Present and discuss the setting for your practicum and ideas for your project. Hospital setting, being survey ready everyday. There are no supplies out dated, the staff all understand where to find records of consent, what the mission is of the hospital or who to ask if they don’t.The hospital environment is well kept and everyone makes sure to take pride in the hospital.Documents are completed, follow up on PRN medications are done in a timely fashion. If a State, Joint Commission or any type of surveyor walks in we are ready as a organization.
What is the purpose of conducting an organizational needs assessment? A recent survey by a paid agency showed we had room to improve as an organization and we are looking for Joint Commission within the next few months.We want to be ready.
What needs have you identified? Cleanliness, outdates supplies, and incomplete documentation.
What tools or methods did you utilize to determine the need? The paid survey agency did a Mock survey and we have conducted Mock surveys in house every day or two in some wing/unit of the hospital picking different nurses each time.
Objectives:
Explain the purpose of conducting an organizational needs assessment.
Identify tools used for conducting a needs assessment.
Describe methods to perform a needs assessment.A Needs Assessment for Development of the
TIME Anesthesia Handoff Tool
Courtney Gibney, DNP, CRNA
Young-Me Lee, PhD, RN
Julia Feczko, DNP, CRNA
Elizabeth Aquino, PhD, RN
Standardized handoff is critical to providing safe and
effective patient care. Limited studies assess the need
for developing a handoff tool for anesthesia providers.
The purpose of this descriptive study was to assess the
need for a standardized anesthesia handoff tool and to
identify the most essential components to develop an
anesthesia handoff tool. A descriptive survey design
was used. Anesthesia providers were asked to complete an online survey.
Fifty-three (64%) of 82 respondents did not currently use a systematic process during anesthesia
handoff. Most (73%) believed they were given inadequate information, and 40 (48.8%) sometimes discovered information that was not shared by the prior
anesthesia provider. The most frequently provided
components by respondents were airway type, airway
I
n January 2006, the Joint Commission developed a
national patient safety goal regarding patient handoffs.1 It is estimated that 80% of serious medical errors
involve miscommunication between caregivers during the transfer of patients.2 The Joint Commission
Center for Transforming Healthcare reported many problems such as delayed or inappropriate treatment, adverse
events, increased length of hospital stay and increased
costs are the result of ineffective handoffs.2 The handoff
quality depends on the dynamics of the situation such as
who is communicating what information to whom and
what necessary information is handed off.3 One way to
address these handoff differences is to standardize handoff methods for specific healthcare specialties.4
In the 1990s, Safer Healthcare brought SBAR into the
healthcare setting from the US Navy, and it has since
been used by healthcare facilities around the world as a
“simple yet effective way to standardize communication
between caregivers”.5 The acronym stands for situation,
background, assessment, and recommendation. SBAR
works by providing communicators with a quick way to
organize information to be shared with others who will
efficiently recognize the format and effectively address
the problem.5 Over the past 10 years, various standardized handoff tools have been developed to improve
communication between healthcare providers, but there
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difficulty, analgesia, anesthetic type, invasive lines,
patient medical history, procedure, and vital signs.
The most frequently received were airway difficulty,
invasive lines, medical history, and procedure. Most
participants perceived that anesthesia providers currently provide inadequate handoff. Anesthesia providers indicated the most essential components for
effective anesthesia handoff were airway difficulty,
invasive lines, medical history, procedure and casespecific concerns, allergies, medications, and plan/
goals. The study findings guided the development of
the concise and efficient TIME (transaction, induction,
maintenance, emergence) anesthesia handoff tool.
Keywords: Anesthesia, checklist, communication,
handoff, handover.
are few anesthesia-specific handoff tools.
To address this gap, Wright6 conducted a study to
improve the quality and effectiveness of the anesthesia
handoff by developing, implementing, and evaluating
the PATIENT protocol. Wright6 found that there was
a gap in the transfer of care process among anesthesia
providers and that some practitioners might be resistant
to changing their current practices. Each letter of the
acronym PATIENT represents a topic or topics to address
during anesthesia handoff. The letter P stands for procedure, patient, and position; A stands for anesthesia, antibiotic, airway, and allergies; T represents temperature; I
stands for intravenous (IV) lines and other invasive lines;
E stands for end-tidal carbon dioxide or ventilation; N
stands for narcotics; and T stands for twitches.
