Handoff Workshop - 2 Hour Training


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Presented at the George Washington University 1st GME Retreat. Includes overview of handoff function and content, pitfalls for handoffs, and strategies for safe and effective communication during handoffs, and how to use process improvement techniques to make handoffs safer. Handout includes handoff menu of educational tools to be used by faculty teaching.

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  • "a system that quickly provides staff and patients with the name of the resident currently responsible, and the name of the attending physician" Who signed out today—where? Describe it? Noisy, pager going off, others in the room?
  • Title of slide 12 supposed to be Response to Communication Failure During Sign-out ?
  • First, studies show that speakers systematically overestimate how well their messages are understood by listeners.15 Secondly, the more knowledge that people share, the worse they communicate new material because they overestimate the knowledge of the other.16 Such general psychological processes could systematically impact the effectiveness of communication during hand-offs. If this is true, then post-call interns should overestimate the effectiveness of their communication.
  • In thinking of the way we communicate, it is important to think about the mode of communicatin. I use the red arrows to highlight two ends of this spectrum that we use to communicate every day in healthcare: paper and face to face communication. And clearly they are very different and it is important to know how they differ. Esp in the context of signout. This passage from Allistair Cockburn, who is actually a software engineer and prominent author on this topic describes it best: When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues that such proximity provides. 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.
  • Now what can we say about communication at the time of Handoffs—here we have to turn to other industries…read slide… Not surprisignly, the main strategies described in this paper resonate with those that have worked in healthcare communication more generally TRANSITION TO JEFF… ********************************************** Human factors researchers noted the same thing as they conducted direct observations of handoffs at NASA Johnson Space center, 2 canadian nuclear power plants, a railroad dispatch center in the US, and an ambulance dispath center in Toronto. From these observations, they identified handoff strategies and face to face verbal update with interactive questioning was definitely a plus… Other things they noted
  • But the good news, is that communication can be improved, and that is one goal of today’s workshop. In fact, more structured communication, such as the use of a read-back, similar to your neighborhood drive-thru that confirms your order, reduces errors during telephone reporting of abnormal lab values. Highlight that 4 people refused to read back the message - > importance of institutional culture **** Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121(6):801-3. The recipients were asked to repeat the name of the patient, the test, and the result; the technologists noted this on the form. In addition, they noted the time necessary for the entire phone call and the extra time necessary to ask for the message to be repeated and for it to be repeated. Data $11.25/hour ($0.19/minute or $0.0032/second), the extra time to repeat the message costs the hospital from $0.11 to $0.16 per call ($0.07 per 13 seconds for a laboratory technologist’s time plus $0.04-$0.09 per 13 seconds for the recipient’s time).
  • Now lets turn to communication in healthcare…what do we know…first we know that it is indispensible. This is important particularly in the context of future IT solutions which are sometimes touted as the safer. **** Refs: Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):121-4. Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322(7294):1101-3. The results from 1443/3228 (45%) of urgent requests from accident and emergency and 529/1836 (29%) from the admissions ward were never accessed via the ward terminal. Results from 794/3228 (25%) of accident and emergency requests and 413/1836 (22%) of admissions ward requests were seen within 1 hour of becoming available while a further 491/3228 (15%) and 341/1836 (19%) respectively were accessed between 1 and 3 hours. In up to 43/1443 (3%) of the accident and emergency test results that were never looked at the findings might have led to an immediate change in patient management. CONCLUSIONS: When used as the sole substitute for telephoning results, the provision of terminal access to laboratory results on wards can hinder rather than promote the communication of emergency blood results to healthcare staff.
  • Fold your paper in half and tear off the bottom right corner of the paper. (Pause and allow the group to try this.) Fold the paper in half again and tear off the upper right hand corner. (Pause) Fold the paper in half again and tear off the lower left hand corner. (Pause) Open your eyes, unfold your paper and hold it out for everyone to see.
