Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium.

Designing Safe and Designing Safe and Effective Patient Effective Patient

HandoversHandovers

Vineet Arora, MD, MA Vineet Arora, MD, MA University of Chicago University of Chicago

Julie Johnson, MSPH, PhDJulie Johnson, MSPH, PhDUniversity of Chicago University of Chicago

Quality Colloquium at HarvardQuality Colloquium at HarvardAugust 21, 2008August 21, 200810:45 – 12:45 pm10:45 – 12:45 pm

ObjectivesObjectives Determine which methods are most appropriate Determine which methods are most appropriate

for exploring hand-offs in clinical settings for exploring hand-offs in clinical settings Develop a standard process to optimize hand-offs Develop a standard process to optimize hand-offs

using a process mapping methodologyusing a process mapping methodology Create a checklist of critical patient and process Create a checklist of critical patient and process

informationinformation Design a strategy for dissemination and trainingDesign a strategy for dissemination and training Identify and overcome barriers to Identify and overcome barriers to

implementationimplementation Develop a plan to evaluate and monitor hand-off Develop a plan to evaluate and monitor hand-off

protocolsprotocols

AgendaAgenda10:45 – 10:5010:45 – 10:50 Introduction and Overview of the AgendaIntroduction and Overview of the Agenda10:50 – 11:0010:50 – 11:00 Participant Introductions and ExpectationsParticipant Introductions and Expectations11:00 – 11:1011:00 – 11:10 Hand-off TheaterHand-off Theater11:10 – 11:1511:10 – 11:15 Audience PollAudience Poll11:15 – 11:3011:15 – 11:30 What is known about Hand-offs in Medicine What is known about Hand-offs in Medicine

and other Industriesand other Industries11:30 – 11:5011:30 – 11:50 Small Group Exercise: Paper TearSmall Group Exercise: Paper Tear11:50 – 12:0011:50 – 12:00 A Model for Developing a Standard A Model for Developing a Standard

ProtocolProtocol12:00 – 12:2012:00 – 12:20 Small Group Exercise: Process MappingSmall Group Exercise: Process Mapping12:20 – 12:30 12:20 – 12:30 Completing the Hand-off ModelCompleting the Hand-off Model12:30 – 12:4012:30 – 12:40 Research PresentationResearch Presentation12:40 – 12:4512:40 – 12:45 Final Comments and AdjournFinal Comments and Adjourn

IntroductionsIntroductions

Who are you? Who are you? What do you do?What do you do? What are your expectations for What are your expectations for

today’s session?today’s session?

What are the types of What are the types of handoffs that come to mind handoffs that come to mind

when you think about when you think about handoffs?handoffs?

““Hand-off Theater”Hand-off Theater”

Role Play of a Intern “Sign-Role Play of a Intern “Sign-out”out”

Use the checklist for observations:Use the checklist for observations:– Please record cultural, communication, Please record cultural, communication,

and environmental barriers that and environmental barriers that interfere with successful patient hand-interfere with successful patient hand-off practices in patient care off practices in patient care

Barriers Observations/Thoughts

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

FacilitatorsWhat went well?

What Do You Look For?What Do You Look For?

Debriefing from the Role Debriefing from the Role PlayPlay

What types of barriers to an effective What types of barriers to an effective hand-off did you observe?hand-off did you observe?– EnvironmentEnvironment– CulturalCultural– CommunicationCommunication– Any others?Any others?

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution When there is a transfer of care, who When there is a transfer of care, who

is primarily responsible for the is primarily responsible for the transfer?transfer?

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution How many senders and receivers of How many senders and receivers of

information are present at the time information are present at the time of the hand-off?of the hand-off?

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution Is a verbal communication required Is a verbal communication required

at the time of a hand-off in your at the time of a hand-off in your institution/program?institution/program?