The transfer of care process between anesthesia providers is still undefined and not standardized. Despite a
growing awareness that a standardized handoff tool is critical to providing safe and effective patient care, there are
limited studies to assess the need for the development of
such tools. The purposes of this descriptive survey project
were (1) to assess the need for a standardized handoff tool
for anesthesia providers and (2) to identify the most essential components, influenced by the PATIENT protocol,
for the development of a handoff tool to be used during
the transfer of care between anesthesia providers.
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431
OBSERVATION PHASE
TRANSACTION PHASE
Collect information about
• surgeon
• procedure
• anesthesia provider
• location
Incoming
Observe
provider
• type of anesthesia
• monitors
• position
• anesthetics used
CONFIRMATION PHASE
Feedback
Info given and
received using
checklist
Confirm all information
is accurate and complete
Outgoing
provider
Physiologic Distractors
Psychological Distractors
External Noise
Figure 1. Observation, Transaction, and Confirmation (OTC) Conceptual Framework
Abbreviation: Info, information.
The conceptual framework developed for this research study was a combination of 2 theories, including the transactional model of communication7 and the
cooperative shift change.8 The transactional model of
communication describes 2 communicators who both
send and receive information. The model also considers
the environment as part of the experience, consisting
of the external noise in the physical location as well
as the physiologic and psychological experience of the
communicators.7 Another theory, the cooperative shift
change theoretical framework for air traffic controllers,
was developed during shift change.8 This framework
consists of 4 phases: end of shift, arrival, meeting, and
taking post. In the end-of-shift phase, the controller
coming onto duty (incoming controller) learns as much
as possible about what is going on with air traffic. In
the arrival phase, the incoming controller sits in and
observes the scene, gaining situational awareness. In the
meeting phase, brief verbal communication guided by a
checklist occurs between the 2 controllers. Finally, the
taking-post phase distributes equal responsibility to both
the incoming and outgoing controllers to confirm that
accurate situational awareness and essential information
is discussed.
Combined, the cooperative shift change framework
and the transactional model of communication result in
the observation, transaction, and confirmation (OTC)
conceptual framework for handoff between anesthesia
providers (Figure 1). Similar to the arrival phase of
the cooperative shift change framework, the observation phase consists of the incoming anesthesia provider
gaining as much information as possible about the transfer-of-care situation before proceeding to the handoff location. During this time, the anesthesia provider should
collect information about the surgeon, procedure, anesthesia provider, and location.
The transaction phase of the OTC conceptual framework uses the transactional model. This phase is similar to
the meeting phase of the cooperative shift change frame-
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work and includes the details of the transactional model.
The incoming and outgoing anesthesia providers have a
brief conversation, ideally using a structured checklist or
tool, in which information is given and received between
the 2 communicators. To optimize this phase, consideration is given toward reducing distracting external noises
such as music, talking, and equipment. Examples of
physiologic distractors of the communicators are stress,
fatigue, and illness. Psychological factors are differences
in willingness, years of experience, gender, power, role,
and attitude between the anesthesia providers.
The final phase of the OTC conceptual framework is
the confirmation phase. After the transaction phase, both
communicators should provide verbal feedback confirming that all information has been shared accurately and
completely, enabling the incoming provider to adequately provide anesthesia to the patient for any length of time.
The OTC phases provide a framework consistent with
existing concepts for transfer of responsibility of events
and communication.
Materials and Methods
• Research Design and Sample. A descriptive survey was
conducted. The objectives of this study were to assess the
need for a standardized handoff tool and to provide information on current handoff processes between anesthesia
providers as well as their opinions on the most essential
aspects to include in the anesthesia-specific handoff tool.
The project describes anesthesia handoff procedures and
attitudes as they currently exist, and the results provide
insight for future studies.
A convenience sample of anesthesia providers practicing in the greater Chicago, Illinois, area at 2 large,
academic institutions was used. The sample included
Certified Registered Nurse Anesthetists (CRNAs), student
registered nurse anesthetists, anesthesia residents, and
anesthesiologists working at 4 hospitals. Participants met
the inclusion criteria of being English-speaking, legally
permitted to provide anesthesia in the state of Illinois in-
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dependently or under direct supervision of an anesthesia
provider, having a minimum of 6 months of providing
anesthesia, and currently practicing anesthesia.
