Transcript Assessing and Improving the Transfer of Patient Care

Designing Safe and
Effective Patient Handovers
Vineet Arora, MD, MA
University of Chicago
Julie Johnson, MSPH, PhD
University of Chicago
Quality Colloquium at Harvard
August 21, 2008
10:45 – 12:45 pm
Objectives






Determine which methods are most appropriate
for exploring hand-offs in clinical settings
Develop a standard process to optimize handoffs using a process mapping methodology
Create a checklist of critical patient and process
information
Design a strategy for dissemination and training
Identify and overcome barriers to
implementation
Develop a plan to evaluate and monitor handoff protocols
Agenda
10:45 – 10:50
Introduction and Overview of the Agenda
10:50
11:00
11:10
11:15
Participant Introductions and Expectations
Hand-off Theater
Audience Poll
What is known about Hand-offs in
Medicine and other Industries
Small Group Exercise: Paper Tear
A Model for Developing a Standard
Protocol
Small Group Exercise: Process Mapping
Completing the Hand-off Model
Research Presentation
Final Comments and Adjourn
–
–
–
–
11:00
11:10
11:15
11:30
11:30 – 11:50
11:50 – 12:00
12:00
12:20
12:30
12:40
–
–
–
–
12:20
12:30
12:40
12:45
Introductions
Who are you?
 What do you do?
 What are your expectations for today’s
session?

What are the types of handoffs
that come to mind when you
think about handoffs?
“Hand-off Theater”
Role Play of a Intern “Sign-out”

Use the checklist for observations:
– Please record cultural, communication, and
environmental barriers that interfere with
successful patient hand-off practices in patient
care
What Do You Look For?
Barriers
Cultural (e.g., not prioritizing hand-offs,
following proper procedures, unprofessional
behavior, etc.)
Communication (e.g., vague terms,
incomplete information, lack of verification,
etc.)
Environmental (e.g., distractions and
obstacles interfering with completing proper
hand-off procedure)
Other
Facilitators
What went well?
Observations/Thoughts
Debriefing from the Role Play

What types of barriers to an effective
hand-off did you observe?
– Environment
– Cultural
– Communication
– Any others?
Audience Poll: Current Practices in
Transfer of Care in Your Institution

When there is a transfer of care, who is
primarily responsible for the transfer?
Audience Poll: Current Practices in
Transfer of Care in Your Institution

How many senders and receivers of
information are present at the time of the
hand-off?
Audience Poll: Current Practices in
Transfer of Care in Your Institution

Is a verbal communication required at the
time of a hand-off in your
institution/program?
Audience Poll: Current Practices in
Transfer of Care in Your Institution

If conducted, where does verbal
communication take place?
– Face to face in a dedicated room
– On the phone
– “On the fly” (wherever/whenever the two
parties can meet)
– At the patient’s bedside
Audience Poll: Current Practices in
Transfer of Care in Your Institution

Does your program/institution use a
standard template for written information
conveyed at the hand-off (“sign-out”)?
Audience Poll: Current Practices in
Transfer of Care in Your Institution

Do you have formal training on how to
perform hand-offs and transition patients
for new personnel at your institution?
Background
and Definitions
Exchange vs. Hand-off

An exchange of information doesn't require that
the other person understand what is being
transmitted but simply conveys information
– information is often acquired and transmitted without
testing for comprehension

A hand-off implies transfer of information as well
as professional responsibility
– Hand-offs with exchange elements that don’t test for
comprehension put teams at risk
Lessons from Other
Industries and Applications
to Healthcare
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
Hand-offs in Other
High-Risk Industries
Direct observations of hand-offs at NASA, 2
Canadian nuclear power plants, a railroad
dispatch center, and an ambulance dispatch
center
 STRATEGIES

–
–
–
–
Standardize - use same order or template
Update information
Limit interruptions
Face to face verbal update
 with interactive questioning
– Structure
 Read-back to ensure accuracy
Patterson, Roth, Woods, et al. Intl J Quality Health Care, 2004
Applications of Standard
Language

