This document provides an update on Inova Health System's Picker Grant project to improve patient handoffs. It discusses: 1) The goals of exploring patient perceptions of bedside handoffs and promoting "Always Events" where patients are included in care transitions. 2) Background on the Picker Institute which supports patient-centered care research and the "Always Events" framework for driving systems to be more patient-focused. 3) Inova's work to standardize handoff processes across its system through a kaizen event, surveys identifying opportunities, and developing education programs with Picker's support.

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. • Explore the patient perceptions of bedside handoffs
will kick of in 2011
• Always Event
2

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. 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. 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. 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. 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. 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. 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. Fumbled handoffs presents a risk for a breach in
patient safety
– Miscommunication
– Disruption in continuity of care
– Omission of critical data
– Medication errors
– Serious Adverse Outcomes
10

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. Kaizen Event Participants
Team:
• 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 Student
Facilitators:
• Mary Ann Friesen RN Project Manager (Quality Consultant)
• Ann Miner - Lean Consultant
• Ken Leeson – Executive Director of Strategic Process Improvement
12

13. Goals and Objectives of System Handoff Kaizen
Performance 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. Team Reviewed Examples of Strategies and Best
Practices (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. ISHAPED
I Introduce
S Story
H History
A Assessment
P Plan
E Error Prevention
D Dialogue
15

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. 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. 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. 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 areas
Riesenberg, L et al. (2009) Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine 84(12) p. 1775-1787.
19

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. 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. 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. 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. Bedside Shift to Shift Process
24

25. Qualitative Results from RN Handoff Perception
Survey
Summary
Patient do not want handoff ????????
Patient do want handoff???????
New Term Bedside Shift to Shift Report
25

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. Bottom Line
• The focus is the
Patient
• Patient Centered
Care
27

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