1. Session 3.7 Applying best practice to develop innovative and
effective communication practices to improve patient outcomes in
NHS Scotland
Design, Test and Learn

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5. http://www.youtube.com/watch?v=3EZ32TygD9c

6. The Capacity Safety Brief
Peter Campbell
Clinical Nurse Manager
RHSC Edinburgh

7. Today's Presentation
• History
• Reason For Change
• Format of New Huddle
• What has worked well
• What hasn‟t worked well
• Outcomes
• Improvement Clinic
• Next steps

8. History
• Morning bed meeting since 1990‟s
• Handover from Night Sister
• Attended by Senior Nurses
• No Medical staff or Service Managers
• Could last up to 45 minutes
• Complete run down of nurse staffing
• Difficult to make decisions
• Not clear where the responsibility lay

9. Reason For Change
• H1N1 – new format for bed meeting 2009/10
• New Venue
• Clinical Director and Service Manager attend
• Change in what was being reported on
• Further bed meetings as the day progressed
• Awareness of national services
• Focus on Critical Care & Retrieval Service
• Visit to Cincinnati

10. Format of New Huddle – January 2012
• Takes place at 8am prompt in Lecture Theatre
• Attended by Charge Nurse or Nurse-in-Charge
• Clinical Management Team
• Medical leads & CNM‟s plus others
• New spread sheet to capture data
• Ward report sheet
• Outcomes

11. What Has Worked Well – Key Safety
Points
• Current Information being reported
• Clinical Coordinator spends less time gathering
information
• Issues are dealt with and responsibilities are clear
• Watchers are being identified
• Look back, look ahead & follow up
• Given plan for the day
• Staffing issues are dealt with
• Improved team working with Charge Nurses
• ER predicted admissions

12. What hasn’t worked well
• Way you are spoken to
• Too many private conversations
• No clear definition of a „Watcher‟
• Don‟t always summarise status & outcomes
• Critical Care dominates the discussion
• Look back, look ahead & follow up
• No medical ARU Consultant
• Site issues not discussed
• No feedback from Senior Nurse on call
• Theatre discussion too brief

13. Outcomes
• Equity of access
• Effective prioritisation and triage
• Reduction in cancellation of patients
• Meeting national targets
• Staff attendance at huddle
• Briefings take no longer than 10 minutes

14. Improvement Clinic
• Select group from „huddle‟ attendees
• Three questions prior to clinic
• Collated responses – circulated
• Meet for 1 hour – focused discussion
• Draw up action plan
• Identify who is responsible
• Feedback and circulate outcomes

15. Next Steps
• Rebrand – Capacity & Safety Brief
• Data recording
• Site specific issues
• Rota to identify who is chairing & CNM for the week
• Plan for safety brief – pre winter 2012
• Weekend and PH CBM
• Dial in facility for SJH

16. Where We Are

17. NHS Ayrshire & Arran
Early recognition of the
deteriorating child - ‘Watchers’
Fiona Scott SCN
Claire Colvine APNP

18. BACKGROUND
Within our children‟s inpatient ward we need a reliable
system of identifying, monitoring, escalating and
communicating information about the children in our care to
the right clinicians, at the right time, using the right format.
To ensure the early recognition of the deteriorating child or
„watchers‟ 24 hours a day, every day (Cincinnati Children‟s
Hospital).

19. QUESTIONS WE ASKED OURSELVES
• What is our model for improvement?
People only want a change if they are going to benefit
from it
• Where are we now?
• Where do we realistically want to be? (What are we
trying to accomplish? How will we know change is an
improvement?)
• How are we going to get there? (What change/s can
we make that will result in an improvement)?

20. IMPROVEMENT AIM
Outcome Primary Drivers Secondary Drivers
SBAR (reporting system)
PAWS (early warning system)
Effective written
and verbal Safety brief
communication Paediatric Global Trigger Tool (PTT)
at all times Nursing staff education
To have a reliable
system of identifying Establish Who?
and successfully multi-disciplinary Where?
managing „watchers‟ handovers in When?
100% of the time by ward area at least 3 Why?
end Sept 2012 times per day
Agreed standard process
Effective Education of MDT
escalation of Data collection and audit
concern process SBAR
Visual prompt

21. VISUAL PROMPT
Ward 1B

22. SMALL TESTS OF CHANGE - PDSA CYCLES
Cycle 4 – Prediction: It continues to work. Plan: nurse in charge, registrars
on duty, every 9pm handover in ward area. Results: All team members see
benefit of change to the children and themselves. Learn: to maintain high
level of communication with all. Action: Monitor continuity of process.
Cycle 3 – Prediction: that process will work. Plan: one nurse, one registrar,
one 9pm handover in ward area. Results: It worked mainly because of
registrar buy- in and same registrar on for next 4 nights. Learn: continuity of
key personnel who see a benefit is essential. Action: share the verbal benefits
to MDT.
Cycle 2 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm
handover in ward area. Results: right people, right place, right format, wrong time. Learn:
ensure staff are aware of timing to ensure handover happens as planned and staff get off
duty on time. Action: update progress report to discuss at morning MDT handover.
Cycle 1 – Prediction: that process would work. Plan: one nurse, one registrar, one 9pm hand
over in ward area. Result: right time, right people, right format, wrong venue. Learn: ensure
registrar aware of where handover to happen and reasons why. Action: email to all registrars.

