The American Nurses Credentialing Center partners with sponsor Cerner to annually confer the $25,000 Pathway Award® to a Pathway to Excellence®-designated organization that demonstrates innovation and technology to enhance and enrich a positive practice environment for nurses. Twice Pathway-designated Union Hospital of Cecil County (UHCC) won the 2017 Pathway Award for its proposal titled “Every Hand-Off Face-to-Face.” One year later, this column describes UHCC's efforts to improve hand-off communication with the implementation of electronic video technology.
Adverse and sentinel events are frequently attributed to ineffective hand-off communication.1 The Joint Commission alerts that “hand-off should be highly reliable, conducted in a high-quality manner for every patient, every day, with every transition of care.”2 Integral components of high-quality hand-offs include a commitment by leadership to a safety culture; face-to-face, interprofessional communication between senders and receivers that involves the patient and family as appropriate; engaging staff through training on how to provide effective hand-offs; and monitoring hand-off interventions for success and opportunities for improvement.2 (For more information on hand-offs, see The Joint Commission's “8 Tips for High-Quality Hand-Offs” infographic at www.jointcommission.org/assets/1/6/SEA_58_HOC_Infographic_8_Tips_FINAL.pdf).
Management support for safety initiatives is critical because nurses' perceptions of high levels of management support regarding safety is associated with higher perceptions of successful hand-offs.3 Making safe and effective hand-offs a leadership priority empowers frontline staff to deliver the highest quality communication to their patients. This starts by including the patient—the subject matter expert—in the hand-off.
A project steering committee was formed, consisting of UHCC's CNO, the director of professional practice, the director of program management, the health information technology manager, the medical specialty nurse manager, the ED nurse manager, and the nurse manager of the clinical decision unit. This group reported up to the research and evidence-based practice steering committee, led by UHCC's chief information officer. The project was granted Institutional Review Board approval through a local university.
The steering committee was tasked with achieving the goal of interfacing the use of tablets and video conferencing software so that sending and receiving nurses, and other healthcare team members, could perform virtual face-to-face hand-offs that included the patient in the transfer of care. Patients are at the center of the hand-off and able to speak directly to the receiving healthcare team before transfer. The nurse and healthcare team members outline the course of treatment and anticipated care plan, and validate patient-specific care plan factors to address patient and family concerns, just as they would be able to do in person at the bedside.
The steering committee first sought to gather data regarding outcomes, patient satisfaction, and nurses' perceptions of safety. The committee gathered quantitative data and qualitative information from reports, data repositories, and staff surveys. Next, the committee trialed various software and hardware in patient care environments. UHCC's clinical decision unit and ED were selected to participate first. Following feedback from frontline staff and unit-based councils, the committee altered the logistics and workflow accordingly.
The aim of the “Every Hand-Off Face-to-Face” project affected three areas: patient satisfaction, nurses' perceptions of safety, and overall patient outcomes based on previous research supporting that hand-off coordination is associated with lower length of stay and higher quality of care.4
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey centers on patient perceptions that the healthcare team is working together for their benefit, involving the patient in the care plan, and taking the patient's individual factors into account. UHCC targeted HCAHPS scores for improvement. The steering committee also wanted to keep a keen eye on patient perceptions that the healthcare team valued their privacy.
Figure 1 shows that UHCC's patient satisfaction scores in all five areas proposed for intervention skyrocketed during initial trials and go-live. Each of the five related measures increased noticeably from baseline: nurses kept you informed (+15%), staff included you in decisions about treatment (+18%), staff attention to personal needs (+16%), staff concern for privacy (+31%), and staff worked together to care for you (+7%). Patients were happier and more involved with their care plan. Interview data indicated that the individual units appearing more as one team working for the patient resonated throughout patient experiences.
Nurses' perception of safety was measured using Agency for Healthcare Research and Quality patient safety measures of success. Figure 2 displays results for four project targets. UHCC's clinical decision unit saw remarkable change in safety perceptions. Improvements from baseline were seen in all four areas: units don't coordinate well (-35%), things “fall between the cracks” when transferring patients (-35%), lack good cooperation among hospital units (-16%), and problems occur in the exchange of information (-19%). Both sending and receiving nurses felt that information was flowing accurately and more smoothly.
