Crew Resource Management Slides - including Handoffs - from 2008 National Patient Safety Foundation Meeting - With Dr. Edward Dunn

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Applying Crew Resource Management to Safe Transitions

in Patient Care

2008 NPSF Annual Patient Safety Congress

Nashville, TN

May 16, 2008

Edward J. Dunn, MD, MPH

Noel Eldridge, MS

VA National Center for Patient Safety

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The Josie King Story

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Clinical Vignette

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Teamwork

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What are the characteristics of a TEAM?

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Communication

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If information flow is the currency of medical practice, why is so little attention paid

to communication effectiveness in medical training and education?

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Communication Skills

In medical school and nursing school, the focus is on

successful communication with the patient.

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Communication failure is a leading source of

adverse events in healthcare.Evidence from Surgery, Medicine, Emergency Medicine• Gawande – 43% of adverse events are due to

communication failures between two or more clinicians– Complications (2002)– Better (2007)

• Risser* – 54 tort claims from ED due to “teamwork failure”– Med Teams Research Consortium

• Sutcliffe – interviewed 26 med residents…communication failure cited in 70 adverse events

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Root Cause Analyses (RCA) Database*

• ~70% to 80% of RCAs cited COMMUNICATION FAILURE as, at least one of the root causes/contributing factors for an adverse event or close call report.

*VA NCPS Database, January 18, 2008

Total Individual + Aggregate RCAs (1999-2008) = 13,774

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Collaboration & Teamwork in ICU = Lower Morbidity & Mortality +

Increased RN RetentionEvidence from ICUs• Knaus – 5030 ICU pts in 13 hospitals

– M&M risk improved with collaboration• Baggs – 286 consecutive Med ICU pts transferred

– M&M risk decreased from 16% to 5%• Shortell – 17440 pts from 42 ICU

– Teamwork across disciplines improved outcomes & RN retention

• Pronovost – Daily briefings in ICU with RNs and Residents– Improved quality of care

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Institute of Medicine* (2000):

“…establish team training programs for personnel in critical care areas using proven methods such as the

crew resource management training techniques employed in aviation.”

Corrigan J, Kohn LT, Donaldson MS. To Err Is Human. Washington, DC: National Academy Press; 1999.

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CommunicationDefinition: The exchange of thoughts,

messages, or information.*

A dynamic process between people:• Sender (talks/writes/signals) & Receiver (listens/reads/signals)• Roles alternate back & forth•Verbal vs. non-verbal

Feedback: • Sending a message is not sufficient• Was it received…understood?

* The American Heritage Dictionary, 4th edition, Houghton Mifflin Company (2001): 179.

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Faculty Role Play

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Was our communication successful?

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Successful Communication

• Many communication improvements focus on improving accuracy and availability of content, e.g. CPOE, CPRS, “Hand-Off” templates

• Poor communication results from context. Context is vulnerable to culture, gender, education, experience, time pressure, stress, mood, etc.

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Communication Context• Culture • Gender• Language barriers• Differing mental models• Professions and disciplines • Power gradient (hierarchy)• Differing information needs• Temperament and personality• Outside interference and distractions

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Assertive StatementsDirect and clearly communicated statements that

facilitate patient advocacy in decision-making.

• Not a license to be rude• Use “I” statements, rather than “You”

statements• “I” statements describe your experience rather

than another’s shortcomings

• Give people options

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Words to Avoid

• “You” - blame/shame, elicits defenses• “Should” – judgmental, value statement• Hyperbole – “never,” “always,”

“nothing,” “everything”– Not fact– Not credible– Inflates correctable problem into

impossible challenge

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Words to Use

• “The” statements (policy) – stick to the facts– Avoiding conflating person with behavior– Attack the problem, not the person

• “We” statements – shared responsibility and shared interests– Invoke common principle, accepted

standard

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CRM Communication Techniques

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Call Out

• Communicate to all what you see and know

• If you “feel the pinch” that trouble is brewing, communicate that to everyone

• If you keep it to yourself, the patient may suffer

Examples from COPD film? Code Scenario film?

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Step Back• “Pause in the Action” – can be dramatic• Reassess a situation that doesn’t appear to be

working• Challenge all previous assumptions• Protects against fixation on prior assumptions

that are not supported by accruing evidence

“Fixation Error:” Persisting in a planned action despite incoming data that contradicts previous assumptions. Wakefield continuing to attempt intubation when the patient might do well with mask ventilation.

