Dr. Glenn Rosenbluth
Director of Quality and Safety Programs UCSF
|
July 20, 2017
You’ve been on UCSF’s faculty since 2006, focusing on quality improvement initiatives. What are some of the key strides you’ve seen your team and the institution make?
Overall, we’ve made dramatic improvements in patient safety, but in particular, understanding the kind of errors that occur in the hospital. During my residency, orders, prescriptions, documentation — everything was done on paper. We were not very good of detecting errors because there wasn’t a systematic way to search for them. We’ve now started tracking metrics: looking for the kinds of mistakes that are being made so we can reduce the likelihood of them occurring again.
My recent work has been focused on communication between physicians and between physicians and patients. I was one of the site leads at UCSF and one of the lead investigators in the I-PASS handoff study.
You’ve been involved in several research studies and papers around handoffs. In your experience, what are the key learnings you’ve gained regarding how to institute a safe, efficient handoff process?
If we teach people and then help them change behaviors, we can improve patient safety. Going into the I-PASS handoff study, residents generally thought they were good communicators, but when we compared what people thought were good handoffs versus handoffs utilizing a standardized bundle (I-PASS), I-PASS was shown to be better and safer. At the Hospitalist Medicine meeting earlier this year, people were raising their hands and saying that their groups don’t need to do handoffs: “we just look at the notes from the past 24 hours, and that’s how we do care transitions.” Doctors really have to own the change to improve patient safety. Nobody questions why we do central line bundles or surgical prep in the way we do that now. Handoff bundles have been shown to have a 21% reduction in medical errors and 30% reduction in preventable adverse events — a huge impact!
To those who want to improve handoff workflows within their own departments or institutions, what advice would you give them?
The first bit of advice is to do a needs assessment. Talk to your colleagues and learn from them, and examine opportunities for improvement at your institution. Take a look at the data and make a decision about how you’d want to change your handoffs. Once the group has decided on the change, I suggest ongoing audit and feedback to support behavior change. It’s only with ongoing reinforcement that we can achieve an improved patient safety outcome.
What do you think are the key barriers to standardizing handoffs within or across departments?
Standardizing handoffs across departments is a challenge because different providers may need different information. We recognize that there are differences in key information needed for surgical patients versus obstetric patients and babies in the nursery. That said, there are “best practices” (e.g., I-PASS) that apply across departments. Institutions should agree on the key information in handoff documents, but individual departments need flexibility to add elements to their particular field. There are resources out there to help people, such as guidelines for printed handoffs (published in Journal of Hospital Medicine), I-PASS materials, and resources from the Joint Commission and AHRQ. Software programs and technology solutions, such as Medisas, also provide opportunity to standardize communication around handoffs.
Another barrier is resistance to behavioral change. As physicians, we think we’re good communicators and therefore we don’t need to change. I think we have a blind spot here. The communications literature tells us that we assume that we are understood better than we actually are. In one study of observed handoffs, followed by surveys of those who gave and received information, the most important information was not communicated half the time.
As for other barriers, up until recently, we have not had good, robust handoff documents. Physicians routinely use handoff documents as a guide during verbal handoffs as well as for reference later, but we haven’t really tapped the potential of electronic handoff documents that are integrated with the EHR where you can change information on the fly.
You’ve conducted studies around handoff documents and tools (e.g., Half-life of a printed handoff document). What are your perspectives around how best to ensure accuracy of the information contained in these tools, particularly once they are printed? What role should they play?
Awareness that the handoff document changes rapidly is the most important, if you are going to print the document. In the ideal world, we would have a technology that obviated the need to print the handoff document. A lot of the electronic interfaces we have right now just aren’t as easy to use compared to making notes on a piece of paper. When handoff documents are printed, they have to be used with caution. Providers have to be aware of who else is taking care of the patient and what changes they are making. We also have to commit to updating the document before the handoff so that the information is up to date for the next provider.
Anything else you would like to mention around handoffs?
There are some missed opportunities that may need further exploration. We need to better understand team handoffs between different levels or professions, for example doctors and nurses handing off patients at the same time. There is a lot we still have to learn about the potential costs and benefits (e.g. efficiency, safety). Another area that hasn’t been explored well is the benefits of handing off with or in front of patients. These are potential opportunities for us to start learning more.
In general, from what we know from the literature, standardization is good. Even if you don’t choose I-PASS as your handoff bundle or process, the communications literature tells us that adopting a single consistent approach to communication is good so that the receiver knows what to expect and the sender remembers the key information.
