(Mt) – Ohio University Handoffs in Patient Care Case Study

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Questions: Read Case 17: Handoffs in Patient Care from the McAlearney and Kovner text, pages 132 – 136. For this assignment, assume you are in the role of hospital administrator at Midwest University Medical Center. In general, the hospital is experiencing problems with patient handoffs and you have been assigned by the CEO to address the multiple factors impacting the process. In 850 words or less, using the template provided, you are asked to develop a response to the questions below. 1. To begin, identify four factors contributing to patient handoff problems at Midwest University Medical Center. 2. For each of the factors identified in question 1, describe one control element that is being negatively impacted by the current managerial control(handoff) process (one paragraph each). 3. As the hospital administrator, identify one managerial control action (one paragraph each) you would undertake to address each of the negatively impacted control elements listed in question 2. Support your decision making with lesson readings and/or outside sources. For additional sources, you might skim the Lesson One readings. 4. In your professional opinion, are there other factors within the existing system that could be impacting trust and cooperation? In 250 words or less, why or why not? Support your opinion with an outside peer reviewed or professional source. CASE 17 Handoffs in Patient Care Brian Hilligoss M idwest University Medical Center (MUMC) is a highly specialized tertiary referral and trauma center affiliated with a major university in the Midwest. The main hospital is a 600-bed acute care facility that receives roughly 45,000 patient admissions each year, more than half of which come through the emergency department (ED). When physicians in the ED decide to admit a patient, they complete an admission form in the electronic medical record (EMR), designating the service to which the patient is to be admitted. They also send a page to the admitting physician on that service. The admitting physician then calls the ED physician and takes a handoff over the telephone. During this handoff, the ED physician presents the patient’s case, including some relevant medical history, information about the chief complaint, and how the patient has responded to care in the ED. To a certain extent, the handoff signifies the transfer of responsibility for the patient from the ED to the inpatient service; however, this transfer can involve considerable ambiguity at times. Sometimes physicians on the inpatient services may feel that a patient would be better served by a different service. In such cases, they may redirect the admission to another service, and the ED physician must then make a handoff to that service. Boarding in the ED Patients must often remain in the ED for some period after the handoff—a process known as “boarding”—until an inpatient bed is available and a transport tech can move the patient to the inpatient ward. Consequently, a kind of gray zone exists in which patients may receive less attention as staff incorrectly assume that someone else is looking after them. This problem is exacerbated by the fact that boarded patients may be physically out of sight. After the handoff conversation has occurred, ED staff often move these patients into the hallways of the ED to make room for incoming patients. ED nurses and physicians, going about their duties caring for new, incoming patients, are physically removed from the hallways where the boarded patients wait. Meanwhile, the inpatient staff are even farther away. The MUMC ED is in the basement of the hospital, and most of the inpatient wards are in the tower on floors 4 through 11. Because MUMC tends to operate at or near capacity, boarding is frequent, and patients often remain in the ED for six or more hours after the handoff. When shift changes occur in the ED or inpatient services during these times of boarding, the risk of a patient falling off someone’s radar increases. A “New” Patient? At 8:35 a.m. on a bleak February morning, Dr. Anita Henderson, a hospitalist, received an urgent page from a nurse. “Orders needed for Saunders. STAT. Nausea. In pain.” Dr. Henderson was perplexed: She knew of no patient by the name of Saunders. She double-checked the paper list of patients she carried in her white coat. No Saunders. She looked at the whiteboard where her service lists the names of expected new patients. No Saunders. She asked several of her colleagues—other general internal medicine physicians on the hospitalist service—if they had a patient by the name of Saunders, but no one recognized the name. Dr. Henderson had just begun her seven-day rotation on the hospitalist service that morning. Dr. Chris Clark had rotated off the service the prior afternoon, and now his patients were her responsibility. When she arrived at 7:00 a.m., Dr. Henderson had taken handoffs from the night float residents who had been cross-covering the patients during the night. They had reported two new admissions, but neither was named Saunders. Whose Patient Is This? Dr. Henderson picked up the phone and called the nurse who had sent the page. The nurse reported that Mr. Saunders was a 61-year-old male with a history of smoking, emphysema, and diabetes. He had been admitted to the ED for shortness of breath and had just recently