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • 2) NPO for procedure “tomorrow”  - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm  --WHAT IF ELYTE ABNORMALITIES?  WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
  • John paro, Vivian chang, Keiki hinami
  • Handoff Workshop - 2 Hour Training

    1. 1. Making the Most of Patient Handoffs: Critical for Patient Safety & Learning Vineet Arora, MD, MAPP Assoc Director, Internal Medicine Residency Asst Dean, Pritzker School of Medicine University of Chicago The George Washington University Medical Center April 16, 2010
    2. 2. Disclosures <ul><li>Funding –Handoff Projects </li></ul><ul><ul><li>Agency for Healthcare Research & Quality </li></ul></ul><ul><ul><ul><li>1 R03HS018278-01 </li></ul></ul></ul><ul><ul><ul><li>1P20 HS017119 A Model for Effective Inpatient Ambulatory Care Transitions </li></ul></ul></ul><ul><ul><li>Pritzker School of Medicine Academy of Distinguished Medical Educators </li></ul></ul><ul><ul><li>Dept of Medicine Medical Education & Clinical Excellence Award </li></ul></ul><ul><li>Other funding </li></ul><ul><ul><li>National Institutes on Aging </li></ul></ul><ul><ul><li>ACGME </li></ul></ul><ul><ul><li>ABIM Foundation </li></ul></ul><ul><ul><li>ACP Foundation </li></ul></ul><ul><li>Consulting / Honoraria </li></ul><ul><ul><li>Illinois Hospital Association </li></ul></ul><ul><ul><li>Michigan Health and Hospital Association </li></ul></ul><ul><ul><li>Maryland Patient Safety Center </li></ul></ul><ul><ul><li>MacNeal Hospital </li></ul></ul><ul><ul><li>Washington Hospital Center </li></ul></ul><ul><ul><li>Society of Hospital Medicine </li></ul></ul><ul><ul><li>Advocate Christ Medical Center </li></ul></ul><ul><ul><li>University of Illinois in Chicago </li></ul></ul><ul><ul><li>Mt Sinai Hospital </li></ul></ul><ul><ul><li>Ohio State University </li></ul></ul><ul><ul><li>Medical College of Wisconsin VA HSR&D </li></ul></ul>
    3. 3. Introductions <ul><li>Who am I? </li></ul><ul><li>Who are you? </li></ul><ul><li>What do you do? </li></ul><ul><li>What are your expectations for today’s session? </li></ul>
    4. 4. Hand-off Theatre
    5. 5. What did you observe? What went well in this scenario? Observations Facilitators Other Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Observations/Thoughts Barriers
    6. 6. Objectives <ul><li>Discuss the importance of handoffs </li></ul><ul><ul><li>Impact on patient safety </li></ul></ul><ul><li>Understanding handoffs through various lenses </li></ul><ul><ul><li>Communication science </li></ul></ul><ul><ul><li>Process engineering </li></ul></ul><ul><li>Techniques for safe and effective handoffs </li></ul><ul><li>Novel ways to teach & evaluate handoffs </li></ul>
    7. 7. Resident Duty Hours & Handoffs <ul><li>ACGME Duty Hour Limits 2003 </li></ul><ul><ul><li>11-20% increase in handoffs (Vidyarthi, 2006) </li></ul></ul><ul><ul><li>Member of the primary team in-house for less than half of the hospitalization (Horwitz, 2006) </li></ul></ul><ul><li>Safety concerns with handoffs </li></ul><ul><ul><li>Error-prone, variable </li></ul></ul><ul><ul><li>Vulnerable “gap” in patient care </li></ul></ul><ul><ul><li>Concern of shift-work mentality </li></ul></ul><ul><li>Lack of infrastructure & education </li></ul>
    8. 8. Calls to Improve Handoffs <ul><li>The Joint Commission , 2006 </li></ul><ul><li>National Patient Safety Goal: a standardized approach to hand-off communications & provide an opportunity for staff to ask and respond to questions about a patient's care </li></ul>Institute of Medicine 2008 Teaching programs &quot;should train residents in how to hand over their patients using effective communications&quot; World Health Organization, 2006 Prevention of handover errors part of “high fives” patient safety solutions
    9. 9. What types of handoffs come to mind when you think about handoffs?
