1. Inova Health System
Picker Grant
Update
For
Patient Advisory Team
Oct. 26, 2011
Mary Ann Friesen PhD, RN, CPHQ
Angela Servidio RN, BSN, BA
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2. • Explore the patient perceptions of bedside handoffs
will kick of in 2011
• Always Event
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3. Picker Institute
Dedicated to advancing the principles of
patient-centered care.
Sponsors awards, research and education to
promote patient-centered care and the
patient-centered care movement.
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4. Always Events
• Picker has determined that an organizing principle
focused on the concept of Always Events℠ can be
implemented to drive the system to become more
patient-centered.
• “Never Events” refer to incidents that should never
happen in the delivery of care.
• Patient-focused Always Events℠ are aspects of the
patient and family experience that should always
occur.
*Brochures
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5. Always Events℠ Challenge Grant Recipients Announced!
• Organization/Institution: Inova Health System
Principal Investigator(s): Mary Ann Friesen, PhD, RN, CPHQ
Project Title: Developing a Patient-Centered Approach to
Handoffs
• Always Event(s): Patients will always be included in the
ISHAPED handoff shift-to-shift hand-off process at the bedside
as this will add an additional layer of safety by allowing the
patient to communicate potential safety concerns.
* Page 6
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6. Journey
• Handoff Issues Identified
– Agency for Healthcare Research & Quality Hospital Survey on Patient Safety
Culture
– Variance Across System
• Quality Leadership CE
• System Kaizen – LEAN (March 2010)
• Pilot Projects
• Systemwide Rollout
• Research
– Nursing Research
– IRC
– IRB
• Education Plan
– Development
– Production
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7. Picker – will support Development of Education Program
• A collaborative exchange of information (conference calls,
webinars, and listserv communications).
• Learning network for achieving the selected Always
Events℠
• Development of key messages and media tools
http://alwaysevents.pickerinstitute.org/?cat=7
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8. Background
• “current state of scientific knowledge regarding hospital
handoffs is limited” (Arora, V.M, Manjarrez, Dressler, D.D, Dresler, D.D, Basaviah, P,
Halasyamani, L, Kripalani, S., 2009 p. 437)
• “Despite the well-known negative consequences of
inadequate nursing handoffs, very little research has
been done to identify best practices.. (Riesenberg, L.A , Leitzsch, J.,
Cunningham, J.M., (2010) p. 24)
Australian Council for Safety and Quality in Health Care. (2005). Clinical handover and patient safety literature review report. Retrieved January 5, 2006, from
http://www.safetyandquality.org/index.cfm?page=Publications#clinhovrlit
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9. AHRQ Patient Safety Culture Survey Results
• Opportunity for improvement Hand-off and teamwork
across units
• Agency for Healthcare Research and Quality Hospital
Survey on Patient Safety Culture -Handoffs average
percent positive response
 2009 - 44%
 2010 - 44%
 2011 - 45%
www. AHRQ.gov
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10. Fumbled handoffs presents a risk for a breach in
patient safety
– Miscommunication
– Disruption in continuity of care
– Omission of critical data
– Medication errors
– Serious Adverse Outcomes
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11. Problem Statement
• The last AHRQ Culture of Safety indicated handoff
opportunity for improvement
• Analysis of Handoff Policies and Procedures
indicates variance in definitions and process across
the system
• There is great variation in handoff practices across
the system and a lack of hardwired processes to
support optimal handoffs
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12. Kaizen Event Participants
Team:
• Darryl Hampton, RN, CVICU, Mgmt Coord, IFH
• Alice Penn Ritter, RN, GYN, Mgmt Coord, IFH
• Barbara Harrison, RN, Peds, Mgmt Coord, IFH
• April Peterson, RN, T7E, IFH
• Cheryl Schmitz, RN, ED Clinical Specialist, ILH
• Okey Hendrick, Acute Care RN, Team Coord, ILH
• Freddi Brubaker, RN, ED Director, IAH
• Monica Work, RN, 21 PCD, IAH
• Kristy Weirsky, RN, Mgmt Coord ED, IMVH
• Season Majors, RN, PCD 3B, IMVH
• Skip Reece, RN, PACU, IMVH
• Angela Servidio, RN, Education Coordinator, IFOH
• Joan Manning, ED, RN, Mgmt Coord, IFOH
• Melanie Martin, Radiology Technical Lead, IFH
• Lea Wotorson, GMU Student
Facilitators:
• Mary Ann Friesen RN Project Manager (Quality Consultant)
• Ann Miner - Lean Consultant
• Ken Leeson – Executive Director of Strategic Process Improvement
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13. Goals and Objectives of System Handoff Kaizen
Performance Improvement - Continuous improvement
• Provide training/exposure to the various handoff
methodologies that have been tried with success
• Select a guiding methodology for patient handoffs
• Identify key components of effective handoff
processes using the selected methodology
• Draft a deployment plan
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14. Team Reviewed Examples of Strategies and Best
Practices (Patterson et al 2004; Park & Mishkin 2005)
• Interactive, face-to-face handoff is
preferred
• Limit interruptions
• Read-back
• Un-ambiguous transfer of
responsibility
• Critical situation delay transfer
• Written summary/information
• Receive paperwork
• Make it clear - who for what
• Monitor
• Educate
• Support “Good Catch”
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15. ISHAPED
I Introduce
S Story
H History
A Assessment
P Plan
E Error Prevention
D Dialogue
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16. What is a “Handoff” ?