arrived on the general medicine floor. The nurse said that Mr. Saunders was complaining of pain and feeling nauseated. Dr. Henderson asked who was listed as the patient’s attending physician. The nurse responded, “Dr. Chris Clark.” Hearing the nurse’s concern regarding the patient’s condition, Dr. Henderson laid aside for the time being any further questions about how this patient came to be on her service without her knowing or receiving some kind of handoff from another physician. She went to see the patient for herself. After examining and interviewing Mr. Saunders, Dr. Henderson concluded that he had missed at least one dose of each of his several home medications because of his stay in the ED. He was somewhat dehydrated, his emphysema was flaring up, and he was clearly short of breath. He was also complaining of a “funny feeling in his heart.” Dr. Henderson also learned that he had been down in the ED since the previous morning and had spent much of the afternoon and all of the night in a bed in a crowded hallway. She offered an apology to soothe the clearly irritated patient and wrote orders for his medications and for fluids. Later, Dr. Henderson sat down and looked closely at the patient’s electronic medical record. She found the name of the ED resident who had issued the admission orders the previous day and sent him a page asking him to call her. Twenty minutes later, Dr. Calvin Lee, a third-year resident in the MUMC ED, called Dr. Henderson. Dr. Henderson: This is Anita Henderson. Dr. Lee: Hi, Anita. It’s Calvin Lee, returning your page. Dr. Henderson: Hi, Calvin. Thanks for calling me back. I wanted to ask you about a patient by the name of Saunders. Did you admit him yesterday? Dr. Lee: Saunders? Sounds familiar. We see so many. Dr. Henderson: He says he came in yesterday morning with shortness of breath and maybe an irregular heartbeat. He has a history of smoking and emphysema. Dr. Lee: Oh, my gosh! Yes! Did he end up on your service? Dr. Henderson: Yes. He just arrived, and he’s not doing well. I think he missed his medications and is dehydrated. Sounds like he was boarded overnight in the ED. Dr. Lee: Could be. We were overflowing yesterday. Still super busy down here today. So, how can I help? Dr. Henderson: Well, I just got a page from the floor nurse saying he was on my service and needed attention, but that was the first I heard of him. I’m trying to learn more about him and also find out where the ball got dropped. Dr. Lee: Wow, nobody handed him off to you? And he’s just getting to the floor now? Dr. Henderson: Yes. Dr. Lee: Well, that was a big ring-around-the-rosy yesterday! His EKG showed an irregular heart rhythm, so I called pulmonary because I thought the abnormal rhythm might be due to his emphysema. But pulmonary said, “Oh, no, no. We think they’re two separate issues. Admit to cardiology to get the heart rate under control and we’ll consult.” But then, when I called cardiology and they heard about the emphysema, they were like, “No, no, no. This is a pulmonary problem, and the heart is just a side victim. This has nothing to do with us, and what are we going to do with this? And he’s going to be on our service for four days recovering from emphysema, and this is ridiculous and this is not what we do.” Oh my gosh! They went back and forth and had me call the hospitalist service— Dr. Clark, I think. I can’t even remember how many phone calls there were. I finally told them to work it out and then call me back. But I guess they never did. When I left at 3:00 p.m., I handed the patient off to my colleague. Handoffs Within the ED As the conversation continued, Dr. Henderson realized that the patient had been handed off several times in the ED—first when Dr. Lee’s shift ended at 3:00 p.m., and then again at subsequent shift changes at 11:00 p.m. and 7:00 a.m. From experience Dr. Henderson knew that details about patient cases tend to get lost with multiple handoffs, particularly when patients have already been officially admitted and are being boarded in the ED. Dr. Henderson learned that Dr. Lee had listed the hospitalist service as the admitting service in the EMR because, at the point when he issued the admission order, neither the pulmonary service nor the cardiology service seemed likely to take the patient, meaning that the hospitalist service would have to take him. (At MUMC, the hospitalist service is sometimes jokingly referred to as the “service of last resort” because they often receive patients whom no other service will accept.) Dr. Henderson knew that the EMR system requires an admitting service to be selected to start the admissions process. She also knew that because Dr. Clark was responsible for the admissions pager for the hospitalist service yesterday, the EMR system would have designated him as the attending by default. Dr. Lee also said that when he handed the patient off to his colleague at the end of his shift, he had instructed her to update the EMR once the final decision on placement had been made and to update the involved services. Epilogue Dr. Henderson cared for Mr. Saunders with consultations from physicians in the pulmonary and cardiology services and discharged him home after several days. When Dr. Clark returned to work a few days later, Dr. Henderson asked him about the patient’s case. Dr. Clark told her that, when he had left that evening, the issue about where the patient would go had not been settled, as