The Network has released its new Inter-Organizational Transfer of Accountability (TOA) Guideline to support effective transitions and improve patient safety and continuity of care.

The new guideline focuses on six principles:

  • Ensure health service providers understand and have knowledge of legislation and policies that guide effective transitions
  • Communicate patient and caregiver preferences and goals to the next level of care
  • Establish one key contact at each transition point
  • Standardize processes for transition by the organization
  • Communicate effectively among health care providers to facilitate transition
  • Acknowledge dual responsibility of senders and receivers in transitions

The guideline content reflects a review of literature, data collected by the Network’s acute care and rehab hospitals and a Network survey of rehab care providers in home and community care. The data highlighted the following:

  • Acute care to rehab: 80% of TOA issues experienced in transfers from acute to rehab hospitals are related to information transfer, such as missing or inaccurate medical administration records or discharge summary reports.
  • Hospital to community: Missing or unclear information in referrals to community care is creating added work and requires follow-up calls to clarify issues such as: contraindications and weight-bearing restrictions; information about rehab the client received during their hospital stay; and rehabilitative goals for the client.

The TOA guideline was reviewed by two Network working groups (acute/rehab/CCC and home and community care) and by a patient advisory committee. The guideline is complementary to HQO’s draft quality standard, Transitions from Hospital to Home, while providing a rehabilitative lens and a greater focus on information transfer.

For more information, contact project managers Sanja Milicic Iafrate (hospitals) or Sharon Ocampo-Chan (home and community care).