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    Medical error is a preventable adverse outcome resulting from a mistake of either omission or commission, an error of execution, planning or a deviation from the processes of care (Makary, 2016). Medical error is a safety issue and has been contributed to systems problems such as inadequate policies and procedures or lack of thorough team communication, both written and verbal. The average cost to a facility for medical errors is estimated to be $11,366 per occurrence (Van Den Bos et al., 2011). Communication between healthcare practitioners is absolutely vital for the safety and quality of patient care and outcomes. An integral part of nursing communication occurs with the transfer of a patients care from one nurse to another, yet the Institute of Medicine reported that “it is in inadequate handoffs that safety often fails first” (2001, p. 45). Handoff can be defined as “the transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm” (TeamSTEPPS, 2006, p. 31). Evidence shows that information degradation occurs between patient transitions due to poor handoff. (Gephart, 2012, Gregory, 2014). The Joint Commission identified that approximately 80% of serious medical errors are caused by communication breakdown (Joint Commission, 2012). The preoperative nurse has an important role in patient safety. Their assessment not only provides a picture of the patient's risk factors and vulnerabilities for surgery, it provides a snapshot of the whole person for the entire perioperative team. It answers questions regarding patient language, ambulatory ability, cognitive function, sensory function and any concerns the patient may have expressed. Postoperatively the preoperative assessment provides knowledge of the patient during a time when the patient cannot speak for themselves, allowing the nurse to identify changes in patient condition. The preoperative assessment establishes an important baseline that must be communicated for patient safety (Malley, Kenner, Kim & Blakeney, 2015).

   Handoffs are intended to ensure that continuity of care is maintained regardless of the persons involved. According to TeamSTEPPS, a proper hand over includes:

• a formal transfer in patient care responsibility and accountability

• unambiguous information

• verbal communication of all relevant information necessary to care for the patient

• a verbal acknowledgment that the patient's care plan and current status is understood by the receiving clinician

• an opportunity to ask questions about the information (TeamSTEPPS, 2014).

   A literature search regarding patient safety generates thousands of journal articles which agree that effective communication in patient handover is critical to patient safety. Studies that have been conducted identify lack of a standardized handoff format as a leading cause of communication error. Interruptions during handoff is also identified as a contributing cause (Riesenberg, Lietzsch & Cunningham, 2010). Much of the current research focuses on the root causes of communication failures but little is found regarding a means of establishing a sustainable and structured handoff system.

   A meeting with nursing leadership at a small, busy, urban, ambulatory surgery center (ASC) led to a proposal of working toward improvement of communication between nurses by focusing on the patient handoff report. In daily rounds, leadership has observed a lack of consistent patient handoff throughout the facility, and often times there is no handoff at all from the preoperative suite to the operating room (OR)/procedure suites. It is the intention of this project to implement a modified SBAR (Situation-Background-Assessment-Recommendation) format for all nurses beginning with the nurses working in the preoperative area (see Appendix A). It is expected that this implementation will improve communication and reduce interruptions during patient transition between units.

Clinical Leadership Theme

    Observation, data collection, literature review and verbal discussions with preoperative and operating room (OR) nurses provides a starting point for beginning an improvement process at this surgery center. Considering the number of improvement possibilities along with the facilities goals, the theme of Communication was chosen in order to create a point of focus (Nelson, Batalden & Godrey, 2007). The Global Aim for this project is to improve the patient handoff process in the preoperative suite. By working on this process, we expect to improve communication of patient status between the preoperative nurse and the OR/Procedure nurse. It is important to work on this now because nurse handoff affects patient safety outcomes. The Clinical Nurse Leader (CNL) curriculum element that best identifies with this project is that of Care Environment Manager, along with the role functions of team manager, and systems analyst/risk anticipator (American Association of Colleges of Nursing (AACN), 2013). A major function of the CNL role is to sustain a culture of safety. CNL's are prepared to conduct a root cause analysis (RCA) for safe, patient centered care delivery and to address the effects of change on the environment (Reid & Dennison, 2011). As a point-of-care leader, the CNL assesses the microsystem to identify outcomes which improve safety, and applies evidence based practice to implement patient safety improvement processes (AACN, 2013).

Statement of the Problem

    During rounding, nursing leadership observed that patients are transferring from the preoperative suite to the OR/Procedure suites with limited or no handoff report between the nurses. Dialogue with nurses identified obstacles to handoff including lack of consistent, standardized approaches to patient transfer, multiple handoffs, and time constraints. Literature is filled with journal articles which relate the magnitude of importance in communication within healthcare settings to ensure quality patient outcomes and safety. Despite this level of evidence, there remains a crucial lack of structured handoff in this facility.

