Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

In line with stage 2 of the positive deviance framework [32], qualitative methods were used to explore how high-performing general practices and hospital specialties succeed. Focus groups, brief observations, and interviews were conducted to explore how multidisciplinary teams support safe transitions from hospital to home for older adults. Ethical approvals were granted by the University of Leeds, UK. Full details of the methods used are available in the published protocol [40]. The study contributes to the Partners at Care Transitions (PACT) programme of research which aims to develop an intervention to improve the safety and experience of older people during transitions from hospital to home [41].

In preparation for this study, high-performing general practices and hospital specialities that demonstrated exceptionally low or reducing readmission rates over time were identified (in line with stage 1 of the positive deviance approach). Routinely collected 30-day emergency readmission data for patients aged 75 years and over were extracted for all general practices (n = 151) clustered within five clinical commissioning groups (CCGs) and all cardiology, respiratory and older people’s specialties (n = 85) clustered within 22 acute National Health Service (NHS) Trusts in the North of England. Routine data were extracted for the most recent timeframes available (2015–17 in primary care; 2013–16 in secondary care), and binomial funnel plots were used to compare 30-day readmission rates for sites within each CCG and type of hospital specialty. High-performing sites were identified as those that exceeded the two but ideally three sigma control limits. In addition, bar charts were plotted to identify hospital specialties that demonstrated the greatest improvement (i.e. reduction) in readmission rates over time.

Up to six high-performing general practices and hospital specialties were purposively sampled to represent a range of healthcare contexts (see [40] for full details). General practices were selected using routine data regarding list size, deprivation, and the proportion of patients over 75 years / in nursing homes [42]. Hospital specialities were selected following short telephone calls with the specialty clinical leads to explore how apparent high performance may have been affected by factors associated with the data, patient case-mix, structure or resources, processes of care, and/or individual carers [43]. Where hospital specialties consisted of multiple wards, clinical leads also identified ward teams that were representative of the data (i.e. had higher proportions of over 75 yr olds and/or were perceived to perform well) and that specialty within the region (i.e. the type of treatment/care delivered).

In total, six general practices and four hospital specialties (two older people’s medicine, one respiratory, and one cardiology) participated in the study (Table 1). Data were gathered from staff who worked across 14 hospital wards including ‘base’ wards, an Elderly Admissions Unit, a ‘Delayed Transfer of Care’ ward for complex discharges, and a community hospital ward. Three hospital specialties (two respiratory and one cardiology) and two general practices did not engage with the study.

In the UK, health services are broadly delivered via secondary care (acute hospitals), primary care (including general practices) and community care (including community nursing). Wider services are also available, for example, via social services and the voluntary sector. The pathways, services and infrastructure to support transitions of care vary by organisation/locality. In principle, hospital discharge is planned from the beginning of an admission. Patients are discharged from secondary care once they are deemed ‘medically fit’ (i.e. clinically optimised/stable) and ‘ready for discharge’ (i.e. necessary community support is in place). Responsibility is then handed over to primary care via discharge letters to the General Practitioner (GP). If required, care is also handed over to relevant community care or social services via referrals. Organisations can incur financial penalties for readmissions within 30-days [44].

Opportunity and maximum variation purposive sampling were used to recruit staff from the high-performing general practice and hospital teams (Table 1). As transitional care is not delivered by hospital and general practice teams alone, we also recruited staff from ten teams clustered within four community care trusts (organisations) that worked into and with the high-performing teams. In total, 157 participants were recruited including doctors, nurses, healthcare assistants, receptionists/administrators, allied health professionals, discharge coordinators, community matrons, district nurses, and specialist nurses. Although social care is also key to supporting transitions of care, their inclusion was beyond the scope of this clinically focused study.

