nurse hand-off process book

NURSE HANDOFF

PROCESS BOOKLOIS WANG

RESEARCH PROJECT

NURSE HANDOFFRESEARCH PROJECT

Emily Carr University of Art + Design 2D Core Design Studio V

Group Members: Lois Wang Sophia Cai

Sherman Tam Winnie Chuang

Instructor: Jonathan Aitken

Process book by Lois Wang

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AbstractThis book documents the process of developing an innovative strategy for nurse handoff communication during shift changes at a hospital. Vancouver Coastal Health approached us and presented the unavoidable mistakes that may happen during nurse handoff due to its current unofficial format. Through research, inter-views and co-creation with different nurses, our team realized that the nurses have to document daily patients’ information in more than five separate forms. The forms are not updated in real time, nor are they accessible for other medical personnel. As such, the design team decided to restructure and unify these different forms into a consistent database system. The final outcome was a conceptual app for a 7-inch tablet. This output offered the nurses a clear and flexible platform for their docu-ments. For them, this was a completely new way of documenting patients’ data.

TABLE OF CONTENT

01. Project Context 06

02. Defining the Problem + Thesis Statement 10

03. Research 16

Research questions 17/ Primary research 19/ Secondary research 23/ Findings 25

04. Design Criteria 28

05. Concept Development 32

Initial concept 33/ Prototype testing 35/ Refining concept 39

06. Final Outcome 44

Typography + Colour 45/ Userflow 47

07. Project Assessment 52

08. Annotated Bibliography 56

PROJECT CONTExT

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The study site for this project was a third year, spring semester core studio. The briefing was delivered by associate professor Jonathan Aitken:

“Vancouver Coastal Health oversees many hospitals in the Greater Vancouver area and beyond. Serving over a million people in BC, they have a huge role in healthcare leadership in the province. […] They have approached Emily Carr Communication Design students [to] consider [the] problem [in the handoff communication].

The Joint Commission (TJC) (formerly the Joint Commission on Accreditation of Healthcare Organizations—JCAHO) is a United States-based not-for-profit organ-ization that accredits over 19,000 health care organizations and programs in the United States. They have reported that communication breakdowns have been impli-cated in 2/3 of sentinel events (defined as unanticipated events in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness). In other words 2/3 of preventable deaths in hospitals are caused by poor communication. One specific example of an area where poor communication has resulted in sentinel events is during shift changes at hospitals. Commonly called “hand off communication”, this involves the transfer of patient information from one nursing shift to another. Vari-ous strategies have already been employed to improve the problem, but challenges remain, and mistakes still happen”.

DEFiNiNg THE PROBLEmTHESiS STATEmENT

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At the beginning of this project, we attended a lecture about the health care handoff given by several nurses from Vancouver Coastal Health. The nursing

handoff is a process of passing information about patients from one caregiver to another. The handoff occurs between individuals, teams or departments at any time or situation of the day (Quality and Patient Safety). It can be a simple handoff, when the patient is stable, and staying in the same unit; it also can be a really complex pro-cess, for instance when the patient has to be transferred to a different department or facility (Handoff Protocol). Because of the variety of situations that the nurses have to deal with during a shift, many unpredictable errors occur. According to Canadian National Study, “7.5% of hospitalized patients experience an adverse event”, and

“2/3 of them result […] in temporary disability and the other 1/3 […] more serious, even death” (Quality and Patient Safety). This fact indicates that an improvement for health care handoff is urgently needed.

The existing technique that nurses currently use for the handoff is a format called SBAR. It stands for Situation (patient basic information), Background (diagnosis, allergies, medical history, etc.), Assessment (changes and safety) and Recommenda-tions (pending actions) (Handoff Protocol). However, most handoffs are just reports in the form of verbal communication, “cheat sheets” or written notes due to limited time. This causes hazards like illegible handwriting, mixture of look-alike or sound-alike terms, unclear abbreviations (Quality and Patient Safety).

