2. Theme “Revving” up for patient safety

3. PI-LDP The MRC Experience

5. MRC Team Amanda Doty, RT(R) Gail Getzendaner, RN BSN Francine Gory, MA CCC-SLP, CBIS Ryan Woodall, RRT RCP Advisors: MRC: – Angela Williams, RN BSN UMHS: – Cindy Brooks, RN BSN

6. Stakeholders Patients Doctors Radiology Nursing (RN,LPN,NT,UC) Therapies (PT, OT, ST) Administration Regulatory

7. Brainstorming Got together as a group to choose a topic Lots of ideas, hardest task to narrow down to reachable goal Needed something that: – Relevant to the entire group – Would improve patient safety – Would be measurable

8. The Plan We would meet weekly (lunch meeting as time is difficult to arrange) Travel time (3 1/2 hours each way to Columbia) for brainstorming 1 st a project Aim Statement Before and after surveys Policy Presentation

9. Project Focus Improving patient safety by ensuring a safe hand off between disciplines when a patient leaves the unit for radiology procedures.

10. Aim Statement We aim to improve the perceived percentage of always completed patient handoff communication between selected disciplines from 3% to 60% at the Missouri Rehabilitation Center by January 28, 2010 to ensure patient safety.

11. Addresses the safety needs of our patient population Meet the needs of staff by improving communication Nursing Therapy Radiology Demonstrate excellent service with our ancillary departments Decreases potential costs by reducing errors and injuries Improved patient identification, status changes, and identification of risk factors Develop ment of PIT Stop form and hospital wide policy

12. Timeline Aug 19, 2009 MRC team formed Aug 28 1 st meeting in Columbia Sept 4 Aim Statement Draft Sept 28, 2009 Pre Survey Nov 16 PIT Stop Form Implemented Jan 19, 2009 Post Survey Feb 11, 2009 Final Aim Statement Feb 19, 2009Presentation in Columbia

15. Narrowing it down Improve handoff between staff Lab Xray RT PT OT ST RT Nsg H4 ICU H5 H5W H6 SBIU Improve handoff between staff during procedures Lab Xray EKG Improve handoff between staff when patient leaves the unit for Xray Xray

16. PreSurvey (interventions chosen) What departments Nursing Respiratory Rehab Radiology 19 responses 4 response 21 responses 5 responses

17. NeverOccasionallyHalf the time Almost Always AlwaysN/A 1. How often is a handoff done before a procedure? 10 12 4 6 1 16 2. How often is a handoff done after a procedure? 13 1 4 117 3. Do you receive adequate information during handoffs? 9 10 3 6 3 18 4. Do you feel like there is open communication between departments during handoffs? 10 (42) 8 (43) 3 (11) 5 (21) 4 (9) 18 (69) PreSurvey Results

18. What information do you feel would be beneficial during handoff? Any patient complaints? Medical information? Why the xray is ordered? What is the patient’s diagnosis? Any precautions? Functional level? Recent status changes? Isolation precautions? Code status? Any problems during procedure? How did the patient tolerate the procedure? Allergies (esp. contrast)? Fall/combative alerts? Any family with the patient? How does the patient communicate? When will results be available? Staff comments included :

19. PIT STOP

22. Staff Education Purpose – Improved patient safety – NSPG (National Patient Safety Goals) – Improved staff satisfaction Forms Procedure Policy

23. So, How Did We Do?

24. How often is a handoff done before a procedure?

25. How often is a handoff done after a procedure?

26. Do you receive adequate information during handoffs?

27. Do you feel like there is open communication between departments during handoffs?

28. Return on Investment Patient Safety Benefits – Improved communication for patient safety – Staff Satisfaction – Increased staff awareness of patient information

29. Lessons Learned Start Small! Not able to implement a big task all at once Include staff in planning process – Allows staff buy-in for performance improvement – Obtaining valuable staff input – Team work and team motivation is needed in order to make process changes Patient safety and process change can impact several areas

30. In Summary As a team, we can make a difference for patient safety and staff satisfaction This was a valuable project because patient safety is an area that can always be improved Communication is the KEY to patient safety Staff who recognize a need will be more proactive in finding a solution Across the board staff felt the need for improvement with communication during a patient handoff.

31. Questions