Recent Blog Posts

Safety Metrics: Are They Measuring Up?

More

Learning to Deal with Drift

More

Enacting resilience in everyday practice: steps along the journey

More

The Learning Review -- Looking up the River

More

Practical Resilience: Misapplication of an Important Concept

More

Topic

Board Education Governance Health


Archive

2017 (4)
June (1)
April (1)
February (1)
January (1)
2016 (3)
September (1)
June (1)
April (1)
2015 (3)
May (1)
March (1)
January (1)
2014 (5)
October (1)
September (1)
June (1)
May (1)
January (1)
2013 (4)
November (2)
October (1)
September (1)

Interactive handover -- Out of the dark ages: Combining high reliability and resilience principles

Posted by Wrae Hill on Thursday May 1st, 2014

Interactive handover – Out of the dark ages  

Combining high reliability and resilience principles

Handover communication is ubiquitous in healthcare. All clinicians do this, often several times a day, yet it is exceedingly rare that this skill is even taught or evaluated in any of the health professions, much less evaluated (in situ) in multi-disciplinary care settings. Most clinicians are not explicitly trained to synthesize and prioritize complex information under time constraint. Compared with aviation communication we are in the dark ages. Efforts to improve healthcare handover communication often focuses on the local creation of detailed transfer forms, however we have largely ignored the importance of the interaction and the art of balancing brevity with relevant information for the receiver. After almost a decade of research there is still no standard mnemonic for handover. Promising practices for handover communication may adopt an interactive approach, grounded in common principles of communication and aimed at high-quality, consistent sharing of critical patient information.

Combining high reliability and resilience principles

In our current research we are studying Interactive Handovers in Critical Care at change of shift report, and there are several factors that are relevant from confluence of high reliability theorya and resilience engineeringb . These are: management by exception(a) , the use of auditory and visual channels to communicate safety critical information(a) and, the use of jointly acceptable tools or formats including the opportunity for the receiver to be active, using anticipatory language, b/ c)

Testing a simple handover tool – IDRAW

Transfer of accountability of care (for nurses) occurs during four key transition points such as:

  1. Nursing Unit to Nursing Unit Transfer (intra facility);
  2. Nursing Unit to Department Transfer (x-ray, endoscopy, etc.);
  3. Facility to Facility Transfer (inter facility);
  4. Nurse to Nurse Handover (shift change, break relief, change in assignment).

 

Based on both QI and research work, we will be proposing a simple standard for transfer of accountability that incorporates basic high reliability and resilience principles. The following requirements govern effective transfer of accountability:

1) Handover communications can be written and/or verbal (in-person, over the telephone but not simply faxed) depending on the situation.

2) Handover communication should include:

I - Patient identifiers (2) and the Most Responsible Practitioner;

D - Diagnosis and current problems;

R - Recent assessment changes and relevant vital signs;

A - Anticipated changes or tasks needing attention in the imminent future;

W - The opportunity to ask questions and clarify (What should I be worried about?)

The anticipatory resilience components (Anticipated changes & What should I be worried about?) trigger the receiver to be active in the interaction and to make a prediction about what may go on in the future. In this way the IDRAW template may help provide a predictable skeletal framework (paradigmatic mode) while explicitly encouraging an interactive (narrative mode) conversation. Because the IDRAW communication format is known to (and expected by) both sender and receiver, we encourage the narrative flesh to be constructed around the paradigmatic bones.

“Many communication-intensive practices in which patient cases are communicated, such as handoffs, rely heavily on the narrative mode, yet most interventions assume the paradigmatic mode. Improving the safety and effectiveness of these practices, therefore, necessitates greater attention to narrative thinking”

Hilligoss, 2014 “The limits of checklists: handoff and narrative thinking (A PDF of this paper can be found in the "Resources" section of the website under the sub-heading "Teleconference").

 

Handover quality score

Research is still in the analysis phase. Our research hypothesis is that explicit behavioural feedback and training (via a focus group) in handover communication skills as well as peer to peer influence demonstrated by both senders & receivers will result in improved; quality of clinical communication (Handover Quality Score/Time). We have developed and tested a novel Handover Quality Score (HQS) which incorporates three areas of communication; i) Characteristics of expert handover, ii) Components of interaction observed, and iii) Non-verbal communication. For characteristics and content, these components are scored out of 10 where three points are deducted if any one component is missed.                        

 i) Characteristics of expert handover      

  1. face to face communication
  2. use of minimum datasets, (Kardex/ other)
  3. opportunity to ask and answer questions
  4. discussion of intention going forward
  5. * use of open ended anticipatory questions by the receiver, such as: What are you worried about? / What else could go wrong?

Mishkin 2005 /*Hill 2010      

 ii) Components of the interaction observed   (IDRAW)

  1. Identity – Patient name/ PHN or DOB and most responsible physician (MRP)
  2. Diagnosis / Current Problems
  3. Recent Changes ( Relevant systems approach)
  4. Anticipated changes   (planned care /anticipated barriers) did the receiver use this opportunity to coordinate/ plan care ?
  5. What to watch out for (Clinical / Psychological –social factors / Family matters)..Did the receiver ask the sender: ”What else should I be concerned with?

 

 iii) Non-verbal communication

Observations look for context, culture and four patterns of non-verbal communication (NVC) such as; 10) joint focus of attention, 8) “the poker hand”, 6) parallel play and 4) curbside consultation, 0) No interaction         R. Frankel 2014 with scores modified by our research team

These components are not either/or, they are composite . A higher quality handover includes ALL of the elements of characteristics of expert communication and components of handover communication. We have consulted experts to help us validate this novel handover quality score

 

Applications for high reliability and resilience principles in ICU handover

Our early results demonstrate that in one ICU setting where audio taped report was routine, it is now interactive, clearer and more concise. In a small group of ICU nurses, handover quality scores improved from 17 to 23 out of 30 and handover time was reduced from 8 to 5 minutes on average.

So by using some simple principles of both high reliability and resilience engineering we are endeavoring to simplify a ubiquitous problem, handover communication under time constraint. Our research team hopes to submit this work to Quality and Safety (BMJ) in the coming months.

 

Looking ahead: Why resilience and Safety II are important

A nursing leader recently suggested, this is pretty simple…certainly not rocket science.

I couldn’t agree more with the latter…it is actually harder [behavioural] science.

As for the former, simplicity, that is the whole point, but alas that is not yet common.

The original resilience “engineer” said it best; Simplicity is the ultimate sophistication (Da Vinci).

If handovers were really that simple why have we struggled for so long with something so fundamental? I think the checklist/linear mentality that permeates so much of healthcare QI is a barrier. This is where this new thinking can loosen these chains of linear/reactive thinking. There are three words        (common in QI parlance) I try not to use because they are emblematic of this old paradigm: “Recommendation, Roll Out and Buy-In”

For me resilience and Safety II offer a new forward looking renaissance in thinking about safety.

Without my exposure to the thinking of Dekker/Hollnagel/ Woods/Nemeth/Wears/Cardiff/Sheps /Robson/ Jeffcott/Frankel and many others I’m sure I’d not have stuck with this problem for so long.

Specifically, Sidney Dekker helped me see that both reliability and resilience (flexible standards) are important for communication safety. Erik Hollnagel helped me understand the inter-related four principles of resilience and the importance of time constraint (ETTO) on our decision making. Both challenged me to seek to understand the necessarily messy normal work in complex situations and to resist the superficial normative approaches. Safety II is about understanding normal work and the constant course corrections necessary to navigate safely. So, safety is indeed a verb and has the half- life of epinephrine (Cook).

Without the ideas of resilience and Safety II, I may have never sought to observe how ICU clinicians (Physicians/Nurses/therapists) formulate and co-create their shared big picture prior to rounds. Without this insight I would not have recognized the crucial role of foresight and the role of the receiver in anticipation of what might go wrong. Safety II and resilience are forward thinking ideas, not more retrospective dissection of a perceived reality contaminated by hindsight. (Wow that was a mouthful)

Look ahead with resilience and Safety II. Simplicity is the ultimate sophistication.

