Designing Safe and Effective Patient Handovers

Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium at Harvard August 21, 2008 10:45 12:45 pm

Objectives Determine which methods are most appropriate for exploring hand-offs in clinical settings Develop a standard process to optimize hand- offs using a process mapping methodology Create a checklist of critical patient and process information Design a strategy for dissemination and training Identify and overcome barriers to implementation Develop a plan to evaluate and monitor hand- off protocols

Agenda 10:45 10:50 Introduction and Overview of the Agenda 10:50 11:00 Participant Introductions and Expectations 11:00 11:10 Hand-off Theater 11:10 11:15 Audience Poll 11:15 11:30 What is known about Hand-offs in Medicine and other Industries 11:30 11:50 Small Group Exercise: Paper Tear 11:50 12:00 A Model for Developing a Standard Protocol 12:00 12:20 Small Group Exercise: Process Mapping 12:20 12:30 Completing the Hand-off Model 12:30 12:40 Research Presentation 12:40 12:45 Final Comments and Adjourn

Introductions Who are you? What do you do? What are your expectations for today s session?

What are the types of handoffs that come to mind when you think about handoffs?

Hand-off Theater

Role Play of a Intern Sign-out Use the checklist for observations: Please record cultural, communication, and environmental barriers that interfere with successful patient hand-off practices in patient care

What Do You Look For? Barriers Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Other Observations/Thoughts Facilitators What went well?

Debriefing from the Role Play What types of barriers to an effective hand-off did you observe? Environment Cultural Communication Any others?

Audience Poll: Current Practices in Transfer of Care in Your Institution When there is a transfer of care, who is primarily responsible for the transfer?

Audience Poll: Current Practices in Transfer of Care in Your Institution How many senders and receivers of information are present at the time of the hand-off?

Audience Poll: Current Practices in Transfer of Care in Your Institution Is a verbal communication required at the time of a hand-off in your institution/program?

Audience Poll: Current Practices in Transfer of Care in Your Institution If conducted, where does verbal communication take place? Face to face in a dedicated room On the phone On the fly (wherever/whenever the two parties can meet) At the patient s s bedside

Audience Poll: Current Practices in Transfer of Care in Your Institution Does your program/institution use a standard template for written information conveyed at the hand-off ( sign( sign-out )?

Audience Poll: Current Practices in Transfer of Care in Your Institution Do you have formal training on how to perform hand-offs and transition patients for new personnel at your institution?

Background and Definitions

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 t test for comprehension put teams at risk

Lessons from Other Industries and Applications to Healthcare

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

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

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

A Word of Caution on Computerized sign-out Technology Brigham and Women s s Hospital (Petersen, et al. Jt Comm J Qual Improv,, 1998) U Washington (Van Eaton, et al. J Am Coll Surg,, 2005) IT solutions alone cannot substitute for a successful communication act Human vigilance still required In an emergency room, replacing a phone call for critical lab values with electronic reporting with no verbal communication resulted in 45% (1443/3228) of urgent labs to go unchecked. Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, 2001.

In both aviation and medicine, people depend on technology as the solution

Newer technology doesn t eliminate error

Nor does even newer technology

Continued Focus on Hand-offs July 2003 ACGME set limits for resident duty hours Reduce sleep deprivation and improve patient safety Unintended consequence is increase in number of hand-offs (discontinuity) Safety of hand-off? Error-prone and variable A vulnerable gap in patient care

ACGME Core Competencies Patient Care Medical Knowledge Professionalism Communication Systems Based Practice Practice Based Learning and Improvement

The Role of the Hand-off: Communication and Patient Safety Transfer of information (content) Different modalities (process) Written Verbal Variable, error-prone Few trainees receive formal education The Joint Commission National Patient Safety Goal (effective Jan 1, 2006) Requires hospitals to implement a standardized approach to hand-off communications and provide an opportunity for staff to ask and respond to questions about a patient's care

How Do We Do At Sharing Verbal handoffs Information? Interruptions lead to diversion of attention, forgetfulness, and error (Coiera, BMJ 1998) Written handoffs Inconsistent Missing code status, allergies, age, sex (Lee, JGIM 1996)

A Brief Example of the Difficulties in Communicating The Purpose of This Exercise To make the distinction between hearing (the biological process of assimilating sound waves) and listening (adding our interpretations of what is being said) To demonstrate the importance of effective communication skills and listening skills to thinking and acting systematically adapted from the Systems Thinking Playbook, Meadows and Sweeney, 1995

Instructions for Part 1 of the exercise Everyone take 1 sheet of colored paper There is no talking Close your eyes and do exactly what I tell you to do Our goal is to produce identical patterns with the pieces of paper

Instructions for Part 2 of the exercise Form groups of 3 or 4 at your table Pick 1 person to be the communicator and the rest will be the listeners Listeners close their eyes Communicators go through at least 3 steps, each step involving a fold and a tear Switch roles and repeat the exercise with your same group but with someone else as the communicator. This time the listeners are allowed to talk, but still have their eyes closed

What happened? How would you describe your listening skills? For those who were communicators, how effective were your skills? Were there any differences in the 3 attempts?

