Learning Objectives. I have no disclosures.

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1 The Handoff Baton Teams, Communication and the plan-do-check-act (PDCA) Model Raquel Pasarón, DNP, ARNP, FNP-BC Department of Pediatric Surgery APSNA 24 th Annual Scientific Conference Ft. Lauderdale, FL April 27, 2015 Learning Objectives 1. Describe the PDCA cycle and its implication to patient safety and handoff communication. 2. Describe the relationship between teamwork and safety. 3. Describe the relationship between situation monitoring, shared mental models, and team effectiveness. I have no disclosures. 1

2 Hand-Off Communication 4 The Deming Cycle Quality Indicators in Nursing Systems 2

3 The Hand-Off: 8 Hand-Off Concepts High Reliability Organizations Nuclear Power NASA and Mission Control Aviation: Crew Resource Management Air traffic control Carrier flight deck Dispatch Services Formula One Pit Crews 9 3

4 Calls to Improve Handoff 1. The Joint Commission 2. World Health Organization 3. Institute of Medicine 4. Accreditation Council of Graduate Medical Education 10 Exchange vs. Hand-Off An exchange of information doesn't require that the other person understand what is being transmitted but simply conveys information. A hand-off implies transfer of information as well as professional responsibility. 11 Hand-Off Defined by The Joint Commission contemporaneous, interactive process of passing patient specific information from one caregiver to another for the purpose of ensuring the continuity and safety of patient care Recognized as a critical, clinical activity occurring at all levels of the hospital from individual to organizational level 12 4

5 13 Sentinel Events Unanticipated event that results in death or serious physical or psychological injury to a patient and is not related to the natural course of the patient s illness. 14 Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type ( Third Quarter 2011) World Health Organization, 2006 prevention of hand-off errors part of "high fives" patient solutions Institute of Medicine, 2008 re: Residency duty hours Teaching programs "should train residents in how to hand over their patients using effective communication" 15 5

6 New ACGME Regulations: Duty Hours Effective as of July 2011 Informed by a landmark Institute of Medicine report released in 2008 Limits shifts for first-year residents to 16 hours or less Further increases the frequency of Hand-Offs Also creates a patchwork of coverage systems, including day and night float services when residents care for patients for whom they lack primary knowledge 16 New ACGME Regulations: Hand-Offs Programs and sponsoring institutions must: Design clinical assignments to minimize the number of transitions in patient care Ensure and monitor effective, structured Hand-Off processes that facilitate both continuity of care and patient safety Ensure that residents are competent in communicating with team members in the Hand-Off process Ensure availability of schedules that inform all health care team members of attending physicians and residents currently responsible for each patient s care 17 How Handoffs Relate to ACGME Core Competencies 18 6

7 Hand-Off Challenges Human Factor Issues Stress, fatigue, interruptions, memory load, multitasking Communication Issues Differences in training, relationships, professional hierarchies Workflow Issues Support, organizational culture 21 7

8 Let s take a test 22 Blurred boundaries of responsibility Decreased surgeon familiarity with patients Diversion of surgeon attention Distorted or inhibited communication 23 Hypothesis: Integration of a standardized resident handoff system into the surgical curriculum would minimize missed or misunderstood information, improving overall patient care. Purpose: Evaluate resident perceptions of handoffs, identify areas of communication deficiency, and evaluate early outcomes after informal implementation of a standardized communication model into the surgical curriculum. 24 8

9 25 Information sharing - a sequelae of educational, psychological and organizational factors

10 28 29 Shared Mental Model! 30 10

11 Shared Mental Model 31 Communication 32 Assertive Communication Organized Competent Disavow perfection while looking for clarification/common understanding Owned by the entire team It must be valued by the receiver to be successful 33 11

12 What do we know about communication? The Hand-Off Players Sender Receiver 36 12

13 Example Post-Call to On-Call Intern Post-Call Intern 1. Follow-up on surgery s recommendations. 2. Post-op, restart patient on feeds and if that improves, stop IV fluids. 3. Patient will stay on IV antibiotics today and will go by mouth tomorrow. On-Call Intern Understood: 1. Coming back from surgery, so restart feeds. 2. I might get a page from [affiliated hospital] and I ll just defer to primary physician. 37 Purpose: Describe critical incidents occurring as a result of resident uncertainty that plague resident decision making and strategies adopted by residents to deal with their own uncertainty. Using Beresford conceptual framework of clinical uncertainty

14 Differential Diagnosis of Uncertainty Domain Definition Example Strategy Technical uncertainty Conceptual uncertainty Personal uncertainty Absence of or inadequate scientific data; limitations of fund of knowledge; knowledge of indications Difficulty applying abstract criteria to concrete situations Lack of personal relationship with patient Performing of a lumbar puncture Transition of Care (PICU transfer); discharge Readiness 40 Goals of care Seek supervision Seek supervision Learn during Hand-Off Categories of Uncertainty 41 Clinical Decision Making 42 14

15 Team Communication Strategies 43 Closed-loop Hand-Off Communication Journal of Quality and Patient Safety, 32(11), Post-Call Hand-Off Close Loop 45 15

16 A word on checklists Not a cure all Does not replace critical thinking Paradigmatic and narrative modes of thought 46 Hilligos, B., & Moffatt-Bruce, S. (2014). The limits of checklists: Handoff and narrative thinking. BMJ Quality & Safety, 23: How do we transfer care in our department? Do we take it seriously? Do we have formal training on how to perform hand-offs? Is verbal communication required for handoffs? Do we have written communication? Is it standardized and structured? Are long term plans/family questions discussed? Psychological concerns? Do we sign out patients with care? Do we role model? 47 Hand-Off A major point of vulnerability OR An opportunity for error detection and recovery 48 16

17 Take Home Points Transfer of content AND professional responsibility Standardized and structured format Communication strategies Face to face communication with opportunity to ask questions (Check for understanding) Use precise language & explain rationale Use of read-back to increase memory Critical Verbal content Anticipatory guidance (IF/then) What may happen and what to do about it Tasks that need to be done ( To-do ) - with specific rationale/instruction A comprehensive updated written sign-out 49 Let's try again

18 References Abraham, J., Kannampallil, T., Patel, B., Almoosa, K., & Patel, V. (2012). Ensuring patient safety in care transitions: An empirical evaluation of a handoff intervention. AMIA Annual Symposium Proceedings, Arora, V.M., & Johnson, J. (2006). A model for building a standardized hand-off protocol. Journal of Quality and Patient Safety, 32(11), Bavare, A., Shah, P., Roy, K., Williams, E., Lloyd, L., & McPherson. (2013). Implementation of a standard verbal sign-out template improves sign-out process in a pediatric intensive care unit. Journal for Healthcare Quality, 0, 1-9. Bump, G., & Jovin, F. (2011). Resident sign-out and patient hand-offs: Opportunities for improvement. Teaching and Learning in Medicine, 23, Chang, V.Y., Arora, V.M., Lev-Air, S., D Arcy, M., & Keysar, B. (2010). Interns overestimate the effectiveness of their hand-off communication. Pediatrics, 125(3), Date, D., Sanfey, H., Mellinger, J., & Dunnington, G. (2013). Handoffs in general surgery residency, an observation of intern and senior residents. The American Journal of Surgery, 206, Farnan, J.E. (2010). Strategies for effective on-call supervision for internal medicine residents: The superb/safety model. JGME, 2(1), References Farnan, J.M., Johnson, J.K., Meltzer, D.O., Humphrey, H.J., & Arora, V.M. (2008). Resident uncertainty in clinical decision making and impact of patient care : A qualitative study, Quality & Safety in Patient Care, 17, Helmreich, R.L. (2000). On error management: Lessons from aviation. BMJ, 320, Hilligoss, B., & Moffatt-Bruce, S. (2014). The limits of checklists: Handoff and narrative thinking. BMJ Quality and Safety, 23, Kitch, B.T., Cooper, J.B., Zapol, W.M., Marder, J.E., Karson, A., Campbell, E.G. (2008). Hand-Offs causing patient harm: A survey of medical and surgical house staff. Journal of Quality and Patient Safety, 34(10), Lane, M., Brooks, A., Wilkins, S., Davis, J., & Riesenberg, L. (2014). Addressing the mandate for hand-off education: A focused review and recommendations for anesthesia resident curriculum development and evaluation. Anesthesiology, 120, Mukherjee, S. (2004). A precarious exchange. New England Journal of Medicine, 351, Nakayama, D.K., Lester, S.S., Rich, D.R., Weidner, B.C., Glenn, J.B., & Shaker, I.J. (2012). Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. Journal of Pediatric Surgery, 47, References Nasca, T.J., Day, S.H., & Amis, E.S. (2010). ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME task force. New England Journal of Medicine, 363, e3. Nelson, E.C., Batalden, P.B., & Godfrey, M.M. (2007). Quality by design: A clinical microsystems approach. San Francisco, CA: John Wiley & Sons, Inc. Telem, D., Buch, K., Ellis, S., Coakley, B., & Divino, C. (2011). Integration of a formalized handoff system into the surgical curriculum. Archives in Surgery, 146, Ulmer, C., Wolman, D.M., Johns, M.M.E. (Eds.). (2008). Resident duty hours: Enhancing sleep, supervision, and safety. Committee on optimizing graduate medical trainee (resident) hours and work schedule to improve patient safety. Institute of Medicine. Washington, DC: The National Academies Press. Vidyarthi, A., Arora, V., Schnipper, J., Wall, S., & Wachter, R. (2006). Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. Journal of Hospital Medicine, 1, Wayne, J.D., Tyagi, R., Reinhardt, G., Rooney, D., Makoul, G., Darosa, D.A. (2008). Simple standardized patient Hand-Off system that increases accuracy and completeness. Journal of Surgical Education, 5(6), Weller, J., Boyd, M., & Cumin, D. (2014). Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medicine Journal, 90, Williams, R., Silverman, R., Schwind, C., Fortune, J., Sutyak, J., Dunnington, G. (2007). Surgeon information transfer and communication: Factors affecting quality and efficiency in patient care. Annals of Surgery, 252,

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