Transcript Project Report - Lean Sigma

Clinical Handoffs
The Cardiac Surgery Translational Study (“CSTS”)
The Quality And Safety Research Group
Ayse P. Gurses, PhD
[email protected]
April 1, 2011 Immersion Call
Immersion Call Schedule
Title
Date /Time
13:00 EST
Presented by
Program Overview
Feb 18, 2011
Peter Pronovost MD PhD
Science Of Safety
February 25, 2011 Jill Marsteller, PhD, MPP
Comprehensive Unit-Based Safety
Program CUSP
Central Line Blood Stream Infection
Elimination
Surgical Site Infection Elimination
Ventilator-Associated Pneumonia
Reduction
Hand-Offs/ Transitions in Care
March 4, 2011
Christine Goeschel MPA MPS ScD RN
March 11, 2011
David Thompson DNSC, MS
March 18, 2011
Elizabeth Martinez, MD, MHS
March 25, 2011
Sean Berenholtz, MD
April 1, 2011
Ayse P. Gurses, PhD
Data we Can Count on
Team Building
April 8, 2011
Lisa Lubomski, PhD.
April 15, 2011
Jill Marsteller, PhD, MPP
Physician Engagement
April 22, 2011
Peter Pronovost, MD, PhD
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Communication breakdowns as
Root Cause of Errors
Communication
breakdowns are
frequently the
root cause of…
undesirable
outcomes
3
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Definitions of Handoff
• “The transfer of information, along with authority and
responsibility, during transitions in care across the
continuum for the purpose of ensuring the continuity
and safety of the patient’s care.”1
• “When responsibility for a patient is passed from one
caregiver to another or when patient information is
transferred from one type of healthcare organization to
another or to a patient’s home”2
• “To communicate patient information to facilitate
continuity in the plan of care”3
1. Standardizing Handoffs for Patient Safety, AORN, 2010.
2. Communication during patient hand-overs, Joint Commission, 2007.
3. Streitenberger K, Pediatric Clinics of North America, 2006.
4
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Primary Objective
• “The primary objective of a “hand off ” is to provide
accurate information about a [patient’s] care,
treatment, and services, current condition and any
recent or anticipated changes. The information
communicated during a hand off must be
accurate in order to meet [patient] safety goals.”1
1. Meeting the Joint Commission 2008 National
Patient Safety Goals, Joint Commission, 2007.
5
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Different types of handoffs
• Within hospital
– One care provider to another
Nurse to nurse handoff intra-operatively
– One unit/ team of care providers to another unit/ team of
care provider
– Handoff of patient from
• OR to PACU/ICU after cardiac surgery
• ICU to floor
• Transfers to and from hospital
– Transfer to skilled nursing facility or home after having
cardiac surgery
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Patient Safety Hazards in Handoffs
• Patients are particularly vulnerable during handoffs
because pertinent care information may be
incorrectly communicated or not communicated at
all
• Nearly 70% of sentinel events were caused by
communication breakdowns1
• Evidence suggested that at least half of these
communication breakdowns occurred during patient
handoffs1
1. Improving Handoff Communications: Meeting
National Patient Safety Goal 2E, Joint Comm
Perspectives on Patient Safety, 2006.
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Evidence of Harm
• Medication errors1,2
• Delays
– Test ordering3
– Medical diagnosis4
– Treatment4
• Increased number of
hospital complications3
• Wrong treatment5
• Increased length of
stay6,7
• Higher costs8
8
•
•
•
•
Higher readmission rates8
Malpractice claims9
Serious adverse events10
Redundancies in
– Procedures11
– Tests11
1. Lofgren RP, Gottlieb D, Williams RA, et al., J Gen Intern Med, 1990.
2. Gottlieb DJ, Parenti CM, Peterson CA, et al., Arch Intern Med, 1991.
3. Laine C, Goldman L, Soukup JR, et al., JAMA, 1993.
4. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010.
5. Australian Council for Safety and Quality in Health Care, 2005.
6. Lofgren RP, Gottlieb D, Williams RA, et al., J Gen Intern Med, 1990.
7. Gottlieb DJ, Parenti CM, Peterson CA, et al., Arch Intern Med, 1991.
8. Lawrence R.H., et al., BMC Health Serv Res, 2008.
9. Kachalia A, Gandhi TK, Puopolo AL, et al., Ann Emerg Med, 2007.
10. Risser D.T., et al., Ann Emerg Med, 1999.
11. Lawrence R.H., et al., BMC Health Serv Res, 2008.
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Barriers to Effective Handoffs
• Physical environment
– Background noise, poor lighting1
• Organizational factors
– Culture, social hierarchy1
– Vast inconsistency in how handoffs are performed2,3
– No formal training on how to give handoff report1
• Provider and patient factors
– Language barriers, diversity in patient and physician
populations1
1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.
