Inova Health System                Picker Grant                   Update                    For           Patient Advisory...
• Explore the patient perceptions of bedside handoffs  will kick of in 2011• Always Event                                 ...
Picker Institute  Dedicated to advancing the principles of    patient-centered care.  Sponsors awards, research and educ...
Always Events • Picker has determined that an organizing principle   focused on the concept of Always Events℠ can be   imp...
Always Events℠ Challenge Grant Recipients Announced!• Organization/Institution: Inova Health System  Principal Investigato...
Journey • Handoff Issues Identified      – Agency for Healthcare Research & Quality Hospital Survey on Patient Safety     ...
Picker – will support Development of Education Program• A collaborative exchange of information (conference calls,  webina...
Background • “current state of scientific knowledge regarding hospital   handoffs is limited” (Arora, V.M, Manjarrez, Dres...
AHRQ Patient Safety Culture Survey Results • Opportunity for improvement Hand-off and teamwork   across units • Agency for...
Fumbled handoffs presents a risk for a breach inpatient safety     – Miscommunication     – Disruption in continuity of ca...
Problem Statement • The last AHRQ Culture of Safety indicated handoff   opportunity for improvement • Analysis of Handoff ...
Kaizen Event ParticipantsTeam:• Darryl Hampton, RN, CVICU, Mgmt Coord, IFH• Alice Penn Ritter, RN, GYN, Mgmt Coord, IFH• B...
Goals and Objectives of System Handoff KaizenPerformance Improvement - Continuous improvement  • Provide training/exposure...
Team Reviewed Examples of Strategies and BestPractices  (Patterson et al 2004; Park & Mishkin 2005)                       ...
ISHAPED      I   Introduce      S   Story      H   History      A   Assessment      P   Plan      E   Error Prevention    ...
What is a “Handoff” ? • “The transfer of information (along with authority and   responsibility) during transitions in car...
Benefit of Handoff    • Necessary to provide care    • 24/7 delivery of care    • Multi-disciplinary and      interdiscipl...
Causes of Handoff Failures • Lack of formal tools to support transitions in   care • Handoffs vary greatly – lack of   sta...
Where are we today?       • We have an opportunity at Inova to improve handoffs,         healthcare communication and cult...
Goals •   Improve communication and handoff process •   Improve patient safety •   Improve team work and collaboration •  ...
ISHAPED – Inova’s New Handoff Methodology • Developed by a system Kaizen team • To be piloted in multiple inpatient units ...
Four Components 1) Handoff methodology is ISHAPED –Standardize key    elements – as designed in pilot except for Assessmen...
ISHAPED Tools                • Tool to be customized                • Pencil or Pen                • Cardstock or Paper   ...
Bedside Shift to Shift Process                                 24
Qualitative Results from RN Handoff PerceptionSurvey Summary Patient do not want handoff ???????? Patient do want handoff?...
Nurses should include: • AIDET Acknowledge, Introduce, Duration, Explanations,   Thank you • Method to identify those pati...
Bottom Line • The focus is the   Patient • Patient Centered   Care                      27
Next Steps • Youtube • Revise Protocol – (IRB) • Patient and Family Developing a Patient Centered Approach to   Handoffs R...
