Standardizing the Handoff Process: Better Handoffs, Safer Care
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1 Standardizing the Handoff Process: Better Handoffs, Safer Care Glenn Rosenbluth, MD Associate Clinical Professor of Pediatrics Director, Quality and Safety Programs, Office of GME Associate Director, Pediatrics Residency Program
2 Disclosures I have no financial relationships related to the material that will be presented.
3 Root Causes of Sentinel Events Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type ( Third Quarter 2011)
4 How can we start to improve patient safety? It starts with good communication!
5 Outline General principles of good communication Communication in handoffs Gaps Strategies Research on a handoff bundle I-PASS handoff bundle Handoffs at UCSF
6 Communicating Effectively
7 Communication Channels Important orders cited in Arora V.
8 Learning Styles Active Sensing Visual Sequential Reflective Intuitive Verbal Global I-PASS Study Group, Children s Hospital Boston
9 Building a Shared Mental Model Situation Monitoring (Individual Skill) Situation Awareness (Individual Outcome) Shared Mental Model (Team Outcome) I-PASS Study Group, Children s Hospital Boston
10 Shared Mental Model
11 Check-Back I-PASS Study Group, Children s Hospital Boston
12 Handoffs Frequent High-stakes Error-prone Gaps in care
13 Quality and Safety Education 2011 ACGME Common Program Requirements Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety
14 New York Times, Sept 3, 2009
15 New York Times, Nov 16, 2009
16 LA Times, April 11, 2011
17 Quality handoffs?
18 Why do we care about handoffs? Handoffs are linked to medical errors Interviews with postcall interns estimate at least 7.5 per 100-patient-days (average 1/night) 59% of residents reported that one or more patients were harmed during their most recent rotation due to handoff problems 12% reported that harm was major Kitch, 2008; Horwitz 2008
19 Handoffs: Frequent and High-Stakes If one team has 15 patients And that team gets handed off every morning And every evening For 28 days 15 x 2 X 28 = 840 per team per month slide courtesy of A. Vidyarthi
20 Problems in Care Continuity Work hour limits and presumed resulting discontinuities associated with increased hospital complications and test ordering Cross coverage associated with an increased risk of errors (OR 5.2) Laine, 1993; Peterson, 1998
21 When do handoffs occur? Before and after nights on-call Changing blocks Receiving patients from referring MD s New patient Changes in clinical status Receiving patients from the ED Workups in progress End of academic year slide courtesy of A. Vidyarthi
22 Errors Due To Discontinuity Resident discontinuity Delayed test ordering Increased in-hospital complications Increased medication errors Presumed increase in length of stay Laine C, JAMA,1993;Gottlieb DJ, Arch Intern Med. 1991
23 Discontinuity and Patient Harm Evaluate factors associated with hospital based medical preventable adverse events Most significant risk for an adverse event: crosscovering MD Petersen, Ann Intern Med 1994
24 Hospitalist Handoffs Hospitalists report various categories of missed information during service change Hospital course, future plans, and disagreements over management In those with incomplete handoff: 57% had adverse or near miss Hinami, 2009 JHM
25 What is the right information? U of Chicago: Study of handoffs Asked senders to guess what receivers would say was the most important information for each patient Most important information was NOT successfully communicated 60% of the time Did not agree on the rationales provided for 60% of items At times contradictory Chang V, et al. Pediatrics 2010
26 Why does this happen? Speakers systematically overestimate how well their messages are understood by listeners People in general believe that their thoughts are transparent to others The more knowledge that people share, the worse they communicate new material because they overestimate the knowledge of the receiver
27
28 Retention Hierarchy of Information Contingency planning (69%) To-Do items (65%) Knowledge Items (35%) Chang V, et al. Pediatrics 2010
29 Read Back: Reduces Errors in Communication Lab Reporting 29 errors detected during requested read-back of 822 lab results All errors detected and corrected. Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004.
