- Email: [email protected]
Developing a Better Understanding of Handoffs
SAFETY CORNER
Developing a Better Understanding of Handoffs Jacqueline Ross, PhD, RN, CPAN
IN TODAY’S HEALTH care environment, patients encounter various health care providers during their experience. Along the continuum of care, these health care providers are engaging in handoffs of patient care. Each handoff is fraught with potential errors, such as the loss of essential information, which could lead to adverse events, delays in treatment and diagnosis, ordering of repeat tests, longer hospitalization, and increased costs. Clearly, poor communications can lead to errors. Communication failure is often cited as a cause in sentinel events. In 2006, a National Patient Safety Goal required health care organizations to implement a standardized method of handoff communication. However, handoffs also offer the opportunity to provide additional information. Studies have shown that 20% to 30% of the information exchanged in handoffs was not included within the patient’s chart.1 Handoffs are an important part of patient care and patient safety. Patterson and Wears1 conducted a literature review of more than 400 articles involving patient handoffs. Their review revealed an emphasis to improve the handoff process, although there is lack of consensus on the purpose of the handoff. Focus groups and observational studies illustrated that the handoff process is highly variable in both structure and quality. Additionally, this review illustrates that a standard, reliable instrument to measure the quality and/or effectiveness of handoffs remains elusive. This review highlights that there is much more to learn in the area of handoff and transitional errors.
Jacqueline Ross, PhD, RN, CPAN, is a Senior Clinical Analyst at The Doctors Company in Napa, CA. Conflict of interest: None to report. Address correspondence to Jacqueline Ross, 17491 Merry Oaks Trail, Chagrin Falls, OH 44023; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.07.010
360
Hopefully, this column will provide some additional insight into these issues. Currently many nurses are using a handoff technique originally developed by the US Navy to help prevent miscommunication—the SBAR method. SBAR covers the patient’s Situation, Background, Assessment, and Recommendation. The Situation refers to what is happening at the current time. The Background is the context of the patient’s condition. Assessment reflects what you consider the problem is. Recommendation includes what needs to be done or observed, including follow-up tests.2 Situation and background reflect objective information and assessment, and recommendation represents subjective information. Because this method is designed to be redundant, if someone veers from the normal process, the receiver of the information can note the omission and ask for the information that was missed.2 The overall goal of this process is to improve patient safety and improve outcomes. The SBAR method is designed to assure error-free handoffs and enhance situational awareness. The SBAR is a structured framework for communication and highlights what requires the immediate attention of the oncoming health care provider, as well as clarifying other issues. At the same time, the improved communication fosters both teamwork among the health care team and enhances the culture of patient care. The primary purpose of the handoff is information processing. Interventions to define and standardize information are included in this function. A read-back would be an example of information process, as is SBAR. One of the concerns with information processing is data overload, so designing an SBAR to assure that essential information is relayed is a priority. Another concern with information processing is distractions, so the SBAR process should be conducted in a quiet area whenever possible.1 In summary, the SBAR handoff process promotes
Journal of PeriAnesthesia Nursing, Vol 27, No 5 (October), 2012: pp 360-362
SAFETY CORNER
interactive communication; provides current information regarding the patient’s condition, care, and treatment; and enhances the ability to have a verification process, such as repeat-backs and enables the receiver of the information to review important data with the other provider. A recent study investigated how nurses, managers, and physicians felt about the use of SBAR within the hospital setting. Although most respondents indicated that SBAR provided a means of standardized communication, many nurses felt that it helped them make intuitive decisions. Nurses also thought that the use of SBAR improved the professional image of nursing. The use of SBAR may help to minimize perceived hierarchal issues between physicians and nurses. Nurses and physicians have different communication styles. Nurses tend to communicate in a very descriptive and narrative manner, whereas physicians are more inclined to summarize and bullet-point their communications. Therefore, the use of SBAR provides a standardized approach to communicate information in a timely, effective, and efficient manner. Additionally, respondents thought that SBAR was a way to further incorporate nurses into the organization.3 For the purpose of this column, the working definition of