Approval from the appropriate institutional review
boards was obtained. No physical or psychological risks
were anticipated to be associated with this research.
Because of the voluntary nature of the survey, participation by subjects implied that they did not feel uncomfortable or embarrassed by completing the survey.
• Instrument. The study survey included multiplechoice questions regarding demographics, a needs assessment for a standardized handoff tool for anesthesia
providers, current anesthesia handoff practices, and
essential components of anesthesia handoff. The survey
questions were influenced by the existing questionnaire
developed by Wright6 for her study and development of
the PATIENT protocol. Modifications were made to best
answer the research questions of this study.
• Data Analysis. Raw data were securely downloaded
from Qualtrics. Data collected from the surveys were analyzed using Microsoft Excel for Mac 2011 version 14.5.3
(Microsoft Corp) and SPSS for Mac version 23 (IBM
Corp) using descriptive statistics to describe frequencies
and means.
Results
As seen in Table 1, of the 82 study participants, most were
anesthesiologists (n = 34, 41.5%) or currently in anesthesia residency (n = 27, 32.9%), whereas 17 were CRNAs
(20.7%) and 4 were student registered nurse anesthetists
(4.9%). Most respondents (n = 62, 75.6%) spend more
than 36 hours per week providing anesthesia and have
been providing anesthesia for 2 to 5 years (n = 28, 34.1%).
There was a slightly greater number of male participants
(n = 44, 54.7%) than female (n = 38, 46.3%), and most
identified their ethnic origin as white (n = 58, 70.7%).
• Perceived Need for a Standardized Handoff Tool.
To address the study question about the perceived need
for a standardized handoff tool for anesthesia providers,
subjects were asked whether they currently used a systematic process for handoff from one anesthesia provider
to another. Of the 82 responses, 53 participants (64.6%)
denied currently having a systematic process for anesthesia handoff. The remaining 29 respondents (35.4%) could
provide a free-typed description of their current handoff
process. There were 21 free-typed responses composed of
about 20 categories with the most frequently described
being patient history, medications given, plan/goals, and
case-specific concerns. In addition, airway management,
type of surgery, and IV access were frequently free-typed
as part of current handoff processes.
Participants were also asked how often they believed
they were given inadequate information during transfer
of care (Table 2). Nineteen respondents (23.2%) thought
they were given inadequate information most of the time
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Variable
No. (%)
Role
Attending anesthesiologist
Certified Registered Nurse Anesthetist
Student registered nurse anesthetist
First-year anesthesia resident
Second-year anesthesia resident
Third-year anesthesia resident
Fourth-year anesthesia resident
Anesthesia fellow
Work experience
< 6 months
6 months to 1 year
2-5 years
6-10 years
11-15 years
16-20 years
21-25 years
26-30 years
31-35 years
> 35 years
Hours per week providing anesthesia
< 36 hours
> 36 hours
Gender
Male
Female
Racial-ethnic origin
White
Black, African, African American
Asian, Pacific Islander, Native Hawaiian
Hispanic, Latino, Spanish origin
34 (41.5)
17 (20.7)
4 (4.9)
1 (1.2)
5 (6.1)
11 (13.4)
9 (11)
1 (1.2)
2 (2.4)
9 (11)
28 (34.1)
9 (11.0)
10 (12.2)
5 (6.1)
6 (7.3)
7 (8.5)
4 (4.9)
2 (2.4)
20 (24.4)
62 (75.6)
44 (53.7)
38 (46.3)
58 (70.7)
1 (1.2)
18 (22.0)
2 (2.4)
Table 1. Study Participants’ Sociodemographics (N = 82)
or always. Half of the respondents (n = 41, 50%) believed
they sometimes were given inadequate information.
When asked about how often they thought they gave
inadequate information to others during transfer of care,
31 participants (37.8%) replied they sometimes gave inadequate information and 11 (13.4%) believed they gave
inadequate information most of the time or always. To
answer how often they discovered something that was
not discussed during handoff, 40 (48.8%) believed they
sometimes discovered something that was not discussed
and 8 participants (9.8%) thought they discovered something that was not discussed most of the time or always.
