Better handoffs. Safer care.
Just -in-time Module
Root Causes of Sentinel Events
Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type
(2004 - Third Quarter 2011)1
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TeamSTEPPSTM
Team Strategies and Tools to Enhance Performance and Patient Safety
Evidence-based team training curriculum
High performing teams
• Must have effective leaders
• Use structured communication strategies
• Develop situational awareness
• Provide mutual support
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Building a Shared Mental Model
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When Mental Models are Not Shared
Example: When your child takes the bus home and you thought the plan was to pick him up at school
Photo courtesy of H. Michael Miley/Wikimedia Commons
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Cross Monitoring
‘Watch each other’s back’
Monitor actions of team members
Help others maintain Situation Awareness
Briefs and Debriefs
Briefs
Debriefs
End of shift
Clear communication?
Roles understood?
Situation awareness?
Work load ok?
Assistance offered?
Errors?
Feedback?
Beginning of shift
Team Members?
Goals understood?
Roles and responsibilities?
Plan of Care?
Staff Availability?
Workload?
Resources
Huddle
Opportunity to express concerns
Anticipate outcomes and talk about contingency plans
Assign Resources
Come to Consensus
Check-Back
Putting it all togetherUsing TeamSTEPPS in Handoffs
Cross MonitoringNight team recognizes medication error during handoff and informs the day teamBriefNight team goes over action list and divides tasks and new admits and plans for time to regroupDebriefIn the morning, the night team and day team discuss what went well with the handoff and items the night team would have liked to know HuddleA patient is unstable, the day and night team examines the patient together and discusses plans for the night with the nurseCheck-BackThe intern obtains new information to add to the hand off from the senior resident, this information is repeated by the intern to confirm communication
Essentials of Team Function
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Communication and Teamwork come together in HANDOFFS!
Effective Handoffs
Leader, assigned roles
Unambiguous transfer of responsibility
Protected time and space
Standardized format
Up-to-date, accurate, relevant information
Awareness of participants’
• Learning styles• Knowledge of patients
• Level of training•Clinical experience
Creation of a shared mental model through active participation of receiver
Effective Verbal Handoffs
Face-to-face
Structured format, beginning with high-level overview
Appropriate pace
Closed-loop communication shared mental model
The Printed Handoff Document
Supplements the verbal handoff
• Allows receiver to follow along
• Provides more comprehensive information
Succinct, specific, accurate, up to date
Senior/supervising resident should edit and ensure quality
• Incorporate time for review and update into daily workflow
The I-PASS Mnemonic
I Illness SeverityStable, “Watcher,” Unstable
P Patient Summary
Summary statement; events leading up to admission;
hospital course; assessment; plan
A Action List
To do list; timeline and ownership
S Situation Awareness & Contingency Planning
Know what’s going on; plan for what might happen
S Synthesis by Receiver
Receiver summarizes what was heard, asks
questions; restates key action/to do items
Illness SeverityA Continuum
Watcher : any clinician’s “gut feeling” that a patient is at risk of deterioration or “close to the edge”
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P = Patient Summary
Describes succinctly:
• Reason for admission (summary statement)
• Events leading up to admission
• Hospital course
• Ongoing Assessment
• Plan for hospitalization
Is concise, utilizes semantic qualifiers, focuses on active issues
P = Patient Summary It’s flexible, as long as it’s complete!
Problem/Dx # 2
•Ongoing Assessment
•Plan
Problem/Dx # 1
•Ongoing Assessment
•Plan
A = Action List
To do list
Includes specific elements:
• Timeline
• Level of priority
• Clearly-assigned responsibility
• Indication of completion
Needs to be up-to-date
If no action items anticipated, clearly specify “nothing to do”
S = Situation Awareness & Contingency Planning
Team level
Patient level
“Know what is going on around you”
• Status of patients
• Team members
• Environment
“Know what’s going on with your patient”
• Status of patient’s disease process
• Team members’ role in this patient’s care
• Environmental factors
• Progress toward goals of hospitalization
S = Situation Awareness & Contingency Planning
Effective Contingency Planning
Identify concerns
Articulate what might go wrong
Define the plan
• List interventions that have/have not worked
• Identify resources for assistance
For stable patients: “I don’t anticipate anything will go wrong.”
S = Synthesis by Receiver
Brief re-statement of essential information in a cogent summary
• Demonstrates information is received and understood
Opportunity for receiver to
• Clarify elements of handoff
• Have an active role in handoff process
Remember, TeamSTEPPSTM elements and effective handoffs go hand-in-hand
Handoff is a Team Sport!The whole is greater than the sum of the parts
Team handoff is the “gold standard”
• Very few programs achieve this
If team handoff is not possible, do a BRIEF!
• Intern and Senior plan for the night
• Agree on roles, identify holes
• Illness severity should be verified for all patients
– Unstable patients should be reviewed in detail and examined together
• PGY1 should do another read-back and verify
Handoffs At Our HospitalAre we meeting the gold standard?
Where do we do handoffs?
• Is this a quiet place with minimal interruptions?
When do we do handoffs?
• Is it at a scheduled time?
Who is present for handoffs?
• Do we need an intern/senior brief?
• When/where?
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Now You’re Ready for an I-PASS Handoff!
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Editors
Lead Editor: Glenn Rosenbluth MD
Additional Editors: April D. Allen MPA, MA, Lauren Destino MD, Jennifer Everhart MD, Shilpa J. Patel MD, Theodore C. SectishMD, Nancy D. Spector MD, Amy J. StarmerMD, Lisa Tse
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