Gap Analysis: Annotated Bibliography
Appendix 1. Annotated Bibliography of Key Articles Identified for Gap Analysis
Abraham, J., Kannampallil, T. G., & Patel, V. L. (2012). Bridging gaps in handoffs: A continuity of care based approach. Journal of biomedical informatics, 45(2), 240-254.
Application to Review: Nurse-Physician, Handoff, Work low, Continuity of Care Model, Clinician Centered Approach
Abstract
Handoff among healthcare providers has been recognized as a major source of medical errors. Most prior research has often focused on the communication aspects of handoff, with limited emphasis on the overall handoff process, especially from a clinician workflow perspective. Such a workflow perspective that is based on the continuity of care model provides a framework …show more content…
required to identify and support an interconnected trajectory of care events affecting handoff communication. To this end, we propose a new methodology, referred to as the clinician-centered approach that allows us to investigate and represent the entire clinician workflow prior to, during and, after handoff communication. This representation of clinician activities supports a comprehensive analysis of the interdependencies in the handoff process across the care continuum, as opposed to a single discrete, information sharing activity. The clinician-centered approach is supported by multifaceted methods for data collection such as observations, shadowing of clinicians, audio recording of handoff communication, semi-structured interviews and artifact identification and collection. The analysis followed a two-stage mixed inductive–deductive method. The iterative development of clinician-centered approach was realized using a multi-faceted study conducted in the Medical Intensive Care Unit (MICU) of an academic hospital. Using the clinician-centered approach, we (a) identify the nature, inherent characteristics and the interdependencies between three phases of the handoff process and (b) develop a descriptive framework of handoff communication in critical care that captures the non-linear, recursive and interactive nature of collaboration and decision-making. The results reported in this paper serve as a “proof of concept” of our approach, emphasizing the importance of capturing a coordinated and uninterrupted succession of clinician information management and transfer activities in relation to patient care events.
Ashbrook, L., Mourad, M., & Sehgal, N. (2013). Communicating discharge instructions to patients: A survey of nurse, intern, and hospitalist practices. Journal of Hospital Medicine, 8(1), 36-41.
Application to Review: Nurse-Physician Communication, Informing Patients, Discharge
Abstract
BACKGROUND:
Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization.
OBJECTIVES:
To understand nurse and physician communication practices around patient discharge education.
SETTING:
University of California, San Francisco Medical Center (UCSFMC).
PARTICIPANTS:
Nurses, interns, and hospitalists caring for hospitalized medicine patients.
MEASUREMENTS:
Participants were surveyed regarding discharge education practices. The survey asked respondents about 13 elements of discharge education found in the literature. For each element, participants were queried regarding: 1) the provider responsible for this element of patient education; 2) the frequency with which they communicate this teaching to patients; 3) how often they directly communicate with the nurse or physician caring for the patient about each element; and 4) tools to improve nurse–physician communication.
RESULTS:
A total of 129/184 (70%) nurses, interns, and hospitalists responded to the survey. The majority of respondents in all 3 groups felt that 9 of 13 elements were a combined responsibility. Nurses reported educating patients on these 9 items significantly more often than physicians (P < 0.05). All groups also agreed that instruction on 2 of the elements, summary of hospital findings and pending results, should be primarily the physicians ' responsibility; these were the elements least often discussed by any provider. Despite the majority of items being agreed upon as a shared responsibility, communication between nurses and physicians regarding discharge education was low. Standardized verbal communication on the day of discharge was supported most strongly by all providers.
CONCLUSIONS:
Ambiguous responsibility for providing discharge education and poor communication between nurses and physicians offers an opportunity for improvement.
Brady, P. W., & Goldenhar, L. M. (2013). A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognized patient risk. BMJ Quality & Safety, bmjqs-2012.
Application to Review: Interdisciplinary Collaboration, Situational Awareness, Patient Safety (Recognition of the Deteriorating Patient)
Abstract
Background Situation awareness (SA)—the perception of data elements, comprehension of their meaning and projection of their status in the near future—has been associated with human performance in high-risk environments, including aviation and the operating room.
The influences on SA in inpatient medicine are unknown.
Methods We conducted seven focus groups with nurses, respiratory therapists and resident physicians using a standardised semistructured focus group guide to promote discussion. Recordings of the focus groups were transcribed verbatim, and transcripts were qualitatively analysed by two independent reviewers to identify convergent and divergent themes.
Results Three themes emerged: (1) team-based care, (2) availability of standardised data and (3) standardised processes and procedures. We categorised these into social, technological and organisational influences on SA. Subthemes that emerged from each focus group were shared language to describe at-risk patients, provider experience in critical care/deterioration and interdisciplinary huddles to identify and plan for at-risk patients. An objective early warning score, proactive assessment and planning, adequate clinician staffing and tools for entering, displaying and monitoring data trends were identified by six of seven groups. Our data better reflected the concepts of team SA and shared SA than individual …show more content…
SA.
Conclusions Team-based care and standardisation support SA and the identification and treatment of patient risk in the complex environment of inpatient care. These findings can be used to guide the development and implementation of targeted interventions such as huddles to proactively scan for risk and electronic health record displays of data trends.
Brady, P. W., Muething, S., Kotagal, U., Ashby, M., Gallagher, R., Hall, D., ... & Wheeler, D. S. (2013). Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics, 131(1), e298-e308.
Application to Review: Interdisciplinary Collaboration, Situational Awareness, Patient Safety (Recognition of the Deteriorating Patient)
Abstract
BACKGROUND AND OBJECTIVE:
Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer.
METHODS:
The setting for our observational time series study was a quaternary care children 's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread.
RESULTS:
The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.
CONCLUSIONS:
A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.
Collins, S. A., Mamykina, L., Jordan, D., Stein, D. M., Shine, A., Reyfman, P., & Kaufman, D. (2012). In search of common ground in handoff documentation in an Intensive Care Unit. Journal of biomedical informatics, 45(2), 307-315.
Application to Review: Handoff, Technology, Tools, Interdisciplinary, Behavior
Abstract
Objective
Handoff is an intra-disciplinary process, yet the flow of critical handoff information spans multiple disciplines. Understanding this information flow is important for the development of computer-based tools that supports the communication and coordination of patient care in a multi-disciplinary and highly specialized critical care setting. We aimed to understand the structure, functionality, and content of nurses’ and physicians’ handoff artifacts.
Design
We analyzed 22 nurses’ and physicians’ handoff artifacts from a Cardiothoracic Intensive Care Unit (CTICU) at a large urban medical center. We combined artifact analysis with semantic coding based on our published Interdisciplinary Handoff Information Coding (IHIC) framework for a novel two-step data analysis approach.
Results
We found a high degree of structure and overlap in the content of nursing and physician artifacts. Our findings demonstrated a non-technical, yet sophisticated, system with a high degree of structure for the organization and communication of patient data that functions to coordinate the work of multiple disciplines in a highly specialized unit of patient care.
