Transitioning patients to different providers is a complex process that requires clear and thorough communication between clinicians to ensure patient safety and quality care. Handing off patients in and out of the operating room can be particularly challenging because of the different types of caregivers involved in the OR — nurses, anesthesiologists, surgeons, orthopedists, cardiologists, etc. — and the risk of the procedures.
Breakdowns in communication during handoffs can lead to medical errors and sentinel events, making skillful communication essential for successful ORs. Michael Cohen, PhD, William D. Hamilton Professor of Complex Systems, Information & Public Policy at the University of Michigan in Ann Arbor, shares five strategies OR team members can use to communicate effectively during handoffs. These strategies are the results of his three-year study of handoffs supported by the Robert Wood Johnson Foundation.
1. Be aware of the different kinds of handoffs. The first step to improving communication in handoffs is to understand that there is more than one kind of handoff, according to Dr. Cohen. Although The Joint Commission's 2006 regulation that hospitals standardize their handoffs sparked a great deal of literature on the subject, this literature often assumes that there is only one kind of handoff and that handoffs occur one at a time, both of which may be untrue, Dr. Cohen says.
He defines a handoff as a transfer of responsibility for a patient or control over a patient between two or more health professionals. However, there are multiple variables that come into play when transferring patient responsibility or control, such as the receiving provider's familiarity with the patient, the providers' familiarity with each other's specialty, the providers' status and the organizations involved in the transfer. "What may be a good method for doing one kind [of handoff] may not be the best method for doing another kind," he says.
2. Discuss the organization's handoff protocols. Developing handoff protocols, whether they follow the Situation, Background, Assessment and Recommendation method or whether they are a customized series of processes, is essential to improving communication during handoffs. Although Dr. Cohen believes SBAR may have been oversold, hospitals need to create and adhere to a system for managing handoffs. In fact, the particular handoff standard may be less important than having the conversation about handoffs — what the problems are and how to improve — Dr. Cohen says.
Once policies are established, a hospital should consider training healthcare professionals in handoffs, as typically physicians and other employees have no prior training on this process, Dr. Cohen says. The amount of training will vary depending on the particular organization. For instance, teaching hospitals have high turnover and may need a consistent training schedule to introduce new people to the procedures, while community hospitals often have lower turnover rates and thus may need less frequent training.
3. Connect with providers from different departments. One of the barriers to effective communication in handoffs in and out of the OR can be misunderstanding between healthcare professionals from different departments. Two professionals in the same field, such as two thoracic surgeons or two anesthetists, will be able to communicate more easily because they have the same jargon, training and experience, Dr. Cohen says. Specialists' different approaches to patient care require providers in a handoff to frequently confirm each other's understanding to ensure patient safety.
In addition to misunderstanding of the content in a handoff, transferring patients between departments may also involve misunderstanding or suspicion of intent, according to Dr. Cohen. "Handoffs into the OR and out of the OR — patients arriving from the emergency room or leaving postoperative recovery areas to go to internal medicine floors — those are especially problematic spots because they are places where people in the OR subfield are dealing with people from outside who have different views and different requirements and different organizational loyalties," he says.
For example, he says people in the OR may suspect the emergency department of transferring patients just to increase patient throughput, while people in the ED may think the OR considers receiving patients from the ED as an inconvenience. Dr. Cohen says some hospitals cross-train employees, such as having a nurse from one unit take a shift in another unit, to improve cross-departmental understanding and communication. Departments can also learn about each other without cross-training, by simply meeting and talking outside of a handoff situation so when a handoff does occur, each party understands the other's background.
4. Ask and encourage questions. Asking questions to check understanding and eliciting questions from the other healthcare professional is an important tool in effective communication during handoffs. One simple way to encourage the person who is receiving the patient to ask questions is to pause, Dr. Cohen says. "If you say ['Is there anything you want to ask me?'] and then a fraction of a second later say 'Thanks,' that just cuts [the conversation] off," he says. "If there's going to be questions, you have to leave time and encourage people to ask them."
A second tactic to elicit feedback from a patient receiver is to frame questions in a way that shows an expectation of follow-up questions. "It's easy to say, 'Are there any questions?/Do you have any questions?' in a way that makes it unlikely that questions will be asked," Dr. Cohen says. "It's very different to say to somebody, 'What else do you need to know?' or 'What do you think is the most important problem?' — something that is clear encouragement for the other person to interact. That makes it difficult [for the other person] to say, '[There's] nothing else I need to know or want to hear.'" Strategically framing questions is especially important when the handoff is between professionals of different status, such as between a nurse and a charge nurse or a resident and an attending, according to Dr. Cohen.
In conversations between people of different positions, there is less shared knowledge and typically less willingness on the part of the lower status person to ask questions. Dr. Cohen suggests ensuring understanding when speaking to someone of a different status by confirming key pieces of information about the patient, such as what the most important issues to consider when treating the patient are. "With juniors, it can be especially useful to say, 'How do you see this?' or 'What do you think is the most important thing here?'" Dr. Cohen says.
5. Balance handoffs with efficiency. Learning about other departments in the hospital, pausing to elicit meaningful questions and confirming understanding requires a significant investment of time and energy by healthcare providers. However, this investment is needed to ensure patient safety and quality. "There is tremendous pressure on surgical pipelines to increase efficiency right now," Dr. Cohen says. "It's very important to do that, but it's [also] very important that it does not become a patient safety hazard. As [healthcare organizations] try to improve the efficiency of these operations, [they] also need to strengthen handoffs that are the connectors between different segments of the surgery pipeline. Otherwise, that's where safety breakdowns will occur." Furthermore, spending time now to improve communication in handoffs will increase efficiency in the long run because it can prevent costly sentinel events.
