Breaking the Routine of Breakdowns in “Hand-Offs”

By Jessica Chao
Jessica Chao is a health system pharmacy administration resident at Johns Hopkins Hospital. A former student at The Carey Business School, she has worked extensively with Sage Growth Partners CEO Don McDaniel and will serve as an occasional guest blogger.

I recently attended a leadership retreat with hospital executives on healthcare innovations lead by IDEO, a design and innovation consulting firm.  The theme of the retreat was ‘hand-offs’, the transfer of patient from one entity or hospital unit to another. Breakdowns in handing-off complete and accurate patient, medical records, and healthcare information, can lead to hospital acquired complication, readmission and perhaps patient harm.

IDEO invited one patient and two clinic providers to interview with the hospital executives. Surprise. Surprise. The hospital executives were shocked to hear the following statements:

  • “I never know who to call to clarify orders and when I found someone, they don’t’ know who I
    am talking about”,
  • “I am surprised that I would actually get a complete discharge order”, and
  • “There is no way I can change the system, I tried.”

The everyday failures of a system have become routine and worse yet, both the patient and the providers believed it.  Unfortunately, due to the nature of consistent negative feedback, frontline concerns and innovative ideas becomes quieter until everything falls into a black hole of irretrievability.  Hospitals need—desperately—a way to funnel frontline patient and staff feedback to improve safety and quality.

My department recently conducted a focus group to discuss employee satisfaction and unraveled multiple areas of dissatisfaction.  Dissatisfaction was initially shocking and unwelcomed, but it’s required in order to bring the department to a better place.

I am currently reading an amazing book called If Disney Ran Your Hospital by Fred Lee. In one of the chapters, it explained why directors and VPs cannot solicit honest patient feedback but frontline staff can.  Tools and channels need to be created for frontline complaints to be funneled to people of authority.  Unfortunately, the results can be horrific; but it’s also reality.

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