Using Continuous Process Improvement Methodology to Standardize Nursing Handoff Communication1
Section snippets
Background
Effective communication among health care providers is imperative to ensure patient safety. Data obtained by The Joint Commission (TJC) from 1995 to 2005 in their review of sentinel events reported during this period indicate that communication was the root cause of 65% of sentinel events (Joint Commission on Accreditation of Healthcare, 2005). These troubling data indicate a clear need for better communication among health care workers to improve patient safety. The accurate transfer of
Use of Continuous Process Improvement to Standardize Handoff: Phase I Identifying the Opportunity for Improvement
In 2006, an assessment of current handoff practice at our organization revealed many opportunities for improvement. At that time, there were no policies or standard methods for either the content or process for change of shift handoff. The shift handoff was similar but not standard across the organization. On most units, the process consisted of a verbal exchange at the nursing station between the off-going and oncoming nurse. On some units, the handoff was preceded by a unit huddle where all
Use of Continuous Process Improvement to Standardize Handoff: Phase II Identifying the Opportunity for Improvement
In early 2009, leadership observations and staff feedback revealed that staff had maintained the use of the standard handoff tool and were still doing safety checks at the bedside 83% of the time. However, use of the medical record as a reliable source of information was not being done consistently, and the standard sequence of the handoff process was not being followed. Families were inconsistently included in the bedside safety check component of the handoff. Recognition of this inconsistency
Conclusions and Implications for Further Study
Many improvements were realized following completion of our workshops. These improvements include increased family involvement, identification of safety concerns or errors before they reach the patient, and improved quality of exchanged information. We believe that the use of CPI methodology enabled us to make significant changes in a shorter timeline than could have been accomplished using traditional change management approaches. The RPIWs ensure that the right stakeholders are given
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The authors of this article have received no extramural funding or commercial financial support for this project. This article has not been previously presented or published.