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Improving Hand-off Report
Student Names
Team Name and First/Last Names of Participants
Problem
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Our task is to propose a change that will address these issues.
Report (timing and hand off errors: Unit managers observed that there was miscommunication between staff during shift report. Often times leaving out important patient information as well as taking a significant amount of time to relay the information. Our goal it to offer a change that will address these issues.
Now here is our SWOT analysis starting off with Derrick talking about the strengths.GROUP
Majka
“Communication failures compromise patient treatment, care quality, and safety. It also leads to medical errors, the third leading cause of deaths in the United States” (Ghosh, et all., 2015)
“The varying parties and large amount of complex information included in patient handoff reports frequently contribute to informational gaps and omissions in the handoff report that can lead to sentinel events and patient hard” (Staggers & Blaz, 2013)
“Research has identifed handovers as a risky time in the care process, when information may be lost, distorted or misinterpreted (Borowitz et al 2008, Owen et al. 2009, Philibert 2009)
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Your task is to propose a change that will address these issues.
Increase of errors during patient hand-off report leading to missed information and incomplete tasks
Hand-off report time is taking a greater deal of time
Our task is to implement the use of SBAR as the standard hand-off report between shifts in order to reduce errors and decrease the time spent giving report.
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SWOTGROUP
Strengths: Multidepartment focus addressing handoff report problems(Robins et al., 2017) Solutions shorten time taken in report while increasing quantity of pertinent information. (Stewart & Hand, 2017) SBAR is supported by the Joint Commision (Stewart & Hand, 2017) Proven error reduction due to use of SBAR tool. (Stewart & Hand, 2017) SBAR is an evidence-based hand-off tool (Eberhardt, 2014) Weakness Use of the tool requires education to reduce user error (Stacey Eberhardt 2014) Medical personnel have personal bias on giving report (Ghosh et al., 2018) Some staff are unreceptive to change (Robins & Dai, 2017). Evaluating execution of report can be affected by observer bias (Robins & Dai, 2017)
Opportunities SBAR is inexpensive as a tool and will earn its cost in education by the reduction of sentinel events (Stewart, 2017) Improve patient handoff by implementing an evidence-based handoff tool in SBAR format (Eberhardt, 2014) For continued nursing education in standardizing hand-off report (Ghosh et al., 2018). Threats Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018). Some staff are unreceptive to change (Robins et al., 2017). Evaluating execution of report is subject to observer bias (Drach-Zahavy, 2014) Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017)
Strengths:
Multidepartment focus on addressing problems with handoff report (Robins et al., 2017)
Solutions manage to shorten time taken to give report while increasing the amount of pertinent information given in that time frame. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness (Wendy)GROUP
Use of the tool requires education for all staff to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on how they want to give report (Ghosh et al., 2018)
Healthcare worker disinterest in changing how they give report. (Robins et al., 2017).
Subjective approach to measuring a handover’s strategies might be subject to bias, as participants may behave differently in the presence of an observer.
Opportunities (ashley)
SBAR is inexpensive as a tool and will earn its cost in education by providers by the reduction of sentinel events (each of which carries a high expense). (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in Situation Background Assessment Recommendation (SBAR) format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).
Threats (Alma)
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
The acuity of patient injury and medical history can increase the amount of time for patient hand-off (Robins, 2017).
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017) and sample size of 200 handovers in 5 wards in another study(Drach-Zahavy, 2014)
3GROUP
Assessment
Inefficient communication during hand off report is a challenge to patient care. (Ghosh, et al., 2018)
Communication error given during report increases risk of poor patient outcomes. (Stewart, 2017)
Hand off communication between medical personnel leads to an increase in medication errors, incomplete tasks, disorder, and eventually poor patient outcomes (Robins et al., 2015)
According to The Joint Commission, communication errors have been among the top three leading root causes of reported sentinel events every year since 2004. (Stewart, 2017)
The information we had gathered from our assessment on giving report overall was –
1. Poor communication leads to poor patient outcome
2. The Joint Commission has stated communication errors has been the top 3 leading root causes of unanticipated major events in the healthcare setting that results in death or serious physical or psychological injury to a client which require immediate investigation by the health care facility since 2004
3. And now we will be talking about our Diagnosis.
Goal should comes from assessments (SMART (MEASURABLE))
Assessment will be bullet points of why is this a problemGROUP
Specific, measurable, attainable, realistic, timely
All RNs and assistive personnel will attend 1 or more in-services on the use of SBAR handoff report within three weeks.
During the same three week period, charge nurses and nursing management will include SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report. Following the three week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of 1 month with the goal of receiving ideas of how we can improve it from the staff at the end of the 1 month period. At the end of the one month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas they have to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the 1 month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year. During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinal events, falls, nosocomial infections, et al will be compared between the two systems.
Majka
4GROUP
Diagnosis
Lack of standardization in report
Communication Barriers (Stewart & Hand, 2017)
Communication practices learned by various career stages of nurses (promise, momentum, harvest)
Different individual communication styles
Gaps in knowledge regarding lack of standardized reporting
A lack of standardization in report increases risk of error and poor patient outcomes
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S.M.A.R.T. Goal
Use an evidence-based standardized hand-off report tool to reduce report times to less than 45 minutes while reducing report-based errors by 20% within 6-month period.
Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.
Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it. Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.GROUP
Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system. Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.
Alma
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Full-Range Leadership Model/Theory
Definition: Focuses on the behavior of leaders towards the workforce in different work situations. (Marquis & Huston, 2011)
Three sub-types
TransactionalGROUP
Transactions between leaders and followers
Leaders promote compliance to standard SBAR method through rewards and punishments
Transformational
Identifies needed change, inspires, and executes change
Emphasize the importance of reducing errors in patient hand-off through application of SBAR. Our goal is to enhance quality of care and thorough communication.
Laissez-faire
No standard rules
Used when nursing staff and PCTs are efficient with and advocating use of SBAR
Full Range Leadership: Promise, Momentum, Harvest
Wendy
Transactional: Promoting buy-in from nurses and PCTs through encouragement of ideas and discussion while also increasing of stakeholder support of the SBAR method
Theory should apply to what we are trying to accomplish
“this is how we plan to use this leadership style because….”
Why is this theory important for our outcome?GROUP
Using more then one theory, where is it applicable?
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Plan
Following the three-week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of one-month with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
At the end of the one-month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the one-month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial.
8GROUP
3 Weeks
RNs and assistive personnel to attend 1 or more in-services on SBAR handoff report
Following in-service, SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
1-month trial
SBAR will be implemented on the unit for a trial period with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
15 days into the trial month/ after the trial month
Nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
Post 1-month trail
Staff invited to discuss their experiences with SBAR, to share ideas to improve it
Second trial(1 – 3 months)
New SBAR form that includes select suggestions from staff will be used. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial. Then again at the end of three months.
Metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
Implementation Through: The Transtheoretical Model: Stages of ChangeGROUP
Precontemplation
Discuss report issues with charge nurses and harvest nurses, asking them for ideas.
Contemplation
Charge and harvest nurses sit with knowledge of the problem. Offer them research on SBAR.
Present plan to stake holders. Invite CNO, directors, harvest nurses and PCTs.
Preparation
Supply staff with SBAR templates, offer in-services on SBAR communication education, and educate on SBAR during pre-shift meetings.
Action
Implement SBAR template during hand-off report.
Maintenance
Continue buy-in from harvest nurses and other staff by asking them to help personalize the form for the unit
Set performance goals related to hand-off associated errors.
Highlight problems related to hand-off report during pre-shift report and how SBAR could circumvent those.
PDF- page 96 management theory
PDF- page 107 leadership theoryGROUP
Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.
Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it. Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.
Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system. Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.GROUP
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Evaluation
Desired Outcome Actual Outcome Maintain Goals and Desired Outcomes
Lower amount of time giving report by < 45 minutes Implement standardized SBAR throughout the unit, structuring the process Nurses will be able to demonstrate standardized process of hand-off report Statistical significance in decreasing the rate of communication errors that leads to errors in patient care Amount of time giving report has decreased by using a standardized process (Stewart & Hand, 2017) Standardized process of giving report increased efficiency of verbal communication (Stewart & Hand, 2017) Decrease in the rate of callbacks for information clarification (Robins & Dai, 2017) Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31% to 11% (Stewart & Hand, 2017 Provide continuous education throughout clinical experience on usage of the standardized process of giving report (Stewart & Hand, 2017) Standardized process for reporting reduces hierarchical barriers (various career stages) increases confidence of the users, decreases length of report time and accuracy of exchanged information. (Stewart & Hand, 2017)
– Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31% to 11% (Stewart & Hand, 2017)
-Discuss if this is successful and why? The reasons
Nurses are encouraged to seek new ways to implement best practices as they work (Eberhardt, 2014)
10GROUP
Implementation Barriers
Medical personnel have personal bias on giving report (Ghosh et al., 2018)
Different nurses have different approaches to how they perform report (Ghosh et al., 2018)
Some staff are unreceptive to change (Robins & Dai, 2017) and it is difficult to [enforce a] change in practice for long time staff (Eberhardt, 2014)
Majka – Our 3 main hurdles that prevent implementation is different nurses give report in different ways and personnel being biased with giving report, as well as, some staff don’t want to change their styles of giving report such as more seasoned nurses that have been in the profession for many years.
With that being said here are some questions to think about…
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Questions to Think About
Why is SBAR preferred to personalized hand off reporting?
What limitations do you think SBAR represents when giving report?
Is it more beneficial to use a single standard SBAR tool or to personalize the tool to match specific units? Why?
References
Drach-Zahavy A ; Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. J Adv Nurs. 2015; 71: 1135-1145
Ghosh, K., Curl, E., Goodwin, M., Morrell, P., & Guidroz, P. (2018). An Exploratory Study on how to Improve Bedside Change-of-Shift Process: Evidence from One Hospital Using Technology to Support Verbal Reporting. HICSS.
Marquis, B.L., & Huston, C. (2011). Leadership roles and management functions in nursing: Theory and application (9th ed). Lippincott, Williams, Wilkins. ISBN: 978-1-4963-4979-8
Robins, H., & Dai, F. (2015). Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care. AANA journal, 83 4, 264-8.
Stewart, Kathryn R., “SBAR, communication, and patient safety: an integrated literature review” (2016). Honors Theses. https://scholar.utc.edu/honors-theses/66
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