would be approximately 5 minutes in length.
Treatment of bedside change of shift video
[SETTING: Interior of hospital room. Patient is lying in hospital bed with family member seated
in chair next to the bed. Two nurses walk into the room and stand at the side of the patient’s
bed.]
•
•
•
•
•
•
•

Nurse 1 greets the patient by name and introduces the patient and family member to
Nurse 2.
Nurse 1 verbally reviews the patient’s diagnosis and symptoms and also reviews
medications, treatments, procedures to date [used to illustrate what information will be
exchanged at the bedside change of shift].
During this process, Nurse 2 asks one or two questions (of Nurse 1 and the patient) and
clarifies as needed [used to illustrate how the patient can be involved].
Nurse 1 asks the patient and family member if they have anything to add to the review of
the patient’s history, asks patient what their goal is for the day, and writes it on the white
board in the patient room [used to illustrate how the family member can be involved].
Nurse 1 asks Nurse 2 if she has any questions.
Nurse 2 tells the patient that she will be back later, provides instructions for if the patient
needs her in the meantime.
Get patient/family reactions to bedside change of shift

[Nurses exit]

1

Bedside change of shift Tool 3b: Treatment for Nurse Training Video

Component 1
Strategy 3:
Discharge Plan IDEAL Discharge Planning

Guide to Patient and Family
Engagement

Strategy 3
IDEAL Discharge Planning
Implementation Handbook

Implementation Handbook: IDEAL Discharge Planning

Implementation Handbook:
IDEAL Discharge Planning

Table of Contents
Overview of the IDEAL Discharge Planning Strategy .............................................................. 1
What are the IDEAL Discharge Planning tools? ........................................................................ 3
What is the IDEAL Discharge Planning process? ...................................................................... 4
Rationale for the IDEAL Discharge Planning Strategy ............................................................ 5
Why is the discharge process important?.................................................................................... 5
What are the key issues related to discharge? ............................................................................. 6
How to prevent adverse events after discharge........................................................................... 7
How does the IDEAL discharge planning strategy improve the discharge process? ................. 8
Implementing the IDEAL Discharge Planning Process ............................................................ 8
Step 1: Form a multi-disciplinary team to identify areas of improvement ................................. 9
Step 2: Decide on how to implement the IDEAL discharge planning strategy ........................ 12
Step 3: Implement and evaluate the IDEAL Discharge Planning Strategy .............................. 13
References .................................................................................................................................... 16

Implementation Handbook: IDEAL Discharge Planning

Implementation Handbook:
IDEAL Discharge Planning
The Guide to Patient and Family Engagement in Hospital Quality and Safety (the Guide) is a
resource to help hospitals develop effective partnerships with patients and family members, with
the ultimate goal of improving hospital quality and safety.1
Discharge from hospital to home requires the successful transfer of information from clinicians
to the patient and family to reduce adverse events and prevent readmissions. Engaging patients
and families in the discharge planning process helps make sure this transition in care is safe and
effective.
This handbook gives you an overview of and rationale for the IDEAL discharge planning
strategy. It also provides step by step guidance to help you put this strategy into place at your
hospital.

Ove rvie w o f th e IDEAL Dis c h a rg e P la n n in g S tra te g y
The goal of the IDEAL Discharge Planning strategy is to engage patients and family members in
the transition from hospital to home, with the goal of reducing adverse events and preventable
readmissions.
The IDEAL discharge strategy highlights the key elements of engaging the patient and family in
discharge planning:

Include the patient and family as full partners in the discharge planning process.
Discuss with the patient and family five key areas to prevent problems at home: describe
what life at home will be like, review medications, highlight warning signs and problems,
give test results, and make followup appointments.

Educate the patient and family in plain language about the patient’s condition, the discharge
process, and next steps at every opportunity throughout the hospital stay.

Assess how well the patient and family understand the diagnosis, condition, and next steps
in the patient’s care – Use Teach Back.

Listen to the patient and family’s goals, preferences, observations, and concerns.

Implementation Handbook: IDEAL Discharge Planning

1

Each part of IDEAL discharge planning has multiple components:

Include the patient and family as full partners in the discharge planning process.
•

Always include the patient and family in team meetings about discharge. Remember that discharge
is not a one-time event, but a process that takes place throughout the hospital stay.
Identify which family or friends will provide care at home and include them in conversations.

•

Discuss with the patient and family five key areas to prevent problems at home.
1. Describe what life at home will be like: Include home environment, support needed, what the
patient can or cannot eat, and activities to do or avoid.
2. Review medications: Use a reconciled medication list to discuss the purpose of each medication,
what and how to take it, and potential side effects.
3. Highlight warning signs and problems: Identify warning signs or potential problems. Write down
the name and contact information of someone to call if there is a problem.
4. Explain test results: Explain test results to the patient and family. If test results are not available at
discharge, let the patient and family know when they should hear about results and identify who
they should call if they have not heard the results.
5. Make followup appointments: Offer to make followup appointments for the patient. Make sure that
the patient and family know what followup is needed.

Educate the patient and family in plain language about their condition, the discharge process, and
next steps at every opportunity throughout the hospital stay.
Getting all the information on the day of discharge can be overwhelming. Discharge planning should be
an ongoing process throughout the stay– not a onetime event. You can:
• Elicit patient and family goals at admission and note how progress is being made each day during
the hospital stay.
• Involve the patient and family in nurse change of shift report or bedside rounds.
• Share a written list of medications every morning during the hospital stay.
• Go over medicines at each administration – what it is for, how to take it, and side effects.
• Encourage the patient and family to take part in care practices to support their competence and
confidence in care giving at home.

Assess how the patient and family understand the diagnosis, condition, and next steps in their care:
Use Teach Back.
• Provide information in small chunks and repeat key pieces of information throughout the hospital
stay.
• Ask the patient and family to repeat back what you said back to you in their own words to be sure
that you explained things well.

Listen to the patient and family’s goals, preferences, observations, and concerns.
•

Invite the patient and family to use the white board in their room to write questions or concerns
throughout their stay.
Ask open-ended questions to elicit questions and concerns
Use Tool 2: Be Prepared to Go Home Checklist, to make sure the patient and family feel prepared
to go home.
Schedule at least one meeting specific to discharge planning with the patient and family caregivers.

•
•
•
2

Implementation Handbook: IDEAL Discharge Planning

What are the IDEAL Discharge Planning tools?
This section provides an overview of the tools included in this strategy. The set of tools included
in this Guide are for discharges to home only, with or without home- and community-based
services, such as home health care.
Tool

Use this tool to…

Description and formatting

Tool 1

Inform clinicians about the
new discharge planning
process and keep track of
when tasks are
accomplished.

•

Used by clinicians, this handout gives
an overview of the IDEAL discharge
planning process and includes a
checklist that could be completed for
each patient.

•

Format: 2-page overview, 2-page
process steps, 2-page checklist

•

Given to patients soon after admission,
this checklist highlights what the patient
and family need to know before leaving
the hospital, gives example questions
they can ask, and gives space for writing
information as needed.

•

Format: Booklet

•

Given to physicians, this handout
describes the new discharge planning
process. A verbal description should
also accompany the distribution of the
handout – either at a staff meeting or
other venue.

