Safer Sign Out
Physician Handoff Communication
Achieving High Reliability Through
Patient-Centered, Team-Based Innovation
v5
Drew C. Fuller, MD, MPH, FACEP
Board of Directors /
Education Committee
Past Chair, Quality
Improvement & Patient
Safety Section (QIPS)
(Synergy Interest)
Director of Safety
Innovation
Safer Sign Out
• Patient Centered
• Team Based
• Risk-Focused
• Physician (Frontline) Developed
• Method for Structured Physician Handoffs
National Patient Safety Goal
2E (2006)
Standardization of Handoff
Communication
“Sign out is the most dangerous
procedure in the Emergency
Department”
Charles “Chaz” Schoenfeld, MD
(1950-2010)
Why Structure?
• Up to 80% of serious medical errors involve
miscommunication during handoffs
(TJC)
Up to 24% ED malpractice claims related to handoff
(Cheung 2010)
Progress
• Nursing profession – Leading
with Models/Methods
• Few Physician Models
Emergency Departments - High Risk
ED Factors – Potentiate Errors
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Production/Time Pressure
High Noise Levels
High Acuity
Multitasking
Time Sensitive Conditions
Rapid Turnover
Frequent Interruptions
New/Unknown Patients
Undifferentiated Diagnosis
Wide Clinical Variation
Increasing Complexity
Handoffs - High Risk
Points of Potential Failure
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Neglected/Missed Information
Unclear Transfer of Responsibility
Team Unaware of Transfer/Issues
Patient/Family Unaware
Change in Status
Lack of Mechanism for QA
Why Structure is Critical
High Risk Process + High Risk Environment
Mandates
High Reliability
High Reliability
• Structured
• Workable
• Predictable
• Measurable
Industries
Committing to High Reliability
Pilots Committed to
Standardized Communication
“Quick” Handoff Practice
(To view the video, click https://vimeo.com/68618147)
Name that Handoff
Hit & Run?
“Typical” Handoff Practice
(To view the video, click https://vimeo.com/68618456)
Name that Handoff
“Hopeful Handoff”
What’s Missing?
Typical ‘Hopeful’ Handoff
• Critical items conveyed?
• Safeguards? (Checklist?)
• Current clinical status?
• Patient aware/Involved?
• Nurse aware/involved?
• QA ?
Hope Model for Safety
• Hope nothing goes wrong
• Safe By Luck or Design?
• Unstructured – No Standard
• Not High Reliability (High Vulnerability)
• Poor Strategy for Safety
Designing a Better Way
• Focus on areas of RISK
• Practical implementation
• Scalable
• WORK for Clinicians
EMA Safety Leadership Group
Physician Representation
12 Hospital/Clinical Sites:
Maryland
Virginia
Washington, DC
West Virginia
American College of Emergency Physicians
(ACEP)
Quality Improvement & Patient Safety (QIPS)
• White Paper on Improving Handoffs
by Dickson Cheung, Jack Kelly et al
• 20 National Clinical & Safety Experts
• Recommendations for Best Practice
Frontline Input
• Sign Out Safety Survey
• 104 ED Physicians & 50 PAs
• Directors’ Guidance
• ACEP QIPS leaders
• Executive Input
• Nursing Input & Feedback
“The Essential Connections”
Physician to Physician
Patient/Family
Nurse (Team)
Key Components
Safer Sign Out
1) Record - Critical Data & Pending Items
2) Review - Form & Computer Data
3) Round – Bedside, Together
4) Relay to the Team – Nurse
Collaboration
_____________________________________________________________________________________________________
5) Receive Feedback – Clinical/QA
Use a Recordable Form
• Clear transfer of responsibility
• Prompts to identify Key items
• Checklist & Reference Tool
Safer Sign Out Form (v16)
Check if No Patients Signed Out
Patient Name & Age
Off-Going Clinician: _________________ Receiving Clinician: _________________ Date (Shift Started)___________
Problem List & Key Issues
Diagnosis/CC:
Room
Key Issues:
Pending Items
Disposition
Home__________
_______ __________________
Receiving Clinician’s Notes
Rounded on Patient
Included/Informed Nurse
Admit__________
______________
Transfer________
______________
NH____________
Potential Safety Issues or Precautions?
TBD___________
Diagnosis/CC:
Room
Key Issues:
Home__________
_______ __________________
Rounded on Patient
Included/Informed Nurse
Admit__________
______________
Transfer________
______________
Potential Safety Issues or Precautions?
NH____________
TBD___________
Diagnosis/CC:
Room
Key Issues:
Home__________
_______ __________________
Rounded on Patient
Included/Informed Nurse
Admit__________
______________
Transfer________
______________
NH____________
Potential Safety Issues or Precautions?
TBD___________
Diagnosis/CC:
Room
Key Issues:
Home__________
_______ __________________
Admit__________
______________
Transfer________
______________
NH____________
Potential Safety Issues or Precautions?
TBD___________
This form is a Quality Assurance Tool and is NOT part of the medical record
Rounded on Patient
Included/Informed Nurse
Back of Sign Out Form (Reinforces Protocol)
Safer Sign Out Success
Patients to Sign Out
It#is#recommended#to#Sign%
out%
ALL%
patients%
that%
remain%
in%
the%
department#including#admitted#patients#yet#to#have#admission#orders
Key Components
Best Practices
1. Record
• Patient, Critical Details, Follow-up Items
1) Pre-Round (Off-going clinician)
Informing the patient prior to S.O. may help:
· Better prepare the patient.