Figure 3 reports results from the project's objective to lower early rapid response team (RRT) calls for new arrivals and transfers to a higher level of care. An early RRT call and subsequent transfer to a higher level of care is a spotlight on poor initial hand-off and placement. The clinical decision unit also experienced a reduction in RRT calls in the early hours of the patient stay. UHCC's patients were happier, the nurses were more comfortable with the care plan, and, ultimately, the clinical decision unit was delivering safer patient care.
The primary key to success was frontline support in the form of unit-based councils and emerging leaders serving as cheerleaders during early adoption. Frontline staff input, as well as unit-based council feedback, kept optimization at the top of the steering committee's agenda.
For example, it was clear early on that the choice of hardware stand wasn't going to work in each care setting. These were quickly changed to rolling stands to give nurses and patients hands-free interaction with the receiving nurse. It also became clear that video conferencing software may not scale as quickly as needed in terms of various usernames and security. Other options, such as in-house hosted telecommunications software, are being explored for the future. Video conferencing software solutions have been excellent at lower scales, but may not be optimal for large-scale adoption.
From gauging users' experience, an unanticipated realization emerged. The receiver was getting almost all of the value, including the comfort of an effective hand-off and the positive user experience, whereas the sender needed to perform all of the logistics and initial setup. The imbalance made it even more of a priority to set ground rules in the ED because this style of hand-off meant giving up something for the gain of the patient and receiving nurse.
It turned out that the ED's value was in throughput. An unforeseen benefit of this project was that it decreased the ED length of stay. Nurses in a recent poll indicated that ED departure was at least 5 to 10 minutes faster, or more, due to tablet usage. This was an unexpected byproduct of giving the ED complete control over the report time. Instead of inpatient units being unready to take the phone call, the patient was essentially calling the receiving nurse via video conferencing software. The inpatient unit is now being asked by the patient rather than the ED nurse to prioritize report. Compliance with answering patients' calls has been 100%. It's much faster for the ED nurse to use a tablet to call the unit and deliver report than for two nurses to make back-and-forth telephone calls, often taking over 30 minutes, at the time of admission.
Pathway standards and UHCC's intervention
Pathway to Excellence is a framework of six standards that promote nurses having a voice: 1) shared decision-making, 2) leadership, 3) safety, 4) quality, 5) well-being, and 6) professional development.
As a Pathway-designated organization, UHCC has demonstrated its commitment to cultivating a positive practice environment where nurses thrive. The application of the Pathway standards is evident in UHCC's “Every Hand-Off Face-to-Face” project, with safety and quality improvement at its core. Nurse leaders and clinical nurses collaborated in shared decision-making with multiple disciplines as they evaluated patient satisfaction scores regarding care planning, nurses' perception of safety during hand-offs and transitions, and planned project enactment. Additionally, participating nurses' well-being and professional development were enhanced at the 2018 Pathway to Excellence conference in West Palm Beach, Fla., on May 2, 2018, recognizing the organizational empowerment of these emerging nurse leaders.
UHCC realized positive outcomes with the “Every Hand-Off Face-to-Face” project that engaged and empowered nurses in planning and implementation. Higher levels of nurse participation in hospital affairs and decision-making are associated with more positive nurse perceptions of quality of care, decreased emotional exhaustion, and increased job satisfaction.5,6,7 Nurses' engagement in shared governance positively impacts patients' experience of care, hospital rating, and willingness to recommend the hospital.8 When nurses report high levels of patient safety management, they also report higher quality of nursing care and patient safety ratings, and lower frequency of adverse events.9
Keeping the momentum
The “Every Hand-Off Face-to-Face” project was piloted during the hand-off between the ED and the clinical decision unit. UHCC also has transfers in progress from the medical-surgical unit to a local skilled nursing facility and the progressive care unit downgrading to the medical-surgical unit. The project is quickly expanding to all other units, with key hand-offs being explored, such as skilled nursing facilities handing off to the ED and surgical in-house transfers. As UHCC forges ahead to implement “Every Hand-Off Face-to-Face” on every unit within the organization and with receiving/sending partners outside of the hospital, maintaining nurse engagement and management support will be important to keep the momentum strong.
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