Our team also interviewed a young nurse who works at a hospital in Abbottsford, BC. She mentioned that nurses have to write many forms such as patient flow sheets (a legal document of a patient’s medical treatment of the day) (Figure 1) and Kar-dex (a rewritable archive of patient information) (Figure 2). Most information in these forms that the nurses have to write down is similar. Thus nurses are writing the same

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Figure 1. Flow sheet

Figure 2. Karkex

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Figure 3. SBAR form

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information over and over again during the day, making the SBAR form at the time of the handoff redundant. The nurses inevitably use their own “shortcuts” to make the handoff process more effi-cient, however this often leads to the serious miscommunications out lined above.

Based on this knowledge, our team found that the problem is the conflict between complicated and repetitive documenting sys-tems and limited processing time. In other words, nurses have to work between different paper-based documents in a short time period, which lack data sharing, live-time updating and error checking.

Thesis statement:

We intend to explore how passing information through a centralized database sys-tem with patient care information will increase efficiency and decrease the human errors, thus ultimately increasing patient safety.

RESEARCH

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We generated some questions as a guide for us to find the research we need for fur-ther development:

- In the forms that nurses have to fill in everyday, which sections work well and which ones do not?

- In which section do mistakes occur most frequently?

- Are there any other modes of shift report except face-to-face and note taking that are used among nurses?

- What are some examples of efficient information systems?

- What is the average computer literacy of nurses?

- What is the average mobile device literacy of nurses?

- Is there a department or database that oversees all the patient information?

- Are there different levels of importance for patient information?

Research Questions

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A co-creation kit is a package that contains several activities for the targeted users of the project to participate. The purpose of the kit is to collect primary research on what the targeted users really need. Our design team created a co-creation kit (Figure 4+5) for this project, which contianed two activities. In the first activity, par-ticipants were given three sheets and two envelopes of cutout words and colours. The three sheets separated the categories: documenting methods, documenting media, and sources of information that nurses often use. Each of these categories had three further options to choose from. We asked participants to choose colours and/or words from the envelopes that best represent their emotions and feelings for each option on each sheet, and place them under each option. Through this activ-ity, we wanted to determine how nurses emotionally interpret these aspects of their work with colours and words. In the second activity, we de-constructed the existing Kardex form into modules like “admission info” and “lab tests”. The participants were asked to place these modules in order of priority according to their preference. Through the second activity, we wanted to see how nurses break down the huge amount of information that they deal with everyday.

Primary Research

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Figure 4. Co-creation Kit

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Figure 5. Co-creation Photos

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We were fortunate to have a group of nurses attend our co-creation. During the first activity, the participants did not react to colours as much as they reacted to words, because they thought that their understanding of colour is different from ours. Some of them mentioned that there is an existing colour coding system at the hospital. One also pointed out that we should have positive and negative sections under each option, because they had both good and bad experience with the different methods we provided. This shows that nurses want every piece of information to be precise and clear. What’s more, words like “benefit”, “choice” or “attention” were chosen many times in the activity. Also many participants mentioned that because each nurse has to take care of more than five patients in every shift, they have to make choices of what to deal with first. They also create their own working habits using existing forms to make their work as efficient as possible.

In the second activity, the participants were more engaged. They thought the priority of these sections varied from each department, even each patient. In most situations, every piece of information is important, so it was difficult to rank them in order of pri-ority. However, these modules could be divided into sections of basic information and imformation that are most pertinent to patients’ conditions. However, the flowsheet and Kardex forms are fixed, and the nurses can only highlight certain sections based on the current situations in their assessment. Thus it can ben seen that nurses need their working tool to be more flexible to fit the changeable situations in their work.

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We researched the existing methodology or strategies for improving nurse handoff. The following cases are the most inspired examples:

An organization named Strategies for Nurse Managers released an article about two facilities sharing creative handoff strategies. Instead of using SBAR, they cre-ated a simple mental tool called “The Four Ps”. The Four Ps stands for patient, place, procedure and pertinent information. Through testing, they found it a more intui-tive and consistent way for nurses to process the handoff (CE). This new strategy adopted the most intuitive human thinking process – who, where, (when), what hap-pened and what’s more. As such, creating a tool that refers to nurses’ thinking habits will be more acceptable and effective. There are also other similar strategies such as SHARQ, I PASS THE BATON the Five “P” etc. (Freisen). However most of them still stay on paper-based format, which did not solve the problem of inflexibility and human errors.

A group of students at the Georgia Institute of Technology in the US designed an online handoff software based on the SBAR format. The software functions with a database of all patients’ information. It helps the nurse fill in the patient’s basic infor-mation in advance, and alert the nurse to typing errors or missing entries (Varifying and Improving the Patient Handoff). When the handoff becomes digital, it signifi-cantly reduces the unavoidable errors made by humans. In this case, the number of computers might be limited at a hospital due to the large size of a computer. Thus, nurses have to share with each other, which may cost nurses more time to document patients’ information than paper-based methods.

Secondary Research

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Foxconn, an electronics manufacturing company in Taiwan deisgned a RFID (Radio Frequency Identification) device for the health care system (Figure 6). This cell-phone-sized device can scan barcodes to provide further information. The barcodes are stickers, which can be put on patients’ wrists, medical equipment or medicine. This device helps nurses to confirm that the right treatments are given to the right patients (Foxconn RFID). What we took from this case is that when the documenting become digital, it provides possibility of accessing information from portable devices, which would offer flexibility to nurses’ work.

Figure 6. Foxconn RFID devices

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Through the primary and secondary research, we summarized several highlights that we want to keep in mind in the design process:

-Most young nurses are more confortable working digitally than the senior ones. Going digital is the new trend of health care documentation.

-Nurses prefer their work platform to be as easy and clear as possible.

-Many nurses intend to create their own ways of using the existing forms based on their own thinking habits.

A more intuitive thinking process is more acceptable to nurses.

-Nurses see colours as levels of emergency. In most case, green is safe, red is serious, yellow is attention.

-The priority of information varies from department to department, even patient to patient.

Findings

DESigN CRiTERiA

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The final solution should be a new way of hospitalized health care documentation that is more effecient but with a low error

rate. This system should consist in a centralized database that is accessible from a number of portable terminals that are easy to carry, use and store. The terminal runs a documenting application that re-formats all existing hospitalized health care forms into one. The application should be easy to learn and memorize, efficient to use, and pleasant to look at over and over again.

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Advantages:

- Up-to-date and verified information always accessible

- It’s not a drastic overhaul of the current system, it only enhances it

- Digital input and third-party verification reduces error

CONCEPT DEvELOPmENT

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At this point, our team started to consider the design of the terminals. It should be a portable device with a built-in application.

In terms of the device, our team decided to look at tablets that are easy to be car-ried by nurses. We researched existing and upcoming tablets on the market. Most of them are either 7 inches or 10 inches. However, most cost more than US$ 300/ each (Franklin). This means that if a mid size hospital switches to the digital database health care system, each nurse would need one tablet to be able to access the data-base. It would cost the hospital more than US$ 60,000 just for the devices. In order to solve the expense problem, we found an India-made cheap tablet called UbiSlate (Figure 7). It is a 7-inch touchscreen tablet with a weight of 350g, and only costs 60 US dollars. It runs Android 2.2 Froyo OS with 800 x 480 resistive multi-touch screen, 2 GB built-in storage, Wi-Fi and GPRS. It also has two USB ports, 3.5mm jack, and a built-in camera (World’s Cheapest Tablet). This tablet is small enough to be put into the pocket of nurses’ uniforms, and not too big or heavy for nurses to carry for the whole day (Figure 8). UbiSlate not only reduces the cost of launching the new sys-tem, but also offers enough functions for health care documentation.

The application was a patient-based digital form with breakdown sections of medical information for viewing and editing. These sections were taken from the existing Kardex form, and were designed into modules to allow each department to restruc-ture these modules into a more suitable form for their patients. The application also provided a summary page that groups patients from high priority to low priority. This summary page was a replacement of the handoff report.

initial Concept

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Figure 7. UbiSlate

Figure 8. Nurses carrying the tablets

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We designed two paper prototypes (Figure 9). The first prototype arranged the patients’ information into three levels: a list of patients’ names, each patient’s file, and detailed sections of each patient’s file. The summary page was also an option for sorting preference of the patient list page. The second one focused on using tabs to place patients into different priority groups.