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution If conducted, where does verbal If conducted, where does verbal

communication take place?communication take place?– Face to face in a dedicated roomFace to face in a dedicated room– On the phoneOn the phone– ““On the fly” (wherever/whenever the On the fly” (wherever/whenever the

two parties can meet)two parties can meet)– At the patient’s bedsideAt the patient’s bedside

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution Does your program/institution use a Does your program/institution use a

standard template for written standard template for written information conveyed at the hand-off information conveyed at the hand-off (“sign-out”)?(“sign-out”)?

Audience Poll: Current Audience Poll: Current Practices in Transfer of Care in Practices in Transfer of Care in

Your InstitutionYour Institution Do you have formal training on how Do you have formal training on how

to perform hand-offs and transition to perform hand-offs and transition patients for new personnel at your patients for new personnel at your institution?institution?

Background Background and Definitionsand Definitions

Exchange vs. Hand-offExchange vs. Hand-off

An exchange of information doesn't An exchange of information doesn't require that the other person understand require that the other person understand what is being transmitted but simply what is being transmitted but simply conveys information conveys information – information is often acquired and transmitted information is often acquired and transmitted

without testing for comprehension without testing for comprehension A hand-off implies transfer of information A hand-off implies transfer of information

as well as professional responsibilityas well as professional responsibility– Hand-offs with exchange elements that don’t Hand-offs with exchange elements that don’t

test for comprehension put teams at risktest for comprehension put teams at risk

Lessons from Other Lessons from Other Industries and Industries and Applications Applications to Healthcareto Healthcare

Hand-off as a Form of Hand-off as a Form of CommunicationCommunication

“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 Hand-offs in Other High-Risk IndustriesHigh-Risk Industries

Direct observations of hand-offs at NASA, 2 Direct observations of hand-offs at NASA, 2 Canadian nuclear power plants, a railroad Canadian nuclear power plants, a railroad dispatch center, and an ambulance dispatch dispatch center, and an ambulance dispatch centercenter

STRATEGIESSTRATEGIES– Standardize - use same order or templateStandardize - use same order or template– Update information Update information – Limit interruptions Limit interruptions – Face to face verbal update Face to face verbal update

with interactive questioning with interactive questioning – StructureStructure

Read-back to ensure accuracyRead-back to ensure accuracy

Patterson, Roth, Woods, et al. Intl J Quality Health Care, 2004

Applications of Standard Applications of Standard LanguageLanguage

““Read-back”Read-back”– Reduces errors in Reduces errors in

lab reportinglab reporting

“Read-backs” at your neighborhood Drive-Thru

Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004.

29 errors detected during requested read-back of 822 lab results at Northwestern Memorial Hospital. All errors detected and corrected.

A Word of Caution on A Word of Caution on TechnologyTechnology

Computerized sign-outComputerized sign-out– Brigham and Women’s Hospital Brigham and Women’s Hospital

((Petersen, et al.Petersen, et al. Jt Comm J Qual Improv, 1998) Jt Comm J Qual Improv, 1998)

– U Washington U Washington (Van Eaton, et al. J Am Coll Surg, 2005)(Van Eaton, et al. J Am Coll Surg, 2005)

IT solutions alone cannot substitute for a IT solutions alone cannot substitute for a “successful communication act”“successful communication act”– Human vigilance still requiredHuman vigilance still required

Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, 2001.

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.

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

Newer technology doesn’t Newer technology doesn’t eliminate erroreliminate error

Nor does even newer Nor does even newer technologytechnology

Continued Focus on Hand-Continued Focus on Hand-offsoffs

July 2003– ACGME set limits July 2003– ACGME set limits for resident duty hoursfor resident duty hours– Reduce sleep deprivation and Reduce sleep deprivation and

improve patient safetyimprove patient safety Unintended consequence is Unintended consequence is

increase in number of hand-increase in number of hand-offs (discontinuity)offs (discontinuity)

Safety of hand-off?Safety of hand-off?– Error-prone and variableError-prone and variable– A vulnerable “gap” in patient A vulnerable “gap” in patient

carecare

ACGME Core CompetenciesACGME Core Competencies

Patient CarePatient Care Medical KnowledgeMedical Knowledge ProfessionalismProfessionalism CommunicationCommunication Systems Based PracticeSystems Based Practice Practice Based Learning and Practice Based Learning and

