I-PASS Just-in-time Module

Communication Failures Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type ( Third Quarter 2011)

 Effective handoffs Ensure transfer of accurate & unambiguous information Facilitate transfer of responsibility May be supervised Ensure quality Provide feedback  Verbal handoffs Utilize standardized format Employ closed-loop communication  Printed handoff documents Supplement verbal handoff Serve as a foundation Provide more detail 3 Photo courtesy of Comstock/Comstock/Thinkstock Global Elements of Effective Handoffs

Effective Verbal Handoffs  Face-to-face  Structured format, beginning with high- level overview  Appropriate pace  Closed-loop communication  shared mental model

The Printed Handoff Document  Supplements the verbal handoff Allows receiver to follow along Provides more comprehensive information  Succinct, specific, accurate, up to date  Senior/supervising resident should edit and ensure quality Incorporate time for review and update into daily workflow

The I-PASS Mnemonic 6 I Illness Severity Stable, “watcher,” unstable P Patient Summary Summary statement Events leading up to admission Hospital course Ongoing assessment Plan A Action List To do list Timeline and ownership S Situation Awareness and Contingency Planning Know what’s going on Plan for what might happen S Synthesis by Receiver Receiver summarizes what was heard Asks questions Restates key action/to do items Starmer. Pediatrics Feb;129(2):201-4.

I I – Illness Severity A Continuum  Watcher: Any provider’s “gut feeling” that a patient is at risk of deterioration or “close to the edge”

P P – Patient Summary  Summary statement (one-liner)  Often also includes: Events leading up to admission May truncated with time Hospital course Ongoing assessment  Organized by problems or diagnoses Plan  Organized by problems or diagnoses

P = Patient Summary It’s flexible, as long as it’s complete! Problem/Dx # 1 Ongoing Assessment Plan Problem/Dx # 2 Ongoing Assessment Plan

A A – Action List To Do: ☐ Check respiratory exam now; if still tachypneic call RT to give albuterol neb ☐ Monitor withdrawal scores at 5pm; if still high increase Ativan drip to 3mg/hour ☐ Check ins and outs at midnight; if less than 500mL urine output call Dr. Brown and give a 1L fluid bolus ☐ Follow up 6PM electrolytes; if K still low please ensure that another sample is drawn in the morning

S S – Situation Awareness & Contingency Planning Situation Awareness  “Know what is going on around you” Status of patients Team members Environment Progress toward team goals Team level  “Know what’s going on with your patient” Status of patient’s disease process Team members’ roles in patient’s care Environmental factors Progress toward goals of hospitalization Patient level

S S – Situation Awareness & Contingency Planning Contingency Planning  Problem solving before things go wrong  “If this happens, then.... “  For stable patients it is permissible to say: “I don’t anticipate anything will go wrong.”

S – Synthesis By Receiver  Provides an opportunity for receiver to Clarify elements of handoff Ensure there is a shared mental model Have an active role in handoff process  Varies in length and content More complex, sicker patients require more detail At times may focus more on action items, contingency planning It is not a re-stating of entire verbal handoff!

TeamSTEPPS TM  Evidence-based team training curriculum  High performing teams Must have effective leaders Use structured communication strategies Develop situational awareness Provide mutual support 14 Team Strategies and Tools to Enhance Performance and Patient Safety

Building a Shared Mental Model 15

Briefs and Debriefs BriefsDebriefs Beginning of shift  Team Members?  Goals understood?  Roles and responsibilities?  Plan of Care?  Staff Availability?  Workload?  Resources End of shift  Clear communication?  Roles understood?  Situation awareness?  Work load ok?  Assistance offered?  Errors?  Feedback?

Huddle  Opportunity to express concerns  Anticipate outcomes and talk about contingency plans  Assign Resources  Come to Consensus

Advocacy and Assertion Strategy for Avoiding Errors  When viewpoints differ Advocate for the patient Make assertive statement Open the discussion State the concern Offer a solution Obtain an agreement 18

Cross Monitoring  ‘Watch each other’s back’  Monitor actions of team members  Help others maintain Situation Awareness

Feedback Essential for Cross Monitoring  Focuses on team performance and improvement  Provides a learning opportunity 20

Check-Back

Putting it all together Using TeamSTEPPS in Handoffs Cross Monitoring Night team recognizes medication error during handoff and informs the day team Brief Night team goes over action list and divides tasks and new admits and plans for time to regroup Debrief In the morning, the night team and day team discuss what went well with the handoff and items the night team would have liked to know Huddle A patient is unstable, the day and night team examines the patient together and discusses plans for the night with the nurse Check-Back The intern obtains new information to add to the hand off from the senior resident, this information is repeated by the intern to confirm communication

Remember, TeamSTEPPS elements and effective handoffs go hand-in-hand

Essentials of Team Function 24

Handoff is a Team Sport! The whole is greater than the sum of the parts  Team handoff is the “gold standard” Very few institutions are able to achieve this  If team handoff is not possible, do a BRIEF! Intern and Senior Resident plan for the night Agree on roles, identify holes Illness severity should be verified for all patients – Unstable patients should be reviewed in detail and examined together Intern should do another read-back and verify

Handoffs At Our Hospital Are we meeting the gold standard?  Where do we do handoffs? Is this a quiet place with minimal interruptions?  When do we do handoffs? Is it at a scheduled time?  Who is present for handoffs? How do we communicate with people who aren’t present? Do we need an intern/senior brief? Nursing brief?

How Are Things Going?  Please provide feedback on how the implementation of I-PASS is going What is going well? Where are we struggling?  How can we improve?  What is the most challenging aspect of the I-PASS mnemonic during handoffs? 27

How Are Things Going?  Please provide feedback on the printed handoff document What needs to be changed? How can we make it better?  Have you been able to use the TeamSTEPPS techniques in practice? 28

How Are Things Going?  Please provide feedback on the handoff observations Is the scheduling appropriate? Front-line Providers Are your receiving timely & useful feedback? How have you adapted your handoffs after receiving the feedback? Champions How is data entry into REDCap been going? 29

How Are Things Going?  Any other issues you have encountered? 30

I-PASS Better Handoffs. Safer Care. 31