We were lucky to have a different group of nurses to test our prototypes. Most nurses really liked this idea of merging all forms into one. However, they also pointed out a problem with this idea. They felt the program needs to define which part is a legal document, and which part is just notes for themselves. The nurses explained that the forms they use are mostly legal documents. Once nurses fill in and store them in the patient file folder, no one is allowed to re-edit it. This is why nurses usu-ally write “cheat sheets” or to-do lists as side notes for themselves.

Based on the feedback from the nurses, we divided the platform of the application into two (see next page)– one was a patient list page and the other one was a side notes page. The former one was a place for legal document, and latter one was an unofficial reminder. The reminder was designed as a time-line-based to do list.

Prototype Testing

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Figure 9. Two paper prototypes

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sort

Joe SmithRoom 2 / Bed No. 5

Peter LeeRoom 5 / Bed No. 4

Amanda Peak

sort

Joe Smith

Elena CharlesRoom 10 / Bed No. 2

Amanda PeakRoom 6 / Bed No. 1

Irene ChrismasRoom 18 / Bed No. 4

select

Amanda Peak

Admission Info

Allergy

Infection Control

Meds

Diagnostic Studies

Lab Tests

Room 6 / Bed No. 1

Priority Notes

select

Amanda Peak

Admission Info

Room 6 / Bed No. 1

priority Notes

Admission Date

Current Diagnose

Pertinent History

Date/OR/Procedure

Blood Pressure HIGH

Heart Rate HIGH

Emotionally Unstable

7am

8am

9am

10am

11am

12pm

CAT scan form

CAT scan form

8:30 am

Peter Lee

Lab 3

Alert

Figure 10. Previous wireflow

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sort



Amanda Peak

sort

Joe Smith

Elena CharlesRoom 10 / Bed No. 2



select

Amanda Peak

Admission Info

Allergy

Infection Control

Meds

Diagnostic Studies

Lab Tests

Room 6 / Bed No. 1

Priority Notes

select

Amanda Peak

Admission Info

Room 6 / Bed No. 1

priority Notes

Admission Date

Current Diagnose

Pertinent History

Date/OR/Procedure

Blood Pressure HIGH

Heart Rate HIGH


7am

8am

9am

10am

11am

12pm

CAT scan form

CAT scan form

8:30 am

Peter Lee

Lab 3

Alert

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Since there were more functions added to the app, it started to become too compli-cated to use. Our team decided to step back and look at it from a different view. We questioned ourselves: is there a different way to include side notes without input-ting new data? Is it really necessary to have a summary page? Is it really a good idea to group patients into different levels of priority? To answer the above ques-tions, we introduced a flag function to the application to replace the summary page and priority sorting. A nurse could highlight any detailed information of a patient, and this patient’s name would be automatically flagged in the patient list page. The high-lighted information would be summed up into a short note under the patient’s name in the list page as an expanded content. This change (Figure 11) avoided the con-fusion that might occur when switching between two documentation places. This change also reduced the steps of calling up certain information, which made the application more efficient and easier to use. What’s more, we realized that the appli-cation should not group patients into priority groups; first because all patients should be important, second because, the colours that used to code the groups might make the nurses overreact or underreact to their patients.

