1. (on behalf of IPASS Workgroup)
Reducing Patient Error By Improving Hand-Off Behaviors: Part 2 – Ideas from Needs Assessment and Next steps
July 27, 2016
Mary Lacy MD
Justin Roesch MD
(on behalf of IPASS Workgroup)

2. Objectives
Create a dialogue to discuss how we can use IPASS to improve patient care at UNM.
Discuss variance in sign-out/sign-in behavior
Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error
Review Resident Commentary on Sign-Out
Discuss Next Steps

3. Objectives
Create a dialogue to discuss how we can use IPASS to improve patient care at UNM.
Discuss variance in sign-out/sign-in behavior
Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error
Review Resident Commentary on Sign-Out
Discuss Next Steps
Please edit these however, haven’t spent much time on them yet

4. What constitutes an effective handoff?
Face-to-face?
What information is exchanged?
What constitutes an effective handoff?
How long does it take?
Is it written? Oral? Both?
(Justin)
Who is signing out the patients?

5. Objectives
Create a dialogue to discuss how we can use IPASS to improve patient care at UNM.
Discuss variance in sign-out/sign-in behavior
Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error
Review Resident Commentary on Sign-Out
Discuss Next Steps
Please edit these however, haven’t spent much time on them yet

6. Best Practice for Handoff Domains
Behaviors
Information
Training
(Justin)

7. Best Practice for Handoff Domains
Synthesis
Feedback
Standardized Tool
Dedicated Training
(Justin)
So what are the best practices of handoff and how do we synthesize the most important elements of handoff/signout into one system?
What do we do at UNM?

8. Best Practice for Handoff Domains
Synthesis
Feedback
Standardized Tool
Dedicated Training
(Justin)
So what are the best practices of handoff and how do we synthesize the most important elements of handoff/signout into one system?
What do we do at UNM?

9. Handoff Failures Omitted Data Superfluous Data (Mary)
When superfluous data is presented it can “squeeze” out other vital information.

10. What is I-PASS? Illness Severity (stable, unstable, watcher)
Patient Summary (summary statement, events of admission, hospital course, active plans)
Action List (“To-Do List”)
Situation Awareness and Contingency Plans
Indication of what to do if adverse contingency is encountered
Allergy List (auto-populated)
Code Status (auto-populated)
Med List (auto-populated)
Dated Vital Signs
Synthesis by Receiver
(Mary)

11. 7 Elements of I-PASS Bundle
I-PASS mnemonic (Information)
2 hour workshop (TeamSTEPPS; teaching teamwork and communication skills)
1-hour role play workshop for skill practice
Computer Module to allow for independent learning
Faculty and Resident Curriculum (Training)
Direct Observation to provide feedback to residents (Behavior)
Process-Change and Culture-Change Campaign
(Mary)

12. Best Practice for Handoff Domains
Synthesis
Feedback
Standardized Tool
Dedicated Training
(Justin)
So what are the best practices of handoff and how do we synthesize the most important elements of handoff/signout into one system?
What do we do at UNM?

13. Best Practices: Behaviors
“Read-back” and “Repeat-back” practices
“Face-to-face, uninterrupted communication combining verbal and written or electronic handoff information is best.”
Handoff as an active dialogue.
(Justin)
The Joint Commission recommended standardizing patient handoff procedures and using read-back and repeat-back practices. This is essentially the “synthesis” portion of IPASS.
Data is poor that face-to-face handoff’s really improve communication. The take-away is that we need to be using synthesis more.
When not face-to-face there are more opportunities for distractions.
Just written sign-out does not provide opportunity for questions, clarifications, or synthesis.

14. Best Practices: Information Transmission
Data must be unambiguous and factually correct.
Contain:
Patient identification
Diagnostic summary
Current condition and trajectory
A plan of care
A prioritized to-do list for anticipated events
CACHE NEEDS TO BE UPDATED

15. Best Practice for Handoff Domains
Synthesis
Feedback
Standardized Tool
Dedicated Training
(Justin)
So what are the best practices of handoff and how do we synthesize the most important elements of handoff/signout into one system?
What do we do at UNM?

16. Best Practices: Training
Physicians need formal didactic and interactive training in handoffs
(VI.B.2) Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety [and]
(VI.B.3) Programs must ensure that residents are competent in communicating with team members in the hand-over process.

