NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

[Slide 1] Hi, and welcome to all! I am _____. Today, I will talk about a serious safety issue in medical care: patient handoff failures in the emergency department (ED). This in-service session aims to provide staff with resources and strategies for effective patient handovers, enhancing communication to increase patient safety and improve medical outcomes.

Part 1: Agenda and Outcomes

Agenda

[Slide 2] The purpose of this session is to resolve the critical concern of patient handoffs in the ED. The primary focus is enhancing nurses’ proficiency to reduce inadequate patient handoffs and improving patient safety. Patient handoff errors pose a significant concern in healthcare facilities. Faults during patient handoffs cause injury, a lower standard of care, prolonged hospitalization, raised expenses, and death (Nawawi & Ibrahim, 2024). The in-service session focuses on offering nursing personnel the tools and abilities to ensure proper patient handoff and assistance while avoiding difficulties and reducing hospital stays.

Attendees will learn evidence-based solutions for reducing errors during patient transitions, including the SBAR (Situation, Background, Assessment, Recommendation) tool and bedside handoff protocols. An adverse event related to a septic patient underlined the need to improve nursing staff abilities for proper patient handoffs. The incident occurred as the exiting nurse did not effectively communicate the serious state of a septic patient because important details were ignored, and documentation remained poor, causing treatment delays.

Goals

[Slide 3] Three specific goals are established to address the patient safety issue and to conduct the safety initiative. These goals are:

Goal 1: Discuss the factors leading to patient handoff errors in the ED of a hospital

We will assess the key reasons for inadequate patient handoffs in the ED. According to facility data and recent evidence, the main factors are insufficient educational opportunities, inadequate time for handoffs, delays or interruptions of handoffs, a lack of standardization of handoff processes, system insufficiency, and staff shortage. Poor communication during handoffs accounts for approximately 22.1% of adverse outcomes related to nurses’ care (Kim et al., 2021). 

Goal 2: Examine evidence-based methods for avoiding mistakes in patient handoff

The session will examine effective methods for proper patient handoffs in the ED, including adopting the SBAR tool to address communication issues, implementing the bedside handoff protocol, and utilizing the Electronic Health Record (EHR) system for patient information transfer. Approaches such as establishing a standard communication protocol, offering standardized tools, and prioritizing information precision enhance the exchange of patient information, efficiency, and productivity (Nawawi & Ibrahim, 2024). 

Goal 3: Determine the importance of avoiding mistakes in patient handoffs and practical abilities to execute the safety enhancement program

We will discuss the significance and necessity of addressing the patient safety concern to avoid its implications. It is vital to resolve the issue as errors in patient handoffs cause injury, a lower standard of therapy, prolonged length, higher expenses, and death (Nawawi & Ibrahim, 2024). The training session will conclude with a presentation of applicable skills that will enable staff to implement the safety enhancement plan in their daily practices. Attending this training will enhance their ability to identify risks, leading to the implementation of measures for proper patient information exchange during shifts and improving patient safety.

Outcomes 

[Slide 4] The anticipated outcomes of this in-service session are: 

• Recognizing the root causes of poor patient handoff in the ED will improve outcomes by allowing personnel to identify flaws in their current processes and client service areas. Nurses will develop better risk analysis skills, providing a foundation for adopting interventions to reduce errors and quickly transmit patient condition information and proper documentation for better patient security. 
• The care staff will be educated on proven practices that have resulted in fewer handoff errors and lower healthcare costs in medical settings. This will instill confidence in the personnel, continuously adopting these avoidance strategies and providing the facility with standardized, efficient communication and handoff practices. These strategies will enhance the exchange of patient information, efficiency, and productivity (Nawawi & Ibrahim, 2024).
• This in-service training will help employees acquire and apply novel skills daily, thereby reducing handoff errors and mishaps. The increased staff readiness will lead to improved standards of care and medical outcomes. Nawawi and Ibrahim (2024) claimed that training or awareness is vital for handoff workers to avert unfavorable occurrences in healthcare caused by inexperienced personnel. Regular training enhances nursing abilities and trust, reducing communication difficulties and mistakes.

