Quality Improvement Student Project Proposal: Improving Hand

QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL: IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL HOSPTITAL’S EMERGENCY DEPARTMENT TMIT Student Projects QuickStart Package

Setting: Emergency departments are “high-risk” contexts; they are overcrowded and overburdened, which can lead to treatment delays, patients leaving without being seen by a clinician, and inadequate patient hand-offs during changing shifts and transfers to different hospital services (Apker et al., 2007). This project will focus on the Emergency Departments in county hospitals, specifically San Francisco General Hospital. SFGH has the only Trauma Center (Level 1) available for the over 1.5 million people living and working in San Francisco County (SFGH website). Health Care Service: This paper will focus on intershift transfers, the process of transferring a patient between two providers at the end of a shift, which can pose a major challenge in a busy emergency department setting. Problem: According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), poor communication between providers is the root cause of most sentinel events, medical mistakes, and ‘‘near misses.'' Furthermore, a recent survey of 264 emergency department physicians noted that 30% of respondents reported an adverse event or near miss related to ED handoffs (Horwitz, 2008). A similar survey notes that 73.5% of hand-offs occur in a common area within the ED, 89.5% of respondents stated that there was no uniform written policy regarding patient sign-out, and 50.3% of those surveyed reported that physicians sign out 2 patient details verbally only (Sinha et al., 2007). At SFGH, handoffs occur in the middle of the ED hallway, usually next to a patient’s gurney. Sign-out is dependent on the Attending and Residents on a particular shift; thus, it is non-uniform, and hand-offs are strictly verbal. Barriers to Quality: In a 2005 article in Academic Medicine, four major barriers to effective handoffs were identified: (1) the physical setting, (2) the social setting, and (3) communication barriers. Most of these barriers are present during intershift transfers at SFGH. The physical setting is usually in a hallway, next to a whiteboard, never in private. Presentations are frequently interrupted, and background noise is intense from the chaos of an overcrowded emergency room. Attendings frequently communicate with each other and assume that the resident can hear them. Solet et al. suggests that Residents are unlikely to ask questions during a handoff if the information is coming from an Attending physician. All transfers are verbal, none are standardized, and time pressures are well known, since sign-out involves all working physicians in the ED at one time.

Paper For Above instruction

The proposed quality improvement project at San Francisco General Hospital’s Emergency Department aims to address critical issues related to patient hand-offs, with a focus on enhancing communication clarity, standardization, and overall patient safety during intershift transfers. Recognizing that ineffective handoff communication contributes significantly to adverse events and medical errors, the initiative seeks to implement a structured, standardized handoff protocol tailored to the hectic environment of an ED.

The primary intervention involves the adoption of the SBAR (Situation, Background, Assessment, Recommendation) communication tool, supported by a Plan-Do-Study-Act (PDSA) cycle methodology. This approach facilitates incremental testing and refinement of the handoff process before organization-wide implementation. The process will initially involve a small team of early adopters—select residents and attendings—who will trial the SBAR format using tangible tools such as index cards or checklists to guide verbal exchanges. These early efforts will focus on reducing noise, minimizing interruptions, and encouraging questions during handoffs. Feedback collected from these initial cycles will inform necessary adjustments, paving the way for broader adoption.

Building upon these preliminary efforts, the project will leverage opinion leaders, such as the Chief Resident, to influence wider acceptance and facilitate training sessions. As familiarity and confidence grow, more staff will be engaged in subsequent PDSA cycles aiming for 100% compliance with the standardized SBAR protocol within an 18-month timeframe. Provider satisfaction, perceived time efficiency, and adherence to the protocol will serve as key metrics to assess progress.

Potential barriers include resistance from physicians accustomed to traditional verbal handoffs, concerns over increased time during shift changes, and challenges in adapting the protocol to the physical and social environment of SFGH’s ED. To mitigate these, active engagement of leadership, ongoing education, and iterative feedback loops will be pivotal. Emphasizing the alignment of the intervention with national patient safety goals, such as those outlined by the Joint Commission, will also support buy-in.

The intervention aligns with the Institute of Medicine’s (IOM) ten simple rules for healthcare improvement, specifically fostering cooperation and communication among clinicians to improve patient safety and care continuity. The cost of implementing SBAR and PDSA cycles is minimal, mainly involving staff training and development of communication materials. The projected outcome is a safer, more reliable handoff process that enhances patient safety, reduces medical errors, and improves staff satisfaction. Continuous monitoring and iterative refinement of the process will ensure sustainability and alignment with broader quality and safety objectives within the hospital setting.