Limitations
This study took place in one CTICU. Further work is needed to determine the generalizability of the results.
Conclusions
Our findings indicate that the development of semi-structured patient-centered interdisciplinary handoff tools with discipline specific views customized for specialty settings may effectively support handoff communication and patient safety.
Collins, S. A., Stein, D. M., Vawdrey, D. K., Stetson, P. D., & Bakken, S. (2011). Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review. Journal of biomedical informatics, 44(4), 704-712.
Application to Review: Handoff, Nurse-Physician Communication, Tool, Computer, Continuity of Care Documentation, Multidisciplinary
Abstract
Purpose
The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs).
Methods
We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed.
Results
Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%.
Conclusion
Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.
Coleman, E. A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555.
Application to Review: Transition Challenges, Plan of Care, Knowledge Development
Abstract
Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.
Crawford, M. J., Rutter, D., Manley, C., Weaver, T., Bhui, K., Fulop, N., & Tyrer, P. (2002). Systematic review of involving patients in the planning and development of health care. Bmj, 325(7375), 1263.
Application to Review: Patients, Care Plan, Engagement Knowledge, Behaviors, and Attitudes
Abstract
Objective: To examine the effects of involving patients in the planning and development of health care.
Data sources: Published and grey literature.
Study selection: Systematic search for worldwide reports written in English between January 1966 and October 2000.
Data extraction: Qualitative review of papers describing the effects of involving patients in the planning and development of health care.
Results: Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported.
Conclusions: Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.
Deering, S., Johnston, L. C., & Colacchio, K. (2011, April). Multidisciplinary teamwork and communication training. In Seminars in perinatology (Vol. 35, No. 2, pp. 89-96). WB Saunders.
Application to Review: Interdisciplinary Teamwork, Training, Communication, Coordination, Intervention, Knowledge, Behavior, Attitudes
Abstract
Every delivery is a multidisciplinary event, involving nursing, obstetricians, anesthesiologists, and pediatricians. Patients are often in labor across multiple provider shifts, necessitating numerous handoffs between teams. Each handoff provides an opportunity for errors. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of complications result from team, rather than individual, failures. In 2004, a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization 's culture and communication failures. It was recommended that hospitals implement teamwork training programs in an effort to improve outcomes. Instituting a multidisciplinary teamwork training program that uses simulation offers a risk-free environment to practice skills, including communication, role clarification, and mutual support. This experience should improve patient safety and outcomes, as well as enhance employee morale.
Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and situation awareness. BMJ quality & safety.
Application to Review: Interdisciplinary Communication, Patient Safety, Intervention (Huddles)
Abstract
Background Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm.
Methods Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children 's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques.
Results Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff 's quality of collective awareness and enhanced capacity for eliminating patient harm.
Conclusions While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.
Hall, J., Peat, M., Birks, Y., Golder, S., Entwistle, V., Gilbody, S., ... & Wright, J. (2010). Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. Quality and Safety in Health Care, 19(5), e10-e10.
Application to Review: Patient Engagement, Patient Safety, Intervention, Knowledge, Behaviors, Attitudes
Abstract
Background There is growing international interest in involving patients in interventions to promote and support them in securing their own safety. This paper reports a systematic review of evaluations of the effectiveness of interventions that have been used with the explicit intention of promoting patient involvement in patient safety in healthcare.
Methods The authors searched Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CENTRAL, CINAHL, EMBASE, HMIC, MEDLINE, MEDLINE in-process, PsycINFO and ASSIA to August 2008. We also searched databases of reports, conference proceedings, grey literature, ongoing research and relevant patient safety organisations, and hand-searched two journals. Meta-analysis of the data was not appropriate; therefore, studies were categorised according to how the interventions encouraged patients ' actions to improve safety—informing the management plan, monitoring and ensuring safe delivery of treatment (by health professional and by self), making systems safer—and were critiqued in a narrative manner.
Findings The authors identified 14 individual experimental and quasiexperimental studies plus one systematic review. The majority of studies fell into the monitoring and ensuring safe delivery of treatment by self category and were all related to enhancing medication safety. Authors reported improved patient safety incident outcomes for the intervention groups compared with controls where the interventions aimed to encourage patient involvement in: (1) monitoring and ensuring safe delivery of treatment by self (self-management of anticoagulation, ‘easy’ read information leaflet, nurse-led education to promote self-medication in hospital, patient package insert using lay terminology); (2) informing the management plan/monitoring and ensuring safe delivery of treatment by self (individualised teaching plan by nurse, pharmacist counselling). It was not possible to draw any clear conclusions as to the effectiveness of the interventions (with the exception of one specific aspect of self-medication, that is, self-management of anticoagulation) due to concerns about the methodological quality of the studies.
Conclusions There is limited evidence for the effectiveness of interventions designed to promote patient involvement on patient safety incidents and in general is poor quality. Existing evidence is confined to the promotion of safe self-management of medication, most notably relating to the self-management of oral anticoagulants.
Henriksen, K., Battles, J. B., Keyes, M. A., Grady, M. L., Dingley, C., Daugherty, K., ... & Persing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements.
Application to Review: Interdisciplinary teams, Communication tools, Interventions, Behaviors and Attitudes
Excerpt
The purpose of this study was to develop, implement, and evaluate a comprehensive provider/team communication strategy, resulting in a toolkit generalizable to other settings of care. The specific aims included implementation of a structured communication tool; a standardized escalation process; daily multidisciplinary patient-centered rounds using a daily goals sheet; and team huddles. The study setting was the 477-bed medical center of the Denver Health and Hospital Authority, an integrated, urban safety-net system. Utilizing a pre-test/post-test design, baseline and post-intervention data were collected on pilot units (medical intensive care unit, acute care unit, and inpatient behavioral health units). Analysis of 495 communication events after toolkit implementation revealed decreased time to treatment, increased nurse satisfaction with communication, and higher rates of resolution of patient issues post-intervention. The resultant toolkit provides health care organizations with the means to implement teamwork and communication strategies in their own settings.
Johnson, S., & Kring, D. (2011). Nurses ' perceptions of nurse-physician relationships: medical-surgical vs. intensive care. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 21(6), 343-347.
Application to Review: Nurse-Physician, Setting Specific, Relationship, Collaboration
Abstract
Effective collaboration between nurses and physicians (RN-MD) is essential in facilitating improved patient care outcomes. A pilot study was conducted among nurses on medical-surgical and intensive care units to identify differences in nurses ' perceptions of RN-MD collaborative efforts.
INTRODUCTION:
Collaboration between nurses and physicians is essential in fostering interdisciplinary relationships. Specialty practice may influence the quality of this collaboration. Effective communication and collegial RN-MD relationships are critical to improved patient outcomes.
PURPOSE:
The purpose of this study was to identify differences in nurses ' perceptions of collaborative efforts between nurses and physicians in medical-surgical (MSUs) units versus intensive care units (ICUs).
