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Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium.

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Presentation on theme: "Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium."— Presentation transcript:

1 Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium at Harvard August 21, :45 – 12:45 pm

2 Objectives Determine which methods are most appropriate for exploring hand-offs in clinical settings Determine which methods are most appropriate for exploring hand-offs in clinical settings Develop a standard process to optimize hand- offs using a process mapping methodology Develop a standard process to optimize hand- offs using a process mapping methodology Create a checklist of critical patient and process information Create a checklist of critical patient and process information Design a strategy for dissemination and training Design a strategy for dissemination and training Identify and overcome barriers to implementation Identify and overcome barriers to implementation Develop a plan to evaluate and monitor hand- off protocols Develop a plan to evaluate and monitor hand- off protocols

3 Agenda 10:45 – 10:50Introduction and Overview of the Agenda 10:50 – 11:00Participant Introductions and Expectations 11:00 – 11:10Hand-off Theater 11:10 – 11:15Audience Poll 11:15 – 11:30What is known about Hand-offs in Medicine and other Industries 11:30 – 11:50Small Group Exercise: Paper Tear 11:50 – 12:00A Model for Developing a Standard Protocol 12:00 – 12:20Small Group Exercise: Process Mapping 12:20 – 12:30 Completing the Hand-off Model 12:30 – 12:40Research Presentation 12:40 – 12:45Final Comments and Adjourn

4 Introductions Who are you? Who are you? What do you do? What do you do? What are your expectations for todays session? What are your expectations for todays session?

5 What are the types of handoffs that come to mind when you think about handoffs?

6 Hand-off Theater

7 Role Play of a Intern Sign-out Use the checklist for observations: Use the checklist for observations: –Please record cultural, communication, and environmental barriers that interfere with successful patient hand-off practices in patient care

8 BarriersObservations/Thoughts Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Other Facilitators What went well? What Do You Look For?

9 Debriefing from the Role Play What types of barriers to an effective hand-off did you observe? What types of barriers to an effective hand-off did you observe? –Environment –Cultural –Communication –Any others?

10 Audience Poll: Current Practices in Transfer of Care in Your Institution When there is a transfer of care, who is primarily responsible for the transfer? When there is a transfer of care, who is primarily responsible for the transfer?

11 Audience Poll: Current Practices in Transfer of Care in Your Institution How many senders and receivers of information are present at the time of the hand-off? How many senders and receivers of information are present at the time of the hand-off?

12 Audience Poll: Current Practices in Transfer of Care in Your Institution Is a verbal communication required at the time of a hand-off in your institution/program? Is a verbal communication required at the time of a hand-off in your institution/program?

13 Audience Poll: Current Practices in Transfer of Care in Your Institution If conducted, where does verbal communication take place? If conducted, where does verbal communication take place? –Face to face in a dedicated room –On the phone –On the fly (wherever/whenever the two parties can meet) –At the patients bedside

14 Audience Poll: Current Practices in Transfer of Care in Your Institution Does your program/institution use a standard template for written information conveyed at the hand-off (sign-out)? Does your program/institution use a standard template for written information conveyed at the hand-off (sign-out)?

15 Audience Poll: Current Practices in Transfer of Care in Your Institution Do you have formal training on how to perform hand-offs and transition patients for new personnel at your institution? Do you have formal training on how to perform hand-offs and transition patients for new personnel at your institution?

16 Background and Definitions

17 Exchange vs. Hand-off An exchange of information doesn't require that the other person understand what is being transmitted but simply conveys information An exchange of information doesn't require that the other person understand what is being transmitted but simply conveys information –information is often acquired and transmitted without testing for comprehension A hand-off implies transfer of information as well as professional responsibility A hand-off implies transfer of information as well as professional responsibility –Hand-offs with exchange elements that dont test for comprehension put teams at risk

18 Lessons from Other Industries and Applications to Healthcare

19 Hand-off as a Form of Communication When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener. –Alistair Cockburn

20 Hand-offs in Other High-Risk Industries Direct observations of hand-offs at NASA, 2 Canadian nuclear power plants, a railroad dispatch center, and an ambulance dispatch center Direct observations of hand-offs at NASA, 2 Canadian nuclear power plants, a railroad dispatch center, and an ambulance dispatch center STRATEGIES STRATEGIES –Standardize - use same order or template –Update information –Limit interruptions –Face to face verbal update with interactive questioning with interactive questioning –Structure Read-back to ensure accuracy Read-back to ensure accuracy Patterson, Roth, Woods, et al. Intl J Quality Health Care, 2004

21 Applications of Standard Language Read-back Read-back –Reduces errors in lab reporting Read-backs at your neighborhood Drive-Thru Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.

