ISHAPED: Developing a Patient-Centered Approach to Handoffs

Develop and implement a patient-centered change of shift handoff Always Event® and education program for nurses with input from patient and families. Patients will always be included in the ISHAPED change of shift bedside report (handoff) process.• Assess perceptions regarding the ISHAPED bedside handoff

process • Use the patient feedback to optimize patient-centered-bedside

handoff process• Developeducationmodulesonhowtoconductpatient-centered

bedside handoff

Aim Statement Context

Lessons Learned

TeamsResearch Team Mary Ann FriesenKaren SperoniAnna HerbstJackieWaveletCynthia EarleyKarenHicksSigrid ButlerBarbara SliversJeannine Turner Anne Hooper James Robinson Joseph Snipp

Education Team Anna Herbst ( Team Lead) Mary Ann Friesen

JackieWaveletAshaRodriguezAngela ServidioDavid Andrews RobinJacksonAnne Doyle

Patient/Family Advisory Council George Lesmes John Morison John PfeifferEleanor Lindeman Elizabeth(Betsy)GaleotaLesOakes

Parent Advisory Council Kristen BendienTom Bendien

Ann CrowderKymberly DeLoatcheJerry JohnsonSandy JohnsonAngelaLozanoLes Touart

Performance Improvement Team AshaRodriguezMary Ann Friesen Stefanie Lescallett Mary Dixon

Clinical Documentation Project TeamChristineCzajkowskiRobinJackson

Kaizen Lean TeamsAnn MinerDarryl HamptonAlice Penn RitterBarbara Harrison,April PetersonCherylSchmitz,FreddiBrubakerKristyWeirskySkipReeceAngela ServidioJoan ManningKen LeesonVickieBamseyNigel BrownKhristina CagayatShirley CahillFrances Collins

OkeyHendrickRachel Lewis-BaylissSeasonMajorsSusanPeldo-MetzlerApril Hardy PetersonAngela ServidioTammy TurnerRobertWatsonMonicaWork

Education TeamMary Anne LeitchJulie PierceJoannaAnukamGloria BoatengLizSakallarisKatieKostkaNina Mosquera

PaulaBlackwellMary SmeillJamieUlrichAshleyRenkesKimGolanskyJessy CartledgeElaine AlexanderMarta LamasKadi JollohAshley MatthewsSonia Astle CherylSchmitzRobinJackson

Acknowledgments: MaureenSwickCNE/SVP,Quality Leadership, Chief Nurses Executives, Patient Care Directors, Inova Nurses

Mary Ann Friesen PhD, RN, CPHQ1, Anna Herbst MSN, RN1, Karen Gabel Speroni PhD, RN1,JeanineW.TurnerPhD2, James Robinson PhD3, & Joseph Snipp MA4

1InovaHealthSystem•2GeorgetownUniversity•3UniversityofDayton•4ProfessionalResearchConsultants

AKaizen(HandoffPerformanceImprovementTeam)utilizingthePughmatrix,theteamassessedsixtypesofhandoff methods and selected the highest scoring method.The team had developed an ISHAPED strategy to guide nursing communication during the change of shift handoff that was based on best practices and evidence-based strategies. The ISHAPED model incorporates a standard template,customizablefordifferentinpatientunits.TheuseoftheISHAPEDmodelandtemplateshelpsassurethat important information is conveyed and provides an opportunity for patients to participate in the process, thereby addressing the principles of patient-centered care. Change The Nursing report at the change of shift changed from a telephone report (asynchronous communication) to a face to face bedside report (interactive with patients).

* Italicized type denotes information that can be communicated away from the bedside based on patient situation and professional discretion.

I IntroduceS StoryH HistoryA AssessmentP PlanE Error PreventionD Dialogue

A step wise regression was conducted to identify contributors to the overall quality of care rating as measured by the HCAHPS -Overall Rating for QualityofCareasmeasuredbyquestion:Usinganynumberfrom0to10,“0”beingtheworstand“10”thebest,whatnumberwouldyouratethishospital?

The following variables collectively were statistically significant and indicated that 49% of thevariancecouldbeexplained;overallteamwork,nursespromptnessinrespondingtocall,staffkeepingyouinformedoncondition,nurseintroductionofnew-shiftnurse,nursesunderstandingandcaring, pain management.

