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Tackling_Inadequate_Hand_off_Communications10-25_1-2.mp4

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    ♪ (music) ♪
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    {Gidion Howell}
    (Gidion Howell) Welcome to Take 5
    with The Joint Commission--
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    a series of casual conversations
    on healthcare topics of interest to you.
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    I am your host, Gidion Howell.
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    In 2006, The Joint Commission
    established a National Patient Safety Goal
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    that addressed
    hand-off communication errors.
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    Now, in Sentinel Event Alert 58:
    Inadequate Hand-off Communication,
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    we’re continuing to address
    this common patient safety risk.
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    A typical teaching hospital may experience
    more than 4,000 hand-offs every day,
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    and the numerous risk points
    during this process
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    make patients vulnerable.
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    Hand-offs are a necessary part
    of patient care and cannot be avoided,
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    so The Joint Commission's Center
    for Transforming Healthcare
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    created a Targeted Solutions Tool®
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    and a project to help
    healthcare professionals
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    improve hand-off communication processes.
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    Klaus Nether, executive director
    of High-Reliability Product Delivery
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    for the Center of Transforming Healthcare
    is here with me today
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    to discuss these tools and strategies.
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    Thank you, Klaus, for joining me.
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    {Klaus Nether}
    (Klaus Nether) Thank you
    for having me today, Gidion.
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    {Gidion Howell}
    (Gidion) The Center's Hand-off
    Communication's project launched in 2009,
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    and we have continued
    to address this topic for years,
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    including in the latest
    Sentinel Event Alert.
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    Why are hand-offs
    still a problem in healthcare?
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    And what improvements
    or updates have been made
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    since this project launched?
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    {Klaus Nether}
    (Klaus) Gidion, hand-offs
    are a very complex process.
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    There are so many different variables
    that can actually impact a hand-off--
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    everything from getting
    the right information,
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    making sure, in terms
    of the method of communication,
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    can communicate
    that information to the receiver.
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    And, finally, even the environment
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    where that hand-off communication
    takes place is so critical.
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    And I think, because of that complexity
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    that it has really been challenging
    in terms of solving the whole problem
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    of ineffective hand-offs
    from taking place.
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    Through the work that we did in the Center
    and with the project teams,
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    what we identified,
    we had three key lessons learned.
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    The first was that the problem itself
    for hand-offs is very complex,
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    there are a number
    of different root causes--
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    we had 20 different root causes
    that were identified
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    with regards to ineffective
    hand-off communications taking place.
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    So, it isn't a simple best-practice
    or a one-size solution
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    that is actually going to fix it.
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    And that really led
    to our second lesson learned,
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    and that is that because you have
    so many different root causes,
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    each root cause requires its own strategy,
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    its own targeted solution,
    to address that particular root cause
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    that was identified.
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    And, finally, the set of root causes
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    not only differs
    from one organization to the next,
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    but also differs
    even within an organization
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    from one hand-off communication
    process to the next as well.
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    For example, the hand-off
    is very different
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    from the ED to the med-surg unit,
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    as compared from the ED
    to the ICU, or the intensive care unit.
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    It is also very different
    in terms of the hand-off
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    that takes place externally,
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    like from a hospital
    to a skilled nursing facility.
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    So, that is one of the reasons
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    that you really want to have
    a good understanding
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    in terms of what your process is
    for hand-off,
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    and what are those root causes
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    that are leading to an ineffective
    hand-off communication.
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    {Gidion Howell}
    (Gidion) There have been
    many high-profile organizations
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    that have adopted the Hand-off
    Communications Targeted Solutions Tool®.
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    What have their findings been?
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    {Klaus Nether}
    (Klaus) There isn't consistent findings
    across the board
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    because, again, it differs
    from one organization to the next,
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    from one hand-off communication
    process to the next.
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    But one consistent finding
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    we did actually see throughout the project
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    and as we worked
    with the pilot organizations,
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    and actually became one
    of our "Aha" moments with this project,
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    was that the expectation
    for an effective hand-off
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    differ from the sender's perception
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    to what the receiver actually needs.
