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Standardized CVOR-to-CVICU Handoff Protocol Reduced Communication Gaps by 20%
Overview
What was the reason for the change?
Failure of an earlier effort to improve fidelity to new CVOR-to-CVICU handoff process.
What were we trying to accomplish?
Sustainable improvement in the fidelity of a redesigned handoff process by using a human factors framework and participatory design approach that integrated team training into the change process.
How will we know that a change is an improvement?
Measuring fidelity to the redesigned handoff process as well as team (teamwork), patient (morbidity) and organizational (LOS) outcomes.
Implementation
How long did it take to get up and running?
12 months.
How was readiness assessed & required resources identified?
Readiness was assessed using an internally designed tool based on institutional successes and failures. The CVTS service line was deemed ready based on:
- its success in developing and implementing a multidisciplinary patient blood management program,
- participation a AHRQ-funded Cardiac Surgery Translational Study (PI: Pronovost) that focused on building comprehensive unit based safety program (CUSP) teams,
- establishment of a quarterly interprofessional “joint” series,
- organizational support provided by a health system quality officer and Team STEPPS Master Trainer.
What were the missteps and lessons learned along the way?
Not engaging executive leadership early and often limited our ability to scale our approach and gain support for redesigning other inter-unit care transfers. The change team must embrace an iterative change process to allow front-line clinicians an opportunity to shape the change process with their context expertise. Unit-based, interprofessional leads and champions need to be carefully selected (eg. creditable, informal leaders who can influence peers). The complexity of the change process requires the support of an experienced project manager.
Solution Design
What changes can we make that will result in an improvement?
Build a guidance team that has the requisite subject matter expertise and leadership capability to provide mentored implementation to a interprofessional set of handoffs leads and assist with organizational change management. Engaged all CVTS service line clinicians in selecting the required information and tasks of the redesigned handoff using Delphi process. Integrate in situ team training into three phases:
- onboarding interprofessional leads;
- testing redesigned handoff with a interprofessional set of champions recruited by the leads; and
- when rolling out the redesigned handoff with all available service line clinicians and technicians.
Using the humans factor framework (SEIPS), we executed a series of rapid cycle quality improvement efforts to address barriers and incorporate enablers that enhance fidelity and teamwork. Promote participatory design by conducting extensive unit-based play-acting to ensure the redesigned process is user-centered and easy for other unit-based clinicians to see, discuss and participate in.
What was your implementation strategy and critical steps?
A 12-step process divided into planning, engaging executing and reflecting/Evaluating was used.
Adoption & Sustainability
How did you communicate the tactic to those affected by it?
Used a multi-modal approach that combined in situ design, demonstration and practice, series of cognitive aids, email communiques and our interprofessional “Joint CVTS Conference”.
How did you design for sustainability of the change?
By employing a participatory/user-centric approach, the redesigned handoff process was viewed “their” unit-based best practice which help them feel more informed, empowered and capable of anticipating potential medical error and patient harms. Hence, they protected what they preferred because they did not want to lose its benefits with turnover.
Evidence & References
Other References
- Geoffrion TR, Lynch IP, Hsu W, Phelps E, Minhajuddin A, Tsai E, Timmons A, Greilich PE. An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit. Ann Thorac Surg. 2020 Jun;109(6):1782-1788. doi: 10.1016/j.athoracsur.2019.09.047. Epub 2019 Nov 9. PMID: 31706873.
- Keebler JR, Lynch I, Ngo F, Phelps E, Huang N, Guttman O, Preble R, Minhajuddin AT, Gamez N, Wanat-Hawthorne A, Landgraf K, Minnis E, Gisick L, McBroom M, Ambardekar A, Olson D, Greilich PE; ECHO ICU Collaborative. Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery. Jt Comm J Qual Patient Saf. 2023 Aug;49(8):373-383. doi: 10.1016/j.jcjq.2023.05.006. Epub 2023 Jun 1. PMID: 37357132.
- Webster KLW, Keebler JR, Lazzara EH, Chaparro A, Greilich P, Fagerlund A. Handoffs and Teamwork: A Framework for Care Transition Communication. Jt Comm J Qual Patient Saf. 2022 Jun-Jul;48(6-7):343-353. doi: 10.1016/j.jcjq.2022.04.001. Epub 2022 Apr 10. Erratum in: Jt Comm J Qual Patient Saf. 2023 Jan;49(1):64. doi: 10.1016/j.jcjq.2022.07.002. PMID: 35715018.
- Keebler JR, Lazzara E, Griggs A, Tannenbaum S, Fernandez R, Greilich P, Salas E. Holistic strategy for promoting effective handoffs. BMJ Lead. 2023 Jun;7(2):91-95. doi: 10.1136/leader-2022-000639. Epub 2022 Dec 30. PMID: 37200171.
- cardiac anesthesia
- cognitive aids
- critical care medicine
- handoff