17. Can put a box over the team stepps part…
IPASS does all three of these, and what’s more, standardizes the process.

18. What did IPASS implementation look like?

19. Written handoff
Can emphasize that it’s not like they were at 100% for all this, specifically perhaps contingency planning – no we aren’t expecting some thorough contingency planning on a placement patient

20. Verbal handoff

21. What did IPASS implementation achieve?

22. IPASS reduced medical errors

23. Objectives
Create a dialogue to discuss how we can use IPASS to improve patient care at UNM.
Discuss variance in sign-out/sign-in behavior
Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error
Review Resident Commentary on Sign-Out
Discuss Next Steps
Please edit these however, haven’t spent much time on them yet

24. What do the cross covering house-staff have to say about sign-out?
Patients: (5 teams)
Time: 30 min to 90 min.
Sign-in: Variable. Notes are common, but other practices have mixed adoption.
Who do you call for help: Other housestaff, but not the other OCD.
APP cross cover are part of IPASS core team and have more standardized processes in general

25. Objectives
Create a dialogue to discuss how we can use IPASS to improve patient care at UNM.
Discuss variance in sign-out/sign-in behavior
Describe 3 practices/systems that can improve hand-off behaviors and reduce potential patient error
Review Resident Commentary on Sign-Out
Discuss Next Steps
Please edit these however, haven’t spent much time on them yet

26. Discussion Protected Sign out Sign-in Process Cache tool
Direct Observations with feedback

27. Protected Sign Out Needs Assessment: Sign out is very vulnerable time
Lack of protected time increases rushed nature of sign out
There is no standardized process
Cross cover survey - Would protected signout help?
Majority said yes
Some possible solutions

28. Solution 1: Moving Sign-Out Forward
Start 6:30
Each team is given a specific “window” for sign-out
Some sign-out takes longer
External Factors (team not “ready” at 7:00)
Nurses usually signing out between 7:00-7:30 can be helpful because they are occupied
6:30-6:45
6:45-7:00
7:00-7:15
7:15-7:30

29. Solution 2: Shield OCD Teams Begin to Sign-out @ 7:00
…But teams cross-cover until ~7:30 to help “shield” OCD while getting sign-out.
Duty Hours?
Residents complying?
Who is responsible for urgent
Issues during this time?

30. Solution 3: The Swap OCD 1 OCD 2
OCD 1 Cross Covers all teams from 6:30-7:00
OCD 2 Cross Covers all teams from 7:00-7:30
OCD 2 get’s Sign-Out from 6:30-7:00
OCD 1 get’s Sign-Out from 7:00-7:30

31. Limitations OCDs covering for one another
OCD will be covering on a large group of patients that they will not have received sign-out on.
What happens if there if there are simultaneous emergencies
Systems/Solutions can be combined

32. Sign-in process Needs assessment: OCD notes in chart have helped
Issues: less verbal/written signout now because of notes  No bird’s eye view of the night, no feedback on issues that came up to provide opportunity for questions
Issues: Some patients without notes (no note on patient who went on 15L NRB recently)  CC resident stated they did not know of this expectation
Ideas: Room for sign-in, verbal sign-in, cache update to allow quick review of nights events?

33. Cache tool Needs Assessment:
Auto-fill areas are useful
Used in dual role  some fields not specifically helpful for sign out but used by day teams
Irregular updates are BIG problem
IPASS Project: All elements of IPASS should be visible on written tool

34. Proposed Update to Printout
Separate printed tool for CC as opposed to day teams?
If so, what columns?
Other Recommendations for the tool?

35. Direct Observations
Needs assessment: No feedback on handoffs in residency
IPASS Project: Goal is for feedback of every resident who is giving or receiving handoffs to be observed with feedback 1x/rotation

36. Direct Observations Insights from initial direct observations Ideas:
30 minutes max
Don’t NEED to know the patients/team
Conference calling may make the process easier (we are looking into this)
Ideas:
IPASS CORE champions will be doing observations with feedback
Could everyone commit to participate in feedback a specific # times/year? (THREE?)

37. What Solutions Do you Have???

38. References
Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care. 2008;17:6 –10.
The Joint Commission. Accreditation Standards. Oakbrook, Ill: The Joint Commission; 2010.
Lofgren RP, Gottlieb  D, Williams  RA, Rich  EC. Post-call transfer of resident responsibility: its effect on patient care. J Gen Intern Med 1990;5 (6) 501- 505
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755–1760.
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006; 145:488 – 496.
Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196 –205.
Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094 –1099.