22 A Word of Caution on Technology Computerized sign-out Computerized sign-out –Brigham and Womens Hospital (Petersen, et al. Jt Comm J Qual Improv, 1998) –U Washington (Van Eaton, et al. J Am Coll Surg, 2005) IT solutions alone cannot substitute for a successful communication act IT solutions alone cannot substitute for a successful communication act –Human vigilance still required Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, In an emergency room, replacing a phone call for critical lab values with electronic reporting with no verbal communication resulted in 45% (1443/3228) of urgent labs to go unchecked.

23 In both aviation and medicine, people depend on technology as the solution…

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25 Newer technology doesnt eliminate error

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27 Nor does even newer technology

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29 Continued Focus on Hand-offs July 2003– ACGME set limits for resident duty hours July 2003– ACGME set limits for resident duty hours –Reduce sleep deprivation and improve patient safety Unintended consequence is increase in number of hand-offs (discontinuity) Unintended consequence is increase in number of hand-offs (discontinuity) Safety of hand-off? Safety of hand-off? –Error-prone and variable –A vulnerable gap in patient care

30 ACGME Core Competencies Patient Care Patient Care Medical Knowledge Medical Knowledge Professionalism Professionalism Communication Communication Systems Based Practice Systems Based Practice Practice Based Learning and Improvement Practice Based Learning and Improvement

31 The Role of the Hand-off: Communication and Patient Safety Transfer of information (content) Transfer of information (content) Different modalities (process) Different modalities (process) –Written –Verbal Variable, error-prone Variable, error-prone Few trainees receive formal education Few trainees receive formal education The Joint Commission National Patient Safety Goal (effective Jan 1, 2006) The Joint Commission National Patient Safety Goal (effective Jan 1, 2006) –Requires hospitals to implement a standardized approach to hand-off communications and provide an opportunity for staff to ask and respond to questions about a patient's care

32 How Do We Do At Sharing Information? Verbal handoffs Verbal handoffs –Interruptions lead to diversion of attention, forgetfulness, and error (Coiera, BMJ 1998) Written handoffs Written handoffs –Inconsistent –Missing code status, allergies, age, sex (Lee, JGIM 1996)

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34 A Brief Example of the Difficulties in Communicating The Purpose of This Exercise The Purpose of This Exercise –To make the distinction between hearing (the biological process of assimilating sound waves) and listening (adding our interpretations of what is being said) –To demonstrate the importance of effective communication skills and listening skills to thinking and acting systematically adapted from the Systems Thinking Playbook, Meadows and Sweeney, 1995

35 Instructions for Part 1 of the exercise Everyone take 1 sheet of colored paper Everyone take 1 sheet of colored paper There is no talking There is no talking Close your eyes and do exactly what I tell you to do Close your eyes and do exactly what I tell you to do Our goal is to produce identical patterns with the pieces of paper Our goal is to produce identical patterns with the pieces of paper

36 Instructions for Part 2 of the exercise Form groups of 3 or 4 at your table Form groups of 3 or 4 at your table Pick 1 person to be the communicator and the rest will be the listeners Pick 1 person to be the communicator and the rest will be the listeners Listeners close their eyes Listeners close their eyes Communicators go through at least 3 steps, each step involving a fold and a tear Communicators go through at least 3 steps, each step involving a fold and a tear Switch roles and repeat the exercise with your same group but with someone else as the communicator. This time the listeners are allowed to talk, but still have their eyes closed Switch roles and repeat the exercise with your same group but with someone else as the communicator. This time the listeners are allowed to talk, but still have their eyes closed

37 What happened? How would you describe your listening skills? How would you describe your listening skills? For those who were communicators, how effective were your skills? For those who were communicators, how effective were your skills? Were there any differences in the 3 attempts? Were there any differences in the 3 attempts?

