Shift-to-shift Handoff Effects on Patient Safety and Outcomes a Systematic Review
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Handoffs, safety civilisation, and practices: evidence from the infirmary survey on patient safety civilization
BMC Wellness Services Inquiry volume 16, Article number:254 (2016) Cite this commodity
Abstract
Groundwork
The context of the written report is the Bureau for Healthcare Research and Quality'southward Hospital Survey on Patient Prophylactic Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient prophylactic civilisation are associated with clinical handoffs and perceptions of patient prophylactic.
Methods
The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships betwixt perceptions of handoffs and transitions practices, patient safe culture, and patient rubber. We statistically controlled for the systematic furnishings of hospital size, type, ownership, and staffing levels on perceptions of patient condom.
Results
The main findings were that the effective handoff of information, responsibility, and accountability were necessary to positive perceptions of patient rubber. Feedback and advice most errors were positively related to the transfer of patient information; teamwork within units and the frequency of events reported were positively related to the transfer of personal responsibleness during shift changes; and teamwork across units was positively related to the unit transfers of accountability for patients.
Conclusions
In summary, staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital's level of patient safety. Given the known psychological links between perception, attitude, and behavior, a potential implication is that better patient safe tin be achieved by a tight focus on improving handoffs through preparation and monitoring.
Peer Review reports
Groundwork
Clinical handoffs, also known as sign-outs, shift reports, or handovers, occur in many places along the healthcare value concatenation. It involves the 'transfer of professional responsibility and accountability for some or all aspects of intendance for a patient, or groups of patients, to another person or professional group on a temporary or permanent ground' [one]. For case, nursing handovers occur very frequently, not only betwixt shifts and amongst function-time nurses, only also because nurses serve as the advice partner and informal coordinator for all healthcare professionals to ensure the continuity of intendance in a 24-hour seven-days-a-week surround [2]. The transfer of professional person responsibility became salient for residents due to increased work-hour restrictions in U.S. residency programs, which shortened the continuity of care and increased the number of shift changes [3]. Business organization for the transfer of unit accountability heightened with the fragmentation in the healthcare to the proliferation of sub-specialties; creating more transitions and handoffs with the increase in number of providers for a unmarried patient [iv]. Consequently, handoffs are a target for quality improvements because they represent high-adventure events. The Joint Committee's 2006 evaluation of accredited healthcare organizations attributed at least 35 % of scout events to handoff errors [v]. Recent estimates implicate handoff errors in nearly 80 % of serious events betwixt 2004 and 2014 [6].
Patient safety culture, which consists of shared norms, values, behavioral patterns, rituals, and traditions [seven] that guide the discretionary behaviors of healthcare professionals matter in handoffs. According to the theory of planned beliefs [8], staff observations of their institution'due south practices and coworkers' behavioral patterns in handoffs will influence their perceptions of overall level of patient condom, and their behavioral responses to such problems. Therefore, employees who perceive that their do institutions non emphasize patient safety may not pay attending to such concerns [9]. To brand improvements in handoffs, healthcare policymakers must commencement understand how employees perceive their organizations' patient safety culture [10].
The extant literature on handoffs largely focuses on the relationship between inadequate communications and perceptions of avoidable impairment [11–thirteen]. Poor handoff communication creates an opportunity for adverse events because incomplete, inaccurate, and omitted data create ambiguities between the sending and receiving providers [14]. However, the literature has establish little empirical evidence to suggest that constructive information transfers are associated with positive perceptions of patient prophylactic [15]. We surmise that this is considering a handoff is multidimensional, involving the transfer of information, responsibility and accountability, implying that previous studies may have over-simplified handoff challenges [xvi].
This study contributes to the literature by empirically investigating what past inquiry has largely ignored: the transfers of professional responsibility and unit accountability for patient safety between providers during handoffs [17]. In the transfer of responsibility, even with constructive information exchange, whether the receiving provider feels the aforementioned sense of responsibility for the patient equally the sending provider cannot be taken for granted. In the case of physicians, this sense of responsibility is defined by Horwitz and colleagues [18] equally a sense among on-call physicians that they were non "but covering" for the admitting medico but rather are integral to the patient's intendance. A systematic review on the transfer of information during nurses' transitions of care establish that senders exhibited few supportive behaviors during the shift change, resulting in a low degree of engagement by receivers as they demonstrated indifference and non-attentive behaviors [nineteen]. Hence, we believe that during shift changes, the agile role and the responsibility of healthcare providers in shaping an effective information exchange protocol go across the mere transmission of structured data [13, 16]. Without the effective transfer and acceptance of responsibility, there is no assurance that the handoff process has created an appropriate mental model of the patient's program of care for the receiving provider.
Our search of the literature did not yield whatever research on how the transfer of unit accountability influences staff perceptions of patient safety. Between-unit of measurement transitions of care tin can create incertitude over who is ultimately accountable for a patient'southward wellbeing. The cantankerous-disciplinary and multi-specialty transition of care create coordination difficulties, every bit handoffs tin can exist irregular and unpredictable [xx, 21]. In addition, complications related to inter-professional differences in expectations, terminologies, and work practices make it challenging to build a shared mental model, necessary for effective transitions between providers [14]. Because conflicting expectations and perspectives betwixt units increase barriers to effective handoffs, we await that when healthcare professionals perceive a supportive environment for cooperation and joint accountability betwixt units, they are more probable to have positive perceptions of patient condom.
We further expect handoffs of information, responsibleness, and accountability to influence each other, so that improvement in one type will positively bear upon the other types, and deposition in 1 will erode the others. Specifically, handing off comprehensive and accurate patient information to a receiver is necessary for effectively handing off responsibleness and accountability [22]. In a handoff, the failure of a sending unit to communicate the rationale for a decision, anticipate problems, and expectations creates uncertainties and ambiguities for the receiving unit [23]. Important information tin can be ignored or misinterpreted by the receiving unit when in that location is unclear handoff of responsibleness and accountability resulting from ambiguous work procedures and a lack of supportive infrastructure [12].
We explore the factors in an organization's patient safe civilization that might be associated with constructive handoffs. Specifically, we posit that an arrangement's communication, teamwork, reporting, and management cultures volition have differential influences on effective handoffs of information, responsibility, and accountability. The literature on information transfer has primarily dealt with the mechanics of communication (i.e., means in which information is transmitted and received). We submit that this perspective is not complete without considering Marx's theory of just culture [24]. Research has shown that when providers experience supported and psychologically safe because their organizations are perceived to be fair, they are more likely to communicate completely by voicing condom concerns [25, 26]. For case, in studies on TeamSTEPPS, a teaming protocol often used in surgical teams, whatever fellow member (surgeon, nurse, technician, and anesthesiologist) tin speak up or call-out observations of potential error because they view each other as having equal responsibility and authority for patient safe [27]. Feedback loops between the sender and receiver are necessary for this process to work. They allow both parties to properly manage expectations and adjust their behaviors. Hence, a strong communications culture, typified by the openness to and willingness of clinicians to speak upwardly, ask questions, and provide feedback, would enhance effective handoff of data.
In the case of shift changes, a civilization of professionalism tin mitigate errors and procedural violations that arise primarily from aberrant mental processes such equally forgetfulness, inattention, low motivation, carelessness, or negligence [28, 29]. Medical professionalism includes a commitment to collaborating with others while engaging in self-regulation to brand the best clinical decisions [thirty]. Professionalism in nursing focuses on value-based cognitive and attitudinal attributes that are harnessed to evangelize patient centered care [31]. Nurses often employ handoffs equally an avenue for socialization, education, and emotional support to facilitate integration and staff cohesion [19]. A teamwork culture facilitates handoff of responsibility between the sending and receiving providers by seeking assistance or voicing concerns and clarifying bug through bidirectional conversations. This procedure creates a shared mental model of the patient'due south clinical conditional and plan of intendance [32]. Professionalism also implies proactive surveillance, detection, and the voluntary reporting of agin events [33]. Errors recurrences are reduced if medical incidences and pitfalls are proactively reported to the incoming provider during shift changes [34]. Therefore, a potent teamwork culture and a culture of reporting agin events enhance effective handoff of personal responsibleness in shift changes.
Patient transfers between units bridge iii domains: provider, service, and location, which are accompanied by differences in social norms, terminologies, and work practices [14, 18]. Such transitions multiply the difficulties providers see when edifice a shared mental model of the patient'due south clinical issues and needs. Add to these are systemic workplace traps such every bit unclear say-so structures, inconsistent management back up, unclear work procedures, and the lack of supporting infrastructure, which brand safe handoffs challenging [21]. Such conflicts could be addressed past improving inter-unit teamwork and coordination [25]. Moreover, the provision of expectations and policies from top management that address the consignment of accountability in the delivery of care could reduce delays and improve the coordination of care beyond unit boundaries. We posit that inter-unit teamwork and a acme management that expects and is supportive of patient safety would facilitate effective handoff of unit of measurement accountability during patient transitions.