   The expectation of this project is that nurse to nurse communication will improve after implementing a standardized approach to patient handover. This will be completed by assessing organizational, behavioral and environmental factors affecting the handover process and establishing nurses understanding of the breadth and scope of the problem and creating an awareness of accountability.

Project Overview

   Communication is an expected core competency for nurses. The Systemic Communication Theory Framework (Appendix B) considers communication to be new messages that are created via through-put, what happens as the message is being interpreted and re-interpreted as it travels through people (Baecker, 2011). Communication breakdown occurs when the sender and receiver are not speaking the same "language." A standardized handoff tool will help to alleviate transmission failure between nurses by reducing the occurrence of omitted and scattered information.

   The specific aim of this project is that the surgery center will improve compliance in appropriate patient handoff report by preoperative nurses, by 50% within three months of implementation. This will be accomplished by determining the root causes underlying the omission of patient handoff, disseminating information to nurses concerning the relationship of communication and patient safety, and creating a standardized handoff report tool to improve nurse to nurse communication. Review of current literature favors the use of the Situation-Background-Assessment-Recommendations (SBAR) tool which was created by clinical staff at Kaiser Permanente in Colorado, California to provide a framework for communication utilizing an easily remembered mechanism (IHI, 2017). The SBAR mnemonic summarizes critical patient information by outlining a conversation that is utilized by every nurse in the same format and same order everytime (Amato-Vealey et al., 2008). This project will meet the facility goal of improving patient safety by decreasing variations in practice. The specific aim statement relates to the global aim of communication as it provides a detailed focus for improvement (Nelson, Batalden & Godfrey, 2007, p. 308).

Rationale

   Starting with the question, "why aren't nurses giving handoff report?"  data was collected by observation and was used to complete a root-cause-analysis (RCA). A partial day was spent observing the handoff processes of the preoperative nurses at the surgical center. The unit charge nurse was informed that nurses would be observed for handoff technique while the unit nurses were only told that the preoperative process was being observed, so as not to influence their usual routine. Notes were taken by hand with pen and paper. Ten patients were randomly chosen to be observed including one general surgery case, five cataract surgery cases and four GI cases. Six registered nurses were working on the unit maneuvering between patients. Two of the patients were Spanish speaking, and for these patients, a Spanish speaking nurse tech (medical assistant) completed the interview while the preoperative nurse was standing by. When the time came to transition the patient to the GI suite, the tech also interpreted for the GI nurse with the preoperative nurse standing by. Thoroughness of the handoff communication could not be determined for the two Spanish speaking patients. Of the eight remaining patients, observations revealed that four nurses gave no report at all, three nurses gave a partial report consisting of a few phrases, and one nurse gave a more informative report. The communication observed between nurses was unformatted and appeared rushed. Two OR nurses, randomly chosen, were asked if they regularly receive handoff report from the preoperative nurses. The OR nurses stated that it can be "hit and miss" and that "some nurses are better at giving report than others." The preoperative area was noted to be fast paced, crowded and noisy. A research study out of Rowan University found distractions in 40% of handoffs, which led to increased handover time and decreased quality, concluding that nearly 50% of those distractions were avoidable (Vlessides, 2015).

   Using a fishbone diagram, potential root causes in five areas were identified, these areas included the environment, interruptions, behavior, patients and processes (Appendix C). This formed a basis for determining solutions and a decision was made to focus on the prevailing problems of processes and behavior. A Strength, Weakness, Obstacle, Threat (SWOT) analysis was completed in order to evaluate the four elements of the organization (Appendix D). Strengths of this organization and its nurses are (1) nurses are skilled and qualified for their work, (2) nurses work as a team, (3) nurses are committed to patient care, and (4) nurses are caring and compassionate. A Stakeholders analysis was completed to identify key people to be involved in this project (Appendix E).

   Following the observation, every nurse in the surgery center representing each department (preoperative, gastroenterology (GI), OR, post anesthesia care unit (PACU)) was invited to participate in a survey to determine their understanding regarding the usefulness of patient handoff report as it is performed at this surgery center. The survey consisted of ten questions on a five point Likert Scale and two completion questions. Thirty surveys were offered which is the number of fulltime, part-time and per-diem nurses at the facility. Fifteen surveys were returned. The majority of nurses surveyed agreed that handoff report is an effective means of communication and that they have ample time to complete it, yet reasons given for not completing it were time issues and lack of participation by other nurses, either being unavailable or seeming disinterested (Appendix F, G, H ).

