Mission Changes Patient Transfer Process Following Asheville Watchdog’s Report on Nurses’ Complaints

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Written by Andrew R. Jones, Asheville Watchdog.

Mission Hospital has updated how some patients are transferred from its emergency department to other areas of the hospital following two years of nurses’ complaints to the North Carolina Department of Health and Human Services and an Asheville Watchdog investigation.

Mission has instructed nurses to call colleagues – a process known as called report or called hand-off – when transferring patients who have been in the emergency department for at least 12 hours, according to an internal document obtained by The Watchdog.

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The procedure, which will move the hospital toward conforming with industry best practices, will improve patient safety, the document states.

The document, titled “Mission Hospital: ED report process-Updated,” is a slide that contains a subhead that reads, “New process will enhance patient safety, improve communication and handoff between our care teams.” It is unclear exactly when the slide was distributed to employees.

Reports should be called on patients coming from the emergency department “or B3 South with a length of stay … (greater than) 12 hours,” according to a bullet point on the slide.

The slide features a flowchart showing how to manage patient transfers, stating “ED Nurse will call report.” It also states “CNC/Charge RN will receive report and will inform receiving RN of new patient and answer questions,” referring to clinical nurse coordinators and registered nurses who oversee teams.

A flowchart in a document obtained by The Watchdog shows the hand-off process Mission nurses should use when transferring some patients.

“If unable to answer call, ED Nurse will send a text indicating the following: attempt made to call report, please review SBAR, call with questions otherwise patient will be transferred in 15 minutes,” the slide states.

SBAR is a communication method many hospitals, including Mission, use during patient transfers.

The Watchdog revealed in late August that nurses with the Professional Practice Committee — a group of union members designated to raise concerns with Mission leadership — had sent complaint letters to the NCDHHS in 2022 and 2023, reporting that the hospital was not requiring nurses to call reports, which they contended was endangering patients by creating communication breakdowns and needless delays in care.

At the time, NCDHHS had not visited the hospital to investigate the complaints, citing a staff shortage. It has been conducting an inspection at Mission this month on behalf of the federal Centers for Medicare & Medicaid Services.

“It is disheartening that it took getting regulatory agencies involved to see the changes that our union and Professional Practice Committee have been fighting for for so long to be implemented,” said cardiology nurse Kerri Wilson, a PPC member. “It is apparent that the hospital administration knew the dangers the patients faced, and how easily the situation could be remedied, but chose to ignore it and continue to prioritize profits over patients.”

The new hand-off process is helping, Wilson added, “but we continue to fight for report on every patient no matter the length of time in the ED. This is a step in the right direction, and a testament to the power of our collective action.”

When asked why and when hand-off process was updated, Mission spokesperson Nancy Lindell downplayed the change, saying, “Nurses at Mission Hospital have always had the option to call report and our policy has always supported the sending nurse and their determination of the best way to communicate with the receiving nurse. This (slide) from this past October provides an additional recommendation that guides RNs to call report when a patient has been holding over a certain amount of time.

Lindell did not respond to a question about why Mission is instructing nurses to call reports for only patients who have been in the emergency department for more than 12 hours.

She also would not say if The Joint Commission (TJC), the nation’s largest hospital accreditation organization, had recently recommended or required Mission to update its emergency department hand-off practices.

“Reporting this as a result of recent DHHS surveys would be completely inaccurate,” Lindell added. “Mission Hospital continues to follow The Joint Commission recommendations regarding handoff communication.”

The NCDHHS has been conducting its inspection at Mission since at least Nov. 13, according to The Watchdog’s previous reporting. The slide was updated on that date, as shown in the version obtained by The Watchdog. TJC also conducted surveys at Mission that week and as early as September.

Former Mission nurse Claire Siegel told The Watchdog that a TJC representative spoke with her for two hours late that month and asked her questions about the nurses’ complaints and hand-off procedures as reported by The Watchdog.

“We’re going to keep fighting”

Data cited by TJC as well as recent academic research show that communication failures, including those involving patient hand-offs, have led to numerous medical errors and thousands of malpractice claims in the past two decades.

TJC’s standards specify that hospitals’ hand-off procedures should allow “for the opportunity for discussion between the giver and receiver of patient information.” The organization recommends that staff communicate by telephone or video conference and not solely by electronic or paper methods.

When asked whether TJC recently recommended Mission update its hand-off process,  spokesperson Maureen Lyons said, “you can find all public information about Mission Hospital via www.qualitycheck.org,” but she would not comment on specifics.

Updates to Mission’s hand-off process happened around the time it started offering emergency department physicians more shifts and stopped accepting some patient transfers from other regional hospitals, as detailed in a recent Watchdog report.

“The union’s frustration has been that we’ve been bringing up … for well over a year that this was an issue,” said Hannah Drummond, an emergency department nurse and a National Nurses United union member. “We’re excited to see this change. It isn’t far enough, but it’s a step in the right direction, and it’s actually enabling and empowering us to give our patients better, safer care. … We’re going to keep fighting until our patients get what they deserve.”

In addition to the NCDHHS and TJC inspections, North Carolina Attorney General Josh Stein’s office has been investigating HCA Healthcare’s management of Mission since the beginning of the year. Stein has requested 41 sets of documents related primarily to oncology and emergency department care and said HCA had violated part of the 15-agreement commitment it made when it bought Mission Health for $1.5 billion in 2019.

HCA has until Dec. 10 to correct those violations, according to a letter that Stein’s office sent  Oct 31.

In response, HCA sent a letter to Stein’s office, written by an attorney from powerhouse law firm Latham & Watkins, denying the corporation had violated the agreement and contending the document request was “legally improper and unenforceable.”

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email [email protected]. To show your support for this vital public service please visit avlwatchdog.org/donate.