Interior Health

Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia.

What should I be worried about ?

Designing Handover focused on the Receiver

Introduction

70% of all Adverse Events • communication gaps• Lack of training and formal systems• We handover to “ourselves” more poorly than other specialties

Greenburg 2007 • Much of the research is of poor quality• Lack of standardization

1. Dynamic nature of handover2. Challenging it’s narrow definition as “information transfer” and

medical “error” source3. Resisting the compliance mindset & over simplification4. Combining handover and team training as inter-related skills

Manser - European Journal of Anaesthesia 2011

Transfer of accountability (Handoff) occurs at four key points 1. Change in Level of Care

Inpatient admission from the ED or ambulatory care clinic or community From ICU to acute care or Acute care to ICU From a Clinic to the ED

2. Temporary Transfer of Care From an inpatient ward or ED to diagnostic imaging, lab, echo/ cath lab and back

3. Discharge (Transitions) Communication to the next care provider (if known) from inpatient unit (phone, letter, discharge summary) Communication to the home health care provider(s) Communication to the receiving facility

4. Change in Provider or Service RN/LPN/RRT at Change of shift report (CoSR) Physician / resident signout Physician / resident rotation change

Communication Fundamentals from Latin "communis", meaning to share

1. The act of conveying information through the exchange of thoughts, messages, or information, as by speech, visuals, signals, writing, or behavior.

2. Communication requires a sender, a message, and a recipient 3. Communication requires that the communicating parties

share an area of communicative commonality. (Same Page)4. The communication process is complete once the receiver

has understood the message of the sender

http://en.wikipedia.org/wiki/Communication

Sender or Receiver ?

The onus is on the “sender” to ensure the ‘receiver’ understands.This can only be achieved with feedback (Interaction)

In athletics, handover (passing) is a fundamental skill that is practiced, even by experts.In fact , experts model this behavior for their juniors.

Interior Health CoSR Findings (Direct Observation n=26 / 11 hospitals , 2011 )

1. No clear standards / expectations about face : face report2. Individualized / Peer expectations 3. Unpaid time4. Most of the time allotted to task orientation5. No standard Kardex – Pt care planning / many different

formats, only a few explicit about D/C planning6. Nursing Worksheet (“Brain”) – hand written notes carried t/o

shift7. Even extremely brief face : face report (< 1 min/pt) can be

valuable IF structured and IF it focuses forward on potential risks.

Interior Health ICU Hand Over Research

• Highly individualized• Not simple, non linear• Time constrained• Complex tradeoffs• Local rationality (makes sense)• Cognitively taxing• Reliance on memory/ few cues• First oncoming ‘report’ crucial

Hill 2010

Healthcare Human Factors – Communication @ UHN Toronto

A properly designed communication system is fundamental to patient safety

3:22 http://humanfactors.ca/projects/patient-centered-perspective-of-hospital-communication-and-handover/

How ICU Experts Communicate• They learn how to perceive like experts. • Expert nurses, Doctors and RRTs use the repetitive teachable moments to help

train themselves and others how to;

– filter out irrelevant information – tune their detective powers to look ahead – “see what for others is invisible”

Deeply understand each others roles Manage efficiency thoroughness tradeoffs Practice , develop expertise Exercise intuition Collaborative sense-making Cascading situation awareness Actively utilize anticipation and foresight

Hill 2010 CJRT 46/4 Winter

Handover Suggestionsbased on literature reviews, peer reviewed original research and direct observation

• Forward focused , concise synthesis , receivers’ perspective• Anticipatory planning modeled in practice by PCCs• Even a brief face : face report (< 1 min/pt) can be valuable IF it is structured

and IF it focuses forward. • Focus on the system of information flow from N-D / N-D through the Patient

Care Coordinator/ Charge RN. • Test a template for anticipatory verbal report using the IDRAW acronym ;

IdentityDiagnosis, (Sick , Not Sick ?)* Recent changes, Anticipated changes, What should I watch out for ?

Forward focused verbal handover* discussion with Dr. Ertel on handover urgency ; sick vs. not sick

House – Puffer (0:33) http://www.youtube.com/watch?v=dMAS2S51bM8

How can I communicate like an expert ?

Frame the interaction on forward focus and encourage interaction and anticipatory questions such as;

“What are you worried about ?” “What should I be worried about ?”

Evaluate outcomes like accuracy of prediction vs. form compliance

1. Face : face interaction2. Use of multiple /minimum data sets

– Patient care summary– “Brain”- Pt census for oncoming shift notes

3. Opportunity to ask and answer questions (read back)4. Discussion, agreement of intention going forward 5. *Anticipatory questions (active receiver) Hill 2012

Interactivity is Key

"Senders" and "receivers" interacting like yin and yang “Our interactions create our realities” (Freed)

http://www.nyt.co.uk/kenfreed.htm

How can I help the receiver

accept this patient ?

Handover Standards for PCCs ?

Virginia Healthcare 2012

Explicit standards for;Patient through put /

Communication / Handover

Adobe Acrobat Document

http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf

ReferencesHill W., Nyce,J. (2010a) Human Factors in Clinical Shift Handover Communication (Review)

Canadian Journal of Respiratory Therapy 46.1 Spring

Hill,W. (2010b) Cognitive Human Factors in ICU – Techniques clinicians report that they use to develop their anticipation, intuition and foresight at change of shift report (CoSR) Canadian Journal of Respiratory Therapy 46.4 Winter

Freed,K. (2007) Global Sense, Awakening your power to change our world http://www.media-visions.com/kf-books.html#GlobalSense

Hill (2012) - Handover Communication - Direct observation of Change of Shift Report (CoSR) Assessment of current state on 26 units at 11 hospitals in Interior Health Interior Health Patient Safety Report 2011, Poster BC Quality Forum 2012

Manser (2011) Minding the Gaps; moving handover research forward European Journal of Anaesthesia

Olvera,M. (2011) Draw 3 – a new handover tool focused on the receiver . IHI Expedition on Handover March 23,2011

Hand off - Frequently asked questions http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf