E1 Rapid Fire: Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T....
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BC Children’s Hospital & Sunny Hill Health Center for Children SHARED Transfer of Care: Safe Intra-Hospital Transfer of Patient Care Rita Janke, Cathy Masuda, & Tracie Northway
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Transcript of E1 Rapid Fire: Passing the Baton for Quality Care - C. Masuda, K. Cooksley, R. Janke and T....
BC Children’s Hospital &
Sunny Hill Health Center for Children
SHARED Transfer of Care:
Safe Intra-Hospital Transfer of
Patient Care
Rita Janke, Cathy Masuda, & Tracie Northway
Clinical Transfer of Care
The transfer of professional responsibility &
accountability for some or all aspects of care for
a patient to another person or professional group
on a temporary or permanent basis (NHS)
Why Focus on Transfer of Care?
•65% of reported sentinel events due to
communication
•Handover process unreliable & highly variable
•Failures in clinical handover major preventable cause of patient harm
Measured Outcomes:
Preparation
Findings
•No consistency among both RNs
•Inaccurate / incomplete information given
•Confusing info takes away from patient
•Creation / perpetuation of errors
“I don’t really
know this
patient”
“6 pages of
orders from 3
different
Physicians!”
Determining Best Practice
Based upon literature review:–Standardization of handover content & process
–Best practices:
1. Two-way Communication
2. Face-to-Face Handovers with Written Support
3. Content of Handover Captures Expectation & Plan of Care
–Mnemonic to guide handover
SHARED Transfer of Care
•Standardized process throughout BCCH / SHHC
•Replaces current transfer sheets, admission or transfer note, flow sheet assessment
•Supports effective communication
SHARED Transfer of Care
SH Form
Transfer Orders Set
Steps in SHARED
Transfer of Care Process
Pre-Kaizen &
Kaizen Week Defects
Lessons Learned from RPIW
Follow-On
•Program-specific champions
•Mediasite education on BCCH website
•Initial site-wide education for nurses Fall 2009
•SHARED process added to orientation
•Revisions to include PACU & Mental Health Process
•Inclusion of PEWS score
•Ongoing measurement via observation
•Indicator placed on PSLS to identify if event occurred during transfer of care
Sustainment
SHARED Transfer of Care: Number of defects per transfer
Defects over time
0
5
10
15
20
25
30
Prep-week
(Jun 2009)
(n=11) 8-21
defects
RPIW Final
(n=14) 0-12
defects
Week 1 (n=2)
2-4 defects
Week 2 (n=3)
1-7 defects
Week 3 (n=5)
0-3 defects
30 days post
(n=6) 0-5
defects
60 days post
(n=12) 1-8
defects
90 days post
(n=15) 1-5
defects
Nov 2009-
July 2010
(n=22) 1-7
defects
2011 (n=7) 1-
8 defects
Contact Info
Rita JankeQuality, Safety & Accreditation Leader – SHHC
Cathy MasudaQuality, Safety & Accreditation Leader – BCCH Specialty Medicine
Tracie NorthwayProject Manager, Strategic Implementation – BCCH & SHHC
Questions???
