Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients

Background: During the analyses of adverse events, a commonly described risk factor is the sharing of patient information. Objective: The objective for this project was to better understand and improve the postoperative handoff process for children with heart disease. Methods: The existing handoff process was evaluated and improved using Six Sigma methodology and medical simulation training. Time-based metrics were compared before and after implementing performance improvement initiatives. Results: 29 preand 142 post-intervention handoff events were studied. Initiatives resulted in a reduced handoff turnaround time (15.3 min to 9.6 min; P <0.001) and time to obtaining critical laboratory studies (13.0 min to 2.4 min; P <0.001); an increase in chest radiographs completed (60 percent vs. 94 percent; P <0.01) and percent of patients placed on cardio-respiratory monitoring (86 percent vs. 99 percent; P <0.01) within unit standards. Conclusion: In children undergoing surgical intervention, performance improvement principles can improve the handoff process and decrease the delay of time-sensitive therapies.

[1]  Steven J Spear,et al.  Fixing health care from the inside, today. , 2005, Harvard business review.

[2]  C. Vincent.  Understanding and responding to adverse events. , 2003, The New England journal of medicine.

[3]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[4]  William B Lober,et al.  Organizing the transfer of patient care information: the development of a computerized resident sign-out system. , 2004, Surgery.

[5]  S. Spear,et al.  Decoding the DNA of the Toyota Production System , 1999 .

[6]  Robert L. Helmreich,et al.  Why crew resource management? Empirical and theoretical bases of human factors training in aviation. , 1993 .

[7]  Donald Berwick,et al.  Developing and Testing Changes in Delivery of Care , 1998, Annals of Internal Medicine.

[8]  Y. Donchin,et al.  A look into the nature and causes of human errors in the intensive care unit , 2022 .

[9]  Mark Hagland.  Six sigma: it's real, it's datadriven, and it's here. , 2005, Health care strategic management.

[10]  D. Bates,et al.  Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. , 1997, Critical care medicine.

[11]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[12]  L L Leape,et al.  Preventing medical injury. , 1993, QRB. Quality review bulletin.

[13]  T. Brennan,et al.  Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. , 1998, The Joint Commission journal on quality improvement.

[14]  T. Brennan,et al.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. , 1991, The New England journal of medicine.

[15]  Kevin G M Volpp,et al.  Residents' suggestions for reducing errors in teaching hospitals. , 2003, The New England journal of medicine.

[16]  E Coiera.  The impact of culture on technology , 1999, The Medical journal of Australia.

[17]  C. Marano,et al.  To err is human. Building a safer health system , 2005 .

[18]  K. Catchpole,et al.  Identification of systems failures in successful paediatric cardiac surgery , 2006, Ergonomics.

[19]  P. Pronovost,et al.  Improving communication in the ICU using daily goals. , 2003, Journal of critical care.

[20]  J. Reason.  Understanding adverse events: human factors. , 1995, Quality in health care : QHC.

[21]  Edward G. Schilling,et al.  Juran's Quality Handbook , 1998 .

[22]  E. Coiera.  When conversation is better than computation. , 2000, Journal of the American Medical Informatics Association : JAMIA.

[23]  Marlene R. Miller,et al.  Developing and implementing measures of quality of care in the intensive care unit , 2001, Current opinion in critical care.

[24]  R. Helmreich.  On error management: lessons from aviation , 2000, BMJ : British Medical Journal.

[25]  Kim M Cardosi,et al.  Human Factors Checklist for the Design and Evaluation of Air Traffic Control Systems , 1995 .

[26]  E. Coiera,et al.  Improving Clinical , 2022 .

[27]  J. Reason,et al.  Human factors and cardiac surgery: a multicenter study. , 2000, The Journal of thoracic and cardiovascular surgery.

[28]  John Whittington,et al.  SBAR: a shared mental model for improving communication between clinicians. , 2006, Joint Commission journal on quality and patient safety.

[29]  Y. Han,et al.  Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2005, Pediatrics.

[30]  M. Endsley,et al.  Objective measures of situation awareness in a simulated medical environment , 2004, Quality and Safety in Health Care.

[31]  J. Reason,et al.  Safety in the operating theatre - Part 2: human error and organisational failure. , 1995, Quality & safety in health care.