38 How Can We Improve Hand-offs? Developing a Standard Hand-off Protocol

39 A Model For Developing a Standard Protocol Principles underlying the model Principles underlying the model –The hand-off protocol will need to be discipline specific –Standardization is key for both process and content PROCESS PROCESS –Create a process map CONTENT CONTENT –Create a standard check-list IMPLEMENTATION IMPLEMENTATION –Leadership and resident buy-in MONITORING MONITORING –Ensure the protocol is in place and identify and resolve barriers

40 Understanding Hand-offs as a Process The first step is to draw a flow diagram. Then everyone understands what his job is. If people do not see the process, they cannot improve it. W.E. Deming, 1993

41 Overview of Process Mapping A process map or flowchart is a picture of the sequence of steps in a process A process map or flowchart is a picture of the sequence of steps in a process Useful for Useful for –Planning a project –Describing a process –Documenting a standard way for doing a job –Building consensus about the process (correct misunderstandings about the process) Detailed process maps are especially helpful to standardize and improve processes Detailed process maps are especially helpful to standardize and improve processes For use as an improvement tool, it is important to map the current process, not the desired process For use as an improvement tool, it is important to map the current process, not the desired process

42 Process Mapping Ovals are beginnings and endings Ovals are beginnings and endings Boxes are steps or activities Boxes are steps or activities Diamonds are questions Diamonds are questions Arrows show sequence and chronology Arrows show sequence and chronology

43 Process Mapping Can be high-level to get an overview of the process Can be high-level to get an overview of the process Assessed in ER Patient arrives in ER Discharged Admitted? No Yes Sent to floor Diagnosed And Treated

44 Process Mapping Can also be very detailed and drilled down to show the details and roles Can also be very detailed and drilled down to show the details and roles Detailed process maps are especially helpful to standardize and improve processes Detailed process maps are especially helpful to standardize and improve processes For use as an improvement tool, it is important to map the current process, not the desired process For use as an improvement tool, it is important to map the current process, not the desired process

45 A Sample Hand-off Process (Internal Medicine)

46 Analyzing Process Maps What is the goal of the process? What is the goal of the process? Does the process work as it should? Does the process work as it should? Are there obvious redundancies or complexities? Are there obvious redundancies or complexities? How different is the current process from the ideal process? How different is the current process from the ideal process?

47 Advanced Process Mapping: Identifying Barriers

48 Small Group Exercise Working in small groups, create a process map of an ideal hand-off process Working in small groups, create a process map of an ideal hand-off process Identify the type of hand-off Identify the type of hand-off Set clear boundaries (where does the process begin and end) Set clear boundaries (where does the process begin and end) Identify key steps and decision points Identify key steps and decision points

49 Process Mapping Demonstration

50 Debriefing

51 Completing the Hand-Off Protocol PROCESS PROCESS Create a process map Create a process map CONTENT CONTENT –Create a standard check-list IMPLEMENTATION IMPLEMENTATION –Leadership and resident buy-in MONITORING MONITORING –Ensure the protocol is in place and identify and resolve barriers

52 Determine the Standard Content: ANTICipate Develop a checklist Develop a checklist Have disciplines customize to their needs Have disciplines customize to their needs Can be used to evaluate the quality of hand-offs Can be used to evaluate the quality of hand-offs

53 Beware technical, cultural, and environmental differences A one-size fits all approach does not allow for customization. A one-size fits all approach does not allow for customization. Environment Environment –Although 4 programs had a designated hand-off location, 3 conducted hand-offs wherever convenient Culture Culture –One resident describes being a slave to The List [sign-out sheet] and information overload –In a different program, only acutely ill patients are on the sign-out Technical Technical –While all disciplines hand-off administrative data (i.e. name, MRN, room number, etc.), major differences in specific categories Surgical fields: Pre-op consent, post-op checks, etc. Surgical fields: Pre-op consent, post-op checks, etc. Pediatrics: Custodial issues (DCFS, parents, etc.) Pediatrics: Custodial issues (DCFS, parents, etc.) –Common use of some language: If/Then for contingency planning

54 Psychiatry check-list Routine fields Routine fields –Admin data –Therapeutics –To-do –If/then Discipline- specific fields Discipline- specific fields –Housing –Court/legal issues –Special instructions etc.

