Presented at the George Washington University 1st GME Retreat. Includes overview of handoff function and content, pitfalls for handoffs, and strategies for safe and effective communication during handoffs, and how to use process improvement techniques to make handoffs safer. Handout includes handoff menu of educational tools to be used by faculty teaching.
Glomerular Filtration rate and its determinants.pptx
Handoff Workshop - 2 Hour Training
1. Making the Most of Patient Handoffs: Critical for Patient Safety & Learning Vineet Arora, MD, MAPP Assoc Director, Internal Medicine Residency Asst Dean, Pritzker School of Medicine University of Chicago The George Washington University Medical Center April 16, 2010
5. What did you observe? What went well in this scenario? Observations Facilitators Other Environmental (e.g., distractions and obstacles interfering with completing proper hand-off procedure) Communication (e.g., vague terms, incomplete information, lack of verification, etc.) Cultural (e.g., not prioritizing hand-offs, following proper procedures, unprofessional behavior, etc.) Observations/Thoughts Barriers
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9. What types of handoffs come to mind when you think about handoffs?
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16. How can we improve handoffs? Understanding the good, bad & ugly… University of Chicago Experience
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21. Differential Diagnosis of Uncertainty Farnan, et al. QSHC. 2008 Beresford E. The Hastings Center Report 1991 Patients’ treatment preferences Transfer of patient from floor to ICU Performing of a lumbar puncture Example Learn during handoff Lack of personal relationship with patient Personal uncertainty Seek supervision Difficulty applying abstract criteria to concrete situations Conceptual uncertainty Seek supervision Absence of or inadequate scientific data; limitations of fund of knowledge Technical uncertainty Strategy Definition Domain
24. Improving Handoffs: Handoffs as a Form of Communication “ who says what to whom in what channel with what effect” Harold Dwight Lasswell
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27. Hand-off as a Form of Communication “ When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener.” – Alistair Cockburn
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31. Now..Let’s put our communication skills to the test The Paper Tear Exercise
57. PCP “pieces together” what happens from available labs & studies “ It’s like a detective” PCP finds out via active surfing of roster, or coaches patient to call PCP if they go to hospital, or home health fax “ Maybe smoke signals”
59. Teaching Handoffs: A Competency Based Approach Communication Professionalism Arora, et al. QSHC 2008. 2/3 of IM programs report some type of teaching on handoffs (APDIM Survey, 2008)
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61. Horwitz et al, JGIM. 2007 “ SIGNOUT?” Sample verbal sign-out S Sick or DNR? OK, this is our sickest patient, and he’s full code. I Identifying data (one liner) Mr. Jones is a 77-year-old gentleman with a right middle lobe pneumonia. G General hospital course He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin. N New events of day Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable chest x-ray was improved from admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. O Overall health status Right now he is satting 98% on 2 L NC and is afebrile. U Upcoming possibilities with plan and rationale If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because possible sepsis. T Tasks to complete overnight with plan, rationale I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up. ? Any questions? Any questions?
69. A nurse calls because the patient wants to know if they can eat. Signout says “Patient is NPO for surgery tomorrow” Always give dates Avoid use of today/tomorrow/yesterday What procedure? How important?
70. Your signout says “Check BMP at 8pm” The patient has a sodium of 124. What are you supposed to do with abnormalities? What is the baseline? What are you looking for?
71. A patient you are covering is being evaluated for small bowel obstruction. The attending surgeon comes by after being in the OR and asks you what the patient’s coags are. You say, I’m sorry but that is not my patient. Handoffs are more than just a transfer of content, but also a transfer of professional responsibility Every patient is your patient
72. Evaluation of Handoff Skills Simulation Peer Evaluation ½ of IM programs are evaluating handoffs (APDIM Survey, 2008)
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80. Jeanne Farnan, MD, MHPE U Chicago Julie Johnson, MSPH, PhD U New South Wales, AU Holly Humphrey, MD U Chicago Boaz Keysar, PhD U Chicago Monica Lypson, MD U Michigan Sam Seiden, MD Stanford Leora Horwitz, MD, MS Yale Arpana Vidyarthi, MD UCSF David Meltzer, MD, PhD U Chicago Julia Kao, MD Northwestern Vivian Chang, MD UCLA Keiki Hinami, MD Northwestern John Paro, MS4 U Chicago
81. Vineet Arora varora@uchicago.edu Questions or Ideas? For copies of our papers or tools: [email_address] For our videos: “ MergeLab” on YouTube http://www.youtube.com/mergelab
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Editor's Notes
"a system that quickly provides staff and patients with the name of the resident currently responsible, and the name of the attending physician" Who signed out today—where? Describe it? Noisy, pager going off, others in the room?
