best practices in handover...
TRANSCRIPT
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Best Practices in Handover Education
Chris Little, Meera Rayar, Nureen Sumar, Zia Bismilla, Trey Coffey Saturday October 25, 2014
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Nous n’avons aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d’appareils médicaux ou un cabinet de communication.
We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.
Authors: Chris Little, Meera Rayar, Nureen Sumar, Zia Bismilla, Trey Coffey Date: Saturday October 25, 2014
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
Seating Instructions
Please sit according to the main clinical setting in which you work:
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Workshop : Best Practices in Handover Education, Saturday October 25, 2014
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
Learning Objectives
Upon completion of the workshop, participants will be able to: Review and discuss current climate in handover
practices in Canada
Review the content and implementation of a comprehensive handover bundle in teaching hospitals in North America
Identify challenges implementing effective handover and handover education in individual programs and institutions
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Workshop : Best Practices in Handover Education, Saturday October 25, 2014
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
Introductions
Chris Little Meera Rayar
Nureen Sumar
Trey Coffey Zia Bismilla
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Workshop : Best Practices in Handover Education, Saturday October 25, 2014
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Handover Education: Best Practices and Current Climate
Chris Little, Meera Rayar, Nureen Sumar
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Your 1st Task! Working at your table
2 minute time limit
One word/Short answer style
1 answer per sticky note
Please describe:
Elements of optimal handover
Hand your sticky notes to a CAIR volunteer
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Optimal Handover
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Your 2nd Task! Working at your table
2 minute time limit
One word/Short answer style
1 answer per sticky note
Please describe:
Barriers to optimal handover
Hand your sticky notes to a CAIR volunteer
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Barriers
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Handover Education Effective patient handover is essential to ensure patient
safety and optimal medical care, however most residents in Canada do not receive formal training in this essential area.
CAIR’s 2012 position paper on Resident Duty Hours recommends “residents must be formally trained in handover skills; the ability to transfer care appropriately when going off duty.”
Development and promotion of handover education remains an area of focus within CAIR
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CAIR Strategic Plan Mission: to drive excellence
in medical education as national voice of resident physicians
Strategic direction #1 Training: to optimize continuum of medical education Anticipate and provide
leadership
Foster exceptional patient-centered care
Integral part of national curriculum development
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Handover Initiatives CAIR has taken a leadership role by examining and evaluating handover methods and best practices within Canada and abroad, with an emphasis on key components and barriers to teaching effective handover to residents: conducted extensive literature reviews (2010-14)
surveyed our membership (2013)
developed the CAIR Policy Statement on Handover Education in Canadian Residency Programs (2014)
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New Competency in CanMEDS 2015 Framework
Handover included in physician Collaborator role Key Competency 3 states
“Physicians are able to effectively and safely transfer care to another health care professional
3.2 Demonstrate safe transfer of care, using both verbal and written communication, during patient transition to a different health care professional, setting, or stage of care.
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CAIR Survey Results
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CAIR National Resident Survey
Surveyed all Canadian residents outside of Quebec in the Spring of 2013
Residents were asked about:
current handover practices
handover educational methods at their training institution
perceived medical errors associated with poor handover
CAIR National Resident Survey, 2013.
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Total of 1,975 Canadian residents participated
Response rate of 22.8%
Demographics
CAIR National Resident Survey, 2013.
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Method of Handover On average, transfer of care between residents of the patients on their
service occurred twice (mean 1.8, median 2.0) within a typical 24-hour period
The mostly commonly used main method of patient handover was face to face (82%)
4%
9%
14%
29%
30%
82%
96%
91%
87%
71%
70%
18%
Other (n=74)
Handwritten only (n=1,975)
E-mail (n=1,975)
Electronic shared document (n=1,975)
Over the phone (n=1,975)
Face to face (n=1,975)
Figure: Please select the main method you use for doing patient handovers.
Main method used Not main method used
CAIR National Resident Survey, 2013.
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Adverse Events Canadian residents view incomplete handover as
placing patients at risk for adverse events
Half of respondents (49%) had either witnessed (33%) or been directly involved (16%) in an adverse event that could have been prevented with more adequate handover
Surgical residents were more likely to have been involved directly (22%)
CAIR National Resident Survey, 2013.
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Currently, there is a lack of formal handover training in Canadian PGME programs
Most residents develop their handover skills through informal observation of senior residents or staff physicians
Handover training/education
4%
17% 11% 11%
57%
Other As part of orientation During an academichalf-day
As part of anotherformal session
Informally taught by asenior resident staff
physician
Only 17% received handover training as part of orientation, 11% during academic half-days, and a further 11% as part of another formal session
Figure: Have you received training in patient handovers in any of the following ways?
CAIR National Resident Survey, 2013.
