1. Team Communication and Transitions of Care Richard M. Frankel Ph.D. Professor of Medicine and Geriatrics Senior Research Scientist The Regenstrief Institute Indiana University School of Medicine Indianapolis, Indiana Senior Scientist Center for Implementing Evidence Based Practice Roudebush VAMC Quality Colloquium August 19-22, 2007

2. Objectives Look at the role of handoffs across the spectrum of medical care Explore the relationship of hand-offs to patient safety Identify elements of safe and effective hand-offs

3. What are the types of handoffs that come to mind when you think about transfers of care?

4. Role of Hand-offs Ensure smooth transition of care from one physician, nurse or team to another Transfer of rights duties and responsibilities Convey any anticipated changes over the next 8-12 hours. Part of the “clinical microsystem” life-cycle. –Intern perspective: No big deal,“just part of the work”.

5. Hand offs and Patient Safety Shift changes (handoffs, sign-outs) represent transitions that can impact the quality of patient care and patient safety –Some estimates put the percentage of adverse events related to shift changes as high as 80%! The literature in this area has been dominated by the nursing profession Wide variation across institutions, professional roles, shifts, and individuals No studies to date have tried to connect the dots as a means of reducing unwanted variation

6. Recent Focus on MD Hand-offs July 2003– ACGME limited resident duty hours to 80 per week to reduce sleep deprivation and improve patient safety An unintended consequence is that the number of hand-offs for hospitalizations has increased significantly Safety of hand-off?  Discontinuity  Error-prone and variable  A vulnerable “gap” in patient care

7. Elements of Effective Hand Offs Communication Standard Setting Education Practice Improvement

8. Keys to Successful Hand Offs: Communication is Critical

9. Exchange vs. Hand-off 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 –Hand-offs with exchange elements that don’t test for comprehension put teams at risk

12. The "relics“ include such as handwritten notes on crumbling memo pads bearing cryptic texts like: "pound pastrami, can kraut, six bagels–bring home for Emma".

13. Timing Is Everything for Sprint-Relay Success By Sean P. Flynn Special to The Washington Post Friday, April 15, 2005; Page D16

14. Keys to Baton Handoffs Timing. Every part of the baton exchange must be as precise as possible, as each split second counts in the 4x100 relay. To minimize time, the runner cannot get out too early or too late. Have a Mark. The runner receiving the baton should set up a mark behind his starting position. At the exact moment the preceding runner arrives, he should be ready to burst out of position. Focus. Because the smallest glitch in the handoff can have a big effect on final placement, intense focus is needed to know exactly when to do exactly what they need to do.

15. Lack of National Standards for Patient Handoffs Only 8% of medical schools teach how to hand off patients in a formal didactic session. (National survey of 125 medical schools). The vast majority (86%) of medical students are taught by interns or residents who were likely taught by their interns or residents and so on. This process exemplifies the “hidden” or informal curriculum in medicine where a task is learned by observing those in charge… Solet et al, 2005

16. JCAHO’s Hand-Off Communication Goal, 2006 The Joint Commission’s new National Patient Safety Goal reads simply: "Implement a standardized approach to 'hand off' communications, including an opportunity to ask and respond to questions.”

17. “That leaves you to figure out what constitutes a hand-off, how to design a standardized approach, and how to implement it.” patient care can often be disrupted due to: interruptions lack of clarity with the process non-standardized technique incomplete information. Patton, Hand-off Communication: Practical Strategies and Tools for JCAHO Compliance, 2006

18. Education and Practice: Resident Handoffs at One University The internal medicine residency program at IUSM utilizes 4 hospitals, each with a unique patient population; 3 different computer systems store and process data related to their care, including handoffs. The handoff process takes a different form at each hospital. Solet et al, 2005

19. At 1 hospital the handoff form is electronic. Information is printed for every patient including: name, record number, age, race, location, code status, admitting diagnosis, problem list (current and historical), allergies, and medications. Space is provided for handwritten comments. The VA handoff form is also electronic and includes name, age, sex, Social Security number, location, team assignment, allergies, and active medications, It has space for comments. Medical subspecialties at another hospital use a word- processing template for handoffs. Standard instructions are at the top of the form. The handoff resident enters the identifying patient information with a medication list, problem list, active issues, and suggestions for potential problems that may be encountered overnight. Cardiology & IM services at the private hospital are handwritten or use a word-processor without a standard format. Their perceived quality and usefulness is variable.

20. Re-enacted Resident Handoff

21. Transcript of A Resident Handoff OGR: A::nd Ms. Strickland (pseudonym) is on five south. She is a fifty four year old lady with history of ( ) cirrhosis, and hepatitis C (0.2) and diabetes. She came in complaining- she’s been here like three times to the ER in the past week and finally got admitted for (a) pancreatitis (0.7)* on Saturday night. ICR: *(Scratches head with his pencil) OGR: A::nd is doing really well, belly pain is improved ( ) her diet-, is on PO meds. She was complaining of some chest pain when she was admitted we’re not sure if it was just kind of radiating from the whole pancreatitis thing (0.3) she was ruled out and she’s supposed to get a stress echo tomorrow. And if she would have a repeat episode of the chest pain I would start with getting an EKG and if that was different then you could check markers.

22. OGR: She ruled out before. Blood sugars have been stable you probably won’t get a call about those. And then today her new complaint was some right sided arm and leg weakness. (0.5) I’m not really sure. It kind of seems like she comes up with new complaints each time you talk to her (0.3) and her exam was non-focal. But my attending wanted me to check a head CT so… that was ordered about 2:30 or so today. That’s really the only thing to follow up on with her. ICR: (Writes on the OGR’s notes which are in her lap.) If there would be something there I would call Neurology. Mrs. Hazelwood….

23. Lessons from Other Industries and Applications to Healthcare

24. 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

25. 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 STRATEGIES –Standardize - use same order or template –Update information –Limit interruptions –Face to face verbal update with interactive questioning –Structure Read-back to ensure accuracy Patterson, Roth, Woods, et al. Intl J Quality Health Care, 2004

26. NASA Video Crew # 7

27. Applications of Standard Language “Read-back” –Reduces errors in lab reporting “ Read-backs” at your neighborhood Drive-Thru Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004. 29 errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.

28. Opportunities for Improvement in Medicine One study of surgeons and primary care physicians (Braddock, JAMA 1999) found that testing for patient comprehension of medical information occurred less than 1.5% of the time. This “gap” represents a tremendous improvement opportunity.

29. Future work We are still in the early stages of work on handoffs Continue research –Identify “vulnerable gaps” across the continuum of care, e.g., admission, care during hospitalization, discharge planning, transition to ambulatory care, physician patient relationship/communication in ambulatory visits –Human factors and ergonomic issues that impede hand offs Ultimately, the goal is to reduce the risks associated with transitions and the patient’s experience of care

30. Thanks for your time and attention