How Can We Improve Hand-offs? Developing a Standard Hand-off Protocol

A Model For Developing a Standard Protocol Principles underlying the model The hand-off protocol will need to be discipline specific Standardization is key for both process and content PROCESS Create a process map CONTENT Create a standard check-list IMPLEMENTATION Leadership and resident buy-in MONITORING Ensure the protocol is in place and identify and resolve barriers

Understanding Hand-offs as a Process The first step is to draw a flow diagram. Then everyone understands what his job is. If people do not see the process, they cannot improve it. W.E. Deming, 1993

Overview of Process Mapping A process map or flowchart is a picture of the sequence of steps in a process Useful for Planning a project Describing a process Documenting a standard way for doing a job Building consensus about the process (correct misunderstandings about the process) Detailed process maps are especially helpful to standardize and improve processes For use as an improvement tool, it is important to map the current process, not the desired process

Process Mapping Ovals are beginnings and endings Boxes are steps or activities Diamonds are questions Arrows show sequence and chronology

Process Mapping Can be high-level to get an overview of the process Patient arrives in ER Assessed in ER Admitted? No Discharged Yes Sent to floor Diagnosed And Treated

Process Mapping Can also be very detailed and drilled down to show the details and roles Detailed process maps are especially helpful to standardize and improve processes For use as an improvement tool, it is important to map the current process, not the desired process

A Sample Hand-off Process (Internal Medicine)

Analyzing Process Maps What is the goal of the process? Does the process work as it should? Are there obvious redundancies or complexities? How different is the current process from the ideal process?

Advanced Process Mapping: Identifying Barriers Primary MD creates written signout Primary MD contacts on call MD On-call MD Meets with Primary MD Primary MD reviews patients with on call MD POTENTIAL FAILURES ENVIRONMENT computer/printer malfunction interruptions/ ongoing workload of on call MD no designated meeting place; interruptions; workload COMMUNICATION interruptions; workload; omission of information text page "signout is on the wall" omissions; failure to verbally communicate/ emphasize important issues CULTURE updating signout not a top priority Signout not a priority "I've gotta go" text page to on call MD "my signout is on the walll" "Nothing to do"

Small Group Exercise Working in small groups, create a process map of an ideal hand-off process Identify the type of hand-off Set clear boundaries (where does the process begin and end) Identify key steps and decision points

Process Mapping Demonstration

Debriefing

Completing the Hand-Off Protocol PROCESS Create a process map CONTENT Create a standard check-list IMPLEMENTATION Leadership and resident buy-in MONITORING Ensure the protocol is in place and identify and resolve barriers

Determine the Standard Content: ANTICipate Develop a checklist Have disciplines customize to their needs Can be used to evaluate the quality of hand-offs Administrative Data Patient name, age, gender Medical record number Room number Admission date Primary inpatient medical team, primary care physician Family contact information New Information (Clinical Update) Chief complaint, brief HPI, and diagnosis (or differential diagnosis) Updated list of medications with doses, updated allergies Updated, brief assessment by system/problem, with dates Current baseline status (e.g., mental status, cardiopulmonary, vital signs, especially if abnormal but stable) Recent procedures and significant events Tasks (What needs to be done) Specific, using if-then statements Prepare cross-coverage (e.g., patient consent for blood transfusion) Warn of incoming information (e.g., study results, consultant recommendations), and what action, if any, needs to be taken that night Illness Is the patient sick? Contingency Planning / Code Status What may go wrong and what to do about it What has or hasn t worked before (e.g., responds to 40mg IV furosemide) Difficult family or psychosocial situations Code status, especially recent changes or family discussions

Beware technical, cultural, and environmental differences A one-size fits all approach does not allow for customization. Environment Although 4 programs had a designated hand-off location, 3 conducted hand-offs wherever convenient Culture One resident describes being a slave to The List [sign-out sheet] and information overload In a different program, only acutely ill patients are on the sign-out Technical While all disciplines hand-off administrative data (i.e. name, MRN, room number, etc.), major differences in specific categories Surgical fields: Pre-op consent, post-op op checks, etc. Pediatrics: Custodial issues (DCFS, parents, etc.) Common use of some language: If/Then for contingency planning