ImprovementImprovement

The Role of the Hand-off: The Role of the Hand-off: Communication and Patient SafetyCommunication and Patient Safety Transfer of information Transfer of information

(content)(content) Different modalities Different modalities

(process)(process)– Written Written – VerbalVerbal

Variable, error-proneVariable, error-prone Few trainees receive Few trainees receive

formal education formal education

The Joint The Joint Commission National Commission National Patient Safety Goal Patient Safety Goal (effective Jan 1, (effective Jan 1, 2006)2006)– ““Requires hospitals Requires hospitals

to implement a to implement a standardized standardized approachapproach to hand- to hand-off communications off communications and provide an and provide an opportunity for staff opportunity for staff to ask and respond to ask and respond to questions about to questions about a patient's care”a patient's care”

How Do We Do At Sharing How Do We Do At Sharing Information?Information?

Verbal handoffsVerbal handoffs– Interruptions lead to diversion of Interruptions lead to diversion of

attention, forgetfulness, and error attention, forgetfulness, and error (Coiera, BMJ 1998)(Coiera, BMJ 1998)

Written handoffsWritten handoffs– InconsistentInconsistent– Missing code status, allergies, age, sex Missing code status, allergies, age, sex

(Lee, JGIM 1996)(Lee, JGIM 1996)

A Brief Example of the A Brief Example of the Difficulties in Difficulties in

CommunicatingCommunicating The Purpose of This ExerciseThe Purpose of This Exercise

– To make the distinction between To make the distinction between hearing (the biological process of hearing (the biological process of assimilating sound waves) and listening assimilating sound waves) and listening (adding our interpretations of what is (adding our interpretations of what is being said)being said)

– To demonstrate the importance of To demonstrate the importance of effective communication skills and effective communication skills and listening skills to thinking and acting listening skills to thinking and acting systematicallysystematically

• adapted from the Systems Thinking Playbook, Meadows and Sweeney, 1995

Instructions for Part 1 of the Instructions for Part 1 of the exerciseexercise

Everyone take 1 sheet of colored Everyone take 1 sheet of colored paperpaper

There is no talkingThere is no talking Close your eyes and do exactly what Close your eyes and do exactly what

I tell you to doI tell you to do Our goal is to produce identical Our goal is to produce identical

patterns with the pieces of paperpatterns with the pieces of paper

Instructions for Part 2 of the Instructions for Part 2 of the exerciseexercise

Form groups of 3 or 4 at your tableForm groups of 3 or 4 at your table Pick 1 person to be the communicator and Pick 1 person to be the communicator and

the rest will be the listenersthe rest will be the listeners Listeners close their eyesListeners close their eyes Communicators go through at least 3 Communicators go through at least 3

steps, each step involving a fold and a tearsteps, each step involving a fold and a tear Switch roles and repeat the exercise with Switch roles and repeat the exercise with

your same group but with someone else as your same group but with someone else as the communicator. This time the listeners the communicator. This time the listeners are allowed to talk, but still have their are allowed to talk, but still have their eyes closedeyes closed

What happened?What happened?

How would you describe your How would you describe your listening skills?listening skills?

For those who were communicators, For those who were communicators, how effective were your skills?how effective were your skills?

Were there any differences in the 3 Were there any differences in the 3 attempts?attempts?

How Can We How Can We Improve Hand-offs?Improve Hand-offs?