Refining Concept

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Allergy

Infection Control

Meds

Diagnostic Studies

Lab Tests

Admission Info



Elena Charles




Admission Info

Admission Date

Current Diagnose

Pertinent History

Date/OR/Procedure

editlist editlist editlist

Blood Pressure HIGH

Heart Rate HIGH



Figure 11. Final wireflow

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Allergy

Infection Control

Meds

Diagnostic Studies

Lab Tests

Admission Info



Elena Charles




Admission Info

Admission Date

Current Diagnose

Pertinent History

Date/OR/Procedure

editlist editlist editlist

Blood Pressure HIGH

Heart Rate HIGH



FiNAL OUTCOm

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Typography + Colours

The typeface we chose for the application is DIN Pro (Figure 12). It is a realist sans-serif typeface designed in 1995 by Albert-Jan Pool, based on DIN-Mittelschrift. “DIN stands for ‘Deutsche Industrie Norm,’ which means exactly as it sounds: German industry standard”. Thus, DIN has a simple and straightforward look that was used in the realm of German public lettering (Dot-font). We believe that the high legibility of this typeface brings great clarity to the app.

Figure 12. DIN Pro

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The colour palette (Figure 13) we used for the app consistes of teal, white and black in two different gradients. These colours would provide senses of neutrality, clean-ness, clarity and authority. We avoided using colour coding in the design because it might conflict to the existing health care colour coding system that the nurses are using.

RGB=255/255/255

CMYK=0/0/0/0

RGB=90/91/94

CMYK=0/0/0/70

RGB=26/24/24

CMYK=0/0/0/100

RGB=26/153/140

CMYK=80/9/45/0

Figure 13. Colour palette

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How to use:

First, the user has to log in using their ID and password (Figure 14). Then (Figure 15), on the first page the user will see is a list of patients who she/he is in charge of (a). When a patient’s name is tapped, the user will see all related information about this patient. The information is broken down into three sections– Basic info, Other info and Assistance (b). When the user goes into detail pages under each section, she/he can add or edit data (d). The user can highlight any information by add-ing star icon to it, which will also show up in the list page as a note under the patient’s name (c). The user can view the note in the list page by dragging down an expanded content from the patient’s name. The app also offers functions such as alerts for reminders, search bar for patients, notification for updates, and camera for taking photos of patients (optional).

For the interactive aspect, we only applied simple gestures like tap and swipe because this app should be fast and easy to use rather than fancy and entertaining to look at..

Userflow

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7:28 am

ID

Password

Log in

Figure 14. Log in page

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Room 6 / Bed No. 8Age 41 female

Jane Shepard

Room 3 / Bed No. 6Age 42 male

James Kirk


Peter Lee

PATIENT LIST


Irene Chrismas


Amanda Tan

7:28 am

Blood Pressure HIGH

Heart Rat HIGH


New updates for Peter LeeNOTIFICATION

NOTES

ALERT + FLAG


Joe Smith


Jane Shepard


James Kirk


Peter Lee

PATIENT LIST


Irene Chrismas


Amanda Tan

7:28 am

Figure 15 Userflow

(a)

(c)

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Peter Lee

PATIENT PROFILE

AssistanceBasic Info AssistanceOther InfoBasic Info

7:28 am

Assistance

SPECIAL CONSIDERATION

SAFETY

LEVEL OF ASSIST

ADLs/HYGIENE

MEAL ASSIST

APPOINTMENTS

BASIC INFO

OTHER INFO

ASSISTANCE


Peter Lee

PATIENT PROFILE

AssistanceBasic Info Assistance

LEVEL OF ASSIST

ADLs/HYGIENE

MEAL ASSIST

APPOINTMENTS

Other InfoBasic Info

Appointment 1

CAT scan

Lab 2 14:00

7:28 am

ALERT + FLAG

(b)

(d)

PROJECT ASSESSmENT

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Our team was able to think outside of the box to create a new method for health care documentation instead of just re-designing existing forms. We considered

a wide range of aspects for developing a new system: from usability of the applica-tion to physical size of the device; from ideal concept development to realistic budget problems. This helped to solidify the final outcome.

The most important part of this project was the co-creation with the nurses. The feedback and critiques they gave us were extremely constructive, and directly influ-enced the decisions we made in every stage.

In terms of the final solution, the outcome was successful in providing the health care industry with an up-to-date digital documentation method with an access-ible centralized database, which enhances the efficency and decreases the human errors in nurse handoff.

