Nursing Handoff & Patient Safety

1. Nursing Handoff & Patient Safety Scholarly Project Presentation Cheryl Miller

2. Setting Munson Medical Center • Magnet Designated Acute Care Facility • 300,00 annual patient visits • ED annual volume of 52,000 (A. Holmes) • A7 Stroke Telemetry Unit annual patient stay volume of 8,905 (M. Ramseyer, 2013)

3. The Joint CommissionDefines Handoff • As transfer and acceptance of patient care responsibility through effective communication, real time process of sharing information for the purpose of ensuring quality patient care • The sender is responsible for transmit patient data and release the care • Receiver gathers data and accepts care TJC (2012)

4. Joint Commission • National Patient Safety Goal: Implement a standardized approach to handoff communication (TJC 2012)

5. TJC Requirements for Implementation • Interactive communication requiring opportunity for questioning between the giver and receiver • Up to date information regarding patients care, treatment services, condition, anticipated changes • Process for verification including read back/repeat back • Opportunity for receiver to review historical data, previous care, treatment and services • Interruptions are minimized to reduce the risk that information will be forgotten TJC (2012)

6. Key Literature Findings • Study showed 96% of nurses perceived receiving adequate ED report during handoff. However, some gaps do exist. • Five essential features • Systematic approach, treatment, appropriate environment, reference to documentation/charts, and efficient communication. • Essential information: patient details, presenting problem, future care and disposition, treatment, and nursing observations. Klim, Kelly, Kerr, Wood & McCann (2010)

7. Research Support of This Issue • An estimated 80% of serious medical errors involve miscommunication during handoff (TJC, 2012) • Breakdown of communication is the leading cause of sentinel events reported to TJC between 1995-2006 (TJC, 2012) • Approximately 40 adverse patient events occurred at in a 12 month period R/T to nursing handoff (Munson Performance Improvement, 2013) • Nursing handoff is complex and variable leading to a risk in patient safety (Patterson & Wears (2010)

8. My Initial Vision • To review, revise and standardize the nursing handoff process for patients being admitted from the ED to an in-patient setting at Munson Medical Center

9. Initial Project Proposal Goals & Objectives • Retrieve evidenced based research to gather support • Identify barriers in nursing handoff process • Formalize an agreed upon process with collaboration of nursing staff • Formalize a targeted education plan • Evaluate through nursing engagement survey • Seek verbal feedback and written feedback

10. Proposed Project Activities • Obtaining relevant research by Sept 5, 2013 • Meet and collaborate with nursing staff to perform a gap analysis by Sept 15, 2013 • Meet and collaborate with nursing staff to brain storm to identify potential barriers/solutions by September 30, 2013 • Formulate and develop strategies by October 30, 2013 • Develop an education plan by November 15, 2013 • Evaluate the revised process by December 15, 2013

11. Revised Project Goals • Observe handoff process on ED & A7 nursing units • Collaborate with ED & A7 nursing staff • Perform a systematic inquiry through direct observation, verbal feedback, review of EMR • Compare & apply evidenced based research • Offer recommendations for review • Receive feedback

12. Project Activities (Personal & Professional Accountability) • Literature search: 15 plus research articles for review and application • Reviewed original charter and handoff goals established in 2011 to understand the nursing handoff process • Observed handoff practice and followed patient admissions from the ED to the A7 nursing units • Interviewed ED and A7 nursing staff to gather insights and perceptions of handoff process • Reviewed EMR charting via FirstNet

13. MMC Nursing Handoff Established 2011 ED • RN completes patient care and completes ED admission handoff report in FirstNet (Admitting assigns bed, 15 min timer for report begins) • RN calls receiving RN (or Shift Coor) to notify patient coming (time for questions/answers) • RN Documents receiving RN name on handoff form in FirstNet MMC ED to IP Handoff (8/14/12)

14. MMC HandoffEstablished 2011 In-Patient Nursing Unit • Shift Coor notifies receiving RN of pending admission • Reviews electronic documentation including ED handoff report & ED summary tab within the 15 minute window • Receives notification that patient is on the way (time for questions/answers) MMC ED to IP Handoff (8/14/12)

