MMHA 6600 Week 11 Handoff Tool Adoption Memo Example

Memorandum

To: Chief Nursing Officer and Medical Staff Informatics Committee, Bramble Creek Hospital

From: Informatics Project Lead (MMHA student)

Date: Month Day, Year

Re: Six-month adoption review of the electronic shift handoff tool on medical-surgical units

Summary

Six months after go-live, the electronic shift handoff tool is used on most handoffs but not in the way it was designed. Nurses open it and update it for most patients; physicians use it far less. Two workarounds have spread: nurses print the tool and write on the printout, and night physicians keep a separate shared list in the messaging product. I recommend keeping the first workaround and building it into the tool, and replacing the second with a change to the tool that meets the need behind it. Adoption is defined in this memo by traces anyone can count, not by survey impressions.

How Adoption Was Measured

Saying a tool is adopted means little unless adoption is defined in observable terms. I used four traces, each available from the record's logs or from direct observation over two weeks on three units. Every percentage in Table 1 is invented to show the method and should be replaced by the hospital's own log extract.

Defining adoption this way follows the view that a technology is adopted when it becomes part of routine work, which can be observed, rather than when it is installed (Greenhalgh et al., 2017).

Table 1

Adoption Traces at Six Months (Illustrative)

Nurses open, update and read the tool for most patients; physicians do so for well under half. Almost nobody uses the screen at the bedside.

Why Physicians Use It Less

Interviews with eight hospitalists pointed to two reasons. The tool's fields were designed around nursing handoff, with sections for lines, drains and mobility, and physicians found the physician section too short for overnight contingency plans. Night physicians also cover patients across units, and the tool is organized by unit, so a cross-cover physician must open three unit lists. Perceived usefulness and fit with work are among the strongest predictors of whether clinicians use a technology (Holden & Karsh, 2010). For physicians, the tool scores poorly on both.

The Two Workarounds

Workarounds are often treated as noncompliance. Some are better understood as users adapting a tool to work it did not anticipate, while others create risks of their own (Koppel et al., 2008). Each workaround here was judged on two questions: does it meet a real need, and does it create a safety or privacy risk?

The printed sheet is useful reinvention. Nurses use the tool as intended at handoff and then carry a paper copy that fits how they move through a shift; the information starts in the record, and the risk is small. The physicians' shared list is different. It meets a need the tool does not, a cross-unit view with room for contingency plans, but it holds clinical information outside the record where nobody else can see or audit it.

Table 2

Workarounds Judged

The first workaround is a sensible adaptation; the second solves a real problem in an unsafe place.

Recommendations

First, keep the printed sheet and improve it: add a print layout designed for annotation, with space beside each patient, and confirm the shredding procedure on every unit. Second, replace the physicians' shared list by changing the tool: add a cross-cover view that lists all of a physician's patients regardless of unit and expand the physician section to include if-then contingency plans. Once that view exists, ask the messaging product administrator to discourage shared patient lists through policy and product settings. Third, keep measuring the same four traces at nine and twelve months, adding physician use of the new cross-cover view. Structured handoff programs have been associated with fewer medical errors when they are used consistently (Starmer et al., 2014), so the goal is consistent use by both professions, not only nurses.

Risks of the Recommended Changes

A cross-cover view could become a second place to keep the same plan if physicians copy text between sections, so the build team should show contingency plans in one field that appears in both views. Expanding the physician section adds length, and a longer form may lower nurse reading of it; the nine-month traces will show whether that happens. Finally, discouraging shared lists in the messaging product will meet resistance until the new view is live, so the policy change should follow the build rather than precede it.

Decisions Requested

I ask the committee to approve the cross-cover view and the expanded physician section for the next build cycle, and the Chief Nursing Officer to approve the annotation print layout.

References

Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A'Court, C., Hinder, S., Fahy, N., Procter, R., & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19(11), e367. https://doi.org/10.2196/jmir.8775

Holden, R. J., & Karsh, B.-T. (2010). The technology acceptance model: Its past and its future in health care. Journal of Biomedical Informatics, 43(1), 159-172. https://doi.org/10.1016/j.jbi.2009.07.002

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., . . . Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556