•

Format: 1-page handout

•

A training for any staff involved in the
discharge process – physicians, nurses,
discharge planners, social workers,
pharmacists, or physicians.

•

Format: PowerPoint presentation and
talking points

IDEAL
Discharge
Planning
Overview,
Process, and
Checklist
Tool 2
Be Prepared to
Go Home
Checklist

Tool 3
Improving
Discharge
Outcomes With
Patients and
Families

Tool 4
IDEAL
Discharge
Planning
Training

Identify and discuss the
patient and family’s
questions and concerns about
going home.

Inform physicians of the
IDEAL discharge planning
process.

Prepare clinicians and
hospital staff to support the
efforts of patient and family
engagement related to
discharge planning.

Implementation Handbook: IDEAL Discharge Planning

3

What is the IDEAL Discharge Planning process?
You can incorporate elements of the IDEAL discharge planning process into your current
discharge process. This process incorporates the IDEAL elements from admission to discharge
and includes at least one meeting between the patient, family and discharge planner to
specifically address the patient and family’s questions and concerns.
What to do?

Who does it?

When: At initial nursing assessment
Bedside nurse
• Identify the family or others who will be at home with
patient.
• Let the patient and family know that they can use the white Bedside nurse
board in the room to write questions or concerns.
Bedside nurse
• Elicit the patient and family goals for hospital stay.
• Inform the patient and family about steps toward discharge. Bedside nurse
When: Daily activities
• Educate the patient and family about the patient’s condition All clinical staff
at every opportunity.
All clinical staff
• Explain medications to the patient and family.
All clinical staff
• Discuss progress toward goals.
All clinical staff
• Involve the patient and family in care practices.
When: Prior to discharge planning meeting (1 to 2 days before discharge planning meeting;
for short stays, may happen on admission)
TBD by hospital: Nurse,
• Give Tool 2: Be Prepared to Go Home Checklist to the
physician, volunteer, patient
patient and family.
advocate, discharge planner
• Schedule discharge planning meeting with the patient,
family, and hospital staff.
When: Discharge planning meeting (1 to 2 days before discharge, earlier for more extended
stays in the hospital)
TBD by hospital: Nurse,
• Use Tool 2: Be Prepared to Go Home Checklist as a
physician, volunteer, patient
starting point for dialogue questions, needs and concerns
advocate, discharge planner,
going home.
or combination
TBD by hospital: Nurse,
• Offer to make followup appointment. Ask if patient has
physician, volunteer, patient
preferred day / time and if they can get to appointment.
advocate, discharge planner
When: Day of discharge
TBD by hospital: Nurse,
• Review a reconciled medication list with the patient and
physician, or pharmacist
family.
Staff who scheduled
• Write followup appointment times on checklist.
appointment
TBD by hospital: Nurse,
• Write name, position, and phone number of a person to
physician, volunteer, patient
contact if there is a problem after discharge.
advocate, discharge planner
4

Implementation Handbook: IDEAL Discharge Planning

Ra tio n a le fo r th e IDEAL Dis c h a rg e P la n n in g S tra te g y
The goal of patient and family engagement is to create an environment where patients, families,
clinicians, and hospital staff all work together as partners to improve the quality and safety of
hospital care. Patient and family engagement encompasses behaviors by patients, family
members, clinicians, and hospital staff, as well as the organizational policies and procedures
that support these behaviors.
Discharge from a hospital can be a complex process: It is not a one-time event, and no single act
will make it work better. For discharge to be most effective, communication among clinicians
and between clinicians, the patient, and family needs to happen throughout the hospital stay.
Education and learning is a two-way path. The patient and family need to learn from clinicians
about their condition and next steps, and clinicians need to learn from the patient and family
about their home situation (both what help and support they can count on and the barriers they
may face in taking care of themselves) and their questions about their health after they get home.
Clinicians also need to make sure that patients and family members really understand the next
steps in their care.

Why is the discharge process important?
Nearly 20 percent of patients experience an adverse event within three weeks of discharge. Of
these adverse events, three-quarters could have been prevented or ameliorated. Common
complications post-discharge include adverse drug events, hospital acquired infections, and
procedural complications.(1) Further, rehospitalization is becoming a focus of attention for
hospitals, purchasers, hospital quality organizations, and others. In a recent study using Medicare
data, Jencks and colleagues (2) concluded that “rehospitalizations among Medicare beneficiaries
are prevalent and costly.” Nearly 20 percent of Medicare patients were rehospitalized within 30
days after discharge. Half the medical patients who were rehospitalized had no claim filed for a
visit with a physician during the period following the discharge. About 70 percent of surgical
patients were rehospitalized for a medical condition. The authors estimate that the cost of these
unplanned hospitalizations in 2004 was $17.4 billion.(2)

Implementation Handbook: IDEAL Discharge Planning

5

What are the key issues related to discharge?
Several important challenges have been identified in providing high quality care as patients leave
the hospital:(3-5)
•

Discontinuity between inpatient and outpatient providers. Studies have shown that
hospital discharge summaries fail to reach outpatient providers, and when they do, often
fail to provide important administrative and medical information. Also, patients go to
multiple providers, making continuity of care more difficult between inpatient and
outpatient settings.

•

Changes or discrepancies in medication lists before and
after hospital stay. To ensure an accurate medication list
at hospital discharge, hospital providers need to take a
complete and accurate medication history at the time of
admission, keep track of changes to medications
administered throughout the hospital stay, and reconcile
medication lists upon discharge. Patients prescribed high
risk medications or complex medication regimens may be
at higher risk of adverse drug events.

Key areas to address prior
to discharge
• Medication reconciliation
• Structured communication
to patients, families, and
outpatient physicians
• Patient and family
education and involvement

•

Inadequate preparation for discharge. Quality of discharge teaching is the strongest
predictor of discharge readiness. Patients may not been properly informed about food
choices, medication side effects, danger signs, and when to resume activities. Also, studies
have shown that there is a disconnect between the information that patients and families
believe they need to know and what providers think patients need to know.

•

Disconnect between provider information-giving and patient understanding. Studies
have demonstrated that providers may not relay information to patients in a way they can
understand. Key instructions at discharge should be given in plain language, use both
verbal and audiovisual instruction, be repeated by multiple providers (e.g., physician,
nurse, pharmacist), and be confirmed using a “teach-back” method, where patients are
asked to repeat back what they understood about discharge instructions in their own words.

•

Burden of care assumed by patients and families after discharge. Patients are
responsible for administering new medications, tracking symptoms, participating in
physical therapy, and following up with their outpatient physician. For many patients,
sufficient social and family support is not available to help perform these activities
effectively. Also, patients may feel overwhelmed and unprepared to take on an active role
in their health care without adequate information, and in some cases, coaching.

Many of these challenges can be attributed to problems in discharge planning. Discharge
planning is the process of identifying and preparing for a patient’s anticipated health care needs
6

Implementation Handbook: IDEAL Discharge Planning

after they leave the hospital.(6) Hospital staff cannot do discharge planning in isolation from the
patient and family.
Comprehensive discharge planning involving the patient and family contributes to positive
patient outcomes, such as reductions in unplanned readmissions and increases in patient and
caregiver satisfaction with the health care experience.(7, 8) However, it is often difficult for
hospitals to do comprehensive discharge planning given the shortened length of stays for most
hospital admissions. That is why it is critical to involve and educate the patient and family
throughout the hospital stay.