• Essential Components of Standardized Handoff Tool.
• Current Practice of Handoff. Participants were given
a list of 18 components of handoff that have previously
been identified in the literature. These included ASA class,
airway type, airway difficulty, allergies, analgesia, antibiotics, antiemetics, anesthetic type, invasive lines, intake/
output, patient medical history, patient surgical history,
position, procedure, neuromuscular blockade status,
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Variable
Never
How often do you feel you are given inadequate information during transfer of care?
How often do you feel you give inadequate information during transfer of care?
How often do you discover something that wasn’t discussed during handoff?
Table 2. Perceived Need for Standardized Handoff
Sometimes
Always
22 (26.8)
41 (50)
19 (23.2)
40 (48.8)
31 (37.8)
11 (13.4)
34 (41.5)
40 (48.8)
8 (9.8)
Toola
aData are displayed as number (percent); N = 82.
Essential
component
Current handoff practice:
How often do you
How often do you
provide the
receive the
following information?
following information?
Ideal handoff
practice:
How essential are the
following components?
Never
Sometimes
Always
Never
Sometimes
Always
Not
Somewhat
Essential
0
12
70a
3
16
63
1
9
72a
1
5
76a
0
2
80a
71a
Airway type
Airway difficulty
1
0
81a
Allergies
10
18
54
14
34
34
0
11
Analgesia
3
8
71a
4
21
57
0
22
60
Anesthetic
6
3
73a
5
13
64
3
9
70a
IV
1
5
76a
3
9
70a
1
6
75a
Medical hx
1
2
79a
0
5
77a
0
4
78a
0
4
78a
0
3
79a
2
18
62
1
8
73a
Mean
Mode
Rank
Patient
2.4
1
1
Airway
2.9
1
2
Procedure
3.6
2
3
Anesthesia
4.2
3
4
Allergies
6.0
3
5
IVs and other invasive lines
6.1
6
6
7
Procedure
1
2
79a
Vital signs
5
6
71a
Table 3. Most Essential Components of Handoff
Abbreviations: IV, invasive lines; hx, history.
aMost commonly identified components.
surgeon, ventilatory status, and vital signs. Participants
were then asked how often they provided each of the 18
components to others as well as how often they received
each of the 18 components during handoff or transfer of
care. Table 3 displays the frequencies for each of the top
9 components that were used in current handoff vs ideal
handoff. Of these top 9, the following 8 were the most frequently provided components in current practice: airway
type, airway difficulty, analgesia, anesthetic type, invasive
lines, patient medical history, procedure, and vital signs.
The components that participants most frequently received from others during handoff were airway difficulty,
invasive lines, medical history, and procedure.
• Ideal Handoff Practice. In addition, participants were
asked which components are essential to anesthesia
handoff. The most essential components identified were
airway type, airway difficulty, allergies, anesthetic type,
invasive lines, patient medical history, procedure, and
vital signs. The allergies component was essential for
an ideal handoff but was not one of the most frequently
provided or received components in current practice.
The most essential components of both current and ideal
handoff practices are airway difficulty, invasive lines,
medical history, and procedure.
Participants were asked to rank the components of the
PATIENT protocol6 in order from most essential (1) to
least essential (12). As shown in Table 4, the components
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Variable
ETCO2 (ventilation)
6.9
6
Narcotics
8.4
11
8
Position
8.5
6
9
Antibiotic
8.7
8
10
Twitches
Temperature
9.3
11
12
11
12
12
Table 4. Components Ranked in PATIENT Protocol
(N = 78)a
Abbreviations: ETCO2, end-tidal carbon dioxide; IV, intravenous.
aRanked most essential (1 point) to least essential (12 points),
indicating a lower score is more essential.
that were ranked most essential were patient and airway.
These were followed by procedure, allergies, anesthesia, and IVs and other invasive lines. Temperature and
twitches both ranked least essential.
• Comparison Between Ideal Handoff Tool and Rank
PATIENT Protocol. The top 5 ranked components of
the PATIENT protocol are patient, airway, procedure,
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T
Transaction
I
M
E
Induction
Maintenance
Emergence
Observations: surgeon, procedure, position, monitors, anesthetic
Patient: history, allergies
Airway, invasive lines, medications
Case-specific timing, interventions, medications
Plan, goals, medications
OBSERVATION PHASE
TRANSACTION PHASE
CONFIRMATION PHASE
Incoming
provider
I – Induction: airway, invasive lines,
medications
M – Maintenance: case-specific timing,
interventions, medications
E – Emergence: plan, goals, medications
Outgoing
provider
Figure 2. A New Anesthesia Handoff Tool: “TIME”
anesthesia, and allergies. The top 5 components of the
ideal handoff are airway difficulty, procedure, patient
medical history, invasive lines, and vital signs. Of these,
patient medical history, airway difficulty, and procedure
are consistent with the same PATIENT protocol components. In addition, allergies, and invasive lines are also
consistently ranked highly among the ideal handoff and
the PATIENT protocol. Anesthesia was determined essential in the PATIENT protocol but was not essential to
an ideal handoff tool.
• Proposal of the TIME Anesthesia Handoff Tool.
Considering the OTC conceptual framework, major
findings from this study, and the importance of systemic
checklists and mnemonics to handoff and anesthesiaspecific workflow, the authors propose the “TIME”
anesthesia handoff tool (Figure 2). This figure illustrates
how the TIME anesthesia handoff tool is integrated into
the OTC conceptual framework. The incoming provider
enters the correct location; sees the outgoing provider;
and notices the surgeon, patient position, procedure
being performed, monitors, and type of anesthetic. These
are all objective qualities that are simply observed. The
letter T in the TIME mnemonic represents the initiation
of this the next phase: transaction. The incoming provider exchanges information with the outgoing provider.
The outgoing provider begins the transaction by providing information regarding the patient, including medical
history and allergies, components determined to be essential to handoff. Next, the I represents the induction
phase and information regarding airway, invasive lines,
and medications given during induction are discussed.
The M stands for the maintenance phase, during which
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information specific to the case is shared, such as timing
of case, what interventions have been done or need to
be completed, and maintenance medications including
analgesics and neuromuscular blockers. The E of TIME
represents emergence. A statement regarding the plan for
emergence or goals for the case and medications such as
anesthesia reversal agents and antiemetics are included
during this phase. Finishing the OTC conceptual framework is the confirmation phase, during which feedback
and further verification that all information is accurate
and understood complete the handoff.
Discussion
Most anesthesia providers participating in this study
believed that handoff from their peers lacked information necessary to adequately care for their patient. About
half of participants admitted they themselves sometimes,
most of the time, or always gave inadequate information to others. Although providers might perceive their
personal practice more confidently than their peers’
practice, many acknowledged they also contributed to inadequate handoff, further supporting it as an area in need
of standardization. The results from this study indicate
that most participants perceive that both their peers and
themselves currently provide inadequate handoff. A standardized handoff tool specific for anesthesia providers
can help improve memory, increase efficiency, decrease
adverse outcomes, and enhance communication.9,10
For evaluation of the factors that anesthesia providers believed were most essential to handoff, participants
were asked questions regarding their current and ideal
handoff practices. Participants currently give and receive
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435
information on airway difficulty, invasive lines, medical
history, and procedure in handoff. Six of 7 of the components participants believed to be essential to an ideal
handoff were consistent with the components currently
used during handoff. Analgesia was always provided by at
least 85% of respondents as part of their current handoff
practice but was not determined to be an essential factor.
One component, allergies, was deemed essential to
handoff but was not provided in current practice.
Airway difficulty, invasive lines, medical history, and
procedure are the most essential components of anesthesia handoff based on the components that are currently
given by and received from most providers, as well as
those determined to be essential to an ideal handoff. Of
the top 5 ranked components of the PATIENT protocol,6
patient, airway, and procedure are consistent with the
most essential components determined by this study.
The allergies component was ranked among the highest
of the PATIENT protocol and was believed to be one of
the most essential components by participants; however,
as mentioned, it was not one of the factors currently used.
Considering open-ended responses by participants
who currently use a standardized method for handoff,
medications given, plan/goals, and case-specific concerns
should also be considered essential because they are
frequently used in current practice; however, they were
not options on survey questions. Use of a more generic
medications category as an open-ended response on
the survey encompasses the specific medication classes
such as analgesia, antibiotics, antiemetics, and anesthesia. Participants view medications as an important part
of handoff, including but not limited to analgesia and
antibiotics. The higher ranking and more frequently
provided answer in the open-ended responses identifies
medications to be an essential component of handoff.