the other services were waiting for results from additional tests. Dr. Clark said he notified the night float resident about Mr. Saunders and that the ED would call if the patient were going to be admitted to the hospitalist service. Assignment 2.2 Template I n healthcare delivery, an effective system of control must monitor a variety of outcomes related to physical functioning (e.g., reduction in pain, ability to climb stairs) and physiological measures (e.g., blood pressure, cholesterol levels), as well as patient perceptions and satisfaction, professional judgment, and cost of care. The need to account for this wide range of factors has led to such concepts as the “value compass” and the “balanced scorecard” to guide control efforts. A system of control comprises five elements: 1.Goals and objectives. For healthcare delivery, the goals and objectives emphasize meeting customer needs. 2.Information. An effective control system should gather information that can be used to measure performance. 3.Performance evaluation. Performance should be evaluated in relation to the goals and objectives. Did the customer get what she wanted? 4.Expectations. A control system should make clear what is expected. Was what the customer got good enough? 5.Incentives. Workers can be motivated by an internalized desire to do a good job or by external rewards. The desire to satisfy the customer and the desire to please the supervisor in hopes of a pay raise ideally go together without conflict; problems start, however, if a disconnect exists between satisfying the customer and satisfying the manager. Goals and Objectives Mission, vision, values, goals, and objectives are widely used concepts, shown in exhibit II.1. In short, an organization might say that our mission is to meet the needs of our customers; our vision is to be the best; the values we live by are our religious beliefs; our goal is to survive this year; and our objective is to break even. Another example is provided in the exhibit. A goal is a broadly stated intention or direction—to improve quality, for example, by lowering the infection rate. Organizational goals are determined by the preferences of individuals with power. Organizations are collectives of people and things brought together to achieve a common purpose, and they are created by individuals with similar goals. Goals provide organizational focus, establish a long-term framework for dealing with conflict, and encourage commitment from people who work in the organization. They are implemented by individuals working together on budgets, involve the allocation of functions, and may be influenced by the authority structure. Imagine that an individual wants housing and food and health and entertainment, and this person decides he can do his best by working for pay as a nurse in a clinic. Nursing can be both a means to an end (providing a paycheck) and an end in itself (providing the satisfaction of helping people in a friendly work environment). The clinic’s goal of good quality and reasonable cost assumes that this nurse continues to have an enjoyable job and a paycheck. The manager has the role of making this happen. Organizations may have objectives to measure production, sales, profit, and quality. Unit or organizational objectives can be determined by reading formal goal statements or by observing what is happening in the organization. These observations may reveal shifts in resources or decision-making power among units or individuals, in the types of individuals leaving or being recruited to the organization, and in what the organization is not doing and what population it is not serving. Many large corporations expend a lot of effort in goal specification. What happens if a healthcare organization does not specify objectives? The organization may lack focus in its programs, and it may be less likely to abandon products and services that are neither effective nor efficient. Powerful individuals and their short-term interests will tend to be favored over weaker individuals and long-term interests; the organization will be less adaptive to the environment; and it will have a greater tendency to retain the status quo. Healthcare managers should determine their organization’s operative objectives. Official goals may not always provide reliable guidelines for managerial behavior. When the people in power go against what a manager sees as the long-range interests of an organization, the manager should be careful, speaking out only if she is willing to pay the price and is certain about the facts. Information Healthcare managers must obtain information for key product lines about volume of services, quality of care, service and production efficiency, market conditions, system maintenance, and the health status of the population served. They may use the following measures to assess performance: cost per case, cost per visit, cost per day, profit, fixed and variable costs, market share, capital expenditures as a percentage of sales, days of receivables and payables, top admitting physicians and their characteristics, staff turnover and overtime, sick time, and disability and fringe benefits costs. In addition, healthcare information systems are being expanded to include revenue by service line, budgeting and variance reporting, and clinical performance review. Computerized medical records are linked to cost and revenue data, concurrent review for quality of care, and