55 Research on Transitions of Care Resident to resident transitions Resident to resident transitions Inpatient to outpatient transitions Inpatient to outpatient transitions

56 University of Chicago Experience with Resident Hand-offs Internal Medicine Department Study Internal Medicine Department Study Development and Implementation of Standard Protocols Development and Implementation of Standard Protocols

57 Critical Incident Study of IM Hand-offs To characterize communication failures during hand-offs and solicit suggestions for improvement To characterize communication failures during hand-offs and solicit suggestions for improvement Question designed to elicit information about adverse events and near misses Was there anything bad that happened or almost happened last night because the (VERBAL/WRITTEN) sign-out wasn't as good as it could have been? Question designed to elicit information about ideas for improvement Regardless of whether anything went wrong or almost went wrong, and thinking about what should be included in a sign-out, is there anything about the (VERBAL/WRITTEN) sign-out that you received that you think should have been better? Arora, Johnson, et al. Quality and Safety in Healthcare, 2005.

58 Taxonomy of Sign-out Quality POOR SIGN-OUT Omissions in Content Medications or Therapies Tests or Consults Medical Problems ActiveAnticipated Baseline status Code status Rationale of primary team Failure-Prone Processes Lack of Face-to-Face Communication Communication Double Sign-out ( Night Float ) Illegible or Unclear Handwriting EFFECTIVE SIGN-OUT Written Sign-out Patient Content Code status Anticipated problems Active Problems Baseline Exam Pending Test or Consults Overall Features LegibleRelevantAccurateUp-to-date Verbal Sign-out Face to Face Anticipate Pertinent Thorough

59 Development and Implementation of a Standard Protocol To date, 8 residency programs have participated. To date, 8 residency programs have participated. Analysis of these protocols demonstrates that the hand-off process is highly variable and discipline-specific. Analysis of these protocols demonstrates that the hand-off process is highly variable and discipline-specific. Process and content analysis of protocols yields several themes. Process and content analysis of protocols yields several themes.

60 1. Understand and attempt to reduce the variation in the process All disciplines required a verbal hand-off All disciplines required a verbal hand-off BUT due to competing demands (OR, clinic, etc.), this verbal communication sometimes did not occur BUT due to competing demands (OR, clinic, etc.), this verbal communication sometimes did not occur –Educate residents on this important priority Individual-level variation also present Individual-level variation also present –Some residents are better at making themselves available and touching base with you [during the hand-off] than others...

61 2. Hand-off = Transfer of information + professional responsibility Transfers were at times separated in time and space Transfers were at times separated in time and space –In one program, departing residents forward their pager to the on-call resident after they provide a verbal hand-off. –In another program, the on-call resident transfers a virtual pager to their own pager at a designated time which often occurs well before they receive a verbal hand-off.

62 Transfer of professional responsibility Verbal hand-off Neurology Hand-Off

63 3. Need to ensure closed-loop hand-off communication In two cases, patient tasks were divided and assigned to other team members In two cases, patient tasks were divided and assigned to other team members –To facilitate early departure of a post-call resident (to meet resident duty hour restrictions) –BUT results of these tasks were not formally communicated to anyone Residents ensured closed-loop communication by building required follow-up on these tasks into the process Residents ensured closed-loop communication by building required follow-up on these tasks into the process

64 closed-loop communication Pediatric Resident Post-Call Hand-Off

65 4. Keep the focus on patient care: Clear roles and back-up behavior Anesthesia resident to PACU RN Anesthesia resident to PACU RN –Interdisciplinary hand-off with challenging complex fast-paced environment Clear delineation of responsibility to ensure patient care Clear delineation of responsibility to ensure patient care Anesthesia resident to call out for a bed Anesthesia resident to call out for a bed Unit clerk to respond with bed # Unit clerk to respond with bed # PACU RN to hook up monitors PACU RN to hook up monitors Equally important back-up behaviors Equally important back-up behaviors Can empower participants to focus on the patient care Can empower participants to focus on the patient care If nursing delay >30 sec, then resident to hook up monitors and call for RN If nursing delay >30 sec, then resident to hook up monitors and call for RN

