Optimizing Handoff Communication for Improved Patient Safety

Optimizing Handoff Communication for Improved Patient Safety Christopher P. Landrigan, MD, MPH Professor of Pediatrics, Harvard Medical School Research Director, Inpatient Pediatrics Service, Boston Children s Hospital Director, Sleep and Patient Safety Program, Brigham and Women s Hospital

Disclosures Dr. Landrigan has consulted and owns equity in the I-PASS Institute, which seeks to help hospitals implement safer handoff systems Dr. Landrigan has served as an expert witness in cases regarding sleep deprivation and safety The presentation will not involve discussion of unapproved or off-label, experimental or investigational use The presentation will show copyrighted materials for which permission has been obtained from Boston Children s Hospital and the I-PASS Study Group

Miscommunications and Medical Errors I-PASS Study Group Research AGENDA Large Scale Implementation and the I-PASS Institute Discussion 3

Patient Safety in the U.S.: Ongoing Problems Institute of Medicine, 1999 44,000-98,000 deaths per year due to adverse events Office of the Inspector General, 2010 180,000 deaths per year due to adverse events Makary et al, BMJ, 2016 251,000 U.S. deaths per year due to medical error 3 rd leading cause of death North Carolina Pt Safety Study 2341 randomly selected admissions from ten randomly selected hospitals statewide Landrigan et al., NEJM 2010: 363:2124-34

Advances in Patient Safety Progress reducing specific types of adverse events Catheter related bloodstream infections Pronovost et al Surgical Safety Checklists Gawande et al

Errors per 1000 pt days Intern Sleep and Patient Safety Study Randomized Controlled Trial of extended shifts (24-30h) vs. 16h limit p<0.001 p=0.03 p<0.001 Landrigan. NEJM 2004; 351: 1838-1848

Consequences of Shorter Shifts Shorter shifts Increased frequency of handoffs

Medical Errors and Root Cause Communication Failure Most Common Root Cause of Sentinel Events Total Joint Commission. (2011). Sentinel Event Statistics Data Root Causes by Event Type (2004 Third Quarter 2011) 8

Transitions of Care: Handoffs Occur Frequently & are Vulnerable to Failure Transitions of care ( Handoffs ) are very common Change of shift; Change of locations; Admissions; Discharges 500 bed hospital; over 4,000 times/day Over 1.6 MILLION times/year! Handoff communication processes Are not formally taught or standardized Cover increasingly complex patients Involve many providers: MDs, NP/PA, Nurses, Pharmacists, Respiratory Therapists, etc.

Joint Commission Sentinel Event Alert A complimentary publication of The Joint Commission Issue 58, September 12, 2017 Sentinel Event Alert September 12, 2017 Published for Joint Commission-accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. Please route this issue to appropriate staff within your organization. Sentinel Event Alert may be reproduced if credited to The Joint Commission. To receive by email, or to view past issues, visit www.jointcommission.org. Inadequate hand-off communication Health care professionals typically take great pride and exert painstaking effort to meet patient needs and provide the best possible care. Unfortunately, too often, this diligence and attentiveness falters when the patient is handed off, or transitioned, to another health care provider for continuing care, treatment or services. A common problem regarding hand-offs, or hand-overs, centers on communication: expectations can be out of balance between the sender* of the information and the receiver. 1 This misalignment is where the problem often occurs in hand-off communication. Potential for patient harm from the minor to the severe is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed. When hand-off communication fails, many factors are involved, such as health care provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few. What is a hand-off? A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a realtime process of passing patientspecific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient s care. 1 This alert provides advice to senders and receivers of hand-off communication, including communication between caregivers within hospitals and other health care settings, as well as between hospital caregivers and those not located in a hospital. Senders are responsible for sending or transmitting patient data and releasing the care of the patient to receivers, who have been identified as those who will receive patient data and accept care of the patient. This alert makes the basic assumption that the hand-off already involves the correct receiver, sender and patient. Inadequate Hand-off Communication I-PASS, as referenced in SEA #58, is an evidenced based solution www.jointcommission.org While it sounds simple, a high-quality hand-off is complex. Failed hand-offs are a longstanding, common problem in health care. In 2006, The Joint Commission established a National Patient Safety Goal that addressed handoff communication. In 2010, the requirement became a standard. Provision of Care standard PC.02.02.01, element of performance (EP) 2, requires that: The organization's process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information. Note: Such information may include the patient's condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. * For the purposes of this alert, the sender is the individual who provides the clinical information to the receiving caregiver. The Joint Commission Published by the Department of Corporate Communications 10