Changingfromatelephonereporttoapatientcenteredreportrequiresamajorculturechangeandongoingeffortstosustain a change of this nature.• Theevolutionfromanursefocusedcommunicationhandofftoapatientcenteredreportrequirescaring, connection and communication.• CollaborationwithPatient/FamilyandParentAdvisoryCouncilswascatalyticinenhancingunderstandingofthe patient/familyperspective• ISHAPEDisamodelthatcanbeutilizedtosupportapatientcenteredcommunicationprocess.Butprocessesand system must be designed to support patient engagement in order to impact patient outcomes in a meaningful manner.• Collaborationwithandengagingpatientsmustbevaluedandsupportedintheinthehealthcareenvironment.

• Thereareanumberofcontributorstooverallratingforthequalityofcarethatwerestatisticallysignificantincluding“nurseintroductionofnew-shiftnurse”• Ifthepatientexperienceorpatientsatisfactionsperceptionsaretobeimpactedpositivelythereisnotoneinterventionthatwillprovideasolution,butratherset

of behaviors focused on patient-centered care.

Handoffs present among the most challenging communication process in healthcare. Inova a multi hospital system identified opportunities to improve the change of shift handoff process. Analyses of a multi-hospital system handoff procedure indicate variance in definitions and processes across the system. A telephone report away from the patient bedside process was used on a number of nursing units.

Project Design/Strategy

Bedside RN Shift to Shift Handoff Process

UpdateISHAPED

handoff toolthroughout shift

Near the end ofyour shift, roundon patients; ask

if there’s anything you

can do for thembefore report

begins

Near end ofshift, review, update, and complete the

ISHAPEDhandoff tool.

Meet with on-coming RN

outside patient’s room

Share any confidential or

sensitiveinformation

outside patient’s room

Conduct bedside handoff using

script

Introducepatient to on-coming

RN

Conduct shift report using

ISHAPED tool, give to

on-coming RN

Walk in room together

UpdateWhite Board& include Ptin Handoff Diaglogue

Ask questions,dalogue with off-going RN

Move to nexthandoff

Figure 1

InnovationISHAPED was piloted on intervention units and compared with control units a quarter before and after the implementation. Of the eleven Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions examined, six questions showed an increase in percentageofpatientswhosaid“Always”inthequarterfollowingtheinterventionandsevenshowinganincreaseinmeanscores.Ontheotherside,thecontrolunitsshoweddeclinesinnineoftheelevenmeasures,bothinpercentofpatientsanswering“always”tothequestionaswellasinmean.NoneofthegainsintheTargetUnitswerestatisticallysignificant.TheISHAPEDinnovationneededtobemorepatientfocused.TheInovaHealthSystemwasawardedaPickerInstituteAlwaysEvents®ChallengeGrantforthedevelopingapatient-centeredhandoff.Inorderto develop a patient-centered handoff, input from patients and families was sought. A patient survey and interview guide were developed in collaborationwiththeParentAdvisoryCouncilandPatient/FamilyAdvisoryCouncil.

Findings:Results obtained from 22 interviews provided insight into patient perceptions regarding change of shift bedside report. Five themes emerged from the qualitative analysis.• Introducingthenewnurse-atthechangeofshift• Knowingthroughcollaborationandcommunication-assuringinformationissharedandcommunicated• Engagingthepatienttoparticipateandprovidetheirperspective-includethepatientintheconversation• Educatingthehealthcareproviders-lessonsfrompatientsfornurseswhattodointhebedsidereport.• Managingprivacy-theneedtoknowandrespectprivacy

ThefindingswerereviewedbytheParentAdvisoryCouncilandPatient/FamilyAdvisoryCouncilwhoprovidedguidancetotheprojectteammembersforthedevelopmentofnursingeducationalmodules.Educationalvideoswere developed to include lessons learned with emphasis on addressing issues of lower scores 1, 3, 6, & 8. Theeducationvideosdevelopedfromthisprojectwereviewedby94%or3,161inpatientnurses.ConversionofISHAPEDtoElectronicRecordisunderway.ThenewISHAPEDelectronictemplateisscheduledtolaunchNovember2012.Educationalvideosweredevelopedtoincludelessonslearnedwith emphasis on addressing issues of lower scores 1, 3, 6, & 8. The educationvideosdevelopedfromthisprojectwereviewedby94%or3,161 inpatient nurses at Inova. The videos are available at http://alwaysevents.pickerinstitute.org/?p=1251

