Best Practices in Handover...

Best Practices in Handover Education

Chris Little, Meera Rayar, Nureen Sumar, Zia Bismilla, Trey Coffey Saturday October 25, 2014

Nous n’avons aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d’appareils médicaux ou un cabinet de communication.

We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.

Authors: Chris Little, Meera Rayar, Nureen Sumar, Zia Bismilla, Trey Coffey Date: Saturday October 25, 2014

The International Conference on Residency Education | La Conférence internationale sur la formation des résidents

Seating Instructions

Please sit according to the main clinical setting in which you work:

3

Workshop : Best Practices in Handover Education, Saturday October 25, 2014


Learning Objectives

Upon completion of the workshop, participants will be able to: Review and discuss current climate in handover

practices in Canada

Review the content and implementation of a comprehensive handover bundle in teaching hospitals in North America

Identify challenges implementing effective handover and handover education in individual programs and institutions

4



Introductions

Chris Little Meera Rayar

Nureen Sumar

Trey Coffey Zia Bismilla

5


Handover Education: Best Practices and Current Climate

Chris Little, Meera Rayar, Nureen Sumar

Your 1st Task! Working at your table

2 minute time limit

One word/Short answer style

1 answer per sticky note

Please describe:

Elements of optimal handover

Hand your sticky notes to a CAIR volunteer

Optimal Handover

Your 2nd Task! Working at your table

2 minute time limit

One word/Short answer style

1 answer per sticky note

Please describe:

Barriers to optimal handover

Hand your sticky notes to a CAIR volunteer

Barriers

Handover Education Effective patient handover is essential to ensure patient

safety and optimal medical care, however most residents in Canada do not receive formal training in this essential area.

CAIR’s 2012 position paper on Resident Duty Hours recommends “residents must be formally trained in handover skills; the ability to transfer care appropriately when going off duty.”

Development and promotion of handover education remains an area of focus within CAIR

CAIR Strategic Plan Mission: to drive excellence

in medical education as national voice of resident physicians

Strategic direction #1 Training: to optimize continuum of medical education Anticipate and provide

leadership

Foster exceptional patient-centered care

Integral part of national curriculum development

Handover Initiatives CAIR has taken a leadership role by examining and evaluating handover methods and best practices within Canada and abroad, with an emphasis on key components and barriers to teaching effective handover to residents: conducted extensive literature reviews (2010-14)

surveyed our membership (2013)

developed the CAIR Policy Statement on Handover Education in Canadian Residency Programs (2014)

New Competency in CanMEDS 2015 Framework

Handover included in physician Collaborator role Key Competency 3 states

“Physicians are able to effectively and safely transfer care to another health care professional

3.2 Demonstrate safe transfer of care, using both verbal and written communication, during patient transition to a different health care professional, setting, or stage of care.

CAIR Survey Results

CAIR National Resident Survey

Surveyed all Canadian residents outside of Quebec in the Spring of 2013

Residents were asked about:

current handover practices

handover educational methods at their training institution

perceived medical errors associated with poor handover

CAIR National Resident Survey, 2013.

Total of 1,975 Canadian residents participated

Response rate of 22.8%

Demographics


Method of Handover On average, transfer of care between residents of the patients on their

service occurred twice (mean 1.8, median 2.0) within a typical 24-hour period

The mostly commonly used main method of patient handover was face to face (82%)

4%

9%

14%

29%

30%

82%

96%

91%

87%

71%

70%

18%

Other (n=74)

Handwritten only (n=1,975)

E-mail (n=1,975)

Electronic shared document (n=1,975)

Over the phone (n=1,975)

Face to face (n=1,975)

Figure: Please select the main method you use for doing patient handovers.

Main method used Not main method used


Adverse Events Canadian residents view incomplete handover as

placing patients at risk for adverse events

Half of respondents (49%) had either witnessed (33%) or been directly involved (16%) in an adverse event that could have been prevented with more adequate handover

Surgical residents were more likely to have been involved directly (22%)


Currently, there is a lack of formal handover training in Canadian PGME programs

Most residents develop their handover skills through informal observation of senior residents or staff physicians

Handover training/education

4%

17% 11% 11%

57%

Other As part of orientation During an academichalf-day

As part of anotherformal session

Informally taught by asenior resident staff

physician

Only 17% received handover training as part of orientation, 11% during academic half-days, and a further 11% as part of another formal session

Figure: Have you received training in patient handovers in any of the following ways?