RESULTS:
A descriptive survey methodology was employed. Nurses in three ICUs and eight MSUs within a 975-bed Magnet hospital completed a 25-item Nurse-Physician Relationship survey, used in previous studies on RN-MD communication. The sample (N = 170) consisted of 54% medical-surgical nurses and 46% ICU nurses. No statistically significant differences were found in the demographic variables between the MSU and ICU nurses except for educational degree. A greater percentage of ICU nurses held a bachelor 's degree. This study found that although some differences existed in ICU and MSU nurses ' perceptions of RN-MD collaboration, there are more similarities between the two areas. Overall, nurses were satisfied with RN-MD relationships, with 75% of ICU and 65% of MSU nurses reporting satisfaction (p = 0.110). MSU nurses were less likely to participate in interdisciplinary rounds than ICU nurses (p < 0.001). ICU nurses were more likely than MSU nurses to report that physicians treat nurses as handmaidens (p = 0.056) and that physicians displayed unprofessional behavior (p = 0.019).
CONCLUSIONS:
Certain nursing specialty areas are not immune to problems with RN-MD relationships. Rather, all clinical service lines should be concerned with fostering collegiality between nurses and their physician partners.
Karalapillai, D., Baldwin, I., Dunnachie, G., Knott, C., Eastwood, G., Rogan, J., & Jones, D. (2013). Improving communication of the daily care plan in a teaching hospital intensive care unit. Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine, 15(2), 97-102.
Application to Review: Multidisciplinary Daily Care Plans, Communication, Handoff, Checklist, Intervention, Documentation, ICU, Knowledge and Behaviors
Abstract
BACKGROUND:
Patients admitted to intensive care units have complex care needs. Accordingly, communication and handover of the medical care plan is very important.
OBJECTIVE:
To assess changes in ICU nurses ' understanding of the medical daily care plan after development and implementation of a pro forma to improve documentation and communication of the plan.
DESIGN, SETTING AND PARTICIPANTS:
The study was conducted between February and November 2012 in a mixed medical-surgical, 18-bed, closed ICU in a teaching hospital. Baseline and post-intervention surveys assessed ICU bedside nurses ' self-reported understanding of elements of the daily care plan.
INTERVENTION:
After receiving input from bedside nurses and medical staff, we developed the daily care plan as a single-page pro forma for handwritten documentation of a clinical problems list, plan and interventions list, daily chest x-ray results, a modified FAST-HUG checklist, and discharge planning during the evening consultant ward round.
The finalised pro forma was introduced on 25 July 2012.
RESULTS:
Introduction of the pro forma daily care plan was associated with marked and statistically significant improvements in nurses ' self-reported understanding of a list of the patient 's clinical problems, the management plan after the ward round, issues for discharge for the following day (all P < 0.001) and, to a lesser extent, the physiological targets and aims (P = 0.003) and interpretation of the daily chest x-ray (P < 0.001). In the post-intervention survey, only 4/118 free-text comments (3.4%) suggested that documentation of the plan was doctor-dependent, compared with 28/198 (14.1%) at baseline (P = 0.002).
CONCLUSIONS:
Introduction of a single-page, handwritten, structured daily care plan produced marked improvements in ICU nurses ' self-reported understanding of elements of the medical plan, and may have reduced practice variation in medical plan documentation. The effects of this intervention on patient outcomes remain
untested.
Keenan, G., Yakel, E., Lopez, K. D., Tschannen, D., & Ford, Y. B. (2013). Challenges to nurses ' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245-251.
Application to Review: Nurse-team Communication, Care Coordination, Orders, Documentation, Knowledge, Behaviors and Attitudes
Abstract:
The leaders of Geriatrics and Extended Care ( GEC) in the Veterans Health Administration ( VHA) undertook a strategic planning process that led to approval in 2009 of a multidisciplinary, evidence-guided strategic plan. This article reviews the four goals contained in that plan and describes VHA 's progress in addressing them. The goals included transforming the healthcare system to a veteran-centric approach, achieving universal access to a panel of services, ensuring that the Veterans Affair 's ( VA) healthcare workforce was adequately prepared to manage the needs of the growing elderly veteran population, and integrating continuous improvement into all care enhancements. There has been substantial progress in addressing all four goals. All VHA health care has undergone an extensive transformation to patient-centered care, has enriched the services it can offer caregivers of dependent veterans, and has instituted models to better integrate VA and non- VA cares and services. A range of successful models of geriatric care described in the professional literature has been adapted to VA environments to gauge suitability for broader implementation. An executive-level task force developed a three-pronged approach for enhancing the VA 's geriatric workforce. The VHA 's performance measurement approaches increasingly include incentives to enhance the quality of management of vulnerable elderly adults in primary care. The GEC strategic plan was intended to serve as a road map for keeping VHA aligned with an ambitious but important long-term vision for GEC services. Although no discrete set of resources was appropriated for fulfillment of the plan 's recommendations, this initial report reflects substantial progress in addressing most of its goals.
King, B. J., Mills, P. D., Fore, A., & Mitchell, C. (2012). The Daily Plan®: Including patients for safety 's sake. Nursing Management, 43(3), 15-18.
Application to Review: Interdisciplinary, Daily Care Plans, Physician-Nurse-Patient, Patient Safety, Knowledge, Behaviors and Attitudes
Abstract:
Actively including patients in their care and educating them about what will occur during hospitalization can help improve patient safety. It has been noted that the patient is the only constant in the healthcare system and the patient 's vigilance is a critical aspect of patient safety. Simple mistakes that lead to patient harm may be prevented when the patient is part of the checks and balances of the healthcare system. A meaningful phrase, credited to an English midwife, “nothing about me without me,” has been used many times to reflect the importance of patients and healthcare professionals working together. Several nationally recognized organizations have provided publications advising patients to participate in patient safety. Among them was The Joint Commission 's Speak Up and the Agency for Healthcare Research and Quality 's 20 Tips. These documents encourage patients to ask questions of their healthcare providers. It has been reported that patients are less willing to ask health professionals challenging questions than factual questions about their condition and treatment. The success of efforts to partner with patients to improve safety depends largely on the attitudes and actions of healthcare professionals, not the consumers. Although most medical literature supports patient involvement for patient safety, healthcare professionals still need to define successful, workable approaches to involve patients in their care. One of our approaches is called The Daily Plan®.
Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. T. (2013). A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU. Critical care medicine.
Application to Review: Interdisciplinary, Care Plans, Intervention (Team Rounding), ICU, Knowledge and Behaviors
OBJECTIVES:
Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU.
DATA SOURCES:
Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012.
STUDY SELECTION:
Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU.
DATA EXTRACTION:
Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool.
DATA SYNTHESIS:
The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians.
CONCLUSIONS:
Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation.
Leipzig, R. M., Hyer, K., Ek, K., Wallenstein, S., Vezina, M. L., Fairchild, S., & Howe, J. L. (2002). Attitudes toward working on interdisciplinary healthcare teams: A comparison by discipline. Journal of the American Geriatrics Society, 50(6), 1141-1148.