How to prevent adverse events after discharge
Ensuring safe transitions from hospital to home requires a systematic approach that includes the
patient and family in the discharge process. At this time, no consensus exists on the single best
method to prevent adverse events after discharge.
Although more research is needed to verify these findings, various medication reconciliation
approaches have shown promise in improving clinical outcomes. Promising interventions include
discharge "checklists" to standardize the discharge process, and structured post-discharge phone
calls to patients. Similarly, evidence is mounting for structured discharge communication
approaches. One approach uses specially trained staff to meet with patients before (and
sometimes after) discharge to reconcile medications, instruct patients and caregivers in self-care
methods, prepare patient-centered discharge instructions, and facilitate communication with
outpatient physicians.
Coleman’s Care Transitions Program, Naylor’s transitional care intervention with advanced
practice nurses, and the Project RED (Re-Engineered Discharge) study use variations of this
method, and all successfully reduced readmissions and emergency department visits after
discharge.(9-11) Other interventions aimed at transitions from hospital to home show similar
promise. The BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care
Transitions project uses a combination of assessment and communication strategies for
improving discharge outcomes for older adults. Also, Transforming Care at the Bedside (TCAB),
a national program from the Robert Wood Johnson Foundation and the Institute for Healthcare
Improvement, developed the How-to Guide: Creating an Ideal Transition Home for Patients
with Heart Failure. This guide integrates what TCAB hospitals have learned as they strive to
improve the quality of care for patients discharged from the hospital to home or to another health
care facility.
The IDEAL discharge planning materials in the Guide build on these important initiatives,
focusing on those elements intended to engage the patient and family in their care. The IDEAL
discharge strategy and tools can stand on their own or be used with these successful
initiatives, rather than instead of them. [Note: Could include example here from Task 7]
Implementation Handbook: IDEAL Discharge Planning

7

How does the IDEAL discharge planning strategy improve the
discharge process?
The IDEAL Discharge Planning strategy focuses on engaging the patient and family in the
discharge process. This approach involves working with patients and families rather than only
doing something to or for patients and families. The tools in this strategy support discharge
planning among the patient, family, clinicians, and hospital staff in several ways. They:
•

Help clinicians and hospital staff include the patient and family as full partners in the
discharge planning process.

•

Provide an opportunity for the patient and family to think about the discharge throughout
the hospital stay.

•

Identify opportunities for educating the patient and family throughout the hospital stay.

•

Train clinicians and hospital staff on ways to conduct patient and family education and
confirm understanding.

•

Provide a structured setting in which patients and families can discuss their concerns and
get their questions answered, prior to the often chaotic day on which the discharge
actually occurs.

•

Ensure that patients have a followup appointment prior to leaving the hospital.

•

Ensure that patients know who to call if they are having problems.

Also, the Joint Commission suggests that hospitals meet the following four goals in a discharge
process. The IDEAL Discharge Planning strategy helps to meet these goals:
1.

Address patient communication needs during discharge and transfer.

2.

Engage patients and families in discharge and transfer planning and instruction.

3.

Provide discharge instruction that meets patient needs.

4.

Identify followup providers that can meet unique patient needs.

(Placeholder for examples from Task 7, Implementation and Evaluation in this section in the
form of patient/family/staff quotes or a case study.)

Implementing the IDEAL Discharge Planning Process
(Note: This is a section where we will want to incorporate information from the Task 7
Implementation and Evaluation. We will also be able to provide more specific guidance about
what worked and what did not work.)
The IDEAL Discharge Planning strategy is designed to be flexible and adaptable to each
hospital’s environment and culture. As such, this guidance provides choices and questions for
hospital leaders about how to implement this strategy. It may be helpful to implement this
8

Implementation Handbook: IDEAL Discharge Planning

strategy initially on a small scale (e.g., a single unit). Identify lessons learned from the singleunit pilot implementation, refine your approach, and then spread to more units. In this way, you
can build on your successes as a pathway to broader dissemination and wider-scale change.

Step 1: Form a multi-disciplinary team to identify areas of
improvement
As with any new activity or quality improvement effort, planning and identifying areas of
improvement are important parts of the process. Below are some key considerations as you get
started implementing the IDEAL Discharge Planning strategy.
Engage patients and families and unit staff in the process: Establish a multidisciplinary team
This team should include hospital leaders, physicians, nurses, other key clinical and management
staff, and patient and family representatives.
Guide Resource

For more information about working with patient and
family advisors, see Component 2, Organizational
Partnership Materials

Throughout the process of implementing the IDEAL discharge planning strategy, patient and
family advisors can:
•

Give feedback on what the current discharge process feels like as a patient or family
member.

•

Contribute to adapting the IDEAL strategy and tools for your hospital (both the overall
process and the individual tools).

•

Take part in training clinicians about the IDEAL discharge process by participating in
role plays or other small group exercises or by describing how the discharge process feels
to the patient or family.

•

Observe clinicians throughout hospital stay and give feedback about how they meet the
key elements of the IDEAL discharge process.

Assess family visitation policies
The family cannot be part of the health care team if they are not present. It is important that the
patient can define who is included their family and that these members of the health care team
are encouraged and supported.

Implementation Handbook: IDEAL Discharge Planning

9

Guide Resource

For more information about family presence policies, see
Supporting Patient and Family Engagement: Best Practices
for Hospital Leaders in Component 3.

Assess the current discharge process, including how and the extent to which
patients and family members are engaged
Use the multi-disciplinary team to review what is known, from formal survey measures,
readmission rates, and people’s sense of how things are going with respect to discharge planning
from the clinician, patient, and family perspectives. Who from the hospital staff are involved in
the process? How do they coordinate their interactions with the patient? How satisfied are the
clinicians and hospital staff involved in the process?
The team can identify strengths related to discharge planning – what is done well in terms of
engaging the patient and family in this discharge planning process and making sure the patient
and family understands all of the next steps in their care. Also, the team can identify areas for
improvement – what can be done better?
Improving the discharge planning process may require new behaviors from each member of the
health care team – the patient, family, clinicians, and hospital staff. Each team member brings a
different perspective to the discharge process, and understanding those perspectives is important
for effective discharge planning.
Keep in mind that taking on new behaviors will be challenging. The multi-disciplinary team can
identify challenges and facilitators for engaging patients and families in discharge planning at
your hospital or unit. What factors seem to support patient and family engagement in discharge
planning? How can we replicate them? What are the challenges that need to be addressed from
the patient, family, clinician, and hospital staff perspectives?
Some examples of challenges related to engaging patients and families in discharge planning and
ways to overcome those challenges are:
•

10

Clinicians and hospital staff may feel that they already engage the patient and family
in discharge planning or may not know how to incorporate new communication
approaches into their care. Some clinicians or hospital staff may feel that they already
engage the patient and family in discharge planning, even when decisions are made about
discharge without the patient and family present. Although many clinicians recognize the
importance of communication, they tend to be overly positive in their perceptions of how
effectively they communicate.(12) Even when providers see the need for better
communication, such as with the use of teach back, it may be difficult to operationalize
those skills in practice.(13)
Implementation Handbook: IDEAL Discharge Planning

•

Inadequate time to prepare the patient and family for discharge. Occasionally, the
physician’s discharge orders may come as a surprise to discharge planning staff or
bedside nurses. Similarly, hospital staff may feel pressure to rapidly make a bed available
for another patient. Because of limited time, hospital staff may not feel able to engage the
patient and family in the discharge planning process, reducing the effectiveness of some
discharges. Recognize that discharge planning is not a one-time event, but a process
throughout the hospital stay.

