Medisas
Using technology to provide safer, more effective care for all
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June 2, 2017
Over the course of an entire day, countless pieces of information are collected for a single patient: lab results, medications administered, and medical history from the PCP — just to name a few. Some information may be more relevant than others at different points of the patient stay, but each piece together create a patient story that guides the care plan.
As hospital care moves more deeply into a shift culture with resident work hour restrictions, creating a common understanding of patient context and needs across shifts becomes more of a challenge. This means that the quality handoff has also become more important than ever to avoid medication errors, overnight decompensation, and other sentinel events that are more likely to arise with information gaps or outdated patient context.
After speaking with handoff researchers, reviewing existing literature, and analyzing our learnings from working with hospitals on improving care transitions, here are what we see as the five essential elements of a good handoff:
1. Standardized, anticipatory content and clear accountability
One of the great challenges of communicating patient information for a handoff is the sheer volume of documents and data generated over the course of a day — not to the mention the synthesis involved in creating a summary of all that knowledge. Having a predetermined, systematic set of key information for each patient will help to ensure that the most crucial pieces are highlighted and passed along. To that end, many teams make use of content and communication mnemonics like SBAR, IPASS, and the 5Ps.
But standardizing the information that is shared is just the first step; mnemonics alone are not enough. Anticipatory guidance prepares the team for possible scenarios that might unfold in the coming shift. More specifically, we emphasize the use of “if / then” statements to convey anticipatory guidance in our Medisas handoff trainings. If adverse developments arise, already knowing the viable options helps the overnight team to quickly choose a course of action and minimize errors. Likewise, explicitly assigning tasks to team members during the handoff — again both verbally and in writing — ensures that nothing gets dropped.
2. Face-to-face communication paired with a written record
An in-person handoff between the day team and overnight coverage team is key to creating the aforementioned shared patient context. The conversation should be structured with an opportunity to ask questions, to clear up any ambiguity, and end with a synthesized summary from the overnight staff to highlight and clarify any potential misinterpretations. Such communication strategies are highly important to patient care, especially when considering that approximately 80% of serious medical errors involve handoff miscommunication.
To best effectively establish a shared context, the handoff conversation should serve as a highlighter for information that is also recorded in a structured, written format that can be referenced later. While paper print-outs are commonly used, using a mobile electronic handoff tool makes it easier and quicker for staff to add updates in real-time throughout the day, helping to ensure that information is accurate for handoff.
3. Ample training and supervision
Just as residents learn to diagnose and treat under the guidance of their attendings, proper handoffs require supervised training. Simulations help both day and overnight teams practice what information to communicate and what questions to ask, and help them familiarize themselves with the tools that should be used. One tip for moving from simulations to real cases: the mere presence of a more senior physician at the handoff can improve the quality of the handoff.
4. Schedules, tools, and spaces designed for successes
Of course, none of this matters if there simply isn’t ample time for the handoff. An ideal staffing schedule would have an overlap between the day and overnight shifts. This setup prevents the staff from rushing through vital patient information or skimping on updating information in the handoff tool. Mobile software integrated with the EMR help ensure patient information is up-to-date, keeping staff focused on the patient story rather than on note-taking. In tandem, a quiet space dedicated for handoffs minimize distractionsthat may lead to key pieces of the patient story being missed.
5. A supporting culture that evangelizes handoffs
To ingrain these handoff best practices, hospitals need to create a culture that prioritizes and supports the process. This starts with establishing an institution-wide understanding of why quality handoffs are important, from hospital executives to department chiefs to front-line physicians. A supportive culture also includes feedback mechanisms that dig deeper into what is working and what needs to be adjusted — after all, the best-laid plans rarely go exactly as anticipated, especially when it comes to something as complex as the choreography that is patient care. Designate champions to regularly gather feedback from the staff on how to improve the processes and tools that support handoffs, and, if possible, quantify the improvements through metrics: overnight sentinel events, RN phone calls for orders, incidence of stale information in the handoff tool, and so forth.
