A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process

Abstract

There is mounting evidence that communication and hand-off failures are a root cause of two-thirds of sentinel events in hospitals. Several studies have shown that non-standardized hand-offs have yielded poor patient outcomes and adverse events. At Stony Brook University Hospital, there were numerous reported adverse events related to poor hand-off during the transfer of patient responsibility from one resident caregiver to the next. A resident-conducted root cause analysis identified lack of a standardized hand-off process and formal training on safe and efficient hand-off among caregivers as key contributing factors.This quality improvement project used the PDSA methodology to test the use of a standardized method, the IPASS mnemonic, and compare it to our conventional hand-off method in our internal medicine residency program. The main goals of this study were to test the feasibility and effectiveness of a standardized I- PASS hand-off and to create a robust sustainability model that includes 1) integration of I-PASS handoff in the Electronic Medical Record (EMR), 2) direct observation of the hand-off process by faculty and senior residents, and 3) surveillance and reporting of hand-off compliance scores.Compared to hand-off with a conventional method, the use of the I-PASS method resulted in significantly fewer reported adverse events (χ2=4.8, df=1, p=0.04). I-PASS was successfully integrated into our EMR system and residents were mandated to use this as the sole method of hand-off. An EMR audit conducted six months after implementation revealed poor compliance, which ultimately led to the creation of a sustainability model that improved overall compliance from 60% to 100%.

Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings

“…Physician adherence to the I-PASS mnemonic illustrates the importance of using a written handoff tool that incorporates I-PASS formating. 20 At the initiation of our project, physician I-PASS adherence increased from ≈40% to ≈90% in 4 months (Fig. 4 ).…”

“…Across all areas, mean adherence rates to using all five components of the I-PASS mnemonic were 76%–89%, exceeding those previously reported. 9 , 20 , 21 Further, perceived handoff error rates decreased for inpatient nurses, overall perceptions of handoff performance increased across all disciplines studied, and most respondents reported increases in personal handoff performance.…”

“…The I-PASS program was selected as it has strong evidence supporting its ability to improve patient safety. 9 , 14 , 20 , 24 Chief among previous research is a multisite study by Starmer et al 9 One compelling aspect of their research was its rigorous methodology, which used extensive resources to attribute reduced errors and AEs to I-PASS use affirmatively. While I-PASS was developed for resident physician handoffs, we presumed that the core elements of I-PASS could be maintained across many handoff contexts and disciplines.…”

“…Handoff performance has been monitored through direct observation in previous handoff research. 9 , 12 , 20 - 22 , 26 Our QI champion volunteers received training that focused on delivering constructive and actionable feedback to enhance individual handoff performance continually. Additionally, regular observation and feedback signals to clinicians that handoff communication is an essential clinical skill worth mastering.…”

“…We defined adherence as the utilization of each of the 5 components of the I-PASS mnemonic. We evaluated adherence through direct observation, 20 - 22 in which a third clinician observed patient handoffs, either in-person or by phone (see Figures 2 and 3, Supplemental Digital Content, which displays model of handoff interaction, direct observation, and provision of formative feedback during physician evening handoff between a daytime fellow and overnight clinician. A peer or supervisor observes handoff, then provides feedback to the handoff giver and receiver, http://links.lww.com/PQ9/A195 ; model of handoff interaction, direct observation, and provision of formative feedback during handoff between an inpatient nurse and diagnostic imaging technologist.…”