Safer Sign Out Physician Handoff Communication

1. Safer Sign Out Physician Handoff Communication Achieving to High Reliability Through Patient-Centered, Team-Based Innovation v5

2. Drew C. Fuller, MD, MPH, FACEP Past Chair, Quality Improvement & Patient Safety Section (QIPS) Board of Directors / Education Committee Director of Safety Innovation (Synergy Interest)

3. Safer Sign Out • Patient Centered • Team Based • Risk-Focused • Physician (Frontline) Developed • Method for Structured Physician Handoffs

4. National Patient Safety Goal2E (2006) Standardization of Handoff Communication

5. “Sign out is the most dangerous procedure in the Emergency Department” Charles “Chaz” Schoenfeld, MD (1950-2010)

6. Why Structure? • Up to 80% of serious medical errors involve miscommunication during handoffs (TJC) Up to 24% ED malpractice claims related to handoff (Cheung 2010)

7. Progress • Nursing profession – Leading with Models/Methods • Few Physician Models

8. Emergency Departments - High Risk ED Factors – Potentiate Errors • Production/Time Pressure • High Noise Levels • High Acuity • Multitasking • Time Sensitive Conditions • Rapid Turnover • Frequent Interruptions • New/Unknown Patients • Undifferentiated Diagnosis • Wide Clinical Variation • Increasing Complexity

9. Handoffs - High Risk Points of Potential Failure • Neglected/Missed Information • Unclear Transfer of Responsibility • Team Unaware of Transfer/Issues • Patient/Family Unaware • Change in Status • Lack of Mechanism for QA

10. Why Structure is Critical Mandates

11. High Reliability • Structured • Workable • Predictable • Measurable

12. Industries Committing to High Reliability

13. Pilots Committed to Standardized Communication

14. “Quick” Handoff Practice (Click on Photo to Start Video)

15. Name that Handoff Hit & Run?

16. “Typical” Handoff Practice (Click on Picture to Start Video)

17. Name that Handoff “Hopeful Handoff”

18. What’s Missing? Typical ‘Hopeful’ Handoff • Critical items conveyed? • Safeguards? (Checklist?) • Current clinical status? • Patient aware/Involved? • Nurse aware/involved? • QA ?

19. Hope Model for Safety • Hope nothing goes wrong • Safe By Luck or Design? • Unstructured – No Standard • Not High Reliability (High Vulnerability) • Poor Strategy for Safety

20. Designing a Better Way • Focus on areas of RISK • Practical implementation • Scalable • WORK for Clinicians

21. EMA Safety Leadership Group Physician Representation 12 Hospital/Clinical Sites: Maryland Virginia Washington, DC West Virginia

22. American College of Emergency Physicians (ACEP) Quality Improvement & Patient Safety (QIPS) • White Paper on Improving Handoffs by Dickson Cheung, Jack Kelly et al • 20 National Clinical & Safety Experts • Recommendations for Best Practice

23. FrontlineInput • Sign Out Safety Survey • 104 ED Physicians & 50 PAs • Directors’ Guidance • ACEP QIPS leaders • Executive Input • Nursing Input & Feedback

24. “The Essential Connections” Physician to Physician Nurse (Team) Patient/Family

25. Key Components Safer Sign Out • Record - Critical Data & Pending Items • Review - Form & Computer Data • Round – Bedside, Together • Relay to the Team – Nurse Collaboration _____________________________________________________________________________________________________ • Receive Feedback – Clinical/QA

26. 1) Record Use a Recordable Form • Clear transfer of responsibility • Prompts to identify Key items • Checklist& Reference Tool

28. Back of Sign Out Form (Reinforces Protocol)

29. 2) Review Joint Focus - Form & Data • Done at a computer Access to lab/rad results • Assure Shared Understanding Purposeful time for Q & A

30. 3) Round - Bedside Bedside Round - Together • Status -“Eyes on the patient” • Introduction/Update • Team Communication

31. 4) Relay to the Team Communicate with the Nurse – Transition/Updates • Opportunity for input/feedback • Assures team understanding • Before, during or after rounds

32. 5) Receive Feedback Form as a Feedback Tool • Clinical Follow Up • Quality Assurance Tool

33. Quality Assurance ✔ ✔ Built-in tool to help with QA

34. Initial Hospital Sites

35. Initial SSO Development Team • Don Infeld, MD (EMA President) • Jackie Pollock, CEO (EMA) • Nicole Bergen, Dir. of Op. (EMA) • Martin Brown, MD, CMO (EMA) • John Schnabel, MD • Chris Morrow, MD • Tim Hsu, MD • Richard Ferraro, MD • Karla Lacayo, MD • Cameron Cushing, MD • Michael Kerr, MD • Steven Smith, MD • David Jacobs, MD • Jennifer Abele, MD • Drew White, MD, MBA • Michael Silverman, MD • MarneyTreese, MD • Justin Green, MD • Napoleon Magpantay, MD • Kurt Rodney, MD • Sora Chung, MD • Matt Sasser, MD • Jon D’Souza, MD • Todd Larson, MD • Junior Williams, MD • Larry Mack-Wilson, PA-C • Eric Parvis, MD • Chris Morrow, MD • Kala Scoggin, PA-C • Elizabeth Cook • Drew Fuller, MD, MPH • Kilole Kanno, MD • Nadia Eltaki,MD

36. Rapid Cycle Improvement

37. What We Learned • Physician Champions (Key) • Ease of implementation • Educate & support • Initial resistance resolves • Use QA to sustain

38. Engaging Physicians “Protect Your Patients, Support Your Colleagues” • Appeal to their interest • Performance => how it ’Occurs’to them • Listen, support & reassure

39. Understanding Adoption

40. Readiness for Change “Start Where They Are”

41. Physician Feedback “ This is so much better than what we use to do” “ I was initially resistant but now I get it” “I sleep better at night”

42. Committed to Collaboration • Share the Process • Teach Others • Seek Understanding • Pursue Refinement • Regionally/Nationally

43. American College of Emergency Physicians (ACEP) Quality Improvement & Patient Safety Section Website First Featured Safety Project

44. Emergency Medicine Patient Safety Foundation(EMPSF) • Voice for Safety in Emergency Medicine • National Collaborator • SSO Flagship Safety Tool • Dedicated SSO Website • Consultation Service

45. SaferSignOut.com Toolkit (Web-based) • Education • Downloads • Forms • Posters • Strategy/Best Practices • Videos & More

46. Logo

47. AMA Handoff Resource Listing • Handoff Resource (RFS) • Description and links to SaferSignOut.com

48. AMA Handoff Resource Listing • Handoff Resource (RFS) • Description and links to SaferSignOut.com

49. Agency for Healthcare Research & Quality (List SaferSignOut.com as a Resource)

50. SSO in the Press