From Efren: Accompanying the patient to give provider DID NOT MANDATE FACE TO FACE SIGNOUT—COULD BE BY PHONE… REQUIRE OPP TO ASK QUESTIONS INTERACTIVE
Title of slide 12 supposed to be Response to Communication Failure During Sign-out ?
GIVE CLINICAL EXAMPLE FOR EACH ONE…TO LAY THE FOUNDATION… MAKE A TABLE
First, studies show that speakers systematically overestimate how well their messages are understood by listeners.15 Secondly, the more knowledge that people share, the worse they communicate new material because they overestimate the knowledge of the other.16 Such general psychological processes could systematically impact the effectiveness of communication during hand-offs. If this is true, then post-call interns should overestimate the effectiveness of their communication.
In thinking of the way we communicate, it is important to think about the mode of communicatin. I use the red arrows to highlight two ends of this spectrum that we use to communicate every day in healthcare: paper and face to face communication. And clearly they are very different and it is important to know how they differ. Esp in the context of signout. This passage from Allistair Cockburn, who is actually a software engineer and prominent author on this topic describes it best: When you move from right to left, you lose richness, such as physical proximity and the conscious and subconscious clues that such proximity provides. You also lose the ability to communicate through techniques other than words such as gestures and facial expressions. The ability to change vocal inflection and timing to emphasize what you mean is also lost…Finally, the ability to answer questions in real time, are important because questions provide insight into how well the information is being understood by the listener.
Now what can we say about communication at the time of Handoffs—here we have to turn to other industries…read slide… Not surprisignly, the main strategies described in this paper resonate with those that have worked in healthcare communication more generally TRANSITION TO JEFF… ********************************************** Human factors researchers noted the same thing as they conducted direct observations of handoffs at NASA Johnson Space center, 2 canadian nuclear power plants, a railroad dispatch center in the US, and an ambulance dispath center in Toronto. From these observations, they identified handoff strategies and face to face verbal update with interactive questioning was definitely a plus… Other things they noted
But the good news, is that communication can be improved, and that is one goal of today’s workshop. In fact, more structured communication, such as the use of a read-back, similar to your neighborhood drive-thru that confirms your order, reduces errors during telephone reporting of abnormal lab values. Highlight that 4 people refused to read back the message - > importance of institutional culture **** Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol. 2004;121(6):801-3. The recipients were asked to repeat the name of the patient, the test, and the result; the technologists noted this on the form. In addition, they noted the time necessary for the entire phone call and the extra time necessary to ask for the message to be repeated and for it to be repeated. Data $11.25/hour ($0.19/minute or $0.0032/second), the extra time to repeat the message costs the hospital from $0.11 to $0.16 per call ($0.07 per 13 seconds for a laboratory technologist’s time plus $0.04-$0.09 per 13 seconds for the recipient’s time).
Now lets turn to communication in healthcare…what do we know…first we know that it is indispensible. This is important particularly in the context of future IT solutions which are sometimes touted as the safer. **** Refs: Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):121-4. Kilpatrick ES, Holding S. Use of computer terminals on wards to access emergency test results: a retrospective audit. BMJ. 2001;322(7294):1101-3. The results from 1443/3228 (45%) of urgent requests from accident and emergency and 529/1836 (29%) from the admissions ward were never accessed via the ward terminal. Results from 794/3228 (25%) of accident and emergency requests and 413/1836 (22%) of admissions ward requests were seen within 1 hour of becoming available while a further 491/3228 (15%) and 341/1836 (19%) respectively were accessed between 1 and 3 hours. In up to 43/1443 (3%) of the accident and emergency test results that were never looked at the findings might have led to an immediate change in patient management. CONCLUSIONS: When used as the sole substitute for telephoning results, the provision of terminal access to laboratory results on wards can hinder rather than promote the communication of emergency blood results to healthcare staff.
Fold your paper in half and tear off the bottom right corner of the paper. (Pause and allow the group to try this.) Fold the paper in half again and tear off the upper right hand corner. (Pause) Fold the paper in half again and tear off the lower left hand corner. (Pause) Open your eyes, unfold your paper and hold it out for everyone to see.
2) NPO for procedure “tomorrow” - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm --WHAT IF ELYTE ABNORMALITIES? WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
2) NPO for procedure “tomorrow” - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm --WHAT IF ELYTE ABNORMALITIES? WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]
2) NPO for procedure “tomorrow” - GIVE DATE ALWAYS use dates, avoid today/tomorrow/yesterday 3) Check BMP at 8pm --WHAT IF ELYTE ABNORMALITIES? WHAT ARE YOU LOOKING FOR? …this just happened to me! 4) Delete someone before they have left the hospital 5) Eliminate necessary meds for the sake of space on the signout [PRN, SQ heparin]