•

Negotiating interactions with family members. Families are complicated, and it may be
difficult for clinicians and hospital staff to know which family members should be
involved in discharge planning and how to interact with those family members. As part of
the initial nursing assessment, it is important for nurses to ask patients which family or
friends would they like to participate and who will be involved in their care at home.

•

Fearing change. Some clinicians or hospital staff may fear losing control of the
discharge planning process or may not feel confident in engaging the patient and family
in discharge planning. Often, if consistent use of the IDEAL discharge planning is not
monitored, clinicians or hospital staff may revert back to the “old way.” It is important to
let clinicians and hospital staff know that the IDEAL discharge planning is not optional.
Acknowledge that change is hard, but stress the importance of engaging the patient and
family in the discharge planning process.

Identify ways to overcome these challenges at your hospital or unit. Are there particular units
where it might be wise to “pilot” this new approach, either because of staff attitudes or because
there is a pressing need to improve discharge for a group of patients?
Set aims to improve discharge planning
Once you have a strong understanding of the existing family presence policies, discharge
planning challenges, and facilitators, you can identify what needs to be improved and ways to
measure that improvement.
Any quality improvement initiative requires setting aims. The aim should be time-specific,
measurable, and define who will be affected.
For example, hospitals may want to improve patients’
experience of care as measured by the CAHPS Hospital
Survey®. CAHPS Hospital Survey® questions related to
discharge include:
•

Q19: During this hospital stay, did doctors, nurses, or
other hospital staff talk with you about whether you
would have the help you needed when you left the
hospital?

Implementation Handbook: IDEAL Discharge Planning

For more information on
setting aims and identifying
measures, see the Institute of
Healthcare Improvement’s
Web site on improvement
methods. Available at:
http://www.ihi.org/IHI/Topics/I
mprovement/ImprovementMet
hods/HowToImprove/.
11

•

Q20: During the hospital stay, did you get information in writing about what symptoms
or health problems to look out for after you left the hospital?

If a hospital wants to improve their CAHPS Hospital Survey® scores related to discharge, an
aim might be “to improve scores on CAHPS Hospital Survey® Questions 19 and 20 by 5 percent
within 1 year.”

Step 2: Decide on how to implement the IDEAL discharge planning
strategy
Once the team has set specific aims for improvement, it may be helpful to identify a single point
person as the primary person staff would go through with any kind of question. This person may
not have the answers to all questions, but would know who would have them. This way, people
are clear about whom to go to, and that person will hear all the questions and concerns.
Decide on how to adapt the IDEAL discharge planning process for your hospital
As described above, the IDEAL discharge planning strategy includes four tools.
Guide Resources

Tool 1: IDEAL Discharge Planning Overview, Process,
and Checklist informs clinicians about the new discharge
planning process and keeps track of when tasks are
accomplished.
Tool 2: Be Prepared to Go Home Checklist identifies the
patient and family’s questions and concerns about going
home.
Tool 3: Improving Discharge Outcomes With Patients and
Families informs physicians of the IDEAL discharge
planning process.
Tool 4: IDEAL Discharge Planning Training prepares
clinicians and hospital staff to support the efforts of patient
and family engagement related to discharge planning.

Answer the following questions to decide how to use and adapt the tools in this strategy at your
hospital:
•

12

Decide on how to use and adapt the IDEAL discharge planning process. First, decide
on which elements of the IDEAL discharge planning process need to be incorporated at
your hospital. Ask clinicians, hospital staff, and patient and family advisors about
possible changes. Adapt Tool 1: IDEAL Discharge Planning Overview, Process, and
Checklist to fit your hospital environment. How can these processes be incorporated into
Implementation Handbook: IDEAL Discharge Planning

electronic health records? Once this tool is adapted, who will review it? What approvals
are needed?
•

Decide how to use and adapt the checklist for the patient and family. Next, adapt the
patient and family checklist, Tool 2: Be Prepared to Go Home Checklist. Ask clinicians,
hospital staff, and patient and family advisors about possible changes. At a minimum, it
would be important to insert hospital name, logo, and tailored information into the
brochure. Who will review it? What approvals are needed?
Once adapted, determine how the checklist be distributed. How will the checklist be
printed? Who will distribute? How will interpreters be involved in the distribution
process, if needed? Can the checklist be integrated into the current admission or
discharge materials? If so, how? What approvals need to be sought? Who will go over the
checklist with the patient and family and invite the patient and family to participate? (The
hospital can determine which staff should be involved in meeting to go over the checklist;
this could include the nurse, doctor, volunteer/patient advocate, discharge planner, or a
combination. The patient should determine if family or friends should be involved and if
so, who.) If applicable, how will temporary staff learn about how to engage patients and
families in the discharge planning process?
Once ready, how will the checklist be printed? Will they be distributed in a folder, online,
or another way? How can the messages from the tools be incorporated or distributed via
different communication methods such as video, social media such as Facebook, or cell
phone text messages?

•

Plan the IDEAL discharge process training for clinicians. Who can conduct the training
for their colleagues? The facilitators should be respected by their colleagues and model
the behaviors being asked of them. Which patient and family advisors can help to
conduct or facilitate the training? How many sessions are needed to train all staff? When
can the training be scheduled? Where can the training happen? How should the Tool 4:
IDEAL Discharge Planning Training be adapted? Who needs to approve the training
materials?
Recognize that individuals have different learning styles. To be most effective, use three
or more different learning strategies during the training, such as giving information,
modeling behavior, providing feedback, and practicing skills.

Step 3: Implement and evaluate the IDEAL Discharge Planning
Strategy
Inform staff of changes
If not already involved, inform unit directors and managers so they know what is coming and
why it is important. Inform staff at staff meetings and through posters in common rooms about
Implementation Handbook: IDEAL Discharge Planning

13

the changes in the discharge planning process and opportunities for training. Specifically,
inform physicians of upcoming changes using Tool 3: Improving Discharge Outcomes With
Patients and Families.
Train staff
Staff training will include those chosen by the hospital to implement the tools. Training includes
a mix of PowerPoint slides and role play, and should take about an hour, but can be tailored to
the needs of your hospital. Main messages to emphasize: (1) To improve safety and quality of
care at home, the patient and family needs to be included as a member of the team for all of
discharge planning, and (2) Discharge planning is not a one-time event with a single fix; it needs
to occur throughout the hospital stay.
After the training, it is important to assess:
•

Did the training happen as planned? What happened during training that could challenge
or facilitate implementation?

•

How did staff react to training?

