Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The quality assurance and performance improvement (QAPI) project in the spotlight this month looked at a pre-op to OR handoff communication.
DEFINE
Effective communication during transitions of care is critical to patient safety. In the pre-operative (pre-op) setting, incomplete or absent handoff communication between healthcare providers increases the risk of errors, including missed allergies, incomplete medical history, and medication-related complications.
A review of current practice in the ASC pre-op department revealed critical safety gaps in face-to-face handoff communication during provider transitions. A trend in near-miss events that could have been prevented with proper face-to-face handoff.
While most handoffs occur, incomplete communication presents a significant risk. By standardizing expectations, improving workflow, and reinforcing accountability, the ASC can achieve ≥ 90% effective face-to-face handoffs, ensuring safer care transitions and improved patient outcomes.
Goal will be met within 60 days.
MEASURE
Data Source:
50 direct observation audits over a 30-day period and 50 chart reviews
Findings
Only 77 out of 100 handoffs were performed
Of the 50 direct observation audits, 18 were incomplete (missing important elements)
ANALYZE
Held a meeting with lead pre-op and OR nurses to narrow down the key contributing factors which were:
- Workflow inefficiencies- staff waiting for availability of pre-op nurses to give report
- Staff feeling rushed/time pressures-Perception of slowing down physician which could affect physician satisfaction
- Communication culture gap-Variable prioritization of handoff importance
IMPROVE
- Staff Education and Engagement
- Staff knowledge/understanding of patient safety risks
- Shared actual adverse events linked to poor handoffs
- Organizational goal of zero patient harm, every handoff is a patient safety event
- Set expectations of culture environment and accountability
- Hand-off communication week where leadership performed direct observation of each hand-off, witness obstacles, and provided immediate feedback
- Email to physicians outlining expectations of staff to perform face-to-face handoff for their patient's safety
- Leadership Rounding for monthly direct observation audits to ensure compliance and continuous improvement
CONTROL
Remeasurement Goal was met at 92%.
184 of 200 (92%) effective handoffs were performed with direct observation audits within a 60-day period.
Obstacles during process improvement
- There was ongoing difficulty with the availability of pre-operative nurses to give reports, as they were frequently engaged in caring for other patients
- Efforts were made to avoid repeatedly interrupting patient care, which contributed to delays in communication
- Additionally, OR nurses would often request reports be given by nurses who were not directly involved in the patient's care
- Additional action item was implementation of charge nurses to give hand-off during breaks, lunches, and peak times
We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. EURP honoree units may use the ASGE Quality Star logo in promotion of their units and enjoy a range of additional benefits. Questions should be directed to eurp@asge.org.