Handoff Implementation Strategies
International Anesthesia Research Society
Annual Meeting
May 11, 2017
Philip E. Greilich, MD, FASE
Professor and Holder
S.T. “Buddy” Harris Distinguished Chair in Cardiac Anesthesiology
Health System Quality Officer, Office of the EVP for Health Affairs
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Objectives
 Barriers to implementing handovers
 Framing principles and approach
 Developing and deploying interventions
 Macro-ergonomic strategy for scaling
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Barriers to implementation
 Composition, training and experience of project team
 Lack of clear mandate for change
 Inadequate executive administrative support and under-resourcing
 Failure to engage multispecialty, multi-level frontline staff
Lack of manpower for measurement
Fear of lost time and autonomy
Lack of systematic change model
Unavailability of key content experts (QI, PM, TT, ED, HFE)
Inadequate tools (cognitive aids, EMR) that promote HRT
 Failure to create “pull” amongst stakeholders
 Staff turnover and multi-level education (UME, GME, CME)
 Lack of understanding between projects teams vs. operations
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Implementation Science Principles
 System-wide intervention
 units, hospitals, health system - similar, if not same
 Pre-service/in-service training
 multi-level, onboarding, experiential, in situ vs. sim lab
 Ongoing coaching and consultation
 site team and champions by coach or guidance team
 Staff performance assessment
 measurements, debriefing plan built into education
 Decisions support data systems
 EMR-based cognitive aids, data collection and feedback
 Facilitative administration
 Guidance team – QI, team training, education, PM, HFE
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Human Factors Approach
 Systematic, user-driven approach to designing,
implementing and changing complex sociotechnical
systems
 Use of tools and content experts to design,
implement and evaluate system changes
 Measure changes in work system, handover process
and outcomes
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Work System and Change Model
System Engineering Initiative for Patient Safety (SEIPS)
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Developing the intervention
Adopt a QI method (PDCA, DMAIC, DMADV)
Identify a project manager
Engage all the primary stakeholders – ANES, SURG, RN, CCM
Perform a needs analysis and review of the evidence base
Co-creation of the redesigned handover
In situ testing
 Use HFE/HRT principles to create “pull” by making it easier,
more effective, reliable and ideally faster
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Deploying the intervention
 Educate and create mandate using baseline data
 Announce and demonstrate
 Practice and revise
 Marketing, recognition and reward
 Plan for measurement and feedback
 Deploy of supportive education
 Commitment to iterative process
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Promoting High Reliability
Heedful interrelations of action – “mindfulness”
High Reliability Organization
High Reliability Team
 Sensitivity to operations
 Cross Training
Commitment to resilience
 Perceptual contrast training
Deference to expertise
 Team coordination training
Reluctance to simplify
Preoccupation with failure
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 Team self-correction training
 Scenario based training
 Guided error training
Application of Participatory Ergonomics
 Macro-ergonomic approach including organizational influencers
 Frontline clinicians plan/control a significant amount of their
work activities, with sufficient knowledge/power to influence
processes/outcomes
 Active involvement of stakeholders and HFE professionals in
content” (what is redesigned) and “process” (how the redesign is
implemented) of handover redesign.
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Application of Participatory Ergonomics
 The “Content” must optimize
–the interaction of all the work system elements
The “Process” must include
– Top management commitment
– Stakeholder participation
– Communication/feedback
– Learning/Training
– Project management
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