What would be most useful? There is a need for more consistent and structured approach

to handover training during residency

Residents ranked receiving feedback and one-on-one teaching as the preferred methods for improving handover skills

11%

16%

23%

27%

57%

65%

35%

33%

37%

38%

32%

26%

48%

45%

35%

30%

8%

8%

6%

6%

5%

4%

2%

2%

0% 20% 40% 60% 80% 100%

Podcast (n=1,784)

E-module courses/training (n=1,806)

Online handover models/examples (n=1,802)

Formal workshop on handovers with simulation(n=1,812)

One-on-one teaching from senior resident/attending(n=1,843)

Receiving feedback on my handover methods/skills(n=1,832)

Useful (8 to 10) 4 to 7 Not useful (1 to 3) Unsure


Today we heard…

Results from our earlier exercise identifying

Key elements of optimal handover

Barriers to optimal handover

CAIR Policy and Recommendations

CAIR policy statement

• Based on extensive lit review

• Makes 5 key recommendations to improve handover education

• Calls on residency programs to develop formal handover curriculum

5 Recommendations to improve Handover education

1) Each patient handover should incorporate direct verbal interaction between care providers. Given the complexity of the handover process, using both verbal and written communication will ensure safe and accurate transfer of patient care.

2) Handover should take place in a quiet area where distractions are minimal. Sufficient time must be allotted for the handover.


3) The handover process should employ evidence- based tools and be standardized for each clinical setting. There are a variety of mnemonics and aids that may be adapted to the particular needs of a clinical setting.

4) A formal handover curriculum should be an accreditation standard for medical education, reflecting the core competencies of the CanMEDS framework.


5) Physicians require both didactic and interactive training in handover. The interactive component is especially important, and supervised evaluation of handover should be part of the training curriculum. A senior or chief resident, faculty member, or program director should regularly observe each resident’s handover performance and provide formal feedback.

Call to Action for Improved Handover Training in PGME

“As recognition of risks associated with handovers grows, it is essential that residency programs develop formal handover curriculum that provides high-quality training to ensure patient safety and optimal care.”

“Each residency program should tailor

handover curriculum and tools to meet the unique needs of its clinical settings”

Key Elements of High Quality Handover

High quality handover: Key elements

Face-to-face, written + verbal is best

Protected time and space Quiet location Interruptions minimized

Has a leader to ensure unambiguous transfer of information and responsibility

Standardized format Articulated by program/service Incorporated into daily work via training and tools

VERBAL handover: Key elements

Structured format Begins with high-level overview

Appropriate pace

Closed-loop communication Ensures salient points ‘received’ Acts as prompt for clarifying questions

Attention to non-verbal communication

WRITTEN handover: Key elements

Supplements the verbal handover

Requires daily updates High-quality, synthesized information

- Do NOT copy and paste - Do NOT “add …add …add” without deleting

Senior/supervising resident should edit and ensure quality

The I-PASS handoff

Zia Bismilla Trey Coffey

© 2013 I-PASS Study Group/Boston Children’s Hospital. All Rights Reserved. For Permissions contact [email protected]

Computerized Handoff Tool

Communication Training

+ = Resident Handoff Bundle

Standardized Verbal Handoffs

+

Associated with a 40% reduction in serious medical errors (Starmer et al. JAMA 2013)

Resident Handoff Bundle Pilot Study

© 2011 I-PASS Study Group/Boston Children's Hospital All Rights Reserved. For Permissions contact [email protected]

From Pilot to

Multi-Centre Implementation: IIPE-PRIS Accelerating Safe Sign-outs

Study Aims To determine if handoff bundle implementation associated with:

Primary outcome A significant reduction in overall error rates and preventable adverse events

Process outcomes Improved written and verbal handoff communication

Balancing measures Impact on resident workflow


Results

Number of errors (rate per 100 patient admissions)

Pre

(n=5516 admissions)

Post (n=5571

admissions) P value

Overall rate of medical errors 24.5 18.8 <.0001

Preventable adverse events 4.7 3.3 <.0001

Near misses / non harmful medical errors 19.7 14.5 <.0001

Non-preventable Adverse Events 3.0 2.6 0.48

Mean handoff duration per patient 2.4 min 2.5 min 0.55


Results – Process Measures % of Verbal Handoffs with Element Present

* P < 0.001

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Illnessseverity

assessment

Patientsummary

To do list Contingencyplans

Readback

Pre-interventionPost-intervention

*

*

* *

*

N = 207 verbal handoff sessions, 2281 unique patient handoffs


A Complex Intervention: More than a Mnemonic

Faculty Development

“Go Live” -Training

-E-Tool

Observation and

Feedback

I. Planning/Development Stage

II. Implementation Stage

III. Reinforcement Stage


Curriculum Development and Implementation:

Guiding Principles and Key Strategies



Faculty Development Rationale

Faculty typically have never received handover training (“by osmosis”)