American Medical Informatics Association provided two tables of strategies for web-based application for nursing handoff tools (NHT) (Figure 16). One is Critical Data Elements for NHT and the other one for Functional Requirements for NHT. Accord-ing to these two strategies, our application meet most of the requirements. The only two things we had not concentrated on were printing capability and links to resour-ces. These two features allow the communication between the devices and the database, which would let these two function better as a whole.

If the final proposed solution of this project were turned into a real system and tested in hospitals, we would see whether the flexibility and the all-in-one feature of this method improves the current hospital system. However, we do believe that going digital and mobile is the future of health care industry.

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Figure 16. Development of a Nursing Handoff Tool: A Web-Based Application to Enhance Patient Safety (Goldsmith)

ANNOTATED BiBLiOgRAPHY

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“CE Article: Two facilities share creative handoff strategies.” Strategies for Nurse Managers, Web. 11 Apr. 2012. <http://www.strategiesfornursemanagers.com/ce_detail/205469.cfm>.

This article showcases two facilities embraced the need to enhance staff communic ation and developed a more effecctive handoff format.

“Dot-font: Industrial-Standard Typefaces | CreativePro.com.” CreativePro.com. Web. 17 Apr. 2012. <http://www.creativepro.com/article/dot-font-industrial-standard-typefaces->.

This website provides information about the typeface DIN pro.¬¬

Franklin, Eric. “CNET Looks at Current and Upcoming Tablets.” CNET News. CBS Interactive, 12 Mar. 2012. Web. 11 Apr. 2012. <http://news.cnet.com/8301-17938_105-20037960-1/cnet-looks-at-current-and-upcoming-tablets/?tag=contentBody;contentHighlights>.

This website shows a detailed comparison of current and upcoming tablets.

Friesen, Mary Ann, Susan V. White, and Jacqueline F. Byers. “Handoffs: Implications for Nurses.” National Center for Biotechnology Information. Apr. 2008. Web. 17 Apr. 2012. <http://www.ncbi.nlm.nih.gov/books/NBK2649/>.

The essay provides several current existing nurse handoff strategies, and discusses the pro. and con. of them.

“Foxconn RFID Health Care Management System Protocol.” HQ technology, 5 Sep. 2011. Web. 11 Apr. 2012. <http://www.hqew.com/tech/fangan/462401.html>.

This article is an introduction to the health care management system created by a Tai wanese comany called Foxconn.

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Goldsmith, Denise, Marc Boomhower, Diane R. Lancaster, Mary Antonelli, Mary Anne Murphy Kenyon, Angela Benoit, Frank Chang, and Patricia C. Dykes. “Development of a Nursing Hand-off Tool: A Web-Based Application to Enhance Patient Safety.” American Medical Informatics Association. 13 Nov. 2012. Web. 16 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041387/>.

This project discusses the functional and data element requirements of a web based Nursing Handoff Tool (NHT).

“Handoff Communication Protocol.” Vancouver Coastal Health. Provided by Instructor Jonathan Aitken. Web pdf. 11 Apr. 2012. < http://jonathanaitken.ca/?page_id=42 >

This article explains the definition of a nurse handoff, as well as the strategies, method ology and applied situations.

“Quality & Patient Safety.” Vancouver Coastal Health. Provided by Instructor Jonathan Aitken. Web ppt. 11 Apr. 2012. < http://jonathanaitken.ca/?page_id=42 >

This power point is showed in the lecture given by nurses from Vancouver Coastal Health about the current problems with nurse handoffs.

“Verifying and Improving the Patient Handoff.” Georgia Institut of Technology. US. Web. 11 Apr. 2012. <http://www.hsi.gatech.edu/icu/images/7/7a/HEF_Team12_FinalReport.pdf>.

This report talks about a project done by a team of students in Georgia Institut of Technology, who developed a software for improving handoffs.

“World’s Cheapest Tablet to Launch in India.” Gizmag. Web. 11 Apr. 2012. <http://www.gizmag.com/aakash-tablet-ubislate-7/20105/>.

This web news is about the world’s cheapest tablet called UbiSlate made in India.

nurse hand-off process book

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