a handoff from Patterson and Wears1 will be used: ‘‘The process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver’’ (p. 53). Following the handoff, the oncoming health care provider assumes responsibility for the patient’s care. In fact, there are two types of handoffs: patient related and provider related. Patient-related handoffs occur when the patient travels from place to place within the health care environment, for example, when the patient moves from the operating room into the postanesthesia care unit. Providerrelated handoffs occur when the patients are stationary, for example, when shift changes occur.4 Regardless of the type of handoff, the potential of error is high with handoff. One of the areas of concern is the transition from hospital or ambulatory surgery center to home. One of the main issues is pending test results at the time of discharge,
361
with many of those test results not getting reported to the patient.4 Simple interventions can be postdischarge follow-up calls, getting a discharge summary to the patient’s primary care doctor on the day of discharge and that the discharge instructions go beyond just a check box type form. Some organizations are using discharge counseling, which consists of a registered nurse who does extensive predischarge planning (averaging about 90 minutes per patient and family) to include more involvement in discharge instructions, follow-up discharge call, and then makes a fairly quick follow-up appointment with the physician. The initial results have shown a 30% decrease in readmission rates.4 While perianesthesia nurses are not involved with discharging inpatients like those in this program, it is important to consider how to best address the transitional communication needs for ambulatory patients, as tests are often pending. How are those transitions being communicated currently within your institution? As with any process, evaluation is needed. To evaluate information processing, several approaches can be used. For example, the recipient of the information can rate whether the information was relayed in an organized fashion, his or her satisfaction with handoff, or the perceived quality of the reports.1 Studies have investigated the impact of SBAR on staff perception of team communication and patient safety culture. Reporting of incidents and near misses before and after the use of SBAR is another means to evaluate the process. All of these examples can provide invaluable information on communication. Findings may reveal that hierarchal issues remain with communication among health care providers, the need for more training among staff, or poor satisfaction with the process. Overall the ability to promote clear communication through processes such as SBAR improves patient safety. Managers within organizations need to evaluate their communication process to assure effectiveness. Although progress has been made, more attention is needed in handoffs and transitions within health care. Collaboration and communication is key to improving patient safety.
362
JACQUELINE ROSS
References 1. Patterson ES, Wears RL. Patient handoffs: Standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36:52-60. 2. Hohenhaus S, Powell S, Hohenhaus JT. Enhancing patient safety during hand-offs. Am J Neurosci. 2006;106:72A-72C. 3. Vardaman JM, Cornell P, Gondo MB, Amis JM, TownsendGervis M, Thetford C. Beyond communication: The role of stan-
dardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37:88-97. 4. Wachter RM. Transition and handoff errors. In: Wachter Robert M, ed. Understanding Patient Safety, 2nd ed. China: McGraw-Hill; 2012.
Developing a Better Understanding of Handoffs Jacqueline Ross, PhD, RN, CPAN
IN TODAY’S HEALTH care environment, patients encounter various health care providers during their experience. Along the continuum of care, these health care providers are engaging in handoffs of patient care. Each handoff is fraught with potential errors, such as the loss of essential information, which could lead to adverse events, delays in treatment and diagnosis, ordering of repeat tests, longer hospitalization, and increased costs. Clearly, poor communications can lead to errors. Communication failure is often cited as a cause in sentinel events. In 2006, a National Patient Safety Goal required health care organizations to implement a standardized method of handoff communication. However, handoffs also offer the opportunity to provide additional information. Studies have shown that 20% to 30% of the information exchanged in handoffs was not included within the patient’s chart.1 Handoffs are an important part of patient care and patient safety. Patterson and Wears1 conducted a literature review of more than 400 articles involving patient handoffs. Their review revealed an emphasis to improve the handoff process, although there is lack of consensus on the purpose of the handoff. Focus groups and observational studies illustrated that the handoff process is highly variable in both structure and quality. Additionally, this review illustrates that a standard, reliable instrument to measure the quality and/or effectiveness of handoffs remains elusive. This review highlights that there is much more to learn in the area of handoff and transitional errors.