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Clear Communication

• Read Back

– Write down what you heard

– Read back what you wrote

– Confirm with the sender

• Repeat Back

– Reflect back what you hear

– Confirm with sender

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Dynamic Skepticism

• Attitude of constantly questioning and evaluating the patient care environment– Avoid trusting what appears to be obvious– Do not assume!– Seek facts– Verification is NOT a mistrust of others– Questioning and verifying is safe practice

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Assume Nothing!

Communicate what you see and know!

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Safe Transitions in Patient Care Responsibility

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Some Conspicuous Types of Handoffs(formality and temporality varies widely)• Shift Changes

– Physicians – Nurses

• Intrafacility (within facilities)– ICU to Med/Surg and vice versa, etc.

• Interfacility (between facilities)• Short-term

– Med/Surg to radiology, etc.– Lunch or bathroom break (for caregiver)

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Why are Good Handoffs Important?• Provide access to new or unknown clinical

information• Increase efficiency/flow

– Prevent pointless re-tests– Decrease length of stay

• Key issue for across all levels of healthcare – Nursing shortage; therefore, temporary staff– Resident 80-hour workweek means more handoffs– Various medical specialties have their own issues

• ICU, Surgeons, et al.

• Reduce likelihood of adverse events… – or substandard care based on misinformation or lack of

information

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What Should be in a Good Handoff?• Team Identifiers - Staff names, phone numbers, covering

staff contact info, distinctive team name/color• Appropriate patient identifier - 2 forms of identification• 1-2 sentence of patient presentation• Active problem list - pertinent past medical history• Medications – all active listed• Allergies• Access - Venous / Arterial Access and what to do if changes• Code status• Pertinent labs• Concerns over next 18-24 hours and what to do in those

situations (problem vs. system based)• Long term plans / family questions that could arise if

indicated• Psychological concerns

Ref: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005

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2007 (and 2008) Joint Commission National Patient Safety Goal

• (2) Improve the effectiveness of communication among caregivers– Requirement 2e– implement a standardized

approach to “hand-off” communications, including an opportunity to ask and respond to questions

– Rationale – the primary objective of a “hand-off” is to provide accurate information about a patient’s care, treatment and services, current condition and any recent or anticipated changes. The information communicated during a hand off must be accurate in order to meet patient safety goals

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RCAs and Handoffs• Most RCAs cite communications as a

contributing factor• Handoffs are situations where

communications lapses can be especially hazardous

• Full disclosure: we haven’t specifically searched for handoffs cited as the cause of specific adverse events– Speculation: more likely to be seen as a

“contributing factor” than a stand-alone “cause”

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Top 10 Topics of VA RCAs

1) Falls (close to 50% of VA reports, but only ~12% of VA RCAs)

2) Delay in Treatment/ Diagnosis/ Surgery

3) High Alert Adverse Drug Events4) Death Other Than Suicide5) Misidentification6) Missing Patient7) Outpatient Suicide8) Hospital Acquired Infection9) Communication about Abnormal

Result10) Medical Device11) Incorrect Surgery

Delay in Treatment/Diagnosis/Surgery

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Developing a Standardized Approach to Hand-off Communications

• A standardized approach should identify :-– The “hand-off” situations that it applies to

– Who is, or should be, involved in the communication

– What information should be communicated

• Diagnoses and current condition of the patient

• Recent changes in condition or treatment

• Anticipated changes in condition or treatment

• What to watch for in the next interval of care

– Opportunities to ask and respond to questions

– When to use certain techniques (repeat-back; SBAR)

– What print or electronic information should be available

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Examples

• Flowcharts for two standardized kinds of shift-change handoffs for nurses– Had more pre-existing standardization

• Shift Handoff Tool software developed for physicians– Had less pre-existing standardization

HANDOFF PROCESS WITH IN-PERSON TRANSFER OF PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am)

Night Staff Nurse prepares tape recorded report for late AM Staff Nurse

Is AM Staff Nurse

LATE or ABSENT?

AM Charge Nurse addresses urgent patient care issues identified by Night

Staff Nurse.

AM Charge Nurse gives AM Staff Nurse verbal report of patient care topics.

AM Staff Nurse listens to tape recorded reports.

Night Staff Nurse briefs AM Charge Nurse on critical / urgent patient care issues.

AM Charge Nurse clarifies /answers all questions from AM Staff Nurse regarding patient care topics.

AM Staff Nurse review patient assignment list.

AM Staff Nurse review end of shift

report list of all active patients on the ward.

AM Staff Nurse locates respective Night Staff Nurse (s) to get verbal report on

prospective patients on his / her assignment listing.

