Assuring Sustainable Gains in Interdisciplinary Performance Improvement: Creating a Shared Mental Model During Operating Room to Cardiac ICU Handoff.

OBJECTIVE: To understand sustainability and assure long-term gains in multidisciplinary performance improvement using an operating room to cardiac ICU handoff process focused on creation of a shared mental model.

DESIGN: Performance improvement cohort project with pre- and postintervention assessments spanning a 4-year period.

SETTING: Twenty-six bed pediatric cardiac ICU in a tertiary care children's hospital.

PATIENTS: Cardiac surgery patients admitted to cardiac ICU from the operating room following cardiac surgery.

INTERVENTIONS: An interdisciplinary workgroup overhauled our handoff process in 2010. The new algorithm emphasized role delineation, standardized communication, and creation of a shared mental model. Our "I-5" mnemonic allowed validation and verification of a shared mental model between multidisciplinary teams. Staff orientation and practice guidelines were revised to incorporate the new process, visual aids were distributed and posted at each patient's bedside, and lapses/audit data were discussed in multidisciplinary forum.

MEASUREMENTS AND MAIN RESULTS: Audits assessing equipment and information transfer during handoff were performed 8 weeks following implementation (n = 29), repeated at 1 year (n = 37), 3 years (n = 15), and 4 years (n = 50). Staff surveys prior to implementation, at 8 weeks, and 4 years postintervention assessed satisfaction. Comprehensiveness of information transfer improved in the 4 years following implementation, and staff satisfaction was maintained. At 4 years, discussion of all elements of information transfer was 94%, increased from 85% 8 weeks following implementation and discussion of four or more information elements was 100% increased from 93%. Of the 73% of staff who completed the survey at 4 years, 91% agreed that they received all necessary information, and 87% agreed that the handoff resulted in a shared mental model.

CONCLUSIONS: Our methods were effective in creating and sustaining high levels of staff communication and adherence to the new process, thus achieving sustainable gains. Performance improvement initiatives require proactive interdisciplinary maintenance to be successful long term.