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Don`t Fumble the Treatment Handoff
Legendary Ohio State University football coach Woody Hayes once quoted the great Michigan State University coach Duffy Daugherty as saying, “There are three things that can happen when you pass the football, and two of them are bad.” Hayes' teams rarely passed the ball, and that worked out pretty well for him—with a record that included three national championships. Exchanges of the football, especially the type that come from throwing the ball, scared him half to death.
“Handoffs” are critically important in virtually any endeavor. Activities as diverse as day care drop-off and pick-up, relay races, 911 calls, railroad dispatch, and movement of patients from surgery to intensive care require a smooth handoff. A failed handoff disrupts service delivery and introduces errors, sometimes with disastrous consequences:
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Air traffic controllers “hand off” planes from one region to another. Twenty-five percent of all air traffic control errors occur within 15 minutes of a handoff, according to federal data. The potential cost of poor handoffs can be enormous.
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In Tampa, Florida, the blackboard to which surgeons refer in the operating room at University Community Hospital listed the wrong leg of a patient for amputation, as did the operating room schedule and the hospital computer system.
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A total of 167 people died on the Piper Alpha oilrig in the North Sea in 1988 because a message didn't get handed off from one maintenance crew to another during a change in shifts.
Handoffs occur regularly in addiction treatment as well. What happens when a person first calls an addiction treatment agency for help? Does a live person answer the phone, or is the caller directed through an endless cycle of automated prompts? The caller might talk first to a receptionist, who then might hand off the call to somebody else, who then might invite the caller to leave a voicemail message.
How many different people does a client meet with during a first intake appointment? How many forms does the client have to complete during the appointment—forms that request the same information multiple times? Every transition from one level of care to the next in addiction treatment is a handoff that presents a potential interruption or even an end to the client's recovery journey.
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We wish to suggest a series of key principles that if followed in the addiction treatment community could dramatically improve the transition of clients between levels of care. These are our eight essential ingredients of a good handoff.
Commitment
Organizations must perceive successful handoffs as essential to service delivery for each client and for the organization as a whole. Securing buy-in from busy front-line staff can be a challenge. To an overwhelmed staff person, a successful handoff might be considered less important than making a bed available for a client in crisis.
The first step in improving handoffs involves all staff members being aware of the important role they play in accepting or transferring a client to or from a level of care. Staff commitment to promoting successful handoffs must accompany this awareness of the critical function they serve in the process. Commitment must begin at the leadership level and be conveyed through all means that leaders have to achieve organizational commitment.
Responsibility
Clients in treatment for substance use problems don't always follow instructions. After all, many patients don't follow doctors' instructions for other types of medical treatment either. The nonprofit Institute for Healthcare Improvement says that “the baton that is being passed bears no responsibility” for whether the handoff is successful.
The idea of caregiver responsibility conflicts with traditional thinking in addiction treatment. Historically we have claimed that clients need to take responsibility for their own behavior. However, organizations that perform handoffs effectively take the position that client noncompliance is the reason for devoting more attention to successful handoffs, not an excuse for failing to do so. In a new paradigm, the caregiver is solely responsible for ensuring that the client with a complicated chronic disease such as addiction gets appropriate care.
Understanding the client
In addiction treatment we are not handing off an inanimate object such as a football or an airplane. While each staff person involved in a handoff needs to have a clear role and responsibility, the process also needs to respect and incorporate each client's unique needs and circumstances. What elements will support or hinder a client's successful transition? Part of a successful handoff involves assessing these needs and understanding a wide spectrum of client characteristics (their physical, psychological, and environmental being).
Designation and clearly defined roles
Other industries have established that for a successful handoff the individual responsible for “giving” the client to the next level of care and the person responsible for “receiving” the client need to be clearly designated. Once designated, the giver must take full responsibility for the client until the “receiver” has effectively received the client. That means the receiver demonstrates clear understanding of client and family needs and that he/she understands and accepts the treatment plan that has been jointly developed by the two levels of care.
In the smooth handoff, the receiver is fully informed of the client and demonstrates that he/she has read and/or heard and understood what the client has experienced. The receiver must provide evidence of this understanding and must accept the client and treatment plan before responsibility can be passed on.
Presence
In industries that are most successful in handoffs, the handoff occurs in person. Handoffs that happen without face-to-face exchange of information can be made more reliable, but will always need to be benchmarked against the in-person method. Clients are not “sent,” but are “delivered.”
The giver never sends off the client with a direction to show up at the next level of care. The giver takes the client to the next level of care and releases the client only upon evidence that the receiver is fully prepared to accept him/her.
Sentara Healthcare, a health system in southeastern Virginia and northeastern North Carolina, has spent years perfecting its transition of patients from surgery to the surgical intensive care unit. In the past, ancillary personnel transferred patients. Now the anesthesiologist (the designated giver) goes with the patient to the ICU and remains with the patient until the doctor in the ICU (the designated receiver) formally accepts him/her and the patient is hooked up to all appropriate lines.
 David H. Gustafson, PhD |
Activation scripts and communication
Paul Chryst, offensive coordinator of the University of Wisconsin football team, says that scripts tell each player what their job is in the next play. “A common language is essential because we only have 25 seconds to decide, communicate, and begin to implement the play. Without a common language it could never happen that fast with any degree of accuracy.”
A common language is crucial to activating any successful handoff process. Organizations in virtually every field we have mentioned use specific, unequivocal, highly clarified language that all “players” understand.
