 Wow, you're all here in this room just to hear from me, right? I really appreciate that and I get introduced by the voice of God. Thank you What could be better? Well, I I have two bits of good news for you What what can be better one is I believe I am the last speaker before president Clinton And I can tell you by experience that he has been a strong supporter of our organization From its beginning. He is not only an outstanding speaker, but he gives some really unique and outstanding Perspectives on our issues and our problem problems and you will love to hear from him The second good thing even more good news. How could there be more good news? I've only got ten minutes So I better get started and get to the point We're gonna talk about handoff communications and I will I'll start with a little foundation And I'm sorry if this is old news and redundant, but bear with me We're gonna get to some new stuff pretty quickly a patient handoff. What is it? It's a transfer of care and responsibility Achieved through effective communication of patient information to ensure continuity and safety of care The handoff process always involves one or more senders the people the person or group who are transferring care From them and one or more receivers the caregivers who accept care of the patient What's the problem with that? It sounds pretty straightforward, right? It's kind of a no-brainer Well, it's you'll be amazed how much of a problem there is with this the AHRQ as Reported in from a survey that half of hospital staff thinks that patient information is being lost in handoffs and I would Humbly submit that the other half of the staff is in denial Because information is being lost Breakdown and communication. This this is a this is a core point Was the not a the leading cause of sentinel events reported to the Joint Commission in the 10-year period from 1995 to 2006 Wow All of these causes that we've been talking about in our apps the leading cause is communications So there are three reasons I have chosen this topic to to discuss with you for the next 10 7 8 minutes One reason is this that one the leading cause the second one oops. Can you back up? I went too far sorry The second one Back up a slide, please. I Know I can't do it Can we off? Thank you the second reason is because that the patient safety movement is in a unique Position to help with this problem because of its makeup now I like most of you I participate in a number of different safe safety Organizations, but this is the only one that's not only doctors doctors and nurses and therapists all caregivers But it's also hospitals hospital administrators industry is a very important component government legal experts insurance companies Safety organizations and last but probably greatest of all Patients and their families. Thank you so much for being here and for being part of this And I want you to be not only part of it, but key contributors to to our solutions The third reason I have chosen it is a kind of a selfish reason and it's because of my background Before I became a clinician. I'm an anesthesiologist for the past 35 years I was an aeronautical engineer and PhD from Caltech and all that and I had something to do with aviation safety and as you have heard previously in this meeting Aviation safety has has set an example for us. They learn from their mistakes from their accidents Better than than most industries we can learn from them And one of the things they have learned is which you already saw a clue of on the next slide And now I'm going to go forward. I hope is the use of checklists This is the startup checklist for a Boeing 747. Nobody could remember all of this every day Obviously, you have to have it in front of you and you read it We have the same issue Part of our solution with handoffs is a checklist for three reasons one we are human We forget stuff and to compound that we live and work in a world of increasing complexity and stress just like pilots Great similarities and the third often the third strike when you analyze accidents both in airplanes and in the Hospital is Distractors the presence of unrelated minor events You know it can be anything that change your same train of thought and make you forget something And I'm not the only one who believes this you heard my good friend rich. Carmona refer to this checklist manifesto by a tool gawande who is a surgeon and he has sold this approach to an audience of surgeons Which is a very tough audience to change their behavior, but he has successfully done it So for each of our handoffs We need a checklist and I our committee our workgroup started off about three years ago Defining this many handoffs, which you can see in this table. I don't expect you to read them all but we identify the most common Transmitters senders emergency department hospital unit operating room paramedics and then for each of those senders We identified the most common receivers and you can see them You know pay patients from the emergency room might go to the hospital ward the operating room Critical care unit or a testing unit, etc. Now what you see there are at least 17 Different checklists already and there's actually more than that. We've got up to about 20 now We have developed 10 of these already. I'll show you just two of them Here's a handoff from the emergency room to the operating room. This is an intense one And and it's got to be bam bam bam bam. It's got to be quick I can remember doing this in less than 60 seconds but not only that quickly while I was literally trotting a Alongside a rolling gurney that was rolling at a very high velocity So time is limited the pressure is on as opposed to some of the other handoffs such such as a shift change on The ward where you can do it more leisurely and use a more leisurely approach. This uses the s bar Analogy acronym which stands for situation background assessment and recommendation so each of these handoffs is very different no two are alike and It's for a reason. They're done in different environments time is flexible in some it is not in other Others so can we simplify this are there any that can be combined? We are ready to go to clinical trials and this is where I want to get your input and your help What else what are these checklists actually look like that is are they pieces of paper or maybe they're on your cell phone? How are they used? Do I look at an index card? Who do I say hey Siri handoff from emergency room to operating room? And that way while I'm running alongside the moving gurney Siri is actually asking me the questions and I don't have to look at an index card Some are time-limited some are not as I said above all we discovered this very early They are not forms to be filled out. They are not to generate more work Now the last point I want to make before I conclude what really happens in a handoff This is the classic view coordinated Coordinated carefully time transfer like the patient is a stick of wood. I something passing I want to get beyond that and this is a somewhat New way of looking at it not entirely But the classic view is the handoff goes from the center to the receiver the information is only flowing in one direction What's missing here two things one that information flow has got to be two-way the center and the receiver Talk to each other the receiver is not a stick of wood either That's how new things get discovered that were perhaps missed The patient needs to be a part of that too and not in every handoff of course if the patient is Unconscious they can't very well participate, but they need to they need to be part of it The Joint Commission has Recognized that fact in their algorithm for handoffs. They mentioned patient participation And I want to conclude by thanking other in other Organizations that are helping with handoffs including the anesthesia patient safety commission the Joint Commission and Finally my conclusions Handoffs occur in a stressful environment where it's easy to forget stuff We have distractors patient handoffs and flying an airplane have a lot in common both need checklists There are more than 20 more than 20 different types of handoffs There may be some institutional variability because of patient populations Handoff is not a one-way process It's a three or a four-way conversation and the patient safety movement is in a unique position Because of our makeup because you patients are here to be an integral part of improving these handoff communications I'll conclude with Paraphrase of my favorite hero Neil Armstrong These are all small steps for man that can lead to a giant leap for mankind Which is zero preventable in hospital deaths. Thank you very much