Methods
Data
In 2006, the United States Department of Health and Human Services' (DHHS) Bureau for Healthcare Research and Quality (AHRQ) funded the development of the Infirmary Survey on Patient Condom Culture (HSOPSC). This survey was administered on a voluntary basis to all hospitals in the United States. The HSOPSC assesses hospital staff opinions on 42 items that measure their establishment's patient safety practices based on 5-signal response scales of agreement ("strongly disagree" to "strongly agree") or frequency ("never" to "ever"). The de-identified data for this study comes from the 2010 survey that was made bachelor for public use. It can be requested from the AHRQ. Information technology represents 885 U.S. hospitals that voluntarily participated in the survey [7]. The views of healthcare professionals were aggregated for each institution, since by studies accept shown that aggregating these items from the individual- and unit-level responses to the hospital level led to more robust psychometric properties [35], which are reported in Additional file 1.
In Table 1, we report the distribution of respondents by job roles. About ii thirds of respondents are from the nursing and centrolineal wellness professions while another third are administrative staff. A small pct of respondents were self-identified as physicians, although an unknown percent of the administrative staff could besides exist physicians. The responses in this survey are therefore representative of the views of nurses, allied health professionals, direction, and physicians.
Measures
Covariates
Four hospital characteristics pertaining to bedsize, hospital type, ownership, and staffing were included equally baseline covariates since we expect these factors to systematically bear on perceptions of patient safety. For instance, large government-owned pedagogy hospitals may experience more incidents because they serve a more diverse population of patients that present with complex co-morbidities than smaller individual specialty hospitals. The frequency distribution for each covariate is reported in Additional file 2.
Handoff transfers
4 items related to handoffs and transitions of care in the survey were used for our analyses. Handoff of patient information comprises two items, 'important patient intendance information is oftentimes lost during shift changes' (reverse coded) and 'problems oft occur in the commutation of information beyond hospital units' (reverse coded). Handoff of personal responsibility in shift changes is measured by the item, 'shift changes are problematic for patients in this hospital' (reverse coded). Handoff of unit accountability is measured by the item, 'things "fall between the cracks" when transferring patients from i unit to another' (reverse coded).
Patient rubber civilization
Advice culture is measured past two composites, communication openness and feedback and communication well-nigh mistake. Teamwork culture is measured by two composite scales, teamwork within units and teamwork beyond units. Reporting culture is measured by the composite, frequency of events reported. Supportive direction action is measured by 3 composites, management support for patient safety, supervisor/manager expectations and actions promoting patient safe, and non-castigating response to error. The items in the HSOPSC survey that represent each of these composites are reported in Boosted file three.
Patient safety perceptions
Patient safety perceptions comprises four items that measures respondents' understanding that 'patient safe is never sacrificed to become more work done', 'our procedures and systems are skillful at preventing errors from happening', 'it is just by take a chance that more than serious mistakes don't happen around here' (contrary coded), and 'nosotros take patient safety bug in this unit' (reverse coded).
Statistical assay
We applied hierarchical multiple linear regression assay using SPSS v21 to analyze the information. This technique allows us to enter a stock-still guild of variables to control for the influence of the covariates and so that we tin can isolate the furnishings of the predictors of patient safety perception. We first entered the four hospital covariates into the regression model every bit baseline predictors on patient safety perception. We and then entered each handoff transfer variable into the regression model. Similarly, to assess the effects of patient prophylactic culture on each handoff transfer, we first entered the four hospital covariates as baseline predictors on each handoff transfer followed by the corresponding patient safety culture composite.
Results
Offset, we cheque for multicollinearity among the covariates and predictors. Multicollinearity, shown by the variance inflation gene (VIF), results in an inflated variance or R2 in the consequence variable in the regression model [36]. In our sample, the VIF was below 3.0, meaning that whatever pregnant relationships establish are not inflated past correlations betwixt the predictor variables [36]. Table two reports strong support for the hypothesis that constructive handoffs of information, responsibleness, and accountability are statistically significantly (p < .001) related to patient safety perceptions.