You’ve been on UCSF’s faculty since 2006, focusing on quality improvement initiatives. What are some of the key strides you’ve seen your team and the institution make?
Overall, we’ve made dramatic improvements in patient safety, but in particular, understanding the kind of errors that occur in the hospital. During my residency, orders, prescriptions, documentation — everything was done on paper. We were not very good of detecting errors because there wasn’t a systematic way to search for them. We’ve now started tracking metrics: looking for the kinds of mistakes that are being made so we can reduce the likelihood of them occurring again.
My recent work has been focused on communication between physicians and between physicians and patients. I was one of the site leads at UCSF and one of the lead investigators in the I-PASS handoff study.
You’ve been involved in several research studies and papers around handoffs. In your experience, what are the key learnings you’ve gained regarding how to institute a safe, efficient handoff process?
If we teach people and then help them change behaviors, we can improve patient safety. Going into the I-PASS handoff study, residents generally thought they were good communicators, but when we compared what people thought were good handoffs versus handoffs utilizing a standardized bundle (I-PASS), I-PASS was shown to be better and safer. At the Hospitalist Medicine meeting earlier this year, people were raising their hands and saying that their groups don’t need to do handoffs: “we just look at the notes from the past 24 hours, and that’s how we do care transitions.” Doctors really have to own the change to improve patient safety. Nobody questions why we do central line bundles or surgical prep in the way we do that now. Handoff bundles have been shown to have a 21% reduction in medical errors and 30% reduction in preventable adverse events — a huge impact!
To those who want to improve handoff workflows within their own departments or institutions, what advice would you give them?
The first bit of advice is to do a needs assessment. Talk to your colleagues and learn from them, and examine opportunities for improvement at your institution. Take a look at the data and make a decision about how you’d want to change your handoffs. Once the group has decided on the change, I suggest ongoing audit and feedback to support behavior change. It’s only with ongoing reinforcement that we can achieve an improved patient safety outcome.
What do you think are the key barriers to standardizing handoffs within or across departments?
Standardizing handoffs across departments is a challenge because different providers may need different information. We recognize that there are differences in key information needed for surgical patients versus obstetric patients and babies in the nursery. That said, there are “best practices” (e.g., I-PASS) that apply across departments. Institutions should agree on the key information in handoff documents, but individual departments need flexibility to add elements to their particular field. There are resources out there to help people, such as guidelines for printed handoffs (published in Journal of Hospital Medicine), I-PASS materials, and resources from the Joint Commission and AHRQ. Software programs and technology solutions, such as Medisas, also provide opportunity to standardize communication around handoffs.
Another barrier is resistance to behavioral change. As physicians, we think we’re good communicators and therefore we don’t need to change. I think we have a blind spot here. The communications literature tells us that we assume that we are understood better than we actually are. In one study of observed handoffs, followed by surveys of those who gave and received information, the most important information was not communicated half the time.
As for other barriers, up until recently, we have not had good, robust handoff documents. Physicians routinely use handoff documents as a guide during verbal handoffs as well as for reference later, but we haven’t really tapped the potential of electronic handoff documents that are integrated with the EHR where you can change information on the fly.
You’ve conducted studies around handoff documents and tools (e.g., Half-life of a printed handoff document). What are your perspectives around how best to ensure accuracy of the information contained in these tools, particularly once they are printed? What role should they play?
Awareness that the handoff document changes rapidly is the most important, if you are going to print the document. In the ideal world, we would have a technology that obviated the need to print the handoff document. A lot of the electronic interfaces we have right now just aren’t as easy to use compared to making notes on a piece of paper. When handoff documents are printed, they have to be used with caution. Providers have to be aware of who else is taking care of the patient and what changes they are making. We also have to commit to updating the document before the handoff so that the information is up to date for the next provider.
Anything else you would like to mention around handoffs?
There are some missed opportunities that may need further exploration. We need to better understand team handoffs between different levels or professions, for example doctors and nurses handing off patients at the same time. There is a lot we still have to learn about the potential costs and benefits (e.g. efficiency, safety). Another area that hasn’t been explored well is the benefits of handing off with or in front of patients. These are potential opportunities for us to start learning more.
In general, from what we know from the literature, standardization is good. Even if you don’t choose I-PASS as your handoff bundle or process, the communications literature tells us that adopting a single consistent approach to communication is good so that the receiver knows what to expect and the sender remembers the key information.
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