Multidisciplinary staff focus groups lasting up to 60 min were held in each high-performing team (Table 1). The group interaction afforded by focus groups enabled multidisciplinary team members to contribute their own experiences, clarify perspectives, and to discuss issues of importance to them [45]. Where teams spanned multiple sites or included several wards, additional focus groups were conducted. Individual or two person interviews were conducted if staff were unable to attend focus groups. Suitable dates and locations for focus groups were organised via practice or ward managers. At the beginning of each focus group the researcher explained the purpose of the study. Semi-structured topic guides were used to explore shared perspectives about the concrete tools and strategies as well as the abstract cultural influences that support safe transitions of care (supplementary file 1). Focus groups and interviews were audio-recorded and transcribed verbatim, and brief field notes were written following each focus group to record contextual information such as team dynamics.

Within secondary care, brief observations of staff meetings relating to patient discharge (e.g. board rounds and multidisciplinary team (MDT) meetings) were also conducted to help researchers familiarise themselves with the ward setting and patient population, and to gather contextual information about how care transitions are planned. Observations in primary and community care were precluded by the rarity of meetings specifically relating to transitions.

Data were primarily collected by RB, a post-doctoral health services researcher, between September 2017 and May 2018. Where possible, three additional researchers with previous experience and a relevant clinical background (occupational therapist, GP registrar, and community nurse) co-facilitated focus groups or conducted individual interviews. Researchers met frequently during the data collection period to develop and discuss the topic guide and to ensure competency.

A pen-portrait approach [46] was used as it facilitated large amounts of qualitative data (from focus groups, interviews, and field note) to be synthesised into rich, holistic accounts for each participating team (ward, general practice, or community team member). The four stages of a pen-portrait analysis were followed (define a focus, design a structure, populate the content, interpretation). The focus was defined as how teams successfully support transitions of care and overcome challenges. The structure included information about context, an overall summary, and detail about the key factors that were important to success. The researcher  populated the content by making notes and mind-maps to distil key information into each pen-portrait (n = 26). Initial pen-portraits (n = 5) were compared against the later ones to ensure a consistent approach, and a second researcher (RS) assessed 10 pen-portraits against the original data to ensure they provided an accurate representation. For the final stage, interpretation, RB initially generated descriptive and analytic themes for teams within primary/community care and secondary care settings and then data were analysed across settings to generate high level conceptual themes about how high-performing teams successfully support safe transitions of care. The researcher recorded analysis progression, and met with wider team to discuss emergent findings.

Staff within the high-performing teams facilitated safe transitions of care in three ways: they got to know their patients by building a holistic understanding of their care needs which was shared within and across teams; they knew each other well by building relationships within and across teams based on valuing and trusting one another; and they bridged gaps within the system to prevent things from going wrong by enhancing communication, adjusting patient expectations and adapting to competing priorities.

Figure 1 depicts how the three themes are hypothesised to interact to produce exceptionally safe transitions of care. The high-performing teams sit within the inner circle (dashed line). Achieving any one of these themes is hypothesised to support safer transitions of care (represented in light grey). Interactions between the themes (represented in medium grey) may further enhance safety, for example, staff felt it was easier to share knowledge about a patient’s transitional care needs if good relationships existed within teams. The safest transitions of care were thought to occur when there was evidence of all themes (represented in dark grey).

Despite this, it was challenging to achieve any one of the themes, particularly when crossing team or service boundaries. As a result, staff perceived exceptionally safe transitions of care to happen relatively rarely and typically only when patients had particularly complex medical/social care needs. These patients were far better known by staff who drew upon their relationships, concertedly involved a range of multidisciplinary teams, and took extra steps to bridge safety gaps. Scarce resources precluded this for every patient, consequently, at times, it is hypothesised that the high-performing teams delivered safe transitional care in a similar way to average and lower performing teams (white areas of the inner circle of Fig. 1).

Each theme is described in detail below including examples of how staff attempted to deliver safe transitional care in the most complex situations. Table 2 provides illustrative extracts from the pen portraits (the unit of analysis), and further extracts from different healthcare contexts are provided in supplementary file 2.

Staff perceived safe transitions of care to be supported by them knowing their patients well and understanding their needs. Although this was important in all teams, it differed by context. For example, general practice and delayed transfer of care ward teams felt they knew their patients ‘better’ than staff on admission or base wards.

