Designing an Audit and Feedback System to Drive Handoff Redesign and Implementation

BACKGROUND: Following the handoff efficacy pilot that was implemented 6 quarters ago at Clements University Hospital, a new measurement system needs to be implemented for preparation of a diffusion pilot to 4-6 additional units. At present there is no such system to monitor and provide feedback to key stakeholders. An Epic based clarity report was identified as a potential measurement system and this project revolved around the feasibility, acceptability, and appropriateness of implementing such a system. A survey was sent out to identify top handoff outcomes to be included in the system and to assess the feasibility of the system. From preliminary results, it was understood that it is possible to successfully implement an acceptable, appropriate, and feasible measurement system. LOCAL PROBLEM: Information loss during care transfers, or "handoffs", can disrupt care coordination and lead to adverse events, especially in high risk, error prone environments like the perioperative setting. Clements University Hospital piloted the redesign and implementation of a structured handoff process to Enhance Communication for Handoffs from the Operating room to the Intensive Care Unit (ECHO-ICU) to improve team-based communication and care. As a result of this successful efficacy pilot, an implementation science-based approach is being taken to prepare for widespread adoption of inpatient handoff redesign. This requires the development of an acceptable and feasible audit and feedback system to support the work led by an inter-professional, unit-based change team guided by institutional subject matter experts. Previous attempts to relay feedback to the original units from the efficacy pilot were unresponsive and slow, leading to disengagement of the stakeholders. This project will attempt to make this process easier, timelier, and scalable. The aim of this project is to reduce the time it takes to perform and Audit and Feedback by 50% by May 2021. METHODS: An initial literature review was performed to identify candidate important outcome measures related to successful handoffs. To assess acceptability, the primary stakeholders were surveyed on what they identified as the most important outcome measures related to handoffs. Feasibility was assessed by determining end users' personal motivation level for entering critical data into the electronic medical record and the complexity of generating an automated report by data specialists from Epic, enterprise, and clinical data registries. Data was collected using multiple methods, including a REDCap survey, small group discussions, and individual interviews. The top three voted upon measures will be added as new data fields into Epic for data collection. RESULTS: The outcomes deemed most important by the survey were all team members present during handoff, the receiving team feeling capable of meeting patient needs, and unanticipated postoperative events. Using these measures of meaning, a prototype dashboard audit and feedback system was designed for use in future efforts. By using participatory design, usability was addressed by focusing on feasibility, acceptability, and fidelity. The guidance team will work with the unit-based change team for handoff redesign and implementation of this audit and feedback. Initially, the feedback will occur quarterly, but each unit will determine their preferred feedback period. CONCLUSIONS: The next steps of this project will be to pilot this prototype with other handoff redesign efforts to collect usability data and assess whether the prototype remains feasible, acceptable, and fidelity. This prototype hopes to align with the University Hospital handoff diffusion pilot within 4 to 6 clinical units. Acceptability and feasibility are leading indicators of successful of widespread adoption, penetration, and sustainability. These latter implementation measure will be applied to future work from this project team.