Hand offs are an important area of focus for improved communication. This is certainly true in the surgical specialties. Prior to resident work hours, there was always a physician at the bedside or by phone who knew everything about a surgical case—the patient, the operation performed, all the tubes and drains, the issues the surgeon was secretly concerned about and when those issues might present. Resident work hours have mandated cross coverage and sign outs. Unfortunately, it is not clear that we are training residents in the art of signing out/handing off. That may be because we aren't particularly good at it ourselves.
But with increased shift work in all fields of medicine, the careful hand off or sign out will be critical to providing high quality and safe care. In a Joint Commission study of 2,455 sentinel events, the root cause analysis of the failure revealed that over 70 percent were related to communication. Patient deaths occurred in 75 percent of those cases. This study was not done at Stanford, but we are all aware that communication is at the root of some of our own adverse events.
Although we have established standard work around many activities such as time outs prior to a procedure or between nurses at shift changes, opportunities for improvement exist in hand offs after surgical procedures: What tubes are in place? Where do they go? What are the expectations from those tubes/drains? This conversation could take place as part of the debrief or at the sign out at the end of a case. It could then be repeated in the PACU and on the floor.
Standard work sets standard expectations. Standardized conversations during transfers of care would minimize the occurrence of "forgetting" to convey particular critical information. With standard work, both parties would have set expectations and a script to follow. The hand off would not go forward without standard information being shared. These conversations could be held during sign outs or hand offs, and could be witnessed by attending faculty and critiqued for adequacy of communication of information and treatment plan.
The Transfer Center is another ideal place for faculty to apply the principles of standard work to communication as patients are "handed off" to us for continuation of their care. When a call comes in at two in the morning, a faculty member may not remember all the appropriate questions to ask. If we applied standard work when handling calls from the Transfer Center with scripted questions for faculty to follow for each specialty, the Transfer Center staff could assist in the assessment. If a faculty member wished, they could confer with the Transfer Center staff to make sure key issues were addressed. This would facilitate our working together as a team in the acceptance of patients appropriate for transfer. Furthermore, we would be able to learn from the patients we accepted with standard work guidelines and further hone our pathway.
Standard work for Transfer Center admissions would also support our junior clinicians who may feel pressured into accepting patients without a true treatment advantage at Stanford. With a detailed care pathway, junior faculty could lean on more senior colleagues with recognized expertise in a specific field as they explained why it might not benefit the patient to transfer care to Stanford.
To further examine issues of communication in the clinical setting, we are holding our seventh annual Summit for Clinical Excellence on November 12. This year's theme is "Choosing Wisely." I look forward to a lively discussion about how we as clinicians can better handle difficult conversations with our patients.