Application to Review: Interdisciplinary Teams, Communication, Coordination, Care Plans, Attitudes
Abstract
Interdisciplinary teams are important in providing care for older patients, but interdisciplinary teamwork is rarely a teaching focus, and little is known about trainees ' attitudes towards it. To determine the attitudes of second-year post-graduate (PGY-2) internal medicine or family practice residents, advanced practice nursing (NP), and masters-level social work (MSW) students toward the value and efficiency of interdisciplinary teamwork and the physician 's role on the team, a baseline survey was administered to 591 Geriatrics Interdisciplinary Team Training participants at eight U.S. academic medical centers from January 1997 to July 1999.
Most students in each profession agreed that the interdisciplinary team approach benefits patients and is a productive use of time, but PGY-2s consistently rated their agreement lower than NP or MSW students. Interprofessional differences were greatest for beliefs about the physician 's role; 73% of PGY-2s but only 44% to 47% of MSW and NP trainees agreed that a team 's primary purpose was to assist physicians in achieving treatment goals for patients. Approximately 80% of PGY-2s but only 35% to 40% of MSW or NP trainees agreed that physicians have the right to alter patient care plans developed by the team. Although students from all three disciplines were positively inclined toward medical interdisciplinary teamwork, medical residents were the least so. Exposure to interdisciplinary teamwork may need to occur at an earlier point in medical training than residency. The question of who is ultimately responsible for the decisions of the team may be an “Achilles heel,” interfering with shared decision-making.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(suppl 1), i85-i90.
Application to Review: Interdisciplinary Communication, Teamwork, Patient Care Plans
Abstract
Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common “critical language” to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
Lingard, L., Whyte, S., Espin, S., Ross Baker, G., Orser, B., & Doran, D. (2006). Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. Journal of interprofessional care, 20(5), 471-483.
Application to Review: Interdisciplinary Teamwork, Intervention (Briefings), Care Plans, Patient Safety, Knowledge, Attitudes, Behaviors
Abstract
"Improved team communication" is broadly advocated in the discourse on safety but rarely supported by a precise understanding of the relationship between specific communication practices and concrete improvements in collaborative work processes. We sought to improve such understanding by analyzing the discourse arising from structured preoperative team briefings among surgeons, nurses, and anesthesiologists prior to general surgery procedures. Analysis of observers ' fieldnotes from 302 briefings yielded a two-part model of communicative "utility", defined as the visible impact of communication on team awareness and behavior. "Informational utility" occurred when team awareness or knowledge was improved by provision of new information, explicit confirmation, reminders, or education. "Functional utility" represented direct communication - work connections: many briefings identified problems, prompting decision-making and follow-up actions. The crux of the model is an elaboration of the causal pathway between a specific communication practice (the team briefing), intermediary processes such as enhanced knowledge and purposeful action, and the quality and safety of collaborative care processes. Modeling this pathway is a critical step in promoting change, as it renders visible both the latent dangers present in current team communication systems and the specific ways in which altered communication patterns can impact team awareness and behaviors.
Makaryus, A. N., & Friedman, E. A. (2005, August). Patients ' understanding of their treatment plans and diagnosis at discharge. In Mayo Clinic Proceedings (Vol. 80, No. 8, pp. 991-994). Elsevier.
Application to Review: Patients, Discharge, Care Plan
OBJECTIVE
To ascertain whether patients at discharge from a municipal teaching hospital knew their discharge diagnoses, treatment plan (names and purpose of their medications), and common side effects of prescribed medications.
PATIENTS AND METHODS
From July to October 1999, we surveyed 47 consecutive patients at discharge from the medical service of a municipal teaching hospital in New York City (Brooklyn, NY). Patients were asked to state either the trade or the generic name(s) of their medication(s), their purpose, and the major side effect(s), as well as their discharge diagnoses. Patients were excluded if they were not oriented to person, place, and time, were unaware of the circumstances surrounding their admission to the hospital, and/or did not speak or understand English.
RESULTS
Of the 47 patients surveyed, 4 were excluded. Of the remaining 43 patients, 12 (27.9%) were able to list all their medications, 16 (37.2%) were able to recount the purpose of all their medications, 6 (14.0%) were able to state the common side effect(s) of all their medications, and 18 (41.9%) were able to state their diagnosis or diagnoses. The mean number of medications prescribed at discharge was 3.89.
CONCLUSIONS
Less than half of our study patients were able to list their diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s). Lacking awareness of these factors affects a patient 's ability to comply fully with discharge treatment plans. Whether lack of communication between physician and patient is actually the cause of patient unawareness of discharge instructions or if this even affects patient outcome requires further study.
McElroy, L. M., Ladner, D. P., & Holl, J. L. (2013). The role of technology in clinician-to-clinician communication. BMJ quality & safety.
Application to review: Interdisciplinary Communication, Technology, Information Flow, Knowledge and Behaviors
Abstract
Incomplete, fragmented and poorly organized communications contribute to more than half the errors that lead to adverse and sentinel events. Meanwhile, communication software and devices with expanding capabilities are rapidly proliferating and being introduced into the healthcare setting. Clinicians face a large communication burden, which has been exacerbated by the additional challenge of selecting a mode of communication. In addition to specific communication devices, some hospitals have implemented advanced technological systems to assist with communication. However, few studies have provided empirical evidence of the specific advantages and disadvantages of the different devices used for communication. Given the increasing quantities of information transmitted to and by clinicians, evaluations of how communication methods and devices can improve the quality, safety and outcomes of healthcare are needed.
O’Leary, K. J., Wayne, D. B., Landler, M. P., Kulkarni, N., Corinne Haviley RN, M. S., Hahn, K. J., ... & Williams, M. V. (2009). Impact of Localizing Physicians to Hospital Units on Nurse—Physician Communication and Agreement on the Plan of Care. Journal of general internal medicine, 24(11), 1223-1227.
Application to Review: Physician-Nurse Communication, Location, Plan of Care, Knowledge, Behaviors, Attitudes
ABSTRACT
BACKGROUND
A significant barrier to communication among patient care providers in hospitals is the geographic dispersion of team members.
OBJECTIVE
To determine whether localizing physicians to specific patient care units improves nurse-physician communication and agreement on patients’ plans of care.
METHODS
We conducted structured interviews of a cross-sectional sample of nurses and physicians before and after an intervention to localize physicians to specific patient care units. Interviews characterized patterns of nurse-physician communication and assessed understanding of patients’ plans of care. Two internists reviewed responses and rated nurse-physician agreement on six aspects of the plan of care as none, partial, or complete agreement.
RESULTS
Three hundred eleven of 342 (91%) and 291 of 294 (99%) patients’ nurses and 301 of 342 (88%) and 285 of 294 (97%) physicians completed the interview during the pre- and post-localization periods. Two hundred nine of 285 (73%) patients were localized to physicians’ designated patient care units in the post-localization period. After localization, a higher percentage of patients’ nurses and physicians was able to correctly identify one another (93% vs. 71%; p
Abraham, J., Kannampallil, T. G., & Patel, V. L. (2012). Bridging gaps in handoffs: A continuity of care based approach. Journal of biomedical informatics, 45(2), 240-254.