final-product cost accounting for groups of similar patients at alternative levels of demand. Risk management relies on incident reports of untoward events, which are then aggregated and analyzed. With the continuing investment in electronic medical records, required performance reporting, and standardized patient satisfaction surveys, healthcare is entering an era of information overload. Whereas management previously lacked data about quality of care, now it has more information than it can cope with. What measures should take priority? What are the key quality characteristics? Performance Evaluation One of the problems with control systems is that they may measure the wrong thing. Another problem is that they may measure the right thing inaccurately. These issues are particularly relevant for outcomes measurement. The easiest response to information we do not like is to say the data are wrong. In a hostile, fearful environment, managers may feel that no information is accurate enough to be accepted. One of the important aspects of quality improvement (QI) is to create a climate free from fear, where data can be accepted for what they are, despite their limitations, and still be used to make improvements. Increasingly, healthcare managers have access to performance data comparing their organizations to other similar ones. In the past, a nursing home board of directors may have simply believed without question that its care was outstanding; now, comparative data allow the board to actually see how the nursing home stacks up. The first step is for the organization to measure its care; for example, it can track the frequency of bed sores or the percentage of patients under physical restraint. The next step is to compare measures. Why are 15 percent of our patients under restraint while the statewide average is 8 percent? The third step is to make this information public on accessible websites. Examples of such sites include Nursing Home Compare (www.medicare.gov/nursinghomecompare) and Hospital Compare (www.medicare.gov/hospitalcompare), from the Centers for Medicare & Medicaid Services. Concurrent with these steps is a change from denial (e.g., claiming “our patients are sicker”) and fear to a desire to improve. Managers at a nursing home with a high restraint rate can visit another similar nursing home with a low restraint rate to learn how to improve their own situation. This effort requires collecting performance data over time to track improvements. The process of systematic comparison to best-practice organizations is called benchmarking. Expectations Medication errors—whether they involve the wrong medicine, the wrong dose, or the wrong time—occur frequently in hospitals. Although no clinic wants such errors to occur, clinics differ in the ways they approach the problem. What is the level of expectation for good performance? It could be “zero tolerance for error,” or it could be that the clinic will make yearly improvements to continuously reduce its error rate. A clinic might assume, “Everyone has this problem, and we are no different”; alternatively, it might think, “We have the best nurses and physicians, so I am sure our error rates are lower than anyone else’s.” Performance expectations make a difference. Six Sigma is one method for reducing unwanted events. Incentives How does the manager transform the individual worker’s desire for a paycheck into a pursuit of organizational goals so that both individual and organizational aims are achieved together? Incentives are stimuli to affect performance. Adoption of incentives is usually based on the answers to the following questions: Does the incentive contribute to the desired results? Is the incentive acceptable to those workers whose behavior managers wish to influence? Could implementation of the incentives produce other dysfunctional consequences (e.g., rewards for cutting costs leading inadvertently to reduced quality of care)? Organizations use both positive and negative incentives, and they can be monetary or nonmonetary. One of the underlying ideas of QI is that monetary incentives are often disruptive. The assumption is that people want to do a good job and that faulty systems—not the intentions or abilities of the employees—prevent that from happening. For instance, how can the admissions clerk rapidly process an admission if the computer has crashed? How can the dietary department provide hot food at the bedside when the patient is waiting in the X-ray department? QI calls for management to lead the effort in improving these systems. Monetary rewards for individuals, by contrast, may create rivalry rather than teamwork. Improving care requires “just-in-time” data about key quality characteristics, as well as an observer who has the expertise to understand this information, whose job it is to improve care, and who is given the power to do so. For example, say the goal is to reduce the burden of asthma for children, measured by the number of school days missed because of asthma in a particular area. A just-in-time information system would show how many children missed school yesterday—not last year or even last month—and an asthma expert would be given the assignment to reduce this rate and the power to do something about it. Such a system would likely be effective, but there are too few examples of such management approaches in healthcare.

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