1

Inova Health System

Picker Grant Update

For Patient Advisory Team

Oct. 26, 2011

Mary Ann Friesen PhD, RN, CPHQ Angela Servidio RN, BSN, BA

2

• Explore the patient perceptions of bedside handoffs will kick of in 2011

• Always Event

3

Picker Institute

Dedicated to advancing the principles of patient-centered care. Sponsors awards, research and education to

promote patient-centered care and the patient-centered care movement.

4

Always Events

• Picker has determined that an organizing principle focused on the concept of Always Events℠ can be implemented to drive the system to become more patient-centered.

• “Never Events” refer to incidents that should never happen in the delivery of care.

• Patient-focused Always Events℠ are aspects of the patient and family experience that should always occur.

*Brochures

5

Always Events℠ Challenge Grant Recipients Announced!

• Organization/Institution: Inova Health System Principal Investigator(s): Mary Ann Friesen, PhD, RN, CPHQ Project Title: Developing a Patient-Centered Approach to Handoffs

• Always Event(s): Patients will always be included in the ISHAPED handoff shift-to-shift hand-off process at the bedside as this will add an additional layer of safety by allowing the patient to communicate potential safety concerns.

* Page 6

6

Journey

• Handoff Issues Identified – Agency for Healthcare Research & Quality Hospital Survey on Patient Safety

Culture – Variance Across System

• Quality Leadership CE • System Kaizen – LEAN (March 2010) • Pilot Projects • Systemwide Rollout • Research

– Nursing Research – IRC – IRB

• Education Plan – Development – Production

7

Picker – will support Development of Education Program

• A collaborative exchange of information (conference calls, webinars, and listserv communications).

• Learning network for achieving the selected Always Events℠

• Development of key messages and media tools http://alwaysevents.pickerinstitute.org/?cat=7

8 8

Background

• “current state of scientific knowledge regarding hospital

handoffs is limited” (Arora, V.M, Manjarrez, Dressler, D.D, Dresler, D.D, Basaviah, P, Halasyamani, L, Kripalani, S., 2009 p. 437)

• “Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices.. (Riesenberg, L.A , Leitzsch, J., Cunningham, J.M., (2010) p. 24)

Australian Council for Safety and Quality in Health Care. (2005). Clinical handover and patient safety literature review report. Retrieved January 5, 2006, from http://www.safetyandquality.org/index.cfm?page=Publications#clinhovrlit

9 9

• Opportunity for improvement Hand-off and teamwork across units

• Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture -Handoffs average percent positive response 2009 - 44% 2010 - 44% 2011 - 45%

www. AHRQ.gov

AHRQ Patient Safety Culture Survey Results

10 10

Fumbled handoffs presents a risk for a breach in patient safety

– Miscommunication – Disruption in continuity of care – Omission of critical data – Medication errors – Serious Adverse Outcomes

11 11

Problem Statement

• The last AHRQ Culture of Safety indicated handoff opportunity for improvement

• Analysis of Handoff Policies and Procedures indicates variance in definitions and process across the system

• There is great variation in handoff practices across the system and a lack of hardwired processes to support optimal handoffs

12 12

Kaizen Event Participants Team: • Darryl Hampton, RN, CVICU, Mgmt Coord, IFH • Alice Penn Ritter, RN, GYN, Mgmt Coord, IFH • Barbara Harrison, RN, Peds, Mgmt Coord, IFH • April Peterson, RN, T7E, IFH • Cheryl Schmitz, RN, ED Clinical Specialist, ILH • Okey Hendrick, Acute Care RN, Team Coord, ILH • Freddi Brubaker, RN, ED Director, IAH • Monica Work, RN, 21 PCD, IAH • Kristy Weirsky, RN, Mgmt Coord ED, IMVH • Season Majors, RN, PCD 3B, IMVH • Skip Reece, RN, PACU, IMVH • Angela Servidio, RN, Education Coordinator, IFOH • Joan Manning, ED, RN, Mgmt Coord, IFOH • Melanie Martin, Radiology Technical Lead, IFH • Lea Wotorson, GMU Student

Facilitators: • Mary Ann Friesen RN Project Manager (Quality Consultant) • Ann Miner - Lean Consultant • Ken Leeson – Executive Director of Strategic Process Improvement

13 13

Goals and Objectives of System Handoff Kaizen Performance Improvement - Continuous improvement

• Provide training/exposure to the various handoff methodologies that have been tried with success