Jacqueline Ross, PhD, RN, CPAN, is a Senior Clinical Analyst at The Doctors Company in Napa, CA. Conflict of interest: None to report. Address correspondence to Jacqueline Ross, 17491 Merry Oaks Trail, Chagrin Falls, OH 44023; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.07.010
360
Hopefully, this column will provide some additional insight into these issues. Currently many nurses are using a handoff technique originally developed by the US Navy to help prevent miscommunication—the SBAR method. SBAR covers the patient’s Situation, Background, Assessment, and Recommendation. The Situation refers to what is happening at the current time. The Background is the context of the patient’s condition. Assessment reflects what you consider the problem is. Recommendation includes what needs to be done or observed, including follow-up tests.2 Situation and background reflect objective information and assessment, and recommendation represents subjective information. Because this method is designed to be redundant, if someone veers from the normal process, the receiver of the information can note the omission and ask for the information that was missed.2 The overall goal of this process is to improve patient safety and improve outcomes. The SBAR method is designed to assure error-free handoffs and enhance situational awareness. The SBAR is a structured framework for communication and highlights what requires the immediate attention of the oncoming health care provider, as well as clarifying other issues. At the same time, the improved communication fosters both teamwork among the health care team and enhances the culture of patient care. The primary purpose of the handoff is information processing. Interventions to define and standardize information are included in this function. A read-back would be an example of information process, as is SBAR. One of the concerns with information processing is data overload, so designing an SBAR to assure that essential information is relayed is a priority. Another concern with information processing is distractions, so the SBAR process should be conducted in a quiet area whenever possible.1 In summary, the SBAR handoff process promotes
Journal of PeriAnesthesia Nursing, Vol 27, No 5 (October), 2012: pp 360-362
SAFETY CORNER
interactive communication; provides current information regarding the patient’s condition, care, and treatment; and enhances the ability to have a verification process, such as repeat-backs and enables the receiver of the information to review important data with the other provider. A recent study investigated how nurses, managers, and physicians felt about the use of SBAR within the hospital setting. Although most respondents indicated that SBAR provided a means of standardized communication, many nurses felt that it helped them make intuitive decisions. Nurses also thought that the use of SBAR improved the professional image of nursing. The use of SBAR may help to minimize perceived hierarchal issues between physicians and nurses. Nurses and physicians have different communication styles. Nurses tend to communicate in a very descriptive and narrative manner, whereas physicians are more inclined to summarize and bullet-point their communications. Therefore, the use of SBAR provides a standardized approach to communicate information in a timely, effective, and efficient manner. Additionally, respondents thought that SBAR was a way to further incorporate nurses into the organization.3 For the purpose of this column, the working definition of a handoff from Patterson and Wears1 will be used: ‘‘The process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver’’ (p. 53). Following the handoff, the oncoming health care provider assumes responsibility for the patient’s care. In fact, there are two types of handoffs: patient related and provider related. Patient-related handoffs occur when the patient travels from place to place within the health care environment, for example, when the patient moves from the operating room into the postanesthesia care unit. Providerrelated handoffs occur when the patients are stationary, for example, when shift changes occur.4 Regardless of the type of handoff, the potential of error is high with handoff. One of the areas of concern is the transition from hospital or ambulatory surgery center to home. One of the main issues is pending test results at the time of discharge,
361
with many of those test results not getting reported to the patient.4 Simple interventions can be postdischarge follow-up calls, getting a discharge summary to the patient’s primary care doctor on the day of discharge and that the discharge instructions go beyond just a check box type form. Some organizations are using discharge counseling, which consists of a registered nurse who does extensive predischarge planning (averaging about 90 minutes per patient and family) to include more involvement in discharge instructions, follow-up discharge call, and then makes a fairly quick follow-up appointment with the physician. The initial results have shown a 30% decrease in readmission rates.4 While perianesthesia nurses are not involved with discharging inpatients like those in this program, it is important to consider how to best address the transitional communication needs for ambulatory patients, as tests are often pending. How are those transitions being communicated currently within your institution? As with any process, evaluation is needed. To evaluate information processing, several approaches can be used. For example, the recipient of the information can rate whether the information was relayed in an organized fashion, his or her satisfaction with handoff, or the perceived quality of the reports.1 Studies have investigated the impact of SBAR on staff perception of team communication and patient safety culture. Reporting of incidents and near misses before and after the use of SBAR is another means to evaluate the process. All of these examples can provide invaluable information on communication. Findings may reveal that hierarchal issues remain with communication among health care providers, the need for more training among staff, or poor satisfaction with the process. Overall the ability to promote clear communication through processes such as SBAR improves patient safety. Managers within organizations need to evaluate their communication process to assure effectiveness. Although progress has been made, more attention is needed in handoffs and transitions within health care. Collaboration and communication is key to improving patient safety.
362
JACQUELINE ROSS
References 1. Patterson ES, Wears RL. Patient handoffs: Standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36:52-60. 2. Hohenhaus S, Powell S, Hohenhaus JT. Enhancing patient safety during hand-offs. Am J Neurosci. 2006;106:72A-72C. 3. Vardaman JM, Cornell P, Gondo MB, Amis JM, TownsendGervis M, Thetford C. Beyond communication: The role of stan-
dardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37:88-97. 4. Wachter RM. Transition and handoff errors. In: Wachter Robert M, ed. Understanding Patient Safety, 2nd ed. China: McGraw-Hill; 2012.