Roughly 80% of serious medical errors (now the third leading cause of death in the United States behind heart disease and cancer) can be traced to poor communication between care providers during patient handoffs, according to a 2012 Joint Commission report. This makes patient handoffs the most frequent and riskiest procedure in the hospital.
Despite the development of numerous techniques and tools to structure patient handoffs and improve the transfer of communication, we haven’t seen much improvement in reducing medical errors. The problem is two-fold: first, hospital administrators and managers struggle to effectively implement these tools. Second, they struggle to sustain change that’s made.
The perioperative unit at Midland Memorial Hospital (MMH) in Texas was in precisely that situation. Leaders noticed that the majority of patient handoffs had some level of missing information. While missing information was often not critically important or time-sensitive (e.g., patient age was more likely to be omitted than patient drug allergies), incomplete handoffs delayed patient care and made it easier for important information to be lost.
To fix this, in 2012 hospital administrators and managers implemented TeamSTEPPS, a commonly used set of evidence-based strategies and tools (e.g., paper checklists, mnemonic devices) for improving teamwork and communication among providers. Surgeons, anesthesia providers, nurses, technicians, and other providers in the perioperative unit were required to undergo training on the program.
Initially, the program seemed to be a success: staff members understood and followed the practices. Yet within a few months, only some care providers were using the new checklists and communication techniques, and only some of the time. By the end of 2013, nurses reported over 20% of patient handoffs still had missing information.
Adopting a more systematic process
We started working with the management and staff of the perioperative unit in 2014 to develop a more systematic, long-term approach for improving patient handoffs from the operating room (OR) to the post-anesthesia care unit (PACU). We knew that a checklist and one-time training wouldn’t produce sustainable change, so we created a plan with six stages: 1) preparing, 2) launching, 3) adjusting, 4) boosting, 5) formalizing, and 6) refreshing.
Our approach engaged management and staff throughout the change process and relied on their feedback. During each stage, both the perioperative unit managers and the care providers who performed the handoffs (i.e., circulator nurses, anesthesia providers, PACU nurses) were responsible for learning and executing their tasks, communicating openly and honestly, and evaluating the initiative’s effectiveness. The core idea was that managers and staff would systematically work together to change their behaviors and work processes, rather than working in a limited and idiosyncratic fashion.
The handoff project successfully reduced the number of handoffs with missing or inaccurate information, and the team has been able to sustain these improvements.
The Six Stages
The first stage was preparing. For about one month, one of us (Margaret) met with management and staff to evaluate the perioperative unit’s current quality of patient handoffs (~21% of handoffs had missing or inaccurate information) and identify how much they wanted to improve (cut the number of deficient handoffs to 10% or less within three months and maintain that level going forward). This involved collecting baseline data on multiple indicators of handoff quality (e.g., missing or inaccurate information, patient recovery rate) from multiple sources (e.g., PACU nurse ratings of each handoff, care provider surveys, observations, patient medical records).
During this stage, Margaret also worked with staff to develop a quality improvement plan. Unit managers selected and organized items for a new checklist and created instructions for a revised handoff protocol (e.g., remain bedside and engaged throughout the handoff). During this stage, we learned that care providers were worried about having additional paperwork. So instead of using a traditional paper checklist, we printed our checklist items on badge cards and PACU bay posters to give care providers easy access to the handoff tool without requiring additional paperwork.
Next was the launching stage. Over two weeks, we trained care providers on the checklist and process of the new handoff protocol. To ensure all staff members involved in the OR-PACU handoff understood the rationale for the new protocol, we conducted several one-hour training sessions during the weekly in-service meetings (explaining the logic behind the new protocol, how to do it, and the anticipated benefits) and even provided individualized coaching. The goal of this stage was to help care providers effectively enact the new protocol. At the end of it, we evaluated handoff quality by having nurses rate each handoff, and we found that of the approximately 250 patient handoffs performed, only about 4% had missing or inaccurate information.
We then transitioned into the adjusting stage. We evaluated initial progress by surveying care providers and asking what could be further improved. We saw slight agreement that the new handoff protocol was an improvement, yet there was consensus that a few changes needed to be made. For example, anesthesia providers recommended removing details like patient age and weight from the checklist, arguing they were not needed at this stage. After confirming changes with the unit managers, we updated the badge cards and bay posters to reflect a revised handoff protocol, and we sent around an information packet detailing the changes and the reasons why they were made.