“Read-back”
– Reduces errors in
lab reporting
“Read-backs” at your
neighborhood Drive-Thru
29 errors detected during
requested read-back of 822
lab results at Northwestern
Memorial Hospital. All errors
detected and corrected.
Barenfanger, Sautter, Lang, et al. Am J Clin Pathol, 2004.
A Word of Caution on
Technology

Computerized sign-out
– Brigham and Women’s Hospital
(Petersen, et al. Jt Comm J Qual Improv, 1998)
– U Washington
(Van Eaton, et al. J Am Coll Surg, 2005)

IT solutions alone cannot substitute for a
“successful communication act”
– Human vigilance still required
In an emergency room, replacing a phone call for critical lab
values with electronic reporting with no verbal communication
resulted in 45% (1443/3228) of urgent labs to go unchecked.
Ash, Berg, Coiera. JAMIA, 2004; Kilpatrick, Holding, BMJ, 2001.
In both aviation and medicine, people
depend on technology as the
solution…
Newer technology doesn’t
eliminate error
Nor does even newer
technology
Continued Focus on Hand-offs

July 2003– ACGME set limits for
resident duty hours
– Reduce sleep deprivation and
improve patient safety
Unintended consequence is
increase in number of hand-offs
(discontinuity)
 Safety of hand-off?

– Error-prone and variable
– A vulnerable “gap” in patient care
ACGME Core Competencies
Patient Care
 Medical Knowledge
 Professionalism
 Communication
 Systems Based Practice
 Practice Based Learning and Improvement

The Role of the Hand-off:
Communication and Patient Safety
Transfer of information
(content)
 Different modalities
(process)

– Written
– Verbal
Variable, error-prone
 Few trainees receive
formal education


The Joint Commission
National Patient Safety
Goal (effective Jan 1,
2006)
– “Requires hospitals to
implement a
standardized
approach to hand-off
communications and
provide an
opportunity for staff
to ask and respond to
questions about a
patient's care”
How Do We Do At Sharing
Information?

Verbal handoffs
– Interruptions lead to diversion of attention,
forgetfulness, and error (Coiera, BMJ 1998)

Written handoffs
– Inconsistent
– Missing code status, allergies, age, sex (Lee,
JGIM 1996)
A Brief Example of the
Difficulties in Communicating

The Purpose of This Exercise
– To make the distinction between hearing (the
biological process of assimilating sound
waves) and listening (adding our
interpretations of what is being said)
– To demonstrate the importance of effective
communication skills and listening skills to
thinking and acting systematically
• adapted from the Systems Thinking Playbook,
Meadows and Sweeney, 1995
Instructions for Part 1 of the
exercise
Everyone take 1 sheet of colored paper
 There is no talking
 Close your eyes and do exactly what I tell
you to do
 Our goal is to produce identical patterns
with the pieces of paper

Instructions for Part 2 of the
exercise





Form groups of 3 or 4 at your table
Pick 1 person to be the communicator and the
rest will be the listeners
Listeners close their eyes
Communicators go through at least 3 steps,
each step involving a fold and a tear
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
What happened?
How would you describe your listening
skills?
 For those who were communicators, how
effective were your skills?
 Were there any differences in the 3
attempts?

How Can We
Improve Hand-offs?
Developing a Standard
Hand-off Protocol
A Model For Developing
a Standard Protocol

Principles underlying the model
– The hand-off protocol will need to be discipline specific
– Standardization is key for both process and content

PROCESS
– Create a process map

CONTENT
– Create a standard check-list

IMPLEMENTATION
– Leadership and resident buy-in

MONITORING
– Ensure the protocol is in place and identify and resolve barriers
Understanding Hand-offs
as a Process
“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.”
W.E. Deming, 1993
Overview of Process Mapping
A process map or flowchart is a picture of the
sequence of steps in a process
 Useful for

–
–
–
–
Planning a project
Describing a process
Documenting a standard way for doing a job
Building consensus about the process (correct
misunderstandings about the process)
Detailed process maps are especially helpful to
standardize and improve processes
 For use as an improvement tool, it is important
to map the current process, not the desired
process