Developing a Standard Developing a Standard Hand-off ProtocolHand-off Protocol

A Model For Developing A Model For Developing a Standard Protocola Standard Protocol

Principles underlying the modelPrinciples underlying the model– The hand-off protocol will need to be discipline specificThe hand-off protocol will need to be discipline specific– Standardization is key for both process and contentStandardization is key for both process and content

PROCESSPROCESS– Create a process map Create a process map

CONTENTCONTENT– Create a standard check-listCreate a standard check-list

IMPLEMENTATIONIMPLEMENTATION– Leadership and resident buy-inLeadership and resident buy-in

MONITORING MONITORING – Ensure the protocol is in place and identify and resolve Ensure the protocol is in place and identify and resolve

barriersbarriers

Understanding Hand-Understanding Hand-offs offs

as a Processas a Process

““The first step is to draw a flow The first step is to draw a flow diagram. Then everyone diagram. Then everyone

understands what his job is. If understands what his job is. If people do not see the process, people do not see the process,

they cannot improve it.”they cannot improve it.”W.E. Deming, 1993W.E. Deming, 1993

Overview of Process Overview of Process MappingMapping

A process map or flowchart is a picture of the A process map or flowchart is a picture of the sequence of steps in a processsequence of steps in a process

Useful forUseful for– Planning a projectPlanning a project– Describing a processDescribing a process– Documenting a standard way for doing a jobDocumenting a standard way for doing a job– Building consensus about the process (correct Building consensus about the process (correct

misunderstandings about the process)misunderstandings about the process) Detailed process maps are especially helpful Detailed process maps are especially helpful

to standardize and improve processesto standardize and improve processes For use as an improvement tool, it is For use as an improvement tool, it is

important to map the current process, not the important to map the current process, not the desired processdesired process

Process MappingProcess Mapping

Ovals are beginnings and endingsOvals are beginnings and endings

Boxes are steps or activitiesBoxes are steps or activities

Diamonds are questionsDiamonds are questions

Arrows show sequence and chronology Arrows show sequence and chronology

Process MappingProcess Mapping

Can be “high-level” to get an Can be “high-level” to get an overview of the processoverview of the process

Assessed inER

Patientarrives in ER DischargedAdmitted?

No

Yes

Sent to floor

DiagnosedAnd

Treated

Process MappingProcess Mapping

Can also be very detailed and “drilled Can also be very detailed and “drilled down” to show the details and rolesdown” to show the details and roles

Detailed process maps are especially Detailed process maps are especially helpful to standardize and improve helpful to standardize and improve processesprocesses

For use as an improvement tool, it is For use as an improvement tool, it is important to map the current important to map the current process, not the desired processprocess, not the desired process

A Sample Hand-off Process A Sample Hand-off Process (Internal Medicine)(Internal Medicine)

Covering intern answers page and sets meeting time(sign out takes precedence

over other activities)

Primary intern goes to location of covering intern for

meeting

Primary intern verbally summarizes status of patients on list, with focus on what needs to be

done, anticipated complications. There is a standard language

Primary Intern forwards pager to

covering intern, via pager system

Primary intern revises written sign out with

emphasis on updating and adding new information

Primary intern pages covering (on-call) Intern for sign out

Covering intern reviews and asks questions for additional clarification (may use read-back technique) as

long as needed

Analyzing Process MapsAnalyzing Process Maps

What is the goal of the process?What is the goal of the process? Does the process work as it should?Does the process work as it should? Are there obvious redundancies or Are there obvious redundancies or

complexities?complexities? How different is the current process How different is the current process

from the ideal process?from the ideal process?

Advanced Process Mapping: Advanced Process Mapping: Identifying BarriersIdentifying Barriers

Primary MDcreates written

signout

On-call MD Meetswith Primary MD

Primary MDcontacts on call

MD

computer/printermalfunction

no designatedmeeting place;interruptions;

workload

omissions; failureto verbally

communicate/emphasize

important issues

omission ofinformation

updating signoutnot a top priority

interruptions/ongoing workload

of on call MD

"Nothing to do"Signout not a

priority"I've gotta go"

text page "signoutis on the wall"

ENVIRONMENT

COMMUNICATION

CULTURE

Primary MDreviews patientswith on call MD

interruptions;workload;

text page to on callMD "my signout is

on the walll"

Page 1

Towards Building a "Safe and Effective Signout"Process Map Exercise: Society of Hospital Medicine

Arpana Vidyarthi, MD (UCSF) and Vineet Arora, MD, MA (UChicago)Monday, October 31, 2005

