Master of Science

thesisThere is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care

A Team-Based Approach to Studying Complex Healthcare Processes

Communication is a critical aspect of clinical work. In 2010, the Joint Commission (JC) found that gaps in communication were among leading factors contributing to medical errors. Healthcare processes, such as patient discharge, depend on interdisciplinary communication to be successful. Electronic health records (EHRs) have the potential to facilitate communication and information sharing between interdisciplinary care team members; however, challenges remain in designing tools for team-based care and questions remain in understanding how EHRs impact interdisciplinary team communication. This dissertation focuses on understanding how EHRs can be designed to support communication and information sharing within interdisciplinary patient care teams. The first aim of the dissertation investigated how EHRs impact interdisciplinary clinical teams’ communication, shared mental models, and information sharing activities. The results showed that implementing new EHR tools appeared to have little impact on communication and shared mental models, but new information sharing activities mediated by EHR developed. These changes and lack thereof suggest that new EHR tools will be specifically needed to facilitate interdisciplinary team information sharing activities. The second aim of the dissertation investigates the information sharing activities and information needs of interdisciplinary team members during patient discharge. The results showed that the information clinicians sought out during discharge depended on the roles that person played as well as the progress of the discharge process. Future EHR tools should be aware of how patient care teams are progressing through the patient discharge process in order to provide information contextualized to their current tasks. In conclusion, interdisciplinary team communication and information sharing remain poorly supported by current EHRs and new tools designed specifically for interdisciplinary teams should provide information based on the completion of team activities

The Development and Testing of a Measurement System to Assess Intensive Care Unit Team Performance

Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives

Perceptions of Teams in Providing Safe Handoffs

Background: Pediatric hematology/oncology patients are highly complex and providing care to these patients requires effective communication and coordination. Purpose: This project explored the perceptions of handoffs and transitions of team, at a quaternary pediatric health care system, with a descriptive, cross-sectional, non-experimental survey using convenient sampling. The goal was to identify the three top themes of team member perceptions to drive improvement efforts. Sample: 411 team members were invited to participate in survey; 124 completed the survey, a 29% participation rate. Methodology: The project employed quantitative methodology using quantitative data collection with a Likert-style survey to rank handoff experiences within the service line. Sixteen questions were divided into four domains, information, responsibility, accountability, and teamwork. The survey tool was validated by a 10 member panel of subject-matter experts. The tool exceeded Lawshe’s Content Validity Index (\u3e0.70- 0.80) with the score 0.9375. Two open-ended questions probed barriers to handoffs, and ideal characteristics of handoffs. Data Analysis: Descriptive findings considered role, focus of work, location of work, and years of work. Nonparametric testing in SPSS used Kendall’s tau (τ), Friedman’s (χ²) ANOVA, and Cronbach’s alpha for analysis. Findings: Two strengths were identified: 1. Team members frequently consider risk to patients of harm during transitions and 2. Team members demonstrate a personal accountability to get the information in handoffs. Shared goals and shared plan of care were identified as low performers. Conflict resolution and role understanding emerged as needs from open-ended comments. Recommendation: These findings support three themes for future work to improve handoffs. The data supports developing a shared mental model of how goals and plan of care moves with the patient across the service line, and care continuum, along with clear contact information for clarification needs. Handoffs are not just about the transfer of information, there are many correlating factors that influence this process. Attending to the relationships and the team dynamics will be an important focus of this project

Handoffs in Hospitals: A review of the literature on information exchange while transferring patient responsibility or control

This document reviews the full collection of literature on hospital handoffs and is referenced by shorter publications. Researchers may see abstracts at http://www.connotea.org/user/signout . Access to the full text of the articles may be requested by contacting the authors.Background: In hospitals, handoffs are episodes in which control of, or responsibility for, a patient passes from one health professional to another, and in which important information about the patient is also exchanged. In view of the growing interest in improving handoff processes, and the need for guidance in arriving at standardized handoff procedures, a review of the research on handoffs is provided. Methods: The authors have attempted to identify all research treatments of hospital handoffs involving medical personnel published in English through July 2008. Results: Findings from the literature are organized into six themes: 1) The definition of 'handoff'; 2) The functions of handoffs; 3) The challenges and difficulties of handing off; 4) The costs and benefits of standardization; 5) Possible protocols for standardizing of handoffs; and 6) Questions needing answers, and methods of research. Conclusions: The large body of relevant literature shows handoff to be highly sensitive to variations in context, to be an activity that is essential for multiple important functions within a hospital that range far beyond patient safety, and to be subject to difficult tensions that necessarily attend efforts to standardize action within a highly differentiated hospital setting. In addition, there is little empirical evidence regarding the magnitude of the impact of handoff on patient safety and service quality, making the potential gains and complications from standardization uncertain.Robert Wood Johnson Foundationhttp://deepblue.lib.umich.edu/bitstream/2027.42/61498/1/Handoffs_in_Hospitals_Literature_Review_081014.pd

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Patient Handoffs between Emergency Department and Inpatient Physicians: A Qualitative Study to Inform Standardization of Practice and Organization Theory

This dissertation is motivated by two problems. First, existing literature characterizes patient handoff as an information transfer activity in which safety and quality are compromised by practice variation. This has prompted a movement to standardize practice. However, existing research has not closely examined how practice variations may be responses to situational and organizational factors or evidence of involved parties accomplishing important functions beyond information transfer. Consequently, standardization efforts run at least two risks: overlooking opportunities for improvement, and engendering negative unintended consequences. Second, despite the fact that roughly 50% of all hospitalized patients are handed off from emergency departments to inpatient units, such handoffs are significantly understudied. I conducted a two-year ethnographic study of handoffs occurring between Emergency Department and General Medicine physicians when patients were admitted to one highly-specialized tertiary referral, teaching hospital. Using theoretical sampling informed by a Grounded Theory methodology, I conducted observations (n=349 hours) and semi-structured interviews (n=48) and recorded handoff conversations (n=48). I analyzed data by means of immersion, various qualitative coding approaches, and memo writing. Findings are organized in three chapters. First, I challenge the dominant model of handoff as information transfer by demonstrating that physicians actively construct understandings of their patients, over time, as they encounter, interpret, assemble, and reassemble information through socially-interactive processes within particular contexts and situations. Consequently, multiple understandings of a single patient are not only possible but likely. Second, I characterize admission handoffs as negotiations, situated by entangled webs of motives and concerns which produce ambiguities. Involved parties must navigate these ambiguities as they develop their differing understandings of patients, resolve conflicts over approaches to care, and agree regarding additional work. Third, I show that boundaries between units are ongoing, effortful accomplishments, re-enacted through interactive negotiations. Over time these negotiations have the potential to shift boundaries and alter the divisions of labor in the hospital, with potential consequences for organizational outcomes. Recommendations for practical improvements and further research are presented.Ph.D.InformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/86293/1/bhilligo_1.pd

Textbook of Patient Safety and Clinical Risk Management

Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties