Improving Quality of Care in Transitions

Education Resources

Capital Health recognizes the importance of quality of care in transitions. Transition, or transitions of care, in the health care environment refer to the movement of patients between health care locations, providers or different levels of care within the same locations as their conditions and care needs change. These transitions involve a set of processes designed to ensure co-ordination and continuity of care.

Appropriate communication and documentation practices during transition are critical to providing safe, quality care for our patients. Doing transitions well is a major challenge for health care systems everywhere and we are no exception. Health organizations are tackling the issues with education, standardized practices and tools to capture necessary information - all of which are being employed at Capital Health.

Tools for Education

The following resources include case studies, reports, e-Learning activities and presentations related to patient safety at points of transition (transitions of care). They are meant to be included in or help shape department-, division- or service-specific education that reinforces patient safety and quality care at points of transition.

Canadian Medical Protective Association Good Practices Guide

Tips, advice and case studies focused on:

Discharge Reports:
The discharge summary is a key component of providing continuity of care for patients as they transition from hospital care to their family physician. Currently, there are no standards or definitions regarding the components of a ‘quality’ discharge summary.  The documents included below were developed through a CMPA Research Initiative called “Development and validation of a quality framework for effective transitions from hospital to home: the eDischarge initiative” undertaken by the Nova Scotia Health Authority Central Zone in 2015.  The quality components were defined through review of the literature review as well physician engagement and feedback.
eSummuary is an online integrated Discharge and Transfer Report application.  Information can flow from the Transfer Reports to the Discharge Reports and vice versa. The system allows multiple transfer notes and one discharge report per encounter.   It is accessible through Central Zone Clinical Portal and requires only Internet Explorer to run. eSummary includes a Patient Copy of the discharge report to communicate information patients or care givers need to make decisions and support their care including: medications, education regarding wound care or symptoms to watch for; instructions regarding restrictions of activities of living; information about appointments or upcoming tests; and recommendations regarding next steps.   More information about eSummary is available on the Clinical Portal Info page (

Dalhousie Faculty of Medicine Communication Skills Workshop - The Communication Skills Program is responsible for the development, implementation and evaluation of teaching communication skills across the continuum of medical education. Workshops for residents and attending physicians including Difficult Patient-Doctor Communication and The Three Cs of Interprofessional Team Work.

Canadian Health Accreditation Report - Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices.

Royal College of Physicians & Surgeons of Canada Resources - Best practices in handover education. A presentation at the 2014 International Conference on Residency Education that includes recommendations to improve handover education, key elements of high quality handover and IPASS study overview, results and recommendations.

CanMeds 2015: Physician Competency Framework - A competency based framework that describes the core knowledge, skills and abilities of specialist physicians. The framework describes seven roles that lead to optimal health and health care outcomes: medical expert (central role), communicator, collaborator, manager, health advocate, scholar and professional. The overarching goal of CanMEDS is to improve patient care. The model has been adapted around the world in the health profession and other professions.

Nursing Best Practice Guidelines for Care Transitions - Available through the Registered Nurses Association of Ontario and endorsed by Accreditation Canada, this is a comprehensive document providing resources for evidence-based nursing practice that should be considered a tool, or template, intended to enhance decision making for individualized care.

Canadian Patient Safety Institute (CPSI) has more than 10 years of experience in safety leadership and implementing programs to enhance safety in every part of the health care continuum. View a list of common acronyms.

Canadian Framework for Teamwork and Communication - The goal of this document is to provide a framework for organizations to understand and convey to their teams the importance and impact of teamwork and communication in healthcare and to select appropriate training tools to improve this. Produced by the Canadian Safety Institute.

Enhancing Effective Team Communication for Patient Safety - An adapted SBAR communication for rehab - Webcast presentation outlining study of adapted SBAR in rehab setting.

Institute for Healthcare Communication - Continuing educational workshops and e-Learning modules for clinicians in all health disciplines and train-the-trainer courses for clinicians wanting to become authorities in healthcare communication.

Patient Safety Library Guide, Dalhousie University Medicine - Guide to library resources for medical students and faculty at Dalhousie University in both Nova Scotia and New Brunswick.

Institute for Health Care Improvement Resources (IHI) - Case studies:
Code Blue - Where To? (AHRQ) - A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team do not know where the service is located, and when the team arrives, they find their equipment to be incompatible with the leads on the patient.

Topic(s): Engage Patients and Families in Care; Hospital Operations; Satisfaction: Patient and Family; Teamwork; Care Coordination and Transitions; Environmental Design; Person- and Family-Centered Care; Communication; Rapid Response Teams

Glucose Roller Coaster (AHRQ) - A woman hospitalized for congestive heart failure (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.

Topic(s): Transitions in Care; Adverse Event; Patient Safety; Handoffs; Teamwork; Adverse Drug Event (ADE); Medication Safety; Care Coordination and Transitions; Communication; Culture of Safety