Part 2: Safety Improvement Plan

Overview of the Patient Handoff Issue and the Need to Address the Issue

[Slide 5] Patient handoff inefficiency and inaccuracy in the ED, which can cause adverse incidents, is a current issue impacting patient safety and organizational performance.  Errors in patient handoffs have severe implications. It leads to patient injury, a lower standard of care, prolonged hospital stays, increased expenses, and even death (Nawawi & Ibrahim, 2024). The cases of inadequate patient handoffs arose from preventable concerns, including communication issues, staff shortages, a lack of standardization in handoff processes, and system insufficiencies.

Poor handoffs cause around 40.2% of negative outcomes, including clinical mistakes and patient fatalities. Inadequate communication in handoffs accounts for approximately 22.1% of adverse outcomes related to nursing care (Kim et al., 2021). Miscommunication during patient transfers is estimated to account for 80.1% of all medical mishaps. In the United States, improper interaction contributes to an average annual expense of $12.1 billion (Janagama et al., 2020). The evidence revealed the immediate necessity of addressing the issue of poor patient handoffs, as they jeopardize patient safety and affect care standards in medical settings.

Process for Safety Improvement 

[Slide 6] An established and well-organized safety advancement plan is essential for enhancing handoff efficacy and accuracy, improving patient outcomes. In the first step, adopting the SBAR approach as a standard communication protocol addresses communication concerns that lead to errors in patient handoffs. SBAR provides a structured framework for medical professionals to maintain clear and consistent communication, conveying patient vital information while minimizing the risk of misconceptions and information gaps (Kay et al., 2022). In the second step, the organization will implement preventive measures, such as improving surveillance systems and refining alert management methods. These efforts will reduce the risks of such adverse events.

In the third step, the organization will utilize proven tools, such as EHR with handoff templates and the Electronic Nursing Handover System (ENHS), to implement immediate system updates without requiring memory reports. Tataei et al. (2023) stated that these systems provide precise data for an organized handover, enhancing the standard of clinical details, reducing handover duration, and improving communication and client satisfaction. The last step is offering staff training to improve the handoff practices and compliance with standard handoff protocols. Handoff workers must be trained to avoid unfavorable patient care incidents caused by less skilled personnel. Regular training enhances nursing staff’s abilities and trust, reducing communication concerns (Nawawi & Ibrahim, 2024). To sustain patient security and treatment standards, it is crucial to reduce adverse events due to improper patient handoffs or transfers of insufficient patient details.

Implications for Poor Patient Handoff and Its Importance for the Medical Organization

[Slide 7] It is crucial for the facility to resolve the existing issue of poor patient handoffs in the ED, where communication failures during transitions lead to preventable medical errors, delayed treatment, and increased healthcare costs. Poor communication contributes to an average annual expense of $12.1 billion (Janagama et al., 2020). Patient harm, length of hospital stays, and legal liability are all issues that poor handoffs contribute to harming the hospital’s safety ratings, reputation, and financial performance. In addition, inefficient handoffs contribute to staff frustration, burnout, and workflow disruptions, leading to further reductions in care quality. Standardizing handoff protocols will enable the organization to reduce errors that incur financial costs, foster interdisciplinary teamwork, and ensure rigorous adherence to accreditation standards through established handoff protocols. Adopting these safety efforts enhances care quality, improving employees’ morale through their enhanced skills, which in turn leads to better patient outcomes. 

Part 3: Audience’s Role and Importance

Audience’s Role in Implementing and Driving the Improvement Plan

[Slide 8] The success of the advancement plan for effective patient handoff depends on the participation of all healthcare stakeholders, notably nurses, clinicians, and hospital administrators. Kim et al. (2021) stated that having sufficient nursing staff is crucial for quality improvement, enhancing the standard of care. During shift changes and patient transfers, nurses, physicians, and other healthcare providers must continue to utilize structured communication tools to avoid omitting critical details.

Furthermore, they attend training sessions, provide feedback on workflow issues, and participate in multidisciplinary rounds to reinforce standardized practices. Staff who take ownership of these changes will ensure successful and sustainable handoff accuracy and patient safety improvements by embedding the processes into daily operations. Hospital managers play a vital role, as they are involved in integrating standard handoff protocols and providing resources such as electronic handoff tools and staff training programs. Their assistance enables nurses to invest time and have the infrastructure to make safe and effective handoffs. 