Distribute tools and incorporate key principles into practice
As defined during Step 2, identified staff will distribute and go over materials with the patient
and family. The main message to emphasize with the patient and family is: The patient and
family are full partners in discharge planning and need to be prepared little by little throughout
the hospital stay to ensure that they know what to do and have what they need to succeed at
home. This will result in higher quality discharges with more positive outcomes.
Keep staff aware of the IDEAL discharge planning by making sure Tool 1: IDEAL Discharge
Planning Overview, Process, and Checklist is available throughout the unit.
Assess implementation intensely during the initial first month and periodically
after that
Make sure that all clinicians and hospital staff have the support needed to implement the new
discharge planning process and to effectively communicate with the patient and family. Have the
nurse manager or other staff leader observe interactions with the patient and family and provide
feedback to individual clinicians and hospital staff. Use a standardized form to keep track of the
observations, such as the checklist that is a part of Tool 1: IDEAL Discharge Planning Overview,
Process, and Checklist. Identify a way to collect and analyze data collected, such as an Excel
Spreadsheet or other database.
Continue to conduct periodic observations at 2 and 4 months after roll-out to ensure consistency
of implementation among staff. Continual feedback and monitoring is needed to make sure
behaviors become more natural.
14

Implementation Handbook: IDEAL Discharge Planning

Get feedback from clinicians, hospital staff, patients and families
Get informal feedback from clinicians, hospital staff, patients, and family members by asking
them about how communication and the tools can be improved. If applicable, it may be helpful
to get feedback from community physicians, especially for those patients who need strong
discharge planning support. What worked well? What could be improved? How could tools be
changed or adapted for use on another unit? What was critical for success? What was not
successful and what could have been made better?
Incorporate formal feedback in mechanisms already in place at hospital such as patient and
family focus groups, patient and family satisfaction surveys, and staff surveys.
Refine process
Share feedback with implementation team, problem solve, and adapt, as necessary. Using the
feedback received, refine the process and tools before implementing in other units.

1

The Guide was developed for the Agency for Healthcare Research and Quality, in the U.S. Department of Health
and Human Services, by a collaboration of partners with experience in and commitment to patient and family
engagement, hospital quality, and safety. Led by the American Institutes for Research (AIR), the team included the
Institute for Patient and Family-Centered Care (IPFCC), Consumers Advancing Patient Safety (CAPS), the Joint
Commission, and the Health Research and Educational Trust (HRET). Other organizations contributing to the
project included Planetree, the Maryland Patient Safety Center (MPSC), and Aurora Health Care.

Implementation Handbook: IDEAL Discharge Planning

15

References
1.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of
adverse events affecting patients after discharge from the hospital. Ann Intern Med.
2003;138(3):161-7.
2.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.
3.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of
care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-23.
4.
Popejoy LL, Moylan K, Galambos C. A review of discharge planning research of older
adults 1990-2008. West J Nurs Res. 2009;31(7):923-47.
5.
Anthony MK, Hudson-Barr D. A patient-centered model of care for hospital discharge.
Clin Nurs Res. 2004;13(2):117-36.
6.
Maramba PJ, Richards S, Myers AL, Larrabee JH. Discharge planning process: applying
a model for evidence-based practice. J Nurs Care Qual. 2004;19(2):123-9.
7.
Bauer M, Fitzgerald L, Haesler E, Manfrin M. Hospital discharge planning for frail older
people and their family. Are we delivering best practice? A review of the evidence. J Clin Nurs.
2009;18(18):2539-46.
8.
Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, et al.
Discharge planning from hospital to home. Cochrane Database Syst Rev.
2010;20;(1):CD000313.
9.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a
randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8.
10.
Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A
reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann
Intern Med. 2009;150(3):178-87.
11.
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS.
Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J
Am Geriatr Soc. 2004;52(5):675-84.
12.
Makoul G, Arntson P, Schofield T. Health promotion in primary care: Physician-patient
communication and decision making about prescription medications. Soc Sci Med. 1995
Nov;41(9):1241-54.
13.
Bruce B, Letourneau N, Ritchie J, Larocque S, Dennis C, Elliot R. A multisite study of
health professionals' perceptions and practices of family-centered care. J Fam Nurs.
[10.1177/107484002237515]. 2002;8(4):408-29.

16

Implementation Handbook: IDEAL Discharge Planning

IDEAL Discharge Planning:
Overview, Process, and Checklist
Ove rvie w o f IDEAL Dis c h a rg e P la n n in g
What is IDEAL discharge planning?
Discharge and transition planning from the hospital to home cannot be done successfully in
isolation from the patient and family. IDEAL discharge planning emphasizes the key elements of
engaging patients and families:



Include the patient and family as full partners in the discharge planning process.
Discuss with the patient and family five key areas to prevent problems at home: (1) what
life at home will be like, (2) medications, (3) warning signs and problems, (4) test results,
and (5) followup appointments.



Educate the patient and family in plain language about their condition, the discharge
process, and next steps at every opportunity throughout the hospital stay.



Assess how the patient and family understand the diagnosis, condition, and next steps in
their care – Use Teach Back.



Listen to the patient and family’s goals, preferences, observations, and concerns.

How can you do IDEAL discharge planning?
Each element of IDEAL discharge planning has multiple components:

Include the patient and family as full partners in the discharge planning process.
•

Always include the patient and family in team meetings about discharge. Remember
discharge is not a one-time event, but a process throughout the hospital stay.

•

Identify which family or friends will provide care at home and include them in
conversations.

Discuss with the patient and family five key areas to prevent problems at home.
1. Describe what life at home will be like: Include home environment, support needed, what
the patient can or cannot eat, and activities to do or avoid.
2. Review medications: Use a reconciled medication list to discuss the purpose of each
medication, what and how to take it, and potential side effects.
3. Highlight warning signs and problems: Identify warning signs or potential problems.
Give the name and contact information of someone to call if there is a problem.

Discharge Tool 1: Clinician Overview, Process, and Checklist

1

4. Explain test results: Explain test results to the patient and family. If test results are not
available at discharge, let the patient and family know when they should hear about
results and identify who they should call if they have not heard the results by that date.
5. Make followup appointments: Offer to make followup appointments for the patient. Make
sure that the patient and family know what followup is needed.

Educate the patient and family in plain language about condition, discharge process, and
next steps at every opportunity throughout the hospital stay.
Getting all the information on the day of discharge can be overwhelming. That’s why discharge
planning should be an ongoing process throughout the stay – not a onetime event. You can:
•

Elicit the patient and family goals at admission and note how progress is being made
toward these goals each day during the hospital stay.

•

Involve the patient and family in nurse change of shift report or bedside rounds.

•

Share a written list of medications every morning during the hospital stay.

•

Go over medicines at each administration – what it is for, how to take it, and potential
side effects.

•

Encourage the patient and family to take over care practices to support their competence
and confidence in care giving at home.

Assess how the patient and family understand the diagnosis, condition, and next steps in
their care: Use Teach Back.
•

Provide information in small chunks and repeat key pieces of information throughout the
hospital stay.

•

Ask the patient and family to repeat back what you said in their own words to be sure that
you explained things well.

Listen to the patient and family’s goals, preferences, observations, and concerns.
•

Invite the patient and family to use the white board in the room to write questions or
concerns throughout their stay.

•

Ask open-ended questions to elicit the patient’s and family’s questions and concerns.

