Better handoffs. Safer care.. Plan for the Day Format 2 hour curricular introduction 1 hour in...

Better handoffs. Safer care.

Plan for the Day

Format• 2 hour curricular introduction• 1 hour in breakout groups for

handoff simulation Worksheet Breaks Transitions Next steps Evaluation

2

Overview

Introduction• Role of communication in medical

errors Team Training: The

TeamSTEPPSTM Model The I-PASS Handoff• Content, structure, and process• Verbal• Printed

Handoff Simulation Exercise3

Overall Learning Objectives

Describe the importance of effective communication in reducing medical errors

Apply effective team training strategies to improve handoffs

Detail the essential content and sequence of effective handoffs

Practice handoff skills

4

Role of Communication in

Medical Errors

5

National Patient Safety Goal

Improve the effectiveness of communication among

caregivers 6

Photo courtesy of Comstock Images/Comstock/Thinkstock

Root Causes of Sentinel Events

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type

(2004 - Third Quarter 2011)1

7

Communication Failures

Can happen even with well-intentioned individuals• Game of “Telephone”• Email address auto-complete

8Photo courtesy of Istvan Takacs/Wikimedia Commons

New ACGME Training Requirements

Teamwork training Communication skills during

transitions of care Supervision and monitoring of

handoffs

9

Team Training: The TeamSTEPPSTM

Model

10

TeamSTEPPSTM

Evidence-based team training curriculum

High performing teams• Must have effective leaders• Use structured communication

strategies• Develop situational awareness• Provide mutual support

11

Team Strategies and Tools to Enhance Performance and Patient Safety

Multi-team System

12

Core TeamCore Team

Ancillary Services

Coordinating Team

Administration

Contingency Team

Support Services

Patient Care

Building a Shared Mental Model

13

When Mental Models are Not Shared

Example: When your child takes the bus home and you thought the plan was to pick him up at school

14

Photo courtesy of H. Michael Miley/Wikimedia Commons

Structured Team Communication Techniques

Technique Function

Brief Plan team activities

Debrief Analyze an interim event

Huddle Solve a problem

Cross monitoring / Feedback

Improve performance

Assertive statement

Identify potential errors

Check-back Ensure accurate information transfer

Handoff Transfer care and responsibility

15


Technique Function



Huddle Problem solve


Improve performance

Assertive statement




16

Video Review and ReflectionBriefs, Debriefs, Huddles

Refer to the Observation Form for Structured Team Communication Techniques

For each video clip• Review the checklist• Record your reflections

Large group discussion afterwards

17

BriefEssential to Team

Planning

• Engages team members in short-term planning

• Provides a “pre-game” team meeting

18

Brief

19

DebriefEssential to

Improvement

Improves teamwork skills and patient outcomes

Reconstructs and analyzes interim events

21

Debrief

22

HuddleEssential to Solve

Problems

Is an opportunity to touch base and regain situation awareness

Focuses on critical issues and emerging events

24

Huddle

25

27

Large Group Discussion:Briefs, Debriefs, Huddles


Technique Function





Improve performance

Assertive statement




28

Video Review and Reflection:Cross Monitoring and Feedback

Assertive Statement

Refer to the Observation Form for Structured Team Communication Techniques

For each video clip• Review the checklist• Record your reflections

Large group discussion afterwards

29

Cross MonitoringAn Essential Technique

Monitor actions of your team members

Provide a safety net for your team

Recognize and address errors actively

‘Watch each other’s back’

30

FeedbackEssential for Cross Monitoring

Focuses on team performance and improvement

Provides a learning opportunity

31

Cross Monitoring / Feedback

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Advocacy and AssertionStrategy for Avoiding Errors

When viewpoints differ• Advocate for the patient• Make assertive statement• Open the discussion• State the concern• Offer a solution• Obtain an agreement

34

Advocacy and Assertion

35

Large Group Discussion:Cross Monitoring / Feedback

Assertive Statement

37


Technique Function





Improve performance

Assertive statement




38

Check-Back

39

Check-Back in Our Daily Lives

Ordering take-out

Customer service at a call center

40

Photo courtesy of Dslninja/Wikimedia Commons

Handoffs Transfer of:• Information • Authority• Responsibility

Occur during transitions in care• Shift changes• End of service

block• Unit transfers• Discharges

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Structured Team Communication TechniquesTechnique Function Example


Day one discussion for team orientation


Recap of events at the end of a shift

Huddle Problem solve Planning for a procedure


Improve performance

Commenting about a decision (selected test)

Assertive statement

Advocate for safe, high quality care

Recognizing a potential error


Reading back a verbal order


Transitions of care

42

Essentials of Team Function

43

Key Points

TeamSTEPPSTM can be used to develop effective communication strategies

Effective communication is critical to ensure effective handoffs of care

Development of a shared mental model is critical to the handoff process

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•Have you experienced a verbal handoff when team members left with vastly different impressions of the acuity of patients on the unit?