Over the course of an entire day, countless pieces of information are collected for a single patient: lab results, medications administered, and medical history from the PCP — just to name a few. Some information may be more relevant than others at different points of the patient stay, but each piece together create a patient story that guides the care plan.
As hospital care moves more deeply into a shift culture with resident work hour restrictions, creating a common understanding of patient context and needs across shifts becomes more of a challenge. This means that the quality handoff has also become more important than ever to avoid medication errors, overnight decompensation, and other sentinel events that are more likely to arise with information gaps or outdated patient context.
After speaking with handoff researchers, reviewing existing literature, and analyzing our learnings from working with hospitals on improving care transitions, here are what we see as the five essential elements of a good handoff:
1. Standardized, anticipatory content and clear accountability
One of the great challenges of communicating patient information for a handoff is the sheer volume of documents and data generated over the course of a day — not to the mention the synthesis involved in creating a summary of all that knowledge. Having a predetermined, systematic set of key information for each patient will help to ensure that the most crucial pieces are highlighted and passed along. To that end, many teams make use of content and communication mnemonics like SBAR, IPASS, and the 5Ps.
But standardizing the information that is shared is just the first step; mnemonics alone are not enough. Anticipatory guidance prepares the team for possible scenarios that might unfold in the coming shift. More specifically, we emphasize the use of “if / then” statements to convey anticipatory guidance in our Medisas handoff trainings. If adverse developments arise, already knowing the viable options helps the overnight team to quickly choose a course of action and minimize errors. Likewise, explicitly assigning tasks to team members during the handoff — again both verbally and in writing — ensures that nothing gets dropped.
2. Face-to-face communication paired with a written record
An in-person handoff between the day team and overnight coverage team is key to creating the aforementioned shared patient context. The conversation should be structured with an opportunity to ask questions, to clear up any ambiguity, and end with a synthesized summary from the overnight staff to highlight and clarify any potential misinterpretations. Such communication strategies are highly important to patient care, especially when considering that approximately 80% of serious medical errors involve handoff miscommunication.
To best effectively establish a shared context, the handoff conversation should serve as a highlighter for information that is also recorded in a structured, written format that can be referenced later. While paper print-outs are commonly used, using a mobile electronic handoff tool makes it easier and quicker for staff to add updates in real-time throughout the day, helping to ensure that information is accurate for handoff.
3. Ample training and supervision
Just as residents learn to diagnose and treat under the guidance of their attendings, proper handoffs require supervised training. Simulations help both day and overnight teams practice what information to communicate and what questions to ask, and help them familiarize themselves with the tools that should be used. One tip for moving from simulations to real cases: the mere presence of a more senior physician at the handoff can improve the quality of the handoff.
4. Schedules, tools, and spaces designed for successes
Of course, none of this matters if there simply isn’t ample time for the handoff. An ideal staffing schedule would have an overlap between the day and overnight shifts. This setup prevents the staff from rushing through vital patient information or skimping on updating information in the handoff tool. Mobile software integrated with the EMR help ensure patient information is up-to-date, keeping staff focused on the patient story rather than on note-taking. In tandem, a quiet space dedicated for handoffs minimize distractionsthat may lead to key pieces of the patient story being missed.
5. A supporting culture that evangelizes handoffs
To ingrain these handoff best practices, hospitals need to create a culture that prioritizes and supports the process. This starts with establishing an institution-wide understanding of why quality handoffs are important, from hospital executives to department chiefs to front-line physicians. A supportive culture also includes feedback mechanisms that dig deeper into what is working and what needs to be adjusted — after all, the best-laid plans rarely go exactly as anticipated, especially when it comes to something as complex as the choreography that is patient care. Designate champions to regularly gather feedback from the staff on how to improve the processes and tools that support handoffs, and, if possible, quantify the improvements through metrics: overnight sentinel events, RN phone calls for orders, incidence of stale information in the handoff tool, and so forth.
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