15. Practice Outcomes • Standardized Process • Opportunity for questioning between the giver and receiver • Up to date information regarding patients care, treatment services, condition, anticipated changes • Process for verification including read back/repeat back • Opportunity for receiver to review historical data, previous care, treatment and services • Interruptions are minimized to reduce the risk that information will be forgotten TJC, 2012

16. Practice Observations • Variability of verbal communication and EMR documentation. These are likely due to environmental and competing work demands such as interruptions from phone calls, tele monitor needs, direct pt care needs, etc. • Staff verbalized that expectations of information necessary for effective nursing handoff communication differ. These are likely due to the divergent focus of nursing care between the ED and A7settings. • Staff also expressed frustration around delay in admission transport due to resource availability such as staff, equipment, curtain changes.

17. Key Literature Findings • Five Factors which impact handoff • The mix of individuals who participate • The content covered • Time pressures and length of the handoff • Location and communication media used • Social structure within which handoff is conducted Cohen & Hilligoss (2010)

18. Analysis of Outcomes • MMC handoff protocol meets standards defined by TJC (2012). • Variability in nursing handoff is consistent finding in research literature (TJC, 2012). • Contributing factors are noted to be nursing experience, time constraints, individual reporting style, and divergent focus of nursing care between patient settings Cohen & Hilligoss (2010).

19. Analysis of Outcomes • Patterson and Wears (2010) suggest that that 20-30% of patient information exchanged is not documented in the electronic medical record and that the baseline conditions for handoff are highly variable. • Cohen and Hilligoss (2012) suggest sharing patient admission information between the ED and the in-patient setting requires nurses to use greater expertise due to differences in work practices and communication styles.

20. Handoff Expectations Sender Vs Receiver Expectations for handoff report do not always align due to unique settings in which care takes place TJC (2012)

21. Evidenced Based Recommendations • Limit interruptions by providing a quiet space/quiet zone for charting or receiving report data. (May reduce variability and risk of omission, and promote retention of information. (McKinney, 2010) • Provide cross training experiences for nursing to experience the ED environment and in-patient setting during the orientation process (Promotes awareness and understanding of unique setting and nursing focus between the ED and in-patient setting. (Cohen & Hilligoss, 2010)

22. Evidenced Based Recommendations • Global reporting of adverse outcomes to create organizational awareness and sense of urgency toward handoff practices (TJC, 2012) • Evaluate nursing satisfaction R/T handoff process in order to engage staff and promote future process improvement (TJC, 2012) • Create an educational workshop which focused on importance of nursing handoff, recognizes unique focus of ED and in-patient settings, celebrates diversity (TJC, 2012)

23. Project Presentation • Setting: Munson Medical Center • Date: November 13, 2013 • Planned Attendees include • Project Preceptors • ED Manager & nursing staff • A7 Manager & nursing staff

24. Adherence Toward Legal & Ethical Standards • Evidence based research was utilized throughout this development, planning, completion, and analysis of scholarly project goals, activities, outcomes, and recommendations. • Handoff practices were analyzed using guidelines set forth by The Joint Commission (2012). These were met.

25. Adherence Toward Nursing Standards • Project activities to observe handoff practice, seek evidence based research, seek barriers, and offer literature based recommendations advocate for nursing in their role to provide safe and effective patient care as described standards of practice in the Nursing AdministrationScope and Standards of Practice (ANA, 2009). • Jean Watson's Philosophy and Science of Caring (2008) theory and principles were utilized to communicate and collaborate with nursing staff. Open communication was utilized with a mutual respect for both positive and negative feelings in order to promote nursing engagement.

26. Adherence to Organizational Standards • My scholarly project goal to review the nursing handoff process, to advocate for nursing and patient care by seeking evidenced based solutions to support effective communication supports the mission, vision and values of Munson Medical Center to provide superior quality patient care.

27. Humility • A fellow student leader recently remarked…one of the greatest attributes a nursing leader can have in a learning environment is humility. Christmas (2009) said it best when she was quoted “true leadership requires equal parts vision and humility, with the ability to confront hard truths and to coach and mentor” (p. 128) Cannon, 2013

28. What I Learned Through This Process • My initial project goals were far too visionary, I lacked the knowledge, experience and management support. So, they were revised. • My intent was good, however, some of my actions were short sighted. My initial draft analysis paper focused strictly upon the perceived shortcomings and possible recommendations. Fortunately, I realized my error and circled back. • I would like to acknowledge the nursing staff in the ED and A7 nursing units who understand these dynamics far more than myself, who navigate the complex system in which we work to provide safe and effective patient care.