66 Anesthesia Resident to PACU Nurse Hand-Off Clear delineation of roles/responsibility Back-up Behavior

67 Future work We are still in the early stages of our work We are still in the early stages of our work Continue our research Continue our research –Mechanisms of human failures during sign-outs, –Human factors and ergonomic issues that impede the sign-out process –Perceived risks associated with shift changes by different classes of providers and administrators –Understanding shared work better Ultimately, the goal is to identify and implement interventions that can reduce the risks associated with transitions in care Ultimately, the goal is to identify and implement interventions that can reduce the risks associated with transitions in care

68 Inpatient to Outpatient Transitions of Care at University of Chicago Our aim was to improve the quality, safety, and continuity of patient care during the transition from inpatient to ambulatory care by developing a model of effective communication between inpatient and ambulatory physicians. Our aim was to improve the quality, safety, and continuity of patient care during the transition from inpatient to ambulatory care by developing a model of effective communication between inpatient and ambulatory physicians. Specifically, we: Specifically, we: –Assessed current methods of communication –Developed a model for effective inpatient physician – primary care physician communication. –Designed an intervention to evaluate the model for effective inpatient physician – primary care physician communication

69 Methods Focus Groups were conducted with Focus Groups were conducted with –Hospitalists –Primary Care Physicians –Internal Medicine residents –Patients The focus groups were used to generate the process maps The focus groups were used to generate the process maps

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71 Methods Observations were used to verify and enhance the process Observations were used to verify and enhance the process

72 Interviews Interviews were conducted with key stakeholders to determine barriers and facilitators to an effective handover process Interviews were conducted with key stakeholders to determine barriers and facilitators to an effective handover process

73 Barrier Representative quote(s) (Hospitalists) Representative quote(s) (PCPs) Unable to correctly identify the PCP But also some notes, we dont recognize their names so its difficult to know if thats really a primary care doctor and not some sort of ancillary person[Resident] The other issue is do they really know who the PCP is? They may see [in the electronic system] like a note from X, but then one from Y, one from Z, and how do they know whos really the PCP? Finding PCP contact info Its a little harder to get a hold of the [community- based] physicians so I end up resorting to Googling – [Resident] Sometimes we get a text page, voic , from the [General Medicine] team or they call the nurse…sometimes smoke signals- - Unaware or variable preference of PCPs You know, this [PCP] wants you to get a hold of him ….but maybe some of them [other PCPs] would say, oh, but the [patient] is in the hospital and you know theres ten people taking care of them, maybe I dont need to be called until the next morning - - [Resident] I think theres a culture of… negative feedback if the team contacts the PCP. PCP says oh fine, but never shows up, thats a learned behavior, theyre going to be less likely to contact. Contacting PCP not a priority Im usually busy with multiple admissions so I dont spend too much time contacting the [primary care] providers right away - - [Resident] With 13 admissions or however many --the priority is taking care of the acute illness and continuity of care falls to number 37 on the list of priorities Fear of losing control I mean there are certain attendings, like some sub-specialists, I mean they want you to call them right away if its like, they have a cough… - - [Resident] I get the sense that people dont call because theyre worried that youre going to intrude or do something that prolongs the hospitalization Forgetting or too busy to contact PCP I know in the hospital Ive just gotten better about [contacting PCPs] from the beginning of my second year as a resident. Like I didnt always do it right off the bat so I think that there is a learning curve - - I wonder how big of a component that being super-busy especially when they are under the pressure to leave the hospital by noon, the day that it would make the most sense to contact

74 Putting it All Together The research informs the improvement work The research informs the improvement work

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76 Artifact Analysis The study of any notes or materials used in the daily workflow of patient care may serve as a powerful supplement to the self-report data The study of any notes or materials used in the daily workflow of patient care may serve as a powerful supplement to the self-report data Provides further evidence of the effectiveness of the handover Provides further evidence of the effectiveness of the handover

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78 Concluding Comments


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