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All of Nebraska Medicine’s inpatient nursing units (approximately 4,000 colleagues or nearly half of the organization’s workforce) were trained in a standardized patient handoff tool known as ISHAPED. It is a communication tool that is to be used for shift-to-shift handoffs, as well as unit-to-unit transfers, unit-to-procedural transfers, and emergency room-to-inpatient transfers.
Inadequate handoffs lead to miscommunication of information, disruptions in continuity of patient care, omissions of critical data, medication errors, and serious adverse outcomes.
Program Details
A working group of nursing leaders did an extensive literature search of existing patient care handoff tools. The guiding principles for a handoff tool were:
- The patient and family should be included.
- The handoff should be done at the bedside.
- The handoff should be made electronic.
After in-depth reviews of 15 different tools, the group chose to use the one developed by Inova Health System, in Falls Church, VA, which had been developed as a part of the Picker Institute’s Always Events Program. It is called the “ISHAPED” tool:
I=Introduce
S=Story
H=History
A=Assessment
P=Plan
E=Error Prevention
D=Dialogue
The tool focuses on making bedside shift reports more patient- and family-centered while ensuring key patient care information is passed from the nurse completing his or her shift to the nurse coming onto his or her shift. An additional layer of safety is added by performing the communication at the bedside because the patient and/or his or her family is able to communicate potential safety concerns. Their proposal was presented to the Nursing Practice Council, which is part of Nebraska Medicine’s shared governance model, and this group agreed to implement the ISHAPED handoff tool.
The training consists of a module created for deployment within the organization’s learning management system (LMS). The module includes information about why there’s a need for an effective handoff tool and the process that is to be utilized for performing an effective handoff. Within the module is a recording of a live demonstration of nurses using the ISHAPED handoff tool at the patient’s bedside. Two nurses discuss pertinent patient care issues and include the patient in the discussion to illustrate an effective bedside handoff report. While the nurses were discussing the patient, videography tools were utilized to zoom in on sections of the computerized ISHAPED tool that were being discussed. This aided in helping staff visualize where information can be found in the ISHAPED tool and how to properly navigate through their discussion using the tool to guide them. Additional specific instructions in the form of a “Tip Sheet” were developed for specific nursing units.
The module utilizes gamification where the learner moves an avatar forward on a “gameboard” guided by voiceover instructions. The sequencing of information presented to learners allows their knowledge to build on previous concepts presented earlier in the module. Knowledge checks in the form of questions that have to be answered correctly in order to move forward are embedded within the module.
The last portion of the module is a screencast of the computer screen the nurse learner will be using to document the ISHAPED handoff. The screencast, which includes voiceovers, is used to visualize the needed workflow within a patient’s Electronic Health Record (EHR) when a nurse is completing the ISHAPED handoff. This screencast is a “staged” role-play handoff of a common interaction between nurses.
The utilization of the Electronic Health Record to facilitate this handoff process by pulling information from a variety of locations within the patient record to a single location had not been done anywhere prior to this project.
New hires are instructed in the use of this tool during their general orientation. Once a new nurse is in his or her home unit, a Nursing Professional Development Specialist provides him or her with one-on-one instruction and reinforcement of use of the tool. The new nurse is also encouraged to practice the tool’s use with his or her preceptor.
Results
Monthly statistics extracted from the EHR are used to track staff compliance with use of the tool. These statistics are provided to the unit managers, who share the results with staff. Shift-to-shift use of the tool has met the goal of being equal to or greater than 90 percent for the last year.
The Vizient Safety Harm Rate goal of 5.20 was met with a result of 3.30 (the lower the number, the better). The Mortality O/E – NMC goal of .84 was not quite met, with a result of .91.