Are handoffs too automatic’? QI experts fear errors could rise
Completing checklists without thinking can present safety challenge
When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) speaks, people listen. That was certainly the case when it began to issue its National Patient Safety Goals; health care professionals sat up and took notice and immediately began designing processes for complying with the new standards.
Things change quickly in today’s world of patient safety, however, and some quality improvement experts are beginning to note a disturbing new trend; medical staff are still going through the same steps to comply with standards such as hand-offs, but a number of them are doing so without really thinking about what it is they are doing — or, as one quality expert put it, "something that is done so automatically that people aren’t really paying attention to the issues they are supposed to be evaluating." This had led in some cases, they say, to errors being made even though staff indicated the processes were followed.
"We’re beginning to hear the same current of conversations amongst ourselves," notes Cheryl Como, RN, senior vice president of patient services at UPMC (University of Pittsburgh Medical Center) McKeesport (PA). "This is a trend; we’ve heightened everybody’s awareness, and things were good for awhile, but now problems seem to be surfacing again. We have done the strategies, but we have not eliminated error. When you study errors that occur, you see the staff went through the motions but were not really aware."
"There’s an argument made out there that when you standardize processes — like here, where we use standardized order sets — there’s value to it, because often you begin with common elements," adds Doris Gaudy, RN, senior director of patient services at UPMC McKeesport. "But as people engage in that kind activity day in and day out, that’s what leads them to go through the motions and take their brain’ out of the process."
"I think that’s the case with anything that becomes routine," offers Judy Homa-Lowry, president of Homa-Lowry Consulting in Metamora, MI. "For example, someone who goes to church regularly may read the same thing they’ve read many times before and yet be somewhere else.’"
A second pair of eyes’
The good news is that quality experts are aware of this potential problem, and are already thinking of ways to heighten quality assurance in hand-offs and other patient safety processes.
"We know some very smart people who have their eye on quality all the time, and their knee-jerk reaction is that we may need someone else to come in and do last-minute checks — somebody not involved in the case," suggests Como. "For example, in the OR, people who are not involved in that room can come in and look at the processes afresh."
Homa-Lowry agrees. "It might help to bring other clinicians in," she says. "Or, you can bring consultants in, who may be more likely to see the forest for the trees. Their knowledge base may be the same, but if they are not part of the process, perhaps they can see things better."
Another option, suggests Homa-Lowry, is to engage someone from another department who isn’t even a clinician. "Why not use an environmental care worker? They’re just doing a separate check sheet to see if you went through the process correctly; you just need someone who is competency-trained. And if you rotate them, that person will not get complacent."
It’s important, she continues, for that person to make sure everyone is participating actively in the process. "That would be part of the role of someone — to assume that leadership and make sure they clearly ask [questions of] everyone in the room," Homa-Lowry observes. "You really are supposed to have input from everybody in the room."
Carleen Penoza, RN, MHSA, clinical informatics specialist at William Beaumont Hospital in Royal Oak, MI, agrees. "One of the key things we felt was important was that we wanted to bring in all the clinical people — including transporters — who touched the case; we did not want to skip over somebody in the handoff process," she asserts. "If the patient was sent to radiology, you didn’t just deal with radiology. A key piece is to include everybody in that transport process."
Whatever approach you take, the key is "to ensure communication is there," says Peter Angood, MD, vice president and chief patient safety officer at JCAHO. "The Joint Commission set the national patient safety goals as just that — we don’t get too prospective of how institutions should do it. When the surveyors come through the hospitals they look for indicators of how the hospital is managing the process — not necessarily the specifics."
Ensure communication
So, how can quality experts best manage those processes? Angood offers several suggestions. "The use of the airline industry model, which is crew resource management, is seen to be very helpful in controlling system-oriented checks and balances," he offers. "Other types of systems that put in place the same sort of things are Six Sigma and Toyota lean processes; those have been implemented and shown some success."
The main components of such systems, he explains, are a routine, standardized process and open communication between each of the team members. "If there is a deficiency, then any one of the team members is able to flag it and stop the process," Angood notes.
SBAR, or Situation-Background-Assessment-Recommendation, is another "reasonable tool" for managing processes, he adds. "There is a variety of process and flow industry tools trying to be applied to health care; they are all meant to routinize things," he says.
Como says her facility has been taking a close look at SBAR. "It’s the kind of communication that keeps the brain engaged — where you follow the process and think about it every step of the way," she notes.
Gaudy agrees. "If you use SBAR as a methodology for communication, if done correctly it forces you to think about what you want as an outcome of your communication," she asserts.
Ensure communication
Health care experts agree such approaches can be helpful, although not always directly translatable to health care.
"In the airline industry, the pilot and co-pilot go through a checklist," Gaudy notes. "Somehow in that industry they are able to keep their brains engaged and not go through the motions. That’s one of the missing pieces in health care."
Homa-Lowry thinks she knows why. "What they do [in the pre-flight checklist] is different, in that they literally have to press the button and say the word like flaps on’" — she observes. "You can’t just look at a light and say Okay.’"
You can also sharpen the concentration of your staff by making specific adjustments to the actual forms you use, says Penoza. "One of the things we are doing is trying to use human factors in making the checklist usable, where you can quickly get the data you need up front," she says. "The first version we used was not as nice looking, and your eyes did not necessarily go to the answers of the questions."
Her team actually conducted some studies, says Penoza, and then looked at compliance. "If something was not directly in a line they were skipping it," she reports, noting that part of the formula for success is how you physically lay out your checklist.
"Another thing we try to minimize is leaving things too open-ended," Penoza continues. "We seem to do better if staff can check a box."
For example, she recalls, in the original forms, if a patient diet was NPO (nothing by mouth), the "diet" area on the checklist was blank. "What are we really trying to get at?" Penoza queries. "Are they NPO or not? If so, since when?"
Keep it interesting
"Even though you have a check sheet, you may want to look at varying the order so it’s just not so routine," adds Homa-Lowry. "Otherwise, your staff can become rote and complacent. You want to still cover all the same things, but vary the process in which it was done to keep it more interesting."
Gaudy offers this final thought: "As we move forward in health care, things are moving at the speed of light," she observes. "Oftentimes, we try to implement things for the sake of doing them — for example, because JCAHO says we should. But I am a firm believer that you have to take the time to implement things correctly, and your staff has to be well educated."
It’s critical, she continues, that your staff clearly understand why the things you are asking them to do are important. "Not everyone always understands these processes that way," she asserts. "Take the time to implement processes in the right way, because you know you can fully engage your staff that way."
For more information, contact:
Judy Homa-Lowry, RN, MS, Homa-Lowry Consulting, 560 W. Sutton Road, Metamora, MI 48455. Phone: (810) 245-1535. E-mail: [email protected].
Carleen Penoza, RN, MHSA, Clinical Informatics Specialist, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 551-1427.
Cheryl Como, RN, senior vice president of patient services,
Doris Gaudy, RN, Senior Director of Patient Services, UPMC McKeesport, 1500 Fifth Avenue, McKeesport, PA 15132-2482. Phone: (412) 664-2000.
Peter Angood, MD, Vice President and Chief Patient Safety Officer, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.
When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) speaks, people listen. That was certainly the case when it began to issue its National Patient Safety Goals; health care professionals sat up and took notice and immediately began designing processes for complying with the new standards.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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