Clinical Practice Improvement Project Report
Project Aim: To roll out the use of a specific ISBAR checklist during each nursing shift handover in the acute ward of Maitland Hospital by 50 percent in 4 months.
Relevance of Clinical Governance: Quality nursing handover and its continuous improvement encompasses all the 4 pillars of Clinical Governance, namely clinical performance and evaluation, professional development and management, clinical risk, and consumer value. Research in nursing handover has resulted in more structured practices in South Australia. In particular, the ISBAR (Identify, Situation, Background, Assessment, Recommendation) format is used, and widely encouraged by the South Australia health safety and quality unit. It is formulated from firm evidence based research and satisfies the first pillar of Clinical Governance.
The second pillar that supports professional development is relevant to nursing handover. Nurses’ professional standards are maintained through ongoing staff education and upholding high quality inter-professional communication. The third pillar relates to clinical risk. There is a strong recognition of the significance of clinical handover in reducing patient risks and improving quality and safety.
Patient centred care, involving patients at handover, not only leads to better patient satisfaction and higher adherence to treatment recommendations. Importantly, consumer input can lead to further improvement and future planning. This CPI project recognizes the high value of patient input and seeks to engage the patients actively during this period. Evidence of issues worth solving: Clinical handover is the transfer of professional responsibility and accountability of patients to another group of professionals either permanently or temporary.
Studies have shown that it is a very high risk time for patients, with possible disruption of care, increased risk of adverse events, and professionals being subject to legal claims of malpractice. This integral part of clinical care, if not performed well, can lead to wasted resources, duplication of tests, diagnostic delays and treatment errors. The student nurse has had the opportunity to observe and take part in a few hospital clinical handovers. It was observed that there was not a formal structure to the handover process in most of the wards. ISBAR is accepted as standard of communication in the health system, demonstrating effectiveness in enhancing patient outcomes. SA Health has endorsed the use of ISBAR as a tool to improve the handover process, an adaption of ISBAR, with I stands for Identity, S for situation of the patient, B for background, A for assessment and R for recommendation. This model provides a structure for transfer of important information. It forms part of the SA Clinical Handover Guidelines policy. Standardization of procedures has an important place in clinical governance.
This CPI project aims to introduce the use of customized ISBAR checklists during the nursing shift handover process. Key Stakeholders:
- Nursing team, unit manager, shift team leader: The leaders are the drivers of the change and need to be actively involved in leading and encouraging the use of a specified ISBAR checklist. They need to be informed of the changes.
- Medical team, allied health team: Teamwork and open communication between all members of the health care team are necessary for optimal patient care.
- Management team: Arrange roster and allocate resources for the project, for example, allowing for rostering changes in-order for staff to attend training. This team also helps in the development of information tools, such as posters, memory aids and other necessary education and training materials.
CPI Tool: There are many methods for gathering and monitoring information following application of new changes. The relevant method applied to this Clinical Practice Improvement (CPI) is the auditing method. There are five stages to this auditing method. These are identification of problem, diagnostic phase, intervention, impact and sustaining the improvement.
This project seeks to introduce the use of standardized, ward specific ISBAR for use during every handover shift. Firstly, there is a need to quantify the number of wards in the hospital who are not using the ISBAR method formally, in-order to establish the full extent of the problem. This is then achieved through contacting the Nurse Unit Manager (NUM) of each ward and discussing the ward’s handover culture. They are the identification and diagnostic phases of the tool.
At every meeting, there is an opportunity for the PDSA cycle to be engaged. PDSA stands for plan, do, study, and act. It is a concept that originates from Edwards Demming’s literature.
In this project, PDSA is the most appropriate tool to use in making decisions about whether the changes proposed will work in the environment of interest to yield the desired outputs. PDSA is utilized optimally with close consideration of its four stages. The first stage is ‘plan’, before executing the project. This stage defines the problem raised, seek data about it and establish its cause. Then the second stage is ‘do’. It involves formulating and implementing solutions through selecting the best measurement upon which to gauge its effectiveness. The third stage ‘study’, entails throwing some light into the results aiming to analyze them by making comparisons. The last stage is ‘act’. Here, the results from the project are documented. Other stakeholders are informed about the changes in process as it makes recommendations for the issue to be addressed in the net PDSA cycle. The key to improvement involves learning from what worked, what should be kept, or changed, and continually using the new knowledge to make improvements for the next cycle. This may mean, for example, refining the ISBAR checklist, or scheduling more training of ISBAR for team leaders. The NUM as team leader and a core team of nurses are to drive and maintain change which is necessary for the improvements to be achievable.
