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Safer Sign Out Physician Handoff Communication Achieving to High Reliability Through Patient-Centered, Team-Based Innovation v5 Slide 2 Drew C. Fuller, MD, MPH, FACEP Director of Safety Innovation Past Chair, Quality Improvement & Patient Safety Section (QIPS) Board of Directors / Education Committee (Synergy Interest) Slide 3 Safer Sign Out Patient Centered Team Based Risk-Focused Physician (Frontline) Developed Method for Structured Physician Handoffs Slide 4 Standardization of Handoff Communication National Patient Safety Goal 2E (2006) Slide 5 Sign out is the most dangerous procedure in the Emergency Department Charles Chaz Schoenfeld, MD (1950-2010) Slide 6 Why Structure? Up to 80% of serious medical errors involve miscommunication during handoffs (TJC) Up to 24% ED malpractice claims related to handoff (Cheung 2010) Slide 7 Progress Nursing profession Leading with Models/Methods Few Physician Models Slide 8 Emergency Departments - High Risk Production/Time Pressure High Noise Levels High Acuity Multitasking Time Sensitive Conditions Rapid Turnover Frequent Interruptions New/Unknown Patients Undifferentiated Diagnosis Wide Clinical Variation Increasing Complexity ED Factors Potentiate Errors Slide 9 Neglected/Missed Information Unclear Transfer of Responsibility Team Unaware of Transfer/Issues Patient/Family Unaware Change in Status Lack of Mechanism for QA Handoffs - High Risk Points of Potential Failure Slide 10 High Reliability High Risk Process + High Risk Environment Why Structure is Critical Mandates Slide 11 Structured Workable Predictable Measurable High Reliability Slide 12 Industries Committing to High Reliability Slide 13 Pilots Committed to Standardized Communication Slide 14 Quick Handoff Practice (Click on Photo to Start Video) Slide 15 Name that Handoff Hit & Run? Slide 16 Typical Handoff Practice (Click on Picture to Start Video) Slide 17 Hopeful Handoff Name that Handoff Slide 18 Whats Missing? Critical items conveyed? Safeguards? (Checklist?) Current clinical status? Patient aware/Involved? Nurse aware/involved? QA ? Typical Hopeful Handoff Slide 19 Hope Model for Safety Hope nothing goes wrong Safe By Luck or Design? Unstructured No Standard Not High Reliability (High Vulnerability) Poor Strategy for Safety Slide 20 Designing a Better Way Focus on areas of RISK Practical implementation Scalable WORK for Clinicians Slide 21 EMA Safety Leadership Group Physician Representation 12 Hospital/Clinical Sites: Maryland Virginia Washington, DC West Virginia Slide 22 American College of Emergency Physicians (ACEP) White Paper on Improving Handoffs by Dickson Cheung, Jack Kelly et al 20 National Clinical & Safety Experts Recommendations for Best Practice Quality Improvement & Patient Safety (QIPS) Slide 23 Sign Out Safety Survey 104 ED Physicians & 50 PAs Directors Guidance ACEP QIPS leaders Executive Input Nursing Input & Feedback Frontline Input Slide 24 The Essential Connections Physician to Physician Nurse (Team) Patient/Family Slide 25 Key Components Safer Sign Out 1)Record - Critical Data & Pending Items 2)Review - Form & Computer Data 3)Round Bedside, Together 4)Relay to the Team Nurse Collaboration _____________________________________________________________________________________________________ 5)Receive Feedback Clinical/QA Slide 26 Use a Recordable Form Clear transfer of responsibility Prompts to identify Key items Checklist & Reference Tool Slide 27 Slide 28 Back of Sign Out Form (Reinforces Protocol) Slide 29 Joint Focus - Form & Data Done at a computer Access to lab/rad results Assure Shared