Creating Better Patient Handoffs
Designing a post-operative handoff tool for Registered Nurses (RNs)
Overview
While working as a bedside nurse I led the research, design, and implementation of a checklist to address problems identified after the rollout of a new patient handoff process. The final product was incorporated into daily workflows, proved to be a valuable tool for both new and experienced nurses, and increased nurse satisfaction with handoffs by 88%.
Final Designs
Background
In 2016 staff working in the Surgical Intensive Care Unit (SICU) at the UW Medical Center (UWMC) experienced a significant change in workflow after the rollout of a new patient transfer process. A key part of this process was a new in-person bedside handoff which brought Operating Room staff and SICU staff together to exchange critical information immediately after a surgical procedure.
After the initial rollout, bedside nurses reported three problems:
Dissatisfaction and confusion with the new handoff process
Inconsistencies with documentation of handoff information
Minor delays in patient care while seeking out additional information
As a co-founder the SICU Unit Practice Council (UPC) and one of these bedside nurses, I set out to explore why this was happening and how the handoff process could be improved for nurses.
The Problem
How might the post-operative handoff experience for bedside nurses be improved?
Process
Discovery
Literature Review
To learn more about the problem space I explored professional and academic publications to see what information already existed. The handoff process was new, so I wanted to account for potential discoveries that my user surveys and interviews might not capture.
Key Insights
High-Risk
Patient handoffs are high-risk processes involving complicated communication
Error Potential
Patient handoffs have high potential for medical errors and compromised patient safety
Checklists Help
Structured documentation, specifically checklists, enable healthcare workers to conduct better handoffs
...patient handoffs are high-risk times associated with sentinel events with a root cause often attributable to communication errors.
Research
Surveys and Interviews
A short survey was sent out to bedside nurses in order to understand and identify perceptions and experiences with the current handoff process.
Discussions and informal interviews took place with 6 nurses on the UPC to gain additional perspectives and add more qualitative context to the survey results.
Observations
I observed and participated in multiple handoff process and took note of tools and methods used to record information, as well as events that happened before, during, and after handoff. This allowed me to identify complex behaviors and interactions that were not possible through the other research methods.
Key Findings
Inadequate Methods
Nurses used blank paper to record handoff information and were unable to write down all the verbal information given during report
Inconsistencies
Nurses had to rely on individual judgement to decide what information to record, leading to inconsistencies in the information being documented
Missed Information
Some information relevant to nursing care was not being covered during handoffs, leading to extra workload, frustration, and minor delays in patient care
Define
Understanding the Current Process
I decided to map out the current experience for nurses in order to summarize my findings and uncover areas of opportunity. I began by writing down the main steps I identified during my research, and then honed in on the experiences of nurses during those stages.
This process allowed me to gain deeper insights into the handoff process, focus on the most impactful findings, and identify how the current experience could be improved.
Starting to Define and Organize the Handoff Process
Requirements and Constraints
After discussing my research findings with nursing leadership during a strategy meeting, we determined that nurses needed:
Efficiency & Consistency
A consistent way to record handoff information quickly and accurately
Clarity
A way to identify what information was critical to the care of their patient
Reminders
A way to recognize when information was missed so that questions could be asked during handoff
During the strategy meeting we also indentified constraints to account for. Limited time and resources were available for creating a solution, it would need to fit within the current handoff process, and it would need to be developed without support from other departments (i.e. hospital IT).
Develop
Brainstorming with Stakeholders
During the same meeting with nurse leadership we brainstormed possible solutions. We decided a paper form would be the best format for our handoff tool as it would be quick and simple to create and revise, low cost and readily available, and easy for nurses to use. In addition, used checklists could be reviewed to provide insights for future iterations.
We chose three common surgeries to design for, as this would allow for adequate testing and feedback opportunities without having to spend a significant amount of time creating checklists for every single surgical procedure.
Initial Prototype
I focused on one surgery type for the initial prototype, in order to test and gather feedback sooner and not waste time developing multiple versions before having initial usability data. The checklist didn't need to be perfect at this point - the goal was to get feedback and initial impressions from nurses.
Nursing leadership determined it would be most efficient to redesign a checklist template that was being used for a different purpose in another ICU. With the goal of quickly creating a functional draft for testing I adapted the layout, categories, and questions of this checklist to fit the specific needs of SICU RNs identified from my research.
- Large title indicates procedure - nurses need to easily identify the correct handoff checklist
- Preparing for patient arrival - nurses reported confusion around the timing and sequence of pre-arrival steps
- Starting the handoff process - steps that should be taken by the SICU Medical Team; nurses reported the need for team members to hold each other accountable to this starting sequence
- Surgery-specific tasks to complete during the handoff - a targeted neurological assessment was identified as a critical part of nursing care
- Surgery-specific information to record - contains items identified as critical, and items that nurses found helpful but were sometimes missed
- Note taking section with general categories - information that nurses indicated as important for all surgical procedures; layout follows the order of information given during handoff; empty space allows nurses to record additional information
Test
Small Group Trial
The first version of the handoff form was trialed over two weeks by a small group of nurses involved in unit leadership. Nurses took notes on the physical form and feedback was collected via a group discussion during a pre-arranged committee meeting. This allowed for comprehensive feedback without requiring additional time from nurses during their busy workdays.
Learning Moment
While testing the initial checklist during a handoff I realized that I had made a pretty big mistake - I had not communicated this new checklist to all the stakeholders involved, resulting in a conflict that could have been avoided.
Fortunately we were able to work things out pretty quickly and smoothly. We put the trial on a brief hold, looped the ICU Medical Team into the project, and waited to get their input before moving forward. Once they understood the design and purpose of the handoff form they were 100% on board, and even provided valuable content feedback.
Results
Nurses found the checklist helpful to their handoff experience. It made recording information easier, decreased confusion with the handoff process, and prompted nurses to ask questions when information was missed.
Nurses desired more surgery-specific information and provided valuable content suggestions.
Iterate
Updates
I incorporated the feedback and content suggestions into a second iteration and created two additional surgery-specific checklists for full-unit trial.
Unit-Wide Trial
Feedback was collected via surveys and collection of used handoff forms annotated by nurses. Content modifications were made as needed and several more handoff forms were created for other common surgeries.
Final Checklists
Results
Increase in nurse satisfaction with the bedside handoff process by 88%
7 surgery-specific checklists developed and currently in use
Promotion of user-centered design within a healthcare setting
I set out to create an intervention that would improve the handoff process for nurses. The result of this initiative was a solution that increased nurse satisfaction with bedside handoffs by 88%. It is still used daily in the SICU and has evolved into a user-owned and managed work tool.
Additionally, I was selected to present my work at the annual Seattle Nursing Research Consortium (SNRC) conference, and share the importance of user-centered research and design when creating tools for healthcare workers.
Reflection
Learning From Mistakes
I learned the importance of including ALL stakeholders in the implementation of a tool - even if the tool would not be used first-hand by those individuals, it still had impact on their handoff experience, and they provided valuable insights that could have been included earlier.
Knowledge Gained
Seemingly simple tools can have big impacts on the people using (and not using) them!
This project opened my eyes to the importance of identifying and including stakeholders into the design process, and the unintentional impacts (both positive and negative) that my designs can have on people.
Designing with and for nurses allowed for ownership over the checklist and long-term engagement
By including other nurses in all stages of the design process (discover, define, develop, and deliver), I was able to create a tool that with long-term success that allowed for ownership and customization by the people using it.