   The Institute of Healthcare Improvement (IHI) has identified the "Triple Aim" framework as an approach to optimize health systems performance by improving the patient experience, improving the health of populations and reducing the cost of health care. The IHI stresses the need for healthcare entities to be accountable to all three dimensions at once (Institute for Healthcare Improvement, 2017). Nurses can play a role in all three of these aims by enacting safe, efficient and equitable patient centered care, understanding the population of their specific unit, and making decisions that utilize resources in an effective manner (Beckers Healthcare, 2016).

   The Hospital Consumer Assessment of Healthcare Providers and systems (HCAHPS) Survey is a data collection tool in use since 2006 to measure patient's perspectives of their hospital care which allows people to make meaningful comparisons among hospitals that they may want to utilize. It also creates incentives for hospitals to improve their quality of care (Centers for Medicare & Medicaid (CMS), 2014).  In 2014 a new survey was developed for use by Medicare certified freestanding ambulatory surgery centers to collect the same type of patient perspective data. This survey specifically measures experiences including communication and preparation for surgery and discharge. Currently the survey submission is voluntary and was slated to be implemented as "pay for reporting" beginning in January of 2018. As of this time CMS is delaying implementation until further notice as they make improvements to the survey (OAS CAHPS, 2017). When the implementation does take place, public reporting of collected data will allow consumers to make informed choices.

   Medical error is a preventable adverse outcome resulting from a mistake of either omission or commission, an error of execution, planning or a deviation from the processes of care (Makary, 2016). Poor communication attributes to malpractice and lost lives (Kern, 2016). Each preventable medical error has legal, marketing, and organizational costs associated with them. A 2015 study in Anesthesiology observed 277 operations with 3,671 medication administrations. Of the 277 observed surgery cases, 193 involved a medication error or adverse drug event and 79.3% of those were preventable ( Nanji, Patel, Shaikh, Seger & Bates, 2016). Although hospitals are the primary site of sentinel events, the Joint Commission reports that ambulatory care centers experienced 351 sentinel events from 2004 to 2015 (Joint Commission, 2015). The average cost to a facility for medical errors is estimated to be $11,366 per occurrence (Van Den Bos et al., 2011).

   Implementing a standardized nurse to nurse patient handoff may save this surgery center thousands of dollars annually by preventing medical error. The cost of implementing this project on the preoperative unit would initially include a nursing in-service to familiarize the nurses with the new process. There are eight preoperative nurses making an average of $45.00 per hour which comes to $360 for the cost of the in-service. The remaining cost would be printing and ink for the document to be used (if any). Future in-services for the remaining full and part-time nurses (based on an average of nurse wages of $45/hour) would amount to an additional one time cost of $1,125.00 (Appendix I).  

   Qualitative benefits would include improved compliance to policy, improved patient satisfaction and improved nurse satisfaction both due to enhanced communication. Improved patient satisfaction will be an even more important feature when the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) is implemented (Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey, 2017).

Methodology

    The initial step in this project was a literature review of evidence focused on the outcome of communication and lack of communication among nurses during handoff report. Most studies of handover practices suggest a significant variation in processes across healthcare settings. The process is often unstructured and informal and takes place in the midst of noise, crowding, interruptions and patient care activity (Manser & Foster, 2011). To address this concern, in 2006 Joint Commission developed their safety goal #2, requiring facilities to utilize a standardized handoff communication system in which the receiving nurse has the opportunity to ask questions prior to assuming care for the patient. In 2007 safety goal #13 was added to actively involve patients in communication about their own care (The Joint Commission, 2008). The goal of this project is to improve nurse to nurse communication regarding the preoperative patient status upon transition from the preoperative suite to the OR/Procedure suites by improving nurse's knowledge and willingness to participate in handoff. To meet this goal, the following objectives will be achieved: (1) After watching a PowerPoint presentation on the relationship between patient safety and handoff report, the preoperative nurses will be able to explain the reasons for consistent and thorough handoff techniques, (2) the nurses will verbalize understanding that handoff is a transfer of professional responsibility and not "just" transfer of information,

 (3) The preoperative nurses will demonstrate the correct process for giving handoff report with each patient transition by using elements of the SBAR (Situation, Background, Assessment, Recommendation) technique (IHI, 2017), and (4) Nurses will consistently provide a thorough handoff report to the receiving nurse.

