How to end the handoff free-for-all A hospital cuts handoff times in half by laying down some ground rules by Phyllis Maguire
Published in the October 2010 issue of Today's Hospitalist
ASK M. CAROLINE BURTON, MD, how morning handoffs used to be run at the Mayo Clinic in Rochester, Minn., and she describes what she calls "organized inefficiency."
The big conference room where morning report was held provided too much space for people to socialize, distracting anyone trying to listen to what patient problems had cropped up during the night. The overnight NP/PAs who were handing off established patients had a hard time figuring out which physicians and midlevels belonged to which of the several day teams.
Those day-team members were never
"We have more time for quality chit-chat because our report time is more focused."
–M. Caroline Burton, MD Mayo Clinic
quite sure when during the report their particular handoff would occur, so they'd show up late—or not at all. And time was consistently wasted with meandering narratives that didn't pinpoint patient issues that needed attention.
With so much riding on handoffs in terms of patient continuity and safety, Dr. Burton, a Mayo hospitalist, wanted to see what a little structure could do to improve morning report. After studying how established patients were handed off between night providers and day teams, Dr. Burton and her fellow researchers identified what they saw as the major problems in how handoffs were being done.
For one, morning reports were hampered by unpredictable start and end times. They were plagued by wasted time and poor communication techniques. And they suffered from a poor environment rife with noise and distractions.
Researchers came up with several interventions that included set-in-stone start and end times; an absolute prohibition on side conversations; a particular time when each day team would receive its report; assigned seats for day-team members; and—perhaps most important— a much smaller room with a door that stays shut during the meeting.
Dr. Burton's study on revamping Mayo's morning report was posted online in August by the Journal of Hospital Medicine. Four day teams of a hospitalist and a midlevel—three general medicine and one orthopedic surgery comanagement team—take handoff for established patients from the night NP/PA.
(To handle new patients admitted during the night, night hospitalists hand those patients off to day physicians in a separate morning report. While many hospitalists attend the morning report that Dr. Burton's team studied and restructured, those teams sometimes are represented at morning report by only the team's midlevel provider.)
Before Dr. Burton's team made its innovations in February 2009, only 60% of the physicians and NP/PAs the researchers surveyed thought morning report was performed in a timely manner, vs. 100% postintervention. The average time spent in morning report was cut by more than half. And postintervention, 100% of the morning reports began on time (7:45 a.m.) and ended on time (8 a.m.). Three months after the changes were made, the meetings continue to run like clockwork.
During report, receiving teams have not only the verbal handoff but a printed electronic service list, which details each patient's diagnoses, medications, allergies, labs and to-do items. Postintervention, that electronic service list has been available and complete 100% of the time.
To shave off minutes, identification cards were created for each of the four teams, allowing night midlevels to know which day providers represent which team. And the decision to place green "good-to-go" cards at the seats of team members whose patients had no pressing problems helped eliminate the need for a verbal handoff.
Location, location, location
Dr. Burton's team also set strict ground rules in terms of time: Each team's handoff could take no more than three minutes, and each day team was assigned a specific time that its handoff would begin (7:45 a.m., 7:48 a.m. and so on). But perhaps the most striking change, Dr. Burton says, was the decision to use a smaller room with few additional seats.
"When you take away the big room with the high ceiling and huge table, it's more uncomfortable," says Dr. Burton. "Any chit-chat is really going to interfere with what you're trying to hear."
There was another change in terms of location: Dr. Burton put the room where morning report occurs on the first floor, the same floor as most of the physician offices. When handoffs used to take place on the second floor, Dr. Burton recalls, doctors would walk upstairs, find that the night NP/PA wasn't ready for them yet, come back downstairs—and perhaps not climb the stairs again.
"Having morning report just around the corner played a role," says Dr. Burton, "as opposed to having to climb stairs."
Another new rule: no side conversations. While some physicians worried that the rule would cut down on collegiality, that hasn't been the case. "Actually, we have more time for quality chit-chat because our report time is more focused," Dr. Burton says. "The only difference is that socializing has to take place outside the handoff room. The door is shut, and we all stand out in the hall and visit."
While many of the new rules focus the way day teams receive information, several changes were designed to improve the quality of handoffs.
Because each team's handoff should take only three minutes, Dr. Burton explains, "it really focuses what you need to say and not give any extraneous information." The new format allows for, "No whining, and no meandering. You're reporting only the important facts, like the patient was running a fever."
Because a succinct handoff is now expected, night NP/PAs are also spending more time during the night noting to-do items in the electronic service list, rather than waiting until 30 minutes before morning report begins.
There is another downstream plus. With morning report now ending at 8 a.m., the day teams are meeting another new expectation: hitting the floors by 8:30. That's been a bonus for the floor nurses.
"Making our behavior more predictable gave nurses a better feel for when we're available to answer questions," Dr. Burton says, "so unnecessary pages are being held. Before, they really had no idea when we'd be there so they'd go ahead and page."
Dr. Burton adds that she plans to build on her team's success and look at other handoffs: those taking place between day teams and night providers in the evening, for instance, and between hospitalists in the morning for new admissions.
Phyllis Maguire is Executive Editor of Today's Hospitalist.