Application to Review: Nurse-Physician, Handoff, Work low, Continuity of Care Model, Clinician Centered Approach
Abstract
Handoff among healthcare providers has been recognized as a major source of medical errors. Most prior research has often focused on the communication aspects of handoff, with limited emphasis on the overall handoff process, especially from a clinician workflow perspective. Such a workflow perspective that is based on the continuity of care model provides a framework …show more content…
required to identify and support an interconnected trajectory of care events affecting handoff communication. To this end, we propose a new methodology, referred to as the clinician-centered approach that allows us to investigate and represent the entire clinician workflow prior to, during and, after handoff communication. This representation of clinician activities supports a comprehensive analysis of the interdependencies in the handoff process across the care continuum, as opposed to a single discrete, information sharing activity. The clinician-centered approach is supported by multifaceted methods for data collection such as observations, shadowing of clinicians, audio recording of handoff communication, semi-structured interviews and artifact identification and collection. The analysis followed a two-stage mixed inductive–deductive method. The iterative development of clinician-centered approach was realized using a multi-faceted study conducted in the Medical Intensive Care Unit (MICU) of an academic hospital. Using the clinician-centered approach, we (a) identify the nature, inherent characteristics and the interdependencies between three phases of the handoff process and (b) develop a descriptive framework of handoff communication in critical care that captures the non-linear, recursive and interactive nature of collaboration and decision-making. The results reported in this paper serve as a “proof of concept” of our approach, emphasizing the importance of capturing a coordinated and uninterrupted succession of clinician information management and transfer activities in relation to patient care events.
Ashbrook, L., Mourad, M., & Sehgal, N. (2013). Communicating discharge instructions to patients: A survey of nurse, intern, and hospitalist practices. Journal of Hospital Medicine, 8(1), 36-41.
Application to Review: Nurse-Physician Communication, Informing Patients, Discharge
Abstract
BACKGROUND:
Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization.
OBJECTIVES:
To understand nurse and physician communication practices around patient discharge education.
SETTING:
University of California, San Francisco Medical Center (UCSFMC).
PARTICIPANTS:
Nurses, interns, and hospitalists caring for hospitalized medicine patients.
MEASUREMENTS:
Participants were surveyed regarding discharge education practices. The survey asked respondents about 13 elements of discharge education found in the literature. For each element, participants were queried regarding: 1) the provider responsible for this element of patient education; 2) the frequency with which they communicate this teaching to patients; 3) how often they directly communicate with the nurse or physician caring for the patient about each element; and 4) tools to improve nurse–physician communication.
RESULTS:
A total of 129/184 (70%) nurses, interns, and hospitalists responded to the survey. The majority of respondents in all 3 groups felt that 9 of 13 elements were a combined responsibility. Nurses reported educating patients on these 9 items significantly more often than physicians (P < 0.05). All groups also agreed that instruction on 2 of the elements, summary of hospital findings and pending results, should be primarily the physicians ' responsibility; these were the elements least often discussed by any provider. Despite the majority of items being agreed upon as a shared responsibility, communication between nurses and physicians regarding discharge education was low. Standardized verbal communication on the day of discharge was supported most strongly by all providers.
CONCLUSIONS:
Ambiguous responsibility for providing discharge education and poor communication between nurses and physicians offers an opportunity for improvement.
Brady, P. W., & Goldenhar, L. M. (2013). A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognized patient risk. BMJ Quality & Safety, bmjqs-2012.
Application to Review: Interdisciplinary Collaboration, Situational Awareness, Patient Safety (Recognition of the Deteriorating Patient)
Abstract
Background Situation awareness (SA)—the perception of data elements, comprehension of their meaning and projection of their status in the near future—has been associated with human performance in high-risk environments, including aviation and the operating room.
The influences on SA in inpatient medicine are unknown.
Methods We conducted seven focus groups with nurses, respiratory therapists and resident physicians using a standardised semistructured focus group guide to promote discussion. Recordings of the focus groups were transcribed verbatim, and transcripts were qualitatively analysed by two independent reviewers to identify convergent and divergent themes.
Results Three themes emerged: (1) team-based care, (2) availability of standardised data and (3) standardised processes and procedures. We categorised these into social, technological and organisational influences on SA. Subthemes that emerged from each focus group were shared language to describe at-risk patients, provider experience in critical care/deterioration and interdisciplinary huddles to identify and plan for at-risk patients. An objective early warning score, proactive assessment and planning, adequate clinician staffing and tools for entering, displaying and monitoring data trends were identified by six of seven groups. Our data better reflected the concepts of team SA and shared SA than individual …show more content…
SA.
Conclusions Team-based care and standardisation support SA and the identification and treatment of patient risk in the complex environment of inpatient care. These findings can be used to guide the development and implementation of targeted interventions such as huddles to proactively scan for risk and electronic health record displays of data trends.
Brady, P. W., Muething, S., Kotagal, U., Ashby, M., Gallagher, R., Hall, D., ... & Wheeler, D. S. (2013). Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics, 131(1), e298-e308.
Application to Review: Interdisciplinary Collaboration, Situational Awareness, Patient Safety (Recognition of the Deteriorating Patient)
Abstract
BACKGROUND AND OBJECTIVE:
Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer.
METHODS:
The setting for our observational time series study was a quaternary care children 's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread.
RESULTS:
The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.
CONCLUSIONS:
A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.
Collins, S. A., Mamykina, L., Jordan, D., Stein, D. M., Shine, A., Reyfman, P., & Kaufman, D. (2012). In search of common ground in handoff documentation in an Intensive Care Unit. Journal of biomedical informatics, 45(2), 307-315.
Application to Review: Handoff, Technology, Tools, Interdisciplinary, Behavior
Abstract
Objective
Handoff is an intra-disciplinary process, yet the flow of critical handoff information spans multiple disciplines. Understanding this information flow is important for the development of computer-based tools that supports the communication and coordination of patient care in a multi-disciplinary and highly specialized critical care setting. We aimed to understand the structure, functionality, and content of nurses’ and physicians’ handoff artifacts.
Design
We analyzed 22 nurses’ and physicians’ handoff artifacts from a Cardiothoracic Intensive Care Unit (CTICU) at a large urban medical center. We combined artifact analysis with semantic coding based on our published Interdisciplinary Handoff Information Coding (IHIC) framework for a novel two-step data analysis approach.
Results
We found a high degree of structure and overlap in the content of nursing and physician artifacts. Our findings demonstrated a non-technical, yet sophisticated, system with a high degree of structure for the organization and communication of patient data that functions to coordinate the work of multiple disciplines in a highly specialized unit of patient care.
Limitations
This study took place in one CTICU. Further work is needed to determine the generalizability of the results.
