Handoff Change Proposal

An Evidence Based Project

Tyler Parsons

Population: Clinical staff at
Pinnacle Treatment Centers.
Outcome: Increased efficacy
of communication between
clinical staff during handoff
and/or patient transfer of
care that results in safer
clinical practice.
PICO Question
Comparison: The lack of
utilizing standardized
Intervention: Utilization of a
communication (current
facility-wide handoff
method) forms or documents
communication document.
vs. a facility-wide
standardized tool.
Question: Will clinical staff at PTC
experience better communication of
essential patient information, thereby
strengthening the quality of patient
care, with the utilization of a facility-
wide standardized handoff tool as
compared to previous procedures?
Handoff communication occurs
during transfers of care.
Can be nurse to nurse, nurse to provider, etc.
Handoff and Patient Outcomes
Poor handoff can increase the risk of
adverse events.
The Joint Commission (2017) identified a
correlation between poor handoff and sentinel
events.
Current practice at clinical site is
lacking in use of standardized
handoff tool.
Increases inconsistency in communication
between clinical staff.
 The Cochrane Library
University of Cincinnati Library CINAHL Plus
portal was used to locate sources: SAGE Journals

nursing handoff
Keywords: communication at transfer
shift handover

Peer reviewed
Requirements for sources: Published within the last five years
Offered relevant evidence to support project

Evidence-Based Practice
 Level 1 Level 2
Prospective Prospective Cohort
Observational Study Study (Gaffney, Farnan,
(Haque, Østerlund, & Hirsch, Mcginty, & Arora,
Fagan, 2017) 2016)
• Identifies patterns in • Provided template for tool
handoff communication. development.
• Gave detailed post-
• Details variations in implementation assessment
handoff tools commonly data.
used. • Supports the connection
between handoff and patient
outcomes.
Summary of Sources
•Level 3 Level 4
•Prospective Sequential
Intervention Study Conversational
(Zou & Zhang, 2016) Analysis (Abraham et
• Provides evidence of al., 2016)
the effectiveness • Summarizes diversity in
accompanied with handoff communication.
standardized handoff. • Outlines outcomes of
• Identifies structure of handoff tool
handoff tool. implementation.
 Gaps in patient
Lack in Confusion High risk for
No standardized information
consistency of among clinical communication
handoff tool. during transfers
communication. staff. errors.
of care.

Current Practice
 Safer clinical
practice

Standardized
Clear Confident
expectations facility-wide communication
handoff tool

Consistency of
information

Offering an Evidence Based

Solution
References
Abraham, J., Kannampallil, T., Brenner, C., Lopez, K. D., Almoosa, K. F., Patel, V. L., & Patel, B. (2016).
Characterizing the structure and content of nurse handoffs: A sequential conversational analysis
approach. Journal of Biomedical Informatics, 59, 76-88. doi:10.1016/j.jbi.2015.11.009
Gaffney, S., Farnan, J. M., Hirsch, K., McGinty, M., & Arora, V. M. (2016). The modified, multi-patient
observed simulated handoff experience (M-OSHE): Assessment and feedback for entering residents on
handoff performance. Journal of General Internal Medicine, 31(4), 438-441. doi:
http://dx.doi.org/10.1007/s11606-016-3591-8
Haque, S. N., Østerlund, C. S., & Fagan, L. M. (2017). What's ideal? A case study exploring handoff routines in
practice. Journal of Biomedical Informatics, 65, 159-167. doi:10.1016/j.jbi.2016.12.003
The Joint Commission. (2017). Inadequate hand-off communication. Sentinel Event Alert, (58), 1-6. Retrieved
February 6, 2019, from
https://www.jointcommission.org/assets/1/18/SEA_58_Hand_off_Comms_9_6_17_FINAL_(1).pdf
Zou, X., & Zhang, Y. (2016). Rates of nursing errors and handoffs-related errors in a medical unit following
implementation of a standardized nursing handoff form. Journal of Nursing Care Quality, 31 (1), 61-67.
doi:10.1097/ncq.0000000000000133