29. Thank you • My preceptors: Ann Holmes and Marianne Cornellier for your guidance..for knowing when to offer support and when to stand back and let me flounder. • Managers: Kristi Johnson and Mary Ramseyer for taking time to meet with me, for allowing me to engage with staff in the handoff process, and for opening up space on your nursing unit. • Nursing staff: A7 and ED for taking the time to engage with me on this crucial topic

30. References American Nurses Association (2009). Nursing administration scope and standards of practice. Silver Spring, MD: Nursebooks.org. Bally, J. M. (2007). The role of nursing leadership in creating a mentoring culture in acute care environments. Nurs Econ, 25(3), 143-148. Cheung, D.S., Kelly, J. J., Beach, C., Berkeley, R. P., Bitterman, R. A., Broida, R. I.,…White, M. L. (2009). Improving handoffs in the emergency department. Annals of Emergency Medicine XX(X), 2-10 Clancy, T. R., Effken & J. A., Pesut, D. (2008). Applications of complex systems theory in nursing education, research, and practice. Nurs Outlook 56(5), 248-256. doi: 10.1016/j.outlook.2008.06.010. Cohen, M. & Hilligoss, B. (2012). Handoffs in hospitals: A review of the literature on information exchange while transferring patient responsibility or control. Retrieved from http://deepblue.lib.umich.edu/bitstream/handle/2027.42/61498/?sequence=1 Delrue, K. S. (2013). An evidence based evaluation of the nursing handover process for emergency department admissions (Doctoral dissertation). Retrieved from http://scholarworks.gvsu.edu Desjarlais, M. & Smith, P. (2011). A comparative analysis of reflection and self-assessment. International Journal of Process Education. Lisle, IL: Pacific Crest. Friesen, M., White, S. & Byers, J. (2008). Handoffs: Implications for nurses. In R. G. Hughes (eds.), Patient Safety and Quality: An Evidence Based Handbook For Nurses (pp. 1-48). Rockville, MD: Agency for Healthcare and Quality. Kempnich, J. (2011). Utilizing decision acceleration for Magnet gap analysis. Nursing Management42(2), 43-45. Kennan, G. M., Tschannen, D., & Wesley, M. L. (2008). Standardized nursing terminologies can transform practice. JONA, 38(3), 103-106. Klee, K., Latta, L., Davis-Kirsch, S. & Pecchia, M. (2012). Using continuous improvement methodology to standardize nursing handoff communication. Journal of Pediatric Nursing, 27, 168-173.

31. References Klim, S., Kelly, A., Kerr, D., Wood. S. & McCann, T. (2010). Developing a framework for nursing handover in the emergency department: An individualized approach. Journal of Clinical Nursing, 22, 2233-2242, Marshall, E.S. (2011). Transformational leadership in nursing: From expert clinician to influential leader. New York: Springer Publishing LLC Mascasoli, S., Laskowski-Jones, L., Urban, S. & Moran, S. (2009). Improving handoff communication. Nursing, 39(2), 268-271. McKinney, M. (2010). Smoothing transition: Joint Commission targets patient handoffs. Retrieved from http://www.modernhealthcare.com/article/20101025/MAGAZINE/10102998 Ong, M., Biomed, E., & Enrico Coiera, M. B. (2011). A systematic review of failures in handoff communication during intrahospital transfers. The Joint Commission Journal on Quality and Patient Safety 37(6), 274-283. Munson Medical Center (2013). Mission Statement. Retrieved from http://www.munsonhealthcare.org/?id=30&sid=2 Patterson, E. S. & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. The Joint Commission Journal on Quality and Patient Safety, 36(2), 51-71. The Joint Commission Center for Transforming Healthcare. (2012). Facts about the hand-off communications project. Retrieved from http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_HOC_Fact_Sheet.pdf Tomajan, J., (2012). Advocating for nurses and nursing. The Online Journal of Issues in Nursing (17)1. doi:10.3912/OJIN.Vol17No01Man04 Watson, J. (2008). Nursing:The philosophy and science of caring (Revised ed.) Boulder: University Press of CO.