    10. 10. Taxonomy of Hospital Handoffs <ul><li>Extra-hospital handoffs </li></ul><ul><li>Admission </li></ul><ul><ul><li>EMS-ED or ED to floor </li></ul></ul><ul><li>Discharge </li></ul><ul><ul><li>Home or SNF, rehab </li></ul></ul><ul><li>Inter-hospital transfer </li></ul><ul><li>Intra-hospital handoffs </li></ul><ul><li>Shift change </li></ul><ul><ul><li>Is the sender returning? (night float with cross-cover) </li></ul></ul><ul><li>Service change </li></ul><ul><li>Service transfer </li></ul><ul><ul><li>Escalation or de-escalaton of care (in and out of ICU) </li></ul></ul><ul><ul><li>Different specialty (med-surgery, OR to PACU) </li></ul></ul>
    11. 11. Risk Stratifying Care Transitions <ul><li>Is the patient physically moving? </li></ul><ul><li>Is the patient critical or unstable? </li></ul><ul><li>Is the hand-off temporary or permanent? </li></ul><ul><li>Is this the first time the receiver is hearing about a patient? </li></ul>If yes to any question, inherent increase in safety risk Admission (EMS-ED or ED-floor/ICU) A floor patient going for urgent surgery OR to PACU
    12. 12. Core Components of Handoffs <ul><li>Verbal Communication </li></ul><ul><ul><li>In person or over phone </li></ul></ul><ul><li>Written communication </li></ul><ul><ul><li>“ Transition Record” </li></ul></ul><ul><ul><ul><li>Discharge summary </li></ul></ul></ul><ul><ul><ul><li>Admission or Transfer note </li></ul></ul></ul><ul><ul><ul><li>Signout </li></ul></ul></ul><ul><li>Transfer of Professional Responsibility </li></ul>
    13. 13. The hand-off is …. <ul><li>“ a fluid, dynamic exchange that is subject to distraction, interruptions, fluctuates on aptitude of & confidence in outgoing and incoming clinician & is contingent on the incoming clinician’s confidence in the quality, completeness of the information.” </li></ul><ul><li>Cook et al. (2003) </li></ul>
    14. 14. Another point of view <ul><li>Best understood as a dialogue </li></ul><ul><ul><li>an interaction that fosters common ground, empathy, and equity to transfer necessary information </li></ul></ul>Gibson CS, et al. Ann Emerg Med 2009 <ul><li>Sender must paint a picture </li></ul><ul><ul><li>receiver must see it, understand it, act on it, and, ultimately, communicate it to someone else </li></ul></ul>
    15. 15. Another point of view <ul><li>Both parties should anticipate potential differences in expectations </li></ul><ul><ul><li>can influence what is said (content) & how messages are communicated (style) </li></ul></ul>Gibson CS, et al. Ann Emerg Med 2009 <ul><li>Like ‘fixing an engine that’s running’ </li></ul><ul><ul><li>the medical environment is changing </li></ul></ul><ul><ul><li>by the time of the handoff, the information may very well be old </li></ul></ul>
    16. 16. How can we improve handoffs? Understanding the good, bad & ugly… University of Chicago Experience
    17. 17. Asked the interns …(back in 2003) <ul><li>Critical incident interviews with interns </li></ul><ul><ul><li>Several hours after sign-out and sign-in </li></ul></ul><ul><li>Aims </li></ul><ul><ul><li>To characterize handoff communication failures that could lead to patient harm </li></ul></ul><ul><ul><li>To solicit suggestions for improvement </li></ul></ul>
    18. 18. Taxonomy of Sign-out Quality <ul><li>POOR SIGN-OUT </li></ul><ul><li>  </li></ul><ul><li>Content Omissions </li></ul><ul><li>Medications or Therapies </li></ul><ul><li>Tests or Consults </li></ul><ul><li>Medical Problems </li></ul><ul><li>Active </li></ul><ul><li>Anticipated </li></ul><ul><li>Baseline status </li></ul><ul><li>Code status </li></ul><ul><li>Rationale of primary team </li></ul><ul><li>  </li></ul><ul><li>Failure-Prone Communication </li></ul><ul><li>Processes </li></ul><ul><li>Lack of Face-to-Face </li></ul><ul><li> Communication </li></ul><ul><li>Double Sign-out (“Night Float”) </li></ul><ul><li>Illegible or Unclear Handwriting </li></ul><ul><li>EFFECTIVE SIGN-OUT </li></ul><ul><li>  </li></ul><ul><li>Written Sign-out </li></ul><ul><li>Patient Content </li></ul><ul><ul><li> Code status </li></ul></ul><ul><ul><li> Anticipated problems </li></ul></ul><ul><ul><li> Active Problems </li></ul></ul><ul><ul><li> Baseline Exam </li></ul></ul><ul><ul><li> Pending Test or Consults </li></ul></ul><ul><li>Overall Features </li></ul><ul><li>Legible </li></ul><ul><li>Relevant </li></ul><ul><li>Accurate </li></ul><ul><li>Up-to-date </li></ul><ul><li>Verbal Sign-out </li></ul><ul><ul><li>Face to Face </li></ul></ul><ul><ul><li>Anticipate </li></ul></ul><ul><ul><li>Pertinent vs. Thorough </li></ul></ul>Arora, et al. QSHC 2005 & Arora, et al. JGIM, 2008.