In addition, case-specific concerns were frequently freetyped and could be interpreted as part of the procedure
component from the list provided by the survey. The
free-typed response of plan/goals does not have an associated survey component and should be determined as one
of the most essential components to include in anesthesia handoff. Therefore, any proposed anesthesia handoff
tool should minimally address airway difficulty, invasive
lines, medical history, procedure/case-specific concerns,
allergies, medications, and plan/goals.
The TIME handoff tool was developed to be a concise
and efficient tool for anesthesia providers to use during
transfer of care. Using the results of this study and the
influence of Wright’s PATIENT protocol,6 the authors
created the acronym TIME. The OTC conceptual framework introduced in this article provides the foundation
for handoff. This framework was strongly considered
during development of an acronym that could be concise,
efficient, and applicable to any situation involving anesthesia handoff. Because the transaction phase of the
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OTC framework is when the interaction between providers occurs, the letter T was important to the acronym.
Next, an anesthesia-specific organization of events was
decided to be a logical and adaptable way to efficiently
communicate the most essential components of a case
from one anesthesia provider to another. An anesthetic is
often divided into 3 phases: induction, maintenance, and
emergence. From this, the letters I, M, and E were added
to complete the TIME acronym.
The TIME handoff tool differs from the PATIENT
protocol in length and organization. In the TIME handoff
tool, there are 4 letters to the acronym, each representing a
chronological order of events that can be addressed at any
point in a case to any provider. This creates an efficient
method to organize the important components of handoff.
In contrast, the PATIENT protocol consists of a 7-letter
acronym with each letter representing 1, 3, or 4 components of handoff. This protocol also includes components
that were determined to be not essential to handoff.
Several limitations for this study were identified. The
nonrandom sampling procedures may have introduced
selection biases and impaired the generalizability of the
results. Study participants were recruited from only 2 institutions in the Chicagoland area. The handoff practices
and perceptions greatly vary depending on practitioners,
geographic location, and workplace. Although this would
suggest that the findings of this study are not generalizable to other anesthesia providers, the demographic
distribution of study participants is quite representative
of the CRNA profession as a whole. The results of this
study can provide a foundation for similar studies with
a broader study population to best generalize the results.
The survey itself had limitations. The list of handoff
factors was limited and very specific. As recognized
earlier, medications as a general category rather than
divided into classes could have yielded different results.
Thus, the study may not have captured the potential
factors influencing handoff. Another limitation of this
study includes use of a convenience sample, a single-informant self-report method, and a cross-sectional design.
An inherent limitation is the limited number of existing
anesthesia-specific handoff tools to which the TIME tool
can be compared.
Anesthetics provided by a CRNA can be more effective and more efficient and can result in fewer adverse
outcomes if an appropriate standardized tool is used.11,12
The findings of this research contribute to changing the
handoff practice of CRNAs by identifying a need for standardization and identifying the most essential components of handoff. Employers of CRNAs should consider
adopting the TIME handoff tool as a standard of practice
to promote more effective and efficient communication.
Improved communication with other anesthesia providers can also enhance the collaborative and teamwork
environment for all anesthesia providers involved.
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Similar to the 2-phase study conducted by Wright,6
the proposed TIME handoff tool can be implemented and
evaluated in the future for its feasibility and acceptability.
Specifically, research on education of the OTC conceptual framework and integrating TIME into the electronic
charting system is a direction for future research. If
leadership recognizes the value of this research, implementation and dissemination throughout the department
can occur. The literature review completed for this study
supports handoff education, electronic integration, and
checklist mnemonics. Given the limited sample size and
survey limitations, more research on existing anesthesia
handoff practices is needed. Currently, there is no protocol or standard of practice for transfer of care between
anesthesia providers in these institutions. The needs
assessment conducted through a descriptive survey provides information on current handoff processes between
anesthesia providers as well as anesthesia providers’ opinions on the most essential aspects to include in handoff.