Conclusions
Our findings indicate that the development of semi-structured patient-centered interdisciplinary handoff tools with discipline specific views customized for specialty settings may effectively support handoff communication and patient safety.
Collins, S. A., Stein, D. M., Vawdrey, D. K., Stetson, P. D., & Bakken, S. (2011). Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review. Journal of biomedical informatics, 44(4), 704-712.
Application to Review: Handoff, Nurse-Physician Communication, Tool, Computer, Continuity of Care Documentation, Multidisciplinary
Abstract
Purpose
The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs).
Methods
We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed.
Results
Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%.
Conclusion
Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.
Coleman, E. A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555.
Application to Review: Transition Challenges, Plan of Care, Knowledge Development
Abstract
Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.
Crawford, M. J., Rutter, D., Manley, C., Weaver, T., Bhui, K., Fulop, N., & Tyrer, P. (2002). Systematic review of involving patients in the planning and development of health care. Bmj, 325(7375), 1263.
Application to Review: Patients, Care Plan, Engagement Knowledge, Behaviors, and Attitudes
Abstract
Objective: To examine the effects of involving patients in the planning and development of health care.
Data sources: Published and grey literature.
Study selection: Systematic search for worldwide reports written in English between January 1966 and October 2000.
Data extraction: Qualitative review of papers describing the effects of involving patients in the planning and development of health care.
Results: Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported.
Conclusions: Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.
Deering, S., Johnston, L. C., & Colacchio, K. (2011, April). Multidisciplinary teamwork and communication training. In Seminars in perinatology (Vol. 35, No. 2, pp. 89-96). WB Saunders.
Application to Review: Interdisciplinary Teamwork, Training, Communication, Coordination, Intervention, Knowledge, Behavior, Attitudes
Abstract
Every delivery is a multidisciplinary event, involving nursing, obstetricians, anesthesiologists, and pediatricians. Patients are often in labor across multiple provider shifts, necessitating numerous handoffs between teams. Each handoff provides an opportunity for errors. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of complications result from team, rather than individual, failures. In 2004, a Sentinel Alert issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization 's culture and communication failures. It was recommended that hospitals implement teamwork training programs in an effort to improve outcomes. Instituting a multidisciplinary teamwork training program that uses simulation offers a risk-free environment to practice skills, including communication, role clarification, and mutual support. This experience should improve patient safety and outcomes, as well as enhance employee morale.
Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and situation awareness. BMJ quality & safety.
Application to Review: Interdisciplinary Communication, Patient Safety, Intervention (Huddles)
Abstract
Background Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm.
Methods Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children 's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques.
Results Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff 's quality of collective awareness and enhanced capacity for eliminating patient harm.
Conclusions While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.
Hall, J., Peat, M., Birks, Y., Golder, S., Entwistle, V., Gilbody, S., ... & Wright, J. (2010). Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. Quality and Safety in Health Care, 19(5), e10-e10.
Application to Review: Patient Engagement, Patient Safety, Intervention, Knowledge, Behaviors, Attitudes
Abstract
Background There is growing international interest in involving patients in interventions to promote and support them in securing their own safety. This paper reports a systematic review of evaluations of the effectiveness of interventions that have been used with the explicit intention of promoting patient involvement in patient safety in healthcare.
Methods The authors searched Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CENTRAL, CINAHL, EMBASE, HMIC, MEDLINE, MEDLINE in-process, PsycINFO and ASSIA to August 2008. We also searched databases of reports, conference proceedings, grey literature, ongoing research and relevant patient safety organisations, and hand-searched two journals. Meta-analysis of the data was not appropriate; therefore, studies were categorised according to how the interventions encouraged patients ' actions to improve safety—informing the management plan, monitoring and ensuring safe delivery of treatment (by health professional and by self), making systems safer—and were critiqued in a narrative manner.
Findings The authors identified 14 individual experimental and quasiexperimental studies plus one systematic review. The majority of studies fell into the monitoring and ensuring safe delivery of treatment by self category and were all related to enhancing medication safety. Authors reported improved patient safety incident outcomes for the intervention groups compared with controls where the interventions aimed to encourage patient involvement in: (1) monitoring and ensuring safe delivery of treatment by self (self-management of anticoagulation, ‘easy’ read information leaflet, nurse-led education to promote self-medication in hospital, patient package insert using lay terminology); (2) informing the management plan/monitoring and ensuring safe delivery of treatment by self (individualised teaching plan by nurse, pharmacist counselling). It was not possible to draw any clear conclusions as to the effectiveness of the interventions (with the exception of one specific aspect of self-medication, that is, self-management of anticoagulation) due to concerns about the methodological quality of the studies.
Conclusions There is limited evidence for the effectiveness of interventions designed to promote patient involvement on patient safety incidents and in general is poor quality. Existing evidence is confined to the promotion of safe self-management of medication, most notably relating to the self-management of oral anticoagulants.
Henriksen, K., Battles, J. B., Keyes, M. A., Grady, M. L., Dingley, C., Daugherty, K., ... & Persing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements.
Application to Review: Interdisciplinary teams, Communication tools, Interventions, Behaviors and Attitudes
Excerpt
The purpose of this study was to develop, implement, and evaluate a comprehensive provider/team communication strategy, resulting in a toolkit generalizable to other settings of care. The specific aims included implementation of a structured communication tool; a standardized escalation process; daily multidisciplinary patient-centered rounds using a daily goals sheet; and team huddles. The study setting was the 477-bed medical center of the Denver Health and Hospital Authority, an integrated, urban safety-net system. Utilizing a pre-test/post-test design, baseline and post-intervention data were collected on pilot units (medical intensive care unit, acute care unit, and inpatient behavioral health units). Analysis of 495 communication events after toolkit implementation revealed decreased time to treatment, increased nurse satisfaction with communication, and higher rates of resolution of patient issues post-intervention. The resultant toolkit provides health care organizations with the means to implement teamwork and communication strategies in their own settings.
Johnson, S., & Kring, D. (2011). Nurses ' perceptions of nurse-physician relationships: medical-surgical vs. intensive care. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 21(6), 343-347.
Application to Review: Nurse-Physician, Setting Specific, Relationship, Collaboration
Abstract
Effective collaboration between nurses and physicians (RN-MD) is essential in facilitating improved patient care outcomes. A pilot study was conducted among nurses on medical-surgical and intensive care units to identify differences in nurses ' perceptions of RN-MD collaborative efforts.
INTRODUCTION:
Collaboration between nurses and physicians is essential in fostering interdisciplinary relationships. Specialty practice may influence the quality of this collaboration. Effective communication and collegial RN-MD relationships are critical to improved patient outcomes.
PURPOSE:
The purpose of this study was to identify differences in nurses ' perceptions of collaborative efforts between nurses and physicians in medical-surgical (MSUs) units versus intensive care units (ICUs).