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    So that was definitely a critical piece,
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    to really get that understanding
    of what the receiver needs.
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    So, the Center's project itself
    focused, really,
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    on the entire hand-off
    communication process--
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    from the sender, looking at the receiver,
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    and then also in terms of the environment
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    where that hand-off was taking place.
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    Some of the root causes
    that were identified included:
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    sender providing inaccurate
    or incomplete information;
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    interruptions that were occurring
    at the time of the hand-off;
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    and receiver having competing priorities
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    and was really unable to focus
    when that hand-off was taking place.
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    Those were some of the root causes,
    but as I mentioned,
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    the key piece is really having
    that understanding,
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    and really being able to identify
    what your root causes are,
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    and then targeting those solutions.
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    {Gidion Howell}
    (Gidion) And what about
    Bartlett Regional Hospital in Alaska?
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    {Klaus Nether}
    (Klaus) Well, Bartlett Regional Hospital
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    was actually a hospital that used
    out Targeted Solutions Tool®
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    to actually improve
    their hand-off communications process,
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    and they decreased their defective
    hand-off communication rate
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    by 58%.
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    While doing that, they also noticed
    that their adverse events
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    that were related
    to hand-off communication
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    actually declined
    as they were making improvements
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    to their hand-off communication process.
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    What we saw is they had
    several months of zero sentinel events
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    actually related
    to hand-off communications.
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    The other thing that we also noticed
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    was that there were only a few,
    a number of contributing factors
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    that actually impacted
    their hand-off communication process.
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    So their top four contributing factors
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    which actually counted
    for almost 70%
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    of all their causes
    of defective hand-offs were:
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    inaccurate and incomplete information;
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    the method was ineffective;
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    and they had no standardized procedures
    for an effective hand-off to take place;
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    and, finally, the person
    initiating the hand-off,
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    known as the sender,
    lacked the knowledge about the patient.
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    And that is something
    that we do see sometimes is,
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    in terms of with the senders,
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    they have designees
    that will actually do the hand-off,
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    and then when there are
    any additional questions for follow-up
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    that the receiver has for the sender,
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    the sender is unable to answer those
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    because they weren't really the person
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    that was actually
    taking care of that patient.
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    {Gidion Howell}
    (Gidion) What do you see in the future
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    for the Center's
    Hand-off Communications project ?
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    {Klaus Nether}
    (Klaus) Well, I'm hoping that more
    and more healthcare organizations
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    take advantage of this complementary tool
    that is available for them
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    to improve their hand-off
    communication processes.
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    The Hand-off Communication
    Targeted Solutions Tool®
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    will actually walk them through
    that systematic approach,
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    to help them identify specifically
    what their root causes are,
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    and then actually supply them
    with the solutions
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    that were validated and targeted
    to those specific root causes
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    that were identified.
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    To date, organizations
    that have actually used
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    the Hand-off Communications Tool,
    over 50% of them
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    have achieved a greater than 50%
    improvement from baseline
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    on their defective
    hand-off communication rates.
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    {Gidion Howell}
    (Gidion) Thank you
    for speaking with me today, Klaus.
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    And thank you for listening.
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    This has been
    Take 5 with The Joint Commission--
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    a series of conversations
    on healthcare topics of interest to you.
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    For more information
    on safe hand-off communication,
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    please visit the Center
    for Transforming Healthcare's website
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    at www.centerfortransforminghealthcare.org
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    Hover over Targeted Initiatives
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    in the blue navigation bar
    at the top of your screen
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    and select Hand-off Communications.
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    To read Sentinel Event 58,
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    please visit
    The Joint Commission's website
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    at www.jointcommission.org
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    Hover over About us
    in the blue navigation bar
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    at the top of your screen
    and click Newsletters--
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    you will see the latest Alert
    to your right.
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    I'm Gidion Howell.
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    Join us next time.
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    This is Take 5.
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    ♪ (music) ♪
Title:
Tackling_Inadequate_Hand_off_Communications10-25_1-2.mp4
Video Language:
English
Team:
On Demand - 908
Project:
BATCH 3 (11.19.18)
Duration:
07:54

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