Process Mapping

Ovals are beginnings and endings

Boxes are steps or activities

Diamonds are questions

Arrows show sequence and chronology
Process Mapping

Can be “high-level” to get an overview of
the process
Patient
arrives in ER
Assessed in
ER
Admitted?
No
Discharged
Yes
Sent to floor
Diagnosed
And
Treated
Process Mapping
Can also be very detailed and “drilled
down” to show the details and roles
 Detailed process maps are especially
helpful to standardize and improve
processes
 For use as an improvement tool, it is
important to map the current process, not
the desired process

A Sample Hand-off Process
(Internal Medicine)
Primary intern revises
written sign out with
emphasis on updating and
adding new information
Primary intern
goes to location of
covering intern for
meeting
Primary intern pages
covering (on-call)
Intern for sign out
Covering intern answers
page and sets meeting time
(sign out takes precedence
over other activities)
Primary intern verbally summarizes status of
patients on list, with focus on what needs to be
done, anticipated complications. There is a
standard language
Covering intern reviews and asks
questions for additional clarification
(may use read-back technique) as
long as needed
Primary Intern
forwards pager to
covering intern, via
pager system
Analyzing Process Maps
What is the goal of the process?
 Does the process work as it should?
 Are there obvious redundancies or
complexities?
 How different is the current process from
the ideal process?

Process Map Exercise: Society of Hospital Medicine
Advanced Process Mapping:
Identifying Barriers
Arpana Vidyarthi, MD (UCSF) and Vineet Arora, MD, MA (UChicago)
Monday, October 31, 2005
Primary MD
creates written
signout
Primary MD
contacts on call
MD
On-call MD Meets
with Primary MD
Primary MD
reviews patients
with on call MD
on call
understa
primary
patient is
interruptions;
workload;
interru
work
POTENTIAL FAILURES
ENVIRONMENT
computer/printer
malfunction
interruptions/
ongoing workload
of on call MD
no designated
meeting place;
interruptions;
workload
COMMUNICATION
omission of
information
omissions; failure
to verbally
communicate/
emphasize
important issues
text page "signout
is on the wall"
failure to que
communicatio
colloqu
CULTURE
updating signout
not a top priority
Signout not a
priority
"I've gotta go"
text page to on call
MD "my signout is
on the walll"
"Nothing to do"
"I'm bus
midd
someth
Small Group Exercise
Working in small groups, create a process
map of an “ideal” hand-off process
 Identify the type of hand-off
 Set clear boundaries (where does the
process begin and end)
 Identify key steps and decision points

Process Mapping Demonstration
Debriefing
Completing the Hand-Off Protocol
PROCESS
Create a process map

CONTENT
– Create a standard check-list

IMPLEMENTATION
– Leadership and resident buy-in

MONITORING
– Ensure the protocol is in place and identify
and resolve barriers
Determine the Standard Content: ANTICipate

Develop a
checklist
 Have
disciplines
customize to
their needs
 Can be used
to evaluate
the quality
of hand-offs
Administrative Data
□
□
□
□
□
□


Patient name, age, gender
Medical record number
Room number
Admission date
Primary inpatient medical team, primary care physician
Family contact information
New Information (Clinical Update)
□
□
□
□
Chief complaint, brief HPI, and diagnosis (or differential diagnosis)
Updated list of medications with doses, updated allergies
Updated, brief assessment by system/problem, with dates
Current “baseline” status (e.g., mental status, cardiopulmonary, vital signs,
especially if abnormal but stable)
□ Recent procedures and significant events

Tasks (What needs to be done)
□ Specific, using “if-then” statements
□ Prepare cross-coverage (e.g., patient consent for blood transfusion)
□ Warn of incoming information (e.g., study results, consultant recommendations),
and what action, if any, needs to be taken that night

Illness
□ Is the patient sick?