23. How do we know a change
is an improvement?
• Quantative data collection and analysis
(keeping record on safety brief measuring attendance
compliance by nurse in charge)
• Qualitative anonymous questionnaire given to middle
grade medical staff and senior nursing staff for
completion

24. RESULTS
Data collected from safety brief notices
Enthusiastic
Registrar Monthly
Unenthusiastic Locum Registrar Compliance
Registrar Cover (mean) 77%

25. RESULTS
Data collected from safety brief notices
Monthly Compliance
(mean) 77%
*
* 3 day week

26. Percentage compliance with
9pm handover Feb-May 2012
100 100
98
Registrar stuck in
Locum registrar
96 resuscitation
unaware of normal
practice
February March April May

27. RESULTS
Are we ready to
do the handover?

28. LEARNING AND CHALLENGES
Learning
• Good quality communication is essential
• Buy in from all members of MDT is vital to success
• Benefit of change obvious to all
Challenges
• Keep the process rolling – make it the norm
• Regular audit to ensure continuation of change
• Staff education (ensuring new medical staff are aware of
process and responsibilities)

29. NEXT STEPS
1. Widen to the healthcare team to
physio, pharmacist, dietician and others;
2. Consideration of medical staff attending huddle at
3pm and 3am;
3. Comparison of quality of escalation when lack of
compliance with MDT handover.

30. Applying Best Practice to Develop
Innovative and Effective Communication
Practices to Improve Patient Outcomes
Medical Handovers
Dr Ailsa Howie
ST6 Acute Medicine
SPSP Fellow

31. WHAT IS A HANDOVER ?
• The transfer of
professional
responsibility and
accountability for some
or all aspects of the care
of a patient or group of
patients to another
person or professional
group on a temporary or
permanent basis

32. OR IS IT A BIT MORE LIKE THIS?

33. • Relies on a clear and comprehensive
system of communication
• Transfer of critical information
• Ensure seamless continuity of patient care
and safety

34. WHY IS GOOD COMMUNICATION SO
IMPORTANT ?
• Communication failure leads to
• uncertainty in decisions in patient care
• inefficient, suboptimal care
• patient harm
• Communication problems are the most
common cause of preventable in hospital
disability or death.

35. LITTLE BIT OF EVIDENCE
• 78% of communication breakdowns occurred within a
single department
– 19% occurred across departments
– 2% across institutions.
• 92% of the breakdowns were verbal
• 64% occurred between a single transmitter and a single
receiver.
• Cross-disciplinary and intra-disciplinary communication
breakdowns occurred with approximately the same
frequency.
– Most commonly, information was never transmitted
(49%)
Caprice C Greenberg et al. Patterns of Communication Breakdowns Resulting
in Injury to Surgical Patients. J Am Coll Surg

36. WHY SHOULD WE TRY TO IMPROVE
HOSPITAL AT NIGHT HANDOVERS?
•Current Handovers
• Lack Structure
• Not valued by participants
• Junior doctors find them stressful
• Potential for patient harm

37. HANDOVER IMPROVEMENTS
• Formal Structure
• Ensure a set time and place that is free of
interruptions, with senior supervision.
• A standardised process
• Standard proforma
• Education
• Focus on Foundation Doctors

38. STANDARDISATION OF THE PROCESS
• How should patient‟s be handed over?
• Patients who need to be reviewed
• Patients “to be aware of”
• Patients who need to be admitted
• Tasks that require completion

39. THE PROFORMA
• Based on SBAR
• Situation
• Background
• Assessment
• Recommendation
• Initially paper based
• Now on TRAK (In Royal Infirmary
Edinburgh)

40. Addressograph
Label WARD
SBAR Handover Sheet
BASE
Requesting HAN Review
Situation
Presenting complaint:
(eg: Central chest pain,
SOB)
Background Relevant PMH Relevant Medication
Include any recent
operations / procedures
Assessment
Provisional Diagnosis
Current Treatment
Tests undergone and
results
Most Recent SEWS Score :
Recommendation s
Tests still needed (eg CT
scan)
Treatment still needed (e.g.
IVI)
Results Awaited
Mandatory Information
ESCALATION CONSULTANT AWARE OF
DETERIORATION
For escalation to critical care
Yes
Not for escalation
No
Ceiling of treatment not decided
RESUSCITATION STATUS TIME TILL REVIEW NEEDED
For Resuscitation < 1 HOUR
DNAR < 4 HOURS
Not Discussed OVERNIGHT

