The Otorhinolaryngology Hand-The Otorhinolaryngology Hand-Off:Off:Pursuing Excellence in Patient Pursuing Excellence in Patient Care and SafetyCare and Safety

Mark A. Zacharek, MD, FACS, FAAOAMark A. Zacharek, MD, FACS, FAAOAAssociate ProfessorAssociate ProfessorAssociate Residency Program DirectorAssociate Residency Program DirectorDepartment of OtorhinolaryngologyDepartment of OtorhinolaryngologyMichigan Sinus CenterMichigan Sinus CenterUniversity of Michigan Health SystemUniversity of Michigan Health System

ACGME Common Program ACGME Common Program RequirementsRequirements

““Sponsoring institutions must ensure Sponsoring institutions must ensure and monitor effective, structured and monitor effective, structured hand-over processes to facilitate both hand-over processes to facilitate both continuity of care and patient safety. continuity of care and patient safety. Programs must ensure that residents Programs must ensure that residents are competent in communicating with are competent in communicating with team members in the hand-over team members in the hand-over process.”process.”

ACGME 2011 CPR www.acgme.org

Halstead on Surgical ResidencyHalstead on Surgical Residency

““It will be objected that this is It will be objected that this is too long an apprenticeship, too long an apprenticeship, that the young surgeon will be that the young surgeon will be stale, his enthusiasm gone stale, his enthusiasm gone before he has completed his before he has completed his arduous term of service. These arduous term of service. These positions are not for those who positions are not for those who soon weary of the study of soon weary of the study of their profession, and it is a fact their profession, and it is a fact that the zeal and industry of that the zeal and industry of these young assistants seem these young assistants seem to increase as they advance in to increase as they advance in years and as their knowledge years and as their knowledge and responsibilities become and responsibilities become greater.”greater.”

The Otorhinolaryngology Hand-The Otorhinolaryngology Hand-offoff

ACGME standards promote teamwork.ACGME standards promote teamwork.

““Residents must work effectively as a member Residents must work effectively as a member or leader of a health care team or other or leader of a health care team or other professional group.”professional group.”

““Residents are expected to work in inter-Residents are expected to work in inter-professional teams to enhance patient safety professional teams to enhance patient safety and improve patient care quality.”and improve patient care quality.”

““Residents should have representation on Residents should have representation on hospital quality improvement committees.”hospital quality improvement committees.”

ACGME 2011 CPR www.acgme.org

Residents have Duty Hour Residents have Duty Hour RestrictionsRestrictions With a focus on restricted duty hours, the With a focus on restricted duty hours, the

importance of communication between teams importance of communication between teams and individuals is of the utmost importance.and individuals is of the utmost importance.

Bo Schembechler (1983)- Bo Schembechler (1983)- “ “The Team, The Team, The Team!”The Team, The Team, The Team!”

The “handoff” (“handover” “signout” ) is The “handoff” (“handover” “signout” ) is part of the continuity of care when one part of the continuity of care when one resident is no longer in the hospital for a resident is no longer in the hospital for a continuous period of time.continuous period of time.

Definition: Transitions of Definition: Transitions of

CareCare

Programs must design clinical assignments to Programs must design clinical assignments to minimize the number of transitions in patient minimize the number of transitions in patient care.care.

Responsibility for each patient may be Responsibility for each patient may be transferred between 2 or more residents within a transferred between 2 or more residents within a 24 hour period.24 hour period.

““Sponsoring institutions and programs must Sponsoring institutions and programs must ensure and monitor effective, ensure and monitor effective, structured structured handover processeshandover processes to facilitate both continuity to facilitate both continuity of care and patient safety. Programs must ensure of care and patient safety. Programs must ensure that residents are that residents are competentcompetent in in communicatingcommunicating with with team membersteam members in the handover process.” in the handover process.”

ACGME 2011 CPR www.acgme.org

Can we standardize the Can we standardize the otorhinolaryngology “handoff”?otorhinolaryngology “handoff”?

Handoffs may occur asynchronously Handoffs may occur asynchronously without person to person/face to face without person to person/face to face interaction.interaction.

Reduction in errors due to fatigue Reduction in errors due to fatigue should not be offset by an increase in should not be offset by an increase in errors due to poor errors due to poor communication/improper information communication/improper information transfer.transfer.

Multiple types of HandoffsMultiple types of Handoffs

Post-op AmbulatoryPost-op Ambulatory Inpatient consultInpatient consult Outpatient/clinicOutpatient/clinic Primary Oto inpatient service Primary Oto inpatient service Primary Oto SICU patient in closed ICU Primary Oto SICU patient in closed ICU

system (General Surgery Staff and Resident)system (General Surgery Staff and Resident) Different Otolaryngology Services Different Otolaryngology Services

(Neurotology, Head and Neck, VA, Pediatric)(Neurotology, Head and Neck, VA, Pediatric) Multiple Hospitals (Home Call vs In House)Multiple Hospitals (Home Call vs In House)

Program Director Strategies:Program Director Strategies:

Supervision and provision of feedbackSupervision and provision of feedback Coaching (Senior resident and faculty Coaching (Senior resident and faculty

observation of junior handoffs)observation of junior handoffs) Objective skills-based examinationsObjective skills-based examinations Simulation of practice handoff skillsSimulation of practice handoff skills Metrics in Portfolio for “Interpersonal Skills Metrics in Portfolio for “Interpersonal Skills

and Communication”and Communication” Using a checklist?Using a checklist? What do other professionals do? What do other professionals do?

Causes of Error in Teaching Causes of Error in Teaching

HospitalsHospitals

Between 1979-2001, closed Between 1979-2001, closed malpractice claims datamalpractice claims data

240 errors in teaching settings240 errors in teaching settings

- errors in judgement 72%- errors in judgement 72%

- problems with teamwork 70%- problems with teamwork 70%

- lack of technical competence 58%- lack of technical competence 58%

Singh H et al. Medical errors involving trainees: a study of Closed malpractice claims for 5 insurers. Arch Intern Med. 2007;167(19):2030-2036

Transitions of Care in the Transitions of Care in the Training Environment: ACGME Training Environment: ACGME StandardsStandards Dr. Bradley Marple, MD  Dr.

Marple is Professor and Vice Chairman of the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Texas Southwestern. Additionally, he is the Chair of the ACGME Otolaryngology Residency Review Committee.

Patient Handoffs: A Cognitive Patient Handoffs: A Cognitive Systems Engineering Systems Engineering PerspectivePerspective Emily Patterson, PhD  Dr. Patterson is

an assistant professor at Ohio State University in the Health Information Management and Systems Division of the School of Allied Medical Professionals in the College of Medicine. She is an expert in the field of cognitive systems engineering with interests in health informatics and macro-cognitive communication.

Patient Hand-offs: A Medical Patient Hand-offs: A Medical Education Perspective Education Perspective

Ingrid Philibert, PhD MBA    Senior Vice President, Department of Field Activities at the ACGME. Dr. Philibert is responsible for the Council's 31 MD and PhD accreditation field representatives as well as the 2000 site visits conducted annually. She is one of the editors of the ACGME's recent monologue regarding Duty Hour Standards "The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development".