•

Use Tool 2: Be Prepared to Go Home Checklist to make sure the patient and family feel
prepared to go home.

•

Schedule at least one meeting specific to discharge planning with the patient and family
caregivers.

2

Discharge Tool 1: Clinician Overview, Process, and Checklist

IDEAL Dis c h a rg e P la n n in g P ro c e s s
The elements of the IDEAL discharge planning process can be incorporated into your current
discharge. The information below describes key elements of the IDEAL discharge from
admission to discharge to home. Note that this process includes at least one meeting between the
patient, family, and discharge planner to help the patient and family feel prepared to go home.

Initial nursing assessment
Identify who the caregiver will be at home along with potential back-ups – these are
the “learners” who need to understand instructions for care at home. Do not assume that
family in the hospital will be caregivers at home.
Let the patient and family know that they can use the white board in the room to
write questions or concerns.
Elicit the patient and family’s goals for when and how they leave the hospital, as
appropriate. With input from their doctor, work with the patient and family to set feasible
and realistic goals.
Inform the patient and family about steps in progress toward discharge. For common
procedures, create a patient handout, white board or poster that identifies the “road map” to
get home. This “road map” may include things like “I can feed myself” or “I can walk 20
steps.”

Daily
Educate the patient and family about their condition at every opportunity: Shift
report, rounds, vital status check, nurse calls, and other opportunities that present
themselves.
Who: All clinical staff
Explain medications to the patient and family daily (for example, print out a list every
morning) and at any time medication is administered. Explain what each medicine is
for, describe potential side effects, and make sure the patient knows about any changes in
the medicines they are taking.
Who: All clinical staff
Discuss the patient, family, and clinician goals and progress toward discharge. Once
goals are set at admission, revisit these goals on a daily basis to make sure the patient and
family understand how they are progressing toward discharge.
Who: All clinical staff
Involve the patient and family in practices to improve confidence in caretaking after
discharge. Examples of care practices could include changing the wound dressing, helping
the patient with feeding or going to the bathroom, or assisting with rehabilitation exercises.
Who: All clinical staff

Discharge Tool 1: Clinician Overview, Process, and Checklist

3

Prior to discharge planning meeting
When: 1 to 2 days before discharge planning meeting; for short stays, may happen on admission
Give the patient and family the Tool 2: Be Prepared to Go Home Checklist.
Who: Hospital identifies person to distribute; this could be a nurse, doctor,
volunteer/patient advocate, or discharge planner.
Schedule discharge planning meeting with the patient, family, and hospital staff.
Who: Hospital identifies person to schedule; this could be a nurse, doctor,
volunteer/patient advocate, or discharge planner.

Discharge planning meeting
When: 1 to 2 days before discharge, earlier for more extended stays in the hospital.
Use the Tool 2: Be Prepared to Go Home Checklist as a starting point for dialogue
about questions, needs and concerns going home.
o If the patient or family did not read or fill out the checklist, review it verbally. Make
sure to ask if they have questions or concerns other than those listed. You can start the
dialogue by asking, “What does being back home look like for you?”
o Repeat the patient’s concerns in your own words to make sure you understand.
o Use Teach Back to check if the patient understands the information given.
o If another clinician is needed to address concerns (e.g., pharmacist, doctor, or nurse),
arrange for this conversation.
Who: Hospital determines which staff should be involved in meeting; this could include the
nurse, doctor, volunteer/patient advocate, discharge planner, or a combination. Patient
determines if family or friends should be involved and if so, who.
Offer to make followup appointment. Ask if the patient has a preferred day / time and
if they can get to the appointment.
Who: Hospital identifies person to schedule followup appointments; this could be a nurse,
doctor, volunteer/patient advocate, or discharge planner.

Day of discharge
Review a reconciled medication list with the patient and family. Go over the list of
current medications. Ask them to repeat what, when, and how to take each medicine.
Make sure that patients have an easy-to-read, printed medication list to take home.
Who: Hospital identifies person to review this list with patient and family. Because this
involves medications, we assume it would be a clinician – nurse, doctor, or pharmacist.
Write down followup appointment times on the Tool 2: Be Prepared to Go Home
Checklist.
Who: Staff who scheduled appointment.
Write the name, position, and phone number of a person to contact if there is a
problem after discharge on the Tool 2: Be Prepared to Go Home Checklist. Make sure
the contact person is aware of the patient’s condition and situation (e.g., if the primary care
physician is the contact person, make sure the primary care physician has a copy of the
discharge summary on the day of discharge to be able to answer questions).
Who: Hospital identifies person to write contact information; this could be a nurse, doctor,
volunteer/patient advocate, or discharge planner.
4

Discharge Tool 1: Clinician Overview, Process, and Checklist

IDEAL Discharge Planning Checklist
Fill-in, initial, and date next to each task as completed.
Patient Name: _______________________________________________________________________________________________
Initial Nursing
Assessment

Prior to Discharge
Planning Meeting

During Discharge
Planning Meeting

_____Identified family _____Distributed checklist
caregiver and
to patient and family
back-ups at
with explanation
home
_____Scheduled
_____Told patient
discharge planning
and family
meeting
about white
board
Scheduled for

_____Discussed patient
questions

_____Elicited patient
and family
goals for
discharge

_____Offered to schedule
followup
appointments with
providers.
Preferred dates /
times for:
PCP:

__ / ___ / _____ at
___________[time]

_____Informed
patient and
family about
steps to
discharge

Day of Discharge
Medication
_____Reconciled medication list

_____Discussed family
questions
_____Reviewed discharge
instructions as
needed

_____Reviewed medication list with patient and
family
Appointments and contact information
_____Scheduled followup appointments:
1. With
_____________________________ at
___ / ___ / ____at _________[time]
2. With
_____________________________ at
___ / ___ / ____at _________[time]
_____Arranged any home care needed

Other:

_____Confirmed appointments with patient /
family
_____Confirmed contact information for followup
person after discharge

Notes:

Discharge Tool 1: Clinician Overview, Process, and Checklist

5

IDEAL Discharge Planning Daily Checklist
Fill-in, initial and date next to each task as completed.
Patient Name: _______________________________________________________________________________________________
Day 1

Day 2

Day 3

Day 4

_____Educated patient and
family about condition

_____Educated patient and
family about condition

_____Educated patient and
family about condition

_____Educated patient and
family about condition

_____Discussed progress
toward patient, family,
and clinician goals

_____Discussed progress
toward patient, family,
and clinician goals

_____Discussed progress
toward patient, family,
and clinician goals

_____Discussed progress
toward patient, family,
and clinician goals

_____Explained medication to
patient and family
AM_________
NOON______
PM_________
BED________
OTHER______

_____Explained medication to
patient and family
AM_________
NOON______
PM_________
BED________
OTHER______

_____Explained medication to
patient and family
AM_________
NOON______
PM_________
BED________
OTHER______

_____Explained medication to
patient and family
AM_________
NOON______
PM_________
BED________
OTHER______

_____Involved patient and
family in care practices,
such as:

_____Involved patient and
family in care practices,
such as:

_____Involved patient and
family in care practices,
such as:

_____Involved patient and
family in care practices,
such as:

Notes:

6

Discharge Tool 1: Clinician Overview, Process, and Checklist

Be Prepared to Go Home Checklist

Before you leave the hospital, we want to make sure you feel ready to be at home. During your
hospital stay, your doctors and nurses will talk with you about the things on this checklist. It is
our responsibility to make sure you have the information you need and that we address your
questions and concerns.
Use this checklist to see what information you still need from us as you or your family member
prepare to go home. Make sure you can check all of the boxes. If you cannot check a box, talk to
your doctor or nurse. Use the questions below to help you get the information you need.

