Exempla Lutheran & Joint Commission to Develop More Effective Communications Between Caregivers
October 28, 2010
JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE
TO DEVELOP EFFECTIVE COMMUNICATIONS BETWEEN CAREGIVERS
(Denver, October 21, 2010) - Exempla Lutheran Medical Center is one of 10 leading hospitals and health systems in the U.S. to team with the Joint Commission Center for Transforming Healthcare and use new methods to find the causes of and develop targeted solutions to hand-off communication failures which are at the root of an estimated 80 percent of serious medical errors.
Health care organizations have long struggled with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another. A hand-off process involves "senders," the caregivers transmitting patient information and releasing the care of the patient to the next clinician, and "receivers," the caregivers who accept the patient information and care of the patient.
Recognizing that this is a critical patient safety issue, the Center, Exempla Lutheran Medical Center and the other participating hospitals and health systems set out to solve the problems through the application of Robust Process Improvement™ tools. RPI is a fact-based, systematic, and data-driven problem-solving methodology that allows project teams to discover specific risk points and contributing factors, and then develop and implement solutions targeted to those factors to increase overall patient safety and health care quality.
"Patients expect and deserve safe care. That's why Exempla Lutheran Medical Center is proud to be a part of the Center's work to end preventable breakdowns in communication during the hand-off process," says Grant Wicklund, president and CEO of Exempla Lutheran Medical Center.
The Hand-off Communications Project began in August 2009. During the measure phase of the project, the participating hospitals found that, on average, more than 37 percent of the time hand-offs were defective and didn't allow the receiver to safely care for the patient. Additionally, 21 percent of the time senders were dissatisfied with the quality of the hand-off. Using solutions targeted to the specific causes of an inadequate hand-off, participating organizations that fully implemented the solutions achieved an average 52 percent reduction in defective hand-offs.
Barriers to effective hand-offs experienced by receivers include incomplete information, lack of opportunity to discuss the hand-off, and no hand-off occurred. Senders identified too many delays, receiver not returning a call, or receiver being too busy to take a report as reasons for hand-off failures.
The targeted hand-off solutions from the Center, which are described using the acronym SHARE, address the specific causes of unsuccessful hand-offs. SHARE refers to:
· Standardize critical content, which includes providing details of the patient's history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
· Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
· Allow opportunity to ask questions, which includes using critical thinking skills when discussing a patient's case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
· Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
· Educate and coach includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.
In addition to Exempla Lutheran Medical Center, other hospitals participating in the Center's hand-off project are:
· Fairview Health Services, Minneapolis, Minnesota
· Intermountain Healthcare LDS Hospital, Salt Lake City, Utah
· Kaiser Permanente Sunnyside Medical Center, Clackamas, Oregon
· The Johns Hopkins Hospital, Baltimore, Maryland
· Mayo Clinic Saint Mary's Hospital, Rochester, Minnesota
· New York-Presbyterian Hospital, New York
· North Shore-LIJ Health System Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
· Partners HealthCare, Massachusetts General Hospital, Boston
· Stanford Hospital & Clinics, Palo Alto, California
The targeted solutions developed by these pioneering hospitals will be shared with the more than 18,000 health care organizations accredited by The Joint Commission. For more information about the Joint Commission Center for Transforming Healthcare visit www.centerfortransforminghealthcare.org.