Transitions of Care and Errors I-PASS Study Group Research AGENDA Large Scale Implementation and the I-PASS Institute Discussion 11

Handoff Video Clip

Handoff Bundle Intervention: Boston Children s Hospital Communication and handoff skills training + Mnemonic + = Redesigned Verbal Handoff Process Resident Handoff Bundle (RHB) + Computerized Handoff Tool (Unit 1 only) Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP. JAMA 2013; 310: 2262-2270

Results: Medical Error and Preventable Adverse Events Rates per 100 Admissions Pre- RHB Post- RHB p-value Medical Errors 33.8 18.3 <0.001 Preventable Adverse Events 3.3 1.5 0.04 Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP. JAMA 2013; 310: 2262-2270

From Pilot to Multi-center PRIS Study Multisite PRIS study to implement refined handoff bundle for resident physician change of shift handoffs at 9 pediatric institutions $3M DHHS Grant

Standardized Structure for Communication: I-PASS Mnemonic I P Illness Severity Stable, Watcher, Unstable Patient Summary Summary statement; events leading up to admission; hospital course; ongoing assessment; plan A Action List To do list; timeline and ownership S S Situation Awareness & Contingency Planning Know what s going on; plan for what might happen Synthesis by Receiver Receiver summarizes what was heard; asks questions; restates key action/ to do items Starmer AJ et al Pediatrics 2012

I-PASS Handoff Bundle Intervention Components I-PASS Campaign I-PASS Structure Workplace Observations & Feedback Champion Development I-PASS Handoff Bundle Training Curriculum Verbal Handoff Process Changes I-PASS Printed Handoff Document Simulation Exercises All Handoff Bundle Components Available at www.ipasshandoffstudy.com

Core I-PASS Workshop 1-2 Hour Session of Didactic and Interactive Exercises TeamSTEPPS TM training Communication skills Handoff skills training Verbal Mnemonic Written Handoff Document Followed by 1 Hour Session of Handoff Simulation Exercises 3 role play scenarios, allows residents the opportunity give, receive and observe a handoff Faculty facilitators provided feedback and guided discussion

I-PASS Faculty Development Faculty Are Key To Success! Development of I-PASS Faculty Champions I-PASS 80-page Champions Guide Opportunity for participation at multiple levels Physicians received Maintenance of Certification credit to encourage participation Workplace Based Assessment and Feedback Periodic observation of resident handoffs in real time Formative feedback provided using validated instrument

I-PASS Campaign Materials Study logo Posters Screen frames Pocket cards Badge clips I-PASS tips of the day Just-in-Time refresher training sessions

Better Handoffs. Safer Care.

Results Process Measures % Of Verbal Handoffs With Key Elements Present 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% * Illness severity assessment * Patient summary All p-values < 0.001 * To do list Contingency plans Readback N = 207 verbal handoff sessions, 2281 unique patient handoffs * * Pre-intervention Post-intervention Starmer AJ, et al. Changes in Medical Errors After Implementation of a Handoff Program. NEJM. 2014 Nov 6; 371(19):1803-12

Results Process Measures % Of Written Handoffs With Key Data Elements All p-values < 0.001 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% * * * * * * * * * Pre-intervention Post-intervention 0% N = 432 written handoff documents, 5752 unique patient entries Starmer AJ, et al. Changes in Medical Errors After Implementation of a Handoff Program. NEJM. 2014 Nov 6; 371(19):1803-12

Starmer AJ, et al. N Engl J Med. 2014 Nov 6; 371(19):1803-12 I-PASS Study Results: Process and Balancing Measures Improvements in Content and Quality of Verbal and Written Handoffs Improvements in Safety Culture Scores No Change in Provider Workflow % of Time per 24 hr Period Spent in Activity Activity Pre-Intervention N = 3510 hours Post-Intervention N = 4618 hours P-Value Patient Family Contact 11.8% 12.5% 0.41 Creating written or computerized handoff document 1.6% 1.3% 0.54 Other Computer Time 16.2 % 16.5% 0.81 Pre-Intervention Post-Intervention P-Value Mean duration of verbal handoff per patient 2.4 min 2.5 min 0.55

I-PASS Study Results: Impact on Medical Error Rates 23% Reduction 30% Reduction Starmer AJ, et al. N Engl J Med. 2014 Nov 6; 371(19):1803-12

Adapting I-PASS

I-PASS for Nurses: Handoff Related Care Failures Bigham MT et al., Pediatrics 2014; 134: e572-579.

