By John Showalter and Kate Millay
“First, do no harm” is an oath taken by all physicians, but despite this aspiration, the Institute of Medicine estimates that 44,000 to 98,000 patients die each year due to medical errors. Sixty percent are due to ineffective communication, and the lion’s share of these miscommunications occurs at the time patients’ care is transferred between providers. In response to these safety concerns, to foster inter-provider communication and a culture of interaction, the Joint Commission’s National Patient Safety Goal 02.05.01 requires “implementation of a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.”
In the summer of 2009, Penn State Milton S. Hershey Medical Center embraced the need for this culture change among its physicians and formed the Physician Handoff Communication team. The goal of this team is build a culture of safety with regards to handoff communication by facilitating the discussion between physicians at all transitions of care. A comprehensive Failure Modes and Effects Analysis (FMEA) was conducted of potential gaps in communication. Following that analysis, to fill those gaps, many educational opportunities were offered, a new physician handoff policy was written, information technology solutions were developed and a communication campaign was undertaken. Based on the premise of being for “every patient, every time,” the main slogan for this quality improvement initiative was the adoption of a brand for our communication culture -- “I.Q.”
I.Q. stands for "interact and question." Physicians were encouraged to interact and question each other at every care transition, thereby confirming each patient’s assessment and overall plan of care. The I.Q. mantra was disseminated through multiple presentations and communication tools at department and institutional levels.
Baseline, preintervention handoff effectiveness data ranged from 42 percent to 100 percent of handoffs being reported by physicians as “sufficient” for the transfer of patient care. Preliminary resurvey, post-intervention data indicate an improvement of the range of physician handoff effectiveness to 93 percent to 100 percent, meaning handoffs are more effective, more often.
In short, a simple message – I.Q. – well conceived and well received, translates into an improved culture of safety and a greater likelihood of achieving the aspiration to “first, do no harm” for every patient, every time.
John Showalter is a fellow in medical informatics, department of internal medicine and Kate Millay, clinical performance improvement specialist, quality services, Penn State Milton S. Hershey Medical Center.