RESULTS:
A descriptive survey methodology was employed. Nurses in three ICUs and eight MSUs within a 975-bed Magnet hospital completed a 25-item Nurse-Physician Relationship survey, used in previous studies on RN-MD communication. The sample (N = 170) consisted of 54% medical-surgical nurses and 46% ICU nurses. No statistically significant differences were found in the demographic variables between the MSU and ICU nurses except for educational degree. A greater percentage of ICU nurses held a bachelor 's degree. This study found that although some differences existed in ICU and MSU nurses ' perceptions of RN-MD collaboration, there are more similarities between the two areas. Overall, nurses were satisfied with RN-MD relationships, with 75% of ICU and 65% of MSU nurses reporting satisfaction (p = 0.110). MSU nurses were less likely to participate in interdisciplinary rounds than ICU nurses (p < 0.001). ICU nurses were more likely than MSU nurses to report that physicians treat nurses as handmaidens (p = 0.056) and that physicians displayed unprofessional behavior (p = 0.019).
CONCLUSIONS:
Certain nursing specialty areas are not immune to problems with RN-MD relationships. Rather, all clinical service lines should be concerned with fostering collegiality between nurses and their physician partners.
Karalapillai, D., Baldwin, I., Dunnachie, G., Knott, C., Eastwood, G., Rogan, J., & Jones, D. (2013). Improving communication of the daily care plan in a teaching hospital intensive care unit. Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine, 15(2), 97-102.
Application to Review: Multidisciplinary Daily Care Plans, Communication, Handoff, Checklist, Intervention, Documentation, ICU, Knowledge and Behaviors
Abstract
BACKGROUND:
Patients admitted to intensive care units have complex care needs. Accordingly, communication and handover of the medical care plan is very important.
OBJECTIVE:
To assess changes in ICU nurses ' understanding of the medical daily care plan after development and implementation of a pro forma to improve documentation and communication of the plan.
DESIGN, SETTING AND PARTICIPANTS:
The study was conducted between February and November 2012 in a mixed medical-surgical, 18-bed, closed ICU in a teaching hospital. Baseline and post-intervention surveys assessed ICU bedside nurses ' self-reported understanding of elements of the daily care plan.
INTERVENTION:
After receiving input from bedside nurses and medical staff, we developed the daily care plan as a single-page pro forma for handwritten documentation of a clinical problems list, plan and interventions list, daily chest x-ray results, a modified FAST-HUG checklist, and discharge planning during the evening consultant ward round.
The finalised pro forma was introduced on 25 July 2012.
RESULTS:
Introduction of the pro forma daily care plan was associated with marked and statistically significant improvements in nurses ' self-reported understanding of a list of the patient 's clinical problems, the management plan after the ward round, issues for discharge for the following day (all P < 0.001) and, to a lesser extent, the physiological targets and aims (P = 0.003) and interpretation of the daily chest x-ray (P < 0.001). In the post-intervention survey, only 4/118 free-text comments (3.4%) suggested that documentation of the plan was doctor-dependent, compared with 28/198 (14.1%) at baseline (P = 0.002).
CONCLUSIONS:
Introduction of a single-page, handwritten, structured daily care plan produced marked improvements in ICU nurses ' self-reported understanding of elements of the medical plan, and may have reduced practice variation in medical plan documentation. The effects of this intervention on patient outcomes remain
untested.
Keenan, G., Yakel, E., Lopez, K. D., Tschannen, D., & Ford, Y. B. (2013). Challenges to nurses ' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245-251.
Application to Review: Nurse-team Communication, Care Coordination, Orders, Documentation, Knowledge, Behaviors and Attitudes
Abstract:
The leaders of Geriatrics and Extended Care ( GEC) in the Veterans Health Administration ( VHA) undertook a strategic planning process that led to approval in 2009 of a multidisciplinary, evidence-guided strategic plan. This article reviews the four goals contained in that plan and describes VHA 's progress in addressing them. The goals included transforming the healthcare system to a veteran-centric approach, achieving universal access to a panel of services, ensuring that the Veterans Affair 's ( VA) healthcare workforce was adequately prepared to manage the needs of the growing elderly veteran population, and integrating continuous improvement into all care enhancements. There has been substantial progress in addressing all four goals. All VHA health care has undergone an extensive transformation to patient-centered care, has enriched the services it can offer caregivers of dependent veterans, and has instituted models to better integrate VA and non- VA cares and services. A range of successful models of geriatric care described in the professional literature has been adapted to VA environments to gauge suitability for broader implementation. An executive-level task force developed a three-pronged approach for enhancing the VA 's geriatric workforce. The VHA 's performance measurement approaches increasingly include incentives to enhance the quality of management of vulnerable elderly adults in primary care. The GEC strategic plan was intended to serve as a road map for keeping VHA aligned with an ambitious but important long-term vision for GEC services. Although no discrete set of resources was appropriated for fulfillment of the plan 's recommendations, this initial report reflects substantial progress in addressing most of its goals.
King, B. J., Mills, P. D., Fore, A., & Mitchell, C. (2012). The Daily Plan®: Including patients for safety 's sake. Nursing Management, 43(3), 15-18.
Application to Review: Interdisciplinary, Daily Care Plans, Physician-Nurse-Patient, Patient Safety, Knowledge, Behaviors and Attitudes
Abstract:
Actively including patients in their care and educating them about what will occur during hospitalization can help improve patient safety. It has been noted that the patient is the only constant in the healthcare system and the patient 's vigilance is a critical aspect of patient safety. Simple mistakes that lead to patient harm may be prevented when the patient is part of the checks and balances of the healthcare system. A meaningful phrase, credited to an English midwife, “nothing about me without me,” has been used many times to reflect the importance of patients and healthcare professionals working together. Several nationally recognized organizations have provided publications advising patients to participate in patient safety. Among them was The Joint Commission 's Speak Up and the Agency for Healthcare Research and Quality 's 20 Tips. These documents encourage patients to ask questions of their healthcare providers. It has been reported that patients are less willing to ask health professionals challenging questions than factual questions about their condition and treatment. The success of efforts to partner with patients to improve safety depends largely on the attitudes and actions of healthcare professionals, not the consumers. Although most medical literature supports patient involvement for patient safety, healthcare professionals still need to define successful, workable approaches to involve patients in their care. One of our approaches is called The Daily Plan®.
Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. T. (2013). A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU. Critical care medicine.
Application to Review: Interdisciplinary, Care Plans, Intervention (Team Rounding), ICU, Knowledge and Behaviors
OBJECTIVES:
Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU.
DATA SOURCES:
Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012.
STUDY SELECTION:
Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU.
DATA EXTRACTION:
Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool.
DATA SYNTHESIS:
The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians.
CONCLUSIONS:
Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation.
Leipzig, R. M., Hyer, K., Ek, K., Wallenstein, S., Vezina, M. L., Fairchild, S., & Howe, J. L. (2002). Attitudes toward working on interdisciplinary healthcare teams: A comparison by discipline. Journal of the American Geriatrics Society, 50(6), 1141-1148.