   The change theory guiding this project is Lewin's three stage model of change (Bozak, 2003).  Multiple literature studies reveal that managing change is challenging and will often incite resistance by nurses who already feel overwhelmed by daily tasks. The Likert survey reveals that the nurses at this surgery center do recognize the importance of handoff report, yet they are not implementing it, and for this reason it is important to overcome the conformity of the status quo.    The first stage of Lewin's model is known as "Unfreezing" which involves increasing forces to direct behavior away from the existing situation, and overcoming individual resistance and conformity. This stage is completed by identifying the key stakeholders who will be affected by the change. The second stage in the model is "Change" or, moving to a new level. This is a process of changing the current thought or behavior by equalizing the driving and the resistant forces. Finally, the "Refreezing" stage will be to establish a new way of practicing until it becomes the standard, thereby reducing the possibility of going back to the old behavior. This stage is completed by evaluating the stability of the change and its effectiveness. To evaluate change and guide improvement, the Plan-Do-Study-Act (PDSA) cycle will be utilized (Institute for Healthcare Improvement (IHI), 2017). The prediction for the outcome of the testing will be that within three months the preoperative nurses will be participating in appropriate handoff report 50% of the time. To test for change, a follow-up observation of nurse handoff in the preoperative area will be conducted at three, six and twelve months following implementation of the new protocol. A post implementation survey of nurse satisfaction with the new protocol will be administered at three months post implementation. Problems and/or unexpected observations will be noted, assessed for RCA, and compared to predictions of the results. Change will be modified as needed and re-tested in the same cycle until the final goal is met. Once the goal has been met on the preoperative unit, the protocol will be tested more broadly with the other surgery departments (IHI, 2017).

Data Source

    This small, busy surgical facility holds three procedure rooms for gastroenterology (GI) patients and three main operating rooms. On average, it performs about 750 elective procedures and surgeries per month. Cases are done primarily on healthy patients who have an American Society of Anesthesiology (ASA) category rating of I-III. The highest number of cases that are performed are cataract surgery, steroid epidural injections, GI cancer screening, otolaryngology, orthopedic surgeries, and general surgery. The ages of patients range from two years old up to ninety years old, the majority of patients are forty to seventy years of age. Procedures and surgeries are performed Monday through Friday, with a daily census that varies anywhere from twenty to seventy patients. Based on net reporter scores, ninety one percent of patients would recommend the surgery center to others. The nurses who participated in the Likert survey have a mean average of 27.5 years in nursing and a mean of ten years working at this facility. Of the 15 who participated, 11 nurses hold an Associate's degree in Nursing and three nurses hold a Bachelor's degree in Nursing.

   The process assessed was focused on the preoperative unit. Qualitative data included recorded notes from staff observations and interviews. Nurses were observed for technique in handoff report. It was observed that the unit nurses vary significantly in their method of handoff report and that at times, no report was given at all in which case the receiving nurse would quickly review details of the patient chart that they considered pertinent, and speak with the patient prior to transfer between units. Due to the number of transitions that occur between preoperative, intraoperative and postoperative areas, these phases are considered high risk for errors (Amato-Vealey, Barba, & Vealey, 2008). (See Appendix J for unit process map).

