Author(s): Kimberly Gray, RN, MSN, CPHQ, CLSSBB
Director Quality Safety and Regulatory Services
Trinity Health Ann Arbor

Kimberly Gray serves as the Director of Quality, Safety and Regulatory services for Trinity Health in Ann Arbor, Chelsea and Howell, MI. This topic is important to our zero harm high reliability journey. Kim is a former hospital and university educator. She is a member of NAHQ, has received her CPHQ and is black belt certified.

Competency Domain: Patient Safety

Description: This session will review the DMAIC process and tools used to improve handoff communication between departments, with transportation services and from the Emergency Department to inpatient nursing units.Problem:Patient handoffs are a well-known time of risk. A handoff contains: critical patient information, clear changes in responsibility and the ability to ask questions. Aggregated incident reporting data in our hospital showed failures in handoff communication contributed to some patient harm events. We wished to reduce handoff related harm.Measurement:CY 2021-2022 aggregated incident reports showed that there were 147 handoff related communication failures, some which led to, or nearly caused, harm. Understanding the root causes of these failures required gemba observations with transportation services, root cause analysis and mapping patient transfers and handoff processes within our organization.Analysis:Statistical analysis was not completed however a taskforce comprised of nursing leadership, quality, risk/ safety and transportation services interviewed staff members, went to the gemba in various departments such as the ED and MRI and observed the paper handoff process, reviewed literature best practices, process mapped and brainstormed potential solutions.Implementation:Our paper handoff tool was not seen as value-added- leading to time and paper waste. We implemented a group secure chat texting process, retrievable in the patient's record and distributed standard work critical information badges. Other organizations that have secure chat features could consider a similar approach.Results/DiscussionSince June 2023 we have had only 15 handoff incident reports. Small tests of change, standard work, strong change management and having a nursing director own and advocate for this change was critical to its success. We continue to meet monthly and retrospectively audit admissions for handoff requirements.

Evaluation: Complete Poster Evaluation