Examples:

Face to Face Interviews (16 patients, 6 parents)“Where as this is really nice because I can hear. I can correct them if I need to.”“It’s good. It shows me that there is continuity, that they are explaining to the next shift what is going on. So, it makes us feel comfortablethat the next shift understands what is happening with our son.”It definitely makes me feel more comfortable knowing that I know what’s being communicated to the next shift and can voice in if I agree or disagree or have something I want to add.”

Surveys (93 patients, 14 parents)“I found the exchange of information to be very reassuring and helpful.”“One thing I do like is seeing the nurse right at the beginning of shift.”

Outcome Measures

OverviewA hospital system used Lean strategies to develop a method to structure transmission of information and to support patient engagement, in the changeofshiftbedsidehandoff.Tobetterunderstandpatientperspectivesofhandoffs,theprojectteamworkedincollaborationwithaParentAdvisoryCouncilandPatient/FamilyAdvisoryCounciltodesignandimplementapatient-centeredhandoffprocessentitledISHAPEDI=Introduce,S=Story,H=History,A=Assessment,P=Plan,E=ErrorPrevention,andD=Dialogue),andeducationcampaign.

Inova Alexandria Hospital

Inova Fair Oaks Hospital Inova Loudoun Hospital Inova Mount Vernon Hospital

Inova Fairfax Hospital Inova Fairfax Hospital

for Children

Inova Health System – Our HospitalsInova Alexandria Hospital

Inova Fair Oaks Hospital Inova Loudoun Hospital Inova Mount Vernon Hospital

Inova Fairfax Hospital Inova Fairfax Hospital

for Children

The ISHAPED logo was designed based on recommendations from the Councils to signify a patient-centered approach to communication and transition of care.

Timeline of Events

n=3659 Standardized P AdjustedRSquare Coefficients Beta Overallteamwork .293 .000 .396Nurses’promptnessinrespondingtocalls .137 .000 .457Staffkeepingyouinformedoncondition .134 .000 .475Painmanagement .102 .000 .484Nurseintroductionofnew-shiftnurse .075 .000 .489Nurses’understandingandcaring .078 .000 .493Nurses’instructionsandexplanations .063 .001 .494

Question  Number        

Patient  n=93  

Parent  n=14  

Combined  n=107  

    Survey Item      

1  I have learned more about my condition and plan of care during the bedside shift to shift report. 3.97   3.69   3.93  

2  The nurses were knowledgeable about my care during the bedside change of shift report. 4.44   4.63   4.47  

3  

The bedside shift to shift report process between nurses made me think that the nurses were really paying attention to me and my health needs. 4.31   4.25   4.3  

4  I liked being introduced to my new nurse at the end of the shift. 4.6   4.81   4.64  

5  I felt comfortable asking questions during the bedside change of shift report. 4.28   4.75   4.36  

6  I felt like the bedside shift to shift process allowed me to contribute to my health care. 4.07   4.13   4.07  

7  The nurses exchanged information with me using words I could understand. 4.32   4.5   4.35  

8  The nurses reviewed today’s goals and wrote the plan of care on the white board 3.71   3.19   3.64  

9  

I would rather the nurses NOT exchange information at my bedside. (This item has reflected and can be interpreted by removing NOT from the item) 4.36   4.81   4.43  

10  The nursing bedside change of shift report gives me confidence in the healthcare I received. 4.13   4.44   4.18  

11  I like having the nurses provide a bedside change of shift report. 4.43   4.75   4.48  

Pilot Study Survey Results

2010March April May June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March April May June July

2011 2012

ISHAPED Pilot Analysis Modify Implement ISHAPED Need to enhance patient centered

aspect of new handoff.

ApplyforPickerGrant

Grant awarded

RecruitPatient/FamilymembersParent Advisory Council and new

Patient Advisory Council

Patient Perception Pilot Study Development of Educational Modules;Script writing; Production Development of New Outcome Indicators

Educational Campaign Program Evaluation

Kaizen