2. Horwitz LI, Krumholz HM, Green ML, et al., Arch Intern Med, 2006.
3. Sinha M, Shriki J, Salness R, et al., Acad Emerg Med, 2007.
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Barriers to Effective Handoffs
• Task
– High workload, hectic schedules and multiple
responsibilities1
– Ambiguity in roles and responsibilities1
• Tools and Technologies
– Ineffective use of cognitive tools1
• Appropriate measures for evaluating
effectiveness of handoffs still need to be
established and validated1
1. Solet DJ, Norvell JM, Rutan GH, et al., Acad Med, 2005.
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Joint Commission’s Handoff
Process Strategies1
• Interactive communications
• Up-to-date and accurate
information transfer
• Limiting interruptions during handoffs
• A process for verification
• An opportunity for the receiver to review
any relevant historical data
1. Joint Commission. National Patient Safety
Goals: History Tracking Report 2008-2009.
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Other Strategies to Improve Handoffs
• Consider using structured tools that can facilitate consistency in
communication exchanges1
• Set aside sufficient time to promote complete and accurate
communication1,2,3
• Assure unambiguous transfer of responsibility and accountability4,5
• Teach and practice how to give/receive handoff reports using
established, common language1
• Document that a handoff has taken place
1.
2.
3.
4.
5.
Cooper A, The OR Connection, 2010.
Hand-off Communications: Recommendations, AORN, 2010.
Standardizing Handoffs for Patient Safety and Handoff Talking Points, AORN, 2010.
Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010.
Gurses AP, Seidl KL, Vaidya V, et al., QSHC, 2008.
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Other Strategies to Improve Handoffs
• Include outgoing care provider’s opinion(s) toward changes to
(contingency) plans1
• Limit initiation of other activities (unless critical) during the handoff1
• Delay transfer of responsibility during critical time periods of the care
process1
• Monitor the effectiveness of handoffs and providers’ adherence to
guidelines concerning handoffs; ascertain feedback from staff 2
• When appropriate, use computers and available technology (e.g.
EMR) to encourage the efficient exchange of pertinent, correct
information. 2,3
1. Patterson ES, Wears RL, Jt Comm J Qual Patient Saf, 2010.
2. Cooper A, The OR Connection, 2010.
3. Vidyarthi AR, Arora V, Schnipper JL, et al., J Hosp Med, 2006.
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Interventions to improve handoffs
between hospital units
• Very few interventions (almost none for cardiac
surgery)
– A new handover protocol of pediatric patients after
congenital heart surgery from OR to ICU.1
• Based on Formula 1 pit-stop and aviation models (e.g.,
clarifying responsibilities, standardizing processes, improving
situation awareness, anticipation, and communication)
• Reduced the number of technical errors (e.g., drains not
located safely) and information handover omissions.
– Implementation of a paper-based discharge survey nearly
eliminated ICU discharge medication errors2
– Few other intervention studies that have not found any
1.
Catchpole KR, de Leval MR, McEwan A et al. Patient handover from
significant impact.
surgery to intensive care: using Formula 1 pit-stop and aviation models
2.
14
to improve safety and quality. Paediatr Anaesth 2007 May;17(5):470-8.
Pronovost P, Weast B, Schwarz M et al. Medication reconciliation: a
practical tool to reduce the risk of medication errors. J Crit Care 2003
December;18(4):201-5.
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Interventions to Improve the
Discharge Process
• A package of discharge services significantly reduced emergency
visits and readmissions among medical patients1
– a nurse discharge advocate to coordinate the discharge process and
educate patients
– an individualized after-hospital care plan for each patient
– pharmacist contacting the patient 2-4 days post- discharge.
• Multi-faceted intervention among elderly reduced readmissions2
– medication self-management system
– ensuring that patients complete physician follow-up visits
– educating patients about health indications to watch for.
•
A Cochrane review (11 RCTs included) did not find any significant
impact of using an individualized discharge plan on mortality, hospital
LOS, or readmissions.3
1. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a
randomized trial. Ann Intern Med 2009 February 3;150(3):178-87.
2. Coleman EA, Smith JD, Frank JC et al. Preparing patients and caregivers to participate in care delivered across settings: the
Care Transitions Intervention. J Am Geriatr Soc 2004 November;52(11):1817-25.
3. Shepperd S, Parkes J, McClaren J et al. Discharge planning from hospital to home. Cochrane Database Syst Rev
2004;(1):CD000313.
