Title of the instrument |
0.93 |
NA |
Maintained |
NA |
Format of the instrument |
1.0 |
NA |
Maintained |
NA |
Instructions for the instrument |
0.83 |
NA |
Modified |
1.0 |
Structure domain |
|
|
|
|
1 The space and the physical structure favor transitional care |
0.71 |
0.86 |
Excluded |
NA |
2 There is a specific program or team to carry out transitional care at hospital discharge |
0.93 |
1.0 |
Maintained |
1.0 |
3 The specific program or team is available at any time |
0.86 |
1.0 |
Maintained |
1.0 |
4 Use of an electronic medical chart system shared across services |
0.86 |
0.93 |
Modified |
0.95 |
5 A specific provider coordinates the team during transitional care |
0.93 |
1.0 |
Maintained |
0.95 |
6 Staffing is adequate to develop transitional care actions |
0.86 |
1.0 |
Modified |
0.80 |
Discharge Planning domain |
|
|
|
|
1 An instrument that identifies patients at a higher risk of readmission is used |
1.0 |
1.0 |
Maintained |
0.90 |
2 Transitional care actions for patients at risk of hospital readmission are prioritized |
0.86 |
0.93 |
Maintained |
0.95 |
3 Discharge planning is performed in advance |
0.93 |
1.0 |
Modified |
0.95 |
4 Discussion rounds or moments between the team members are implemented to plan and execute transitional care |
0.93 |
1.0 |
Modified |
0.95 |
5 The providers are informed about discharge of the patient in advance |
1.0 |
1.0 |
Maintained |
0.95 |
6 The team considers the patient/caregiver values and preferences when defining the care plan |
0.93 |
1.0 |
Maintained |
0.90 |
7 Medication reconciliation is performed |
0.93 |
0.93 |
Modified |
0.85 |
Care Education domain |
|
|
|
|
1. Information is provided about the personal needs and the care measures after discharge |
1.0 |
1.0 |
Maintained |
1.00 |
2 Information is provided about care with the devices that will continue to be used in the patient's home |
1.0 |
1.0 |
Maintained |
1.00 |
3 Information is provided about medication use in the patient's home |
1.0 |
1.0 |
Modified |
0.95 |
4 The warning signs and symptoms that must be observed are explained |
1.0 |
1.0 |
Maintained |
1.00 |
5 Information is provided about the tests, consultations and/or monitoring to be performed after discharge |
1.0 |
1.0 |
Maintained |
0.95 |
6 Information is provided regarding which service/provider should be contacted in case of post-discharge health problems |
0.78 |
0.93 |
Excluded |
NA |
7 The patient's and/or caregiver's questions are clarified while providing the discharge guidelines |
1.0 |
1.0 |
Maintained |
1.00 |
8 The patients and caregivers are asked if they understand the discharge guidelines provided |
1.0 |
1.0 |
Modified |
0.95 |
9 The discharge guidelines are provided in a short period of time on the day the patient is discharged from the hospital |
0.86 |
0.93 |
Maintained |
1.00 |
10 Educational material with diverse information about the care measures after discharge is handed to the patient/caregiver |
1.0 |
1.0 |
Maintained |
0.95 |
11 Educational and easy-to-understand material is provided with simple illustrations and language |
1.0 |
1.0 |
Maintained |
0.95 |
12. A discharge plan, report or letter is provided with the care recommendations, list of medications, tests and consultations to be performed after discharge |
1.0 |
1.0 |
Maintained |
0.95 |
Referral for Continuity of Care domain |
|
|
|
|
1 Referral to services that provide necessary materials for the patient after hospital discharge is performed |
0.93 |
1.0 |
Maintained |
0.95 |
2 The Primary Care team attending to the patient is informed about their hospital admission and the home care plan |
1.0 |
1.0 |
Modified |
0.90 |
3 There are communication problems between this hospital unit and the Primary Care units |
0.78 |
0.78 |
Excluded |
NA |
4 After discharge, the patient is contacted to verify adherence to the treatment, clarify questions and/or reinforce diverse information on post-discharge care |
1.0 |
1.0 |
Maintained |
0.90 |
Safety Culture domain |
|
|
|
|
1 A number of instruments (scripts, checklists, protocols) are used for qualified discharge |
1.0 |
0.93 |
Maintained |
0.95 |
2 The team knows about the responsibilities and actions to be performed during transitional care |
1.0 |
1.0 |
Modified |
0.90 |
3 The transitional care processes of this institution are standardized |
0.78 |
0.86 |
Excluded |
NA |
4 There is participation in regular meetings or training sessions |
0.93 |
1.0 |
Modified |
0.85 |
5 The management and leaders of this unit are committed to promoting the best quality in transitional care |
0.86 |
1.0 |
Maintained |
1.00 |
6 During the discharge process, it is common to miss important information about the care to be provided to the patient |
0.86 |
0.78 |
Excluded |
NA |
7 Ways to prevent errors in transitional care are discussed |
0.93 |
1.0 |
Maintained |
0.85 |
Care Transitions Results domain |
|
|
|
|
1 There are delays in hospital discharge due to avoidable reasons |
1.0 |
0.93 |
Maintained |
0.90 |
2 Patients and caregivers show that they are prepared to return home |
1.0 |
1.0 |
Maintained |
0.85 |
3. Some hospital readmissions might be avoided |
0.93 |
1.0 |
Maintained |
1.00 |
4 Patients seek emergency care after being discharged from this unit |
1.0 |
1.0 |
Modified |
0.95 |
5 There are errors that affect patient safety at hospital discharge from this unit |
0.86 |
0.86 |
Maintained |
0.90 |
6 I am satisfied with the quality of transitional care when discharging patients from this unit |
1.0 |
1.0 |
Maintained |
0.85 |