TJC looks at caregiver communications

Quality patient hand-offs crucial

The Joint Commission's Center for Transforming Healthcare has teamed with 10 hospitals and health care systems to try to discover new solutions to the quality care problems associated with miscommunication between caregivers during hand-offs.

"It's a fairly new arm of The Joint Commission, but it was formed a few years ago under the leadership of Dr. Mark Chassin, their new director, to try to have an entity that isn't perceived by hospitals and clinicians as being the policeman, but instead is an arm that's dedicated to trying to improve patient safety through developing best practices," says Douglas L. Smith, MD, associate chief medical officer of Intermountain Healthcare, which has one of the 10 participating facilities.

Hand-offs are a matter of medical ethics related to patient safety, he says.

"Ethics is not just end-of-life orders and ventilator support decisions; it's . . . a much broader question. It's more of an issue of trying to do the right thing for people," Smith notes. "Clearly, if we do a good job of transferring care from one setting to another setting, that increases the odds that [a] patient is going to get the right care, the appropriate care, and reduces the risk of harm to that patient."

The center sent out surveys to hospitals and health care systems requesting information as to the major concerns those facilities had regarding major safety issues, he says.

Intermountain Healthcare's participating hospital, LDS Hospital in Salt Lake City, then identified hand-offs as a major area of concern that presents the greatest potential for miscommunication.

"Hand-offs are really complicated . . . and part of the complexity has to do with day-to-day operations of the hospital, but there's also complexity around all the different kinds of hand-offs," Smith says.

For example, there are hand-offs from the outpatient setting to the inpatient setting, from one unit to another unit within the hospital, or from one provider or team of providers to a separate individual or team of providers, including physician-to-physician and nurse-to-nurse hand-offs.

The requirements of different transfers to complete a successful hand-off also are all different, although there are consistent elements, such as name, diagnosis, and allergies. But beyond that basic information, the differences "makes it a challenge in terms of designing a tool or a process that can be universally applied," Smith says.

The 10 hospitals or systems spent a great deal of time in defining terms, i.e., answering questions, such as, "What is a hand-off?; How do we measure what a good hand-off is?; and How do we judge whether it's being done right or not? And those are tougher questions than you might think," Smith explains.

Each hospital then selected one or two types of hand-offs for further study. Intermountain's LDS Hospital, which was selected to be that system's pilot site, chose two different hand-off types to study: emergency department to the inpatient floor; and from the operating room to the post-anesthesia care unit (PACU).

"We thought these were two higher-risk sorts of hand-offs," Smith says.

To investigate these hand-offs, LDS Hospital looked at Sentinel Event data and tried to identify patterns in errors. Each hospital also developed "survey tools to try to measure hand-offs and the quality of the hand-offs. So, that was one methodology, and then, each of the institutions worked on developing a hand-off tool — it's like a checklist."

Such checklists are helpful in determining — and following — the process that needs to be followed and the list of things that need to be confirmed in that process before going forward, much like pre-surgical procedures to determine such things as whether it is the correct patient, etc.

These checklists for hand-offs were developed "as opposed to the kind of the way it's always been done, which is, one person picks up the phone and calls another person and says, 'Mrs. Smith is here in the emergency room with pneumonia; we're going to send her up right away. She's a diabetic and she's on these medicines. We started on this antibiotic and . . .'"

Currently, LDS is using the hand-off checklist developed as a result of the project. Smith says the checklist for the two types of hand-offs identified as problematic by LDS Hospital is "being used around 95% of the time in those two particular scenarios, the ED to the floor and the PACU to the floor. The nurses involved in those hand-offs are using this checklist 95% of the time."

The key to adoption of the checklist by nurses at LDS is due to the fact that the nurses were the ones who participated in its development, Smith says.

"We identified nursing leaders — front-line people who wanted to participate in this project — and these folks got together for two hours every other week," Smith explains. "It included people from the various departments and floors that were involved. We did a very detailed analysis of all of the different steps that are involved in moving a patient from one setting to another setting. It's more than just a phone call, of course. . . It turns out there [are] dozens of different steps involved, and some of them are crucial steps in terms of information transfer. So, we started with a real breakdown workflow analysis," Smith says.

Working in concert with nurses, the hospital spent weeks and months developing a checklist from suggestions they received — and categorizing and ranking those suggestions.

"We came up with an initial checklist, and we tried it for a week and people said, 'Oh, you know, that sounded good on paper, but when we started to use it, it really had some problems.' So, we tweaked it a lot for a period of several months until people felt pretty comfortable with it. And then, for six months or so, we said, "OK. This is the one we're going to use during our pilot project,' and that was the checklist that we've used, really, for the last eight months or so," he says.

LDS Hospitals is using metrics to evaluate the success of its checklist. One of those is a box that asks receivers, on a 10-point scale, "How satisfied were you with the hand-off in terms of its safety?"

Smith says that this box is completed by the receiver — as opposed to the person conveying the information in the hand-off. A hand-off ranked 7 or below is considered "defective," he says. If the hand-off was ranked 8, 9, or 10, it was thought that receivers were "pretty happy with the hand-off."

"The percentage of defective hand-offs dropped over time as people got used to it and became familiar with it," Smith notes. "We were using this 900 times a month toward the end of the study, once it was widely adopted. . . Our rating of the hand-off as measured by that scale went from fairly low to fairly high. It wasn't perfect, but it was very much a statistically significant trend in the right direction."

[For more information, contact:

Douglas L. Smith, MD, Associate Chief Medical Officer, Intermountain Healthcare, Salt Lake City.]