My family or someone close to me knows I am coming
home. They also know about the next steps in my care.
Family or someone close to you can help keep track of and understand information about
your health. It is up to you to say who you want to be involved.
Ask:

Do I need help from my family or someone close to me when I get home?
If so, who will help me? What do they need to do to get ready?
How do I make sure my family or someone close knows what I need when I get
home?
What should I do if there is no one at home who can help me?

I know what problems to look for and who to call if I have
problems at home.
Some symptoms such as pain or swelling may be normal when you get home. Sometimes,
these symptoms are signs of bigger problems. Be sure you understand when you need to call
for help and who you should call.
Ask:

What problems do I need to watch for when I get home? When do I need to call
if there are problems?
Who do I call if I have questions or problems after I leave the hospital?

Discharge Tool 2: Be Prepared to Go Home Checklist

1

I know when my followup appointments are and how to get
there.
You will need followup appointments after you leave the hospital. At these appointments,
your doctor will check on how well you are recovering. Your doctor may also ask you to get
some tests or give you test results that you are waiting for.
Be sure to keep these appointments.
Ask:

What followup appointments do I need to have after I leave the hospital? Can the
hospital help me make these appointments?
Am I waiting on results of any tests? When should I get the results?
Are there tests I need after I leave the hospital?

I know what my medicines are and how to take them.
Before you leave the hospital, go over the medicines you need to take when you get back
home (your medication list) with your doctor or nurse. The medicines you need to take may
be different from what you took before you went into the hospital.
Tell your doctor and nurse about all the medicines you usually take at home, including overthe-counter medicines, vitamins, and herbal supplements.
Ask:

What is the name of this medicine? Is this the generic or brand name?
Why do I take this medicine? What does this medicine look like?
How much do I take? When and how do I take this medicine?
What are potential side effects of this medicine? What problems do I need to
look out for?
Will this medicine interfere with other medicines I am taking?
Will this medicine interfere with vitamins or other herbal supplements I am
taking?
Where and how do I get this medicine?
What medicines can I take for pain? Upset stomach? Headaches? Allergies?

2

Discharge Tool 2: Be Prepared to Go Home Checklist

I feel confident that I or someone close to me can take care
of me when I leave the hospital.
Before leaving the hospital, you will get written instructions about your care.
Make sure you understand these instructions. Repeat these instructions back to the doctor or
nurse in your own words. That way, you can check your understanding. If needed, ask your
doctor or nurse to explain things more clearly.
Ask:

How do I take care of any wounds, cuts, or incisions? Can you show me how to
do this?
What foods or drinks should I avoid? For how long?
Are there any activities I should avoid (for example, driving, sex, heavy lifting,
climbing stairs)? For how long?
What exercises are good for me? When can I start doing them? How often
should I do them?
What do I need to do to make my home safer?

I know about other help I need at home.
You may need other help at home. Or, you may do fine on your own.
We will set up nursing care, therapy, or other help if you need it. Family or friends can also
help. Ask your doctor or nurse how others can help you recover.
Ask:

When I get home, what kind of help or care will I need? Should someone be with
me all the time? Will I need…
•

Nursing care (for taking my medicines or taking care of cuts or wounds)?
For how long? Who pays for it?

•

Physical or occupational therapy (for help doing exercises or relearning
how to do things)? For how long? Who pays for it?

•

Help with eating, bathing, or going to the bathroom? For how long? Who
pays for it?

Will I need any equipment such as crutches or oxygen? Where do I get it? Who
pays for it? How do I use it?
How can friends or family members help me at home?

Discharge Tool 2: Be Prepared to Go Home Checklist

3

My doctors or nurses answered questions that are
important to me and my family.
You may have other questions or concerns that are not in this checklist. Write them down
here, and make sure you have the answers you need before you leave the hospital.

Tips for Going Home
Patients and families at [insert hospital name] wrote these tips to help you get ready to go home:
[Use patient and family advisors to tailor this list to your hospital.]
 Write down what your doctors and nurses say.
 Ask questions again until you get the answers you need.
 Make lists – what has to be done, who can do it, and who can help.
 Talk with someone else who has been in the same situation to help you prepare and know
what to expect.
 Talk to other people in the hospital, such as social workers, chaplains, and other patients
about your care or other support you may need.

Going Home Too Soon?
If you feel that you are going home before you are ready, call [insert name] at [phone number].

4

Discharge Tool 2: Be Prepared to Go Home Checklist

Use this space to write any information you need.

Notes

Discharge Tool 2: Be Prepared to Go Home Checklist

5

IDEAL Discharge Planning
Improving Discharge Outcomes With Patients and Families
Nearly 20 percent of patients experience an adverse event within three weeks of discharge. Of
these adverse events, three-quarters could have been prevented or ameliorated. Common
complications post-discharge include adverse drug events, hospital acquired infections, and
procedural complications. 1 Many of these complications can be attributed to problems in
discharge planning. For this reason, [insert hospital name] is pioneering the use of the IDEAL
discharge planning tools to engage patients and families in preparing for discharge to home.

Changes to the discharge planning process at [insert hospital name]
Discharge planning cannot be done successfully in isolation from the patient and family.
Families are the constants in a patient’s life and are instrumental for ensuring the patient
continues to get high quality and safe care at home. [insert hospital name] will incorporate the
following in our discharge planning process:

Include the patient and family as full partners in the discharge planning process.
Always include the patient and family in team meetings about discharge.

Discuss with the patient and family five key areas to prevent problems at home: Describe
what life at home will be like, review medications, highlight warning signs and problems,
give test results, and make followup appointments.

Educate the patient and family in plain language about their condition, the discharge
process, and next steps at every opportunity throughout the hospital stay.
Assess how the patient and family understand the diagnosis, condition, and next steps in
their care – Use Teach Back.

Listen to the patient and family’s goals, preferences, observations, and concerns.
For patients transitioning home, there will be at least one discharge planning meeting to discuss
the patient and family’s concerns and questions. This meeting will include the patient, family of
their choice, and a [nurse, discharge planner, other].

What does this mean for you?
We expect you to incorporate the IDEAL discharge elements throughout the hospital stay and
make yourself available to the [nurse, discharge planner, other HCP] who is working with the
patient and family in case they have questions.
This process ensures that your patients will be better equipped to support the best possible
recovery when they go home, which will lead to better patient outcomes. Copies of the IDEAL
discharge process overview and checklist for clinicians and a checklist for patients and family
members are available at the nurses’ station.
1
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting
patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167

Discharge Tool 3: Physician Handout

1

IDEAL Discharge Planning:
Clinician Training
[Insert hospital name, presenter name and title, date
of presentation]
Discharge Tool 4: Clinician Training Presentation

Today’s session

 What is patient and family engagement?
 What is the patient and family
experience of discharge?
 IDEAL discharge planning:
♦ What are we asking patients and
families to do?
♦ What are we asking you to do?
 Practice exercises

What is patient and family
engagement?

