Good Little Insights that Can Help Everyone Succeed (GLITCHES)

Gathering Ideas for Improvement

Participants in the Handoffs and Transitions Learning Network Session I on April 19, 2007 took part in an activity designed to help them gather information on how handoffs are working in their facilities. The session was facilitated by Diane Frndak of West Penn Allegheny Health System.

Participants prepared for the meeting by observing handoffs in their facilities prior to the meeting and taking notes on an Observation Handoff Worksheet. With their notes in hand, attendees participated in a discussion with their small groups to identify ideas for improving handoffs in their facilities. These observations of what works and what doesn’t work were called “Good Little Insights that Can Help Everyone Succeed” or GLITCHES.

The goal of the exercise was to provide teams with a new approach to gathering ideas for changes within their organizations and to begin a discussion of where teams may want to focus their efforts on improving handoffs. Participants were encouraged to use this approach with staff to generate ideas collaboratively, instead of taking ideas back to the facility for implementation. An outline of this process is provided below:

 Pre-Work: Observe at least one or up to five handoffs. Use the attached Handoff Observation Worksheet to take notes during the observation.

 Part 1: Gather glitches and share current condition (what works and what doesn’t work). Participants at small tables brainstorm in teams for 15 minutes to select two things that are working and two that are not working in their facilities related to handoffs. Where possible, participants use specific examples from their observations. Each team writes at least two of each on the wall. A group discussion probes into people’s observations.

 Part 2: Generate Ideas for Actionable Change. Participants contemplate in silence for 20 to 30 seconds about how to amplify what works and address what does not work. The tables will then discuss these ideas in groups. At the end of the period, the groups count the number of ideas and share their thoughts on some of the ideas. This exercise demonstrates that by working in groups many more ideas can be generated than by working individually.

Part 3: Action Plan. Participants discuss how to replicate this brainstorming experience in their home hospitals to move forward with action planning. Participants plan how they will use this method when working with their own staff. This method will assist participants in going back to their facilities and gathering ideas from staff on where to start making changes around handoffs. The goal is to work with staff and teams to identify next steps and to begin to design an action plan for improving the handoff process targeted by the team.

Attached are the Handoff Observation Worksheet and graphics shared by Diane Frndak on mapping out current processes.

Handoffs and Transitions Learning Network

Handoff Observation Worksheet

Instructions:In preparation for the April 19th Kick-off Session, we are asking each attendee to conduct a few observations of handoffs at their facility. The observed handoff can be a shift-to-shift report, discharge handoff or any type of handoff that you would like to observe. This form may be used to assist you through this exercise. You are not required to submit this form to us; however please bring your thoughts and notes to the April 19 meeting as it will assist with the discussion.

Facility Name:______

Type of Staff Involved in Handoff--From: To:

Mode of Transfer: VerbalWrittenWritten and Verbal

Type of Transfer: Shift ChangePatient transfer to another Unit

Patient transfer to another Treatment Area

Other: ______

Observations: Please observe at least one handoff or transition in healthcare. What did you observe? [Please describe the steps and use the back if necessary]

What worked in this handoff/transition? What did not work in this handoff/transition?

Were the people involved in the handoff/transition aware of what worked and did not work?

“The Hairball”

Map of Current Process – Steps in a Four-Hour Shift

Shared by Diane Frndak of West Penn Allegheny Health System