Operational Excellence
 

Document Type

Article

Publication Date

10-2018

Institution/Department

Operational Excellence

MeSH Headings

patient handoffs, academic tertiary medical center, survey, AHRQ patient safety culture survey, patient transfer, goal root cause analysis

Abstract

SAFE TRANSITIONS AND PATIENT HANDOFFS IN A LARGE ACUTE CARE HOSPITAL

It is well documented in the literature that ineffective patient handoffs and transitions continues to be an area that can lead to adverse patient safety events so it is an urgent opportunity for a performance improvement plan. At an academic tertiary care medical center, the lowest scoring domain from the FY2017 AHRQ Patient Safety Culture Survey was patient handoffs and transitions.

A team was established consisting of staff from the Emergency Department and a medical/surgical unit to develop a plan for implementing improvement interventions. Their goal was to attain a ≥ 5% improvement on the patient handoff and transitions question in the Survey by the end of 12/30/2018.

A root cause analysis was initiated and resulted in a KPI being developed to collect baseline data on handoffs and transitions between the two units. After three phases to analyze and improve, several countermeasures were created. Amongst them was the development of a evidence based mnemonic handoff tool to be used within 30 minutes of patient transfer.

Pulse surveys of the involved units conducted at various intervals demonstrated significant improvement of >5% in the 3 teamwork questions. Next steps will be to standardize, sustain and spread the improvement methods.

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