42. HOW DO WE KNOW A CHANGE HAS LEAD
TO AN IMPROVEMENT?
• Process measures
• Percentage of SBAR handover forms completed
compared to reviews requested.
% of SBAR Forms Completed for Reviews Requested RIE
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
Months

43. Process Measures
Number of patients being handed over per
month
Total Number of Reviews Requested per Month RIE
300
250
200
150 Total Number of Reviews
Requested
100
50
0

44. Outcome Measures
• Number of “surprises” per month
– A surprise is defined as a patient requiring review
overnight who should have been identified at the
handover process.
Total Number of Surprises per Month RIE
90
80
70
60
50
40
30
20
10
0
Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
Months

45. GOOD HANDOVER
•files.me.com/simonfairway/fnjhp7.mov
•https://vimeo.com/40182588

46. WHERE SHOULD WE FOCUS ATTENTION?
• Foundation Doctors
– Education
• Lecture and role play
• Doctors on line training module
• Difficult Decisions
• Identify the patients at risk of deterioration during
ward rounds
• Make decisions regarding escalation of care

47. OPPORTUNITIES !?
• Internal ward handovers
• Evening handovers
• Weekend handovers

48. ANY QUESTIONS?
THANK YOU

49. Structured Ward Rounds
Claire Gordon
Consultant in Acute Medicine
NHS Lothian
SPSP Fellow

50. Background
• Variation: area to area, disciplines, practice and
performance
• Many functions: decision making, communication,
„housekeeping‟?
• No „standards‟, no definition
• But definitely important?

51. Person centred, safe and effective care
• Clinical diagnosis
• Reviewing patients progress against anticipated
trajectory
• Making decisions about future investigations and
treatments
• Discharge arrangements
• Communicating with pt, interested others and MDT
• Active safety checking to mitigate against avoidable
harm
• Training and development of healthcare professionals

52. Patient centred care
• Patient perspective – of central importance in
collectively caring for and communicating
with patient
• Pt „centre of attention‟, empowered
• Need engagement of clinicians, managers
and organisations to improve ward round
quality
• Protect time and resources

53. Multidisciplinary Team Ward Rounds
• Effective multi-disciplinary team-working
improves patient outcomes
• Pharmacist on the ward round – improves
prescribing, med rec, reduces errors
• Allows thorough discharge planning
• ?board round/ huddles/ run-down

54. Background – Patient Safety
• SPSP fellowship
• Daily goals in ICU
• Post take ward round checklist
• Apply „daily goals‟ to general medical patients
• Communication issues between „silos‟
• MDT ward round
• Boarding

55. What changes were made
• Old model: Doctors go round
• Handover to nursing staff at end
• New model: attempt to have nurse on WR
• Formal MDT huddle at 11.45
• Structured WR/ daily goals proforma

56. Date……………….. Time……………
WR………………….
Review
Daily goals:1)…………………………………………………
2)…………………………………………………
3)…………………………………………………
4)…………………………………………………
5)…………………………………………………
Nursing: PVC Y/N Needed Y/N Review site
Incontinent? Diarrhoea?
For LCP?
Pharmacy: Antibiotics………………..………………
Thromboprophylaxis Y/N
Dosette box Y/N
Patient at risk of deterioration Y/N
FOR ESCALATION/ NOT FOR ESCALATION/
UNDECIDED
FOR CPR/ DNACPR/ UNDECIDED
Signed………………………….. Bleep………………….

57. Structured Ward Round Outcomes
• LoS: reduced by 0.7
• <11am discharge increased to 18%
• Transfers to critical care: 3.2% to 0.7%
• PVC bundle compliance 52% to 93%
• Cardiac arrest calls 2 to 0
• Number of outliers 15 to 9.4
• Number of 4h breaches 20.8 to 10.8
• Antibiotic prescribing 100% from 85%

58. Structured ward round outcomes
• The less measurable…
– DNACPR
– Palliative care referrals
– Complaints/ communication
• The not so good:
– readmissions  7.8% from 6.3%

59. Patient Centred Care
• Care rounding
• „go at the pace of the patient‟
• Communication round v business round
• Patient communication sheet

60. Name________________________________
Date__________________
Problems: 1)
2)
3)
4)
5)
Plan: 1)
2)
3)
4)
5)
Consultant: Claire Gordon
Please feel free to write any comments or questions on the
reverse of this.
Patient’s property

61. Vision
• Patient held record
• Problem list
• Daily goals – MDT and patient
• Aid to communication for patients and relatives/
carers

62. Next Steps
• Claire.gordon@luht.scot.nhs.uk