Safe transitions of care were perceived to depend not only on knowing the patient well, but also on knowing other team members and those from different teams and settings.

Across all settings, staff attempted to bridge gaps within the system to improve transitions of care. They did this by trying to enhance communication, adjust patient expectations, and by adapting to evolving services and competing priorities.

Involving patients and families in care is a central tenet of healthcare policy globally [47, 48] and may be key to enhancing safety at transitions [26, 49]. However, the extant literature predominantly focuses on the need to provide patients and families with information and to communicate discharge plans [17, 23]. This is undoubtedly important, but this study also emphasises the key role that patients and families can play in providing staff with information - and the conditions under which this is facilitated i.e. when relationships are established.

Familiarity with the patient has previously been shown to impact the quality of knowledge sharing, assessments, and decision making within teams at transitions [38, 50]. Furthermore, Waring and colleagues have found that safer, more patient-centred discharges from stroke and hip fracture wards are facilitated by incorporating holistic patient knowledge (psychological, social and personal needs) with traditional biomedical knowledge. Importantly, this holistic knowledge was gathered through informal interactions with patients and families [51], highlighting the importance of building relationships with patients. This finding is supported by Simms-Gould et al. [52] who found staff use investigative skills to gather information and collateral accounts to support safe transitions.

Providing staff with information may be one way in which patients and families can support and scaffold the quality and safety of their care [53, 54]. Without overburdening them, initiatives could effectively support patients and families to complete this ‘work’, for example, by educating them on the types of information that healthcare professionals value and/or need to know. Supporting patients to do this will be essential as they do not always feel comfortable or skilled in relaying information, especially when unwell and/or in busy hospital environments [55]. Structural changes, for example re-configuring staff rotas may also help enhance continuity and facilitate the development of trust and rapport between patients and staff.

The importance of working within inter-professional, integrated, non-hierarchical teams is well documented, both in general and in relation to transitions of care (e.g. [35, 51, 56]). This study suggests that integrated working may be underpinned by the relationships and trust that staff build within and across teams, and that this is often facilitated by proximity and informal interactions. Previous research suggests that staff build relationships across settings specifically to overcome uncertainty and discontinuity at transitions [52]. Staff also perceive relationships and communication to improve as a result of physically bringing people together for meetings [17]. However, in addition to formal meetings, informal interactions may enable staff to share experiential knowledge, develop mutual understanding, and build trust to enhance collaboration at discharge [51].

Technology is often proposed as a way of enhancing safety at transitions, for example, by developing electronic patient records to facilitate communication and coordination between staff/teams who work remotely [22]. Technological solutions are undoubtedly required but they do not necessarily provide a ‘magic bullet’. In fact, electronic patient records have previously been found to unintentionally, negatively impact interpersonal communication by facilitating discharge through computers rather than encouraging the interaction of multidisciplinary team members [18]. Further to this, healthcare policy in the UK and further afield emphasises the need to develop integrated care systems (e.g. the NHS Long Term Plan [57]) and interventions to improve care coordination. However, achieving integration has been slow [58] and interventions rarely demonstrate unequivocal positive effects [24]. In part, this may be due to fundamental cultural differences between healthcare setting [58], but robust evaluations are required to understand how interventions work in some contexts but not others.

Findings from this study highlight that safe transitions of care may depend on informal communication facilitated through staff relationships. Contextual and cultural factors (such as relationships) are therefore likely to be important [28] and, as such, priority should be given to help facilitate conditions under which staff relationships and collaboration can flourish [56]. System changes could better support staff to build and maintain relationships with one another, for example, by minimising staff rotations across hospital wards and the relocation/reorganisation of primary and community care teams [59]. Alternatively, organisations may be able to improve relationships and collaboration within their own workforce by recruiting people based on their values and beliefs.

