ED Transfer Communication Quality Improvement Study

This study is completed.


The ED Transfer Communication Quality Improvement Study (QIS) ran from September 2016 to August 2017.

Full Statewide Results Report (August 2017)

  • 27 of 39 facilities improved in at least 6 of the 7 measures or on the All Communications* measure
    • * percent of transfers with all 27 elements documented and communicated to the receiving facility
  • 25 facilities have an average of 90% or higher for the 7 main measures (excludes All Communications)
  • There was overall improvement in 6 of the 8 measures (the other 2 measures were less than 1% lower)
  • The average for the state is over 90% for 5 measures (up from 3 measures in 4Q 2016)
  • 2 facilities maintained their perfect scores on all measures:
  • 4 facilities improved to 100% on all measures:
  • 5 facilities have scores greater than 90% on the All Communications measure

Study Goals:

  • determine why specific elements are frequently missed
  • identify why some facilities are successful in meeting all elements
  • share best practices of those with the best scores with those who need improvement
  • provide education (if needed) about EMTALA and how ED Transfer Communication Measures confirm that all requirements are met for transferred patients
  • create simple tools to help facilities meet all elements  and reduce the number of locations where information might be hiding

There is a lot of room for improvement across Montana!

  • The state average for the percent of patients with ALL COMMUNICATIONS documented was only 59%, while the national average is much greater at 74% – improved to 68% 
  • Only 2 MT CAHs had 100% on all measures during Q4 – improved to 6 CAHS with 100% on all measures
  • Only 7 MT CAHs scored over 90% on all measures-  National Goal is >90% – improved 25 CAHs with over 90%
  • Of those 7 MT CAHs, only 3 scored over 90% on the ALL COMMUNICATIONS measure – improved to 12 CAHS scored over 90% 

Improvement Tools and Resources

EDTC QIS Performance Improvement Webinar Recording
EDTC QIS Performance Improvement Webinar Presentation
EDTC Specification Manual
EMTALA Presentation (St. Joseph Health System, Kentucky)
CCD Screen Shot
Sample EMTALA Policy
Complete Transfer Form