A Culture of Patient Safety: Crucial Communication by Gayle Thompson Smillie, CRA, RT

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A Culture of Patient Safety: Crucial Communication By Gayle Thompson Smillie, CRA, RT

In 2006, The Joint Commission identified When WHC applied for and was awarded the AHRA and handoff communication as essential to keeping patients safe within the hospital Toshiba America Medical Systems, Inc. Putting Patients First environment.1 Yet ineffective communication is the most frequently cited category grant, the subsequent funding was used to host a conference. of root causes of sentinel events. National Patient Safety Goal (NPSG) 2E requires that a standardized approach to handoff America Medical Systems, Inc. Putting The Meaning of a Culture of Safety communication be implemented, the goal Patients First grant, the subsequent funding The first speaker was Stephen Schenkel, MD, being to increase effectiveness, reduce was used to host a conference in November chief of emergency medicine at Mercy Med- error, and improve patient safety. Washing- 2009 titled, “A Culture of Patient Safety: ical Center in Baltimore, MD and assistant ton Hospital Center (WHC) in Washing- Crucial Communication.” professor of emergency medicine at the Uni- ton, DC has focused a lot of effort on The conference presented three lec- versity of Maryland School of Medicine. Dr. improving handoff communication. Other tures discussing safety related topics: Schenkel spoke about the definition of cul- industries (eg, NASA, the nuclear power • “Culture Eats Strategy for Lunch: ture, which is based on actions, attitudes, industry, and transportation dispatch cen- Uncovering What We Mean By a Cul- beliefs, and traditions. Culture forms the ters) have developed a strategic framework ture of Safety” foundation of any patient safety structure. for handoffs: • “Patient Handoffs: Critical to Safety and Different strategies, projects, and objectives • Standardized face-to-face verbal com- Learning” can affect institutional culture in ways that munication with opportunity for ques- • “The Washington Hospital Center Expe- may advance or challenge patient safety. tions is supported by evidence and rience: It’s All About Keeping the Patient Dr. Schenkel presented several case stud- expert opinion to be best practice. Safe” ies and evaluated how various interventions interact with an institution’s culture and • A one-size-fits-all approach will not The objectives of the conference were to: work. The handoff should be tailored to address the challenges to sustaining a culture the users, the environment (ED, ICU, • Illustrate basic and subtle meanings of a of safety. One example highlighted the way radiology, etc), and the type of patient. culture of safety in which miscommunication can have • Reduce variation. • Evaluate interactions within institutions adverse affects on patients. An ED patient • Highlight that the handoff is the transfer that create challenges to sustaining a cul- who had an abdominal CT began complain- of professional responsibility. ture of safety ing of a headache. The ED physician ordered • Describe a model for developing com- a head CT. Later, when the physician An interdisciplinary handoff communi- munication protocols and evaluation returned to see the patient, he called CT for cations committee has been actively working methods the results. He asked, “How did the CT on safety improvements at WHC since early • Share real world experiences related to look?”and CT answered that is was negative. 2007. Accordingly, when WHC applied for handoff communications within the CT was relaying the results of the abdominal and was awarded the AHRA and Toshiba hospital setting CT, but the physician was referring to the