POTENTIAL FAILURES

on call MDunderstandsprimary MD'spatient issues

"I'm busy...in themiddle of

something..."

failure to question; illegiblecommunication; short hand;

colloqualisms

interruptions;workload;

page 2

Small Group ExerciseSmall Group Exercise

Working in small groups, create a Working in small groups, create a process map of an “ideal” hand-off process map of an “ideal” hand-off processprocess

Identify the type of hand-offIdentify the type of hand-off Set clear boundaries (where does the Set clear boundaries (where does the

process begin and end)process begin and end) Identify key steps and decision pointsIdentify key steps and decision points

Process Mapping Process Mapping DemonstrationDemonstration

DebriefingDebriefing

Completing the Hand-Off Completing the Hand-Off ProtocolProtocol

PROCESSPROCESSCreate a process map Create a process map

CONTENTCONTENT– Create a standard check-listCreate a standard check-list

IMPLEMENTATIONIMPLEMENTATION– Leadership and resident buy-inLeadership and resident buy-in

MONITORING MONITORING – Ensure the protocol is in place and Ensure the protocol is in place and

identify and resolve barriersidentify and resolve barriers

Determine the Standard Content: Determine the Standard Content: ANTICipateANTICipate

Develop a Develop a checklistchecklist

Have Have disciplines disciplines customize customize to their to their needsneeds

Can be Can be used to used to evaluate evaluate the quality the quality of hand-offsof 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, Beware technical, cultural, and environmental and environmental

differencesdifferences A “one-size fits all” approach does not allow for A “one-size fits all” approach does not allow for customization.customization.

EnvironmentEnvironment– Although 4 programs had a designated hand-off location, 3 Although 4 programs had a designated hand-off location, 3

conducted hand-offs wherever convenientconducted hand-offs wherever convenient CultureCulture

– One resident describes being a “slave to ‘The List’ [sign-out One resident describes being a “slave to ‘The List’ [sign-out sheet]” and “information overload” sheet]” and “information overload”

– In a different program, only acutely ill patients are on the sign-In a different program, only acutely ill patients are on the sign-outout

TechnicalTechnical– While all disciplines hand-off “administrative data” (i.e. name, While all disciplines hand-off “administrative data” (i.e. name,

MRN, room number, etc.), major differences in specific MRN, room number, etc.), major differences in specific categoriescategories

Surgical fields: Pre-op consent, post-op checks, etc.Surgical fields: Pre-op consent, post-op checks, etc. Pediatrics: Custodial issues (DCFS, parents, etc.)Pediatrics: Custodial issues (DCFS, parents, etc.)

– Common use of some language: “If/Then” for contingency Common use of some language: “If/Then” for contingency planningplanning

Psychiatry check-listPsychiatry check-list Routine fieldsRoutine fields

– Admin dataAdmin data– TherapeuticsTherapeutics– To-doTo-do– If/thenIf/then

Discipline-Discipline-specific fieldsspecific fields– HousingHousing– Court/legal Court/legal

issuesissues– Special Special

instructions instructions etc.etc.

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

Consults (pending or recommendations

Research on Transitions of Research on Transitions of CareCare

Resident to resident transitionsResident to resident transitions Inpatient to outpatient transitionsInpatient to outpatient transitions

University of Chicago University of Chicago Experience with Resident Experience with Resident

Hand-offsHand-offs Internal Medicine Department StudyInternal Medicine Department Study Development and Implementation of Development and Implementation of

Standard ProtocolsStandard Protocols

Critical Incident Study of Critical Incident Study of IM Hand-offsIM Hand-offs

To characterize communication failures To characterize communication failures during hand-offs and solicit suggestions for during hand-offs and solicit suggestions for improvementimprovement

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 QualityTaxonomy of Sign-out Quality POOR SIGN-OUTPOOR SIGN-OUT  Omissions in ContentOmissions in Content

Medications or Therapies Medications or Therapies Tests or ConsultsTests or ConsultsMedical ProblemsMedical Problems

Active Active AnticipatedAnticipated

Baseline statusBaseline statusCode statusCode statusRationale of primary teamRationale of primary team