In this study, the resilient actions of healthcare teams (e.g. verbally communicating risk or chasing missing information) helped bridge gaps in the transitional care system. Informal, verbal handovers are known to overcome formal communication systems deficiencies, but it is also recognised that staff cannot do this for all patients [39, 52]. Although these bridging actions improve safety, they only provide a temporary fix typically for specific individuals with more complex needs. In fact, it could be argued that these bridging actions shift resources (e.g. staff time) away from other patients within the system. To enhance safety for a wider range of patients, not just those with particularly complex needs, structural and systemic changes are required to overcome common system inadequacies.

Understanding peoples’ roles and constraints helped staff mitigate transitional care problems by allowing them to engage appropriately with other teams and adjust patient expectations. However, staff often struggled to achieve this. Staff don’t always understand how care is delivered in other parts of the system and how their actions positively or negatively impact this [52, 60]. Bringing people together from different settings may help improve transitional care. For example, inter-professional simulation has helped staff recognise different professional perspectives and appreciate the challenges faced when transitioning older people from hospital to home [56]. Through this staff reported improvements in communication across settings, use of available services, and behavioural changes such as earlier discharge planning and taking a more holistic approach [56].

Staff also reported having few opportunities to learn across settings, and limited agency to affect change. The ability to learn is key to a positive patient safety culture [61‐63]. Furthermore, high-performing US hospitals that successfully reduce readmission rates have engaged in trial and error learning and built relationships with post-acute providers in order to share expertise and data [28]. As such, NHS trusts and CCGs may have an important role in highlighting exceptional performance and supporting a learning environment. Healthcare organisations could provide opportunities for shadowing or job swaps to give staff experience of delivering care in a different setting. However, this would need to be balanced against the potentially negative impact of disrupting teams. The findings also suggest a need to embed accessible and visible mechanisms that support learning across settings so that frontline staff feel empowered to influence care and generate change. By better understanding the pressures, constraints and competing priorities that other people face, staff may be able to systematically bridge system gaps that make their jobs more challenging.

It is important to reflect on the study’s limitations. First, the teams may not have truly demonstrated exceptionally high performance as the validity of emergency readmission data can be questioned [64, 65] and case-mix/service level differences could not be fully adjusted for. Moreover, the high performing hospital and general practice teams were not linked to one another, which may have contributed to contrasting or contradictory views about how safe care was delivered.

Second, in terms of the trustworthiness, the credibility of findings (i.e. confidence in their ‘truth’) can be questioned [66]. People become habituated to their everyday work when things go right far more frequently than they go wrong [27]. As such, participants may not have been able to articulate what they do to succeed. Staff may also have revealed what they are ‘meant’ to do (aligned to policies and procedures etc.) rather than what they actually do, and/or some may have felt inhibited during discussions due to the focus group method [45]. Although data were, to some degree, gathered from multiple sources and triangulated (via focus groups, interviews, and observations), prolonged engagement with sites via ethnographic methods may have helped overcome these challenges [66, 67]. In addition, data saturation may not have been reached despite the large amount of data collected [68].

Third, the findings may have lacked transferability (i.e. applicability to other contexts) [66]. Although purposive sampling was used and findings were member checked with key stakeholders, some high performing teams did not engage with the study and participating staff may not have represented their multidisciplinary teams. Furthermore, teams from settings/specialties that were not included in this study may deliver safe transitions in different ways.

Fourth, the findings may have lacked confirmability (i.e. then extent to which they could be corroborated). The researchers will have held their own biases and motivations which will have been influenced by the overarching aims of the wider programme of work [66]. Furthermore, a pen portrait analysis was conducted to generate high level conceptual themes, however, analysing the source data may have led to more descriptive findings. Our use of pen portraits represents an adaptation of how the analytic technique was used in its original incarnation. Pen portraits allow the researcher to integrate multiple sources of qualitative data and so are often used in longitudinal qualitative analyses [46]. The authors of the technique were consulted prior to its use in a static analysis and offered advice on how to pursue this. As such, we did not encounter any specific challenges related to this. Our broad research question did, at times, make it challenging to define a structure and populate the pen portrait content. The method though explicitly advises against creating rigid structures [46], and we rigorously second checked the pen portraits to ensure they accurately represented the raw data.