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 Improving Hand-off Report

Student Names

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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.

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. 

2

SWOT

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) 

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)

3

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 problem 

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 

4

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

5

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. 

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 

6

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

Transactional

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?

Using more then one theory, where is it applicable? 

7

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.

8

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.

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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