Designing Safe and Effective Patient · PDF fileDesigning Safe and Effective Patient Handovers Vineet Arora, ... What are the types of handoffs ... not prioritizing hand-offs,

Designing Safe and Designing Safe and Effective Patient HandoversEffective Patient Handovers

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

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

Quality Colloquium at HarvardQuality Colloquium at HarvardAugust 21, 2008August 21, 2008

10:45 10:45 –– 12:45 pm12:45 pm

ObjectivesObjectives

Determine which methods are most appropriate Determine which methods are most appropriate for exploring handfor exploring hand--offs in clinical settings offs in clinical settings Develop a standard process to optimize handDevelop a standard process to optimize hand--offs using a process mapping methodologyoffs using a process mapping methodologyCreate a checklist of critical patient and process Create a checklist of critical patient and process informationinformationDesign a strategy for dissemination and trainingDesign a strategy for dissemination and trainingIdentify and overcome barriers to Identify and overcome barriers to implementationimplementationDevelop a plan to evaluate and monitor handDevelop a plan to evaluate and monitor hand--off protocolsoff protocols

AgendaAgenda10:45 10:45 –– 10:5010:50 Introduction and Overview of the AgendaIntroduction and Overview of the Agenda

10:50 10:50 –– 11:0011:00 Participant Introductions and ExpectationsParticipant Introductions and Expectations11:00 11:00 –– 11:1011:10 HandHand--off Theateroff Theater11:10 11:10 –– 11:1511:15 Audience PollAudience Poll11:15 11:15 –– 11:3011:30 What is known about HandWhat is known about Hand--offs in offs in

Medicine and other IndustriesMedicine and other Industries11:30 11:30 –– 11:5011:50 Small Group Exercise: Paper TearSmall Group Exercise: Paper Tear11:50 11:50 –– 12:0012:00 A Model for Developing a Standard A Model for Developing a Standard

ProtocolProtocol12:00 12:00 –– 12:2012:20 Small Group Exercise: Process MappingSmall Group Exercise: Process Mapping12:20 12:20 –– 12:30 12:30 Completing the HandCompleting the Hand--off Modeloff Model12:30 12:30 –– 12:4012:40 Research PresentationResearch Presentation12:40 12:40 –– 12:4512:45 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 todayWhat are your expectations for today’’s s session?session?

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

think about handoffs?think about handoffs?

““HandHand--off Theateroff Theater””

Role Play of a Intern Role Play of a Intern ““SignSign--outout””

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

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

Barriers Observations/ThoughtsCultural (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 PlayDebriefing from the Role Play

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

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

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

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

Audience Poll: Current Practices in Audience Poll: Current Practices in Transfer of Care in Your InstitutionTransfer of Care in Your InstitutionIf 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 flyOn the fly”” (wherever/whenever the two (wherever/whenever the two

parties can meet)parties can meet)–– At the patientAt the patient’’s bedsides bedside

Audience Poll: Current Practices in Audience Poll: Current Practices in Transfer of Care in Your InstitutionTransfer of Care in Your InstitutionDoes your program/institution use a Does your program/institution use a standard template for written information standard template for written information conveyed at the handconveyed at the hand--off (off (““signsign--outout””)?)?

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

Background Background and Definitionsand Definitions

Exchange vs. HandExchange vs. Hand--offoff

An exchange of information doesn't require that An exchange of information doesn't require that the other person understand what is being the other person understand what is being transmitted but simply conveys information transmitted but simply conveys information –– information is often acquired and transmitted without information is often acquired and transmitted without

testing for comprehension testing for comprehension

A handA hand--off implies transfer of information as well off implies transfer of information as well as professional responsibilityas professional responsibility–– HandHand--offs with exchange elements that donoffs with exchange elements that don’’t test for t test for

comprehension put teams at riskcomprehension put teams at risk

Lessons from Other Lessons from Other Industries and Applications Industries and Applications

to Healthcareto Healthcare

HandHand--off as a Form of Communicationoff as a Form of Communication“When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener.”