30 Strategies for Effective Handoffs Direct observations of handoffs 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, Int J Qual Health Care. 2004
31 Creating the Proper Environment Quiet location and protected time Notify nurses and others in advance Minimize unnecessary interruptions Face-to-face is the gold standard Not always possible or practical If face-to-face is not possible, create a mechanism for a check-back I-PASS Study Group, Children s Hospital Boston
32 Global Elements of Handoffs Importance of leadership Assign roles, ensure quality Unambiguous transfer of responsibility Protected time and space Standardized format Include verbal and written components I-PASS Study Group, Children s Hospital Boston
33 Global Elements of Handoffs Agreed-upon specific order Up-to-date, accurate, relevant information Contingency plans included Aware of learning styles of giver and receiver I-PASS Study Group, Children s Hospital Boston
34 Effective Verbal Handoffs Face-to-face Structured format, beginning with high-level overview Appropriate pace Closed-loop communication shared mental model I-PASS Study Group, Children s Hospital Boston
35 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 I-PASS Study Group, Children s Hospital Boston
36 Printed handoff documents Not immune from error Fatigue also affects written handoffs Due to carelessness in updates, proof-reading Often not actually reflective of current status Petersen 1998
37 Data should include: Patient summary (exam findings, laboratory data, any clinical changes); Assessment of illness severity; Active issues (including pending studies); Contingency plans ( If/then statements); Synthesis of information (e.g. read-back by receiver to verify); Family contacts; Any changes in responsible attending physician; and An opportunity to ask questions and review historical information. UCSF GME policy 2011
38 Outline General principles of good communication Communication in handoffs Gaps Strategies Research on a handoff bundle I-PASS handoff bundle Handoffs at UCSF
39 Pilot Study of a Handoff Bundle Communication and Handoff Skills Training + Standardization of Verbal Handoffs + = Computerized Handoff Tool Resident Handoff Bundle (RHB) 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
40 Pilot Study Aims Test the hypotheses that the following outcomes will improve with the implementation of a Resident Handoff Bundle: Rates of serious medical errors (primary outcome) Written and verbal communications Resident workflow (time-motion study) 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
41 Study Design Prospective pre-post intervention study Two general inpatient units at Boston Children s Primary analyses Compare pre- vs. post intervention Rates of medical errors Key data elements on written handoff document Resident workflow patterns Secondary analyses Compare changes between the two study units 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
42 Methods Determined medical error rates using a comprehensive active surveillance methodology Study nurse reviews Medication orders MAR Progress notes Nursing notes Discharge summary Hospital incident reports Solicitation of verbal reports from nurses Daily solicited error reports from physicians 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
43 Results: Medical Error Rates % of Admissions with Medical Error Total admissions reviewed: 1255 Pre-RHB Post-RHB p-value Unit 1 (Full RHB) 32% (n=117) 19% (n=68) <0.001 Unit 2 (No Computer Tool) 45% (n=128) 25% (n=62) < I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
44 Intern Time-Motion Activity Pre- vs. Post-intervention (average minutes per 24 hours in specified activity) Pre-RHB Post-RHB P-value Computer <0.001 Patient Contact <0.001 Communication I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
45 Outline General principles of good communication Communication in handoffs Gaps Strategies Research on a handoff bundle I-PASS handoff bundle Handoffs at UCSF
46 I P A S Illness Severity Patient Summary Action List Situation Awareness & Contingency Planning S Synthesis by Receiver 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
47 I Illness Severity 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
48 Illness Severity A Continuum Watcher : any clinician s gut feeling that a patient is at risk of deterioration or close to the edge 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
49 P Patient Summary 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
50 Sections of a Patient Summary Summary statement Events leading up to admission Hospital course Ongoing assessment Organized by problems/diagnoses Plan Organized by problems/diagnoses 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
51 High Quality Patient Summaries Create a shared mental model Facilitate the transfer of information and responsibility Transmit information concisely Describe unique features of the patient s presentation Use semantic qualifiers 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
52 A Action List 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu 53
53 Action List To Do: Check respiratory exam now Monitor respiratory exam Q2h overnight Check pain scores Q4h Check ins and outs at midnight Follow up 6PM electrolytes Follow up blood culture results 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
54 S Situation Awareness & Contingency Planning 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
55 Situation Awareness Team level Patient level Know what is going on around you Status of patients Team members Environment Progress toward team goals 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 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
56 Contingency Planning Problem solving before things go wrong If this happens, then 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
57 S Synthesis by Receiver 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu 58
58 Synthesis by Receiver Provides an opportunity for receiver to Clarify elements of handoff Ensure there is a clear understanding 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! 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
59 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu Synthesis by Receiver
60 Synthesis by Receiver Provides an opportunity for receiver to Clarify elements of handoff Ensure there is a clear understanding 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! 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
61 Better Handoffs. Safer Care I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
62 Outline General principles of good communication Communication in handoffs Gaps Strategies Research on a handoff bundle I-PASS handoff bundle Handoffs at UCSF
63 APeX
64
65 UCSF Handoff Policy Each training program must design clinical assignments to minimize the number of transitions in patient care Day/night teams Staggering of intern/resident/attending switch times and/or days to maintain continuity, Outpatient clinic pods or teams Schedule overlaps should include time to allow for face-to-face handoffs
66 The institution and each program must ensure and monitor effective, structured hand-over processes that facilitate both continuity of care and patient safety Faculty oversight of the handoff process may occur directly or indirectly Programs should use the applicable tools to assist them in this structured process Approved, GMEC: July 18, 2011 Editorial Revision Approved, GMEC: September 26, 2011
67 Programs at UCSF: 33 programs report face-to-face handoffs 15 programs using I-PASS 9 programs use -based handoffs 21 programs use electronic 9 are not APeX 4 programs report handoffs are not applicable
68 Handoffs should include at least: Patient summary (exam findings, labs, clinical changes) Assessment of illness severity Active issues (including pending studies) Contingency plans ( If/then statements) Synthesis of information (e.g. read-back by receiver to verify) Family contacts Any changes in responsible attending physician; An opportunity to ask questions and review historical information Approved, GMEC: July 18, 2011 Editorial Revision Approved, GMEC: September 26, 2011
69 Summary Duty hour standards More handoffs Training needed to Standardize approach to handoffs Pilot study using a Resident Handoff Bundle demonstrated Decreased medical errors Increased resident time with patients Handoff curricula and educational materials available online 2011 I-PASS Study Group/Children s Hospital Boston All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu
70 Resources I-PASS: A Handoff Bundle including educational resources, online module, videos, and simulations Handoffs and Signout Primer: Agency for Healthcare Research and Quality (AHRQ) Literature overview with links to case scenarios and expert discussion Specialty-Specific Tool-Kits One specific one focused on peri-operative handoffs can be found here: Teaching Video: Handoffs: A Typical day on the Wards Peer-reviewed video that can be used as a trigger for teaching handoffs
71 Acknowledgements I-PASS Study Group Amy Starmer Arpana Vidyarthi
72 Questions?
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