Communication During Handoffs Varies Greatly Among Hospital Teams

Alicia A. Bergman, Ph.D. Research Health Scientist VA Greater Los Angeles Healthcare System Center for the Study of Healthcare Innovation, Implementation & Policy North Hills, CA 91343MedicalResearch.com Interview with:
Alicia A. Bergman, Ph.D.
Research Health Scientist
VA Greater Los Angeles Healthcare System
Center for the Study of Healthcare Innovation, Implementation & Policy North Hills, CA 91343

 Medical Research: What is the background for this study? What are the main findings?

Dr. Bergman: The impetus for this study comes from several sources but most notably the IOM report of 2002 entitled, Crossing the Quality Chasm in which the IOM estimated that between 44,000 and 98,000 lives are lost each year due to preventable medical errors in the hospital.  The IOM further reported that 80% of all adverse outcomes in the hospital can be traced back to breakdowns in communication during handoffs and transfers of care.  A 2005 study by our VA research team found that only 7% of medical schools in the US teach the handoff as part of the formal curriculum. As such, handoffs represent a vulnerable gap in the quality and safety of patient care.

We were interested to know how end of shift handoffs in medicine, nursing, and surgery were enacted and audio and videotaped them in a single VA hospital. We found that there was a great deal of variation in how the handoffs were conducted and similar variations in the ways in which language was used to characterize technical and interpersonal aspects of care. We were especially interested in what we term “anticipatory management communication” and its functions during handoffs. While much technical information can easily be conveyed in the electronic medical record, some types of psychological or social information that are more informal in nature, such as “Mr. Smith’s been our problem child today,” do not lend themselves to being transmitted in the electronic medical record. However, such ‘heads up’ information and communication is often critical to understanding a patient’s context, course, and outcome of care. We also found that indirect anticipatory management communication was used among all dyads but more commonly among nurse dyads, with instructions and tasks implied and often inferential. We conclude that contextually sensitive information about anticipated events is best communicated directly (and ideally face-to-face), and that talk-backs and more explicit use of language can improve handoff quality, making them safer for patients.

Medical Research: What should clinicians and patients take away from your report?

Dr. Bergman: Because a handoff evolves over the course of a shift, self and situation awareness are helpful concepts to keep in mind as clinicians are organizing which information to share during handoffs. They might ask themselves, “what would I want or need in terms of information about the patient if I were starting, not ending, my shift?”.  During  standardized or structured handoffs, there should be agreed-upon strategies for sharing unstructured psycho-social or contextual information relevant to upcoming patient care. Also, clinicians should employ language that is clear and precise in characterizing the needs for upcoming shifts, clarifying who exactly should be starting or completing which tasks. Being aware of potential ambiguities in language use and checking frequently to verify comprehension is also useful.  Patients can ask if there are particular concerns for their care in the upcoming shift and keep track of tests or procedures that have been ordered but haven’t yet taken place.  Such information is useful to share with the incoming physician/nurse to ensure that there is mutual understanding of what needs to be done.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Bergman: More research needs to be done linking communication during handoffs with near misses and adverse outcomes.  There is currently a gap in our understanding of what kinds of communication breakdowns lead to suboptimal care.  There is also a need to teach and do research on the best methods for improving handoffs. While there is a great deal of interest in handoffs worldwide, many if not most of the interventions that have been developed do not lead to lasting change.  Better understanding of the ingredients that will lead to long term improvements are needed.

Citation:

“Mr Smith’s been our problem child today…”: anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs

Alicia A Bergman, Mindy E Flanagan, Patricia R Ebright, Colleen M O’Brien,Richard M Frankel

BMJ Qual Saf bmjqs-2014-003694Published Online First: 28 July 2015 doi:10.1136/bmjqs-2014-003694

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Alicia A. Bergman, Ph.D. (2015). Communication During Handoffs Varies Greatly Among Hospital Teams 

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