at OU Medicine Leadership Development Institute August 6, 2010

Transcription

1 Effective Patient Handovers at OU Medicine Leadership Development Institute August 6, 2010

2 Quality and Patient Safety Realize OU Medicine s position with respect to a culture of safety and quality. Improve quality and patient safety outcomes by optimizing handover communication processes across the care continuum. Standardize methods of communication about patient safety concerns and/or risks. Enhance multidisciplinary teamwork to improve quality and ensure patient safety. Implement system and behavioral changes that improve work flow processes, enhance critical thinking in at various points in the clinical decision-making process and promote best practices and accountability for patient safety. 2

3 Quality and Patient Safety Framework Create a structure that positively affects quality and patient safety e.g. culture of quality e.g. culture of safety Develop processes of care that positively impact quality and patient safety e.g. standardized/streamlined handover communications Produce outcomes exhibiting provision of high quality and safe care e.g. zero defects, decreased medical errors, etc. These are the things that we want to and need to improve 3

4 Why the Push Towards Standardized Why the Push Towards Standardized Handover Communication?

5 Medical Errors in the U.S. According to the IOM report To Err is Human, between 44,000 and 98,000 deaths are recorded each year as a result of preventable medical errors 1. According to HealthGrades' fifth annual Patient Safety in American Hospitals Study, patient safety incidents cost the federal Medicare program $8.8 billion and resulted in 238,337 potentially preventable deaths during 2004 through IOM Report, To Err is Human;

6 Communication Breakdowns Complaints and Legal Issues Each one point decrement in patient satisfaction scores is associated with a: 6% increase in complaints (RR 1.06, 95% CI ;p<.0001). 5% increase in risk management episodes (RR 1.05, 95% CI ;p<.008) 1. Communication breakdowns have been documented to occur in nearly 80% of medicolegal cases 2. Faulty handoffs are specifically implicated in up to 24% of malpractice claims in the ED Stelfox HT, et al, The American Journal of Medicine 2005; 118: Levinson W. Physician-patient communication: a key to malpractice prevention. JAMA. 1994;272: Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:

7 Communication Issues Leading Factor in Root Causes Source: Joint Commission Sentinel Event Database,

8 Communication Breakdowns According to The Joint Commission s Sentinel Event Database, communication breakdowns were the root cause of more than 65% of 3,811 sentinel events. Of those communications breakdowns, approximately 75% result in the patient s t death. More than half of these communication breakdowns were associated with patient handoffs 1. Source: Joint Commission Sentinel Event Database,

9 Joint Commission National Patient Safety Goal-2E Implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions. Source: Joint Commission 2008 National Patient Safety Goals Requirement 2E. 9

10 JC Implementation Expectations Systems and processes in place for effective handover communication include the following: Allowance for questioning between the giver and receiver of patient information. Up-to-date information regarding the patient s care, treatment and services, condition and any recent or anticipated changes. A process for verification of the received information, including repeat- back or read-back, as appropriate. An opportunity for the receiver of the hand off information to review relevant patient historical data, which may include previous care, treatment, and services Source: Joint Commission 2008 National Patient Safety Goals Requirement 2E. 10

11 Education Issues In a survey of 125 U.S. medical schools, only 8% teach how to hand over patients in a formal didactic session 1. Due to the reduction of residency duty hours to 80 hours per week, increased handovers and reduced continuity of patient care are a considerable concern Solet etal. Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs. Academic Medicine: 80 (12); December Riesenberg etal. Residents and Attending Physicians Handoffs: A Systematic Review of the Literature. Academic Medicine: 84 (12); December

12 Communication Breakdowns Inpatient-Outpatient Physician Discontinuity About 75% of the time, discharge summaries have not yet arrived to the PCP at the time of the patient s first follow up. In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable. Source: Kripalani et al. Transitions of Care at Hospital Discharge. Journal of Hospital Medicine 2007; 2:

13 Handover Communications Benefits of Standardizing/Streamlining Handover Communications: Improve quality, safety and continuity of care during care transitions Improve handover communication and transfer of information Decrease medical errors Reduce the number of duplicated tests Decrease readmissions Increase patient satisfaction Reduce patient complaints and litigation Save staff time and reduce provider frustration 13

14 Where Must We Start?

15 Create a Culture of Safety Create an organizational culture of safety that: Focuses on patient safety and the prevention of errors Is aware and knowledgeable about patient safety and error prevention Focuses on improvement and prevention rather than blame Fosters collaboration and communication between departments, teams and individuals Provides organization-wide patient safety education and policy development that includes practitioners, staff, patients and families Recognizes unexpected outcomes and medical errors through data collection and analysis with appropriate reporting, follow-up and action 15

16 AHRQ Survey Measures The Hospital Survey on Patient Safety Culture is designed to measure: Four overall patient safety outcomes: 1. Overall perceptions of safety 2. Frequency of events reported 3. Number of events reported 4. Overall patient safety grade 16

17 Survey Methodology On July 13, 2010, the Hospital Survey on Patient Safety Culture was distributed to LDI invitees via and Survey Monkey link. 434 total individuals surveyed 209 respondents (48.2%) 184 completed surveys (42.4%) 4%) Note: Since not all questions were responded to, the totals for each survey question will not equal 209. The percentages are based on the number of respondents to each specific question. 17

18 Demographic Data about Respondents 1. Primary work area, department or clinical area where respondents spend most of their work time (209 respondents): 7.7% Many different units/no specific unit 6.8% Medicine (non-surgical) 9.2% Surgery 2.9% Obstetrics 10.6% Pediatrics 1.4% Emergency Department 3.4% ICU (any type) 1.9% Psychiatry/mental health 1.0% Rehabilitation 1.4% Pharmacy 3.4% Laboratory 3.4% Radiology 3.4% Anesthesiology 45.9% Other (primarily administration) 2. Staff position at OU Medicine (185 respondents): 11.9% Registered Nurse 1.6% Physician Assistant/Nurse Practitioner 0.5% LVN/LPN 0.5% Patient Care Asst/Hospital Aide/Care Partner 21.6% Attending/Staff Physician 0.0% Resident physician/physician in Training 0.0% Pharmacist 0.5% Dietician 0.0% Unit Assistant/Clerk/Secretary 1.1% 1% Respiratory Therapist 1.1% Physical, occupational, or speech therapist 0.5% Technician (EKG, Lab, Radiology) 53.0% Administration/Management 12.4% Other 13.0% Skipped 18

19 Demographic Data (continued) 3. Time worked (184 respondents) --at OU Medicine 05%L 0.5% Less than 20h hours 38%20t 3.8% to 39h hours 95.7% 40 hours (hours/week) --at OU Medicine (years) --in their current work area (years) --in their current specialty (years) 3.3% Less than 1 year 27.3% 1 to 5 years 21.3% 6 to 10 years 16.4% 11 to 15 years 10.9% 16 to 20 years 21.3% 21 years 7.6% Less than 1 year 34.1% 1 to 5 years 23.2% 6 to 10 years 14.6% 11 to 15 years 9.2% 16 to 20 years 11.4% 21 years 1.1% Less than 1 year 10.9% 1 to 5 years 19.0% 6 to 10 years 14.7% 11 to 15 years 19..6% 16 to 20 years 35.3% 21 years 4. Percentage of respondents with direct interaction or contact with patients (184 respondents): 58.2% 19

20 Main Findings: Strengths We identify as strengths, those positively worded items which about 75% of respondents endorse by answering Agree/Strongly agree, or Most of the time/always (or when about 75% of respondents disagreed with negatively worded items). Areas in which we are strong are: Teamwork within units Supervisor/Manager expectations & actions promoting patient safety Organizational learning continuous improvement 20

21 Main Findings: Areas for Improvement Areas with the potential for improvement were identified as items which 50% or less of respondents answered positively using Agree/Strongly agree or Most of time/always (or when 50% or less of respondents disagreed with negatively worded items). Areas in which there is a need for improvement are: Handoffs & transitions Teamwork across units 21

22 OU Medicine / Region Comparison Region = Arkansas, Louisiana, Oklahoma, and Texas 22

23 OU Medicine Percentile Ranking Composite Level Comparative Results for the 2010 Database Safety Culture Dimension OU Medicine Percentile Rank OU Medicine Average % Positive Response 2010 Database Median / 50th Percentile Overall Perceptions of Safety 50th 69% 65% Frequency of Events Reported 50th 63% 62% Supervisor/Manager Expectations & Actions 75th 80% 75% Promoting Patient Safety Organizational Learning Continuous Improvement 50th 76% 72% Teamwork Within Units 75th 85% 80% Communication Openness 90th 71% 62% Feedback & Communication About Error 75th 70% 63% Nonpunitive Response to Error 90th 57% 43% Staffing 25th 52% 55% Hospital Management Support for Patient Safety 25th 66% 72% Teamwork Across Hospital Units 25th 50% 57% Hospital Handoffs & Transitions < 10th 27% 43% 23

24 OU Medicine Overall Grade on Patient Safety Please give your work area/unit at OU Medicine an overall grade on patient safety. Region = Arkansas, Louisiana, Oklahoma, and Texas 24

25 Blinded Case Scenario

26 Handover Communication Concerns Patient Disposition Referring physician documents the patient had been dispositioned to the consulting service. Critical Lab Value Communicated to the referring physician after the consulting service had written orders (to include admission orders). What s missing? What s missing? 33

27 Handover Communication Concerns Shift to Shift Handover Not all of the critical elements of the patients clinical picture reported to oncoming shift. Bed Assignment Patient t with deteriorating ti clinical picture assigned to a general floor bed. What s missing? What s missing? 34

28 Handover Communication Concerns Faxed Report Transmission verified by fax receipt stating successful. No direct communication RN to RN prior to transport. Incomplete transfer form. Inconsistent clinical information on the transfer form. Patient Status Changes in patient condition not reported to physicians in a timely manner. What s missing? What s missing? 35

29 Handover Communication Improvement Patient Disposition Referring physician documents the patient had been dispositioned to the consulting service. No evidence of consulting service admission note. Critical Lab Value Communicated to the referring physician i after the consulting service had written orders (to include admission orders). Patient Disposition Physician to Physician handover of care clearly documented and communicated to the team. Critical Lab Value Clear communication of what service has primary responsibility for patients holding, awaiting a bed. 36

30 Handover Communication Improvement Shift to Shift Handover Shift to Shift Handover Not all of the critical Bedside Report elements of the patients Chart/documentation readily clinical picture reported to available during report. oncoming shift. Bed Assignment Patient t with deteriorating ti clinical picture assigned to a general floor bed. Bed Assignment All involved in the clinical decision making process have all current data when requesting/assigning a bed. 37

31 Handover Communication Improvement Faxed Report Transmission verified by fax receipt stating successful. No direct communication RN to RN prior to transport. Incomplete transfer form. Inconsistent clinical information on the transfer form. Patient t Status t Changes in patient condition not reported to physicians in a timely manner. Faxed Report Assure successful transmission of information prior to transport. Transfer form should be completed with most current clinical information; should also contain contact information allowing the accepting team easy access to referring staff should they have questions. Patient Status Report changes and document interventions. 38

32 Communication Tools: Communication Tools: A Refresher

33 Handover Communication Tools AIDET (Communication for Safety) SBAR Crew Resource Management (CRM) Checklists Rounding 40

34 AIDET Used with SBAR AIDET (Communication for Safety) Acknowledge Introduce Duration Explain utilizing SBAR (Situation, Background, Assessment, Recommendation) Format Thank you SBAR Situation: Briefly describe the current situation. Give a clear, succinct overview of pertinent issues. Background: Briefly state the pertinent history. What got us to this point? Assessment: Summarize the facts and give your best assessment. What is going on? Use your best judgment. Recommendation: R d What actions are you asking for? What do you want to happen next? 41

35 SBAR Example SBAR Communication Use the following SBAR steps to communicate issues, problems or opportunities for improvement to coworkers or supervisors. SBAR can be applies to both written and verbal communications. Situation State what is happening at the present time that has warranted the SBAR communication. Example: A Primary Care Physician makes an after hours phone call to the hospital ER physician on duty to let him know that she has advised one of her patients to go to the ER urgently for evaluation. Background Explain the circumstances leading up to this situation. Put the situation into context for the reader/listener. Example: The patient is a 65 year old man who is three years post coronary artery bypass surgery. He has had no chest pain since surgery and has been working full time. He has type II diabetes and hypertension, both of which have been well controlled. Over the past two days he has experienced pressure across the front of his chest and aching in the left arm with exertion. Symptoms seem to be progressively noticeable. Assessment What do you think the problem is? Example: Symptoms are compatible with crescendo angina. Recommendation d What would you do to correct the problem? Example: Please take a good look at him and give me a call. 42

36 43

37 SBAR Handover Form Example 44

38 Crew Resource Management Crew (or Team) Your team: PAT, Transport, Surgical, PACU, SICU, Floor, Admitting, IT, Billing, Lab, Pharmacy, Housekeeping, etc. Resource Other team members, equipment, protocols, EMR, family, chaplain, patient, etc. Management Specific behavioral skills to lead, communicate, decide, and catch errors before they become serious / fatal. 45

39 Examples of Handover Tools Forms Check lists IT support Nursing Notes Nursing newsletter 3 x 5 laminated pocket cards Stickers on the phone Screen savers 46

40 Handover Target Areas Nursing shift changes Physicians transferring complete responsibility for a patient Physicians transferring on-call responsibility Temporary responsibility for staff leaving the unit for a short time Anesthesiologist s s report to the post-anesthesia recovery room nurse Nurse and physician handoffs from the emergency department to inpatient units Different hospitals, nursing homes, home health care, and other types of organizations Critical laboratory and radiology results sent to physician offices Source: Joint Commission 2008 National Patient Safety Goals Requirement 2E. 47

41 Table Exercises

42 We Want Your Help! Standardization of protocols of handover communication processes: ED to Unit Scenarios Pre-Admit Admit Process Discharge to Unit ED to Clinic Utilize AIDET, CRM, SBAR, Rounding, and Checklists to develop these handover protocols. 49

43 Table Exercise Instructions Each table choose the scenario that matches the table color regarding the handover process. Utilize the tools that you have been trained on and are aware of to develop recommended standardized approaches for the scenario corresponding to your table s color (i.e., AIDET, AIDET with SBAR, Checklists, Rounding, CRM, etc.). List your ideas on the worksheet that has been provided to you. The worksheets will be collected and the information will be compiled and taken to the Quality and Patient Safety Leadership Council for review. Dissemination of the agreed upon standardized handover protocol will take place at the November 12 th LDI. 50