Night Staff Nurse and AM Staff Nursesconducts walking (bedside) rounds for all

patients assigned to the respective AM Staff Nurse and provides summary

information on patient status and needs schedules.

HandOff complete for All Active Patients

Night Staff Nurse clarifies / answer all questions from AM Staff Nurse regarding

patient care topics.

AM Staff Nurse goes to report room

Note: Morning and Evening Shift Change is the same as above

NOYES

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HANDOFF PROCESS WITH TAPE RECORDED PATIENT INFORMATION Midnight (AM) to Morning (AM) Shift Change (7:30 – 8:00 am)

Night Staff Nurses prepares tape recorded reports for AM Staff

AM Staff Nurse listens to tape recorded reports.

AM Charge Nurse clarifies /answers all questions from AM Staff Nurse

regarding patient care topics.

AM Staffreview patient assignment list.

AM Staff Nurse may leave room to discuss patient care

topics with Night Staff nurses before he /she

leaves.

Review patient assignment

list.

Review end of shift report.

AM Staff Nurses goes to report room

AM Charge Nurse and Staff Nurses listen to tape recorded reports.

Is AM Staff

Nurse LATE or

ABSENT?

AM StaffReview end of shift

report list of all active patients on the ward.

AM Charge Nurse conduct walking (bedside) rounds with Night

Charge Nurse to discuss patient care topics before he/she leaves.

HandOff complete for All Active Patients

Note: Morning and Evening Shift Change is the same as above

NO

YES

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Options for nurses: In the event that a question remains or occurs after getting a shift report by tape, face-to-face, or in a text (paper or

electronic) version, the following options may be available:

1) Ask face-to-face to the nurse from previous shift if he or she hasn’t left yet and is still present in the unit.

2) Ask a nurse whose schedule is crossing the shift change (e.g., on a 12 hour shift, staggered overlapping shift, or doing overtime into the new shift).

3) Ask the charge nurse that received a separate report from the previous shift’s charge nurse.

4) Ask another member of the staff if the question is within their areas of expertise to answer, for example:– Ask the resident or attending

physician that is responsible for the patient, either in-person or by pager/mobile phone.

– Ask ancillary staff on duty, for example, a respiratory therapist or phlebotomist, if the question is within their scope of knowledge.

5) Read the recent progress notes, nursing notes, or other information in the patient’s medical record.

6) Telephone the nurse from the previous shift, calling their home or mobile phone number. (A list of all the mobile and home phone numbers for all the nurses on the unit would have to be readily available when needed for official use if this method is recommended by the organization.)

7) Some questions may be appropriate to ask the patient, depending on the nurse’s assessment of the patient’s ability to answer accurately, e.g., questions about what the patient ate, if the patient was visited by a specialist that had been scheduled, etc.

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Shift Handoff Tool (Short) HistoryCreated by Indianapolis (Roudebush) VAMC with inputs from

pilot testers at the following VAMCs: Washington, DC; Iowa City; Des Moines; Ann Arbor; Loma Linda; Dallas; White River Junction

December 2005: • Paper published in Academic Medicine by Indianapolis

VAMC: Lost in Translation: Challenges and Opportunities in Physician-to-Physician Communication During Patient Handoffs, Academic Medicine, Dec 2005

January 2006: • New JCAHO Patient Safety Goal to standardize Handoffs

goes into effect, software from Indianapolis reviewed…September 2006: • Meeting in Washington, DC to establish consensus

requirementsJuly 2007:• Tool installed & being tested and/or used at 12 facilities.• Selected for upgrade to “Class 1” software – Helpdesk

support, etc.April/May 2008 (planned):• Made available to VA System (150+) hospitals

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Create Link To HANDOFF TOOL in

CPRS Tool Bar

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These fields can be specified by site/department – i.e. HPI

Time limits to ensure fields are updated

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HPI

To Do List

Problem List

Pending Workup

Covering Physician

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Patient and Team Identifiers from CPRS which can be site specified.

i.e.) Full SSN vs. last four / DOB / Sex / Agei.e.) Date of admission / Length of stay / Admitting diagnosis

i.e.) Room location / Assigned team, attending, outpatient provider

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CODE status from CPRS

Allergies from CPRS

Active medications from CPRS

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Typically 3-5 patients per printed page --

depends mostly on meds

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Modifiable fields

Identifiers / CPRS retrieved fields

Team list name/Sign-out provider info

Entire Team name / titles / contact numbers

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Time and date sign-out created Page numbersi.e.) 2 of 3