•Have you experienced consultants who formed different conclusions about an individual patient based on their own biases or a narrow perspective?

Shared Mental Model Exercise

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The I-PASS Handoff

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Global Elements of Handoffs

Unambiguous transfer of • Information• Responsibility

Protected time and space• Quiet location• Interruptions minimized

Standardized format Importance of the leader• Assign roles, ensure quality

47

Learning Styles

Active Reflective

Sensing Intuitive

Visual Verbal

Sequential Global

48http://www.engr.ncsu.edu/learningstyles/ilsweb.html

http://www.engr.ncsu.edu/learningstyles/ilsweb.html

Learning Styles Exercise

Pair share with a partner Review your learning styles • Based on inventory completed

before workshop

Interview each other Elicit 2 techniques• To enhance the way you receive

information

Large group debrief

49

Elements of Verbal Handoffs

Structured format • Begins with high-level overview

Appropriate pace Closed-loop communication

shared mental model• Solicit check back of salient points• Prompt for clarifying questions• Be aware of non-verbal

communication• Nodding approval, eye rolling, puzzled look

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The Printed Handoff Document

Supplements the verbal handoff• Allows receiver to follow• Provides more comprehensive

information Creates efficient information transfer Requires daily updates• High-quality information

• Don’t copy and paste

• Senior/supervising resident should edit and ensure quality

51

Verbal Handoff ComplementsPrinted Handoff Tool

Printed handoff is foundation Content / length of verbal handoff depends

on• Level of training• Prior contact with and knowledge of

patients• Length of time on rotation

• Verbal summary is more lengthy during handoffs on the first few days of the rotation

Should provide an opportunity for discussion• Creates a shared mental model• Facilitates active participation by receiver

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Large Group Discussion

What techniques did they use that were particularly effective?

What pitfalls did you notice?

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Mnemonic Provides Organizational Framework

Standard language Sequence Key elements Memory aids• Catchy• Symbolic• Utilitarian• Parsimonious• May conjure up a visual image

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The I-PASS Mnemonic

I Illness SeverityStable, “Watcher,” Unstable

P Patient SummarySummary statement; events leading up to admission; hospital course; ongoing assessment; plan

A Action ListTo do list; timeline and ownership

S Situation Awareness & Contingency PlanningKnow what’s going on; plan for what might happen

S Synthesis by ReceiverReceiver summarizes what was heard; asks questions; restates key action/to do items

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Key Points Effective handoffs

• Ensure transfer of accurate information

• Facilitate transfer of responsibility

Verbal handoffs• Are structured• Employ closed-loop

communication Printed handoff documents

• Provide more detail• Integrate with verbal

handoffs

57

Photo courtesy of Comstock/Comstock/Thinkstock

Illness SeverityWhy is it important to classify?

Focus attention appropriately Use standard language May vary based on• Unit acuity• Provider type• Institutional culture

Helps develop shared mental model

59

Illness SeverityA Continuum

Watcher : any clinician’s “gut feeling” that a patient is at risk of deterioration or “close to the edge”

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Illness SeverityAssessment

Be aware of using these terms• Printed document may be

considered part of medical record• Potential for incorrect assignment• Changes in patient status

Make assessment during verbal handoff

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The Patient SummaryWhy is it Important?

Describes succinctly• Reason for admission• Events leading up to admission• Hospital course by

problem/diagnoses• Plan for hospitalization

Communicates concerns and nuances

Anticipates expected course Creates a shared mental model

63

Sections of a Patient Summary

Summary statement Events leading up to

admission Hospital course Ongoing assessment• Organized by

problems/diagnoses Plan • Organized by

problems/diagnoses

64

Summary Statement Section

“One-liner” Sets the clinical

context Contains critical

identifying information• Name• Age• Gender• Pertinent past

history• Reason for

admission65

Events Leading Up To Admission Section

Lists chronologically

Includes essential history & physical exam/lab findings

Should be bulleted Section can be

truncated when high level of diagnostic certainty is attained

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Hospital Course Section

Lists key events and updates

Highlights special considerations • Family/social issues• Nursing concerns• Chronic medical

conditions

67

Ongoing Assessment Section

Provides diagnostic reasoning

Offers differential diagnosis and assessment

Uses appropriate organizational framework

68

Problem vs. Systems List

Choose problems or systems based on• Patient complexity• Patient settings• Institutional culture

