Decreasing Handoff-Related Care Failures in Children’s Hospitals

The Collaborative

Twenty-three children’s hospitals (see Acknowledgments) participated in a 12-month Improving Patient Handoffs quality improvement collaborative. This project was coordinated by the Child Health Corporation of America (CHCA, Shawnee Mission, KS), a business alliance of 43 children’s hospitals with extensive experience in overseeing collaborative quality improvement.^12–14 CHCA subsequently merged with the National Association of Children’s Hospitals and Related Institutions to form the Children’s Hospital Association. The project was open to all CHCA-affiliated hospitals as of May 1, 2010. Participating hospitals obtained local institutional review board approval or a waiver of institutional review board oversight.

The Intervention

A multidisciplinary advisory panel (see Acknowledgments) consisting of content experts in patient handoffs was convened by CHCA, and they developed a comprehensive, pediatric-specific change package of evidence-based practices used to guide sites in improving handoffs (Supplemental Appendix 1). Each institution was encouraged to adapt relevant practices based on handoff type targeted locally. The 4 elements identified in the change package as required for implementation across participating sites regardless of handoff types were:

1. Defined handoff intent: Ensure a common understanding (shared mental model) of the patient is achieved, confirmed by receiver.

2. Defined handoff content: Establish core and unique elements of a given handoff type.

3. Defined handoff process:

   1. Use standardized tools and methods, including minimized interruptions and distractions, and commit to a standard structure (eg, situation, background, assessment, recommendation,¹⁵ I-PASS¹⁶) for verbal communication;

   2. Use standardized handoff format (encourage receiver to ask questions, use of electronic medical record information to supplement verbal handoff wherever possible);

   3. Ensure a clear and timely transition of responsibility (defining when responsibility is passed from 1 person or team to another).

4. Maximized team effectiveness: Establish leadership and use team-building tools to develop a culture of safe handoffs.

The Institute for Healthcare Improvement’s Collaborative Model for Achieving Breakthrough Improvement was used to facilitate improvement.^17,18 Each site assembled a multidisciplinary oversight team including a project leader and a senior leader, along with front- line leaders and staff from the handoff areas being targeted. An introductory virtual learning session (webinar) provided patient handoff education and an introduction to the change package and measurement grid. Hospitals learned improvement strategies that emphasized both small tests of change (Plan-Do-Study-Act) and specific sustain/spread strategies.¹⁷ Hospitals were also free to apply other improvement methods (eg, Lean Six Sigma).^19,20 During the collaborative, sites made numerous process improvements and reported key outcome and process measures on a Web-based data repository.²¹ Transparency through unblinded data reporting and sharing of successes/barriers was a critical requirement for participation. All site members had access to a project-specific Web site and a listserv coordinated by CHCA.²² CHCA staff provided monthly feedback to site-specified senior leaders, coordinated learning sessions, provided content oversight and process management, and disseminated the project results.

The study period spanned 1 year (October 2010–September 2011). Each site chose to target ≥1 handoff type, in or between ≥1 unit within their hospital. To assess the handoff, data were collected for this specific patient handoff within 4 to 8 hours of the handoff completion by using a face-to-face structured interview of the caregiver directly involved in the posthandoff care. Each improvement team used their own notification strategy to ensure interviews at 4 to 8 hours’ posthandoff, although exceptions were made in which the “observation period” was shortened to capture data immediately before shift change. The interviewer was an independent observer not involved in the handoff process, and the interviewee was the receiving clinician(s) of the specific patient. The interviewers varied within and between hospitals but were primarily quality and safety representatives or clinical staff not involved in the handoff process. The 4- to 8-hour posthandoff observation period before the structured interview allowed receiving clinicians adequate time to “uncover” handoff-related care failures that might not be apparent immediately after the handoff (ie, missed medications, delay in subspecialist notification). The receiving clinician (interviewee) was the primary caregiver and the recipient relevant to the specific handoff (eg, ICU attending physician when the handoff was between the operating room and the ICU, nurse when the handoff was between shifts). The receiving clinician (interviewee) answered simple questions from a standard interview tool with “yes” or “no,” itemizing specific care failures and giving the opportunity to identify additional care failures. The interviewee then specified (“yes” or “no”) if that care failure was a result of the handoff or lack of handoff, which ultimately determined if a care failure had occurred. The required standard interview tool was created to ascertain frequency of handoff-related care failures, frequency of interruptions/distractions, appropriateness of transition from the sending team to the receiving team, and clinical understanding of the patient’s condition. Baseline and follow-up interviews were conducted by using the same locally modified interview tool and interviewing caregivers from the same discipline. Hospitals were instructed to evaluate a minimum of 20 handoffs each month by using a convenience sampling approach.

