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Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions
  1. Julie K Johnson1,
  2. Jeanne M Farnan2,
  3. Paul Barach3,4,
  4. Gijs Hesselink5,
  5. Hub Wollersheim5,
  6. Loes Pijnenborg,
  7. Cor Kalkman3,6,
  8. Vineet M Arora2,
  9. on behalf of the HANDOVER Research Collaborative
  1. 1Faculty of Medicine, Centre for Clinical Governance Research, University of New South Wales, Sydney, New South Wales, Australia
  2. 2Department of Medicine, University of Chicago, Chicago, Illinois, USA
  3. 3Patient Safety Center, UMC Utrecht, University of Utrecht, Utrecht, The Netherlands
  4. 4Department of Health Studies, University of Stavanger, Stavanger, Norway
  5. 5Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  6. 6Department of Anesthesiology, UMC Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr Julie K Johnson, Faculty of Medicine, Centre for Clinical Governance Research, University of New South Wales, Sydney, NSW 2052, Australia; j.johnson{at}


Background Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk.

Objective Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality improvement.

Methods We conducted focus group interviews to facilitate a process mapping exercise with clinical teams in six academic health centres in the USA, Poland, Sweden, Italy, Spain and the Netherlands.

Findings At a high level, the process of patient admission to the hospital through the emergency department, inpatient care, and discharge back in the community were comparable across sites. In addition, the process maps highlighted similar barriers to providing information to primary care physicians, inaccurate or incomplete information on referral and discharge, a lack of time and priority to collaborate with counterpart colleagues, and a lack of feedback to clinicians involved in the handovers.

Conclusions Process mapping is effective in bringing together key stakeholders and makes explicit the mental models that frame their understanding of the clinical process. Exploring the barriers and facilitators to safe and reliable patient transitions highlights opportunities for further improvement work and illustrates ideas for best practices that might be transferrable to other settings.

  • Hand-off
  • Process mapping
  • Transitions in care

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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