Table iii reports the inter-relationships among handoffs of information, responsibility, and accountability. Model 1 in Table 3 reports that enhancing handoffs of responsibility and unit accountability enhance the handoff of patient data. Model two in Table 3 explores the human relationship between communication culture and the handoff of information. The results in Model 2 shows that while feedback and communication on error had a significantly positive effect on perceptions of constructive handoff of patient information, communication openness had no influence on perceptions of constructive handoff of patient information. Thus, a strong advice culture but partially enhances the effective handoff of patient information.
Model three in Table 3 shows that enhancing handoffs of patient information and unit accountability enhance the handoff of responsibility during shift changes. Model iv in Table three shows that both teamwork inside units and frequency of events reported had statistically significant positive influences on perceptions of constructive handoff of responsibleness in shift changes. Thus, a strong teamwork civilization and a reporting culture enhance the handoff of responsibility during shift changes.
Model 5 in Table three shows that enhancing handoffs of patient information and personal responsibility raise the handoff of unit accountability. Model 6 in Tabular array 3 shows that while teamwork between units had a positive and pregnant association on perceptions of the constructive handoff of unit accountability, supportive management culture and non-punitive response to error had no issue on the handoff of accountability. Nosotros also plant that supervisor/managing director expectations and actions promoting patient safety had a statistically negative influence on perceptions of unit accountability. The data indicates that a strong teamwork culture enhances the handoff of unit accountability but this is not in instance for management support.
Discussion
Most handoffs studies accept focused on advice issues. They generally recommend structured information handoffs, such as IPASS, every bit a solution to communication problems. Ours is the outset to delineate and empirically test the relationships of iii different handoffs in information, responsibility, and accountability on perceptions of patient safety. The results generally show that effective handoffs of patient information, personal responsibility during shift changes, and unit of measurement accountability for patient transfers are significantly related to patient safety perceptions. The results also prove that each handoff influences the others such that the improvement (or degradation) of one also improves (or erodes) the others. The information shows that communication exchanges, individual behaviors, and organizational processes accept to be addressed before shared beliefs and values on perceptions of patient safety tin be formed [37].
The results signal that each type of handoff is affected by different patient safety culture composites. Providing feedback and communication about errors enhanced perceptions of effective handoff of patient data. Even so, the results indicate that a potent advice civilisation only partially ensures the effective handoff of patient information. Since communication openness is highly correlated with feedback and advice about errors (r = 0.63, p < 0.01), this finding may be the simple result of measurement since the outcome of 1 cultural composite may mask the effects of the other. Futurity studies should start with a comprehensive definition of communication civilisation to include having a minimum information set, the employ of mnemonics for communicating relevant information, and a procedure that include electronic ways to back up communication.
The data shows that stiff teamwork civilisation and reporting civilisation enhance perceptions of the constructive handoff of responsibility during shift changes. Demonstrating such professionalism may require providers to create protected fourth dimension and space for the handoff during shift change, prepare rationales for plans of care and tasks to perform, and verify that the receiving provider has accurately understood the information received.
The data indicates that providers making the effort to ensure strong teamwork between units by demonstrating cooperation, collaboration, and coordination enhance the handoff of unit accountability. All the same, it was surprising that management back up did not significantly enhance the handoff of unit accountability. Perhaps constant process improvement efforts tin create fatigue, so that 'management support' is met with cynicism if resources to implement these efforts are insufficient. Likewise, frontline staff may not observe management support if the former practice not routinely interact with the latter. Similarly, non-punitive responses to error are not appreciable if no deportment were taken when errors were made. In short, management may need to exhibit the observable appropriate behaviors before unit of measurement accountability in handoffs tin can exist enhanced.
The results indicate that we have to focus on specific cultural composites when designing and training healthcare professionals to meliorate specific types of handoffs. For example, in large hospitals or in complex medical systems, the loftier workload and the pressures of analogous clinical care between different units with different experiences and expectations increase challenges to proper handoffs. Here, management may demand to invoke the sense of professionalism for all healthcare providers by offering evidence on the causes and consequences of poor handoffs while providing incentives and recognition for performing expert handoffs.