Contingency Planning / Code Status
□
□
□
□
What may go wrong and what to do about it
What has or hasn’t worked before (e.g., responds to 40mg IV furosemide)
Difficult family or psychosocial situations
Code status, especially recent changes or family discussions
Beware technical, cultural, and
environmental differences


A “one-size fits all” approach does not allow for customization.
Environment
– Although 4 programs had a designated hand-off location, 3 conducted
hand-offs wherever convenient

Culture
– One resident describes being a “slave to ‘The List’ [sign-out sheet]” and
“information overload”
– In a different program, only acutely ill patients are on the sign-out

Technical
– While all disciplines hand-off “administrative data” (i.e. name, MRN,
room number, etc.), major differences in specific categories
 Surgical fields: Pre-op consent, post-op checks, etc.
 Pediatrics: Custodial issues (DCFS, parents, etc.)
– Common use of some language: “If/Then” for contingency planning

Psychiatric history
□
□
□

One liner with hospital presentation “21 yo AAF with hx depression and previous SA
presented now with SI and the plan of cutting wrists.”
Hospital course including what was tried (i..e trial of Seroquel, etc.) and worked (i.e.
Geodon 20mg IM worked) and progress to date (i.e. “no restraints since 3/6”)
Systems-based list of current problems (psychiatric and medical)
Special instructions
□
□
□
□
□
Precautions: Seizure, Fall Suicide, etc.
Roomate (“Can have roommate” or “needs private room”)
Restraint use “Please do NOT allow restraints unless pt is violent & undirectable”
Primary team rationale (i.e. “Avoiding high-EPS neuroleptics”)
Patient nuance (i.e. “Never tell her she’s doing better. This is not therapeutic for her.”)
Psychiatry check-list

–
–
–
–
 “For You, For me “
□
□

□
□
□

To do list for cross-cover (i.e. “check x level and adjust x” or “NTD”)
Continuing reminder for hospital stay in the “For me”
Court/Legal Issues
□
Decision-making capacity (“Voluntary” or “Involuntary”)
Status of certificate (i.e. “Awaiting judge’s decision at trial for involuntary” )
Name and contact of decision maker if patient is not able to make decisions
When to notify decision maker (i.e. “NOTIFY OF ALL MED CHANGES”)
Housing and Social Issues
□
□
Nursing home placement or other dispo (i..e “home”)
Needs to get check
 If/Then
□
□

Administrative data/Allergies
□
□
□
□
□
□

Patient name, Medical record number
Room number
Admission date
Outpatient psychiatrist
Family contact information
Allergies (medication, latex, contrast, food, etc.)
Therapeutics
□
□
□

Frequent issues to be expected with a plan to resolve using IF/then format (i.e. “if
insomnia, try Prosom” or “if agitated, try Haldol” etc.) especially for sleeping problems
ALSO What does NOT WORK (i.e. Avoid BNZ, restraints, etc)
Medications (updated list with doses, start date, any recent adjustments)
Include PRN’s and what works
ECT Orders
Results of Pertinent Labs & Radiology
□
□
Labs (i.e. Drug levels, CK levels)
Radiology findings and test date
Routine fields

Admin data
Therapeutics
To-do
If/then
Disciplinespecific fields
– Housing
– Court/legal
issues
– Special
instructions etc.
Research on Transitions of Care
Resident to resident transitions
 Inpatient to outpatient transitions

University of Chicago Experience
with Resident Hand-offs
Internal Medicine Department Study
 Development and Implementation of
Standard Protocols

Critical Incident Study of
IM Hand-offs

To characterize communication failures during
hand-offs and solicit suggestions for
improvement
Question designed to elicit information about adverse events and near misses
Was there anything bad that happened or almost happened last night
because the (VERBAL/WRITTEN) sign-out wasn't as good as it could have been?
Question designed to elicit information about ideas for improvement
Regardless of whether anything went wrong or almost went wrong, and thinking about
what should be included in a sign-out, is there anything about the (VERBAL/WRITTEN)
sign-out that you received that you think should have been better?
Arora, Johnson, et al. Quality and Safety in Healthcare, 2005.
Taxonomy of Sign-out Quality
POOR SIGN-OUT
EFFECTIVE SIGN-OUT
Omissions in Content
Medications or Therapies
Tests or Consults
Medical Problems
Active
Anticipated
Baseline status
Code status
Rationale of primary team
Written Sign-out
Patient Content
Code status
Anticipated problems
Active Problems
Baseline Exam
Pending Test or Consults
Overall Features
Legible
Relevant
Accurate
Up-to-date
Failure-Prone Processes
Lack of Face-to-Face
Communication
Double Sign-out (“Night Float”)
Illegible or Unclear Handwriting
Verbal Sign-out
Face to Face
Anticipate
Pertinent
Thorough
Development and Implementation
of a Standard Protocol
To date, 8 residency programs have
participated.
 Analysis of these protocols demonstrates
that the hand-off process is highly variable
and discipline-specific.
 Process and content analysis of protocols
yields several themes.

