Quality of Pediatric Hospital-to-Home Transitions Toolkit

The Pediatric Hospital Care Improvement Project (P-HIP) Collaborative used and created multiple resources that can be leveraged and adapted for use at other organizations and institutions. Links to these resources are available throughout the earlier sections of this toolkit and in the change package. Additionally, links to the resources are provided here for users’ convenience.

• Gap analysis tool (PDF): This tool may be used to compare the best practices with the processes currently in place in your organization, determine the “gaps” between your organization’s practices and the identified best practices, and identify which practices your organization will implement.
• Case study (PDF, 122 KB): An example of how the University of Iowa Stead Family Children’s Hospital improved their electronic template for family/caregiver written discharge instructions. 
• Example of the materials produced using a ‘dot phrase/smart phrase’ (PDF, 67 KB): This example illustrates how relevant contact information for discharge providers may be displayed as part of written family/caregiver instructions. 
• Example of a telephone list template for family/caregivers: Table 1 below offers an example template for a telephone list for family/caregivers to receive at discharge. 
• Example showing the difference between a complete primary diagnosis and an incomplete primary diagnosis (PDF, 1.9 MB). This example highlights the importance of including the “principal diagnosis” on a patient’s discharge report and how to designate it in the medical record documentation.
• Discharge instructions template (PDF, 576 KB): An example template showing written family discharge instructions, provided by the University of Iowa Stead Family Children’s Hospital.
• Medical record (MR) abstraction tool (Zipped file, 740 KB): This tool was created for the Transitions in Family Centered (TFC) Care Measure – Hospital-to-Home Transitions. (Note: Persons with disabilities who experience problems accessing this content or file should contact AHRQ at PQMP@ahrq.hhs.gov.)
• MR abstraction tool guidance document (PDF, 1.2 MB): Instructions for using the MR abstraction tool.

Contact List Suggestions

Mount Sinai Kravis Children’s Hospital and UCSF Benioff Children’s Hospital San Francisco went through a process of collecting and verifying numbers for each individual service to create lists of phone numbers to input into a dot phrase (or equivalent) that populated the correct phone number when addressing the 24/7 contact information item. 

A table shell is provided below as an example of how the contact list could be set up. The contact list may be accompanied by instructions to families about how to go about deciding when and which provider to contact.

Table 1. Example Contact List Template for Child’s Providers