· Increase efficiency
· Save your colleague’s time
2. Review
· SSO Form & Computer/chart Data
2) Confirm Mutual Understanding
3. Round Together
• Meet the Patient & Assure a Plan
Complete the sign out with:
“What Questions Do You Have?”
4. Relay to the Team
• Confirm the Plan with the Nurse/Team
3) Minimize Interruptions
4) Establish a Reliable QA process
5. Receive Feedback
• Use SSO Form for Clinical Follow-up & Process QA
· Collect & review forms
· Encourage Peer Coaching
Credits:
The Safer Sign Out process was originally developed by the Safety Leadership Group of Emergency Medicine Associates, PA, PC of Germantown, Maryland
and will be advanced with the following innovation and research partners:
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(Safer Sign Out Form Back Page)
Joint Focus - Form & Data
• Done at a computer
Access to lab/rad results
• Assure Shared Understanding
Purposeful time for Q & A
Bedside Round - Together
• Status -“Eyes on the patient”
• Introduction/Update
• Team Communication
Communicate with the Nurse –
Transition/Updates
• Opportunity for input/feedback
• Assures team understanding
• Before, during or after rounds
Form as a Feedback Tool
• Clinical Follow Up
• Quality Assurance Tool
Quality Assurance
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Built-in tool to help with QA
Initial Hospital Sites
Initial SSO Development Team
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Don Infeld, MD (EMA President)
Jackie Pollock, CEO (EMA)
Nicole Bergen, Dir. of Op. (EMA)
Martin Brown, MD, CMO (EMA)
John Schnabel, MD
Chris Morrow, MD
Tim Hsu, MD
Richard Ferraro, MD
Karla Lacayo, MD
Cameron Cushing, MD
Michael Kerr, MD
Steven Smith, MD
David Jacobs, MD
Jennifer Abele, MD
Drew White, MD, MBA
Michael Silverman, MD
Marney Treese, MD
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Justin Green, MD
Napoleon Magpantay, MD
Kurt Rodney, MD
Sora Chung, MD
Matt Sasser, MD
Jon D’Souza, MD
Todd Larson, MD
Junior Williams, MD
Larry Mack-Wilson, PA-C
Eric Parvis, MD
Chris Morrow, MD
Kala Scoggin, PA-C
Elizabeth Cook
Drew Fuller, MD, MPH
Kilole Kanno, MD
Nadia Eltaki,MD
Rapid Cycle Improvement
What We Learned
• Physician Champions (Key)
• Ease of implementation
• Educate & support
• Initial resistance resolves
• Use QA to sustain
Engaging Physicians
“Protect Your Patients, Support Your Colleagues”
• Appeal to their interest
• Performance => how it
’Occurs’ to them
• Listen, support & reassure
Understanding Adoption
Readiness for Change
“Start Where They Are”
Physician Feedback
“ This is so much better than what we use to
do”
“ I was initially resistant but now I get it”
“I sleep better at night”
Committed to Collaboration
• Share the Process
• Teach Others
• Seek Understanding
• Pursue Refinement
• Regionally/Nationally
Quality Improvement & Patient Safety Section
Website
First Featured Safety
Project
Emergency Medicine Patient Safety Foundation
(EMPSF)
• Voice for Safety in
Emergency Medicine
• National Collaborator
• SSO Flagship Safety Tool
• Dedicated SSO Website
• Consultation Service
SaferSignOut.com
Toolkit (Web-based)
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Education
Downloads
Forms
Posters
Strategy/Best Practices
Videos & More
Logo
AMA Handoff Resource Listing
• Handoff Resource (RFS)
• Description and links to
SaferSignOut.com
AMA Handoff Resource Listing
• Handoff Resource (RFS)
• Description and links to
SaferSignOut.com
Agency for Healthcare Research & Quality
(List SaferSignOut.com as a Resource)
SSO in the Press
SSO in the Press
ABEM MOC PI Tool
• Help your physicians
meet their MOC PI
requirement
• Easily Utilized
• To be featured on ACEP’s
Handoff education tool
Collaborative Synergistic Innovation
(CSI)
• Model for Innovation
• Open Resource
• Clinician Driven
• Best Practice Refinement
• Supports Research,
Distribution, Education
Innovation Partners
Leading the Way
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Use EMPSF as a resource
Enlist “Champions”
Build the case for a structured method
Launch as a Team based approach
Monitor the process & give feedback
Atul Gawande
"Better is possible. It does not take genius. It
takes diligence. It takes moral clarity. It takes
ingenuity. And above all, it takes a willingness
to try.”
Make the Commitment
1963 Speech at NASA
Throw Your Hat Over the Wall
SSO “Stand Up for Safety” Video
https://vimeo.com/65199210
We Stand
Committed to Safety
Further Information
Dianne Vass
Drew Fuller, MD, MPH, FACEP
Executive Director
Emergency Medicine Patient Safety
Foundation (EMPSF)
Folsom, California
Director of Patient Innovation
Emergency Medicine Associates, PA, PC
Germantown, Maryland
EMAOnline.com
Dvass@EMPSF.org
Drewfuller@mac.com