The goal of this stage was to increase consensus and commitment among the care providers and create a broader sense of ownership of the handoff protocol. We also addressed another pain point we discovered: pressure on the circulator nurse to promptly return to help clean the OR to expedite room turnover time. During the launch stage, patient handoffs took about one minute longer as care providers were learning the new protocol. We learned that this additional time led some to accuse the circulator nurses of dawdling between cases. The unit managers addressed this counterproductive behavior in a weekly in-service meeting and arranged for additional staff to be available to help clean the ORs. After about one month of “adjusting,” we administered the staff survey again and found that providers strongly agreed there was improvement in the patient handoffs.
Next was the boosting stage. Unlike the adjusting phase which focused on the technical elements of the handoff protocol and addressing barriers to change, “boosting” focused on helping care providers maintain, renew, and enhance their effectiveness. At MMH this involved providing them with two weeks of individual coaching. We found that care providers had a fairly easy time memorizing and presenting the required patient information, but they struggled more with the behavioral changes involved in the new protocol.
For example, prior to our initiative, providers would often provide their part of the handoff and then leave. This made it difficult to have a complete crosscheck between the anesthesia provider, circulator nurse, and PACU nurse. But in order to transform the handoff from a risky procedure to a safety checkpoint, we needed them all to remain bedside and engaged throughout. This required a shift in mentality from focusing on one’s individual role to focusing on working with others and providing backup. Although in hospitals we frequently see teamwork within units (e.g., PACU nurses helping other PACU nurses), backup behaviors are less frequent across units (e.g., OR nurses helping PACU nurses) – in part because there is often pressure to get back to help your unit complete its work.
So one focus of coaching was emphasizing the importance of the crosscheck. For example, we shared examples of how it helped people add or correct information, such as when an anesthesia provider misread a chart and said that a patient was allergic to codeine, instead of iodine – the circulator nurse was able to correct him.
During this stage, the average handoff duration had decreased from 4-5 minutes to 2-3 minutes. Several of the care providers told us that although initially learning the new protocol was a challenge, patient handoffs were now much easier and consistently better. We again evaluated handoff quality, and from nurse ratings, found that about 6% of the approximately 250 handoffs occurring over these two weeks had missing or inaccurate information. (We should note that this percent increase was confounded by nurses rating fewer handoffs; they were also more likely to remember to rate when something was deficient.)
The next stage involved formalizing the protocol into hospital policy – making it formally required as opposed to recommended – a process which took about one month. This was meant to help care providers avoid slipping back to previous behaviors.
Before we formally submitted the handoff protocol to the unit’s policy management system, we evaluated the influence of the new protocol on patient recovery. Adjusting for patient and surgical procedure characteristics, we found that patients’ Aldrete scores in PACU improved 40% faster compared to before the initiative, and their length of stay in the hospital post-surgery decreased by about 2%, from which the hospital could expect to save about a million dollars per year given their case load (~10,000 surgeries per year) and utilized capacity (usually over 90%).
After the final OR to PACU handoff protocol was formalized, Margaret created training materials (e.g., handouts, PowerPoint slides, quizzes) and a protocol to help managers monitor handoff quality every six months. We also asked PACU nurses to continue rating handoffs for one to two weeks every six months in order to promote accountability and to surface warning signs that the initiative needed to be refreshed.
The final (and ongoing) stage is refreshing, where the goal is to promote compliance and proficiency by increasing knowledge of the handoff protocol. The perioperative unit staff educators provide training to new staff members and administer yearly refresher training.
Through their continued efforts, providers have sustained the success of the handoff project. Almost three years after it launched, staff members agree that they “follow a standardized method of sharing information when handing off patients,” and managers suggest that the percentage of handoffs with missing or inaccurate information is still consistently under 10%. This translates to each PACU nurse receiving, on average, only one deficient handoff per week – suggesting high quality handoffs are now the norm. (Anecdotally, the PACU nurses have said that when a handoff is deficient, it is usually something minor, and that the structured protocol helps them to catch any omission earlier on.)
Ultimately, patient handoffs are one of many areas for quality improvement in health care, and a similarly structured approach may help with other initiatives. Success will depend on 1) viewing change as a process instead of an event; 2) engaging both management and staff; and 3) systematic evaluation of the initiative, using quality indicators, across all stages. Healthcare organizations have an important opportunity to improve the quality of patient care, but they have to make their efforts last.
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