Application to Review: Interdisciplinary Teams, Communication, Coordination, Care Plans, Attitudes
Abstract
Interdisciplinary teams are important in providing care for older patients, but interdisciplinary teamwork is rarely a teaching focus, and little is known about trainees ' attitudes towards it. To determine the attitudes of second-year post-graduate (PGY-2) internal medicine or family practice residents, advanced practice nursing (NP), and masters-level social work (MSW) students toward the value and efficiency of interdisciplinary teamwork and the physician 's role on the team, a baseline survey was administered to 591 Geriatrics Interdisciplinary Team Training participants at eight U.S. academic medical centers from January 1997 to July 1999.
Most students in each profession agreed that the interdisciplinary team approach benefits patients and is a productive use of time, but PGY-2s consistently rated their agreement lower than NP or MSW students. Interprofessional differences were greatest for beliefs about the physician 's role; 73% of PGY-2s but only 44% to 47% of MSW and NP trainees agreed that a team 's primary purpose was to assist physicians in achieving treatment goals for patients. Approximately 80% of PGY-2s but only 35% to 40% of MSW or NP trainees agreed that physicians have the right to alter patient care plans developed by the team. Although students from all three disciplines were positively inclined toward medical interdisciplinary teamwork, medical residents were the least so. Exposure to interdisciplinary teamwork may need to occur at an earlier point in medical training than residency. The question of who is ultimately responsible for the decisions of the team may be an “Achilles heel,” interfering with shared decision-making.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(suppl 1), i85-i90.
Application to Review: Interdisciplinary Communication, Teamwork, Patient Care Plans
Abstract
Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common “critical language” to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
Lingard, L., Whyte, S., Espin, S., Ross Baker, G., Orser, B., & Doran, D. (2006). Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. Journal of interprofessional care, 20(5), 471-483.
Application to Review: Interdisciplinary Teamwork, Intervention (Briefings), Care Plans, Patient Safety, Knowledge, Attitudes, Behaviors
Abstract
"Improved team communication" is broadly advocated in the discourse on safety but rarely supported by a precise understanding of the relationship between specific communication practices and concrete improvements in collaborative work processes. We sought to improve such understanding by analyzing the discourse arising from structured preoperative team briefings among surgeons, nurses, and anesthesiologists prior to general surgery procedures. Analysis of observers ' fieldnotes from 302 briefings yielded a two-part model of communicative "utility", defined as the visible impact of communication on team awareness and behavior. "Informational utility" occurred when team awareness or knowledge was improved by provision of new information, explicit confirmation, reminders, or education. "Functional utility" represented direct communication - work connections: many briefings identified problems, prompting decision-making and follow-up actions. The crux of the model is an elaboration of the causal pathway between a specific communication practice (the team briefing), intermediary processes such as enhanced knowledge and purposeful action, and the quality and safety of collaborative care processes. Modeling this pathway is a critical step in promoting change, as it renders visible both the latent dangers present in current team communication systems and the specific ways in which altered communication patterns can impact team awareness and behaviors.
Makaryus, A. N., & Friedman, E. A. (2005, August). Patients ' understanding of their treatment plans and diagnosis at discharge. In Mayo Clinic Proceedings (Vol. 80, No. 8, pp. 991-994). Elsevier.
Application to Review: Patients, Discharge, Care Plan
OBJECTIVE
To ascertain whether patients at discharge from a municipal teaching hospital knew their discharge diagnoses, treatment plan (names and purpose of their medications), and common side effects of prescribed medications.
PATIENTS AND METHODS
From July to October 1999, we surveyed 47 consecutive patients at discharge from the medical service of a municipal teaching hospital in New York City (Brooklyn, NY). Patients were asked to state either the trade or the generic name(s) of their medication(s), their purpose, and the major side effect(s), as well as their discharge diagnoses. Patients were excluded if they were not oriented to person, place, and time, were unaware of the circumstances surrounding their admission to the hospital, and/or did not speak or understand English.
RESULTS
Of the 47 patients surveyed, 4 were excluded. Of the remaining 43 patients, 12 (27.9%) were able to list all their medications, 16 (37.2%) were able to recount the purpose of all their medications, 6 (14.0%) were able to state the common side effect(s) of all their medications, and 18 (41.9%) were able to state their diagnosis or diagnoses. The mean number of medications prescribed at discharge was 3.89.
CONCLUSIONS
Less than half of our study patients were able to list their diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s). Lacking awareness of these factors affects a patient 's ability to comply fully with discharge treatment plans. Whether lack of communication between physician and patient is actually the cause of patient unawareness of discharge instructions or if this even affects patient outcome requires further study.
McElroy, L. M., Ladner, D. P., & Holl, J. L. (2013). The role of technology in clinician-to-clinician communication. BMJ quality & safety.
Application to review: Interdisciplinary Communication, Technology, Information Flow, Knowledge and Behaviors
Abstract
Incomplete, fragmented and poorly organized communications contribute to more than half the errors that lead to adverse and sentinel events. Meanwhile, communication software and devices with expanding capabilities are rapidly proliferating and being introduced into the healthcare setting. Clinicians face a large communication burden, which has been exacerbated by the additional challenge of selecting a mode of communication. In addition to specific communication devices, some hospitals have implemented advanced technological systems to assist with communication. However, few studies have provided empirical evidence of the specific advantages and disadvantages of the different devices used for communication. Given the increasing quantities of information transmitted to and by clinicians, evaluations of how communication methods and devices can improve the quality, safety and outcomes of healthcare are needed.
O’Leary, K. J., Wayne, D. B., Landler, M. P., Kulkarni, N., Corinne Haviley RN, M. S., Hahn, K. J., ... & Williams, M. V. (2009). Impact of Localizing Physicians to Hospital Units on Nurse—Physician Communication and Agreement on the Plan of Care. Journal of general internal medicine, 24(11), 1223-1227.
Application to Review: Physician-Nurse Communication, Location, Plan of Care, Knowledge, Behaviors, Attitudes
ABSTRACT
BACKGROUND
A significant barrier to communication among patient care providers in hospitals is the geographic dispersion of team members.
OBJECTIVE
To determine whether localizing physicians to specific patient care units improves nurse-physician communication and agreement on patients’ plans of care.
METHODS
We conducted structured interviews of a cross-sectional sample of nurses and physicians before and after an intervention to localize physicians to specific patient care units. Interviews characterized patterns of nurse-physician communication and assessed understanding of patients’ plans of care. Two internists reviewed responses and rated nurse-physician agreement on six aspects of the plan of care as none, partial, or complete agreement.
RESULTS
Three hundred eleven of 342 (91%) and 291 of 294 (99%) patients’ nurses and 301 of 342 (88%) and 285 of 294 (97%) physicians completed the interview during the pre- and post-localization periods. Two hundred nine of 285 (73%) patients were localized to physicians’ designated patient care units in the post-localization period. After localization, a higher percentage of patients’ nurses and physicians was able to correctly identify one another (93% vs. 71%; p