Improving Handoffs The Next Wave 32 Hospitals Adopted I-PASS through SHM Mentored Implementation 16 Institutions Phase 1 16 Institutions Phase 2 Brigham & Women's Hospital Mayo Clinic Virginia Commonwealth University Hospital New York Hospital Queens Maimonides Medical Center Intermountain Medical Center UCSD/University of California Medical Center Arkansas Children's Hospital University of Cincinnati Levine Children's Hospital at Carolinas HealthCare System Hurley Medical Center Children's Hospital of Michigan Trident Medical Center University of Hawaii John A Burn School of Medicine Sunnybrook Hospital-Ontario Boston Medical Center Children s Hospital Of Philadelphia Johns Hopkins, Baltimore Children s National, DC Children s Hospital Colorado New Hanover Lankenau Medical Center Children s Hospital Montefiore, NY University of New Mexico Hackensack UMC Mountainside Medical University of South Carolina Sparrow Hospital / Michigan State University Toledo Children s Hospital AtlantiCare, New Jersey Sanford Children s Hospital, South Dakota Gwinnett Medical Center, Georgia Children s Mercy, Kansas City

Mentored Implementation Results: Adherence to all 5 I-PASS Elements SHM Annual Meeting, 2018

Mentored Implementation Results: Adverse Event Rate (Event/person year) 47.1% reduction in handoff-related major harm events (p < 0.05) 46.9% reduction in handoff related minor-harm events (p < 0.001) p < 0.05 for all comparisons SHM Annual Meeting, 2018

Adapting I-PASS For Patient & Family Patient and Family I-PASS Study Funded by a grant from PCORI Aim: To determine if improving communication and integrating patients/families into all aspects of decision making during hospitalization will Improve patient safety Improve patient and family experience Centered Rounds

Preliminary Results: Improved Safety 35.6% PAS Annual Meeting, 2017

Further I-PASS Dissemination Dissemination in > 60 hospitals Including Internal Medicine, Surgery, OB/GYN, Nursing, other transitions Adaptation to Family-Centered Rounds Adaptation to other Handoff types 2016 Eisenberg Award Innovations in Patient Safety 2016 Harvard Business / Medical School Health Acceleration Challenge Formed I-PASS Patient Safety Institute

Transitions of Care and I-PASS I-PASS Study Group Research AGENDA Large Scale Implementation and the I-PASS Institute Discussion 34

Full-Scale Adoption Challenges Requires change in workflow and adaptation to culture Scale required to train thousands of providers Sustaining change requires re-enforcement and feedback Needs integration and alignment with hospital systems (e.g. EHR) Requires experience and mentoring Shahian DM, et al. BMJ Qual Saf 2017;01-11 doi:10.1136/bmjqs-2016-006195 35

What is the I-PASS Institute? Mission-based company established in 2015 focused on reducing medical errors that occur during patient handoffs and transitions of care Accelerate adoption and sustainment of the I-PASS Handoff Method Cloud based digital tools and support services efficiently scale I-PASS Mentor services to guide I-PASS adaptation and implementation Customized bundle of solutions to Assess and plan Train and implement Improve and sustain

I-PASS Process for Adoption and Sustainment Assess and Plan Train and Implement Improve and Sustain Assess Institutional Environment Define Local Team & Champions Implement & Train Institutional Benchmarking Gamer Support/Secure Resources Define Scope & Timeline Process Improvement Campaign Optimize Verbal Handoff Process Standardize use of Written & Data Computerized Collection/ Handoff Handoff Observations & Reporting Plan Institutionalize Cultural Change Ensure Sustainability & Ongoing Monitoring 37