    19. 19. Overwhelming Feeling of Uncertainty <ul><li>In nearly all cases, communication failures resulted in uncertainty during patient care decisions: </li></ul><ul><ul><li>“ I did not know what to do” </li></ul></ul><ul><ul><li>“ unaware…” </li></ul></ul><ul><ul><li>“ Not sure…” </li></ul></ul><ul><ul><li>“ unclear…” </li></ul></ul><ul><li>Interns responded to this uncertainty </li></ul><ul><li>Patients suffered due to uncertainty </li></ul>
    20. 20. Response to Uncertainty <ul><li>Attempt to resolve uncertainty (9) </li></ul><ul><ul><li>Solicit Information from others (8) </li></ul></ul><ul><ul><li>Chart, Other Resident, or Patient: </li></ul></ul><ul><ul><li>The cross-cover ordered a pain medication…. I did not know why it was ordered and then I asked the patient but I felt like I should know that the patient was having back pain. </li></ul></ul><ul><ul><li>Unnecessary or Repeat Work (2) </li></ul></ul><ul><ul><li>A patient who had a trach got disconnected. I was not even sure why this patient had a trach... We 4 belled anesthesia b/c the trach was pulled out but later I found out that the trach was just for supplemental oxygen and not necessary. </li></ul></ul>Completed 6 month study of hospitalist service change with similar findings (Hinami, et al, J Hosp Med 2009.)
    21. 21. Differential Diagnosis of Uncertainty Farnan, et al. QSHC. 2008 Beresford E. The Hastings Center Report 1991 Patients’ treatment preferences Transfer of patient from floor to ICU Performing of a lumbar puncture Example Learn during handoff Lack of personal relationship with patient Personal uncertainty Seek supervision Difficulty applying abstract criteria to concrete situations Conceptual uncertainty Seek supervision Absence of or inadequate scientific data; limitations of fund of knowledge Technical uncertainty Strategy Definition Domain
    22. 22. Duty Hours Debate: Fatigue vs Uncertainty <ul><li>Choice between </li></ul><ul><ul><li>a fatigued post-call intern who is familiar with patient </li></ul></ul><ul><ul><li>well rested covering intern who just picked up a patient (i.e. post handoff) </li></ul></ul>Vigilance tasks – susceptible to fatigue Familiarity tasks – susceptible to handoffs Wayne & Arora, JGIM 2009
    23. 23. Fatigue vs Uncertainty: Task Matters n=300 incoming interns at 3 Midwestern institutions
    24. 24. Improving Handoffs: Handoffs as a Form of Communication “ who says what to whom in what channel with what effect” Harold Dwight Lasswell
    25. 25. Psychology of Miscommunication <ul><li>Speakers systematically overestimate how well their messages are understood by listeners </li></ul><ul><li>Egocentric heuristic – Senders assume that receiver has all the same knowledge that they do </li></ul><ul><ul><li>Worsens better you know someone </li></ul></ul><ul><li>Study of pediatric handoffs </li></ul><ul><ul><li>Optimal environment </li></ul></ul><ul><ul><li>Dedicated room & time </li></ul></ul><ul><ul><li>Supervised by senior resident & attending physicians </li></ul></ul>Keysar, et al. Psychol Sci. 2002; J Pers Soc Psychol. 2004; Intercultural Pragmatics. 2007
    26. 26. Testing these Theories <ul><li>Interviewed incoming and outgoing pediatric interns 1 h after handoff over 6 months </li></ul><ul><ul><li>Asked senders to guess what receivers would say was the most important information for each patient (had access to signouts) </li></ul></ul><ul><li>The most important piece of information was NOT communicated 60% of the time </li></ul><ul><ul><li>despite the sender believing it had been </li></ul></ul><ul><li>Did not agree on the rationales provided for 60% of items </li></ul><ul><ul><li>At times contradictory (pt going home vs. pt needed to stay) </li></ul></ul><ul><li>Retention hierarchy of information </li></ul><ul><ul><li>To do items (65%) & If/then items (69%) more likely to be remembered than knowledge items (35%), p=0.003 </li></ul></ul>Chang V, et al. Pediatrics 2010
    27. 27. Hand-off as a Form of Communication “ When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener.” – Alistair Cockburn
    28. 28. Safe and Effective Hand-offs: Other Industries <ul><li>Direct observations of hand-offs at NASA, 2 Canadian nuclear power plants, a railroad dispatch center, and an ambulance dispatch center </li></ul><ul><li>STRATEGIES </li></ul><ul><li>Standardize - use same order or template </li></ul><ul><li>Update information </li></ul><ul><li>Limit interruptions </li></ul><ul><li>Face to face verbal update </li></ul><ul><ul><li>with interactive questioning </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Read-back to ensure accuracy </li></ul></ul>Patterson, et al. Intl J Quality Health Care, 2004.