Use caution for systems-based approach• Don’t lose sight of active, high-priority

issues by including all systems Use caution for problem-based

approach• Don’t forget to monitor all systems

69

Plan Section Develops specific plan

for each problem or diagnosis

Uses appropriate organizational framework

Reflects global plan for entire hospital stay• Avoid “to-do” items for

next shift

Specifies “None” if no plan is required

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Maintenance of Patient Summary

Updates problems/diagnoses and plans daily• Provides current assessments• Establishes diagnoses • Lists changes in treatment

plans

71

Maintenance of Patient Summary

Retains reason for admission and events leading up to admission• Allows others to understand the

nuances of presentation• For new providers• Working diagnosis may be incorrect

72

PATIENT SUMMARIES An Essential Clinical Skill

Requires • Structured approach• Practice• Feedback• Reinforcement with faculty review• Verbal – direct observation and feedback• Written – review and critique

73

Patient Summary Example 1

74

Photo courtesy of John Howard/Lifesize/Thinkstock

Patient Summary Exercise 1

Review the admission history and physical examination for the next five minutes.

Create a patient summary to include in the printed handoff document• Use bulleted format and word limit <

200• Summary statement• Events leading up to admission• Ongoing assessment by problems/diagnoses • Plan by problems/diagnoses

76

Patient Summary Exercise 1Summary Statement: AJ is a 4 year old male with history of ex 26-week gestation admitted with hypoxia and respiratory distress secondary to a left lower lobe pneumonia. In the ED was found to have a Na of 130, likely secondary to volume depletion versus SIADH. Events Leading Up to Admission:Two days PTA–cough and high grade feversDay of admission –worsening respiratory distressHospital Course

O2 increased to 2.5 L on arrival to the floorS/P fluid bolus in EDOngoing Assessment Plan LLL Pneumonia 1. Continue ampicillin

2. Wean O2 as tolerated

Hyponatremia 1. D5NS at maintenance2. Repeat electrolytes

Q8H

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Large Group Questions

Did they capture all of the essential elements?

Did the verbal handoff differ from your written patient summary?

79

Patient Summary Exercise 2

You are the day intern leaving and need to handoff back to the night intern.

Based on the updated hospital course, compose a patient summary on the patient after 48 hours in the hospital.

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48 Hours LaterSummary Statement:AJ is a 4 year old male admitted two days ago with a left lower lobe pneumonia and resolving hyponatremia now with worsening respiratory distress and left sided effusion s/p chest tube placement today with resultant improvement in status. Hospital CourseLeft sided pleural effusion noted on CXR with decubitus filmsChest tube placed with improving clinical statusSerum sodium is normalOngoing Assessment PlanLLL Pneumonia 1. Continuing ampicillin and O2

• Complicated by empyema 2. Chest tube to low wall suction

3. Surgery following4. Repeat chest X-Ray in am

Hyponatremia 1. No further laboratory studies 81

High Quality Patient Summaries

Create a shared mental model Facilitate the transfer of

information and responsibility Transmit information concisely Describe unique features of the

patient’s presentation Use semantic qualifiers

82

Semantic Qualifiers Dichotomous qualifiers along an axis• Provide clarity • Enable clear communication of

representative clinical features

Examples

83

Make an Assessment Using Semantic Qualifiers

Swelling developed in both this child’s knees over a two day span.

Acute, polyarticular swelling of both knees

84

Image courtesy of Dana Toib, MD

Make an Assessment Using Semantic Qualifiers

Jane has bouts of upper abdominal pain over the past 6 months that come and go

Recurrent, intermittent epigastric pain

85

Photo courtesy of Stockbyte/Stockbyte/Thinkstock

Key Points

Effective patient summaries • Allow providers to create a

shared mental model• Are succinct and concise• Include semantic qualifiers

86

Action List To do list Includes specific elements• Timeline• Level of priority• Clearly-assigned responsibility (if

not receiver)• Indication of completion

Needs to be up-to-date• If no action items anticipated, clearly specify “nothing to do”

88

Action List

To Do:

☐ Check respiratory exam now

☐ Monitor respiratory exam Q2h overnight

☐ Check pain scores Q4h

☐ Check ins and outs at midnight

☐ Follow up 6PM electrolytes

☐ Follow up blood culture results

89

Situation Awareness

“Know what is going on around you”• Status of

patients• Team members• Environment• Progress toward

team goals

“Know what’s going on with your patient”• Status of patient’s

disease process• Team members’ role

in this patient’s care• Environmental

factors• Progress toward

goals of hospitalization

Team level Patient level

91

Contingency Planning

Problem solving before things go wrong

“If this happens, then…”92

Photo courtesy of Photodisc/Photodisc/Thinkstock

Importance of Contingency Planning

Is critical for patient safety Provides the receiver with

specific instructions for what might go wrong

Ensures accepting team is prepared to • Anticipate changes in patient

status• Respond to potential events or

changes in status93

Effective Contingency Planning

Articulate what might go wrong Define the plan• List interventions that have/have not

worked• Consider code status• Identify resources and chain of command

Provide details based on receiver’s• Level of experience• Knowledge of disease process• Familiarity with service and/or patient

94

Additional ConsiderationsContingency Planning

Difficult family or psychosocial situations

Nursing and family concerns

95

For stable patients:

“I don’t anticipate that anything will go wrong.”

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Contingency Planning: An Example

Points of Emphasis

Video example illustrated• Contingency planning• Synthesis by receiver

Contingency plans included• Events• Interventions• Notifications

97

Contingency PlanningExercise

Refer to the patient summary you wrote about AJ, the 4 year old ex-premie, admitted with pneumonia and hyponatremia

Discuss with a partner for 1 minute• What contingency plans would you

recommend for this patient at the time of the handoff after admission?

(before complication of the effusion) Report back to large group

98

Key Points

Situation awareness involves knowing what is going on around you

Effective contingency planning prepares for potential events or outcomes with specific instructions

100

Importance of Synthesis by Receiver

Provides brief re-statement of essential information in a cogent summary• Demonstrates information is

received and understood• Includes verbal and written

elements Ensures effective transfer of

information and responsibility Promotes a shared mental model

102

Synthesis by Receiver

Opportunity for receiver to• Clarify elements of handoff• Ensure there is a clear

understanding• Have an active role in handoff

process

103

Elements of Synthesis by Receiver

Vary in length and content• More complex, sicker patients require

more detail• At times may focus more on action

items, contingency planning Address priorities for individual

patients Affirm understanding by receiver

It is not a re-stating of entire verbal handoff!

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I Illness SeverityP Patient SummaryA Action ListS Situation Awareness & Contingency PlanningS Synthesis by Receiver 105

Handoff Simulation Exercise

106

Format I-PASS Handoff Simulation Exercise

Breakout large group Form groups of three with faculty

facilitator Practice handoffs with each of three

roles• Giver of handoff• Receiver of handoff• Observer of handoff• Complete Direct Observation Form

Debrief each handoff simulation• Faculty facilitator

107

Putting It All TogetherI-PASS Handoff Bundle

108

Next Steps

I-PASS Handoff implementation• Today’s workshop• Complete workshop evaluation

• I-PASS Campaign launch• Real time• Observation• Feedback and reinforcement

109

References"Agency for Healthcare Research and Quality. TeamSTEPPS Curriculum

Tools and Materials." http://www.ahrq.gov/. N.p., n.d. Web. 6 Feb 2012. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.

Bordage, G. "Prototypes and Semantic Qualifiers: From Past to Present." Medical Education. 41.12 (2007): 1117-21.

Cohen, M.D., and Hilligoss, P.B. "The Published Literature on Handoffs in Hospitals: Deficiencies Identified in an Extensive Review. " Quality and Safety in Health Care. 19.6 (2010): 493-497.

Kaplan, D.M. "Perspective: Whither the Problem List? Organ-Based Documentation and Deficient Synthesis by Medical Trainees." Academic Medicine. 85.10 (2010): 1578-1582.

Solomon, B. A., and Felder, R.M. "Index of Learning Styles Questionnaire." North Carolina State University. N.p., 2011. Web. 6 Feb 2012. http://www.engr.ncsu.edu/learningstyles/ilsweb.html.

Starmer, A.J., Spector, N.D., Srivastava, R., Allen, A.D., Landrigan, C.P., Sectish, T.C. et al. "I-PASS, a Mnemonic to Standardize Verbal Handoffs." Pediatrics. 129.2 (2012): 201-204.

Starmer, A.J., Sectish, T.C., Simon, D., and Landrigan, C.P. "Impact of a Resident Handoff Bundle on Medical Error Rates and Written Handoff Miscommunications." Pediatric Academic Societies Annual Meeting. Denver, CO. 2011.