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Interventions (Summary)
•
•
•
•
Very few
Almost none in cardiac surgery
Conflicting findings
Most of the interventions implemented without
being informed by detailed hazard analysis
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Action Items for Handoffs/Transitions
in Care
• For now, NOT MUCH!
• We will contact you as we make progress on the detailed
study plan and next steps for this study component.
• Sites that will be part of the initial handoff study will be
determined based on
– Their interests
– Variability (hospital characteristics and variations in
handoff/transitions of care processes)
– Resources available (i.e., travel costs of researchers)
• Will share findings from the initial handoff study
• Other sites will
– self-identify hazards and develop appropriate interventions using the tools
developed
– have an opportunity to implement several tools
• GOAL: Learn from each other and find ways to improve
transitions of care/handoffs
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Aims in this study
• To improve the safety of care transitions from
cardiac OR to ICU, from ICU to inpatient floor, and
from inpatient floor to hospital discharge.
– To identify and prioritize safety hazards during these
transitions of care
– To implement a patient safety program and evaluate its
impact on the prioritized hazards (i.e., from OR to ICU, ICU
to floor).
– To pilot test interventions aimed at reducing/mitigating
floor to hospital discharge hazards.
Hazard: Anything that has the potential to cause failure.
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Conceptual Frameworks
• Systems Engineering Initiative for Patient Safety
(SEIPS Model)
• Systems Ambiguity Framework
• Trajectory Framework
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SEIPS Model of Work System and Patient Safety
Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System
Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.
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Ambiguity Framework
AMBIGUITY
TYPE
Task
Responsibility
Expectation
Method
Exception
EXAMPLES
- Status: Which additional tasks need to be completed before this patient can get discharged?
- Plan: Which task(s) need to be completed?
- Timing: When should a particular task be completed?
- Goal: What are the goal(s) that should be achieved?
- Role: Who is responsible for a particular task (e.g., monitoring patient’s anticoagulation
medication)?
- Accountability: Who is accountable for the consequences of a particular action?
- Authority: Who has the authority to make a particular decision?
- Standards: What are the acceptable practices in this unit or organization for providing
handoff reports? What are the expectations of the admitting unit? What is the regular
practice?
- Performance: How is my performance in providing handoff reports?
- Feasibility: Is it feasible for me to provide a comprehensive handoff report in addition to my
other responsibilities?
- Procedural: How should this piece of information be conveyed to the admitting unit?
- Source: Where can I find information on which medications the patient is taking?
- Supplies and equipment: Where and how can I find this special device that the patient being
transferred from the ICU to my step-down unit needs?
- Help: Who should I contact for help for a particular task? How do I contact him?
- For what conditions is a deviation from the standard procedures acceptable?
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Trajectory Framework
Trajectory: A sequence of actions toward a goal (e.g., timely
and safe discharge) including any contingencies.
Shaping a trajectory requires combined efforts of the individuals
involved including care providers, patients and families (Corbin &
Strauss, 1991).
Content of the discharge-related communication can be
described in three major dimensions using this framework:
– Patient’s status on the discharge trajectory
– Deviations from/complications on the trajectory
– Anticipating/planning for the rest of the trajectory
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Activities
•
•
•
•
Sample
– 5 hospitals: OR-ICU, ICU-Floor
– 2-3 hospitals: Discharge Process
Prospective hazard identification
– Observations (one HFE + one clinician pair) at each transition point
– Semi-structured interviews with care providers and patients
– Artifact analysis
– Shadowing of patients from surgery to discharge and post-discharge
Retrospective hazard identifications
– If possible, hospitals will review data from adverse event reporting
systems (AERS)
– Clinical incident technique interviews
Development of tools/methods/other interventions
– Self-assessment tools to identify and prioritize hazards
– Tools/methods/other interventions to improve transitions of care
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Study Plan
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QUESTIONS
[email protected]
Works Consulted
•
•
•
•
•
•
•
•
Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and
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nhovrlitrev.pdf
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nhovrlitrev.pdf
Carayon, P., Hundt, A.S., Karsh, B.-T., Gurses, A.P., Alvarado, C.J., Smith, M. and Brennan, P.F. “Work System
Design for Patient Safety: The SEIPS Model”, Quality & Safety in Health Care, 15 (Suppl. 1): i50-i58, 2006.
Catchpole KR, de Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, MacDonald C, Goldman AJ. Patient
handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and
quality. Pediatric Anesthesia. 2007; 17(5): 470-478.
Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in
care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004 November;52(11):181725.
Communication during patient hand-overs, Joint Commission, 2007. Accessed August 24, 2010. Available at:
http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf
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Works Consulted
•
•
•
•
•
•
•
•
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http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf
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randomized trial. Ann Intern Med 2009 February 3;150(3):178-87.
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