    29. 29. Applications of Standard Language <ul><li>“ Read-back” </li></ul><ul><ul><li>Reduces errors in lab reporting </li></ul></ul>“ Read-backs” at your neighborhood Drive-Thru Barenfanger, 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.
    30. 30. A Word of Caution on Technology <ul><li>Computerized sign-out </li></ul><ul><ul><li>Brigham and Women’s Hospital ( Petersen, et al. Jt Comm J Qual Improv, 1998) </li></ul></ul><ul><ul><li>U Washington (Van Eaton, et al. J Am Coll Surg, 2005) </li></ul></ul><ul><li>IT solutions alone cannot substitute for a “successful communication act” </li></ul><ul><ul><li>Human vigilance still required </li></ul></ul>Ash et al. JAMIA, 2004 and Kilpatrick et al. BMJ, 2001. <ul><ul><li>In an emergency room, the replacement of a phone call for critical lab values with an electronic results-reporting system with no verbal communication resulted in 45% (1443/3228) of urgent lab results to go unchecked. </li></ul></ul>
    31. 31. Now..Let’s put our communication skills to the test The Paper Tear Exercise
    32. 32. A Brief Example of the Difficulties in Communicating <ul><li>The Purpose of This Exercise </li></ul><ul><ul><li>To make the distinction between hearing (the biological process of assimilating sound waves) and listening (adding our interpretations of what is being said) </li></ul></ul><ul><ul><li>To demonstrate the importance of effective communication skills and listening skills to thinking and acting systematically </li></ul></ul><ul><li>adapted from the Systems Thinking Playbook, Meadows and Sweeney, 1995 </li></ul>
    33. 33. Instructions for Part 1 of the exercise <ul><li>Everyone take 1 sheet of colored paper </li></ul><ul><li>There is no talking </li></ul><ul><li>Close your eyes and do exactly what I tell you to do </li></ul><ul><li>Our goal is to produce identical patterns with the pieces of paper </li></ul>
    34. 34. Instructions for Part 2 of the exercise <ul><li>Form groups of 3 or 4 at your table </li></ul><ul><li>Pick 1 person to be the communicator and the rest will be the listeners </li></ul><ul><li>Listeners close their eyes </li></ul><ul><li>Communicators go through at least 3 steps, each step involving a fold and a tear </li></ul><ul><li>Switch roles and repeat the exercise with your same group but with someone else as the communicator. This time the listeners are allowed to talk, but still have their eyes closed </li></ul>
    35. 35. What happened? <ul><li>How would you describe your listening skills? </li></ul><ul><li>For those who were communicators, how effective were your skills? </li></ul><ul><li>Were there any differences in the 3 attempts? </li></ul>
    36. 37. Improving handoffs: <ul><li>Understanding handoffs </li></ul><ul><li>as a process </li></ul><ul><li>“ The first step is to draw a flow diagram. Then everyone understands what his job is. If people do not see the process, they cannot improve it.” </li></ul><ul><ul><ul><ul><ul><li>W.E. Deming, 1993 </li></ul></ul></ul></ul></ul>
    37. 38. Process Mapping – Brief Overview <ul><li>A process map or flowchart is a picture of the sequence of steps in a process </li></ul><ul><li>Useful for </li></ul><ul><ul><li>Planning a project </li></ul></ul><ul><ul><li>Describing a process </li></ul></ul><ul><ul><li>Documenting a standard way for doing a job </li></ul></ul><ul><ul><li>Building consensus about the process (correct misunderstandings about the process) </li></ul></ul>
    38. 39. Process Mapping <ul><li>Ovals are beginnings and endings </li></ul><ul><li>Boxes are steps or activities </li></ul><ul><li>Diamonds are questions </li></ul><ul><li>Arrows show sequence and chronology </li></ul>
    39. 40. Process Mapping <ul><li>Can be “high-level” to get an overview of the process or more “drilled down” </li></ul>Assessed in ER Patient arrives in ER Discharged Admitted? No Yes Sent to floor Diagnosed And Treated
    40. 41. Process Mapping <ul><li>Can also be very detailed and “drilled down” to show the details and roles </li></ul><ul><li>Detailed process maps are especially helpful to standardize and improve processes </li></ul><ul><li>For use as an improvement tool, it is important to map the current process, not the desired process </li></ul>
    41. 42. A Sample Hand-off Process (Internal Medicine)
    42. 43. Analyzing Process Maps <ul><li>What is the goal of the process? </li></ul><ul><li>Does the process work as it should? </li></ul><ul><li>Are there obvious redundancies or complexities? </li></ul><ul><li>How different is the current process from the ideal process? </li></ul>
    43. 44. Advanced Process Mapping: Identifying Barriers