Without training, will struggle with teaching residents

Faculty do not need to radically change their own handover practice


Faculty Development Module

60-90 minutes • Brief intro to study • Review of I-PASS handoff techniques • Introduction to observation tools • Video simulations of handoffs to allow practice

with tools


Levels of Faculty Involvement

Faculty roles

I-PASS Workshop Leader/Facilitator Facilitate the 2-hour interactive didactic

training

Handoff Simulation Small Group Facilitators

Facilitate the hour long handoff simulations at the end of the workshop

“Live” Handoff Faculty Observers Observe live handoffs after bundle

implemented, provide feedback on faculty observation forms

“Just in Time” refreshers for rotating residents, students


Multimodal Delivery of the Curriculum

Delivery vehicles

Initial training • Didactics • Videos • Simulation • On-line module

Reinforcement • Daily reminders • Observation and feedback


Resident Handoff Workshop

1 Hr Communication Training (TeamSTEPPS)

1 Hr Handoff Training

1 Hr Small-group Simulations


Shared Mental Model


The I-PASS Mnemonic I Illness Severity

Stable, “watcher,” unstable

P Patient Summary Summary statement; events leading up to admission; hospital course; ongoing assessment, plan

A Action List To do list; specific timelines

S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen

S Synthesis by Receiver Receiver states key action items; asks questions


Handoff Simulations

Allows learners to: Practice new behaviours Gain insight into other

roles • giver vs. receiver • more worried vs. worried

Promotes skill acquisition


The Campaign

© 2013 I-PASS Study Group/Boston Children’s Hospital.

All Rights Reserved. For Permissions contact [email protected]

Reinforcement of Learning: Handoff Observation and Feedback

51

Verbal Handoff Observation Tool



Planning for Implementation


2 months 1 month 3 months 12 months

Faculty development • Handoff best practices and I-PASS mnemonic • Facilitate resident retreat and just-in-time training • Direct observation of resident handoffs

Resident curriculum • 3-hour “half-day” vs. 1 hour lunch series • Just-in-time training • Direct observations by faculty

Campaign activities

Overview


Enlisting a Critical Mass of Believers

Program director, NP/PA lead, hospitalist lead, etc.

Chief residents

Safety officer CEOs, CMOs

Quality managers Faculty willing to help!


1 month 3 months 12 months 2 months

Explore current handoff environment • Gather patient safety data • Conduct needs assessment

Garner Institutional Support • Hospital and Education Leadership • Information technology team

Secure Resources • Time, Money, Space

Implementation Checklist


1 month 3 months 12 months 2 months

Format

Trainers and facilitators

Logistics of resident coverage

Strategies to include non-physicians

Prototype of printed handoff tool for sims Prepare Packets

Implementation Checklist


Will I-PASS Stick?

Transformational change takes time

Requires sustained effort • Repeat curriculum for new learners • Continue observations, engage senior learners

as handoff teachers/coaches

Seeing impact on resident attitudes/skills as program matures is VERY REWARDING!


Better handoffs. Safer care.

All handoff materials are available at www.ipasshandoffstudy.com and MedEdPortal


http://www.ipasshandoffstudy.com/

Handover Improvement Planning Small Group Exercise

Working at your assigned tables, refer to the exercise Worksheet in your handout package

Your Task is to plan a handover improvement initiative at YOUR institution First, take a few minutes on your own to brainstorm

responses for each of the prompts/categories listed

Then report out to others at your table and discuss a common approach for your initiative

Report back to larger group



In Summary..

61


There is a clear and demonstrated need for structured handover practices and formal curriculum

Evidence from CAIR survey of residents, lit reviews, policy recommendations, today’s sticky notes


In Summary..

62


Lessons from I-PASS experience

Provide us all with suggested tools, approaches and solutions to barriers for implementing structured handover in our own programs and institutions


In Summary..

63


CAIR invites your support in the “Call for Action” to PG Deans to incorporate formal handover training into PGME curriculum

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

CAIR Policy Statement

IPASS Handouts Components of curriculum

Observation tool

Example of SIM

Workbook (see display table)

Key Elements of quality handover

Suggested reading list

Thank

You!

Any questions? Take Aways

mailto:[email protected]

• Download the ICRE App,

• Visit the evaluation area in Pre-function Hall B, near Registration, or

• Go to: http://www.royalcollege.ca/ icreevaluations to complete the session evaluation.

• Téléchargez l’application de la CIFR

• Visitez la zone d’évaluation, au vestibule de la salle B, près du kiosque d’inscription, ou

• Visitez le http://www.collegeroyal .ca/evaluationscifr afin de remplir une évaluation de la séance.

You could be entered to win 1 of 3

$100 gift cards.

Vous courrez la chance de gagner l’un des trois chèques-cadeaux

d’une valeur de 100 $.

Help us improve. Your input matters.

Aidons-nous à nous améliorer. Votre opinion compte.

http://www.royalcollege.ca/icreevaluations

http://www.royalcollege.ca/icreevaluations

http://www/collegeroyal.ca/evaluationscifr

http://www/collegeroyal.ca/evaluationscifr

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