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Shift Handoff Tool

• Uniform and Easy to Learn– Not another software training requirement

• Legible, and standardized abbreviations in text pulled from CPRS (VA’s EMR)

• Forces updates to predetermined fields– Minimizes obsolete data or information

• Site/service customizable (within limits)• Time saving (in preparing report for

recipient)

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Results from Research Project• Selected findings from surveys and abstracted ad hoc (pre) and software-based (post) tools– Less Time Typing– Same Time Talking– Perception of improving safety among users– Perception of having received more complete

information among users– Key information measured as always or almost

always present in software-based tool• Medications• Allergy info• Demographics and Room number

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Take Home Points

• Good information in a Handoff Tool does not replace the medical record/chart

• Faster Handoffs (i.e., less time talking face-to-face) is not the goal

• Handoffs that foster real communication (text and verbal) is the goal

• Need standardization/ consistency/ accuracy/ secure processes

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Special Thanks to:

Richard J. Sowinski, Chief of Application Development, Roudebush VAMC, MSCS, BSEE

Charlet Lynn Cottee, Senior Developer, Roudebush VAMC, BSCS

Divya Shroff, MD, Associate Chief of Staff – InformaticsWashington DC VAMC

Jaclyn Anderson, DO, VA Quality ScholarIowa City VAMC

Research Project Mentioned: Abstract at 2008 SGIM ConferenceTHE PHYSICIAN-TO-PHYSICIAN HANDOFF: THE VETERANS AFFAIRS CAIRO PROJECT

J.K. Anderson1; D. Shroff2; A. Curtis1; N. Eldridge3; K. Cannon1; R.M. Karnani1; T.E. Abrams1; P. Kaboli1. 1VA Iowa City Health Care System/University of Iowa, Iowa City,

IA; 2Washington DC VA Healthcare System, Washington, DC; 3VA Central Office, Washington, DC. (Tracking ID # 190036)

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What are the elements of a safe patient hand-off?

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Patient Hand-Offs: SBAR

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SBAR

Clearly communicates the critical elements of a case to another clinician: Situation

What is the problem?

BackgroundBrief background information

AssessmentWhat is your assessment of the patient?

RecommendationsWhat do you recommend?

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SBAR• Melds MD and RN cultures

– RN: holistic focus; background important; paints a complete picture of the patient

– MD: time urgency; focus on specific problem; data

• SBAR is a rule of language for communicating information, such as patient handoffs– RN-to-RN at change of shift/admission/transfer– MD-to-MD on call– RN-to-MD report of change in patient condition

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SBAR Film 5:MD-to-MD Hand-OffHospitalist-to-PCP

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Debrief SBAR Film 5MD-to-MD Hand-Off Hospitalist-to-PCP

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NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Patient Transfer

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Situation

Situation: What is the situation with this patient? Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service: _________________ Attending MD: ________________ Resident MD: ________________ Admitting Diagnosis: _____________________ Procedure(s): ______________________________________ Brief Clinical Summary:______________________________________________________________________ ____________________________________________________________ Expected Time of Arrival: ______

B

Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ___________________________________________________________ _________________________________________________________________________________________

2. Medications: _____________________________________ Allergies: ____________________________ 3. Code Status: _____________________ Health Care Proxy: _____________________________________

4. Family / Social Support: __________________________________________________________________

A

Assessment

Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only)

BP ____/_____ HR ______ Resp. Rate _________ Temp _________ SaO2 ___________ Pain (1-10)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ________________________________ Wound(s):_____________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: ____________________________________________________________________________ 3. Lab / Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:___________________________________ Tubes/Drains: ____________________________

R

Recommendation

Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 2. To-Do List: _____________________________________________________________________________ 3. Red Flags: ______________________________________________________________________________

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SBAR Film 7 MD-to-MD Medical Resident

Sign Out

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Debrief SBAR Film 7MD-to-MD Medical Resident

Sign-out

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NCPS SBAR Hand-Off Guide RN-to-RN or MD-to-MD Change of Shift

S

Situation

Situation: What is the situation with this patient? Patient Condition? Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: ________ Clinical Service: _________________ Attending MD:________________ Resident MD:________________ Admitting Diagnosis: _____________________ Procedure(s): ____________________________________ Brief Clinical Summary:___________________________________________________________________ _______________________________________________________________________________________

B

Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________

________________________________________________________________________________

2. Medications: ________________________________________ Allergies: ________________________

3. Code Status: __________________________ Health Care Proxy: _______________________________ 4. Family/Social Support: _______________________________________________________________