1. Understand and attempt to reduce
the variation in the process
All disciplines “required” a verbal hand-off
 BUT due to competing demands (OR, clinic,
etc.), this verbal communication sometimes did
not occur

– Educate residents on this important priority

Individual-level variation also present
– “Some residents are better at making
themselves available and touching base
with you [during the hand-off] than
others...”
2. Hand-off = Transfer of information
+ professional responsibility

Transfers were at times separated in time
and space
– In one program, departing residents forward
their pager to the on-call resident after they
provide a verbal hand-off.
– In another program, the on-call resident
transfers a virtual pager to their own pager at
a designated time which often occurs well
before they receive a verbal hand-off.
Neurology Hand-Off
Universal pager is
transferred to
on-call Intern
(8 am – 9 am)
Team conducts
rounds (Attending,
PGY4, PGY2)
Are there tasks to
be completed?
PGY4 runs the list
with Post-call
Intern
No
Post-call Intern
updates signout on
the computer
Post-call Intern
pages on-call
Intern
Yes
PGY4 assigns
tasks
Transfer of
professional
responsibility
Verbal
hand-off
Are the tasks
completed?
Post-call Intern runs the
list with oon-call Intern in
the Conference Room
(noon-1 pm)
Yes
Intern reports
status of task to
PGY4 and on-call
intern
No
Input given to PGY4 that
tasks not completed
Unfinished tasks
go to on call intern
Post-call intern
forwards pager to
on-call intern
On-call intern continues
care and follow-up on any
tasks
3. Need to ensure “closed-loop”
hand-off communication

In two cases, patient tasks were divided
and assigned to other team members
– To facilitate early departure of a post-call
resident (to meet resident duty hour
restrictions)
– BUT results of these tasks were not formally
communicated to anyone

Residents ensured “closed-loop”
communication by building required
follow-up on these tasks into the process
Pediatric Resident Post-Call Hand-Off
The post call intern updates
sign-out on the computer
(noon – 1p.m.)
Post call intern
brings copy of signout for on call intern
Are there tasks to be
completed? (e.g., f/u labs,
imaging, discharge)
No
Team meets to review list after
noon conference (team includes
other interns, senior residents)
Post-call intern
forwards pager to
on-call intern
Sign-out given to
on-call intern
Post call intern
reports on each
patient
On-call intern continues
care and follow-up on any
tasks
Yes
Sr resident assigns
tasks to other interns
Are the tasks
completed?
Yes
Intern reports
status of task to
senior resident
and on-call intern
No
Sr Resident offers input on
completing task
Unfinished tasks
go to on call intern
“closed-loop”
communication
4. Keep the focus on patient care:
Clear roles and back-up behavior

Anesthesia resident to PACU RN
– Interdisciplinary hand-off with challenging complex
fast-paced environment

Clear delineation of responsibility to ensure
patient care
 Anesthesia resident to call out for a bed
 Unit clerk to respond with bed #
 PACU RN to hook up monitors

Equally important back-up behaviors
 Can empower participants to focus on the patient care
 “If nursing delay >30 sec, then resident to hook up
monitors and call for RN”
Anesthesia Resident to PACU Nurse
Hand-Off
Patient in OR
Is patient ok to
go to PACU?
yes
Resident tells
circulating nurse
about special
needs (venilator,
a-line, invasive
monitors, etc.)
Resident mentally
summarizes case
to prepare for
documentation
Resident moves
patient to PACU
Resident arrives in
PACU and shouts
out to unit clerk
“Where am I
going/what
number bed?”
Sec’y or someone
else answers with
bed or slot number
Resident takes
patient to
designated slot
no
Patient goes
to ICU
Are nurses
waiting at slot?
yes
Nursing hooks up
monitors with
priority on oxygen
and pulse ox, then
EKG and blood
pressure, etc.
Clear delineation of
roles/responsibility
Is there a greater
than 30 second
delay in hook up?
no
Resident puts
monitor on patient
and hooks up
oxygen, questions
why no nurses
no
Resident
completes
documentation of
case (fills out
PACU vitals,
writes note,
documents
handoff given)
Is patient high risk?
(difficult airway, labile
vitals, anes problem)
no
Back-up
Behavior
yes
Resident identifies
nurses that are
taking care of
patient
Resident mobilizes
nursing team to
put on monitors
Resident gives
report (content
checklist)
Resident mobilizes
nursing
Nurses accept
patient
Nurses arrive
Resident
completes and
signs PACU
orders
yes
PACU resident
called and given
special report
Future work
We are still in the early stages of our work
 Continue our research