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Media Sources Media courtesy of the National Capital Consortium

Pediatric Residency Program, Bethesda, MD with input from the I-PASS Education Executive Committee, Simulation Subcommittee, Faculty Development Subcommittee, Campaign Subcommittee, and the Coordinating Council

The IIPE logo is used with permission from the Initiative for Innovation in Pediatric Education

The PRIS logo is used with permission from the Pediatric Research in Inpatient Settings Network

Some content in the I-PASS Handoff Study Curriculum includes materials adapted from TeamSTEPPSTM, an evidence-based teamwork curriculum developed by the Agency for Healthcare Research and Quality and the Department of Defense. All materials are used with permission.

All graphics are provide courtesy of Concurrent Technologies Corporation unless otherwise noted

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ContributorsI-PASS Study Group

Lead Editors: April Allen MPA, MA, Theodore C.

Sectish MD, Nancy Spector MD, Amy Starmer MD

Additional Editors: Jennifer O’Toole MD, Clifton Yu MD, Lisa Tse

I-PASS Study LeadershipI-PASS Study PI: Christopher P. Landrigan MD, MPHI-PASS Project Leader: Amy J. Starmer MD, MPHI-PASS Coordinating Council: April D. Allen MPA, MA, Jaime Blank CCRP, Christopher P. Landrigan MD, MPH, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH

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Contributors

Membership of Additional I-PASS Committees Include: I-PASS Education Executive Committee (EEC) Co-chairs: Nancy D. Spector MD, Amy J. Starmer MD, MPH

I-PASS EEC: April D. Allen MPA, MA, James F. Bale Jr. MD, Zia Bismilla MD, Sharon Calaman MD, Maitreya Coffey MD, F. Sessions Cole MD, Lauren Destino MD, Jennifer Everhart MD, Jennifer Hepps MD, Madelyn Kahana MD, Christopher P. Landrigan MD, MPH, Joseph O. Lopreiato MD, Robert S. McGregor MD, Jennifer K. O’Toole MD, Shilpa J. Patel MD, Glenn Rosenbluth MD, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH, Adam Stevenson MD, John Webster MD, MBA, Daniel C. West MD, Clifton E. Yu MD

Contributors I-PASS EEC Campaign Subcommittee: Glenn Rosenbluth MD (Chair),

April D. Allen MPA, MA, Sharon Calaman MD, Lauren Destino MD, Jennifer Everhart MD, Jennifer Hepps MD, Christopher P. Landrigan MD, MPH, Jennifer K. O’Toole MD, Shilpa J. Patel MD, Theodore C. Sectish MD, Nancy D. Spector MD, Amy J. Starmer MD, MPH, Adam Stevenson, Clifton F. Yu MD

I-PASS Faculty Development Subcommittee: Jennifer K. O’Toole (Co-chair), Nancy D. Spector MD (Co-chair), April D. Allen, MPA, MA, Glenn Rosenbluth MD, Theodore C. Sectish MD, Amy J. Starmer MD, MPH, Daniel C. West, Clifton E. Yu MD

I-PASS EEC Simulation Subcommittee: Sharon Calaman, MD (Chair), Jennifer Hepps MD, Joseph O. Lopreiato MD, MPH, Robert McGregor MD, Clifton E. Yu MD

I-PASS Scientific Oversight Committee: Christopher P. Landrigan MD, MPH, Sanjay Mahant MD, MSc, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH, Karen M. Wilson, MD, MPH, Daniel C. West, MD

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Participating I-PASS Institutions

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Children’s Hospital Boston / Harvard Medical School (Coordinating Site) Brigham and Women’s Hospital / Harvard Medical School (Data

Coordinating Center) Benioff Children’s Hospital / University of California San Francisco

School of Medicine Cincinnati Children’s Hospital Medical Center / University of Cincinnati

College of Medicine Doernbecher Children’s Hospital / Oregon Health & Science University

School of Medicine Hospital for Sick Children / University of Toronto Lucile Packard Children’s Hospital / Stanford University School of

Medicine National Capital Consortium / Uniformed Services University of the

Health Sciences Primary Children’s Medical Center / Intermountain Healthcare /

University of Utah School of Medicine St. Christopher’s Hospital for Children / Drexel University College of

Medicine St. Louis Children’s Hospital / Washington University School of Medicine

Funding and Resources

The I-PASS project is supported by Grant Number R18AE000029 from the U.S. Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Health and Human Services.

The Pediatric Research in Inpatient Settings (PRIS) Network and the Initiative for Innovation in Pediatrics Education (IIPE) contributed to the management and oversight of the I-PASS Study.

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