Audience Critical for Plan’s Success

[Slide 9] The audience, including nursing staff, is the frontline implementers of the safety enhancement plan, so involving them in its success is critical. They are involved in daily handoff practices, and their perspective towards protocol adherence is crucial to reduce communication errors. Without the buy-in of administrators and medical staff, even the best-designed systems, such as SBAR and tools like EHR and ENHS, fail to address patient handoff inefficiencies. Their effective adoption of these systems can provide precise data for an organized handover, enhancing the standard of clinical details, reducing handover duration, and improving communication and patient satisfaction (Tataei et al., 2023). Finally, staff insights into difficulties like insufficient time, workflow inefficiency, and these processes being real-world and sustainable help refine processes. It fosters a culture in which all stakeholders take responsibility for patient safety, reinforcing best practices to enhance outcomes.

Benefits of Embracing Their Role

[Slide 10] Embracing their role in the improvement plan will reduce their stress, reduce errors, and create smoother workflows for themselves. Structured handoff tools, such as SBAR and EHR templates, simplify, expedite, and enhance the accuracy of the handoff process. Nurses, through SBAR, will be able to maintain clear and consistent communication, conveying patient vital information while minimizing the risk of misconceptions and information gaps (Kay et al., 2022).

As a result, patient outcomes are better, callbacks for clarification are fewer, and healthcare providers suffer less burnout due to chaotic handoffs. Furthermore, regular training will also enhance staff confidence in their skills, contributing to improved job satisfaction. Nawawi and Ibrahim (2024) stated that regular training enhances nurses’ abilities and trust, reducing communication difficulties and mistakes. These improvements over time can result in better team morale, fewer adverse events, and a safer safety culture.

Part 4: New Process and Skills Practice

New Processes and Skills

[Slide 11] This safety advancement plan for improving patient handoff accuracy involves novel practices, such as adopting SBAR communication tools. This practice will enable medical staff to exchange patient critical condition information efficiently and accurately, without any misconceptions (Kay et al., 2022). Using the SBAR framework, nurses will coordinate handoffs by exchanging information about the patient’s condition through the elements of Situation, Background, Assessment, and Recommendation, ensuring continuity of care during shift changes.

Another novel practice is the adoption of an EHR with a handoff template and ENHS to streamline patient information documentation and prevent omissions. A standard EHR-incorporated handoff report helps staff improve the success and efficacy of patient handoffs through its organized, uniform format, which encourages the current and pertinent exchange of patient data, decreases errors, and optimizes verbal exchanges. Handoff uniformity can facilitate safe and outstanding care (Abraham et al., 2024). Applying these practices will support overcoming issues related to patient handoff in the ED, promoting effective transfer of critical information about patient condition during staff shift change, and boosting outcomes.

Practical Activity 

[Slide 12] A simulation-based activity will be developed to enhance nurses’ skills and ensure that new practices are efficiently adopted. Nawawi and Ibrahim (2024) asserted that simulation-based instruction effectively enhances handoff proficiency and strengthens nurses’ trust and communication skills. Participants will perform a simulation-based activity in groups. Participants will role-play hand-offs with a simulated patient, a 35-year-old patient admitted for sepsis care.

Using the SBAR tool, each group has two minutes to help hand off the patient’s condition, history, assessment findings, and recommendations for immediate care. Distractions are introduced to simulate a real-world environment. Then, the participants receive feedback from the facilitators about the gaps and strengths in their communication and discuss how to clarify and reduce the mistakes. This simulation activity highlights the importance of a structured communication tool like SBAR in increasing patient safety during care transitions.

Collaborative Question and Answer (Q/A) Activity

This exercise will involve a Q/A session to include nurses and promote the talents of successful patient handoff methods. Questions such as “How will you ensure proper patient handoff during shift change?” will be asked. This question inspires nurses to ponder various methods, such as SBAR, to ensure that all critical information regarding the patient’s condition is clearly transferred to the other staff, avoiding misunderstanding.

