Main barriers to effective handoffs identified
Main barriers to effective handoffs identified
Treatment settings seen as key challenges
With the implementation of a standardized approach to handoff communications being incorporated into the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) National Patient Safety Goals for 2006, the issue has taken on increasing importance for quality managers. Given this heightened level of interest, new research conducted at the Indiana University School of Medicine may prove valuable in identifying some of the key barriers to effective handoffs.
The authors, who defined handoffs as "any transfer of role and responsibility from one person to another"1, reviewed the literature on patient handoffs and evaluated the patient handoff process at Indiana University School of Medicine’s internal medicine residency. House officers there rotate through four hospitals with three different computer systems. Two of the hospitals employ a computer-assisted patient handoff system; the other two utilize the standard pen-to-paper method. Considerable variation was observed in the quality and content of handoffs across these settings.
The major barriers to effective handoffs, they say, include:
- physical setting;
- social setting;
- language and communication barriers;
- time and convenience.
Handoffs, note the authors, involve the transfer of rights, duties, and obligations from one person or team to another. In many high-precision, high-risk contexts such as a relay race or handling air traffic, handoff skills are practiced repetitively to optimize precision and anticipate errors. In medicine, wide variation exists in handoffs of hospitalized patients from one physician or team to another. Their recommendations call for development of standard educational practices and incorporation of handoff tools into existing information technology systems.
They also note that while handoff skills have received much attention in the medical literature, scholarship has focused on physician-to-patient, not physician-to-physician, communication.
Examining the barriers
Darrell J. Solet, MD, lead author of the study and now part of the University of Texas, Southwestern, Department of Internal Medicine-Cardiology Division, shares with HBQI his insights into the impact of each of the aforementioned barriers and how they might be overcome.
For example, he notes, when it comes to the physical setting, "One of the major issues involves distractions such as lighting and background noise; these are often seen as barriers to effective communication when doing a handoff."
To avoid these distractions, Solet recommends having a designated location that has been set aside to do the handoffs, "and avoid areas such as nurses’ stations or lounges, where there are TVs or other distracting noises going on."
The social setting can become a barrier because the interchange usually is between residents, and occasionally between a resident and a staff physician, Solet notes. "It’s important to limit the potential for hierarchy during that setting; there has to be a cultural standard," he warns.
"For example, an intern may be a bit more intimidated by asking questions of the staff physician, or suggesting what they should do if they disagree," he continues. "For interns or others seen as more junior, you should recognize this potential, and help them overcome their reluctance. Make them realize this is their obligation."
Language and communication barriers can involve staff from other countries but not exclusively, says Solet. "We are a melting pot, so we do have more physicians from other countries," he notes, "But in the same regard, it’s important to avoid things like colloquialisms between different parts of the country. Language needs to be standardized."
The same holds true for staff from other countries, most of whom speak good English. "Use the standard medical language they are used to seeing in their textbooks," he suggests.
The handoff process, Solet concedes, can be extremely time-consuming and inconvenient, both in preparation and in execution. "You should focus all your efforts on making the process as efficient and as safe as possible," he advises.
How can you accomplish this? "One thing that is very helpful is to have a computer system that can extract a great deal of the medical information you need for a patient handoff," says Solet. "For example, if you work in a team environment, the physician team should be very clearly defined; then, there are the basic patient identifiers, such as name, age, sex, race, where the patient is located in the hospital, date of admission, and so forth."
Face-to-face is best
In addition to calling for the development of standard educational practices, the authors also recommend the incorporation of handoff tools into existing information technology systems. "One of the packages we’ve been using is part of the VA’s CPRS system," notes Solet. "As part of the Indiana University initiative, there was a program written to be incorporated into CPRS as a patient handoff module. They are in the process of piloting it there, and then maybe it will be disseminated nationwide."
The authors conclude that irrespective of local context, precise, unambiguous, face-to-face communication is the best way to ensure effective handoffs of hospitalized patients. They also maintain that the handoff process must be standardized and that students and residents must be taught the most effective, safe, satisfying, and efficient ways to perform handoffs.
Since more experienced physicians already have completed their education, however, how can they be helped to improve their communication skills? "
A lot of the educational material we used with med students crosses over," says Solet. "Teaching could be in the form of CME, patient safety conferences, and so on. Hopefully, our manuscript will be one of the tools used."
(See "Essential Elements for Successful Handoffs")
Finally, he says, it’s important to identify your challenges before beginning such a program. "Communication is key in providing effective and safe patient handoffs, but it’s important to recognize what barriers are there before you can actually overcome them," he concludes.
For more information, contact:
Darrell J. Solet, MD, University of Texas, Southwestern, Department of Internal Medicine-Cardiology Division, 5323 Harry Hines Blvd, Dallas, TX 75390-9047. Phone: (214) 590-5027. E-mail: [email protected].
Reference
- 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.
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