Understanding Purposeful time for Q & A Slide 30 Bedside Round - Together Status -Eyes on the patient Introduction/Update Team Communication Slide 31 Communicate with the Nurse Transition/Updates Opportunity for input/feedback Assures team understanding Before, during or after rounds Slide 32 Form as a Feedback Tool Clinical Follow Up Quality Assurance Tool Slide 33 Quality Assurance Built-in tool to help with QA Slide 34 Initial Hospital Sites Slide 35 Initial SSO Development Team Don Infeld, MD (EMA President) Jackie Pollock, CEO (EMA) Nicole Bergen, Dir. of Op. (EMA) Martin Brown, MD, CMO (EMA) John Schnabel, MD Chris Morrow, MD Tim Hsu, MD Richard Ferraro, MD Karla Lacayo, MD Cameron Cushing, MD Michael Kerr, MD Steven Smith, MD David Jacobs, MD Jennifer Abele, MD Drew White, MD, MBA Michael Silverman, MD Marney Treese, MD Justin Green, MD Napoleon Magpantay, MD Kurt Rodney, MD Sora Chung, MD Matt Sasser, MD Jon DSouza, MD Todd Larson, MD Junior Williams, MD Larry Mack-Wilson, PA-C Eric Parvis, MD Chris Morrow, MD Kala Scoggin, PA-C Elizabeth Cook Drew Fuller, MD, MPH Kilole Kanno, MD Nadia Eltaki,MD Slide 36 Rapid Cycle Improvement Slide 37 What We Learned Physician Champions (Key) Ease of implementation Educate & support Initial resistance resolves Use QA to sustain Slide 38 Engaging Physicians Appeal to their interest Performance => how it Occurs to them Listen, support & reassure Protect Your Patients, Support Your Colleagues Slide 39 Understanding Adoption Slide 40 Readiness for Change Start Where They Are Slide 41 This is so much better than what we use to do I was initially resistant but now I get it I sleep better at night Physician Feedback Slide 42 Committed to Collaboration Share the Process Teach Others Seek Understanding Pursue Refinement Regionally/Nationally Slide 43 Quality Improvement & Patient Safety Section Website First Featured Safety Project Slide 44 Emergency Medicine Patient Safety Foundation (EMPSF) Voice for Safety in Emergency Medicine National Collaborator SSO Flagship Safety Tool Dedicated SSO Website Consultation Service Slide 45 SaferSignOut.com Toolkit (Web-based) Education Downloads Forms Posters Strategy/Best Practices Videos & More Slide 46 Logo Slide 47 AMA Handoff Resource Listing Handoff Resource (RFS) Description and links to SaferSignOut.com Slide 48 AMA Handoff Resource Listing Handoff Resource (RFS) Description and links to SaferSignOut.com Slide 49 Agency for Healthcare Research & Quality (List SaferSignOut.com as a Resource) Slide 50 SSO in the Press Slide 51 Slide 52 Slide 53 ABEM MOC PI Tool Help your physicians meet their MOC PI requirement Easily Utilized To be featured on ACEPs Handoff education tool Slide 54 Collaborative Synergistic Innovation (CSI) Model for Innovation Open Resource Clinician Driven Best Practice Refinement Supports Research, Distribution, Education Slide 55 Innovation Partners Leading the Way Slide 56 1.Use EMPSF as a resource 2.Enlist Champions 3.Build the case for a structured method 4.Launch as a Team based approach 5.Monitor the process & give feedback Slide 57 "Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try. Atul Gawande Slide 58 Make the Commitment 1963 Speech at NASA Throw Your Hat Over the Wall Slide 59 SSO Stand Up for Safety Video https://vimeo.com/65199210 Slide 60 We Stand Committed to Safety Slide 61 Further Information Dianne Vass Executive Director Emergency Medicine Patient Safety Foundation (EMPSF) Folsom, California Dvass@EMPSF.org Drew Fuller, MD, MPH, FACEP Director of Patient Innovation Emergency Medicine Associates, PA, PC Germantown, Maryland EMAOnline.com Drewfuller@mac.com