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

rdjanke@cw.bc.ca

Cathy MasudaQuality, Safety & Accreditation Leader – BCCH Specialty Medicine

cmasuda@cw.bc.ca

Tracie NorthwayProject Manager, Strategic Implementation – BCCH & SHHC

tnorthway@cw.bc.ca

Questions???