In Sentara Healthcare's effort to produce a foolproof method of transferring patients from surgery to the ICU, it has established a common language to minimize errors in communication. One hour before the patient's surgery ends, a nurse calls the ICU, using a script, to provide precise information of the patient's status and what is going to happen. That script defines exactly what the ICU “receivers” need to do to get ready for the patient. To improve communication even further, interactive television screens in the ICU and in surgery keep ICU staff updated on key events that happen in surgery.
Sentara's handoff process also builds in time for the patient “giver” and the patient “receiver” to talk about the care plan. The plan should not just be written. The face-to-face dialogue between giver and receiver allows time for questions and for both sides to express concern about what the other is thinking about doing. As a final key communication step, the receiver reads the plan of care back to the giver.
Synchronization and practice
Donald M. Berwick, MD, President and CEO of the Institute for Healthcare Improvement, says, “Soon is not a time.” Two minutes is a time. Thirty minutes is a time. Thirty-five seconds is a time, but soon is not a time.
A smooth handoff is standardized, synchronized, and scripted. It is practiced over and over again and the outcomes are measured, evaluated, and fed back to the caregiver and receiver to allow continual improvement. In rethinking the importance of systems for client handoffs, we can improve transfer rates to levels comparable to those of other industries where successful transfers are equally important.
We can see the importance of synchronization in addiction treatment. Clients in residential care follow a regimen of programs and activities. If new clients are going to be properly greeted and integrated into that care, they need to arrive at certain times. Both sides need to be assured that their time will not be wasted by waiting for the client or waiting for residential program staff to receive the client. The tasks that need to take place during this handoff need to be identified and properly ordered to ensure that nothing is missed. A schedule of activities is essential.
Every field that performs good handoffs engages in incredible amounts of practice to make them happen. We need to ask ourselves how much effort we put into training our staff to appreciate the importance of handoffs and to carry them out effectively. “Lots” is not a number.
Monitoring, evaluation, and improvement
At Sentara, handoffs are considered so important that they are routinely monitored in order to assess their effectiveness and to identify opportunities for improvement. Staff members receive regular feedback on their performance, with financial rewards or penalties depending on their skill in handoffs. Similarly, any organization that is really committed to doing something well is going to monitor its performance.
In sports, team members are consistently graded on how well they are playing their roles, and they retain or lose their spots in the lineup based on performance. But the grading also identifies areas where teaching can improve performance. In addiction treatment, we need to establish mechanisms for monitoring the success of our handoffs from one level of care to another, and use those results to improve.
The potential to improve handoffs in addiction treatment is enormous. By focusing on the elements necessary for good handoffs, all providers in the field can address one of the most critical barriers to successful treatment outcomes for our clients.
David H. Gustafson, PhD, is a Research Professor of Industrial and Systems Engineering at the University of Wisconsin and director of the National Program Office at NIATx (formerly known as the Network for the Improvement of Addiction Treatment). His e-mail address is dhgustaf@facstaff.wisc.edu. Roger Resar is a Senior Fellow at the Institute for Healthcare Improvement, a nonprofit organization based in Cambridge, Massachusetts. Kimberly Johnson, MBA, is a Senior Research Fellow at the University of Wisconsin and directs NIATx's ACTION (Adopting Changes to Improve Outcomes Now) campaign. John G. Daigle is a consultant and former executive director of the Florida Alcohol and Drug Abuse Association.Sidebar
Addiction centers hone their technique
Palladia, Inc. of New York City offers a full continuum of substance use treatment services. The agency was losing clients in the handoff from residential treatment to continuing care. A process improvement exercise revealed that:
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Paperwork authorizing the change in level of care was lost or delayed;
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Continuing care team members were not fully informed or prepared to accept clients who had completed residential treatment;
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Clients did not have complete information on when or where to report; and
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Some clients believed that the certificate they received upon completion of residential treatment indicated that they were “done” with recovery.
Palladia took steps to promote a seamless transition between levels of care by improving the handoffs. Improvements that resulted in increased participation in continuing care included:
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Engaging in electronic transfer of paperwork between facilities;
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Establishing clear two-way communication between sending and receiving sites; and
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Requiring patients to attend an orientation to continuing care before completing residential treatment.
In South Carolina, the Georgetown County Alcohol and Drug Abuse Commission found that 51% of people referred from inpatient treatment did not complete the handoff to their first outpatient appointment. To address this problem, outpatient caseworkers talked to both the client and inpatient staff before discharge. They got appointments scheduled and tried to remove barriers the client might face in making the transfer. Clients received reminder calls the morning before the first outpatient appointment. The agency's unsuccessful transfer rate dropped to 24%.
At Manatee Glens, a treatment center in Bradenton, Florida, 66% of clients were not showing up for outpatient care after detox. The agency applied the principle of presence and sent recovery coaches instead of staff to the detox facility to talk about the outpatient program and to invite the clients to attend. No-show rates dropped to 37%. Then, using the principle of activation, staff members also called the day before the client was going to leave detox and reminded him/her about the outpatient program. No-show rates dropped to 30%.
Finally, in addition to the recovery coaches and reminder calls, staff began to invite the clients in detox who were being discharged on the same day to arrive as a group at the new level of care, rather than one by one. In all, the series of process changes reduced no-shows from 66% to 26%.
Sidebar
For more on addiction treatment centers' efforts to improve processes of care, visit https://www.addictionpro.com/enos010207.
Addiction Professional 2008 September-October;6(5):30-33