• “The transfer of information (along with authority and
responsibility) during transitions in care across the continuum;
to include an opportunity to ask questions, clarify and confirm.”
(Agency for Healthcare Research and Quality, 2006)*
– Transfer of information
– Transfer of responsibility
– Accountability
– Acknowledgement
– Interaction
– Verification
– Opportunity to address patient safety
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17. Benefit of Handoff
• Necessary to provide care
• 24/7 delivery of care
• Multi-disciplinary and
interdisciplinary care
• Education
• Debriefing/Support
• “Rescue and Recovery”
Parker, J., Gardner, G., & Wiltshire, J. (1992). Handover: the collective narrative of nursing practice. Australian Journal of Advanced Nursing., 9(3), 31-37.
KLally, S. (1999). An investigation into the functions of nurses' communication at the inter-shift handover. Journal of Nursing Management., 7(1), 29-36.
Kerr. M.P (2002) A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing, 37(2), 125-134.
Perry, S. (2004). Transitions in care: studying safety in emergency department signovers. Focus on Patient Safety, 7(2), 1-3.
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18. Causes of Handoff Failures
• Lack of formal tools to support transitions in
care
• Handoffs vary greatly – lack of
standardization (expectation)
• Not interactional
• Interruptions - staggering
• Memory lapse - omissions
• Verbal issues - accents, sound alike
medications, acronyms, abbreviations, lack of
common understanding
• Lack of access to patient data
• Need for skill and education
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19. Where are we today?
• We have an opportunity at Inova to improve handoffs,
healthcare communication and culture of safety.
• “Very little evidence to support the use of any specific,
structure, protocol or method.” Riesenberg, L et al. (2009)
– Need for discipline specific handoffs studies
– Different content needed for different areas
Riesenberg, L et al. (2009) Residents’ and attending physicians’ handoffs: A systematic review of the literature. Academic Medicine 84(12) p. 1775-1787.
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20. Goals
• Improve communication and handoff process
• Improve patient safety
• Improve team work and collaboration
• Improve staff satisfaction with handoff process
• Improve patient satisfaction
• Patient Centered Handoff
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21. ISHAPED – Inova’s New Handoff Methodology
• Developed by a system Kaizen team
• To be piloted in multiple inpatient units for the shift-to-
shift RN handoff
I Introduce
S Story
H History
A Assessment
P Plan
E Error Prevention
D Dialogue
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22. Four Components
1) Handoff methodology is ISHAPED –Standardize key
elements – as designed in pilot except for Assessment
Section
Customize the Assessment by unit – owned by the unit’s
CPC with input sought from unit staff
2) Verbal handoff is face to face between oncoming and off-
going RN
3) Handoff happens at the bedside S, H, A outside of room; I,
P, E, D in room. Clinical judgment and common sense
used to determine if beside component is inappropriate
for a particular patient. Optional entire ISHAPED at
bedside.
4) Written ISHAPED handoff template completed by off-
going RN and given to oncoming RN
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23. ISHAPED Tools
• Tool to be customized
• Pencil or Pen
• Cardstock or Paper
• RN give to oncoming RN
• Oncoming RN will update
and pass on
• RN Report
• Tech Report
• RN/Tech Report
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24. Bedside Shift to Shift Process
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25. Qualitative Results from RN Handoff Perception
Survey
Summary
Patient do not want handoff ????????
Patient do want handoff???????
New Term Bedside Shift to Shift Report
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26. Nurses should include:
• AIDET Acknowledge, Introduce, Duration, Explanations,
Thank you
• Method to identify those patients who do not wish to
participate
• RN performs hand-off tasks such as:
Checking MAG
Checking chart orders
Checking computer for medications charted
Checking computer for orders reviewed by RN
In room: Whiteboards, IV lines, etc.
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27. Bottom Line
• The focus is the
Patient
• Patient Centered
Care
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28. Next Steps
• Youtube
• Revise Protocol – (IRB)
• Patient and Family Developing a Patient Centered Approach to
Handoffs Research Team Advisory Board will include patient
and families to assure that the experiences, perceptions and
knowledge are recognized and utilized.
• Interviews
• Analysis
• Education Plan
• Education Materials
• Video
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