Julie K. Johnson

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

Background: The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or “sign-out”. This study aims to describe how communication failures during this process can lead to patient harm. Methods: In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers. Results: Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (κ 0.78–1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems. Conclusion: Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

A theoretical framework and competency-based approach to improving handoffs

Background: Once characterised by remarkable continuity of care by a familiar doctor, patient care today is delivered by multiple physicians with varying degrees of knowledge of the patient. Yet, few trainees learn the potential risks of these transitions and the strategies to improve patient care during handoffs. Little is known regarding the mechanisms by which handoffs affect patient care. Results: Building on theoretical constructs from the social sciences and illustrated with a case study of the implementation of a night float service for the inpatient general medicine services at the University of Chicago, a conceptual framework is proposed to describe how handoffs affect both patients and physicians. Conclusion: Using this conceptual framework, recommendations are made for formal education based on the core competencies of communication and professionalism. Opportunities to educate trainees in acquiring these skills are described in the context of handoffs of patient care.

Hand-off Education and Evaluation: Piloting the Observed Simulated Hand-off Experience (OSHE)

AimThe Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students’ sign-out skills using a real-time assessment tool, the Hand-off CEX.SettingThirty-two 4th year medical students participated as part of an elective course.Program descriptionOne week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video.Program evaluationInternal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the “Mini-CEX,” which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre- and post-student self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4–9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post- vs. 27% pre-reporting ‘well-prepared,’ p < 0.009).DiscussionThis brief, standardized hand-off training exercise improved students’ confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument.

A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease

OBJECTIVE To explore the impact of human factors on intraoperative adverse events and compensation mechanisms in pediatric cardiac surgery. METHODS Prospective observations of pediatric cardiac surgical procedures were conducted. Patient complexity scores were calculated and outcomes recorded. The process of care was divided into epochs. Events were extracted and coded into compensated or uncompensated major and minor adverse events. Linear regression and analysis of variance were used to analyze the relationships between epochs, complexity, adverse events, and outcome. Patient-specific and procedure-specific variables were tested in a forward stepwise logistic regression as predictors of cases with 1 or more major adverse events. RESULTS One hundred two patients undergoing pediatric cardiac surgery were observed. An average of 1.2 (range 0-6) major adverse events occurred per case. The most common type of major adverse event was cardiovascular, and most occurred during the surgery/postbypass epoch. Cognitive compensation was the most common compensation mechanism for major adverse events. An average of 15.3 minor adverse events occurred per case. Minor adverse events occurred frequently during the surgery/bypass epoch and related to communication and coordination failures. Higher case complexity, longer surgery duration, and higher number of major adverse events per patient correlated with death compared with other outcome groups (P < .01). Case complexity (P < .01) and surgery duration (P < .05) were both significant predictors of major adverse events. CONCLUSIONS Pediatric cardiac surgery is an ideal model to study the coordinated efforts of team members in a complex organizational structure. Adverse events occurred routinely during pediatric cardiac surgery and were mostly compensated. Case complexity was a significant predictor of major adverse events. The number of major adverse events per patient correlated with clinical outcomes.

Understanding the complexity of redesigning care around the clinical microsystem

The microsystem is an organizing design construct in which social systems cut across traditional discipline boundaries. Because of its interdisciplinary focus, the clinical microsystem provides a conceptual and practical framework for simplifying complex organizations that deliver care. It also provides an important opportunity for organizational learning. Process mapping and microworld simulation may be especially useful for redesigning care around the microsystem concept. Process mapping, in which the core processes of the microsystem are delineated and assessed from the perspective of how the individual interacts with the system, is an important element of the continuous learning cycle of the microsystem and the healthcare organization. Microworld simulations are interactive computer based models that can be used as an experimental platform to test basic questions about decision making misperceptions, cause-effect inferences, and learning within the clinical microsystem. Together these tools offer the user and organization the ability to understand the complexity of healthcare systems and to facilitate the redesign of optimal outcomes.

Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules

SummaryIntroduction/aimStandard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.Program descriptionUsing the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.Program EvaluationTo date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.DiscussionThe ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study

Background: Little is known regarding how internal medicine residents manage uncertainty during decision making and subsequent effects on patient care. The aims of this study were to describe types of uncertainty faced by residents, strategies employed to manage uncertainty and effects on patient care. Methods: Using critical incident technique, residents were asked to recall important clinical decisions during a recent call night, with probes to identify decisions made during uncertainty. They were also asked to report who they approached for advice. Three authors independently coded transcripts using the constant comparative method. Results: The 42/50 (84%) interviewed residents reported 18 discrete critical incidents. Six categories emerged and mapped to the domains of the Beresford Model of Clinical Uncertainty: technical uncertainty (procedural skills, knowledge of indications); conceptual uncertainty (care transitions, diagnostic decision making and management conflict) and personal uncertainty (goals of care). In managing uncertainty, residents report a “hierarchy of assistance”, using colleagues and literature for initial management, followed by senior residents, specialty fellows and, finally, the attending physician. Barriers to seeking the attending physician’s input included the existence of a defined hierarchy for assistance and fears of losing autonomy, revealing knowledge gaps, and “being a bother”. For 12 of the 18 cases reported, patient care was compromised: delay in procedure or escalation of care (n = 8); procedural complications (n = 2); and cardiac arrest (n = 2). Conclusion: Resident uncertainty results in delays of indicated care and, in some cases, patient harm. Despite the presence of a supervisory figure, residents adhere to a hierarchy when seeking advice in clinical matters.

Computer-Facilitated Substance Use Screening and Brief Advice for Teens in Primary Care: An International Trial

OBJECTIVE: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system. METHODS: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12- to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and “talking points” designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up. RESULTS: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38–0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57–0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17–0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32–0.71). CONCLUSIONS: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.

Nurses’ workarounds in acute healthcare settings: a scoping review

BackgroundWorkarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses’ use of workarounds in acute care settings.MethodsA literature assessment was undertaken in 2011–2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses’ workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses’ conceptualisation and rationalisation of workarounds.ResultsThe majority of studies examining nurses’ workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses’ workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, ‘being competent’, and collegiality influence the implementation of workarounds.ConclusionWorkarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses’ individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses’ use of workarounds.

Organizational culture: an important context for addressing and improving hospital to community patient discharge

Background:Organizational culture is seen as having a growing impact on quality and safety of health care, but its impact on hospital to community patient discharge is relatively unknown. Objectives:To explore aspects of organizational culture to develop a deeper understanding of the discharge process. Research Design:A qualitative study of stakeholders in the discharge process. Grounded Theory was used to analyze the data. Subjects:In 5 European Union countries, 192 individual and 25 focus group interviews were conducted with patients and relatives, hospital physicians, hospital nurses, general practitioners, and community nurses. Results:Three themes emerged representing aspects of organizational culture: a fragmented hospital to primary care interface, undervaluing administrative tasks relative to clinical tasks in the discharge process, and lack of reflection on the discharge process or process improvement. Nine categories were identified: inward focus of hospital care providers, lack of awareness to needs, skills, and work patterns of the professional counterpart, lack of a collaborative attitude, relationship between hospital and primary care providers, providing care in a “here and now” situation, administrative work considered to be burdensome, negative attitude toward feedback, handovers at discharge ruled by habits, and appreciating and integrating new practices. Conclusions:On the basis of the data, we hypothesize that the extent to which hospital care providers value handovers and the outreach to community care providers is critical to effective hospital discharge. Community care providers often are insufficiently informed about patient outcomes. Ongoing challenges with patient discharge often remain unspoken with opportunities for improvement overlooked. Interventions that address organizational culture as a key factor in discharge improvement efforts are needed.