Another query is “How can you validate the patient details during transition?” The inquiry stimulates contestants to discuss efficient tools, such as EHR-incorporated handoff reports and ENHS, which help nurses improve patient handoffs through their organized, uniform format. This format encourages the current and pertinent exchange of patient data, decreases errors, and optimizes verbal exchanges.  This Q&A activity facilitates brainstorming, allowing individuals to share their ideas and generate analytical learning, enabling personnel to adopt efficient handoff practices and enhance patient safety.

Part 5: Soliciting Feedback

[Slide 13] Effective feedback approaches will be used to acquire feedback regarding the plan for improving patient handoff practices. First, survey questionnaires will be retained anonymous and completed after the in-service session so that the participants can rate the comprehensiveness and efficacy of the handoff-related tools and practices like SBAR. Audience will be provided an open-ended inquiry feedback document in which employees can express their insights and views about new practices and propose realistic revisions. They can offer input regarding activities and challenges while executing the patient handoff methods.  Maassen et al. (2024), asserted that evaluating open-ended questions enables adjustments that are consistent with staff’s experiences and needs. Lastly, a feedback appraisal of the obtained facts will be conducted to identify trends and areas that require adjustment to enhance practices. 

Conclusion

[Slide 14] Overcoming inefficiencies in patient handoffs in the ED is vital to ensure patient safety. This in-service training will enhance nurses’ skills and knowledge regarding the risks of patient handoff errors and equip them with best practices to improve communication during handoffs. Adopting novel practices and tools like SBAR, EHR, and ENHS addresses communication difficulties and streamlines the patient handoff process during staff shift change. Stakeholders’ efforts ensure the success of quality advancement efforts for precise patient information exchange during transition.

References

Abraham, J., King, C. R., Pedamallu, L., Light, M., & Henrichs, B. (2024). Effect of standardized EHR-integrated handoff report on intraoperative communication outcomes. Journal of the American Medical Informatics Association, 31(10), 2356–2368. https://doi.org/10.1093/jamia/ocae204

Janagama, S. R., Strehlow, M., Gimkala, A., Rao, G. V. R., Matheson, L., Mahadevan, S., & Newberry, J. A. (2020). Critical communication: A cross-sectional study of signout at the prehospital and hospital interface. Cureus, 12(2), e7114. https://doi.org/10.7759/cureus.7114

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Kay, S., Unroe, K. T., Lieb, K. M., Kaehr, E. W., Blackburn, J., Stump, T. E., Evans, R., Klepfer, S., & Carnahan, J. L. (2022). Improving communication in nursing homes using plan-do-study-act cycles of an SBAR training program. Journal of Applied Gerontology, 42(2), 194–204. https://doi.org/10.1177/07334648221131469

Kim, J. H., Lee, J. L., & Kim, E. M. (2021). Patient safety culture and handoff evaluation of nurses in small and medium-sized hospitals. International Journal of Nursing Sciences, 8(1), 58–64. https://doi.org/10.1016/j.ijnss.2020.12.007

Maassen, S. M., Bentvelzen, L. S. V., Marie, A., Vermeulen, H., & Oostveen, V. (2024). Systematic RADaR analysis of responses to the open-ended question in the culture of care barometer survey of a Dutch hospital. British Medical Journal Open, 14(4), e082418. https://doi.org/10.1136/bmjopen-2023-082418

Nawawi, M. H. M., & Ibrahim, M. I. (2024). Nurses’ perceptions of patient handoffs and predictors of patient handoff perceptions in tertiary care hospitals in Kelantan, Malaysia: A cross-sectional study. British Medical Journal Open, 14(8), e087612. https://doi.org/10.1136/bmjopen-2024-087612

Tataei, A., Rahimi, B., Afshar, H. L., Alinejad, V., Jafarizadeh, H., & Parizad, N. (2023). The effects of electronic nursing handover on patient safety in general (non-COVID-19) and COVID-19 intensive care units: A quasi-experimental study. BioMed Central Health Services Research, 23(1), 527. https://doi.org/10.1186/s12913-023-09502-8 

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

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