  Failure-Prone ProcessesFailure-Prone Processes

Lack of Face-to-FaceLack of Face-to-Face CommunicationCommunication

Double Sign-out (“Night Double Sign-out (“Night Float”)Float”)Illegible or Unclear Illegible or Unclear HandwritingHandwriting

EFFECTIVE SIGN-OUTEFFECTIVE SIGN-OUT  Written Sign-out Written Sign-out

Patient Content Patient Content Code status Code status Anticipated problems Anticipated problems Active Problems Active Problems

Baseline Exam Baseline Exam Pending Test or Consults Pending Test or Consults

Overall Features Overall Features Legible Legible Relevant Relevant Accurate Accurate Up-to-date Up-to-date

  Verbal Sign-outVerbal Sign-out

Face to Face Face to Face Anticipate Anticipate Pertinent Pertinent ThoroughThorough

Development and Development and Implementation of a Standard Implementation of a Standard

ProtocolProtocol To date, 8 residency programs have To date, 8 residency programs have

participated. participated. Analysis of these protocols Analysis of these protocols

demonstrates that the hand-off demonstrates that the hand-off process is highly variable and process is highly variable and discipline-specific. discipline-specific.

Process and content analysis of Process and content analysis of protocols yields several themes.protocols yields several themes.

1. Understand and attempt to 1. Understand and attempt to reduce the variation in the processreduce the variation in the process

All disciplines “required” a verbal hand-offAll disciplines “required” a verbal hand-off BUT due to competing demands (OR, BUT due to competing demands (OR,

clinic, etc.), this verbal communication clinic, etc.), this verbal communication sometimes did not occur sometimes did not occur – Educate residents on this important priority Educate residents on this important priority

Individual-level variation also presentIndividual-level variation also present– ““Some residents are better at Some residents are better at

making themselves available and making themselves available and touching base with you [during the touching base with you [during the hand-off] than others...”hand-off] than others...”

2. Hand-off = Transfer of 2. Hand-off = Transfer of information + professional information + professional

responsibilityresponsibility Transfers were at times separated in Transfers were at times separated in

time and spacetime and space– In one program, departing residents In one program, departing residents

forward their pager to the on-call resident forward their pager to the on-call resident after they provide a verbal hand-off. after they provide a verbal hand-off.

– In another program, the on-call resident In another program, the on-call resident transfers a virtual pager to their own pager transfers a virtual pager to their own pager at a designated time which often occurs at a designated time which often occurs well before they receive a verbal hand-off. well before they receive a verbal hand-off.

Transfer of professional responsibility

Verbal hand-off

Neurology Hand-Off

3. Need to ensure “closed-3. Need to ensure “closed-loop” hand-off loop” hand-off

communication communication In two cases, patient tasks were divided In two cases, patient tasks were divided and assigned to other team members and assigned to other team members – To facilitate early departure of a post-call To facilitate early departure of a post-call

resident (to meet resident duty hour resident (to meet resident duty hour restrictions)restrictions)

– BUT results of these tasks were not formally BUT results of these tasks were not formally communicated to anyone communicated to anyone

Residents ensured “closed-loop” Residents ensured “closed-loop” communication by building required follow-communication by building required follow-up on these tasks into the processup on these tasks into the process

The post call intern updates sign-out on the computer

(noon – 1p.m.)

Team meets to review list after noon conference (team includes other interns, senior residents)

Post call intern reports on each

patient

Sign-out given to on-call intern

Post call intern brings copy of sign-out for on call intern

Sr Resident offers input on completing task

Are there tasks to be completed? (e.g., f/u labs,

imaging, discharge)

Sr resident assigns tasks to other interns

Are the tasks completed?