Outcome Measures and Data Reporting

The primary outcome measure was handoff-related care failures, defined in a standard fashion across the collaborative as failures in information transfer that directly affected the patient or delayed/complicated patient care. Examples of handoff-related care failures include the reporting of incorrect or inaccurate diagnostic testing information or the failure to communicate information related to medication administration, resulting in duplicated medications (Supplement Appendix 2). All participant sites were provided with a template interview tool itemizing a core set of handoff-related care failures; that tool was specifically customized at the hospital level to meet the needs of the local handoff type and handoff environment. This paradigm provided a preintervention and postintervention level of standardization within a single hospital but intentionally permitted integration of local hospital care failures in each hospital’s local interview tool. Handoff-related care failures were recorded, although they were not qualified according to severity or direct patient harm. Process measures reflected compliance to core components of the change package and included percentage of handoffs with minimal interruptions and distractions that resulted in a common understanding about the patient and demonstrated a clear transition of patient care responsibility. Questions related to interruptions and clear transitions were simple yes/no interview questions. Establishing a common understanding required the following 4 explicit components: I know my patient’s issues and clinical condition, I know what my patient requires, I know when to be concerned about my patient, and I know when and how to escalate my concerns. The balancing measure of staff satisfaction was assessed to monitor the possible unintended consequence of staff dissatisfaction with standardized handoffs. Interviewees were asked to respond to the question “How satisfied were you with this handoff?” and were given a 5-option Likert-like scale with options of very satisfied, somewhat satisfied, neutral, somewhat unsatisfied, and very unsatisfied. Only responses of very satisfied were included in the staff satisfaction reporting.

Data and Statistical Analyses

The baseline period occurred between October 1, 2010, and December 31, 2010, and the 3 intervention quarters spanned 9 months from January 1, 2011, to September 30, 2011. The baseline study period began after the first collaborative learning session. During the baseline period, each site identified target handoff types and relevant specific handoff-related care failures, which then guided the targets for baseline data collection. Baseline data collected predated implementation of the local intervention. All data were submitted by each hospital on a monthly basis during all phases of the collaborative through a secure online repository.²¹ Data were aggregated to the quarterly level both to align with rapid improvement cycle durations and to maximize statistical power.

The primary outcome of percentage of handoffs with at least 1 handoff-related care failure was derived from the total number of handoff interviews identifying at least 1 handoff-related care failure (numerator) divided by the total number of handoff interviews (denominator). Percentages of handoffs with interruptions/distractions, achievement of common understanding about the patient, and a clear transition of patient care responsibility were similarly derived by using the total number of handoff interviews in which each component was met (numerator) among all handoff interviews (denominator). All measures were tracked according to hospital and handoff type. Collaborative-wide data were aggregated to the quarterly level by using raw data to derive collaborative results. Comparisons between baseline and intervention periods for individual hospitals were made by using Fisher’s exact tests. Comparisons between baseline and intervention periods for the aggregated hospital data were made by using χ² tests with SAS version 9.3 (SAS Institute, Inc, Cary, NC). Data are expressed as means with 95% confidence intervals (CIs). Results were considered significant for P < .05.