Where: Division of hospital medicine, Mayo Clinic, which covers four general medicine services and two consulting orthopedic comanagement services in Rochester, Minn.
The issue: Improving the efficiency of the morning handoff from night-covering nurse practitioners (NPs) and physician assistants (PAs) to their daytime counterparts.
“Our handoff process for the hospital medicine division was not well organized and consequently it was not an efficient process. Handoff was a time for us to talk about patient care, and it was also a time for chitchat,” said M. Caroline Burton, ACP Member and Mayo hospitalist. All of the clinicians who were handing off would meet in a large room with those who were coming on. The handing-off clinicians would have to find their daytime counterparts, and then convey the necessary information about what had happened overnight. “Because it was not an efficient process, there was not great provider satisfaction, and attendance was variable,” Dr. Burton said.
The division formed an improvement team, including hospitalists, NPs, PAs and clinical assistants, to identify problems with the handoff process. They found four main ones: unpredictable start and finish times, inefficiency, poor communication and a poor physical environment. A new handoff process was developed, targeted at correcting these four problems.
How it works
Eliminating inefficient chitchat may sound like a near-impossible task, but the Mayo group found a simple solution: Move the handoffs to a smaller room, and the chitchat will move itself out to the hall. “If you do have chitchat, it directly interferes with the handoff conversation because the room is smaller, so you're sitting right next to the providers giving and receiving reports. We made it an expectation that no conversation occurred that did not pertain to handoff,” said Dr. Burton.
Efficiency was also increased by setting time limits for reports. “Each night provider and each day team had three minutes,” Dr. Burton said. “We had timed reports beginning at 7:45 for the first team to receive the report.”
To get reports to fit into three minutes, the program also instituted a requirement that handoff information be provided in written form, as part of the existing electronic service list. “For example, ‘Chest X-ray ordered. Please follow up,’” described Dr. Burton. “It would be verbal [before], but now the expectation was that it was also on the electronic service list.”
Table cards were also used to identify who was on which service, and to indicate when no report was needed.
The changes significantly reduced the length of the morning handoff, from an average of 11 minutes to five minutes, according to results published in August 2010 by the Journal of Hospital Medicine.
A survey also indicated that participating clinicians were more satisfied with the experience. Before the intervention, 60% of those surveyed believed that the handoff was performed in a timely fashion, and they saw an average of 6.5 minutes as wasteful. After the changes, 100% of surveyed clinicians found the handoff timely and only 0.5 wasteful minute was reported.
“We monitored 90 days later and it was still timely. People were showing up on time and the report time did not extend past the designated time period,” said Dr. Burton. “I think the changes were really good and do-able.”
How patients benefit
The effect on patients hasn't been studied, but the more efficient handoff process should allow clinicians to get to the floor and start rounds more quickly with an organized report, Dr. Burton theorized.
Now that the improvement team has tackled the night-to-day handoff, it is going to apply its efforts to the exchange at the other end of the day. “We're going to look at our evening handoff. Our next step, too, is to study our physician-to-physician handoff of admissions during the night. We're going to build on our initial success,” said Dr. Burton.
Words of wisdom
“Typically [handoff] is an informal process that occurs at a shift change where people get together and whoever's ready to receive report receives report and whoever's ready to give report gives report. I think that making it a structured process makes the process more efficient without doing anything else. It's recognized as a formal part of patient care.”