    44. 45. Process Mapping Demonstration <ul><li>You will need </li></ul><ul><ul><li>Sticky notes </li></ul></ul><ul><ul><li>A pen </li></ul></ul><ul><ul><li>Wall space, flip chart or a white board </li></ul></ul><ul><li>First start with beginning and end </li></ul><ul><li>“And then what happens?” </li></ul>
    45. 46. Small Group Exercise <ul><li>Working in small groups, create a process map of a hand-off process </li></ul><ul><li>Identify the type of hand-off </li></ul><ul><li>Set clear boundaries (where does the process begin and end) </li></ul><ul><li>Identify key steps and decision points </li></ul>
    46. 47. Debriefing
    47. 48. Building a Standard Handoff Protocol 2006 <ul><li>Principles </li></ul><ul><ul><li>Protocol will be discipline specific </li></ul></ul><ul><ul><li>Standardization is key for both process and content </li></ul></ul><ul><li>“ Handoff Clinic” for 9 specialties </li></ul><ul><ul><li>PROCESS </li></ul></ul><ul><ul><ul><li>Create a process map </li></ul></ul></ul><ul><ul><li>CONTENT </li></ul></ul><ul><ul><ul><li>Create a standard check-list </li></ul></ul></ul><ul><ul><li>IMPLEMENTATION </li></ul></ul><ul><ul><ul><li>Resident buy-in </li></ul></ul></ul><ul><ul><li>MONITORING </li></ul></ul><ul><ul><ul><li>Identify and resolve barriers </li></ul></ul></ul>
    48. 49. 1. Understand and attempt to reduce the variation in the process <ul><li>All disciplines “required” a verbal hand-off BUT sometimes did not occur due to competing demands (OR, clinic, etc.) </li></ul><ul><ul><li>Educate staff on this important priority </li></ul></ul><ul><ul><li>Establish contigency plans in light of competing demands </li></ul></ul><ul><li>2. Handoff = Transfer of information + professional responsibility </li></ul><ul><li>At times, these transfers were separated in time and space…. </li></ul>
    49. 50. Neurology Hand-Off Transfer of professional responsibility Verbal hand-off
    50. 51. 3. Need to ensure “closed-loop” hand-off communication <ul><li>In 2 cases, patient tasks were divided and assigned to other team members </li></ul><ul><ul><li>To facilitate early departure of a post-call resident (due to duty hour limits) </li></ul></ul><ul><ul><li>BUT results of tasks not formally communicated to anyone </li></ul></ul><ul><li>Built “closed-loop” communication by integrating follow-up of tasks into the process </li></ul>
    51. 52. Pediatric Post-Call Hand-Off “ closed-loop” communication
    52. 53. Anesthesia Resident to PACU Nurse Hand-Off Clear delineation of roles/responsibility Back-up Behavior
    53. 54. Mercy Hospital Sign Out Evening Handoff to Night Float
    54. 55. Mercy Hospital Sign in Morning Handoff from Night Float
    55. 56. Resorts to operator, pill bottles, or Google to get PCP contact info
    56. 57. PCP “pieces together” what happens from available labs & studies “ It’s like a detective” PCP finds out via active surfing of roster, or coaches patient to call PCP if they go to hospital, or home health fax “ Maybe smoke signals”
    57. 58. Redesigning the Process… Engage frontline staff in redesign of process…
    58. 59. Teaching Handoffs: A Competency Based Approach Communication Professionalism Arora, et al. QSHC 2008. 2/3 of IM programs report some type of teaching on handoffs (APDIM Survey, 2008)
    59. 60. Strategies for Verbal Communication <ul><li>Face to face communication is BEST </li></ul><ul><li>Prioritize time on those most sick </li></ul><ul><li>Interactive and ask questions for clarification </li></ul><ul><ul><li>Aim for a shared mental model </li></ul></ul><ul><ul><li>Overcome egocentric heuristic (think about the other person) </li></ul></ul><ul><li>Focus on upcoming issues </li></ul><ul><li>“ If/Then” </li></ul><ul><ul><li>Anticipatory guidance </li></ul></ul><ul><ul><li>What may happen overnight and what to do about it </li></ul></ul><ul><li>“ To-do” </li></ul><ul><ul><li>Tasks that need to be done </li></ul></ul>
    60. 61. Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR? OK, this is our sickest patient, and he’s full code. I Identifying data (one liner) Mr. Jones is a 77-year-old gentleman with a right middle lobe pneumonia. G General hospital course He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin. N New events of day Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable chest x-ray was improved from admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. O Overall health status Right now he is satting 98% on 2 L NC and is afebrile. U Upcoming possibilities with plan and rationale If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because possible sepsis. T Tasks to complete overnight with plan, rationale I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up. ? Any questions? Any questions?
