Transcript frankel_1a

Team Communication and
Transitions of Care
Richard M. Frankel Ph.D.
Professor of Medicine and Geriatrics
Senior Research Scientist
The Regenstrief Institute
Indiana University School of Medicine
Indianapolis, Indiana
Senior Scientist
Center for Implementing Evidence Based Practice
Roudebush VAMC
Quality Colloquium
August 19-22, 2007
Objectives
• Look at the role of handoffs across the
spectrum of medical care
• Explore the relationship of hand-offs to
patient safety
• Identify elements of safe and effective
hand-offs
What are the types of handoffs that
come to mind when you think about
transfers of care?
Role of Hand-offs
• Ensure smooth transition of care from one
physician, nurse or team to another
• Transfer of rights duties and responsibilities
• Convey any anticipated changes over the
next 8-12 hours.
• Part of the “clinical microsystem” life-cycle.
– Intern perspective: No big deal,“just part of the
work”.
Hand offs and Patient Safety
• Shift changes (handoffs, sign-outs) represent
transitions that can impact the quality of patient care
and patient safety
– Some estimates put the percentage of adverse events
related to shift changes as high as 80%!
• The literature in this area has been dominated by the
nursing profession
• Wide variation across institutions, professional roles,
shifts, and individuals
• No studies to date have tried to connect the dots as
a means of reducing unwanted variation
Recent Focus on MD Hand-offs
July 2003– ACGME limited resident duty hours to
80 per week to reduce sleep deprivation and
improve patient safety
•
An unintended consequence is that the
number of hand-offs for hospitalizations has
increased significantly
•
Safety of hand-off?

Discontinuity

Error-prone and variable

A vulnerable “gap” in patient care
Elements of Effective Hand Offs
• Communication
• Standard Setting
• Education
• Practice Improvement
Keys to Successful Hand Offs: Communication is Critical
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
The "relics“ include such as handwritten
notes on crumbling memo pads bearing
cryptic texts like:
"pound pastrami, can kraut, six
bagels–bring home for Emma".
Timing Is Everything for Sprint-Relay
Success
By Sean P. Flynn
Special to The Washington Post
Friday, April 15, 2005; Page D16
Keys to Baton Handoffs
• Timing. Every part of the baton exchange must be
as precise as possible, as each split second counts
in the 4x100 relay. To minimize time, the runner
cannot get out too early or too late.
• Have a Mark. The runner receiving the baton should
set up a mark behind his starting position. At the
exact moment the preceding runner arrives, he
should be ready to burst out of position.
• Focus. Because the smallest glitch in the handoff
can have a big effect on final placement, intense
focus is needed to know exactly when to do exactly
what they need to do.
Lack of National Standards for
Patient Handoffs
• Only 8% of medical schools teach how to hand
off patients in a formal didactic session.
(National survey of 125 medical schools).
• The vast majority (86%) of medical students are
taught by interns or residents who were likely
taught by their interns or residents and so on.
• This process exemplifies the “hidden” or informal
curriculum in medicine where a task is learned
by observing those in charge…
Solet et al, 2005
JCAHO’s Hand-Off Communication
Goal, 2006
The Joint Commission’s new National
Patient Safety Goal reads simply:
"Implement a standardized approach to
'hand off' communications, including an
opportunity to ask and respond to
questions.”
“That leaves you to figure out what constitutes a
hand-off, how to design a standardized
approach, and how to implement it.”
• patient care can often be disrupted due to:
• interruptions
• lack of clarity with the process
• non-standardized technique
• incomplete information.
Patton, Hand-off Communication: Practical Strategies and Tools for JCAHO
Compliance, 2006
Education and Practice: Resident
Handoffs at One University
The internal medicine residency
program at IUSM utilizes 4 hospitals,
each with a unique patient population;
3 different computer systems store and
process data related to their care,
including handoffs. The handoff
process takes a different form at each
hospital.
Solet et al, 2005
•
At 1 hospital the handoff form is electronic. Information is
printed for every patient including: name, record number,
age, race, location, code status, admitting diagnosis,
problem list (current and historical), allergies, and
medications. Space is provided for handwritten comments.
•
The VA handoff form is also electronic and includes name,
age, sex, Social Security number, location, team
assignment, allergies, and active medications, It has space
for comments.
•
Medical subspecialties at another hospital use a wordprocessing template for handoffs. Standard instructions
are at the top of the form. The handoff resident enters the
identifying patient information with a medication list,
problem list, active issues, and suggestions for potential
problems that may be encountered overnight.
•
Cardiology & IM services at the private hospital are
handwritten or use a word-processor without a standard
format. Their perceived quality and usefulness is variable.
Re-enacted Resident Handoff
Transcript of A Resident Handoff
OGR: A::nd Ms. Strickland (pseudonym) is on five south.
She is a fifty four year old lady with history of (
)
cirrhosis, and hepatitis C (0.2) and diabetes. She came in
complaining- she’s been here like three times to the ER in
the past week and finally got admitted for (a) pancreatitis
(0.7)* on Saturday night.
ICR: *(Scratches head with his pencil)
OGR: A::nd is doing really well, belly pain is improved ( ) her
diet-, is on PO meds. She was complaining of some chest
pain when she was admitted we’re not sure if it was just
kind of radiating from the whole pancreatitis thing (0.3) she
was ruled out and she’s supposed to get a stress echo
tomorrow. And if she would have a repeat episode of the
chest pain I would start with getting an EKG and if that
was different then you could check markers.
OGR: She ruled out before. Blood sugars have
been stable you probably won’t get a call
about those. And then today her new
complaint was some right sided arm and
leg weakness. (0.5) I’m not really sure. It
kind of seems like she comes up with new
complaints each time you talk to her (0.3)
and her exam was non-focal. But my
attending wanted me to check a head CT so…
that was ordered about 2:30 or so today. That’s
really the only thing to follow up on with her.
ICR: (Writes on the OGR’s notes which are in her lap.)
If there would be something there I would call
Neurology. Mrs. Hazelwood….
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
NASA Video Crew # 7
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.
Opportunities for Improvement
in Medicine
• One study of surgeons and primary care
physicians (Braddock, JAMA 1999) found
that testing for patient comprehension of
medical information occurred less than
1.5% of the time. This “gap” represents a
tremendous improvement opportunity.
Future work
• We are still in the early stages of work on
handoffs
• Continue research
– Identify “vulnerable gaps” across the continuum of
care, e.g., admission, care during hospitalization,
discharge planning, transition to ambulatory care,
physician patient relationship/communication in
ambulatory visits
– Human factors and ergonomic issues that impede
hand offs
• Ultimately, the goal is to reduce the risks
associated with transitions and the patient’s
experience of care
Thanks for your time and attention