No

Yes

Yes

NoOn-call intern continues

care and follow-up on any tasks

Post-call intern forwards pager to

on-call intern

Intern reports status of task to senior resident

and on-call intern

Unfinished tasks go to on call intern

“closed-loop” communication

Pediatric Resident Post-Call Hand-Off

4. Keep the focus on patient 4. Keep the focus on patient care: care:

Clear roles and back-up Clear roles and back-up behaviorbehavior Anesthesia resident to PACU RNAnesthesia resident to PACU RN

– Interdisciplinary hand-off with challenging complex Interdisciplinary hand-off with challenging complex fast-paced environmentfast-paced environment

Clear delineation of responsibility to ensure Clear delineation of responsibility to ensure patient carepatient care

Anesthesia resident to call out for a bedAnesthesia resident to call out for a bed Unit clerk to respond with bed #Unit clerk to respond with bed # PACU RN to hook up monitorsPACU RN to hook up monitors

Equally important back-up behaviors Equally important back-up behaviors Can empower participants to focus on the patient Can empower participants to focus on the patient

care care ““If nursing delay >30 sec, then resident to hook up If nursing delay >30 sec, then resident to hook up

monitors and call for RN”monitors and call for RN”

Anesthesia Resident to PACU Nurse Hand-Off

Is patient ok to go to PACU?

Patient in OR

Patient goes to ICU

Resident tells circulating nurse

about special needs (venilator, a-line, invasive monitors, etc.)

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

Are nurses waiting at slot?

Resident puts monitor on patient

and hooks up oxygen, questions

why no nurses

Resident mobilizes nursing

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?

Resident mobilizes nursing team to put on monitors

Resident completes

documentation of case (fills out PACU vitals, writes note, documents

handoff given)

Nurses arrive

yes

no

no

Resident identifies nurses that are taking care of

patient

Resident gives report (content

checklist)

Nurses accept patient

Is patient high risk? (difficult airway, labile vitals, anes problem)

no

Resident completes and

signs PACU orders

no

yes

yes yesPACU resident

called and given special report

Clear delineation of roles/responsibility

Back-up Behavior

Future workFuture work

We are still in the early stages of our workWe are still in the early stages of our work Continue our researchContinue our research

– Mechanisms of human failures during sign-outs,Mechanisms of human failures during sign-outs,– Human factors and ergonomic issues that impede Human factors and ergonomic issues that impede

the sign-out process the sign-out process – Perceived risks associated with shift changes by Perceived risks associated with shift changes by

different classes of providers and administratorsdifferent classes of providers and administrators– Understanding shared work betterUnderstanding shared work better

Ultimately, the goal is to identify and Ultimately, the goal is to identify and implement interventions that can reduce the implement interventions that can reduce the risks associated with transitions in carerisks associated with transitions in care

Inpatient to Outpatient Inpatient to Outpatient Transitions of Care at Transitions of Care at University of ChicagoUniversity of Chicago

Our aim was to improve the quality, safety, and Our aim was to improve the quality, safety, and continuity of patient care during the transition continuity of patient care during the transition from inpatient to ambulatory care by developing from inpatient to ambulatory care by developing a model of effective communication between a model of effective communication between inpatient and ambulatory physicians.inpatient and ambulatory physicians.

Specifically, we:Specifically, we:– Assessed current methods of communicationAssessed current methods of communication– Developed a model for effective inpatient physician – Developed a model for effective inpatient physician –

primary care physician communication.primary care physician communication.– Designed an intervention to evaluate the model for Designed an intervention to evaluate the model for

effective inpatient physician – primary care physician effective inpatient physician – primary care physician communicationcommunication

MethodsMethods

Focus Groups were conducted with Focus Groups were conducted with – HospitalistsHospitalists– Primary Care PhysiciansPrimary Care Physicians– Internal Medicine residentsInternal Medicine residents– PatientsPatients

The focus groups were used to The focus groups were used to generate the process maps generate the process maps

MethodsMethods

Observations were used to verify and Observations were used to verify and enhance the processenhance the process

InterviewsInterviews

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

Barrier Barrier Representative quote(s) (Hospitalists)Representative quote(s) (Hospitalists) Representative quote(s) (PCPs)Representative quote(s) (PCPs)

Unable to Unable to correctly correctly identify the identify the PCP PCP

But also some notes, we don’t recognize their But also some notes, we don’t recognize their names so its difficult to know if that’s really a names so its difficult to know if that’s really a primary care doctor and not some sort of ancillary primary care doctor and not some sort of ancillary personperson—[Resident]—[Resident]

The other issue is do they really know who the The other issue is do they really know who the PCP is? They may see [in the electronic PCP is? They may see [in the electronic system] like a note from X, but then one from system] like a note from X, but then one from Y, one from Z, and how do they know who’s Y, one from Z, and how do they know who’s really the PCP? really the PCP?