Implementation Guide Table of Content I. Introduction 3 II. Essential First Steps 3 A. Garnering Support Across the Institution 3 B. Site Team Structure 11 C. Site Leader Roles and Responsibilities 15 D. Establishing Team Rules 23 E. Securing Resources 25 II. Assessing the local Environment and Planning for Implementation 29 A. Understanding Current Handoff/ Processes 29 B. Adapting I-PASS and the Local Environment 34 C. Scope end Timing of Institutional Implementation 35 D. Development of a Communication Plan 36 III. The I-PASS Handoff Curriculum 39 A. Overview of the Program and Training Materials 39 B. Types of Learners 40 C. Education and Training Activities 40 D. Timing of Curricular Interventions 43 E. Tips for Executing the ln-person Workshops and Presentations 44 F. Considerations for Temporary or Visiting Healthcare Providers 44 G. Just-In-Time Training Sessions 45 H. Special Considerations for Bedside Handoffs 46 IV. Guidelines for Handoff Observations and Reinforcement 47 A. Goals for Institute Champion Observation and Assessment of Front-line Provider Handoffs 47 B. Guidelines for Observation of Front-fine Providers on the Institute Teams/Units 48 C. How to Use the I-PASS Handoff 0.08 Assessment Tools 49 V. How Will You Know You Are Making a Difference? 51 A. Data Collection and Reporting 54 B. Analysis and Interpretation of Data: Run Charts 52 C. Creating Your Own General Goals, Key Outcome Metrics and SMART Aims 53 D. Development of a Data Collection and Reporting Plan 59 E. Iterative Improvement Cycles 60 VI. The I-PASS Printed Handoff Document 62 A. Overview and importance 62 B. Formatting and Content 62 C. Maintenance of the Printed Handoff Document 63 VII. Guidelines for the I-PASS Campaign 64 A. Overview 64 B. Tracking/Adherence 68 VIII. Incentivizing Institute Mandell Observers 68 A. Quality Improvement Opportunities and Certification 68 B. Requirement by Leadership of the Local Level 69 C. Types of Learners 69 IX. Encountering Resistance and Challenges to Sustainability 72 A. Focus on Starting Off VII the Right Foot 72 B. Changing Culture and engaging Late Adopters 73 C. Giving Feedback and Promoting Sustainability 73 X. Continuing to Improve 74 XI. Spreading the Handoff Process 76 XII. Closing Remarks 76 38

Key Aspects of I-PASS Mentor Support 39

I-PASS EHR Integration 40

I-PASS EHR Integration 41

I-PASS EHR Integration 42

I-PASS EHR Integration 43

Hospital Implementation: Timing and Cadence 44

I-PASS Learning You can select four different handoff scenarios including nursing, medicine, pediatrics and surgery. In addition, we offer a service where you can add your own handoff case scenarios. 45

I-PASS Learning Once the written handoff is complete this can then be used for the verbal handoff 46

I-PASS Learning The verbal handoff is given by the learner and recorded into the computer 47

I-PASS Learning Once the verbal recording is complete, the user will then review and self assess elements of the handoff to see if they have captured the right information. If you are not happy you can simply record again! 48

I-PASS Learning So, how did you score? Happy? If not try it again! 49

https://www.youtube.com/watch?v=inikpwuba3q 50

I-PASS Assessment The I-PASS Assessment App is a cloud-based system that allows you to measure adherence and provide feedback when observing a handoff. In addition, measurements for reduction of errors can be tracked. This data generates customizable run charts to demonstrate adoption over time. 51

Percent of Handoffs (%) Institution-Wide I-PASS Implementation Experience at One Institution: Quality Fig 2. Adherence to Qualitative Elements of I-PASS in Observed Handoffs by Handoff Type* (3/21/17-3/21/18; n=1013)** 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% Month of Implementation 0.0% 1 2 3 4 5 6 7 8 9 10 11 12 13 Single-patient Handoff Adherence 70.4% 73.5% 85.9% 94.8% 87.4% 96.4% 97.3% 96.4% 97.1% 97.6% 100.0% 91.7% 100.0% Single-patient Handoffs (n) 54 117 85 115 127 137 73 56 35 41 18 12 11 Multiple-patient Handoff Adherence 70.0% 93.3% 80.0% 92.6% 94.4% 60.0% 100.0% Multiple-patient Handoffs (n) 30 15 25 27 18 5 2 Goal Adherence (%) 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 52

Medical Malpractice Emerging Evidence 30% of all malpractice cases due to miscommunication CRICO Strategies From 2009 2013, 41% of communication-related cases closed with an indemnity payment at an average cost of $433,000 Cases that involve a breakdown in communication among clinicians had average cost of $493,000 I-PASS Retrospective Malpractice claims review of 500 cases shows 52% off all claims had a miscommunication errors* 48% of those were handoff related I-PASS Program could have addressed 85% of those handoff errors This represents 18% of all malpractice claims * PAS 2017 53

In Summary: I-PASS Handoff Program Implementation Patient Medical Staff Hospital Reduction in preventable adverse events Reduction in medical error rates Time neutral Significant financial benefits from AE reduction Insurer 54

Transitions of Care and Errors I-PASS Study Group Research AGENDA Large Scale Implementation and the I-PASS Institute Discussion 55