E1 Rapid Fire:  Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T. Northway
Upcoming SlideShare
Loading in...5

E1 Rapid Fire: Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T. Northway






Total Views
Slideshare-icon Views on SlideShare
Embed Views



1 Embed 91

http://qualityforum.ca 91



Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment
  • Role & Function of Transfer of Care:Sharing of patient infoContinuity of careProtection of the patientClinical educationGroup collaborationSocial support for staffDemonstration of knowledge & expertise
  • Other than being an Accreditation Canada ROP, 65% of reported sentinel events are due to communication. At least half of the communication breakdowns occur during transfer of care. Majority of avoidable adverse events are due to lack of effective communicationROP:The team transfers information effectively among providers at transition points. Transition points include shift changes, discharge & client movement between health services and sectors.Handover process unreliable & highly variable  poor handover may lead to wasted resources & consequences that include:unnecessary delays in diagnosis, treatment & careRepeated testsMissed or delayed communication of test resultsIncorrect treatment or medication errors
  • Before Improvement Week: Observed 11 patient transfersNotes recorded by 1-2 observers Process timed Notes reviewed & standard practices identified definition of handover based on NHSDefects were defined: “practices which hindered the team’s availability to deliver or receive report & subsequent barriers for receiving nurse to care for patient”Transferring RN Preparation : unfamiliar with pt; left behind supplies; incomplete documentation prior to transfer; had not completed care; chart organizationTransferring MD Preparation: orders not written, valid, or clear; no accepting service identified Receiving RN Preparation: Room not ready; supplies or equipment missing or not readyTechnology Transfer: Pump profile changed; respond to medical events; alarms set within pt limits; discrepancy b/w PICU & 3rd floor practicesHandover Information: RRN not ready to accept; handover away from pt; no info recorded; conflicting info provided; family clarifies info; info not taken from best source; important info missed; next med time/dose missed; no clear plan; report disruptedClarify Info for Care: Calls TRN for clarificationDocument Handover: Handover not documented by TRN &/or RRN
  • Need for standardization to ensure consistency in critical information exchangesFace-to-face transfers with written support:improved process if supported with structured written materialstandard operation procedures in many high-risk domains such as in US nuclear power plants & air traffic controlFace-to-face communication: Enables rich aspects of personal communication such as gestures, eye contact, tones of voice, degrees of confidenceEnables the receiving RN toask questions, rephrase the handover material
  • Standardized process to ensure consistency throughout BCCH/SHHC that supports effective communication at transition points which was to engage in Face-to-face communication with written support.Past necessary paperwork was combined to include: transfer sheets, admit/transfer note, patient assessment
  • SH form: enables the receiving unit and RN with necessary info to adequately prepare the room and provide brief patient historyTRN completes SH formTRN prepares patient & family for transferRRN reviews SH form, orders, & prepares room with necessary equipment is present in room as outlined on SH formfor physical arrival of patientRRN notifies TRN when ready to accept patientTRN transports patient to receiving unit
  • 3-page Standard Physician order setEnsures complete & thorough orders for care teamEnsures necessary info to adequately care for patient upon transfer to unitOrders valid until receiving physician assesses patient & writes new ordersReceiving physician assumes responsibility for patient care upon patient arrivalFulfills medication reconciliation requirement on transferBack copies of completed SH form, physician transfer orders & opioid infusion orders sent to receiving unit
  • TRN & RRN complete ARED sections of SHARED form at at patient’s bedsideReceiving RN:Conducts focused baseline physical assessmentCommunicates & clarifies findings with TRNTransferring RNGuides and supports process Clarifies findings, answers questionsPatient / caregivers encouraged to participate in handover communication, as BCCH is a family-centered care facilityTRN & RRN sign form to indicate the completion of the SHARED Transfer of Care process
  • Note: Receiving MD Preparation was not measured pre-Kaizen or Kaizen week *Due to interrater reliability the magnitude of the change may not be reliable. It is visible that the defects in the handover of info greatly decreased pre/post kaizen
  • Ongoing measurement: 3 per program per month

E1 Rapid Fire:  Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T. Northway E1 Rapid Fire: Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T. Northway Presentation Transcript

  • SHARED Transfer of Care: Safe Intra-Hospital Transfer of Patient Care BC Children’s Hospital & Sunny Hill Health Center for Children Rita Janke, Cathy Masuda, & Tracie Northway
  • Clinical Transfer of Care The transfer of professional responsibility &accountability for some or all aspects of care fora patient to another person or professional group on a temporary or permanent basis (NHS)
  • Why Focus on Transfer of Care?•65% of reported sentinel events due to communication•Handover process unreliable & highly variable•Failures in clinical handover major preventable cause of patient harm
  • Measured Outcomes: Preparation
  • Findings•No consistency among both RNs•Inaccurate / incomplete information given•Confusing info takes away from patient•Creation / perpetuation of errors “6 pages of “I don’t really orders from 3 know this different patient” Physicians!”
  • Determining Best PracticeBased upon literature review: –Standardization of handover content & process–Best practices: 1. Two-way Communication 2. Face-to-Face Handovers with Written Support 3. Content of Handover Captures Expectation & Plan of Care–Mnemonic to guide handover
  • SHARED Transfer of Care•Standardized process throughout BCCH / SHHC•Replaces current transfer sheets, admission or transfer note, flow sheet assessment•Supports effective communication
  • SHARED Transfer of Care SH Form
  • Transfer Orders Set
  • Steps in SHAREDTransfer of Care Process
  • Pre-Kaizen &Kaizen Week Defects
  • Lessons Learned from RPIW
  • Follow-On•Program-specific champions•Mediasite education on BCCH website•Initial site-wide education for nurses Fall 2009•SHARED process added to orientation•Revisions to include PACU & Mental Health Process•Inclusion of PEWS score•Ongoing measurement via observation•Indicator placed on PSLS to identify if event occurred during transfer of care
  • Sustainment SHARED Transfer of Care: Number of defects per transfer Defects over time302520151050 Prep-w eek RPIW Final Week 1 (n=2) Week 2 (n=3) Week 3 (n=5) 30 days post 60 days post 90 days post Nov 2009- 2011 (n=7) 1- (Jun 2009) (n=14) 0-12 2-4 defects 1-7 defects 0-3 defects (n=6) 0-5 (n=12) 1-8 (n=15) 1-5 July 2010 8 defects (n=11) 8-21 defects defects defects defects (n=22) 1-7 defects defects
  • Contact InfoRita JankeQuality, Safety & Accreditation Leader – SHHCrdjanke@cw.bc.caCathy MasudaQuality, Safety & Accreditation Leader – BCCH Specialty Medicinecmasuda@cw.bc.caTracie NorthwayProject Manager, Strategic Implementation – BCCH & SHHCtnorthway@cw.bc.ca
  • Questions???