No Problem is an Island: Improving OR Efficiency Through Systems Thinking
5 Top Challenges in the Hospital OR — And How to Overcome Them
Breakdowns in communication during handoffs can lead to medical errors and sentinel events, making skillful communication essential for successful ORs. Michael Cohen, PhD, William D. Hamilton Professor of Complex Systems, Information & Public Policy at the University of Michigan in Ann Arbor, shares five strategies OR team members can use to communicate effectively during handoffs. These strategies are the results of his three-year study of handoffs supported by the Robert Wood Johnson Foundation.
1. Be aware of the different kinds of handoffs. The first step to improving communication in handoffs is to understand that there is more than one kind of handoff, according to Dr. Cohen. Although The Joint Commission's 2006 regulation that hospitals standardize their handoffs sparked a great deal of literature on the subject, this literature often assumes that there is only one kind of handoff and that handoffs occur one at a time, both of which may be untrue, Dr. Cohen says.
He defines a handoff as a transfer of responsibility for a patient or control over a patient between two or more health professionals. However, there are multiple variables that come into play when transferring patient responsibility or control, such as the receiving provider's familiarity with the patient, the providers' familiarity with each other's specialty, the providers' status and the organizations involved in the transfer. "What may be a good method for doing one kind [of handoff] may not be the best method for doing another kind," he says.
2. Discuss the organization's handoff protocols. Developing handoff protocols, whether they follow the Situation, Background, Assessment and Recommendation method or whether they are a customized series of processes, is essential to improving communication during handoffs. Although Dr. Cohen believes SBAR may have been oversold, hospitals need to create and adhere to a system for managing handoffs. In fact, the particular handoff standard may be less important than having the conversation about handoffs — what the problems are and how to improve — Dr. Cohen says.
Once policies are established, a hospital should consider training healthcare professionals in handoffs, as typically physicians and other employees have no prior training on this process, Dr. Cohen says. The amount of training will vary depending on the particular organization. For instance, teaching hospitals have high turnover and may need a consistent training schedule to introduce new people to the procedures, while community hospitals often have lower turnover rates and thus may need less frequent training.
3. Connect with providers from different departments. One of the barriers to effective communication in handoffs in and out of the OR can be misunderstanding between healthcare professionals from different departments. Two professionals in the same field, such as two thoracic surgeons or two anesthetists, will be able to communicate more easily because they have the same jargon, training and experience, Dr. Cohen says. Specialists' different approaches to patient care require providers in a handoff to frequently confirm each other's understanding to ensure patient safety.
In addition to misunderstanding of the content in a handoff, transferring patients between departments may also involve misunderstanding or suspicion of intent, according to Dr. Cohen. "Handoffs into the OR and out of the OR — patients arriving from the emergency room or leaving postoperative recovery areas to go to internal medicine floors — those are especially problematic spots because they are places where people in the OR subfield are dealing with people from outside who have different views and different requirements and different organizational loyalties," he says.
For example, he says people in the OR may suspect the emergency department of transferring patients just to increase patient throughput, while people in the ED may think the OR considers receiving patients from the ED as an inconvenience. Dr. Cohen says some hospitals cross-train employees, such as having a nurse from one unit take a shift in another unit, to improve cross-departmental understanding and communication. Departments can also learn about each other without cross-training, by simply meeting and talking outside of a handoff situation so when a handoff does occur, each party understands the other's background.
4. Ask and encourage questions. Asking questions to check understanding and eliciting questions from the other healthcare professional is an important tool in effective communication during handoffs. One simple way to encourage the person who is receiving the patient to ask questions is to pause, Dr. Cohen says. "If you say ['Is there anything you want to ask me?'] and then a fraction of a second later say 'Thanks,' that just cuts [the conversation] off," he says. "If there's going to be questions, you have to leave time and encourage people to ask them."
A second tactic to elicit feedback from a patient receiver is to frame questions in a way that shows an expectation of follow-up questions. "It's easy to say, 'Are there any questions?/Do you have any questions?' in a way that makes it unlikely that questions will be asked," Dr. Cohen says. "It's very different to say to somebody, 'What else do you need to know?' or 'What do you think is the most important problem?' — something that is clear encouragement for the other person to interact. That makes it difficult [for the other person] to say, '[There's] nothing else I need to know or want to hear.'" Strategically framing questions is especially important when the handoff is between professionals of different status, such as between a nurse and a charge nurse or a resident and an attending, according to Dr. Cohen.
In conversations between people of different positions, there is less shared knowledge and typically less willingness on the part of the lower status person to ask questions. Dr. Cohen suggests ensuring understanding when speaking to someone of a different status by confirming key pieces of information about the patient, such as what the most important issues to consider when treating the patient are. "With juniors, it can be especially useful to say, 'How do you see this?' or 'What do you think is the most important thing here?'" Dr. Cohen says.
5. Balance handoffs with efficiency. Learning about other departments in the hospital, pausing to elicit meaningful questions and confirming understanding requires a significant investment of time and energy by healthcare providers. However, this investment is needed to ensure patient safety and quality. "There is tremendous pressure on surgical pipelines to increase efficiency right now," Dr. Cohen says. "It's very important to do that, but it's [also] very important that it does not become a patient safety hazard. As [healthcare organizations] try to improve the efficiency of these operations, [they] also need to strengthen handoffs that are the connectors between different segments of the surgery pipeline. Otherwise, that's where safety breakdowns will occur." Furthermore, spending time now to improve communication in handoffs will increase efficiency in the long run because it can prevent costly sentinel events.
Related Articles on OR Efficiency:
Structuring OR Management for Success: Q&A With Long Beach Medical Center Perioperative Services VP Dana CromptonNo Problem is an Island: Improving OR Efficiency Through Systems Thinking
5 Top Challenges in the Hospital OR — And How to Overcome Them