How Handoffs Can Kill
I've blogged before about how handoffs in a process create opportunities for errors. I wrote about a trivial situation where I got the wrong muffin and Seth Godin wrote about getting the right breakfast because there were fewer handoffs.
Now, the article linked above focuses on standardizing handoffs in hospital settings. In an effort to reduce errors, many hospitals have shortened doctor and nurse shifts, to prevent errors that are caused by fatigue. The unintended consequence is that you now have more patient handoffs… and communication is more critical than with a bran muffin.
Here is the standard method that some hospitals are adopting, borrowed from nuclear sub practices (and more proof that you CAN learn from other industries):
“The SBAR checklist some hospitals are using to improve patient hand-offs:
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- S: Describe the Situation. In a few seconds, get someone's attention.
- B: Background. Provide enough information to give the listener some context for the problem.
- A: Assessment. Give your assessment of the overall condition
- R: Recommendation. Give your specific recommendations.”
It's a great opportunity, as we return to work Wednesday, to think about the handoffs in our own processes. Can we standardize communication from shift to shift or person to person in a process? How can we simplify our work to reduce the opportunities for errors? How can we use communication to encourage teamwork and get people to speak up?