    61. 62. Written Sign-out <ul><li>All patients </li></ul><ul><ul><li>Even those that are discharged that day </li></ul></ul><ul><li>Update daily – need to build in time to do this! </li></ul><ul><ul><li>Focus on critical medication changes (ideally integrated with EHR) </li></ul></ul><ul><ul><li>“ to do” with specific rationale / instruction </li></ul></ul><ul><li>Information that may become important in a critical situation </li></ul><ul><ul><li>Code status/iv access/PCP/family contact info etc. </li></ul></ul>Arora, et al, JGIM. 2008
    62. 63. Is the checklist the holy grail?
    63. 64. Caution for ‘checklists’ <ul><li>Check the box mentality </li></ul><ul><ul><li>Complete the form but don’t improve care </li></ul></ul><ul><ul><ul><li>Checkbox for “I contacted the PCP” </li></ul></ul></ul><ul><li>Forms don’t fill out themselves </li></ul><ul><ul><li>Training and frontline buy-in </li></ul></ul><ul><li>One size fits all doesn’t always work </li></ul><ul><ul><li>Customization often needed (i.e. SBAR) </li></ul></ul><ul><li>Sustaining behavior change difficult </li></ul><ul><ul><li>Audits to ensure continued use </li></ul></ul><ul><ul><li>Engage frontline staff to customize </li></ul></ul>
    64. 65. Case of SBAR <ul><li>Originated in Navy to communicate critical situations </li></ul><ul><li>Adapted for nurse to physician communication </li></ul><ul><li>Became most commonly described handoff mneumonic </li></ul>
    65. 66. Misuse of SBAR <ul><li>Using “SBAR” as a verb </li></ul><ul><ul><li>“ I’m SBARing” </li></ul></ul><ul><li>Failing to customize and specify the precise elements in each category </li></ul><ul><ul><li>Likely that situation for a L&D unit differs from a geriatrics unit </li></ul></ul><ul><li>Assumption that using SBAR checklist will result in comprehensive information transfer </li></ul>
    66. 67. SBAR Arora, Johnson, Jt Comm J Qual Patient Saf. Schilling, eds. 2009
    67. 68. Some Case Examples… Based on real signouts…
    68. 69. A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?
    69. 70. Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?
    70. 71. A patient you are covering is being evaluated for small bowel obstruction. The attending surgeon comes by after being in the OR and asks you what the patient’s coags are. You say, I’m sorry but that is not my patient. Handoffs are more than just a transfer of content, but also a transfer of professional responsibility Every patient is your patient
    71. 72. Evaluation of Handoff Skills Simulation Peer Evaluation ½ of IM programs are evaluating handoffs (APDIM Survey, 2008)
    72. 73. OSHE (Objective Simulated Hand-off Experience) <ul><li>10 minutes to review mock patient H&P </li></ul><ul><ul><li>Based on actual patient </li></ul></ul><ul><ul><ul><li>Mrs. H is a 68y/o Caucasian female with a history of COPD, HTN and DM2 presenting via the ED c/o SOB x 3 days </li></ul></ul></ul><ul><li>H&P including routine data for sign-out </li></ul><ul><ul><li>reason for admission, home medications, code status, PCP and contact information for family </li></ul></ul>Farnan, et al. JGIM. In press
    73. 74. Interval Patient Events Video <ul><li>5 minute “interval patient events” video </li></ul><ul><li>Contains important clinical updates to trigger anticipatory guidance & to-do items </li></ul><ul><ul><li>Follow-up on labs </li></ul></ul><ul><ul><ul><li>“ Remember to tell your cross-cover to take a peek at the potassium on the 10PM BMP” </li></ul></ul></ul><ul><ul><li>Oxygen requirement </li></ul></ul><ul><ul><ul><li>“ Dr., the patient is looking more tachypneic and is hypotensive” </li></ul></ul></ul><ul><ul><li>Family meeting </li></ul></ul>
    74. 75. Written sign-out and hand-off <ul><li>Verbally hand-off patient to a standardized receiver </li></ul><ul><li>1 h training with facilitator guide </li></ul><ul><li>Feedback using Handoff-CEX </li></ul>