A

Assessment

Assessment: What is your assessment of this patient? 1. 1. Nursing Assessment (choose relevant items only)

BP _____/______ HR _______ Resp. Rate _________ Temp _________ SaO2 _______ Pain (1-10) _____ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ____________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ______________________________________ Wound(s):______________________________________ Psychosocial: ____________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. Lines/Fluids:________________________________________ Tubes/Drains: ________________________

R

Recommendation

Recommendations: What is the recommended plan of care? 1. Plan of Care: ____________________________________________________________________________ ________________________________________________________________________________________ Lab/Imaging Tests: __________________________________________________________________________ Treatments/Procedures: _______________________________________________________________________ Consults: __________________________________________________________________________________ 2. To-Do List: _____________________________________________________________________________ 3. Red Flags: ______________________________________________________________________________

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SBAR Film 3RN-to-MD Change in Patient

Condition

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Debrief SBAR Film 3RN-to-MD Change in Patient

Condition

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NCPS SBAR Hand-Off Guide RN-to-MD Change in Patient Condition

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Situation

Situation: What is the situation you are calling about? Relevant patient issues? I’m calling about… Patient Name: ______________________ SSN: __________ DOB: _________ Admit Date: __________ Clinical Service:___________________ Attending MD: ________________ Resident MD: ______________ Admitting Diagnosis: _________________________ Procedure(s): _________________________________ Problem(s) you are calling about: _____________________________________________________________ ______________________________________________________________________________________

B

Background Background: What is relevant in this patient’s past medical history? 1. Relevant Past Med/Surg History: ________________________________________________________________________________________ ________________________________________________________________________________________ 2. Medications: __________________________________________ Allergies:_________________ 3. Code Status: ___________________ Health Care Proxy:__________________________________ 4. Family/Social Support: ___________________________________________________________

A

Assessment

Assessment: What is your assessment of this patient? 1. Nursing Assessment (choose relevant items only)

BP ____/____ HR ______ Resp. Rate _______ Temp _________ SaO2 _________ Pain (1-10 scale)_______ Cardiac: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ GI: ___________________________________________________________ Diet: _____________________ GU: ______________________________________________________________________________________ Musculoskeletal: ____________________________________ Fall Precautions: _________________________ Neuro: ____________________________________________________________________________________ Skin: ____________________________________ Wound(s):________________________________________ Psychosocial: ______________________________________________________________________________ 2. Rx Concerns: _______________________________________________________________________ 3. Lab/Imaging Data: _____________________________________________________________________ 4. IV Lines/Fluids: _______________________________ Tubes/Drains: _____________________________

R

Recommendation

Recommendations: What should be done? I suggest …or…request that you:

See the patient for medical evaluation ASAP / STAT Order tests, treatments, consultations: __________________________________________________

If a change in patient care is ordered: To-Do List: ______________________________________________________________________ Red Flags: _______________________________________________________________________ Guidelines for follow-up call to physician: _______________________________________________

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SBAR Film 9RN-to-RRT Patient Hand-Off

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Debrief SBAR Film 9RN-to-RRT Patient Hand-off

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Is Organizing Change Like Herding Cats?

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“If you want to go quickly, go alone.

If you want to go far, go together.”

African Proverb

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Thank You

[email protected]

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Extra Slides

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Code Scenario

Film

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Debriefing

• Facilitator

• Team-based discussion

• Review of a shared experience:– What went well? – What didn’t go well?– What lessons were learned?

• Promotes situational learning

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Code Team Debriefing

Film

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Debrief Code Scenario Debriefing Film

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CARDIAC ARREST (CODE 4000) DEBRIEFING GUIDE

Review Elements of a Good Code Did all members of the Code Team arrive at the bedside quickly? Was there an appropriate number of staff (or too many, few, etc)?

Did the Medical Consult identify him/herself quickly and clearly?

Were all necessary supplies/medications readily available/accessible?

Was the cardiac rhythm determined quickly?

Was the airway managed appropriately? Was the airway established timely?

Was IV access established timely?

Were emotional issues handled effectively?

Were there futility issues?

Was there effective leadership? Poor = 1 (explain) Good = 3 Excellent 5

Physician Satisfaction: 1 2 3 4 5

Nurse Satisfaction: 1 2 3 4 5

Resp. Ther. Satisfaction: 1 2 3 4 5

Safety Breech: Yes (explain) No

Unanticipated Events: Yes (explain) No

Did the post-code debriefing detect a problem?

None Minor (explain) Major (explain)