The impact of the change will be through monthly surveys and questionnaires for the nurses and patients with formal measurements of parameters, which are clearly defined. Once the project is formally over, there will need to be commitment from leaders to maintain the momentum. Summary of proposed interventions: Intervention consists of using minimum data-set ward specific ISBAR checklists during each nursing shift handover implemented for a period of 4 months. The ISBAR checklist is formulated by the leadership of the ward, in-order for it to be functional and appropriate. The stakeholders, including the nurses, patients, patients’ family, and other healthcare organizations and the nursing unit manager, are responsible for implementing the agreed-on interventions after the other procedures have been executed. The standard data that will be recorded by the unit manager in each domain includes the standard time for handover in a day, time taken for a complete handover, the participants in the handover, the functionality of the tools used, if a common structure is employed in the process, and the quality of data transferred.
All stakeholders have a meeting before implementation to ensure everyone agrees with the CPI rollout. The team leader orders the lanyards and posters available from South Australia website as memory inducers to promote and maintain changes. The core team leaders, consisting of the nursing unit manager, undergo teaching sessions in-order to be able to lead the ISBAR changes effectively. The project will involve three intervention stages. First, the registered nurses in the healthcare facility will be evaluated to ascertain the level of their knowledge of the problem under investigation in the project that includes factors that undermine effective nursing shift handover. One of the main stakeholders in this project are the nurses. After confirmation of their knowledge, the registered nurse then undergoes a discussion about improving quality in nursing shift turnover in the healthcare facility. Applying the information from the discussions held, the intervention plan is then formulated.
Secondly, ensure that relevance and accuracy are achieved, each ward will have its specific minimum data set. The computer support team will be involved in the formation of a printable format PDF template for the checklist that will be used to ensure that all the aspects are covered. This way, a minimum data for each patient handover is critical in minimizing interruption given that both the issuer and the receiver have exclusive knowledge of the checklist.
The facility currently adopts an office based handover practice so that each nurse and interested party is available and gets the information as first hand. Core team leaders allocated to specific roles to ensure that each steer his or her teams through diligence and determination to give exceptional results. Also, the team leaders ensure that every aspect is dealt with sufficiently for useful results.
The project facilitation team devises surveys and questionnaires for monthly periodic analysis and collection of data on the percentage of random handovers completed as per the new process. After the data collected is processed, weekly reports are sent back to the nursing unit manager for documentation. Barriers to implementation and sustaining change: The potential barriers to successful implementation of the ISBAR checklist are multiple. The main barrier is the lack of engagement of stakeholders. Secondly, resistance from nursing staff to new changes may be encountered. There may be a lack of understanding of the importance of handover standardization. A feeling of disempowerment when change is imposed upon the staff from the top of the management cannot be underestimated. Others may feel threatened by the project, when they may be already involved in similar projects. The CPI team leaders should consider strategies such as informal discussions, listening to concerns of those at the frontline of patient care, and being open to collaborative opportunities to advance a shared commitment to handover improvement.
Those who are supportive of change may feel inadequately prepared to be fully engaged in the project. Professional development needs to be provided to them to improve their necessary skills. An environment of trust needs to be maintained through engaging clinicians in a non-threatening way during delivery of safety and quality improvement initiatives.
Another potential barrier to this CPI is the risk of miscommunication. Clinicians have competing demands to their daily workload, and messages and updates of the project may not filter through. Regular face-to-face contact by the CPI team leaders to maintain stakeholder involvement is crucial.
It is the nature of hospital wards that there will be staff turnover. In-order to keep everyone, especially new staff up to date, it is crucial that updates and rolling education sessions be maintained during the project duration. The distribution of available ISBAR posters and lanyards will also promote and maintain the momentum of the handover project. A strong commitment by hospital management to allocate resources and support for the educational activities for CPI is crucial to its success.
Evaluation of the project: The impact of the changes will be recorded through monthly surveys and questionnaires. This is over a finite period of 4 months. The questionnaires will focus on the level of uptake of the use of the ISBAR checklist, nurse satisfaction, ease of use, and identify problems related to its use. Other measures such as level of participation, efficiency and quality of information transfer will be measured. Regular patient surveys about their quality of care at monthly intervals will also be conducted. This will attempt to identify whether high quality of care is maintained or if there are any areas for improvement on ISBAR checklist implementation. At the end of 4 months, there will be a meeting of all the stakeholders to discuss the success or problems with the roll-out of CPI project. Any problems identified especially on early stage can be appraised for further refinement and improvement of the CPI.