Hospital quality





Patients get care that is safe



No differences in treatment based on race,
ethnicity, income, education, or social status



Care is patient- and family-centered

Patients get the right care for their condition
Patients get care they need when they need it
Patients get care that makes wise use of
resources

Patient- and family-centered care


Mutually beneficial partnerships among
clinicians, hospital staff, patients, and families



Core concepts:
♦

Dignity and respect

♦

Information sharing

♦

Participation

♦

Collaboration

What is patient and family engagement?


Critical component of patient- and familycentered care



Patient and family engagement means
involving patients and family members as:
♦

Members of the health care team

♦

Advisors working with clinicians and leaders
to improve policies and procedures

Goal of patient and family engagement


To create an environment where clinicians,
hospital staff, patients, and families all work
together as partners to improve the quality and
safety of hospital care.

Why is the discharge process important?



Nearly 20 percent of patients experience an
adverse event within 3 weeks of discharge, of
which ¾ could be prevented



Common complications post-discharge are:



♦

Adverse drug events

♦

Hospital acquired infections

♦

Procedural complications

Growing concern about re-admissions to the
hospital, especially those that are preventable
♦

20 percent Medicare patients rehospitalized
within 30 days of discharge

What is the patient and family
experience of discharge at our
hospital?

What is it like being a patient?


How do patients and families feel at discharge?
♦

Relieved and excited to go home

♦

Scared or nervous about home situation or
lack of support

♦

Worried about their ability to take care of
themselves or the patient

♦

Hesitant to ask questions or raise concerns,
especially about home life, with hospital staff

What is it like being a patient?
Clinicians and hospital staff

Patients and family members

• Are taught that discharge
starts at admission, but may
not do this often

• Can feel as if they are being forced out of the
hospital when you raise the idea of discharge
starting at admission
• May not start to think about discharge until
later in stay

• May prioritize clinical care at
home (e.g., wound care)

• May prioritize functioning and quality of life
(e.g., activities, diet)
• May not know all the questions they should
ask or what they need to know when they are
home

• Have limited time for
discharge planning

• May not understand all written information
related to discharge
• Feel rushed on the day of discharge

• Want patient to succeed at
home

• Want to know one person to call if they have
problems

What is it like being a patient?




[Insert1 to 2 experiences from real patients or
family members on what the discharge
process feels like from the patient/family
perspective, using:
♦

Live presentation / story

♦

Video

♦

Vignette or quote

Preferably include at least one positive and
one negative story (what worked well, what did
not work well)]

What will we do to improve the
discharge planning process?
IDEAL discharge planning materials and
process

What is the IDEAL discharge?



Include the patient and family as full partners



Educate the patient and family throughout the
hospital stay



Assess how the patient and family understand
the diagnosis, condition, and next steps in
their care – Use Teach Back



Listen to the patient and family’s goals,
preferences, observations, and concerns

Discuss with the patient and family 5 key
areas to prevent problems at home

What is the IDEAL discharge process?
1. At initial nursing assessment
♦

Identify who will be at home with patient

♦

Let the patient and family know that they can
use the white board in the room to write
questions or concerns

♦

Elicit the patient and family goals for hospital
stay

♦

Inform the patient and family about steps
toward discharge

What is the IDEAL discharge process?
2. Daily
♦

Educate the patient and family about condition
at every opportunity

♦

Explain medications to the patient and family

♦

Discuss progress toward goals

♦

Involve the patient and family in care practices

What is the IDEAL discharge process?
3. Prior to discharge planning meeting
♦

[Identify who] will give the Be Prepared to Go
Home Checklist to the patient and family

♦

[Identify who] will schedule the discharge
planning meeting with patient and family of
their choice
• When depends on patient condition: at least
1 to 2 days before discharge, earlier if
needed

What is the IDEAL discharge process?
4. At discharge planning meeting
♦

[Identify who] to discuss and address patient
and family questions

♦

Use Teach Back to check your understanding
of concerns and patient’s understanding of
information you give

♦

Follow up on any questions you cannot
address right at the meeting

♦

Offer to schedule followup appointments with
all providers as needed (primary care,
specialists, therapy)

What is the IDEAL discharge process?
5. Day of discharge
♦ [Bedside nurse] will review reconciled
medication list with patient and family
• Hand patient list of medications they need
to take after they get home
• Go over list with patient and family
• Ask them to repeat back what, when and
how to take each medicine
♦ [Insert who] will write down followup
appointments and give name and contact
information of someone to call with problems

Benefits of discharge process for clinicians



Improves information about the patient’s
condition and discharge situation




Reduces risk and liability
May take some more time at first, but can
eventually save time

Benefits of discharge process for patients



Demonstrates that hospital staff view patient
perspective as important



Reassures patients and families that they know
how and what to do – less anxiety




Shows teamwork among hospital staff



Prevent post-discharge complications and
avoidable readmissions

Patient and family have a better experience of
care

Potential challenges


Difficult to identify family members who will be
caregivers
♦

Patient has no family or other support

♦

Family caregiver has not been at the
hospital



Discharge plans change immediately before
discharge



Patient unable to read, write, or articulate
questions or concerns

Practice exercises

Vignette 1: An easy discharge


Emily, a 50 year old woman, came in for a gall
bladder removal. She is married, has a college
education, and is generally quite healthy, as is her
husband. She is not in the med/surg unit for long.



You are doing the discharge planning meeting
with Emily and her husband Jack the day before
she expects to be discharged.



Let’s form groups of three for this exercise. Take
about 5-8 minutes.

Vignette 1 debrief


Debrief each role:
♦

How did you each feel during this
interaction?

♦

What really went well?

♦

What could have been done differently?

♦

Anything else?

Tips for effective engagement







Slow down
Use plain language
Reassure patient and family by giving
information
Thank patient or family for calling attention to
any issue they raise; don’t act annoyed
Invite them to continue asking questions
Remember non-verbal communication says
just as much as verbal communication

Vignette 2: A tougher discharge





Arnold, 84 with serious exacerbation of congestive heart
failure. He lives alone. His children live in another city.
His long-time neighbor has visited him in the hospital.
This is Arnold’s 3rd hospitalization in the last year.
Mobility is okay, but he has shortness of breath. He is
fine cognitively, but is getting depressed and worried
about his circumstances.
Arnold will go home in 2 days, with home health care to
help him with new portable oxygen. He is worried about
using the oxygen, getting it, moving it around.
You are doing the discharge planning meeting with
Arnold alone. Form pairs for this exercise. Take 8-10
minutes.

Vignette 2 debrief


Debrief each role:
♦

How did you each feel during this
interaction?

♦

How was this different from the first
vignette?

♦

What really went well?

♦

What could have been done differently?

♦

Anything else?

Final thoughts




Our hospital is committed to patient and family
engagement – everyone plays a critical part
Patients and families won’t engage if they
believe that you don’t want them to – it is
simply too risky for them
Your job is to make it safe for them to be here,
not just as patients, but as partners in their
care

Thank you!


For questions or more information
[Insert name, phone number, and email]