Kaiser standardizes the hand-off process

Reliability key to improvement

You probably remember the days when nurse-to-nurse shift reports involved a nurse and a voice recorder. "There would be a lot of people coming in and people going and a lot of chaos. Quite often, in general care units, nurses wouldn't even see each other and be able to see the patient at the same time when giving a hand-off," recalls Lisa Schilling, RN, MPH, vice president, performance improvement and education with Kaiser Permanente's division of care and service quality.

"We knew that wasn't reliable. We knew that wasn't best for the patient," she says. So Kaiser's work began with, first, standardizing and simplifying the process to make it more reliable and, thus, more likely to be done right, and, second, to ensure the process is delivering the optimal outcome.

"I've been with Kaiser since 2005 and...one of the things we've known is that the No. 1 cause of failures in health care is this communication hand-off issue," Schilling, formerly a critical care nurse, says.

It was her colleague, Doug Bonacum, Kaiser's vice president, safety management, who introduced the SBAR process for critical communications in health care. The team used that and the concept of reliable design from the Institute for Healthcare Improvement to standardize hand-offs. It also went beyond that to address what to do if a problem occurred, to mitigate it from causing harm. Schilling says if a process is successfully standardized and implemented correctly, with training and practice, if one were to visit any unit or department and watch five nurses go through the process at hand, it should look the same.

"We know that we have to standardize and simplify practices and processes so if you go to any unit or department, you ask five nurses or watch five nurses. Can they tell you how they are going to do something and can you watch them and can they do it the same way every time? If you can see that, it's standardized and simplified, and it will be more reliable if at least four of five can do it," she says. Beyond that, she says, "then you have to think about, when problems occur, how do you mitigate that from actually causing a failure that results in harm to the patient. And how do you monitor that? Are you monitoring to make sure that it is working reliably?"

To standardize the process, Kaiser looked at what is the critical content of a hand-off. Now, hand-offs, particularly nurse-to-nurse, are always done at the patient's bedside and involve the patient. And after that interchange, the nurses are allowed what Schilling refers to as "protected time" to ask questions to ensure all needed information is presented.

It's important that the facility make it easy for nurses to do it the right way, that nurses are educated and practice the process so that it becomes ingrained and simply the way to do it for every patient, every time, she says.

The "Nurse Knowledge Exchange"

The hand-off between inpatient RNs at Kaiser is referred to as the "Nurse Knowledge Exchange" and follows the SBAR tool. First, the work to redesign hand-offs focused on creating a template, now a part of KP Health Connect, the system's electronic medical record system. "This is the critical content you need to share at every shift hand-off," she says.

Second, the clinicians involved in the hand-off were given the opportunity to ask questions "by actually saying to the two nurses, 'this is protected time. At the change of shift, the two of you will go around to each patient that you're caring for and do a face-to-face communication between you, and by the way, involving the patient in that hand-off,'" she says.

So they standardized what is to be shared, when it is to be shared, and who it is to be shared with. To measure the use of the process, nurses are asked if they followed the process, did the get the information the need?

Schilling says, "We took the SBAR approach and added an I to that." The first is identify yourself and the patient. Second, the nurse shares the two to three major issues she is working on to ready the patient to go home. Information such as, "'What do we know about this patient, and what might be pending for diagnostics or labs or information?'"

Then the assessment is, "'Where are we? This lab is pending, but we also need to have an X-ray today,'" Schilling says.

Then the nurse addresses what needs to be fixed or "what does success look like." The nurse might say to the patient, "These are the three things we are going to work on today in order for you to go home. First, you are going to get up and walk down the hallway with us three times. We also need to make sure your pain is well managed."

Pain is assessed at each shift change, and the plan for management is reinforced at hand-off. Of course, she says, the nurses will talk about the important medical history and any patient-specific risks are addressed. So if a patient is at risk for falls, when does he or she need assistance? If there is a risk for skin breakdown, when was the skin assessed? Or nutrition may be an important topic for a specific patient. This is all included in the shift change report, as well as when the patient is expected to go home.

One thing she has learned from her experience is that if your policy is more than one page, it's less likely to be followed.

Other types of hand-offs

Following and maintaining quality of care across the continuum for patients, Kaiser dealt with other hand-off communication issues. "Now we had to say when I don't physically see them and I am from a different care environment, what is the communication approach that we use for hand off between an emergency room and a general care unit, and then we did one from a general care unit to a skilled nursing facility. Those were the two that we addressed," she says.

The work was a great opportunity to engage staff who don't see each other, don't work in same venue, or provide the same care, Schilling says. "How do they create a shared understanding of what quality means to the person receiving this report, what quality means to the person sending the report, and certainly as a result, what the quality means to the patient?"

Addressing this, she says, was a lot different from working with nurses who saw each other as part of change of shift. For this transfer, there was more preparation involved. So the sender would be able to say, "The patient will be coming within the next five minutes. We are going to give a hand-off report, and I am going to give you an opportunity to ask questions. So you have all your informational needs met when this patient comes to your care environment," she says.

Defining defective

Schilling says the system's work on hand-offs led to a "pretty tremendous reduction in defects." What could cause a defective hand-off? Schilling says:

  • The wrong time, "meaning someone calls a report an hour before the patient comes in and you might even have a change of shift after that," she says.
  • It is not a "warm hand-off." A warm hand-off, she says, involves the sender and the receiver being in the same physical area or, if the transfer is between a nurse and a skilled nursing unit, both being on the phone. "So one thing we measured is did that sending nurse get a hold of that receiving nurse within five minutes?" she says. There are times when one clinician cannot be present, but she says Kaiser culture prioritizes warm hand-offs, which also involves including patients.
  • The wrong people. For instance, an ED nurse tries to contact the receiving nurse on the floor but she isn't available so another person takes the report.
  • The wrong information. "Either unnecessary information or not comprehensive information," she says. It could be too little information, with not enough data.
  • The wrong setting. "I'm trying to call the general care unit and I can't get a hold of somebody to take the report,'" she says.
  • The wrong method of hand-off. The hand-off has to be by the phone if the practitioners are not in the same environment. If someone writes down the report to go with the patient because he or she can't reach the receiver, that's defective, Schilling says.

"First of all, we don't consider it a hand-off if they haven't connected. So one thing we measured is, did that sending nurse get a hold of that receiving nurse within five minutes? What we did was we prioritized this hand-off communication as being an important thing. Mind you, if something is happening with a patient and the nurse is doing something else, that can happen. But how often does it occur that they can't connect within five minutes of requesting a warm hand-off... They got to a very, very high rate of reliability," she says.