Picture this: a patient is discharged from the hospital. Treatment has been completed successfully, the discharge letter has been sent and the transfer to district nursing has been initiated. On paper, everything has been arranged – but in practice, things go slightly differently. The district nurse receives the information too late, the GP does not know anything about it yet, and the patient himself? They try to explain exactly what happened in the hospital, but gets lost halfway through the story.
Where one organisation’s responsibility ends, another’s begins. But what lies in between is often a grey area. And this is precisely where mistakes can occur. So the question is not only ‘are we working well together?’, but also ‘how do we ensure quality and safety across the borders of our organisations for a smooth transfer of care?‘
As a healthcare organisation, you naturally feel very strongly about quality. We see that healthcare organisations have often secured quality processes internally and comply with strict requirements. In other words, well organised! But what about when quality also needs to be safeguarded outside of the organisation? In many cases, there is no obvious structure for this yet. Indeed, 50% of elderly people who transferred from the hospital to a (home) care setting, experienced at least one medical error, according to a large international study by PMC.
These are errors that in some cases involve serious risks. These include administering the wrong medication, making diagnoses (too) late and lack of patient or client information, leading to mistakes in treatment. These risks are caused by factors such as inconsistent working methods, lack of clarity about working agreements and a lack of joint incident analysis. So it is high time to take a closer look at quality and safety assurance in regional collaborations!
When it comes to patient safety, gaining visibility into what goes wrong is a prerequisite. But with cross-institutional incidents – i.e. incidents that occur at the interface of organisations – this is anything but obvious. Because where do you report an incident that takes place between institutions? And more importantly, who feels responsible for resolving it?
There is a high risk that these reports fall between two places. And that is worrying, because it is precisely at transfer moments that many errors occur, often with an impact on the patient. A missed medication adjustment, a lab value not transferred or an unclear discharge letter: these are incidents that repeat themselves as long as they are not reported, discussed and translated into better agreements.
Safety starts with clarity. And that requires working agreements that are unambiguous, up-to-date and accessible to all parties involved. Yet in practice, these agreements are still often scattered, outdated or unknown to healthcare professionals from other organisations. This complicates quality assurance across the chain, when it is so important.
Curious about a good way to bring working agreements to life in practice? You can read more about it here.
Learning and improving together across organisational boundaries requires more than good intentions. It requires structure, ownership and a clear route. Because only when you know how to learn together can you really strengthen that collaboration.
Zenya supports regions in easily reporting cross-institutional incidents. With one shared reporting environment, organisations can not only identify incidents, but also take up the follow-up and learn from them together. This makes reporting not only easier, but also more meaningful.
Working agreements are the basis for safe healthcare, especially in regional collaborations. But then they need to be well organised. In Zenya, organisations can build a shared environment in which cross-institutional working agreements are recorded, managed and retrieved. This way, it is always clear who is responsible for what, which working method applies, and how to act in case of doubt or escalation. These aspects make working together not only safer, but also increasingly effective.
Quality and safety do not stop at the doorstep of your own organisation. It is precisely in the cooperation between institutions – where patients literally pass from hand to hand – that risks and opportunities lie. Therefore, as a region, it is good to ask yourself from time to time: are we really walking together, or is it every man for himself?
What steps have you already taken to ensure safety and quality across the chain? And what steps are still to come? By consciously investing in joint agreements, sharing incidents and learning from them structurally, as a region you build something greater than the sum of its parts: a care chain in which patients feel safe and professionals feel supported.
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