–Alistair Cockburn

HandHand--offs in Other offs in Other HighHigh--Risk IndustriesRisk Industries

Direct observations of handDirect observations of hand--offs at NASA, 2 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 centercenterSTRATEGIESSTRATEGIES–– Standardize Standardize -- use same order or templateuse 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

ReadRead--back to ensure accuracyback to ensure accuracyPatterson, Roth, Woods, et al. Intl J Quality Health Care, 2004

Applications of Standard Applications of Standard LanguageLanguage

““ReadRead--backback””–– 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 signComputerized sign--outout–– Brigham and WomenBrigham and Women’’s Hospital s Hospital

((Petersen, et al.Petersen, et al. JtJt CommComm J J QualQual ImprovImprov, 1998) , 1998)

–– U Washington U Washington (Van Eaton, et al. J Am (Van Eaton, et al. J Am CollColl SurgSurg, 2005), 2005)

IT solutions alone cannot substitute for a IT solutions alone cannot substitute for a ““successful communication actsuccessful 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, people In both aviation and medicine, people depend on technology as the depend on technology as the solutionsolution……

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

Nor does even newer Nor does even newer technologytechnology

Continued Focus on HandContinued Focus on Hand--offsoffs

July 2003July 2003–– ACGME set limits for ACGME set limits for resident duty hoursresident 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 handincrease in number of hand--offs offs (discontinuity)(discontinuity)Safety of handSafety of hand--off?off?–– ErrorError--prone and variableprone and variable–– A vulnerable A vulnerable ““gapgap”” in patient carein patient care

ACGME Core CompetenciesACGME Core Competencies

Patient CarePatient CareMedical KnowledgeMedical KnowledgeProfessionalismProfessionalismCommunicationCommunicationSystems Based PracticeSystems Based PracticePractice Based Learning and ImprovementPractice Based Learning and Improvement

The Role of the HandThe Role of the Hand--off: 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, errorVariable, error--proneproneFew trainees receive Few trainees receive formal education formal education

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

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

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

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

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

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

JGIM 1996)JGIM 1996)

A Brief Example of the A Brief Example of the Difficulties in CommunicatingDifficulties in CommunicatingThe Purpose of This ExerciseThe Purpose of This Exercise–– To make the distinction between hearing (the To make the distinction between hearing (the

biological process of assimilating sound biological process of assimilating sound waves) and listening (adding our waves) and listening (adding our interpretations of what is being said)interpretations of what is being said)

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

•

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 paperEveryone take 1 sheet of colored paperThere is no talkingThere is no talkingClose your eyes and do exactly what I tell Close your eyes and do exactly what I tell you to doyou to doOur goal is to produce identical patterns Our goal is to produce identical patterns with the pieces of paperwith 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 tablePick 1 person to be the communicator and the Pick 1 person to be the communicator and the rest will be the listenersrest will be the listenersListeners close their eyesListeners close their eyesCommunicators go through at least 3 steps, Communicators go through at least 3 steps, each step involving a fold and a teareach step involving a fold and a tearSwitch roles and repeat the exercise with your Switch roles and repeat the exercise with your same group but with someone else as the same group but with someone else as the communicator. This time the listeners are communicator. This time the listeners are allowed to talk, but still have their eyes closedallowed to talk, but still have their eyes closed

What happened?What happened?

How would you describe your listening How would you describe your listening skills?skills?For those who were communicators, how For those who were communicators, how effective were your skills?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 HandImprove Hand--offs?offs?

Developing a Standard Developing a Standard HandHand--off Protocoloff Protocol

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

Principles underlying the modelPrinciples underlying the model–– The handThe hand--off protocol will need to be discipline specificoff 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 checkCreate a standard check--listlist

IMPLEMENTATIONIMPLEMENTATION–– Leadership and resident buyLeadership and resident buy--inin

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

Understanding HandUnderstanding 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 understands diagram. Then everyone understands what his job is. If people do not see what his job is. If people do not see the process, they cannot improve it.the process, they cannot improve it.””

W.E. Deming, 1993W.E. Deming, 1993

Overview of Process MappingOverview of Process Mapping

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 processUseful 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 to Detailed process maps are especially helpful to standardize and improve processesstandardize and improve processesFor use as an improvement tool, it is important For use as an improvement tool, it is important to map the current process, not the desired to map the current process, not the desired processprocess

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 Can be ““highhigh--levellevel”” to get an overview of to get an overview of the processthe process

Assessed inER

Patientarrives in ER DischargedAdmitted?

