Dr. William H. Morris Director Clinical Informatics. Staff, Department of Hospital Medicine

1. Dr. William H. MorrisDirector Clinical Informatics. Staff, Department of Hospital Medicine Effective Sign-Out for Safety and Continuity of Care

2. Learning Objectives Define Signout: What it is and what it is NOT Identify regulatory and patient safety factors of implementing a Signout process Identify key workflow and tool opportunities for an effective tool

3. What is it…. • Process of transitioning care from one “provider” to another. Includes: • Patient identifiers, location • Summary of active issues • Expected tasks • Anticipated events • Identification of the treatment team (name, contact info, and times of coverage)

4. Why is it important to perfect? • 44,000 – 98,000 deaths annually due to medical errors (IOM) • 2/3 of medical errors due to communications errors (JCAHO) Joint Commission: Issue 26 - June 17, 2002 Delays in treatment

5. After duty-hours restrictions, resident sign-outs increased by 40% Average number of patient sign-outs per month for a single resident: 300 Estimated total number of patient sign-outs per day (including all health care providers) in large academic hospital: 4,000 Estimated total number of patient sign-outs per year in a hospital: 1.6 million Why is it important to perfect? Arpana Vidyarthi MD; derived from MDHCUPnet, Healthcare Cost and Utilization Project.

6. Who are the Users? Residents Residency training requirement Fellows Physician Assistants and Nurse Practitioners Staff Physicians Nursing Ancillary services ACGME Executive Committee Approved February 14, 2005 www.acgme.org/acWebsite/RRC_140/140_EIP_%20PR205.pdf 6

7. A Focus on Signout National Patient Safety Goal: NPSG 02.05.01 The hospital implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions Leadership Standard: LS.03.04.01 “Effective communication is essential among individuals and groups within the hospital…” Medical Staff Standard: MS.05.01.03 “The organized medical staff participates in coordination of care, treatment and services with other practitioners and hospital personnel, as relevant to the care, treatment and services of an individual patient…” “The hospital must coordinate the care, treatment and services provided to a patient. In order to provide continuity of care, it should have an established method of communication between inpatient services and outpatient care in order to provide continuity of care to its patients.” Joint Commission Requirements CMS Requirements 7

8. Systems around us Limitations Tool Capabilities

9. Psssssss….the password… “transfer2medince”

10. Word Excel Email Functionality Market Solutions Verbal EHR

11. Scenario • Ms. Smith is a 76 year old patient who is currently under the care of an outside hospital. Due to worsening pneumonia, a request to be transfer to Cleveland Clinic is made. • The OSH physician speaks to the medicine transfer attending at CCF whom gathers the clinical story and accepts the patient to be transferred to CCF. Information

12. Scenario Information Using paper, email, or spreadsheet to record the information…. ..information is tied up, and NOT easily accessible to future providers

13. Scenario Using the Continuity of Care tool The accepting physician enters clinical data and important bed placement information Bed Utilization: Unit request Confirmation by Bed utilization

14. On arrival at Cleveland Clinic… Ms. Smith arrives, the system alerts the user that the patient is registered with ADT. Using unique patient identifiers, the system looks for matches within patients on the “to come in” list and those admitted. The system prompts the user to reconcile those matches.

15. Ms. Smith Arrives at Cleveland Clinic The floor nurse reads the sign-out, and contacts the correct admitting attending. The admitting attending can access all the clinical history obtained by the accepting physician hours before.

16. Signout System displays a Team Based Schematic

18. Dynamic links back to the EHR and ADT systems. The system will provide for updates to EHR and ADT systems for treatment teams Clinical history obtained by the accepting physician hours earlier Drive the clinical plan as soon as patient arrives

19. The admitting Attending reads the sign-out, and sees that Dr. Morris was concerned for a Pulmonary embolism. A CTA study is order immediately. • The study returns 1 hour later POSITVE for PE • The treatment team starts on appropriate meds and consults Vascular Medicine. • Vascular Medicine makes recommendations in the EHR and adds Ms. Smith to their Consult Signout Team • The Continuity of Care tools allows ALL providers to view each others signout 1 patient, all signouts

20. Word Excel Email Functionality Continuity of Care EHR Market Solutions Verbal

21. Challenges • Double Documentation • Source of Truth • Legal Medical record vs. Discoverable • Metrics of “success” (sign out of typical high-throughput surgical service a good marker of care?) • Quality not quantity: NOTE BLOAT