2017 HSR&D/QUERI National Conference

4059 — Improving Handoffs from Acute to Sub-Acute Care: A VA Interdisciplinary HFMEA Quality Improvement Project

Lead/Presenter: Amy Baughman
All Authors: Baughman AW (VA Boston Healthcare System (VABHS)) Shahood B (VABHS) Ruopp M (VABHS) Jindal S (VABHS) Vilbrun-Bruno S (VABHS) Mitchell D (VABHS) Cain G (VABHS) Swamy L (VABHS) Ronan M (VABHS) Simon SR (VABHS)

Communication has been cited as the most common root cause in sentinel events, with failed patient care handoffs contributing to an estimated 80% of serious preventable adverse events; handoffs to sub-acute care such as nursing homes are at particularly high risk for communication breakdown given high patient complexity and comorbidity. Our system did not have a standardized process for hospital transfers and verbal handoffs and discharge documentation were highly variable in quality, format and completion. Handoff data from June 2014 -April 2015 showed that for 159 transfers, handoff was absent for 29 transfers (18%). Our goal was to improve the handoff process from a VA hospital to a VA sub-acute care facility. Specifically: 1) Increase usage and standardize content of verbal handoff 2) Simplify communication modes 3) Decrease inappropriate transfers and delays in care (transfer, discharge summary completion)

Setting: Our VA system includes a 400-bed acute care hospital and 112-bed sub-acute care facility. Intervention: In conjunction with Patient Safety, we conducted a Healthcare Failure Modes Effects Analysis (HFMEA) from Mar-Oct 2016. Strategy: 1) Establish Interdisciplinary Team: hospital and subacute care providers, nurses, social workers, and unit secretaries. 2) Define goals, outcomes, and a data collection system 3) Process map transfers with detailed sub-process maps 4) Conduct Failure Modes Analysis to identify failures 5) Hazard Analysis to prioritize failures based on severity and probability 6) Action Plans for high scoring failures: a) Standard Operating Procedures (SOP) for transfer notification and cancellations b) Standardize verbal handoff content for nursing and providers (I-PASS: Illness severity; P: Patient summary; A: Action items; S: Situation awareness and contingency planning; S: Synthesis by receiver) c) Retrain administrative staff on travel processes

We developed 7 measures that were tracked daily from Apr-Oct 2016 (interventions began June 2016). Completion of provider Verbal handoff improved from 80 % to 100%. IPASS uptake, which was started in July, improved from 11% to 82%. Discharge documentation was high at baseline (93-96%) and remained at 95%. Nursing verbal handoffs also were high at baseline (93-100%) and remained at 100%. There were only 2 inappropriate transfers, 1 in baseline period and 1 in June. Transfers with "unfinished business" decreased from 10% to zero in the last two months. Transfers with adverse events or delays in care decreased from 13% to zero.

The HFMEA process improved several hand-off process measures for acute care to sub-acute care transfers. Key features were sound data collection, collaboration with Patient Safety, and having an interdisciplinary team from both acute and sub-acute care.

A systematic QI process was essential: process maps to evaluate processes and failures, analysis to prioritize failures, and action plans to develop interventions.