– Mechanisms of human failures during sign-outs,
– Human factors and ergonomic issues that impede the
sign-out process
– Perceived risks associated with shift changes by
different classes of providers and administrators
– Understanding shared work better

Ultimately, the goal is to identify and implement
interventions that can reduce the risks
associated with transitions in care
Inpatient to Outpatient Transitions
of Care at University of Chicago


Our aim was to improve the quality, safety, and
continuity of patient care during the transition from
inpatient to ambulatory care by developing a model of
effective communication between inpatient and
ambulatory physicians.
Specifically, we:
– Assessed current methods of communication
– Developed a model for effective inpatient physician – primary
care physician communication.
– Designed an intervention to evaluate the model for effective
inpatient physician – primary care physician communication
Methods

Focus Groups were conducted with
– Hospitalists
– Primary Care Physicians
– Internal Medicine residents
– Patients

The focus groups were used to generate
the process maps
Methods

Observations were used to verify and
enhance the process
Interviews

Interviews were conducted with key
stakeholders to determine barriers and
facilitators to an effective handover
process
Barrier
Representative quote(s) (Hospitalists)
Representative quote(s) (PCPs)
Unable to
correctly
identify the
PCP
But also some notes, we don’t recognize their
names so its difficult to know if that’s really a
primary care doctor and not some sort of ancillary
person—[Resident]
The other issue is do they really know who the
PCP is? They may see [in the electronic
system] like a note from X, but then one from Y,
one from Z, and how do they know who’s really
the PCP?
Finding
PCP
contact
info
It’s a little harder to get a hold of the [communitybased] physicians so I end up resorting to
Googling – [Resident]
Sometimes we get a text page, voicemail, from
the [General Medicine] team or they call the
nurse…sometimes smoke signals- -
Unaware
or variable
preference
of PCP’s
You know, this [PCP] wants you to get a hold of
him ….but maybe some of them [other PCPs]
would say, oh, but the [patient] is in the hospital
and you know there’s ten people taking care of
them, maybe I don’t need to be called until the
next morning - - [Resident]
I think there’s a culture of… negative feedback
if the team contacts the PCP. PCP says oh fine,
but never shows up, that’s a learned behavior,
they’re going to be less likely to contact.
Contacting
PCP not a
priority
I’m usually busy with multiple admissions so I
don’t spend too much time contacting the [primary
care] providers right away - - [Resident]
With 13 admissions or however many --the
priority is taking care of the acute illness and
continuity of care falls to number 37 on the list
of priorities
Fear of
losing
control
I mean there are certain attendings, like some
sub-specialists, I mean they want you to call them
right away if its like, they have a cough… - [Resident]
I get the sense that people don’t call because
they’re worried that you’re going to intrude or
do something that prolongs the hospitalization
Forgetting
or too
busy to
contact
PCP
I know in the hospital I’ve just gotten better about
[contacting PCP’s] from the beginning of my
second year as a resident. Like I didn’t always do
it right off the bat so I think that there is a learning
curve - -
I wonder how big of a component that being
super-busy especially when they are under the
pressure to leave the hospital by noon, the day
that it would make the most sense to contact
Putting it All Together

The research informs the improvement
work
Artifact Analysis
The study of any notes or materials used
in the daily workflow of patient care may
serve as a powerful supplement to the
self-report data
 Provides further evidence of the
effectiveness of the handover

Concluding Comments