• Select a guiding methodology for patient handoffs • Identify key components of effective handoff

processes using the selected methodology • Draft a deployment plan

14 14

• Interactive, face-to-face handoff is preferred

• Limit interruptions • Read-back • Un-ambiguous transfer of

responsibility • Critical situation delay transfer • Written summary/information • Receive paperwork • Make it clear - who for what • Monitor • Educate • Support “Good Catch”

Team Reviewed Examples of Strategies and Best Practices (Patterson et al 2004; Park & Mishkin 2005)

15 15

ISHAPED

I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue

16 16

• “The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm.” (Agency for Healthcare Research and Quality, 2006)*

– Transfer of information – Transfer of responsibility – Accountability – Acknowledgement – Interaction – Verification – Opportunity to address patient safety

What is a “Handoff” ?

17 17

Benefit of Handoff

• Necessary to provide care • 24/7 delivery of care • Multi-disciplinary and

interdisciplinary care • Education • Debriefing/Support • “Rescue and Recovery”

Parker, J., Gardner, G., & Wiltshire, J. (1992). Handover: the collective narrative of nursing practice. Australian Journal of Advanced Nursing., 9(3), 31-37. KLally, S. (1999). An investigation into the functions of nurses' communication at the inter-shift handover. Journal of Nursing Management., 7(1), 29-36. Kerr. M.P (2002) A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing, 37(2), 125-134. Perry, S. (2004). Transitions in care: studying safety in emergency department signovers. Focus on Patient Safety, 7(2), 1-3.

18 18

Causes of Handoff Failures • Lack of formal tools to support transitions in

care • Handoffs vary greatly – lack of

standardization (expectation) • Not interactional • Interruptions - staggering • Memory lapse - omissions • Verbal issues - accents, sound alike

medications, acronyms, abbreviations, lack of common understanding

• Lack of access to patient data • Need for skill and education

19 19

Where are we today?

• We have an opportunity at Inova to improve handoffs, healthcare communication and culture of safety.

• “Very little evidence to support the use of any specific, structure, protocol or method.” Riesenberg, L et al. (2009)

– Need for discipline specific handoffs studies – Different content needed for different areas

Riesenberg, L et al. (2009) Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine 84(12) p. 1775-1787.

20 20

Goals

• Improve communication and handoff process • Improve patient safety • Improve team work and collaboration • Improve staff satisfaction with handoff process • Improve patient satisfaction

• Patient Centered Handoff

21 21

ISHAPED – Inova’s New Handoff Methodology

I Introduce S Story H History A Assessment P Plan E Error Prevention D Dialogue

• Developed by a system Kaizen team • To be piloted in multiple inpatient units for the shift-to-

shift RN handoff

22

Four Components 1) Handoff methodology is ISHAPED –Standardize key

elements – as designed in pilot except for Assessment Section Customize the Assessment by unit – owned by the unit’s

CPC with input sought from unit staff 2) Verbal handoff is face to face between oncoming and off-

going RN 3) Handoff happens at the bedside S, H, A outside of room; I,

P, E, D in room. Clinical judgment and common sense used to determine if beside component is inappropriate for a particular patient. Optional entire ISHAPED at bedside.

4) Written ISHAPED handoff template completed by off-going RN and given to oncoming RN

23

ISHAPED Tools

• Tool to be customized • Pencil or Pen • Cardstock or Paper • RN give to oncoming RN • Oncoming RN will update

and pass on • RN Report • Tech Report • RN/Tech Report

24

Bedside Shift to Shift Process

25

Qualitative Results from RN Handoff Perception Survey

Summary Patient do not want handoff ???????? Patient do want handoff??????? New Term Bedside Shift to Shift Report

26 26

Nurses should include:

• AIDET Acknowledge, Introduce, Duration, Explanations, Thank you

• Method to identify those patients who do not wish to participate

• RN performs hand-off tasks such as: Checking MAG Checking chart orders Checking computer for medications charted Checking computer for orders reviewed by RN In room: Whiteboards, IV lines, etc.

27

Bottom Line

• The focus is the Patient

• Patient Centered Care

28

Next Steps

• Youtube • Revise Protocol – (IRB) • Patient and Family Developing a Patient Centered Approach to

Handoffs Research Team Advisory Board will include patient and families to assure that the experiences, perceptions and knowledge are recognized and utilized.

• Interviews • Analysis • Education Plan • Education Materials • Video