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Inova Health System: Developing a patient centered approach to handoffs

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Inova Health System: Developing a patient centered approach to handoffs

  1. 1. Inova Health System Picker Grant Update For Patient Advisory Team Oct. 26, 2011 Mary Ann Friesen PhD, RN, CPHQ Angela Servidio RN, BSN, BA 1
  2. 2. • Explore the patient perceptions of bedside handoffs will kick of in 2011• Always Event 2
  3. 3. Picker Institute Dedicated to advancing the principles of patient-centered care. Sponsors awards, research and education to promote patient-centered care and the patient-centered care movement. 3
  4. 4. Always Events • Picker has determined that an organizing principle focused on the concept of Always Events℠ can be implemented to drive the system to become more patient-centered. • “Never Events” refer to incidents that should never happen in the delivery of care. • Patient-focused Always Events℠ are aspects of the patient and family experience that should always occur. *Brochures 4
  5. 5. Always Events℠ Challenge Grant Recipients Announced!• Organization/Institution: Inova Health System Principal Investigator(s): Mary Ann Friesen, PhD, RN, CPHQ Project Title: Developing a Patient-Centered Approach to Handoffs• Always Event(s): Patients will always be included in the ISHAPED handoff shift-to-shift hand-off process at the bedside as this will add an additional layer of safety by allowing the patient to communicate potential safety concerns.* Page 6 5
  6. 6. Journey • Handoff Issues Identified – Agency for Healthcare Research & Quality Hospital Survey on Patient Safety Culture – Variance Across System • Quality Leadership CE • System Kaizen – LEAN (March 2010) • Pilot Projects • Systemwide Rollout • Research – Nursing Research – IRC – IRB • Education Plan – Development – Production 6
  7. 7. Picker – will support Development of Education Program• A collaborative exchange of information (conference calls, webinars, and listserv communications).• Learning network for achieving the selected Always Events℠• Development of key messages and media tools http://alwaysevents.pickerinstitute.org/?cat=7 7
  8. 8. Background • “current state of scientific knowledge regarding hospital handoffs is limited” (Arora, V.M, Manjarrez, Dressler, D.D, Dresler, D.D, Basaviah, P, Halasyamani, L, Kripalani, S., 2009 p. 437) • “Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices.. (Riesenberg, L.A , Leitzsch, J., Cunningham, J.M., (2010) p. 24) Australian Council for Safety and Quality in Health Care. (2005). Clinical handover and patient safety literature review report. Retrieved January 5, 2006, from http://www.safetyandquality.org/index.cfm?page=Publications#clinhovrlit 8
  9. 9. AHRQ Patient Safety Culture Survey Results • Opportunity for improvement Hand-off and teamwork across units • Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture -Handoffs average percent positive response  2009 - 44%  2010 - 44%  2011 - 45% www. AHRQ.gov 9
  10. 10. Fumbled handoffs presents a risk for a breach inpatient safety – Miscommunication – Disruption in continuity of care – Omission of critical data – Medication errors – Serious Adverse Outcomes 10
  11. 11. Problem Statement • The last AHRQ Culture of Safety indicated handoff opportunity for improvement • Analysis of Handoff Policies and Procedures indicates variance in definitions and process across the system • There is great variation in handoff practices across the system and a lack of hardwired processes to support optimal handoffs 11
  12. 12. Kaizen Event ParticipantsTeam:• Darryl Hampton, RN, CVICU, Mgmt Coord, IFH• Alice Penn Ritter, RN, GYN, Mgmt Coord, IFH• Barbara Harrison, RN, Peds, Mgmt Coord, IFH• April Peterson, RN, T7E, IFH• Cheryl Schmitz, RN, ED Clinical Specialist, ILH• Okey Hendrick, Acute Care RN, Team Coord, ILH• Freddi Brubaker, RN, ED Director, IAH• Monica Work, RN, 21 PCD, IAH• Kristy Weirsky, RN, Mgmt Coord ED, IMVH• Season Majors, RN, PCD 3B, IMVH• Skip Reece, RN, PACU, IMVH• Angela Servidio, RN, Education Coordinator, IFOH• Joan Manning, ED, RN, Mgmt Coord, IFOH• Melanie Martin, Radiology Technical Lead, IFH• Lea Wotorson, GMU StudentFacilitators:• Mary Ann Friesen RN Project Manager (Quality Consultant)• Ann Miner - Lean Consultant• Ken Leeson – Executive Director of Strategic Process Improvement 12
  13. 13. Goals and Objectives of System Handoff KaizenPerformance Improvement - Continuous improvement • Provide training/exposure to the various handoff methodologies that have been tried with success • Select a guiding methodology for patient handoffs • Identify key components of effective handoff processes using the selected methodology • Draft a deployment plan 13
  14. 14. Team Reviewed Examples of Strategies and BestPractices (Patterson et al 2004; Park & Mishkin 2005) • Interactive, face-to-face handoff is preferred • Limit interruptions • Read-back • Un-ambiguous transfer of responsibility • Critical situation delay transfer • Written summary/information • Receive paperwork • Make it clear - who for what • Monitor • Educate • Support “Good Catch” 14
  15. 15. ISHAPED I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue 15
  16. 16. What is a “Handoff” ? • “The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm.” (Agency for Healthcare Research and Quality, 2006)* – Transfer of information – Transfer of responsibility – Accountability – Acknowledgement – Interaction – Verification – Opportunity to address patient safety 16
  17. 17. Benefit of Handoff • Necessary to provide care • 24/7 delivery of care • Multi-disciplinary and interdisciplinary care • Education • Debriefing/Support • “Rescue and Recovery” Parker, J., Gardner, G., & Wiltshire, J. (1992). Handover: the collective narrative of nursing practice. Australian Journal of Advanced Nursing., 9(3), 31-37. KLally, S. (1999). An investigation into the functions of nurses communication at the inter-shift handover. Journal of Nursing Management., 7(1), 29-36. Kerr. M.P (2002) A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing, 37(2), 125-134. Perry, S. (2004). Transitions in care: studying safety in emergency department signovers. Focus on Patient Safety, 7(2), 1-3. 17
  18. 18. Causes of Handoff Failures • Lack of formal tools to support transitions in care • Handoffs vary greatly – lack of standardization (expectation) • Not interactional • Interruptions - staggering • Memory lapse - omissions • Verbal issues - accents, sound alike medications, acronyms, abbreviations, lack of common understanding • Lack of access to patient data • Need for skill and education 18
  19. 19. Where are we today? • We have an opportunity at Inova to improve handoffs, healthcare communication and culture of safety. • “Very little evidence to support the use of any specific, structure, protocol or method.” Riesenberg, L et al. (2009) – Need for discipline specific handoffs studies – Different content needed for different areasRiesenberg, L et al. (2009) Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine 84(12) p. 1775-1787. 19
  20. 20. Goals • Improve communication and handoff process • Improve patient safety • Improve team work and collaboration • Improve staff satisfaction with handoff process • Improve patient satisfaction • Patient Centered Handoff 20
  21. 21. ISHAPED – Inova’s New Handoff Methodology • Developed by a system Kaizen team • To be piloted in multiple inpatient units for the shift-to- shift RN handoff I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue 21
  22. 22. Four Components 1) Handoff methodology is ISHAPED –Standardize key elements – as designed in pilot except for Assessment Section Customize the Assessment by unit – owned by the unit’s CPC with input sought from unit staff 2) Verbal handoff is face to face between oncoming and off- going RN 3) Handoff happens at the bedside S, H, A outside of room; I, P, E, D in room. Clinical judgment and common sense used to determine if beside component is inappropriate for a particular patient. Optional entire ISHAPED at bedside. 4) Written ISHAPED handoff template completed by off- going RN and given to oncoming RN 22
  23. 23. ISHAPED Tools • Tool to be customized • Pencil or Pen • Cardstock or Paper • RN give to oncoming RN • Oncoming RN will update and pass on • RN Report • Tech Report • RN/Tech Report 23
  24. 24. Bedside Shift to Shift Process 24
  25. 25. Qualitative Results from RN Handoff PerceptionSurvey Summary Patient do not want handoff ???????? Patient do want handoff??????? New Term Bedside Shift to Shift Report 25
  26. 26. Nurses should include: • AIDET Acknowledge, Introduce, Duration, Explanations, Thank you • Method to identify those patients who do not wish to participate • RN performs hand-off tasks such as: Checking MAG Checking chart orders Checking computer for medications charted Checking computer for orders reviewed by RN In room: Whiteboards, IV lines, etc. 26
  27. 27. Bottom Line • The focus is the Patient • Patient Centered Care 27
  28. 28. Next Steps • Youtube • Revise Protocol – (IRB) • Patient and Family Developing a Patient Centered Approach to Handoffs Research Team Advisory Board will include patient and families to assure that the experiences, perceptions and knowledge are recognized and utilized. • Interviews • Analysis • Education Plan • Education Materials • Video 28

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