No

Yes

Sent to floor

DiagnosedAnd

Treated

Process MappingProcess Mapping

Can also be very detailed and Can also be very detailed and ““drilled drilled downdown”” to show the details and rolesto show the details and rolesDetailed process maps are especially Detailed process maps are especially helpful to standardize and improve helpful to standardize and improve processesprocessesFor use as an improvement tool, it is For use as an improvement tool, it is important to map the current process, not important to map the current process, not the desired processthe desired process

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

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 from How different is the current process from the ideal process?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"

POTENTIAL FAILURES

Small Group ExerciseSmall Group Exercise

Working in small groups, create a process Working in small groups, create a process map of an map of an ““idealideal”” handhand--off processoff processIdentify the type of handIdentify the type of hand--offoffSet 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 DemonstrationProcess Mapping Demonstration

DebriefingDebriefing

Completing the HandCompleting the Hand--Off ProtocolOff Protocol

PROCESSPROCESSCreate a process map Create a process map

CONTENTCONTENT–– Create a standard checkCreate a standard check--listlistIMPLEMENTATIONIMPLEMENTATION–– Leadership and resident buyLeadership and resident buy--ininMONITORING MONITORING –– Ensure the protocol is in place and identify Ensure the protocol is in place and identify

and resolve barriersand resolve barriers

Determine the Standard Content: Determine the Standard Content: ANTICipateANTICipate

Develop a Develop a checklistchecklistHave Have disciplines disciplines customize to customize to their needstheir needsCan be used Can be used to evaluate to evaluate the quality the quality of handof hand--offsoffs

Administrative Data □ Patient name, age, gender □ Medical record number □ Room number □ Admission date □ Primary inpatient medical team, primary care physician □ Family contact information

New Information (Clinical Update) □ Chief complaint, brief HPI, and diagnosis (or differential diagnosis) □ Updated list of medications with doses, updated allergies □ Updated, brief assessment by system/problem, with dates □ Current “baseline” status (e.g., mental status, cardiopulmonary, vital signs,

especially if abnormal but stable) □ Recent procedures and significant events

Tasks (What needs to be done) □ Specific, using “if-then” statements □ Prepare cross-coverage (e.g., patient consent for blood transfusion) □ Warn of incoming information (e.g., study results, consultant recommendations),

and what action, if any, needs to be taken that night

Illness □ Is the patient sick?

Contingency Planning / Code Status □ What may go wrong and what to do about it □ What has or hasn’t worked before (e.g., responds to 40mg IV furosemide) □ Difficult family or psychosocial situations □ Code status, especially recent changes or family discussions

Beware technical, cultural, and Beware technical, cultural, and environmental differencesenvironmental differences

A A ““oneone--size fits allsize fits all”” approach does not allow for customization.approach does not allow for customization.EnvironmentEnvironment–– Although 4 programs had a designated handAlthough 4 programs had a designated hand--off location, 3 conducted off location, 3 conducted

handhand--offs wherever convenientoffs wherever convenientCultureCulture–– One resident describes being a One resident describes being a ““slave to slave to ‘‘The ListThe List’’ [sign[sign--out sheet]out sheet]”” and and

““information overloadinformation overload””–– In a different program, only acutely ill patients are on the sigIn a different program, only acutely ill patients are on the signn--outout

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

room number, etc.), major differences in specific categoriesroom number, etc.), major differences in specific categoriesSurgical fields: PreSurgical fields: Pre--op consent, postop consent, post--op checks, etc.op checks, etc.Pediatrics: Custodial issues (DCFS, parents, etc.)Pediatrics: Custodial issues (DCFS, parents, etc.)

–– Common use of some language: Common use of some language: ““If/ThenIf/Then”” for contingency planningfor contingency planning

Psychiatry checkPsychiatry check--listlist

Routine fieldsRoutine fields–– Admin dataAdmin data–– TherapeuticsTherapeutics–– ToTo--dodo–– If/thenIf/then

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

issuesissues–– Special Special

instructions etc.instructions 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

Research on Transitions of CareResearch on Transitions of Care

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

University of Chicago Experience University of Chicago Experience with Resident Handwith Resident Hand--offsoffs

Internal Medicine Department StudyInternal Medicine Department StudyDevelopment and Implementation of Development and Implementation of Standard ProtocolsStandard Protocols

Critical Incident Study of Critical Incident Study of IM HandIM Hand--offsoffs

To characterize communication failures during To characterize communication failures during handhand--offs and solicit suggestions for 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 SignTaxonomy of Sign--out Qualityout QualityPOOR SIGNPOOR SIGN--OUTOUT

Omissions in ContentOmissions in ContentMedications 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

FailureFailure--Prone ProcessesProne ProcessesLack of FaceLack of Face--toto--FaceFace

CommunicationCommunicationDouble SignDouble Sign--out (out (““Night FloatNight Float””))Illegible or Unclear HandwritingIllegible or Unclear Handwriting

EFFECTIVE SIGNEFFECTIVE SIGN--OUTOUT

Written SignWritten Sign--out 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 UpUp--toto--date date

