UT Southwestern Medical Center Building High-Functioning Teams To Spread Handoffs and Transitions: Use of In Situ Simulation and Observer Training Fallon Ngo DO,1, Isaac Lynch MD,1 Glory Gituma CCRN,2 Rachel Harrison MD,3 Oren Guttman, MD,1 Aditee Ambardekar, MD,1 Daiwai Olson, PhD, CCRN,2 Kamal Abdulkadir, CCRN,2 Mandy McBroom,1 MPH, Aimee Gardner, PhD3, Joseph Keebler, PhD , Jim Sheng MS II,1,5 Thomas Lowrey MS II,1,5 Eleanor Phelps BSN MA RN,5 Philip Greilich MD1,5 Department of Anesthesiology & Pain Management,1 Nursing, 2 Department of Surgery, 3 and Embry Riddle Aeronautical University4, and Office of Quality, Safety Outcome Education5 UT Southwestern Medical Center Introduction Results Results The Agency for Healthcare Research and Quality has consistently identified “handoffs and transitions” as one of the lowest performing composites in its Hospital Survey on Patient Safety (HSOPS) culture. (1) Care transitions are the most common type of team communication and when poorly executed leave patients vulnerable to preventable medical errors and non-routine events. Successful re-engineering efforts require multi-modal, multi-dimensional interventions and should be “built for spread”. (2,3) Perioperative transitions represent a high-opportunity leverage point given its high-frequency, high-impact, multi-unit and multi-disciplinary characteristics. Given this, a charter to reduce perioperative non-routine events by improving the reliability of handoffs was initiated in 2014. The University of Texas Clinical Safety & Effectiveness approved funding for our pilot study entitled “Enhanced Communication from the OR-to-ICU (ECHO-ICU)” in 2015. The initial AIM of this work was to create a pragmatic model for: 1) transforming clinicians’ attitude and approach to handoffs; 2) measuring its impact on reliability; and 3) reinforcing knowledge, skills, and teamwork behaviors necessary for project sustainability and spread. The step-by-step process co-created by our clinical team and content experts is outlined in Figure 1. The process was divided into four phases: team formation, ideal handover creation, creating an evaluation tool, and observer training. The design of the ideal handoff utilized 5 one-hour sessions that included “play acting” to design unit-specific OR-to-ICU handoffs at two University Hospitals. Four video recordings were selected to represent the ideal and three non-ideal variants for demonstration and training observers. A five-step program was designed to create handoff evaluation tool that assessed critical, technical, and adaptive elements of high-quality handoffs. Critical-to-quality technical elements are shown in Table 1. A hardcopy version of the evaluation from is shown in Figure 2A&B. Visual cognitive aids are shown in Figure 3. The six-step observer training program is learner-paced and interactive. Independent grading of videos are repeated on separate days to allow determination inter- and intra-rater reliability.(4,5) Conclusion Methods Our “Step-by-Step” approach facilitated the building of high- functioning teams to implement and spread a re-designed handover process. Content experts work in concert with frontline clinicians to co-create a final product that is intuitive, of sound design and includes “what matters most” to nurses and physicians receiving these handovers. The use of site-specific critical-to-quality (CTQ) surveys both engaged the end-users and guided the team in the creation of cognitive visual aids designed to promote process conformance. The standardized evaluation tool (based on the CTQ results) will facilitate high-fidelity data collection of technical and non- technical elements deemed crucial to efficient and effective transitions of care. Having a standardized training process increases the pool of potential observers (e.g., student, house staff, and faculty) for assessing conformance and team work. The method described provides the foundation needed to conduct our implementation-effectiveness pilot study (ECHO- ICU). From August 2015 to February 2016, a multi-disciplinary team of clinical stakeholders and content experts was formed to co-create a step-by-step approach for: 1) re-designing a unit-based OR-to-ICU handoff process; 2) producing videos for training and debriefing; 3) creating an evaluation tool; and 4) training observers using a series of PDCA (Plan-Do-Check-Act) cycles. In situ simulation, TeamSTEPPS training and videotaping were used to create the program for designing the “ideal” handover. Delphi methodology and human factors experts were used to design an evaluation tool for assessing technical and non-technical handoffs elements. A master physician educator (MSEd), and videos from our in situ simulation sessions were used to create the observer training program. Figure 2a. Handover Evaluation Form (Technical Elements). Figure 2b. Handover Evaluation Form (Non Technical Elements) References   http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2014/hsops14pt1.pdf Starmer, A.J., Spector N.D., Srivastava R.K., et al. New England Journal of Medicine. 2014; 371: 1803-12. Seagall, N., Bonifacio, A., Schroeder, R.A., et al. Anesthesia-Analgesia. 2012; 115: 102-115. Hallgren KA. Computing Inter-Rater Reliability for Observational Data: An Overview and Tutorial. Tutorials in Quantitative Methods for Psychology. 2012;8(1):23-34. McHugh ML. Interrater reliability: the kappa statistic. Biochemia Medica. 2012;22(3):276-282. Figure 3 Visual Cognitive Aids Table 1: Critical to Quality Elements