This study found that most participants perceive that
both their peers and themselves currently provide inadequate handoff. The most essential components to include
in anesthesia handoff as a result of this study should minimally address airway difficulty, invasive lines, medical
history, procedure/case-specific concerns, allergies, medications, and plan/goals. Thus, guided by the conceptual
framework of OTC and the major findings of this study,
the TIME anesthesia handoff tool is proposed as a concise,
efficient handoff tool to be used during transfer of care
between anesthesia providers in these institutions.
REFERENCES
AUTHORS
Courtney Gibney, DNP, CRNA, was a student at NorthShore University
HealthSystem School of Nurse Anesthesia, Evanston, Illinois, at the time
this article was written. She is a full-time nurse anesthetist at University of
Chicago Medicine, Chicago, Illinois. Email: courtks@gmail.com.
Young-Me Lee, PhD, RN, is an associate professor at the DePaul University School of Nursing, Chicago, Illinois.
Julia Feczko, DNP, CRNA, is a full-time nurse anesthetist at NorthShore University HealthSystem and a faculty member at the NorthShore
University HealthSystem School of Nurse Anesthesia.
Elizabeth Aquino, PhD, RN, is an assistant professor at DePaul University’s School of Nursing. She has nursing experience in a Level I surgicaltrauma intensive care unit, and her research focus is on health disparities
for vulnerable populations.
DISCLOSURES
The authors have declared no financial relationships with any commercial
entity related to the content of this article. The authors did not discuss
off-label use within the article.
ACKNOWLEDGMENTS
This research was supported by committee member and coauthor Julia
Feczko, DNP, CRNA, whose experience and guidance greatly influenced
this project and who also served as staff advisor to NorthShore University HealthSystem, Evanston, Illinois. Lead author (CG) would like to
acknowledge committee member and coauthor Elizabeth Aquino, PhD,
RN, for her positive support and comments on this manuscript. Randal
Dull, MD, PhD, served as staff advisor and mentor from the University of
Illinois at Chicago Hospital, Chicago, Illinois. Joseph D. Tariman, PhD,
RN, ANP-BC, provided expertise and knowledge that greatly assisted the
formation of this research project. Ms Gibney also is immensely grateful
for the constant support, guidance, mentorship, and wisdom of committee
chair and coauthor Young-Me Lee, PhD, RN, without whom this project
would not have been possible.
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CENTER FOR
HEALTHCARE
GOVERNANCE
Nurses on Healthcare
Boards
A smart and logical move to make.
As the spotlight on healthcare reform
continues, it is becoming clear that
hospitals need to focus on improving
value by optimizing the balance
among healthcare cost, quality and
accessibility for patients and other
stakeholders. In moving toward a
more value-driven basis for healthcare
delivery, hospital boards and leaders
will benefit from tapping resources
with clinical care expertise and an
understanding of patient and community needs. Add to that skills in
communications, decision making,
management and leadership, and you
have the basic job description of
many of todays nurse executives.
Research on nonprofit hospital governing boards indicates that only
about 2 percent of their members are
nurses. In this column we examine
why hospital boards should take a
closer look At nurses—a governance
resource that remains largely
untapped by most boards.
The value nurses can bring to the
board table has been acknowledged
and supported by many healthcare
leaders. Donald M. Berwick, MD,
president and CEO ofthe Institute
for Healthcare Improvement, noted
in the April 2005 issue oîBoardRoom
Press, ^’It is key that nurses be as
involved as physicians, and I think
84
Hcahhcare Executive
MAY/JUNE 2010
boards should understand that the
performance ofthe organization
depends as much on the well-being,
engagement, and capabilities of nursing and nursing leaders as it does on
physicians. I would encourage much
closer relationship between nursing
and the board.”
Because nurses have the most
contact with patients, families
and physicians, nurses have
in-depth knowledge of
healthcare delivery that could
prove valuable to a board of
trustees on relevant issues.
In 2007, the Center for Healthcare
Govertiatice’s Blue Ribbon Panel on
Health Care Governance recommended that boards “include physicians, nurses and other clinicians on
the board. Their clinical competence
and viewpoints are valuable to other
board members and will help the
board better understand the needs
and concerns of several ofthe organization’s stakeholders.”
