inova health system: developing a patient centered approach to handoffs

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Inova Health System

Picker Grant Update

For Patient Advisory Team

Oct. 26, 2011

Mary Ann Friesen PhD, RN, CPHQ Angela Servidio RN, BSN, BA

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• Explore the patient perceptions of bedside handoffs will kick of in 2011

• Always Event

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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.

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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

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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.

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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

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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

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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

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• 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

AHRQ Patient Safety Culture Survey Results

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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

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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

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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

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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

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• 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”

Team Reviewed Examples of Strategies and Best Practices (Patterson et al 2004; Park & Mishkin 2005)

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ISHAPED

I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue

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• “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

What is a “Handoff” ?

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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.

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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

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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.

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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

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ISHAPED – Inova’s New Handoff Methodology

I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue

• Developed by a system Kaizen team • To be piloted in multiple inpatient units for the shift-to-

shift RN handoff

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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

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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

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Bedside Shift to Shift Process

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Qualitative Results from RN Handoff Perception Survey

Summary Patient do not want handoff ???????? Patient do want handoff??????? New Term Bedside Shift to Shift Report

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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.

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Bottom Line

• The focus is the Patient

• Patient Centered Care

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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