The strengths in using the HSOPSC survey data is the large number of hospital participants, which provide robust and stable coefficients in the regression model [38]. The limitations include the following. Outset, the information is cross-exclusive from i time-period. A better estimation technique would be to employ a panel of data going over several years, but that is not possible considering the respondents are anonymous; a different dataset needs to be constructed. Second, physician representation in the data is low and therefore, ane cannot generalize the responses or the implications of the results to physicians alone. Steps to incentivize medico participation volition demand to be taken for the information to represent all stakeholders in the hospital community. Third, no outcomes are reported from this dataset, such as the number of medical errors due to handoffs, the number of close-calls during transitions, or hospital length of stay. Therefore, future studies involving interventions related to handoffs of data, responsibleness, and accountability are needed to correlate the implications for handoff practice to actual outcomes every bit at that place are none to date. Examples of such interventions may include having a minimum data set when handing over patient information, assessing the efficacy of inter-professional person teamwork training on enhancing professionalism, and team-based governance reporting structures to improving unit accountability. Fourth, from a theoretical standpoint, we were express by the fashion the constructs were operationalized in the survey and the reliance on self-study data [38]. An opportunity clearly exists to develop comprehensive measures of these constructs in future studies by considering more fine-grained measures of information substitution and communication processes, personal responsibility as it relates to learning and team behaviors as well every bit unit accountability related to systems improvement, grooming, and staff empowerment. Having noted all these limitations, we all the same believe that the study points u.s.a. toward a richer and theoretically robust way of conceptualizing handoffs.
Conclusions
The contribution of this study lies in the deconstruction of handoffs into information, responsibleness, and accountability and in identifying the accompanying patient prophylactic civilization composites that differentially influence each type of handoff. Nosotros provided an in-depth look at the cultural drivers of effective handoffs than the literature has thus far examined. The different and sometimes stiff cultures betwixt professional specialties can cause the fragmentation of shared values, making it difficult for such professionals to view themselves every bit function of an organization. If the organization does not take a formal process to aid healthcare professionals perceive each other equally a resource, the handoff procedure is carried out in 'silos'.
In society to help healthcare professionals navigate the tradeoff betwixt efficiency and thoroughness, hospitals can build a strong culture of teamwork beyond units, while using other organizational evolution activities to bind its members to a common vision and shared mental model. The theory of planned behavior suggests that mental attitude is a key factor, which can be influenced by grooming and pedagogy [39]. Mayhap training healthcare professionals with handoffs procedures and protocols can be used to influence a healthcare system's patient safety civilisation. Other techniques include mentoring and leading by instance with a sharp focus on transitions of care as a central theme in a hospital's rubber program [twoscore–42]. The interactions between the different types of transitions we showed in this study advise that spillovers into other aspects of patient safety are likely to occur. More importantly, defining patient rubber civilisation in a specific form (transitions of care) attenuates ambiguity so that stakeholders can more clearly place with the goals and process of patient safety improvement programs.
Abbreviations
AHRQ, Agency for Healthcare Research and Quality; DHHS, Department of Health and Human Services (United States); HSOPSC, Hospital Survey on Patient Safe Culture
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Information is bachelor from the Agency for Healthcare Research and Quality (AHRQ) at http://www.ahrq.gov/inquiry/data/dataresources/index.html (accessed: June 29, 2016).
Authors' contributions
SHL designed the study, conducted the literature review, statistical analysis, and drafted the manuscript. PP designed the written report, participated in the statistical analysis, and helped typhoon the manuscript. TD interpreted the information, and participated in the revision of the manuscript. SW acquired the data, interpreted the findings, and participated in the revision of the manuscript. PJP contributed to the conceptual development, interpreted the findings, and participated in the revision of the manuscript. All authors read and approved the final manuscript.
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The authors declare that they have no competing interests.
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Additional files
Additional file 1:
Psychometric Properties of the Variables. Descriptive statistics and reliability analyses of the items in each patient safety civilization blended. (DOCX fifteen kb)
Additional file 2:
Frequency Distribution of Covariates. The distribution frequency for each covariate (control) variable used in the hierarchical regression model. This is study to describe the sample characteristics. (DOCX 12 kb)
Additional file 3:
Hospital Survey on Patient Safety Culture (HSOPC) survey items for each Patient Safety Culture Blended. A list of the items and descriptions from the HSOPC used in this study. (DOCX 13 kb)
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Lee, SH., Phan, P.H., Dorman, T. et al. Handoffs, safety culture, and practices: evidence from the hospital survey on patient safe civilisation. BMC Health Serv Res sixteen, 254 (2016). https://doi.org/10.1186/s12913-016-1502-7
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DOI : https://doi.org/ten.1186/s12913-016-1502-7
Keywords
- Handoffs
- Staff attitudes
- Patient rubber culture
- Communication
- Personal responsibility
- Accountability
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