By Megan Headley
An oft-cited 2011 report from the American Clinical and Climatological Association estimates that “the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020 it is projected to be 0.2 years—just 73 days.” Understandably, one of the largest challenges facing physicians today is getting their hands around the multitude of best practices for their field that are constantly being introduced, studied, and either adopted or discarded. This makes it a nearly impossible task for those same physicians to study best practices related to other fields.
It’s for this reason that the Envision Healthcare Center for Quality and Patient Safety established a committee in the spring of 2018 to create a shared database of tools aimed at improving patient handoffs.
As recently as September 2017, The Joint Commission had identified poor communication during patient handoffs as a “longstanding, common problem in health care.” During the transition between care providers, the potential for patient harm grows due to the transfer of inaccurate, incomplete, delayed, misinterpreted, or otherwise unhelpful information about the patient’s condition. So the Envision project aimed to unite many of the tools being used across service lines to improve communication across all transitions of care.
“I think the real success was in getting all this information into one place,” shares Gerald Maccioli, MD, MBA, FCCM, FASA, chief quality officer at Envision Healthcare, who led the project. “For physicians, the challenge is getting the critical information. So having a group of experts refine down and push out these best practices for adoption across our enterprise, and really seek to solve this problem and improve patient safety, I would say is innovative.”
As Maccioli puts it, “Following-through implementation is almost as important as discovery innovation.”
The project began with a committee of cross-department specialists: an anesthesiologist, a diagnostic radiologist, an emergency medicine specialist, a neonatologist, a hospital medicine specialist, and the director of Envision’s Patient Safety Organization: a nurse with a strong clinical background. Each of these specialists brought insight about their siloed specialties, and they looked collectively at their best practices to see how those practices might be applied elsewhere.
“This work group looked at the best practices by specialty and then sought to integrate the best from each of them and redraft it so they had a consistency,” Maccioli explains. He offers an example: “In anesthesiology we have what we’ve defined as a great tool, the TEMPO (Together Everyone Molds Patient Outcomes) handoff tool, whereas in neonatology they’re using SBAR (Situation, Background, Assessment, and Recommendation). Our approach has been to identify the best practice for handoff for each service line, create a white paper from our AHRQ-certified Patient Safety Organization, and put this information in the hands of our clinicians to drive adoption of a standardized practice.” (Those best practices are available online.)
Because Envision Healthcare reaches more than 30 million patients each year, there’s a lot of opportunity for improvements. But Maccioli notes that Envision’s two largest service lines— emergency medicine and anesthesiology—stand out as offering the greatest opportunities.
“All of our service lines and all of our patients are of great importance to us, but when we look at emergency medicine, where we’re the largest emergency medicine provider in the U.S., [we’re seeing] one in every eight emergency medicine visits,” Maccioli says. Research indicates that emergency room physicians are interrupted approximately 10 times in an hour, making it easy to understand how handoff information may suffer. “The environmental situation, the noise, the stress involved in those environments is really pretty significant in terms of patient care,” Maccioli adds.
To improve these transitions, Envision aims to drive adoption of iHELPRR, a mnemonic checklist developed by its QuestCare organization, and Safer Sign Out, developed by the Emergency Medicine Patient Safety Foundation. In addition, Maccioli points to research that found poor communication during handoffs from anesthesiology was an implicating factor in 44% of bad outcomes. “So we’re really trying to drive adoption of our TEMPO handoff tool there,” he says.
Maccioli believes that having this information more easily discoverable will drive adoption. “Physicians by nature are very competitive people, so I believe once we get the critical mass of adopters, everyone will want to get on board. We’re looking for a little friendly competition to drive adoption as part of our culture of patient safety and patient care,” he says. Of course, Envision’s clinical quality committees will also focus on this handoff white paper to further drive adoption.
Because the white paper was just recently published, the organization’s goal is to conduct a survey across all service lines in the first quarter of 2019 to gauge adoption of best practices. The goal is to measure both the rate of adoption and the impact on patient outcomes to understand where additional improvements may be needed.
“We have a large and ongoing quality program at every service line where we track patient outcomes and certain complications, and we’re now going to refine our complication data set specifically around handoffs and begin to track that on a time basis and look for improvements there,” Maccioli says. “If we see global improvements, that’s obviously great, but what we really want to do is make sure that in this critical window that we’re focusing on that we’re getting the results we want.”
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at firstname.lastname@example.org.