February 2010 Volume 34 No. 2

Third-year medicine resident Chris Woo, left, hospitalist Pat Gibbons, and Nerissa Del Rosario, an assistant patient care manager on B3, use Epic to review care plans of patients transferred from ICUs to intermediate ICUs. While caregivers rely on computer data for information on patients, personal communication among team members is crucial and is the focus of a clinical initiative at SHC.

Show me the metrics…
At Summit, team was already on the climb

How many steps does it take for a physician or nurse to hand-off a patient from intensive care to an intermediate ICU?

Faculty Hospitalist Patrick Gibbons and Nancy Szaflarski, quality outcomes program director, can answer that question definitively: They’ve been studying the complex process of hand-off communication since September.

The overall goal of the SHC communications project is to improve hand-off communication associated with transitions of care on inpatient units. The downstream consequences of poor hand-offs may impact patient safety, medication reconciliation, clinical inefficiencies (such as callbacks and rework loops) and redundancy, explained Szaflarski, who holds a PhD in nursing.

Gibbons and Szaflarski noted that the hand-off project, already two months in the planning, was embraced as one of the eight initiatives launched after last November's Annual SUMC Summit for Clinical Excellence. The conference focused on provider-to-provider healthcare communication.

At the day-long Summit, physicians in small groups brainstormed with other professionals to produce one-page action plans that were submitted for vetting and approval to Chief of Staff Bryan D. Bohman and Kim Pardini-Kiely, vice president for quality and effectiveness. The eight initiatives accepted in succeeding weeks included several that were new, but the Hand-off Communication Project sponsored by the Joint Commission Center for Transforming Healthcare and involving 10 healthcare organizations, had already been accepted as one of SHC’s 2010 Strategic Clinical Initiatives. (See list of projects below).

So … how many steps does it take to hand-off a patient? “Thirty-eight,” said Gibbons. “And knowing that kind of detail is the philosophy behind how the program is run.”

Traditionally, improvement projects were spurred by the mantra, “‘Here’s a problem let’s fix it’, but we were determined not to jump to conclusions and initiate changes before we had frontline nurses and residents sit down together and critically examine the entire complex process,” Szaflarski said.

“We’re defining, analyzing the process, determining what occurs for nurses and physicians, then identifying which are the problematic steps,” said Gibbons, a recent medicine chief resident now clinical assistant professor. He’s also associate medical director for quality in the Department of Medicine, where he mentors a quality improvement elective for housestaff.

The Joint Commission Center’s project methodology, Six Sigma, is based on a model first adopted by Motorola Inc. to improve assembly line production and has since been adopted by health care organizations and companies, including General Electric and some SHC peer institutions. It’s a disciplined, data-driven approach and methodology for eliminating defects.

Six Sigma expert Marlena Kuruvilla, assistant director for process excellence, is the third team leader working in close collaboration with Gibbons and Szaflarski, and notably, with physicians, nurses, other caregivers and managers who work on the units that are part of the project.

The baseline survey to assess clinician satisfaction with hand-offs will be completed in February and will serve to define focused improvements , Szaflaski said. By mid-June, Szaflarski said the team will have an action plan defined and ready to be implemented in the East and North ICUs and B-2 and B-3.

What has the team learned so far? While Szaflarski, Gibbons, and Kuruvilla, are hesitant to discuss results before the process analysis is finished, they are willing to make a few observations:

Universal themes are emerging from the 10 hospitals, which include peer institutions such as Johns Hopkins, the Mayo Clinic, Massachusetts General Hospital, and Kaiser. Common issues should help ensure a national team approach to develop and disseminate solutions widely.

Senders (ICU nurse or physician) and receivers (intermediate ICU caregivers) have varying expectations for hand-offs. “Research on hand-offs is just beginning to elucidate that individuals have different mental models about hand-offs which can affect their perceptions and satisfaction levels”, said Szaflarski.

The quality of hand-offs can be improved when senders and receivers have the opportunity to interact with each other and ask questions, which is a key 2010 Joint Commission standard.

For questions, contact Szaflarski nszaflarski@stanfordmed.org or Gibbons, pgibbons@stanford.edu.

Team Communication Initiatives

Here are additional projects currently being developed from workshops at November’s Summit on Clinical Excellence, which focused on team communications:

Cancer Center Communication Project to facilitate communication between clinics and the infusion treatment area to reduce wait times.

Expand and improve the communication protocol SBAR (Situation, Background, Assessment and Recommendation) to include paging and texting, especially during patient transfers.

Ensure effective use of SBAR in CCU and CSU.

Ensure hand-off of patients from OR to ICU, an extension of programs already adopted by the Department of Surgery and SHC.

Ensure that all Emergency Department transfers to inpatient units will have appropriate isolation precautions and that community physicians will be notified of their patients’ status in ED.

Modify and implement the World Health Organization’s surgical checklist in the Cath-Angio lab.

Promote a methodology called “Huddles” to improve communication within outpatient clinics.