Presentation on theme: "Designing Safe and Effective Patient Handovers"— Presentation transcript:
1Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of ChicagoJulie Johnson, MSPH, PhD University of ChicagoQuality Colloquium at HarvardAugust 21, 200810:45 – 12:45 pm
2ObjectivesDetermine which methods are most appropriate for exploring hand-offs in clinical settingsDevelop a standard process to optimize hand-offs using a process mapping methodologyCreate a checklist of critical patient and process informationDesign a strategy for dissemination and trainingIdentify and overcome barriers to implementationDevelop a plan to evaluate and monitor hand-off protocols
3Agenda 10:45 – 10:50 Introduction and Overview of the Agenda 10:50 – 11:00 Participant Introductions and Expectations11:00 – 11:10 Hand-off Theater11:10 – 11:15 Audience Poll11:15 – 11:30 What is known about Hand-offs in Medicine and other Industries11:30 – 11:50 Small Group Exercise: Paper Tear11:50 – 12:00 A Model for Developing a Standard Protocol12:00 – 12:20 Small Group Exercise: Process Mapping12:20 – 12:30 Completing the Hand-off Model12:30 – 12:40 Research Presentation12:40 – 12:45 Final Comments and Adjourn
4Introductions Who are you? What do you do? What are your expectations for today’s session?
5What are the types of handoffs that come to mind when you think about handoffs?
7Role Play of a Intern “Sign-out” Use the checklist for observations:Please record cultural, communication, and environmental barriers that interfere with successful patient hand-off practices in patient care
8What Do You Look For? Barriers Observations/Thoughts Facilitators 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)OtherFacilitatorsWhat went well?
9Debriefing from the Role Play What types of barriers to an effective hand-off did you observe?EnvironmentCulturalCommunicationAny others?
10Audience Poll: Current Practices in Transfer of Care in Your Institution When there is a transfer of care, who is primarily responsible for the transfer?
11Audience 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?
12Audience 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?
13Audience Poll: Current Practices in Transfer of Care in Your Institution If conducted, where does verbal communication take place?Face to face in a dedicated roomOn the phone“On the fly” (wherever/whenever the two parties can meet)At the patient’s bedside
14Audience 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”)?
15Audience 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?
17Exchange vs. Hand-offAn exchange of information doesn't require that the other person understand what is being transmitted but simply conveys informationinformation is often acquired and transmitted without testing for comprehensionA hand-off implies transfer of information as well as professional responsibilityHand-offs with exchange elements that don’t test for comprehension put teams at risk
18Lessons from Other Industries and Applications to Healthcare
19Hand-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 CockburnIn thinking of the way we communicate, it is important to think about the mode of communication.I use the red arrows to highlight two ends of this spectrum that we use to communicate every day in healthcare: paper and face to face communication. And clearly they are very different and it is important to know how they differ. Esp in the context of signout.This passage from Allistair Cockburn, who is actually a software engineer and prominent author on this topic describes it best:When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues that such proximity provides. 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.
20Hand-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 centerSTRATEGIESStandardize - use same order or templateUpdate informationLimit interruptionsFace to face verbal updatewith interactive questioningStructureRead-back to ensure accuracyNow what can we say about communication at the time of Handoffs—here we have to turn to other industries…read slide…Not surprisignly, the main strategies described in this paper resonate with those that have worked in healthcare communication more generallyTRANSITION TO JEFF…**********************************************Human factors researchers noted the same thing as they conducted direct observations of handoffs at NASA Johnson Space center, 2 canadian nuclear power plants, a railroad dispatch center in the US, and an ambulance dispath center in Toronto.From these observations, they identified handoff strategies and face to face verbal update with interactive questioning was definitely a plus…Other things they notedPatterson, Roth, Woods, et al. Intl J Quality Health Care, 2004
21Applications of Standard Language “Read-back”Reduces errors in lab reporting“Read-backs” at your neighborhood Drive-ThruBut the good news, is that communication can be improved, and that is one goal of today’s workshop. In fact, more structured communication, such as the use of a read-back, similar to your neighborhood drive-thru that confirms your order, reduces errors during telephone reporting of abnormal lab values.****Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121(6):801-3.The recipients were asked to repeat the name ofthe patient, the test, and the result; the technologists notedthis on the form. In addition, they noted the time necessaryfor the entire phone call and the extra time necessary to askfor the message to be repeated and for it to be repeated. Data$11.25/hour ($0.19/minute or $0.0032/second), the extratime to repeat the message costs the hospital from $0.11 to$0.16 per call ($0.07 per 13 seconds for a laboratory technologist’stime plus $0.04-$0.09 per 13 seconds for therecipient’s time).29 errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004.
22A Word of Caution on Technology Computerized sign-outBrigham and Women’s 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”Human vigilance still requiredNow lets turn to communication in healthcare…what do we know…first we know that it is indispensible. This is important particularly in the context of future IT solutions which are sometimes touted as the safer.****Refs:Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):121-4.Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322(7294):The results from 1443/3228 (45%) of urgent requests from accident and emergency and 529/1836 (29%) from the admissions ward were never accessed via the ward terminal. Results from 794/3228 (25%) of accident and emergency requests and 413/1836 (22%) of admissions ward requests were seen within 1 hour of becoming available while a further 491/3228 (15%) and 341/1836 (19%) respectively were accessed between 1 and 3 hours. In up to 43/1443 (3%) of the accident and emergency test results that were never looked at the findings might have led to an immediate change in patient management. CONCLUSIONS: When used as the sole substitute for telephoning results, the provision of terminal access to laboratory results on wards can hinder rather than promote the communication of emergency blood results to healthcare staff.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.Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, 2001.
23In both aviation and medicine, people depend on technology as the solution…
29Continued Focus on Hand-offs July 2003– ACGME set limits for resident duty hoursReduce sleep deprivation and improve patient safetyUnintended consequence is increase in number of hand-offs (discontinuity)Safety of hand-off?Error-prone and variableA vulnerable “gap” in patient careIn July of 2003, the ACGME set limits on resident duty hours. One reason for these limits was to relieve sleep deprivation in medical trainees.In addition to the limit of 80 hours per week, there was also a maximum of 30 consecutive hours per call shift, otherwise known as the “24+6 rule”.While the ACGME and others, especially in light of recent studies, have been debating the optimal length of a call period, we are ignoring another potential way of relieving fatigue. Naps are a proven method to relieve fatigue in other industries requiring long shifts. In residency programs, naps can be provided by using nigh float (NF) systems. In fact, this type of system was used by internal medicine residency programs prior to the duty hours to provide residents with some rest so they could continue to provide care for patients throughout the next day.
30ACGME Core Competencies Patient CareMedical KnowledgeProfessionalismCommunicationSystems Based PracticePractice Based Learning and Improvement
31The Role of the Hand-off: Communication and Patient Safety Transfer of information (content)Different modalities (process)WrittenVerbalVariable, error-proneFew trainees receive formal educationThe 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”Who signed out today—where? Describe it? Noisy, pager going off, others in the room?
32How Do We Do At Sharing Information? Verbal handoffsInterruptions lead to diversion of attention, forgetfulness, and error (Coiera, BMJ 1998)Written handoffsInconsistentMissing code status, allergies, age, sex (Lee, JGIM 1996)
34A Brief Example of the Difficulties in Communicating The Purpose of This ExerciseTo 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 systematicallyadapted from the Systems Thinking Playbook, Meadows and Sweeney, 1995
35Instructions for Part 1 of the exercise Everyone take 1 sheet of colored paperThere is no talkingClose your eyes and do exactly what I tell you to doOur goal is to produce identical patterns with the pieces of paperFold your paper in half and tear off the bottom right corner of the paper. (Pause and allow the group to try this.)Fold the paper in half again and tear off the upper right hand corner. (Pause)Fold the paper in half again and tear off the lower left hand corner. (Pause)Open your eyes, unfold your paper and hold it out for everyone to see.
36Instructions for Part 2 of the exercise Form groups of 3 or 4 at your tablePick 1 person to be the communicator and the rest will be the listenersListeners close their eyesCommunicators go through at least 3 steps, each step involving a fold and a tearSwitch 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
37What happened? How would you describe your listening skills? For those who were communicators, how effective were your skills?Were there any differences in the 3 attempts?
38How Can We Improve Hand-offs? Developing a Standard Hand-off Protocol
39A Model For Developing a Standard Protocol Principles underlying the modelThe hand-off protocol will need to be discipline specificStandardization is key for both process and contentPROCESSCreate a process mapCONTENTCreate a standard check-listIMPLEMENTATIONLeadership and resident buy-inMONITORINGEnsure the protocol is in place and identify and resolve barriers
40Understanding 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
41Overview of Process Mapping A process map or flowchart is a picture of the sequence of steps in a processUseful forPlanning a projectDescribing a processDocumenting a standard way for doing a jobBuilding consensus about the process (correct misunderstandings about the process)Detailed process maps are especially helpful to standardize and improve processesFor use as an improvement tool, it is important to map the current process, not the desired process
42Process Mapping Ovals are beginnings and endings Boxes are steps or activitiesDiamonds are questionsArrows show sequence and chronology
43Process Mapping Can be “high-level” to get an overview of the process Admitted?Patientarrives in ERAssessed inERNoDischargedYesDiagnosedAndTreatedSent to floor
44Process MappingCan also be very detailed and “drilled down” to show the details and rolesDetailed process maps are especially helpful to standardize and improve processesFor use as an improvement tool, it is important to map the current process, not the desired process
48Small Group ExerciseWorking in small groups, create a process map of an “ideal” hand-off processIdentify the type of hand-offSet clear boundaries (where does the process begin and end)Identify key steps and decision points
51Completing the Hand-Off Protocol PROCESSCreate a process mapCONTENTCreate a standard check-listIMPLEMENTATIONLeadership and resident buy-inMONITORINGEnsure the protocol is in place and identify and resolve barriers
52Determine the Standard Content: ANTICipate Develop a checklistHave disciplines customize to their needsCan be used to evaluate the quality of hand-offs
53Beware technical, cultural, and environmental differences A “one-size fits all” approach does not allow for customization.EnvironmentAlthough 4 programs had a designated hand-off location, 3 conducted hand-offs wherever convenientCultureOne 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-outTechnicalWhile all disciplines hand-off “administrative data” (i.e. name, MRN, room number, etc.), major differences in specific categoriesSurgical fields: Pre-op consent, post-op checks, etc.Pediatrics: Custodial issues (DCFS, parents, etc.)Common use of some language: “If/Then” for contingency planning
54Discipline-specific fields Psychiatry check-listRoutine fieldsAdmin dataTherapeuticsTo-doIf/thenDiscipline-specific fieldsHousingCourt/legal issuesSpecial instructions etc.
55Research on Transitions of Care Resident to resident transitionsInpatient to outpatient transitions
56University of Chicago Experience with Resident Hand-offs Internal Medicine Department StudyDevelopment and Implementation of Standard Protocols
57Critical Incident Study of IM Hand-offs To characterize communication failures during hand-offs and solicit suggestions for improvementQuestion designed to elicit information about adverse events and near missesWas 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 improvementRegardless 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.
58Taxonomy of Sign-out Quality POOR SIGN-OUTOmissions in ContentMedications or TherapiesTests or ConsultsMedical ProblemsActiveAnticipatedBaseline statusCode statusRationale of primary teamFailure-Prone ProcessesLack of Face-to-FaceCommunicationDouble Sign-out (“Night Float”)Illegible or Unclear HandwritingEFFECTIVE SIGN-OUTWritten Sign-outPatient ContentCode statusAnticipated problemsActive ProblemsBaseline ExamPending Test or ConsultsOverall FeaturesLegibleRelevantAccurateUp-to-dateVerbal Sign-outFace to FaceAnticipatePertinentThorough
59Development and Implementation of a Standard Protocol To date, 8 residency programs have participated.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.
601. Understand and attempt to reduce the variation in the process All disciplines “required” a verbal hand-offBUT due to competing demands (OR, clinic, etc.), this verbal communication sometimes did not occurEducate residents on this important priorityIndividual-level variation also present“Some residents are better at making themselves available and touching base with you [during the hand-off] than others...”
612. Hand-off = Transfer of information + professional responsibility Transfers were at times separated in time and spaceIn 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.
62Neurology Hand-Off Transfer of professional responsibility Verbal hand-off
633. Need to ensure “closed-loop” hand-off communication In two cases, patient tasks were divided and assigned to other team membersTo facilitate early departure of a post-call resident (to meet resident duty hour restrictions)BUT results of these tasks were not formally communicated to anyoneResidents ensured “closed-loop” communication by building required follow-up on these tasks into the process
64Pediatric Resident Post-Call Hand-Off “closed-loop” communication
654. Keep the focus on patient care: Clear roles and back-up behavior Anesthesia resident to PACU RNInterdisciplinary hand-off with challenging complex fast-paced environmentClear delineation of responsibility to ensure patient careAnesthesia resident to call out for a bedUnit clerk to respond with bed #PACU RN to hook up monitorsEqually important back-up behaviorsCan empower participants to focus on the patient care“If nursing delay >30 sec, then resident to hook up monitors and call for RN”
66Anesthesia Resident to PACU Nurse Hand-Off Clear delineation of roles/responsibilityBack-up Behavior
67Future work We are still in the early stages of our work Continue our researchMechanisms of human failures during sign-outs,Human factors and ergonomic issues that impede the sign-out processPerceived risks associated with shift changes by different classes of providers and administratorsUnderstanding shared work betterUltimately, the goal is to identify and implement interventions that can reduce the risks associated with transitions in care
68Inpatient 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.Specifically, we:Assessed current methods of communicationDeveloped 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
69Methods Focus Groups were conducted with HospitalistsPrimary Care PhysiciansInternal Medicine residentsPatientsThe focus groups were used to generate the process maps
71MethodsObservations were used to verify and enhance the process
72InterviewsInterviews were conducted with key stakeholders to determine barriers and facilitators to an effective handover process
73BarrierRepresentative quote(s) (Hospitalists)Representative quote(s) (PCPs)Unable to correctly identify the PCPBut also some notes, we don’t recognize their names so its difficult to know if that’s 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 who’s really the PCP?Finding PCP contact infoIt’s 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 PCP’sYou 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 there’s ten people taking care of them, maybe I don’t need to be called until the next morning - - [Resident]I think there’s a culture of… negative feedback if the team contacts the PCP. PCP says oh fine, but never shows up, that’s a learned behavior, they’re going to be less likely to contact.Contacting PCP not a priorityI’m usually busy with multiple admissions so I don’t 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 prioritiesFear of losing controlI 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 don’t call because they’re worried that you’re going to intrude or do something that prolongs the hospitalizationForgetting or too busy to contact PCPI know in the hospital I’ve just gotten better about [contacting PCP’s] from the beginning of my second year as a resident. Like I didn’t 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
74Putting it All Together The research informs the improvement work
76Artifact AnalysisThe study of any notes or materials used in the daily workflow of patient care may serve as a powerful supplement to the self-report dataProvides further evidence of the effectiveness of the handover