May 2010 Volume 34 No. 5

April Highlights of Performance Improvement at SHC
-Quality Improvement and Patient Safety
Committee [QIPSC]–

Joseph Hopkins, Senior Medical Director of Quality, chair

Moving patients from one environment to another is always a challenge. And I’m not talking about the obvious — and usually well-handled — choreography using wheelchairs, gurneys, ambulances or helicopters.

We currently have two crucial initiatives at our hospital involving movement of patients from the care of one team (or system) to another. A patient Transfer Task Force is addressing the challenges when we receive patients from another institution under our transfer program. This publication, in February, already introduced a second initiative, the Hand-off Communication Project: [see article >>]

Both of these projects involve fine-tuning communication, often the most serious challenge that any otherwise highly qualified professional faces. And more specifically, both of these projects include elements that ill-informed skeptics could falsely label as “cookbook medicine.” That’s because both projects require rules to be set and then for necessary steps to be standardized, albeit with built-in flexibility. The success of both projects will depend on the cooperation of everyone responsible for moving patients so that crucial information is available for important decisions in real time.

The goals of the Patient Transfer Task Force, led on the physician side by Stephen Ruoss, medical director of the Stanford Transfer Center, is to standardize a defined process to accept patients using guidelines, notably clinical criteria appropriate to each service. Processes are currently being defined for the 11 services initially affected.

The project mandates that only attending physicians may accept transfer patients using the criteria established for each service, but it empowers appropriate RNs to respond flexibly to patient and institutional changes during the process to make transfers and bed allocations work. Also required is that the accepting MD — it must be an attending and not a resident — must directly handoff the patient to the admitting MD.

In my mind this effort to improve the intake of patients into our hospital fulfills some critical evidence-based processes. Put simply, the buck stops at the individuals most knowledgeable and directly responsible for the patient. It gives flexibility and responsibility to other members of the team, notably experienced nurses, and it sets up criteria with enough flexibility to allow caregivers to do the right things without the inefficiencies of needless ambiguity — often caused by making assumptions.

The hand-off project was designed to reduce the mean number of defects in both nurse and physician hand-off communication when patients are transferred from intensive care (E2ICU and NICU) to intermediate intensive care units (B2 and B3).

This project is about to move from planning stage to implementation. One of the findings of this effort is that physicians and sometimes nurses didn’t provide adequate formal information via the electronic medical record (EPIC) when they sent patients to stepdown units. So as you probably have anticipated, a next implementation step is to standardize the process and the written forms used for handoff to accomplish the all-too-obvious goal of making sure that staff members receiving a patient will have all the information they need. A primary recommendation in the planning stage was creation of a standardized MD “Transfer Note” completed in Epic and used to guide verbal communication handoff. Another quick win solution is to use verbal communication AND standardized handoff templates for nursing handoffs.

Overall this project calls for creation of a formal communication plan before pilot implementation in June. One key issue is to overcome the expectation gap between what the receiving unit needs and what the sending unit thinks it needs.

Smoothing patient flow in both project scenarios sounds simple enough, but it’s easy to understand obstacles when you take into account some common barriers: ego, misunderstandings about the way others do THEIR jobs, and time pressures that at times can shriek, “your not my patient anymore and I have others to take care of.” But we should not be defensive about the need for checklists. There is strong evidence-based data that they work.

Are we moving toward “cookbook medicine”? Not when you ensure people have the information they need, give responsibility to appropriate people for making decisions, and then build in the flexibility needed to ensure that decisions and actions are based on solid premises that account for exceptions.

I’d like to close this month with some really great news, again from the world of evidence-based metrics. Our Core Measures Quarterly Composite survey showed zero defects for a two-week period in three diagnostic groups/projects — acute myocardial infarction, heart failure and the Surgical Care Improvement Project. And pneumonia wasn’t far behind at 95 percent. Is that perfect medicine? It certainly beats a lower score.