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What would be most useful? There is a need for more consistent and structured approach
to handover training during residency
Residents ranked receiving feedback and one-on-one teaching as the preferred methods for improving handover skills
11%
16%
23%
27%
57%
65%
35%
33%
37%
38%
32%
26%
48%
45%
35%
30%
8%
8%
6%
6%
5%
4%
2%
2%
0% 20% 40% 60% 80% 100%
Podcast (n=1,784)
E-module courses/training (n=1,806)
Online handover models/examples (n=1,802)
Formal workshop on handovers with simulation(n=1,812)
One-on-one teaching from senior resident/attending(n=1,843)
Receiving feedback on my handover methods/skills(n=1,832)
Useful (8 to 10) 4 to 7 Not useful (1 to 3) Unsure
CAIR National Resident Survey, 2013.
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Today we heard…
Results from our earlier exercise identifying
Key elements of optimal handover
Barriers to optimal handover
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CAIR Policy and Recommendations
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CAIR policy statement
• Based on extensive lit review
• Makes 5 key recommendations to improve handover education
• Calls on residency programs to develop formal handover curriculum
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5 Recommendations to improve Handover education
1) Each patient handover should incorporate direct verbal interaction between care providers. Given the complexity of the handover process, using both verbal and written communication will ensure safe and accurate transfer of patient care.
2) Handover should take place in a quiet area where distractions are minimal. Sufficient time must be allotted for the handover.
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5 Recommendations to improve Handover education
3) The handover process should employ evidence- based tools and be standardized for each clinical setting. There are a variety of mnemonics and aids that may be adapted to the particular needs of a clinical setting.
4) A formal handover curriculum should be an accreditation standard for medical education, reflecting the core competencies of the CanMEDS framework.
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5 Recommendations to improve Handover education
5) Physicians require both didactic and interactive training in handover. The interactive component is especially important, and supervised evaluation of handover should be part of the training curriculum. A senior or chief resident, faculty member, or program director should regularly observe each resident’s handover performance and provide formal feedback.
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Call to Action for Improved Handover Training in PGME
“As recognition of risks associated with handovers grows, it is essential that residency programs develop formal handover curriculum that provides high-quality training to ensure patient safety and optimal care.”
“Each residency program should tailor
handover curriculum and tools to meet the unique needs of its clinical settings”
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Key Elements of High Quality Handover
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High quality handover: Key elements
Face-to-face, written + verbal is best
Protected time and space Quiet location Interruptions minimized
Has a leader to ensure unambiguous transfer of information and responsibility
Standardized format Articulated by program/service Incorporated into daily work via training and tools
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VERBAL handover: Key elements
Structured format Begins with high-level overview
Appropriate pace
Closed-loop communication Ensures salient points ‘received’ Acts as prompt for clarifying questions
Attention to non-verbal communication
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WRITTEN handover: Key elements
Supplements the verbal handover
Requires daily updates High-quality, synthesized information
- Do NOT copy and paste - Do NOT “add …add …add” without deleting
Senior/supervising resident should edit and ensure quality
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The I-PASS handoff
Zia Bismilla Trey Coffey
© 2013 I-PASS Study Group/Boston Children’s Hospital. All Rights Reserved. For Permissions contact [email protected]
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Computerized Handoff Tool
Communication Training
+ = Resident Handoff Bundle
Standardized Verbal Handoffs
+
Associated with a 40% reduction in serious medical errors (Starmer et al. JAMA 2013)
Resident Handoff Bundle Pilot Study
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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From Pilot to
Multi-Centre Implementation: IIPE-PRIS Accelerating Safe Sign-outs
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Study Aims To determine if handoff bundle implementation associated with:
Primary outcome A significant reduction in overall error rates and preventable adverse events
Process outcomes Improved written and verbal handoff communication
Balancing measures Impact on resident workflow
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Results
Number of errors (rate per 100 patient admissions)
Pre
(n=5516 admissions)
Post (n=5571
admissions) P value
Overall rate of medical errors 24.5 18.8 <.0001
Preventable adverse events 4.7 3.3 <.0001
Near misses / non harmful medical errors 19.7 14.5 <.0001
Non-preventable Adverse Events 3.0 2.6 0.48
Mean handoff duration per patient 2.4 min 2.5 min 0.55
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Results – Process Measures % of Verbal Handoffs with Element Present
* P < 0.001
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Illnessseverity
assessment
Patientsummary
To do list Contingencyplans
Readback
Pre-interventionPost-intervention
*
*
* *
*
N = 207 verbal handoff sessions, 2281 unique patient handoffs
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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A Complex Intervention: More than a Mnemonic
Faculty Development
“Go Live” -Training
-E-Tool
Observation and
Feedback
I. Planning/Development Stage
II. Implementation Stage
III. Reinforcement Stage
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Curriculum Development and Implementation:
Guiding Principles and Key Strategies
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Faculty Development Rationale
Faculty typically have never received handover training (“by osmosis”)
Without training, will struggle with teaching residents