And a 2009 Grant Thornton LLP
study of governance in community
health systems urged that “All boards
should consider enriching their membership with greater racial and gender
diversity; they also should consider
the appointment of highly respected
and experienced nursing leaders as
voting members ofthe board to complement physician members and
strengthen clinical input in board
deliberations.” The study also said,
“Engaging leaders in the nursing
profession on hospital and health system boards has not yet become the
norm, nor has it been accepted as a
benchmark of good governance.
However, given the importance of
nursing in the provision of^ patient
care, it seems likely that the idea of
engaging nurses on boards and board
committees will receive growing consideration in the future.”
Exploring Nurse Executive Skills
Nurses are the largest group of
healthcare professionals and the
fastest growing group of primary
care professionals in the United
States, according to the National
Nursing Centers Consortium. As
boards consider governance effectiveness under healthcare reform,
the skills and attributes that nurses
can bring to the board table are
worth closer examination.
Because nurses have the most contact with patients, families and
Governance Insights
physicians, nurses have in-depth
knowledge of healthcare delivery
that could prove valuable to a
board of trustees on relevant issues.
Nurse leaders also possess additional attributes that make them a
key asset for healthcare organization governing boards. These
include having:
‘ Credibility with policy-makers,
employees, health plan administrators, physicians and executives.
• The ability to identify and triage
problems.
• An understanding of issues
concerning hospital staff and
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bogcommunitv.ache.ora
86
Ht-althcarc hxciurlve
MAY/JUNE 2010
effective approaches to employee
retention.
• Av^’areness of comtnunity health
needs.
Despite these positive qualities, nurses
are not solidly among the ranks of
todays healthcare governing board
members, and this practice needs to be
re-examined in light of current realities
in healthcare, according to Lawrence
D. Prybil, PhD, FACHE, governance
researcher and professor at the
Department of Health Management
and Policy at the University of Iowa.
Potential conflicts of interest issues may
arise during the selection process of a
nurse to the board, btit questions can
easily be resolved, he says. For example,
as they sometimes do with physician
board candidates, hospital boards can
consider nurses who hold leadership
positions at organizations outside of the
hospital’s service area. Or, if a nurse
trustee is a member of the board of a
hospital where he or she is also
employed, the board should ensure that
any conflicts are disclosed and handled
in accordance with the board’s conflict
of interest policy and process.
Removing obstacles to nurse participation on boards and embracing
what nurses can bring to governance
are good first steps. The number of
nurses on boards also is likely to
increase when nurses themselves
focus on the advantages of serving on
boards and better understand what it
takes to be an effective trustee.
“Board service brings with it both
valuable benefits and awesome
responsibility,” says Connie Curran,
RN, EdD, CEO of Best On Board,
an organization that provides
integrated governance education,
testing and certification services for
current and potential healthcare
organization board members and
leaders. “As healthcare boards seek to
expand the diversity of their membership, they will view nurses as a ready
resource to draw on as they become
more aware of what nurses can bring
(o the board table and as nurses take
the initiative and prepare themselves
to become trustees.”
CAjrran suggests a number of actions
healthcare boards and CEOs can take
to increase nurse participation on
boards. These include;
• Seeking nurse leaders from
within and outside of their organizations CO serve on the board.
Schools of nursing and other
community organizations, such
as the American Cancer Society,
American Heart Association or
Visiting Nurses Association, are
good resources to tap.
Supporting and encouraging
nurse leaders within their
organizations to prepare for
board service by educating
themselves on healthcare governance issues and board roles
and responsibilities.
Working with organizations,
such as the Robert Wood
Johnson Foundation, that have
developed initiatives to help
nurses become hospital board
members.
As healthcare organizations and
their boards grapple with how to
‘
address issues of cost, quality and
access under healthcare reform, they
should embrace the stakeholder perspective, clinical expertise and other
contributions nurse trustees can
bring to governance. •
Mary K. Totten is director of content
development for the Center for
Healthcare Governance, a community
of board members, executitm and
thought leaders dedicated to advancing
excellence, innovation and accountability in healthcare governance.
Center for Healthcare Governance
155 N. Wacker Dr., Ste. 400
Chicago, IL 60606
(888) 540-6111
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HIMIIIU.IIV l’,CLll(ivC
MAY/JUNE 2010
87
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