Wrae Hill, May 2014

 

Footnotes:

a)     High Reliability Organizations have five characteristics which include: 1) Deference to expertise during emergencies, 2) Management by exception, 3) Climate of continuous training, 4) Several channels are used to communicate safety critical information, 5) In-built redundancy including the provision of back-up systems in case of a failure.   http://www.hse.gov.uk/research/rrpdf/rr899.pdf

b)     Resilience is the intrinsic ability of a system (or person) to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress. It is an emergent property of systems (or persons) who effectively integrate and balance safety and productivity. (Nemeth et al 2009)   Resilience has four key features: 1) Anticipation, 2) Monitoring, 3) Learning, and 4) Responding.   http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Nemeth_116.pdf

c)     Hill,W. (2010) Cognitive Human Factors in ICU – Techniques clinicians report that they use to develop their anticipation, intuition and foresight at change of shift report (CoSR) Canadian Journal of Respiratory Therapy 46.4 Winter

 References:

  • Brian Hilligoss and Susan D Moffatt-Bruce (2014) The limits of checklists; Handoff and Narrative thinking , Downloaded from qualitysafety.bmj.com on April 12, 2014
  • Richard M Frankel, et al (2012) Context, culture and (non-verbal) communication affect handover quality BMJ. BMJ Qual Saf 21:i121–i127
  • Handoff of Care 2012 - Virginia Health System http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf
  • Hill,W. (2010) Cognitive Human Factors in ICU – Techniques clinicians report that they use to develop their anticipation, intuition and foresight at change of shift report (CoSR) Canadian Journal of Respiratory Therapy 46.4 Winter
  • Hill (2012) - Handover Communication - Direct observation of Change of Shift Report (CoSR) Assessment of current state on 26 units at 11 hospitals in Interior Health Interior Health Patient Safety Report 2011, Poster BC Quality Forum 2012
  • Park,B., Mishkin,A. (2005) Best Practices in Shift Handover Communication : Mars Explorer Rover Surface Operations Proceedings of the International Association for the Advancement of Space Safety Conference, sponsored by the ESA, NASA, and JAXA, Nice France. 25-27 October 2005
  •  Horwitz, L,I,.Moin,T.,Krumholz,H..,Wang,L.,Bradley,E.H. (2009) What are covering doctors are told about their patients? Analysis of sign-out among internal medicine house staff. Quality and Safety in Health Care 18:248-255
  • Jeffcott,S.A., Ibrahim,J.E., Cameron,P.A. (2009) Resilience in healthcare and clinical handover Quality and Safety in Health Care ;18 pp. 256-260

 

Add your comment

Submit comment

Wrae works in the Interior of British Columbia as the Manager of Human Factors and System Safety in a large health region (18,000 staff/ 2,000 Physicians). As a Respiratory Therapist (Toronto 1988), Wrae spent many years caring for patients, and leading others in neonatal, pediatric and adult critical care units in Vancouver, Riyadh, Toronto and Edmonton. 

In 2005 Wrae moved into the growing quality improvement field and was trained as a Canadian Patient Safety Officer and faculty trainer in investigations and disclosure. His graduate work (2008-2010) in Human Factors and System Safety was at the University of Lund , School of Aviation (Sweden).  Wrae co-developed a Patient Safety Investigation (PSI) curriculum and has experience in major system safety work including cognitive task analyses in medical device patient safety. Wrae’s keen interest and research is in Interactive Handover for all healthcare providers. This research combines high reliability/resilience science and direct observation of the nature of clinical expertise. This has led to the development of a simple handover mnemonic and quality score (HQS) to measure improved communication in healthcare. Wrae also serves as an adjunct Professor of Nursing at UBC-Okanagan.

Wrae works in the Interior of British Columbia as the Manager - Human Factors and System Safety in a large health region (18,000 staff/ 2,000 Physicians).
As a Respiratory Therapist,(Toronto 1988), Wrae spent many years caring for patients, and leading others in ; neonatal, pediatric and adult critical care units in; Vancouver, Riyadh, Toronto and Edmonton. 

In 2005 Wrae moved into the growing quality improvement field and was trained as a Canadian Patient Safety Officer and faculty trainer in investigations and disclosure. His graduate work (2008-2010) in Human Factors and System Safety was at the University of Lund , School of Aviation (Sweden).  Wrae co-developed a Patient Safety Investigation (PSI) curriculum and has experience in major system safety work including cognitive task analyses in medical device patient safety. Wrae’s keen interest and research is in Interactive Handover for all healthcare providers. This research combines high reliability / resilience science and direct observation of the nature of clinical expertise. This has led to the development of a simple handover mnemonic and quality score (HQS) to measure improved communication in healthcare. Wrae also serves as an adjunct Professor of Nursing at UBC-Okanagan.

Events:More...


News:More...

6th Resilient Health Care Meeting

For details about the 6th Resilient Health Care Meeting being hosted in Vanco

More