    75. 76. Hand-off CEX <ul><li>Based on “Mini- CEX” instrument widely used in internal medicine (Norcini, et al, 2003) </li></ul><ul><li>Domains assessed: </li></ul><ul><ul><li>Organization/Efficiency </li></ul></ul><ul><ul><li>Communication skills </li></ul></ul><ul><ul><li>Clinical judgment </li></ul></ul><ul><ul><li>Professionalism </li></ul></ul><ul><li>9-point scale </li></ul>
    76. 77. Peer Evaluations <ul><li>Competency-based </li></ul><ul><li>Anonymously delivered via New Innovations at end of inpatient medicine month </li></ul><ul><ul><ul><li>delivering signout (updated written sign-out, etc.) </li></ul></ul></ul><ul><ul><ul><li>receiving signout (listening behavior, cross-cover, documentation of overnight events, etc.) </li></ul></ul></ul>
    77. 79. Take Home Points <ul><li>Transfer of content AND professional responsibility </li></ul><ul><li>Communication strategies </li></ul><ul><ul><li>Face to face communication with opportunity to ask questions (Check for understanding) </li></ul></ul><ul><ul><li>Use precise language & explain rationale </li></ul></ul><ul><ul><li>Use of read-back to increase memory </li></ul></ul><ul><li>Critical Verbal content </li></ul><ul><ul><li>Anticipatory guidance (IF/then) </li></ul></ul><ul><ul><ul><li>What may happen and what to do about it </li></ul></ul></ul><ul><ul><li>Tasks that need to be done (To-do) </li></ul></ul><ul><li>A comprehensive updated written sign-out </li></ul>
    78. 80. Jeanne Farnan, MD, MHPE U Chicago Julie Johnson, MSPH, PhD U New South Wales, AU Holly Humphrey, MD U Chicago Boaz Keysar, PhD U Chicago Monica Lypson, MD U Michigan Sam Seiden, MD Stanford Leora Horwitz, MD, MS Yale Arpana Vidyarthi, MD UCSF David Meltzer, MD, PhD U Chicago Julia Kao, MD Northwestern Vivian Chang, MD UCLA Keiki Hinami, MD Northwestern John Paro, MS4 U Chicago
    79. 81. Vineet Arora varora@uchicago.edu Questions or Ideas? For copies of our papers or tools: [email_address] For our videos: “ MergeLab” on YouTube http://www.youtube.com/mergelab
    80. 83. Questions I am often asked <ul><li>Can we mandate residents take naps (for 5h!)? </li></ul><ul><ul><li>No, but can mandate break time </li></ul></ul><ul><ul><li>Work intensity, handoffs & professional culture need to be improved so that residents willing to take a break </li></ul></ul><ul><li>Can we improve patient safety during handoffs? </li></ul><ul><ul><li>UNCLEAR, but certainly investments can be made (i.e. formal training etc) so residents feel more confident in the process </li></ul></ul><ul><li>Why not just get rid of extended shifts (>24h)? </li></ul><ul><ul><li>Patients don’t want sleep deprived residents </li></ul></ul><ul><ul><li>Is there really educational value for interns who stay all night? ** </li></ul></ul>QUESTION FOR YOU… Would you rather be cared for by a sleep deprived resident who knows you OR well rested resident who does not know you?
    81. 84. My answer: it depends! If the resident is… <ul><li>Performing a vigilance-based task (i.e. arterial lines, interpretation of EKG, etc.) </li></ul><ul><ul><li>Well rested residents outperform fatigued residents </li></ul></ul><ul><ul><li>Knowledge of patient is NOT important </li></ul></ul><ul><ul><li>In fact, take the most experienced resident (or faculty) </li></ul></ul><ul><li>Making a medical management decision (i.e. give antibiotics, diagnosing or treating a new symptom) </li></ul><ul><ul><li>FAMILIARITY with patient matters </li></ul></ul><ul><ul><li>With handoffs, decisions made with a high degree of uncertainty due to unfamiliarity with case </li></ul></ul><ul><ul><li>Patients often have to repeat story </li></ul></ul><ul><ul><li>A one size fits will not work for all disciplines… </li></ul></ul>