Verbal SignVerbal Sign--outoutFace to Face Face to Face Anticipate Anticipate Pertinent Pertinent ThoroughThorough

Development and Implementation Development and Implementation of a Standard Protocolof a Standard Protocol

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

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

All disciplines All disciplines ““requiredrequired”” a verbal handa verbal hand--offoffBUT due to competing demands (OR, clinic, BUT due to competing demands (OR, clinic, etc.), this verbal communication sometimes did etc.), this verbal communication sometimes did not occur not occur –– Educate residents on this important priority Educate residents on this important priority

IndividualIndividual--level variation also presentlevel variation also present––

““Some residents are better at making Some residents are better at making themselves available and touching base themselves available and touching base with you [during the handwith you [during the hand--off] than off] than others...others...””

2. Hand2. Hand--off = Transfer of information off = Transfer of information + professional responsibility+ professional responsibility

Transfers were at times separated in time Transfers were at times separated in time and spaceand space–– In one program, departing residents forward In one program, departing residents forward

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

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

Transfer of professional responsibility

Verbal hand-off

Neurology Hand-Off

3. Need to ensure 3. Need to ensure ““closedclosed--looploop”” handhand--off communication off 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 postTo facilitate early departure of a post--call 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 Residents ensured ““closedclosed--looploop””communication by building required communication by building required followfollow--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 care: 4. Keep the focus on patient care: Clear roles and backClear roles and back--up behaviorup behaviorAnesthesia resident to PACU RNAnesthesia resident to PACU RN–– Interdisciplinary handInterdisciplinary hand--off with challenging complex off with challenging complex

fastfast--paced environmentpaced 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 bedUnit clerk to respond with bed #Unit clerk to respond with bed #PACU RN to hook up monitorsPACU RN to hook up monitors

Equally important backEqually important back--up behaviors up behaviors Can empower participants to focus on the patient care Can empower participants to focus on the patient 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 RNmonitors 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 workContinue our researchContinue our research–– Mechanisms of human failures during signMechanisms of human failures during sign--outs,outs,–– Human factors and ergonomic issues that impede the Human factors and ergonomic issues that impede the

signsign--out process 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 implement Ultimately, the goal is to identify and implement interventions that can reduce the risks interventions that can reduce the risks associated with transitions in careassociated with transitions in care

Inpatient to Outpatient Transitions Inpatient to Outpatient Transitions of Care at University of Chicagoof Care at University 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 from continuity of patient care during the transition from inpatient to ambulatory care by developing a model of inpatient to ambulatory care by developing a model of effective communication between inpatient and effective communication between inpatient and ambulatory physicians.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 primary

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

inpatient physician inpatient physician –– primary care physician communicationprimary care physician communication

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 generate The focus groups were used to generate the process maps 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 and stakeholders to determine barriers and facilitators to an effective handover facilitators to an effective handover processprocess

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

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

But also some notes, we donBut also some notes, we don’’t recognize their t recognize their names so its difficult to know if thatnames so its difficult to know if that’’s really a 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 Y, system] like a note from X, but then one from Y, one from Z, and how do they know whoone from Z, and how do they know who’’s really s really the PCP? the PCP?

Finding Finding PCP PCP contact contact info info

ItIt’’s a little harder to get a hold of the [communitys 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 GooglingGoogling –– [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 nursenurse……sometimes smoke signalssometimes smoke signals-- --

Unaware Unaware or variable or variable preference preference of PCPof PCP’’ss

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

I think thereI think there’’s a culture ofs a culture of…… negative feedback 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, thatfine, but never shows up, that’’s a learned s a learned behavior, theybehavior, they’’re going to be less likely to re going to be less likely to contact. contact.

Contacting Contacting PCP not a PCP not a prioritypriority

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

With 13 admissions or however many With 13 admissions or however many ----the 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 I mean there are certain attendingsattendings, like some , like some subsub--specialists, I mean they want you to call them specialists, I mean they want you to call them right away if its like, they have a coughright away if its like, they have a cough…… -- -- [Resident][Resident]

I get the sense that people donI get the sense that people don’’t call because t call because theythey’’re worried that youre worried that you’’re going to intrude or 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 II know in the hospital I’’ve just gotten better about ve just gotten better about [contacting PCP[contacting PCP’’s] from the beginning of my s] from the beginning of my second year as a resident. Like I didnsecond year as a resident. Like I didn’’t always do 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 supersuper--busy especially when they are under the 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 improvement The research informs the improvement workwork

Artifact AnalysisArtifact Analysis

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

Concluding CommentsConcluding Comments