• July 2008 FEATURE ARTICLES •
Patient Safety: Case History
The Bermuda Triangle of Healthcare
An Illinois healthcare system closes the gaps in patient handoff communication.
By Robert S. White, M.D., and David M. Hall, M.D.
When you hear "Bermuda Triangle" what comes to
mind? Fear and confusion as planes and ships seem to disappear
without a trace? It’s a mysterious and unsettling image. What’s
more unsettling is that an activity that takes place thousands
of times each day in healthcare organizations — handing over
care of a patient to a new caregiver or location — has come to
be known as the Bermuda Triangle of Healthcare. Various sources
identify this step as the cause of a large portion of mistakes
and oversights that result in harm to patients. Whether the
mistake is giving a patient a dose of a drug already given on
the previous shift, or an oversight that leads to intubation of
a patient with a "Do Not Resuscitate" order, it’s easy to
imagine the many ways faulty handoff communication can lead to
disastrous results.
In light of the well-documented problems, the
Joint Commission made handoff communication the subject of its
National Patient Safety Goal Requirement 2E. Now it’s up to
organizations like ours — OSF HealthCare System based in Peoria,
Ill. — to wrestle with how to improve this fundamental activity
without making patient care more complex or cumbersome.
OSF HealthCare is owned and operated by The
Sisters of the Third Order of St. Francis, Peoria, Ill., and
includes seven acute care facilities, one long-term care
facility, two colleges of nursing, the philanthropic OSF
HealthCare Foundation and other healthcare related businesses.
It also has a primary care physician network consisting of 194
physicians and 48 mid-level providers known as OSF Medical
Group.
Bringing Handoffs Into Focus
In early 2006, OSF took aim at improving
handoff communication as part of an enterprisewide patient
safety push. As the authors of "Internal Bleeding: The Truth
Behind America’s Terrifying Epidemic of Medical Mistakes"
concluded in their book, faulty systems, not bad people, are
responsible for medical errors. With that in mind, we focused on
facilitating the underlying process for handoff communication,
which we believed to be the key to improving patient safety
overall.
We started by bringing together a highly
collaborative, multi-disciplinary group that included nurses,
patient safety officers, physicians, IT specialists and
corporate executives from our six acute care facilities. Using
Six Sigma principles, our charge was to create a standard
process and format for handoffs, and determine how best to
support the process electronically.
OSF uses the GE Centricity Enterprise
clinical information system. Having a clinical system in place
gave us the advantage of having critical patient information
available. However, we needed additional tools to bring the
information together in a format that supported our handoff
process. We looked to our GE alliance partner (The Menon Group
Inc.) to provide an application that would augment the
capabilities of our clinical system.
According to Kathy Haig, RN, OSF corporate
patient safety officer, the previous non-standardized handoff
communications model meant that, enterprisewide, nurses had
their own unique routines that worked for them. Additionally, a
non-standardized framework left the information included in the
handoff up to each person, which was based on individual
assumptions about what the next caregiver needed to know.
The new caregiver also had to anticipate any
questions that might arise before the departing caregiver left
their shift.
Recognizing those inherent gaps, we soon
settled on the SBAR communication model. SBAR — Situation,
Background, Assessment and Recommendation — has been adapted
from a process used to quickly brief nuclear submarine
commanders during a change in command. We found this model to be
a good framework for a concise yet thorough approach to patient
handoffs.
One of the biggest challenges was to define
content such that we didn’t regurgitate what is already
contained in the online patient record. The intent was to
distill the essential elements into a one-page-per-patient
format that puts a rigorous structure around the SBAR model. At
the same time, if a nurse needs additional information for a
patient, it is readily available online.
Distilling those essential elements presented
challenges as well. For example, it was fairly straightforward
to pick the top few lab values, but the last few were in a grey
zone. We needed feedback from actual use.
"This group was willing to experiment with
the prototypes," says Cathy Smithson, RN, vice president and
chief nursing officer for OSF St. Mary Medical Center,
explaining how we enlisted a group of ICU nurses. "They tried
them out and worked through the pros and cons to give us the
feedback we needed to refine our form."
As a parallel process, we had to make sure
that the electronic handoff report would become an integral part
of the workflow. With that in mind, our Six Sigma team studied
the workflow and found it to be a 12-step process. By utilizing
the new electronic report, they found that we would eliminate
the need to gather information from the patient’s chart and
write it down. This enabled us to condense the process down to
eight steps. At the same time, it would support a standard
communication between caregivers.
Throughout the process, we worked closely
with The Menon Group to create the electronic handoff report.
With discussion and compromise, we arrived at consensus for the
specific data needed from the electronic record and the format
of the SBAR handoff. The application was designed to pull the
data directly from our clinical system and place it in the SBAR
handoff format. The new report could be used either online or in
print.
Handoff Report Rollout
We began the application rollout in March
2007 with a pilot unit. Based on that pilot, we made some
additional adjustments to the application before making it
available enterprisewide. Each facility planned their user
education and rollout according to their environment. We found
that although our staff could use the report online, most
preferred to print it for each of their patients in preparation
for shift report or other handoff situations.
According to Kelly Anderson, OSF team lead
for clinical development and clinical decision support, use of
the handoff report grew steadily over the first year. By the end
of 2007, caregivers across six OSF facilities were creating an
average of more than 66,000 handoff reports per month. By the
end of March 2008, they were creating more than 85,000 reports
per month. Word around our facilities was that the handoff
report was faster, cleaner and more complete. According to
Smithson, we have nearly 95 percent compliance with use of the
electronic handoff at OSF St. Mary Medical Center.
Just as telling, are the results of a time
study conducted at one of our facilities. Before implementation,
patient handoffs took an average of 8.7 minutes. Post
implementation, similar handoffs averaged only 4.1 minutes.
Conservatively, if nurses complete two handoffs per shift for
each of five patients, this translates to a potential savings of
about 45 minutes per nurse per shift.
Our recent Joint Commission survey validated
our results further. "Our staff used the report when discussing
patients with The Joint Commission surveyors," says Smithson.
"The handoff report has been a great validation of communication
and the use of SBAR. Because the electronic tool was developed
in that format, it keeps those communication points in
everyone’s mind."
Lessons Learned
For OSF, there were two key elements that
were critical to making this project a success. First, we had
active participation and support of the leadership of the
corporation as well as the individual facilities. Just as
important, nursing drove the format and content, as they would
be the primary users. Put the two together and you have an
environment where collaboration and concrete changes can occur.
As physicians responsible for implementing IT
solutions within our organization, we have found that as long as
we continue to seek to understand the workflow of our clinical
staff — particularly the painful parts — we can continue to
imagine solutions that will help.
Taking imagination to implementation takes us
back to one of the conclusions of the book "Internal Bleeding,"
which states that faulty processes are the central cause of
errors. By and large, the people in healthcare organizations —
from the clinicians who care directly for patients through the
executive leadership — want what is good for the patients in
their care. With that higher purpose in focus, wide-scale change
that helps rather than hinders the work of caregivers across
large, complex organizations is possible.
Robert S. White (left), M.D., FAAFP, is the
chief medical officer of clinical informatics and David M. Hall,
M.D., FAAP, is a physician informatics specialist for OSF
HealthCare System. Contact them at
robert.white@osfhealthcare.org or
david.hall@osfhealthcare.org.