Finding Finding PCP PCP contact contact info info

It’s a little harder to get a hold of the [community-It’s a little harder to get a hold of the [community-based] physicians so I end up resorting to based] physicians so I end up resorting to Googling – Googling – [Resident][Resident]

Sometimes we get a text page, voicemail, from Sometimes we get a text page, voicemail, from the [General Medicine] team or they call the the [General Medicine] team or they call the nurse…sometimes smoke signals- - nurse…sometimes smoke signals- -

Unaware Unaware or variable or variable preference preference of PCP’sof PCP’s

You know, this [PCP] wants you to get a hold of You know, this [PCP] wants you to get a hold of him ….but maybe some of them [other PCPs] him ….but maybe some of them [other PCPs] would say, oh, but the [patient] is in the hospital would say, oh, but the [patient] is in the hospital and you know there’s ten people taking care of and you know there’s ten people taking care of them, maybe I don’t need to be called until the them, maybe I don’t need to be called until the next morning - - next morning - - [Resident][Resident]

I think there’s a culture of… negative feedback I think there’s a culture of… negative feedback if the team contacts the PCP. PCP says oh if the team contacts the PCP. PCP says oh fine, but never shows up, that’s a learned fine, but never shows up, that’s a learned behavior, they’re going to be less likely to behavior, they’re going to be less likely to contact. contact.

Contacting Contacting PCP not a PCP not a prioritypriority

I’m usually busy with multiple admissions so I I’m usually busy with multiple admissions so I don’t spend too much time contacting the [primary don’t spend too much time contacting the [primary care] providers right away - - care] providers right away - - [Resident][Resident]

With 13 admissions or however many --the With 13 admissions or however many --the priority is taking care of the acute illness and priority is taking care of the acute illness and continuity of care falls to number 37 on the list continuity of care falls to number 37 on the list of priorities of priorities

Fear of Fear of losing losing controlcontrol

I mean there are certain attendings, like some I mean there are certain attendings, like some sub-specialists, I mean they want you to call them sub-specialists, I mean they want you to call them right away if its like, they have a cough… - - right away if its like, they have a cough… - - [Resident][Resident]

I get the sense that people don’t call because I get the sense that people don’t call because they’re worried that you’re going to intrude or they’re worried that you’re going to intrude or do something that prolongs the hospitalization do something that prolongs the hospitalization

Forgetting Forgetting or too or too busy to busy to contact contact PCP PCP

I know in the hospital I’ve just gotten better about I know in the hospital I’ve just gotten better about [contacting PCP’s] from the beginning of my [contacting PCP’s] from the beginning of my second year as a resident. Like I didn’t always do second year as a resident. Like I didn’t always do it right off the bat so I think that there is a learning it right off the bat so I think that there is a learning curve - - curve - -

I wonder how big of a component that being I wonder how big of a component that being super-busy especially when they are under the super-busy especially when they are under the pressure to leave the hospital by noon, the day pressure to leave the hospital by noon, the day that it would make the most sense to contactthat it would make the most sense to contact

Putting it All TogetherPutting it All Together

The research informs the The research informs the improvement workimprovement work

Artifact AnalysisArtifact Analysis

The study of any notes or materials The study of any notes or materials used in the daily workflow of patient used in the daily workflow of patient care may serve as a powerful care may serve as a powerful supplement to the self-report data supplement to the self-report data

Provides further evidence of the Provides further evidence of the effectiveness of the handovereffectiveness of the handover

Concluding CommentsConcluding Comments