Executing high‐quality care transitions: A call to do it right

As a hospital practitioner, you have undoubtedly experiencedthe frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acu-men, they are discharged “tuned up ” and stable to return home. Days later, however, you may learn that your best-laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of “patient noncompliance, ” such readmis-sions are now being recognized as system failures and reflect a discharge process that has been described as “random events connected to highly variable actions with only a remote possibility of meeting implied expectations ” (Roger Resar, MD, Senior Fel-low, Institute for Healthcare Improvement). Once an area that received relatively little attention, transi-tions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in qual-ity and safety, many esteemed organizations, including the Joint