Psychiatric history One liner with hospital presentation 21 yo AAF with hx depression and previous SA presented now with SI and the plan of cutting wrists. Hospital course including what was tried (i..e trial of Seroquel, etc.) and worked (i.e. Geodon 20mg IM worked) and progress to date (i.e. no restraints since 3/6 ) Systems-based list of current problems (psychiatric and medical) Special instructions Precautions: Seizure, Fall Suicide, etc. Roomate ( Can have roommate or needs private room ) Restraint use Please do NOT allow restraints unless pt is violent & undirectable Primary team rationale (i.e. Avoiding high-eps neuroleptics ) Patient nuance (i.e. Never tell her she s doing better. This is not therapeutic for her. ) For You, For me To do list for cross-cover (i.e. check x level and adjust x or NTD ) Continuing reminder for hospital stay in the For me Court/Legal Issues Decision-making capacity ( Voluntary or Involuntary ) Status of certificate (i.e. Awaiting judge s decision at trial for involuntary ) Name and contact of decision maker if patient is not able to make decisions When to notify decision maker (i.e. NOTIFY OF ALL MED CHANGES ) Housing and Social Issues Nursing home placement or other dispo (i..e home ) Needs to get check If/Then Frequent issues to be expected with a plan to resolve using IF/then format (i.e. if insomnia, try Prosom or if agitated, try Haldol etc.) especially for sleeping problems ALSO What does NOT WORK (i.e. Avoid BNZ, restraints, etc) Administrative data/allergies Patient name, Medical record number Room number Admission date Outpatient psychiatrist Family contact information Allergies (medication, latex, contrast, food, etc.) Therapeutics Medications (updated list with doses, start date, any recent adjustments) Include PRN s and what works ECT Orders Results of Pertinent Labs & Radiology Labs (i.e. Drug levels, CK levels) Radiology findings and test date Psychiatry check-list Routine fields Admin data Therapeutics To-do If/then Discipline- specific fields Housing Court/legal issues Special instructions etc.

Research on Transitions of Care Resident to resident transitions Inpatient to outpatient transitions

University of Chicago Experience with Resident Hand-offs Internal Medicine Department Study Development and Implementation of Standard Protocols

Critical Incident Study of IM Hand-offs To characterize communication failures during hand-offs and solicit suggestions for improvement Question designed to elicit information about adverse events and near misses Was there anything bad that happened or almost happened last night because the (VERBAL/WRITTEN) sign-out wasn't as good as it could have been? Question designed to elicit information about ideas for improvement Regardless of whether anything went wrong or almost went wrong, and thinking about what should be included in a sign-out, is there anything about the (VERBAL/WRITTEN) sign-out that you received that you think should have been better? Arora, Johnson, et al. Quality and Safety in Healthcare, 2005.

Taxonomy of Sign-out Quality POOR SIGN-OUT Omissions in Content Medications or Therapies Tests or Consults Medical Problems Active Anticipated Baseline status Code status Rationale of primary team Failure-Prone Processes Lack of Face-to to-face Communication Double Sign-out ( Night( Float ) Illegible or Unclear Handwriting EFFECTIVE SIGN-OUT Written Sign-out Patient Content Code status Anticipated problems Active Problems Baseline Exam Pending Test or Consults Overall Features Legible Relevant Accurate Up-to to-date Verbal Sign-out Face to Face Anticipate Pertinent Thorough

Development and Implementation of a Standard Protocol To date, 8 residency programs have participated. Analysis of these protocols demonstrates that the hand-off process is highly variable and discipline-specific. specific. Process and content analysis of protocols yields several themes.

1. Understand and attempt to reduce the variation in the process All disciplines required a verbal hand-off BUT due to competing demands (OR, clinic, etc.), this verbal communication sometimes did not occur Educate residents on this important priority Individual-level level variation also present Some residents are better at making themselves available and touching base with you [during the hand-off] than others...

2. Hand-off = Transfer of information + professional responsibility Transfers were at times separated in time and space In one program, departing residents forward their pager to the on-call resident after they provide a verbal hand-off. In another program, the on-call resident transfers a virtual pager to their own pager at a designated time which often occurs well before they receive a verbal hand-off.

Neurology Hand-Off Transfer of professional responsibility Verbal hand-off

3. Need to ensure closed-loop hand-off communication In two cases, patient tasks were divided and assigned to other team members To facilitate early departure of a post-call resident (to meet resident duty hour restrictions) BUT results of these tasks were not formally communicated to anyone Residents ensured closed-loop communication by building required follow-up on these tasks into the process

Pediatric Resident Post-Call Hand-Off The post call intern updates sign-out on the computer (noon 1p.m.) Post call intern brings copy of signout for on call intern Team meets to review list after noon conference (team includes other interns, senior residents) Post call intern reports on each patient Are there tasks to be completed? (e.g., f/u labs, imaging, discharge) No Sign-out given to on-call intern Post-call intern forwards pager to on-call intern On-call intern continues care and follow-up on any tasks Yes Sr resident assigns tasks to other interns Are the tasks completed? No Yes Intern reports status of task to senior resident and on-call intern closed-loop communication Sr Resident offers input on completing task Unfinished tasks go to on call intern