Literature Review

    The articles in the literature review describe the need for improved communication between nurses to improve safety and quality in patient care. A PICO search using Google and CINAHL databases was performed. The terms handoff, bedside handoff, nursing handoff, communication, patient safety, incomplete handoff were used, along with the limits of English language, Academic Journals and the years 2012-2017. Gephardt (2012) performed a systematic review of literature regarding protocol for handoffs. Gephardt discusses the need to improve communication between healthcare providers in order for the quality of healthcare itself to improve. The author notes that research has identified information degradation with ineffective handoffs and relates the recommendation for structured handoffs that include opportunity for questions and answers. The author suggests that there is little evidence supporting any specific protocol for handoffs and that quality research in this area is lacking and finishes by discussing recommendations for improving handoffs. Gregory, Tan, Tilrico, Edwardson & Gamm (2014) summarize a systemic literature review of bedside shift reports in order to relate support for improving quality of care, patient centered care and patient safety. They discuss evidence that supports breakdown in communication during patient handoffs and shows that bedside report is an opportunity to reduce errors. Vlessides (2015) explains research published by clinical investigators at Cooper Medical School of Rowan University examined patient handoffs in the ASC setting. Researchers collected audio recordings of 80 ASC's over six weeks, rating the quality of the handoff, the distractions that occurred and secondary activities during handoff. The study found distractions in 40% of handovers which led to increased handover time, decreased quality and lower satisfaction scores of the handoff reporter. Researchers concluded that nearly 50% of the distractions were avoidable. Kern (2016) discusses a news feature article describing how poor communication attributes to malpractice and lives lost. The study examined over 7,000 cases where information was lost between those that had it and those that needed it. There is no single, exclusive reason but every system of communication between healthcare workers is vulnerable. Reasons for communication lapses is discussed. Starmer et al. (2014) is a prospective study which looks at the implementation of a hand-off program to reduce preventable failures in processes of care and improve communication between healthcare providers. Six months of pre-intervention and six months of post-intervention outcomes were measured. Using best evidence from literature the team developed the I-PASS handoff bundle which includes a mnemonic for handoffs. Implementation of the handoff bundle was associated with a 23% reduction in medical errors and a 30% reduction in preventable adverse events establishing a causal link between implementation of the I-PASS bundle and improved patient safety. Smeulers, Lucas & Vermeulen (2014) review a prospective, pre-post intervention study which was performed in order to identify nursing handover styles associated with improved outcomes. No evidence was found to support conclusions but the authors were able to provide guiding principles based on literature research which include face to face communication, structured documentation, patient involvement and IT technology support.  The study reports that handover practice was often evaluated by self-reported satisfaction rather than level of effectiveness and states that there is an urgent need for high quality studies in this area. Bavare et.al (2015) performed a prospective, interventional study based on the need identified by numerous studies regarding inadequate handoff. They reveal the intervention of a simple pocket card template providing a model to transfer important clinical details in a structured manner. The intervention was well received by clinicians and found to be beneficial. Further research is planned to assess the impact on patient outcomes. Dixon et al. (2015) explain a prospective study performed which led to development of a formalized handoff process after gathering data by observing 60 handoff observations (pre/post), evaluating 52 parameters and surveying providers perspectives of the hand off process. The purpose was to assess the impact of a standardized checklist driven protocol for OR to ICU handoff. A 3-month education and adjustment period was provided before post intervention data was collected. Baseline survey revealed negative responses to perception of handoff. Follow up survey showed improvement of provider perspectives. Time required for key steps in transfer decreased while duration of handoff increased. The conclusion of the study was that change in protocol dramatically improved key steps in transfer of patient care. A prospective study was performed by Achrekar, Murthy, Kanan, Shetty, Nair & Khattry (2016) to evaluate compliance with SBAR utilization. Twenty nurses selected by random sampling were audited at one week and sixteen weeks post introduction to SBAR. Findings indicated that SBAR helped nurses to stay focused and communicate easily during transition of care. The authors state that research regarding communication failures is needed for long-term evaluation of patient outcomes, but that use of SBAR in nursing practice will improve communication between nurses thereby ensuring patient safety.

   The literature highlights the need for more comprehensive understanding of the content and structure of handoff. These articles are used to support the project by showing both the need for, and the outcomes of standardized handoff communication between healthcare workers.

Timeline

   This project began in August of 2017 with a needs assessment and data collection which took place into October of 2017.  The next stage will be to implement nurse education by a PowerPoint presentation which will take place in two separate sessions over two weeks beginning in November of 2017. Short unit based in-services will also take place during November to introduce staff to a new format for handoff report based on the SBAR technique. (see Appendix F). In December of 2017 the new handoff protocol will begin and will continue until March of 2018 at which time the nurses will be observed during handoff, and the process will be assessed for any modifications needed. If changes are made, the PDSA cycle will begin again. If the nurses are showing 50% compliance by March of 2018 we will 75% expect compliance by June of 2018 and 100% compliance by August of 2018 (see Gantt chart, appendix K).

Expected Outcomes

   It is expected that the preoperative nurses will engage in consistent handoff of patient information and responsibility to the receiving nurse in a consistent manner. Sustainability of the handoff process is dependent on leadership initiative and support. Without leadership involvement, it is not expected that the handoff process will continue once it is in action. Tobben (2014) says, " Regardless of the catalyst for the change, it will be your employees who determine whether it successfully achieves its desired outcome" (para. 2). Successful change in an organization depends on managers who support change by their influence, recognizing that their support is crucial to its success (Stagl, 2011).

   Another measurable outcome that could come out of this project would be patient transfer time. Published research indicates that having structure and decreasing distractions allows patients to get into the OR faster which improves efficiency and safety (Vlessides, 2015).

Nursing Relevance

   This project reiterates the importance and need for standardized nursing handoff. The issue of nursing handoff has been discussed in literature thousands of times, over several decades, yet it remains elusive. Joint Commission attempted to address it back in 2006 with their National patient safety goal on handoffs, but it remains a challenge to implement effective strategies that will meet the needs of diverse populations and organizations. Because communication in healthcare settings is so critical to patient outcomes, it is important that it continues to be addressed so that every member of the healthcare team is aware of all information pertinent to each patient in their care. As the literature has suggested, further research is needed to evaluate the effects of nurse handoff on patient's outcomes specifically, but research is ripe with evidence that communication is a primary source of adverse outcomes and sentinel events.

   

 

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