Standardizing Patient Handoff Communication Case Study

Strategic Plan for Change: Standardizing Patient Handoff Communication
Patient handoff is a challenge in any healthcare organization. Inadequate handoffs jeopardize patient safety and quality of care (Lim & Pajarillo, 2016). The Joint Commission on Accreditation of Healthcare Organizations (2012) reports an estimated 80% of serious medical errors involve miscommunication at patient handoff. This is important to all healthcare organizations and providers because our fundamental ethical principle of do no harm. We have an ethical obligation to make healthcare safer for patients. Blouin (2011) reports that some root causes for handoff failures are a lack of standardization and differing expectations between sender and receiver. The Emergency

SWOT analysis (identification of strengths, weaknesses, opportunities, and threats) is the most commonly used tool by healthcare organizations for strategic planning (Marquis & Huston, 2015b). The strengths in this situation are the overall patient satisfaction scores for the department and the desire of the staff to provide excellent patient care. The weakness is change of shift can be hectic, and handoff report is inconsistent. The opportunities are to improve patient flow and transitions between caregivers. The threat is the department has recently enacted bedside report after a failed attempt a few years prior due to staff resistance.
The hospital has the following mission statement: “Improve the health of the people and communities we serve” and the vision is “To provide the best outcome, every patient, every time” (UnityPoint Des Moines, 2016). Marquis and Huston (2015b) report that a vision statement is a description of what a group wants to accomplish. Creating a nursing procedure for the standardization of nursing handoff will improve safety and quality of care for the patients. This is in direct alignment with the mission and the vision of the

The knowledge stage occurs when there is an awareness and rationale for the initiative. The persuasion stage is when the staff develops an opinion about the practice. This stage is important to identify champions of the project to help promote the diffusion (Fabry, 2015). The next step is the decision stage. This is when staff will start to accept or reject the standardized framework for patient handoff. The fourth step is the implementation stage. It is important to decide if modifications need to happen. The final stage is confirmation where the adopters need support and reinforcement (Fabry, 2015). This stage is especially important given the fact that there was a failed attempt at instituting bedside handoff communication a few years prior. The manager-leader will need to remain involved with this project to assure the standardized tool becomes the norm.
Change will be implemented by a collaborative process that involves stakeholders. Marquis and Huston (2015a) recommend involving those affected by change whenever possible. The unit manager will ask for interested staff to form an ad hoc committee with the unit based educator identified as the leader. This group will initially meet every one to two weeks in the medical library so they can elicit help from the medical librarian to identify and develop the best handoff