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head CT. Within the hospital, we all live in handoffs) function as a transient workforce. representatives from physicians, nursing, relative worlds, where even language is dif- The turnover every year makes system radiology, respiratory medicine, CT, patient ferent. The word “stable” means very differ- improvements difficult to sustain. transport, and telemetry. A brief history of ent things to radiology versus the ED versus In 2005, the University of Chicago efforts to sustain a culture of patient safety an ICU. Dr. Schenkel also presented recent developed a model for dissemination and was discussed, which included the develop- patient safety literature as it relates to a cul- training for effective handoff communica- ment of a handoff checklist form. Handoffs ture of safety. He stated the importance of tion. The model uses 2 principles: occur between physicians, nurses to physi- measuring a culture of safety and recom- cians, residents to residents, shifts to shifts, mended a blameless reporting system for • Principle 1: Handoffs are discipline spe- and nursing to ancillary departments. incident or occurrence reports. Encourage cific and organization specific. In January 2007, WHC’s interdiscipli- people to report in what must be a non • Principle 2: Standardization is the core nary handoff communications committee punitive system. goal for both handoff process and was formed and charged with developing a content. standardized handoff protocol and to cre- Sustaining Standard Handoff Models ate a form to facilitate the process. A litera- Situation, Background, Assessment, ture search assisted the group to identify The second lecture was presented by Vineet and Recommendation (SBAR) is a nation- best practices, in which two articles excelled Arora, MD, assistant professor of medicine, ally recognized model for standardizing in fostering the creation of the form.4,5 internal medicine residency at the Univer- handoff communication, originating in In 2006, the hospital implemented sity of Chicago, and assistant dean at the the United States Navy, and used by Kaiser SBAR as the handoff model for use by Pritzker School of Medicine. Dr. Arora’s Permanente to improve nurse to physician nurses and physicians. The handoff check- lecture was titled,“Patient Handoffs: Criti- communication. In order to evaluate the list form (Figure 1) was then developed cal to Safety and Learning.” She observed handoff communication process, Dr. using the SBAR format, and assigned a that, for most industries that operate 24/7, Arora recommends process mapping to travel status to the patient as green, yellow, the exchange of information that occurs identify every step and opportunity for or red. Green means the patient is safe to during shift change is critical for maintain- improvement.3 Information technology travel, yellow signals the department to ing continuity and safety in the workplace. (IT) alone can help handoffs, but cannot expedite the patient, and red means that a The complexity of the handoff process substitute for a successful act of commu- nurse must accompany the patient. Educa- presents a “vulnerable gap” in patient care nication. Structural templates and check- tion and re-education is ongoing. It is that can result in errors, near misses, and lists also help, but are not the total answer. important for staff to understand that it’s adverse patient events. Consequently, hand- In her endeavors at the University of not about filling out the form, it’s about offs have become a focus of worldwide Chicago, Dr. Arora lists the following les- keeping the patient safe. One ICU attend- patient safety improvement efforts. The sons learned: ing physician calls it “cocooning” the World Health Organization (WHO) listed patient. However, the form is useful only if 1. Institutional endorsement by leaders is “communication during patient care han- it aids critical thinking skills and begs the necessary to make the change part of dovers” as one of its High 5 Patient Safety question,“Is my patient safe to travel?” the culture. Initiatives.2 What started in 2006 as The Additionally, a variety of initiatives have 2. Although compliance is a strong lever, Joint Commission’s NPSG 2E to develop a resulted from handoff improvement efforts, it can also undermine participants’ standardized approach to handoff commu- including installation of direct phone lines recognition that the improvement is nications has now become part of the Pro- from ancillary areas to telemetry, education important. vision of Care Standard. regarding the speed at which e-tanks of O2 3. A one size fits all approach will not The goal is particularly challenging for empty, and patient transporters’ refusal to work; to achieve sustained change, one academic teaching hospitals that train resi- transport without the handoff form. The needs to tailor the intervention to the dents in maintaining the enthusiasm of the handoff form identifies patient vulnerabili- local environment. initial effort. The handoff process is highly ties for the receiving caregiver. This essential 4. Determine appropriate measurement variable and discipline specific. Medical information is helping us sustain a culture to be used in the monitoring effort and trainees receive little or no formal training of patient safety. plan for the resources necessary for or education about communication dur- monitoring. ing handoffs. Also, as academic teaching Conclusion hospitals continue to adopt systems to The WHC Experience ensure resident duty-hour restrictions are The conference was attended by a cross- met, an increased focus on the integrity of The third presentation was an interdis- section of disciplines, including nursing, the handoff is crucial to patient safety. Resi- ciplinary panel discussion of real world residents, fellows, radiology techs, radiology dents (especially interns who do the bulk of experiences at WHC. The panel had students, transporters, respiratory therapy,

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Figure 1 • Handoff checklist form.

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Figure 1 • Handoff checklist form (continued).

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and physicians. The attendees appreciated References 5 Corcoran R, Ford-Weaver C, Mueller J, Ward the interactive structure the speakers uti- 1 Vineet A and Johnson J. A Model for Building M. Red Light/Green Light: Who Transports lized. There was a lively question and a Standardized Hand-Off Protocol. Joint the Patient? American Association of Critical answer period for the WHC interdiscipli- Commission Journal on Quality and Patient Care Nurses. May 2004. Available at: http:// nary panel. In WHC’s experience, while Safety. November 2006; 32:11. classic.aacn.org/AACN/NTIPoster.nsf/vwdoc/ this handoff model is generalized, frontline 2 World Health Organization. Action on Patient 2004CSMWard?opendocument. Accessed: Safety: High 5s. Available at: http://www.who. February 12, 2010. buy-in is very important. Engaging people 6 int/patientsafety/events/07/01_11_2007/en/ Kaiser Permanente of Colorado. SBAR Tech- during process improvement initiatives nique for Communication: A Situational and the ongoing monitoring process will index.html. Accessed February 12, 2010. 3 Arora V and Johnson J. Spreading and Sustain- Briefing Model. Available at: http://www.ihi. have more positive results. The bottom ing Use of Standardized Handoff Protocols org/IHI/Topics/PatientSafety/SafetyGeneral/ line: it’s all about keeping the patient safe. for Residency Training. In: Implementing Tools/SBARTechniquefor Communication We would like to acknowledge and thank and Sustaining Improvement in Health Care. ASituationalBriefingModel.htm. Accessed AHRA and Toshiba Medical Systems for Oakbrook Terrace, IL: The Joint Commis- April 23, 2008. the funding to support this program. The sion; 2008. grant enabled us to offer a forum to share 4 UHC best practice recommendation: patient Gayle Thompson Smillie,CRA,RT is director of radiology at Washington Hospital Center in handoff communication white paper. Uni- best practices within WHC and with our Washington,DC.She can be reached at area colleagues. We also thank Dr. Arora versity HealthSystem Consortium; May [email protected]. and Dr. Schenkel for their input, recom- 2006. mendations, and expertise.

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