4. Keep the focus on patient care: Clear roles and back-up behavior Anesthesia resident to PACU RN Interdisciplinary hand-off with challenging complex fast-paced environment Clear delineation of responsibility to ensure patient care Anesthesia resident to call out for a bed Unit clerk to respond with bed # PACU RN to hook up monitors Equally important back-up behaviors Can empower participants to focus on the patient care If nursing delay >30 sec, then resident to hook up monitors and call for RN

Patient in OR Anesthesia Resident to PACU Nurse Is patient ok to go to PACU? yes Resident tells circulating nurse about special needs (venilator, a-line, invasive monitors, etc.) Hand-Off Resident mentally summarizes case to prepare for documentation Resident moves patient to PACU Resident arrives in PACU and shouts out to unit clerk Where am I going/what number bed? Sec y or someone else answers with bed or slot number Resident takes patient to designated slot no Patient goes to ICU Clear delineation of roles/responsibility Are nurses waiting at slot? no yes Nursing hooks up monitors with priority on oxygen and pulse ox, then EKG and blood pressure, etc. Is there a greater than 30 second delay in hook up? no Resident completes documentation of case (fills out PACU vitals, writes note, documents handoff given) Is patient high risk? (difficult airway, labile vitals, anes problem) no yes PACU resident called and given special report Resident puts monitor on patient and hooks up oxygen, questions why no nurses Resident mobilizes nursing Back-up Behavior yes Resident mobilizes nursing team to put on monitors Resident identifies nurses that are taking care of patient Resident gives report (content checklist) Nurses accept patient Nurses arrive Resident completes and signs PACU orders

Future work We are still in the early stages of our work Continue our research Mechanisms of human failures during sign-outs, Human factors and ergonomic issues that impede the sign-out process Perceived risks associated with shift changes by different classes of providers and administrators Understanding shared work better Ultimately, the goal is to identify and implement interventions that can reduce the risks associated with transitions in care

Inpatient to Outpatient Transitions of Care at University of Chicago Our aim was to improve the quality, safety, and continuity of patient care during the transition from inpatient to ambulatory care by developing a model of effective communication between inpatient and ambulatory physicians. Specifically, we: Assessed current methods of communication Developed a model for effective inpatient physician primary care physician communication. Designed an intervention to evaluate the model for effective inpatient physician primary care physician communication

Methods Focus Groups were conducted with Hospitalists Primary Care Physicians Internal Medicine residents Patients The focus groups were used to generate the process maps

Methods Observations were used to verify and enhance the process

Interviews Interviews were conducted with key stakeholders to determine barriers and facilitators to an effective handover process

Barrier Unable to correctly identify the PCP Finding PCP contact info Unaware or variable preference of PCP s Contacting PCP not a priority Fear of losing control Forgetting or too busy to contact PCP Representative quote(s) ) (Hospitalists) Representative quote(s) ) (PCPs) But also some notes, we don t t recognize their The other issue is do they really know who the names so its difficult to know if that s s really a PCP is? They may see [in the electronic primary care doctor and not some sort of ancillary system] like a note from X, but then one from Y, person [Resident] one from Z, and how do they know who s s really the PCP? It s s a little harder to get a hold of the [community- Sometimes we get a text page, voicemail, from based] physicians so I end up resorting to the [General Medicine] team or they call the Googling [Resident] nurse sometimes sometimes smoke signals- - You know, this [PCP] wants you to get a hold of I think there s s a culture of negative feedback him.but maybe some of them [other PCPs] if the team contacts the PCP. PCP says oh would say, oh, but the [patient] is in the hospital fine, but never shows up, that s s a learned and you know there s s ten people taking care of behavior, they re going to be less likely to them, maybe I don t t need to be called until the contact. next morning - - [Resident] I m m usually busy with multiple admissions so I With 13 admissions or however many --the don t t spend too much time contacting the [primary priority is taking care of the acute illness and care] providers right away - - [Resident] continuity of care falls to number 37 on the list of priorities I mean there are certain attendings,, like some I get the sense that people don t t call because sub-specialists, specialists, I mean they want you to call them they re worried that you re going to intrude or right away if its like, they have a cough - - do something that prolongs the hospitalization [Resident] I know in the hospital I ve I just gotten better about I wonder how big of a component that being [contacting PCP s] from the beginning of my super-busy especially when they are under the second year as a resident. Like I didn t t always do pressure to leave the hospital by noon, the day it right off the bat so I think that there is a learning that it would make the most sense to contact curve - -

Putting it All Together The research informs the improvement work

Artifact Analysis The study of any notes or materials used in the daily workflow of patient care may serve as a powerful supplement to the self-report data Provides further evidence of the effectiveness of the handover

Concluding Comments