Ann Spangler Final Project ACMD 512

Curriculum:  Use of the SBAR model to facilitate end-of-rotation handoffs in Radiation Oncology

Competency to be addressed:   Communication (with component of professionalism as well).

Purpose:  Patient safety has been a major focus in health care since the Institute of Medicine report estimating approximately 98,000 patient deaths in American hospitals each year due to medical errors. ¹ In 2006, the Joint Commission on Accreditation of Hospitals analyzed sentinel events related to medication errors, with the finding that communication errors occurred in 60% of the cases analyzed.  This resulted in adding an additional National Patient Safety Goal, 2E, in 2006: Implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions.² Arora et al proposed that harm to patients from handoff errors occurs by two mechanisms, which can be translated into two of the ACGME competencies.  The first is the costs of coordination, which can be seen in the form of communication failures, and inability to make correct medical care decisions due to lack of information (Communication competency); the second is an agency problem, manifested by a shift-work mentality, and lack of “ownership” when covering another physician’s patients (Professionalism competency).  Both of these mechanisms can become educational opportunities for residents, through formal teaching of handoffs with a tool such as the SBAR, and by viewing handoffs as a transfer of professional responsibility.³

Our residency program is structured in disease site-specific rotations, generally three months in length, where one resident is assigned to a single attending physician concentrating on a particular disease site.  Handoffs occur at the completion of the rotation, from the completing resident to the resident coming onto the service, and include patient demographics, cancer stage, proposed radiation therapy treatment, concurrent chemotherapy, and details of progress so far in completing the proposed course of treatment including adverse reactions to treatment.  Specifics included in the radiation therapy patient handoffs should also include details of the selection of a proposed treatment plan, including computer planning and dosimetry, alternative plans which were considered but not chosen for a particular patient, and literature supporting the treatment chosen.  Residents have been advised to discuss the above information when changing rotations, but observation of resident presentations at our departmental chart rounds has revealed that this is often not done.  The residents will report that they do not know the details of a patient’s treatment plan because the patient started treatment before they started on the service.  This demonstrates a problem with the communication in the handoff of patient care, as well as a breakdown in professionalism in that the oncoming resident has not fully accepted “ownership” of the patient and responsibility for that patient.  The development and use of a structured handoff tool will provide a framework for the components of patient care which must be communicated from the departing to the incoming resident on service.  By having the residents develop the tool themselves, the residents should have more acceptance and “buy-in” for implementing and continuing to use their handoff tool.

Learners:  Radiation Oncology residents, PGY-2 through PGY-5 (8 residents)       

Duration of Curriculum: Two sessions, each 55 minutes.  Curriculum to be presented once (potential for use in other specialties with specific handoff needs).

Goal:  To teach residents the importance of handoffs in meeting patient safety goals, via creating and implementing a handoff tool based on the SBAR.

Objectives:  By the completion of this curriculum, the residents should be able to:

1. Modify an existing tool for patient handoffs, the SBAR, to end-of-rotation hand-offs in Radiation Oncology
2. Demonstrate the ability to work as a team to develop and implement their SBAR tool
3. Apply the modified SBAR tool in radiation oncology chart rounds

Instructional Methods:

Directed reading prior to session 1:  Haig KM et al.  SBAR: A shared mental model for improving communication between clinicians. Quality and Patient Safety 2006; 32(3): 167-175.

Session 1: 

0 – 6:00                Overview of medical errors, and impact of poor communication at handoffs

7 – 12:00              Think-pair-share – What are potential risks to radiation oncology patients from poor communication at handoffs?  How can these risks be

                            reduced?

13 – 20:00            Introduction of SBAR tool

21 – 55:00            Residents work in two groups to develop their own handoff tool modeled on the SBAR to meet their needs in end of rotation handoffs, using

                           SBAR Tool and Competency Check Off⁴

Session 2:

0  –  20:00            Residents from each group present their handoff tools for discussion

21 – 45:00            Large group discussion and consensus on final version of handoff tool

46 – 55:00            Practice use of handoff tool with current patient records

Evaluation:

1. Of learners – Observation of use of handoff tool at chart rounds following next rotation change
2. Of curriculum – Completion of course evaluation by residents

References:

1   Institute of Medicine.  To err is human: Building a safer health system.  Washington, DC: National Academy Press, 2000.

2   Improving America’s Hospitals:  The Joint Commission’s Annual Report on Quality and Safety 2006.  www.jointcommisionreport.org

3   Arora VM et al.  A theoretical framework and competency-based approach to improving handoffs.  Quality and Safety in Health Care 2008; 17: 11-14.

4   SBAR Tool and Competency Check Off, Kaiser Permanente.  From the Institute for Healthcare Improvement at www.ihi.org.