Patient Safety Tools-Summer- 2006

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Welcome

Welcome to the first issue of Patient Safety Tools, IPRO's electronic newsletter designed to provide information and resources on patient safety to health care providers across New York State.

We have adopted this format to increase the reach and effectiveness of our efforts to communicate a range of useful, current information regarding patient safety initiatives sponsored by IPRO and others. We hope that by bringing key findings, lessons learned, workable strategies, and practical tools to your attention, these newsletters will highlight proven ways to apply quality improvement processes to achieve "transformational" advances in patient safety.

If you prefer not to receive future free electronic editions of Patient Safety Tools, it is easy to opt out. Send a blank email message to %%email.unsub%%

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Introduction and Purpose

Improving patient safety in hospitals has emerged as a top national priority. A large and growing body of evidence clearly demonstrates that errors associated with hospital care cause significant harm to patients while adding major costs to health care delivery. The Centers for Medicare & Medicaid Services (CMS) has focused quality improvement efforts on insuring patient safety and encouraging hospitals to share their patient safety initiatives with their communities. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) approved its first set of six National Patient Safety Goals (NPSGs) in 2002 and has updated these goals for Hospitals and Critical Access Hospitals annually. Several other national organizations (Leapfrog, Institute for Healthcare Improvement IHI, American Hospital Association AHA, etc.) have also established patient safety as a top priority.

In each newsletter, we will be presenting information focused around each one of the twelve safety dimensions for hospitals defined by the Agency for Healthcare Research and Quality (AHRQ) as implemented in their Patient Safety Climate Survey. This is a valuable survey that is currently being used by IPRO in a CMS directed rural hospital initiative to promote an improved hospital patient safety environment and is available for any hospital to use. The survey identifies specific patient safety strengths and vulnerabilities associated with each of the twelve measured dimensions and can facilitate a data-driven plan to engage senior leadership to promote safety improvement activities using specific evidence-based, proven interventions.

The patient safety dimensions that reflect various hospital processes are the following:

This issue of the newsletter will focus on "Communication/Handoffs & Transitions"

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Communication/Handoffs & Transitions

Communication, team culture, shift reports, sign outs, hand-offs, and other forms of information exchange have been identified as some weak links in organizational systems that increase the likelihood of hospital errors. A root cause analysis of 3,548 hospital "sentinel events" (JCAHO defined) for the decade between 1995-2005 identified "communication" problems as a primary root cause in nearly two-thirds of these events.

Patient handoffs can occur several times during a typical hospital stay, including:

Ideally, medical information should move seamlessly with the patient, so caregivers can stay fully informed. However, we all know that there are many factors that can hinder effective communication between individuals and within a team. Some people, due to culture, experience or personality, become intimidated easily and find it difficult to speak directly with a senior staff member even if they, themselves, have considerable expertise. Oftentimes, different members of the team have different communication styles, and have been trained to communicate in different ways. Other reasons for poor communication may include interruptions, lack of clarity with the process, non-standardized techniques and incomplete information.

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SBAR is a proven practice

JCAHO established a new National Patient Safety Goal for acute-care and critical access hospitals in 2006, goal 2E, that requires hospitals to "Implement a standardized approach to 'handoff' communications, including an opportunity to ask and respond to questions."

"Situation, Background, Assessment and Recommendation", (SBAR), is a powerful tool borrowed from the military that assists individuals in a team to communicate with greater clarity and focus by providing a framework for communication about a patient's condition. Originally used in health care to improve nurse-to-physician communication, the SBAR process has also been successfully applied to improve communication within larger provider teams. SBAR is an easy-to-remember, straightforward, and concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how communication will occur among members of the team.

At the heart of SBAR is a communication template that can be divided into four sections:

SBAR is efficient and streamlined, predictable and logical, and easy to incorporate into clinical practice. Hospitals and clinicians have found that SBAR not only supports patient quality and safety but also offers many other secondary benefits: It limits duplicate calls and convoluted planning while simultaneously promoting an environment for proactive and effective action plans, consistency, dependability, and a culture of trust and teamwork. There have also been a few studies that show increased professional satisfaction among teams that use SBAR.

When Vanderbilt University Medical Center assembled a team of physicians, nurses, and other staff to research ways to improve hand-off communications, the SBAR technique was established as a template for system-wide information exchange. The SBAR technique was then included as part of their 2005 Hand-Off Communication Policy.

Finally, the IHI 100K Lives Campaign Rapid Response Team initiative, which highlights the need for highly reliable and standardized formats for emergency communications, promotes the SBAR technique as a proven briefing method.

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References

M Leonard, S Graham and D Bonacum The human factor: the critical importance of effective teamwork and communication in providing safe care Qual Saf Health Care 2004;13: i85 - i90

V Arora, J Johnson, D Lovinger, H J Humphrey, and D O Meltzer Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual. Saf. Health Care 2005; 14(6): 401 - 407

Haig, Kathleen M.; Sutton, Staci; Whittington, John SBAR: A Shared Mental Model for Improving Communication Between Clinicians Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 3, March 2006, pp. 167-175(9)

Joint Commission Perspectives on Patient Safety. The SBAR Technique: Improves Communication, Enhances Patient Safety. February 2005. Volume 5, Issue 2.

Institute for Healthcare Improvement. SBAR Technique for Communication: A Situational

Briefing Model.

saferhealthcare. Lertzman, R. No More Hinting and Hoping: An Interview with Frances Griffin 27 July 2005
HealthCare Benchmarks and Quality Improvement SBAR initiative to improve staff communication: tool was first developed, used by the military April, 2005
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For more information, contact:

Richard Corcoran, Safety Project Lead, rcorcoran@nyqio.sdps.org

Charles Stimler, MD, MPH, Medical Officer, cstimler@nyqio.sdps.org

Marguerite Shaffer, RN, Senior Director, mshaffer@nyqio.sdps.org

Patient Safety Tools is produced by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-NY-TSK1C1-06-08.
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