A Texas hospital has learned that a checklist and one-time training do not always yield lasting results, so it developed a systematic, long-term approach to a vexing problem.
Addressing the issue of incomplete information for patient handoffs, leaders at Midland (TX) Memorial Hospital first implemented TeamSTEPPS, a set of evidence-based strategies and tools from the Agency for Healthcare Research and Quality that includes checklists and mnemonic devices. TeamSTEPPS is intended to improve teamwork and communication in healthcare settings. (More information on TeamSTEPPS is available at:
Midland Memorial required all surgeons, anesthesia providers, nurses, technicians, and other clinicians in the perioperative unit to undergo TeamSTEPPS training, explains Bob Dent, DNP, RN, senior vice president, chief operating officer, and chief nursing officer at the hospital.
Long-term Solution Needed
TeamSTEPPS has a good track record of helping hospitals improve quality and patient safety, and the first few months at Midland Memorial were no different. But while staff and physicians adhered to the processes they learned in the TeamSTEPPS training at first, they soon slipped back into their old ways, says Wes Barnt, vice president of ancillary services at Midland Memorial.
The more time passed after their training in the program, the less they used the checklists and communication techniques they had learned, Dent says.
Midland Memorial still uses and endorses the TeamSTEPPS approach, but for the patient handoff problem they found that they needed a strategy that would have a more lasting effect than the previous training. So, they developed another approach that involved ongoing education.
“Whatever training you’re doing, we learned that you have to follow up or you revert back to old behaviors and you don’t make the changes you want,” Dent says. “It takes relentless leadership and oversight to do that, but in a strong culture people step up and do that. We feel that we have been working on a strong culture of ownership and using TeamSTEPPS as a foundation for a culture of safety. We just needed to follow up on a process that was broken.”
A new program was implemented in six stages that included introducing a new handoff procedure, studying the initial implementation before formalizing it as a policy, and then following up with refresher training.
Involve All Parties
A first step was to show everyone involved in patient handoffs that the current performance was not satisfactory, Dent says.
“Once we got them to agree that the current process was not working, then the next step was to get everyone thinking about where we wanted to go,” Dent says. “From there we used evidence-based guidelines and put together a checklist, trialed it, improved it, and we also developed a way to maintain our proficiency in the new process. We knew that simply training staff was not going be enough, that there had to be a way to keep that momentum going.”
The new process was developed with input from nurses, anesthesia providers, and anyone else who had some part in the patient handoff, Barnt says.
“An important part of the effort, and one thing we think ultimately was key to it being successful, was including all members of the team that provide care to the patient when we developed this new process,” Barnt says. “We were able to draw on the expertise of everyone involved in the handoff to determine how to design the best process, and to get their feedback on how any proposed changes would actually work on a day-to-day basis.”
Dent attributes the success of the handoff program to a combination of strong leadership support and seeking the input of clinicians from all levels and different departments. Midland Memorial is now looking at opportunities to improve similar processes with the same approach.
One area of concern is the number of patients arriving in the OR without proper consent forms. A study from Johns Hopkins found that consent forms were missing for 66% of surgeries, and that missing consent forms delayed 10% of all surgical procedures and cost hospitals an average hospital $580,000 each year. (The study is available online at: https://bit.ly/2zuaRNx.)
“We still hear that there is inconsistency with completing that perioperative checklist, including getting consent, when preparing the patient for surgery,” Dent says. “It doesn’t happen often, but there’s enough that we can probably take what we’ve learned here and reverse for improving the handoff to the perioperative area.”