Improving Hand-Off Behaviors: Strategies to Reduce Patient Error

1. Reducing Patient Error By Improving Hand-Off Behaviors: Part 2 – Ideas from Needs Assessment and Next steps July 27, 2016 Mary Lacy MD Justin Roesch MD (on behalf of IPASS Workgroup)

2. Objectives • Create a dialogue to discuss how we can use IPASS to improve patient care at UNM. • Discuss variance in sign-out/sign-in behavior • Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error • Review Resident Commentary on Sign-Out • Discuss Next Steps

3. Objectives • Create a dialogue to discuss how we can use IPASS to improve patient care at UNM. • Discuss variance in sign-out/sign-in behavior • Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error • Review Resident Commentary on Sign-Out • Discuss Next Steps

4. What information is exchanged? Face-to-face? What constitutes an effective handoff? Is it written? Oral? Both? How long does it take? Who is signing out the patients?

5. Objectives • Create a dialogue to discuss how we can use IPASS to improve patient care at UNM. • Discuss variance in sign-out/sign-in behavior • Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error • Review Resident Commentary on Sign-Out • Discuss Next Steps

6. Best Practice for Handoff Domains Behaviors Information Training

7. Best Practice for Handoff Domains Synthesis Feedback Standardized Tool Dedicated Training

8. Best Practice for Handoff Domains Synthesis Feedback Standardized Tool Dedicated Training

9. Handoff Failures Omitted Data Superfluous Data

10. What is I-PASS? • Illness Severity (stable, unstable, watcher) • Patient Summary (summary statement, events of admission, hospital course, active plans) • Action List (“To-Do List”) • Situation Awareness and Contingency Plans • Indication of what to do if adverse contingency is encountered • Allergy List (auto-populated) • Code Status (auto-populated) • Med List (auto-populated) • Dated Vital Signs • Synthesis by Receiver

11. 7 Elements of I-PASS Bundle • I-PASS mnemonic (Information) • 2 hour workshop (TeamSTEPPS; teaching teamwork and communication skills) • 1-hour role play workshop for skill practice • Computer Module to allow for independent learning • Faculty and Resident Curriculum(Training) • Direct Observation to provide feedback to residents (Behavior) • Process-Change and Culture-Change Campaign

12. Best Practice for Handoff Domains Synthesis Feedback Standardized Tool Dedicated Training

13. Best Practices: Behaviors • “Read-back” and “Repeat-back” practices • “Face-to-face, uninterrupted communication combining verbal and written or electronic handoff information is best.” Handoff as an active dialogue. http://unmhospitalist.pbworks.com/w/page/6810353/Sign%20OutCross%20Cover

14. Best Practices: Information Transmission • Data must be unambiguous and factually correct. • Contain: • Patient identification • Diagnostic summary • Current condition and trajectory • A plan of care • A prioritized to-do list for anticipated events CACHE NEEDS TO BE UPDATED

15. Best Practice for Handoff Domains Synthesis Feedback Standardized Tool Dedicated Training

16. Best Practices: Training Physicians need formal didactic and interactive training in handoffs (VI.B.2) Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety [and] (VI.B.3) Programs must ensure that residents are competent in communicating with team members in the hand-over process.

18. What did IPASS implementation look like?

19. Written handoff

20. Verbal handoff

21. What did IPASS implementation achieve?

22. IPASS reduced medical errors

23. Objectives • Create a dialogue to discuss how we can use IPASS to improve patient care at UNM. • Discuss variance in sign-out/sign-in behavior • Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error • Review Resident Commentary on Sign-Out • Discuss Next Steps

24. What do the cross covering house-staff have to say about sign-out? • Patients: 45-70 (5 teams) • Time: 30 min to 90 min. • Sign-in: Variable. Notes are common, but other practices have mixed adoption. • Who do you call for help: Other housestaff, but not the other OCD. • APP cross cover are part of IPASS core team and have more standardized processes in general

25. Objectives • Create a dialogue to discuss how we can use IPASS to improve patient care at UNM. • Discuss variance in sign-out/sign-in behavior • Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error • Review Resident Commentary on Sign-Out • Discuss Next Steps

26. Discussion • Protected Sign out • Sign-in Process • Cache tool • Direct Observations with feedback

27. Protected Sign Out • Needs Assessment: • Sign out is very vulnerable time • Lack of protected time increases rushed nature of sign out • There is no standardized process • Cross cover survey - Would protected signout help? • Majority said yes • Some possible solutions

28. Solution 1: Moving Sign-Out Forward • Start Sign-out @ 6:30 • Each team is given a specific “window” for sign-out • Some sign-out takes longer • External Factors (team not “ready” at 7:00) • Nurses usually signing out between 7:00-7:30 can be helpful because they are occupied 6:30-6:45 6:45-7:00 7:00-7:15 7:15-7:30

29. Solution 2: Shield OCD • Teams Begin to Sign-out @ 7:00 • …But teams cross-cover until ~7:30 to help “shield” OCD while getting sign-out. • Duty Hours? • Residents complying? • Who is responsible for urgent Issues during this time?

30. Solution 3: The Swap OCD 1 OCD 2 OCD 1 Cross Covers all teams from 6:30-7:00 OCD 2 Cross Covers all teams from 7:00-7:30 OCD 2 get’s Sign-Out from 6:30-7:00 OCD 1 get’s Sign-Out from 7:00-7:30

31. Limitations • OCDs covering for one another • OCD will be covering on a large group of patients that they will not have received sign-out on. • What happens if there if there are simultaneous emergencies • Systems/Solutions can be combined

32. Sign-in process • Needs assessment: OCD notes in chart have helped • Issues: less verbal/written signout now because of notes  No bird’s eye view of the night, no feedback on issues that came up to provide opportunity for questions • Issues: Some patients without notes (no note on patient who went on 15L NRB recently)  CC resident stated they did not know of this expectation • Ideas: Room for sign-in, verbal sign-in, cache update to allow quick review of nights events?

33. Cache tool • Needs Assessment: • Auto-fill areas are useful • Used in dual role  some fields not specifically helpful for sign out but used by day teams • Irregular updates are BIG problem • IPASS Project: All elements of IPASS should be visible on written tool

34. Proposed Update to Printout • Separate printed tool for CC as opposed to day teams? • If so, what columns? • Other Recommendations for the tool?

35. Direct Observations • Needs assessment: No feedback on handoffs in residency • IPASS Project: Goal is for feedback of every resident who is giving or receiving handoffs to be observed with feedback 1x/rotation

36. Direct Observations • Insights from initial direct observations • 30 minutes max • Don’t NEED to know the patients/team • Conference calling may make the process easier (we are looking into this) • Ideas: • IPASS CORE champions will be doing observations with feedback • Could everyone commit to participate in feedback a specific # times/year? (THREE?)

37. What Solutions Do you Have???

38. References • Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care. 2008;17:6 –10. • The Joint Commission. Accreditation Standards. Oakbrook, Ill: The Joint Commission; 2010. • Lofgren RP, Gottlieb  D, Williams  RA, Rich  EC. Post-call transfer of resident responsibility: its effect on patient care. J Gen Intern Med 1990;5 (6) 501- 505 • Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755–1760. • Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006; 145:488 – 496. • Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196 –205. • Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094 –1099.