Information sharing among nurses is critical to patient safety. In the fall of 2012, the Nursing Handoff & Transitions Task Force, a subcommittee of the Practice Council, was formed to address patient safety issues and to review UNC Health Care’s culture surrounding patient handoffs and transitions. This was prompted by the results of the Patient Safety Culture Survey which identified 45 – 65 percent of nurses across the organization feeling that information “falls through the cracks” either during shift changes or when transferring a patient to another area within the hospital system. This placed our hospital in the 10th percentile compared to the national benchmark for both 2009 and 2011 survey periods.
It became the taskforce’s mission to understand the critical elements of a thorough handoff and to review and understand the current processes across units during handoffs; identifying both things that work well and areas of needed improvement.
“By changing our safety culture to include a standardized patient engaged report during shift change, we hope to ensure that these aren’t our patient safety culture results in the future,” says task force co-chair Andrea Dicus, BSN, RN, who became familiar with the evidence surrounding effective communication during handoffs while pursuing her graduate studies.
Serving as a trial for improved handoffs, Andrea and the leadership team in the ISCU has implemented the standardized handoff tool designed by the Handoff and Transitions Taskforce on their unit. The tool is intended to significantly reduce the likelihood that information will be missed during shift change.
“Across the hospital we have very good nurses who relay the important information consistently,” she says. “But there are instances when all of us, no matter the unit, are interrupted and information may not be relayed. The tool is a standardized method for giving report that helps the nurse remember what information must be communicated and reviewed with the receiving nurse.”
The intent is to provide all relevant information that the oncoming nurse will need to properly care for the patient.
In addition to filling out the tool, ISCU nurses also present the completed tool to the oncoming nurse in front of the patient.
“We see a lot of opportunity by presenting handoff information in front of the patient,” Andrea says. “As a culture, we always stand at the nursing station to exchange information. But when we do it in front of the patient, we inherently learn more about each patient and about our work, and we invite the patient into the process of their care.”
The ISCU has found that patients react favorably to the new process.
“They’re very receptive,” she says. “Some listen and take part, while others wait until the end of the report to weigh in about their care plan.”
Andrea believes that the results of including patients in their care will be seen on future patient satisfaction scores.
“If patients feel more a part of the communication, they will feel added security with their care,” she says. “Studies have shown that hospitals that effectively implement patient-engaged reports also see an improvement with their HCAHPS scores. Patients surveyed after being included in the shift report described better communication with the nursing staff, feeling more respected by nursing, and that nurses explained information in a way they could understand. When we do our shift changes this way, patients have an opportunity to ask questions and clarify the plan for the shift.”
Andrea points out that the benefits of a standardized shift change are felt in other important areas. For instance, evidence suggests that overtime decreases when shift-change tools are in place.
“If you have a process in which you effectively prepare for the shift change, then you save time for the oncoming nurse,” she says. “If a thorough report is given, there’s no time wasted researching something that could have been communicated during the handoff. Essentially you’re starting your shift on time by spending less time searching for missed information.”
Other patient needs may be met as well. For example, conducting the handoff in the patient’s room rather than at the nursing station or in the hallways provides the oncoming nurse the help of a second person in case a patient needs to be repositioned. It ensures that double signoffs are performed. Furthermore, the patient’s presence sometimes reminds the nurse of certain happenings or assessment points that they may have forgotten.
Andrea and the task force hope that shift change standardization will become a hospital-wide effort. The Handoff Taskforce is asking all units to implement the standardized process on Nov. 18. She acknowledges, however, that challenges lie ahead. But she believes standardizing handoffs in such a way will improve patient safety and satisfaction, and has hopes that nursing will experience benefits from standardizing the report process
“If we can improve the 2011 Patient Safety Culture Survey results, if those same nurses can be asked the same questions after this implementation, then hopefully we will see those numbers decrease when nurses are asked whether information ‘falls through the cracks,’ and then we will know we’re doing what we need to do to improve patient safety.”
Please take the 2013 Patient Safety Culture Survey by Nov. 20. In addition to measuring traditional metrics for patient safety, this year’s survey will measure how well UNC Hospitals’ units and outpatient clinics recognize the effects of stress as well as their levels of resilience.