Faculty do not need to radically change their own handover practice
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Faculty Development Module
60-90 minutes • Brief intro to study • Review of I-PASS handoff techniques • Introduction to observation tools • Video simulations of handoffs to allow practice
with tools
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Levels of Faculty Involvement
Faculty roles
I-PASS Workshop Leader/Facilitator Facilitate the 2-hour interactive didactic
training
Handoff Simulation Small Group Facilitators
Facilitate the hour long handoff simulations at the end of the workshop
“Live” Handoff Faculty Observers Observe live handoffs after bundle
implemented, provide feedback on faculty observation forms
“Just in Time” refreshers for rotating residents, students
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Multimodal Delivery of the Curriculum
Delivery vehicles
Initial training • Didactics • Videos • Simulation • On-line module
Reinforcement • Daily reminders • Observation and feedback
© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]
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Resident Handoff Workshop
1 Hr Communication Training (TeamSTEPPS)
1 Hr Handoff Training
1 Hr Small-group Simulations
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Shared Mental Model
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The I-PASS Mnemonic I Illness Severity
Stable, “watcher,” unstable
P Patient Summary Summary statement; events leading up to admission; hospital course; ongoing assessment, plan
A Action List To do list; specific timelines
S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen
S Synthesis by Receiver Receiver states key action items; asks questions
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Handoff Simulations
Allows learners to: Practice new behaviours Gain insight into other
roles • giver vs. receiver • more worried vs. worried
Promotes skill acquisition
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The Campaign
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Reinforcement of Learning: Handoff Observation and Feedback
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Verbal Handoff Observation Tool
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Planning for Implementation
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2 months 1 month 3 months 12 months
Faculty development • Handoff best practices and I-PASS mnemonic • Facilitate resident retreat and just-in-time training • Direct observation of resident handoffs
Resident curriculum • 3-hour “half-day” vs. 1 hour lunch series • Just-in-time training • Direct observations by faculty
Campaign activities
Overview
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Enlisting a Critical Mass of Believers
Program director, NP/PA lead, hospitalist lead, etc.
Chief residents
Safety officer CEOs, CMOs
Quality managers Faculty willing to help!
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1 month 3 months 12 months 2 months
Explore current handoff environment • Gather patient safety data • Conduct needs assessment
Garner Institutional Support • Hospital and Education Leadership • Information technology team
Secure Resources • Time, Money, Space
Implementation Checklist
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1 month 3 months 12 months 2 months
Format
Trainers and facilitators
Logistics of resident coverage
Strategies to include non-physicians
Prototype of printed handoff tool for sims Prepare Packets
Implementation Checklist
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Will I-PASS Stick?
Transformational change takes time
Requires sustained effort • Repeat curriculum for new learners • Continue observations, engage senior learners
as handoff teachers/coaches
Seeing impact on resident attitudes/skills as program matures is VERY REWARDING!
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Better handoffs. Safer care.
All handoff materials are available at www.ipasshandoffstudy.com and MedEdPortal
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Handover Improvement Planning Small Group Exercise
Working at your assigned tables, refer to the exercise Worksheet in your handout package
Your Task is to plan a handover improvement initiative at YOUR institution First, take a few minutes on your own to brainstorm
responses for each of the prompts/categories listed
Then report out to others at your table and discuss a common approach for your initiative
Report back to larger group
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
In Summary..
61
Workshop : Best Practices in Handover Education, Saturday October 25, 2014
There is a clear and demonstrated need for structured handover practices and formal curriculum
Evidence from CAIR survey of residents, lit reviews, policy recommendations, today’s sticky notes
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
In Summary..
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Workshop : Best Practices in Handover Education, Saturday October 25, 2014
Lessons from I-PASS experience
Provide us all with suggested tools, approaches and solutions to barriers for implementing structured handover in our own programs and institutions
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The International Conference on Residency Education | La Conférence internationale sur la formation des résidents
In Summary..
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Workshop : Best Practices in Handover Education, Saturday October 25, 2014
CAIR invites your support in the “Call for Action” to PG Deans to incorporate formal handover training into PGME curriculum
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CAIR Policy Statement
IPASS Handouts Components of curriculum
Observation tool
Example of SIM
Workbook (see display table)
Key Elements of quality handover
Suggested reading list
Thank
You!
Any questions? Take Aways
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• Download the ICRE App,
• Visit the evaluation area in Pre-function Hall B, near Registration, or
• Go to: http://www.royalcollege.ca/ icreevaluations to complete the session evaluation.
• Téléchargez l’application de la CIFR
• Visitez la zone d’évaluation, au vestibule de la salle B, près du kiosque d’inscription, ou
• Visitez le http://www.collegeroyal .ca/evaluationscifr afin de remplir une évaluation de la séance.
You could be entered to win 1 of 3
$100 gift cards.
Vous courrez la chance de gagner l’un des trois chèques-cadeaux
d’une valeur de 100 $.
Help us improve. Your input matters.
Aidons-nous à nous améliorer. Votre opinion compte.