1 QQUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL: IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL HOSPTITAL’S EMERGENCY DEPARTMENT TMIT Student Projects QuickStart Package ™ 1. BACKGROUND Setting: Emergency departments are “high-risk” contexts; they are over-crowded 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. 2. THE INTERVENTION The Institute for Health Care Improvement (IHI) lays out several steps for conducting a quality improvement ...

1. 1
QQUALITY IMPROVEMENT STUDENT PROJECT
PROPOSAL:
IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL
HOSPTITAL’S EMERGENCY DEPARTMENT
TMIT Student Projects QuickStart Package ™
1. BACKGROUND
Setting: Emergency departments are “high-risk” contexts; they
are over-crowded 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

2. (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

3. 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

4. involves all working physicians
in the ED at one time.
2. THE INTERVENTION
The Institute for Health Care Improvement (IHI) lays out
several steps for conducting a quality
improvement project. First, an organization needs to explicitly
state what they are trying to
accomplish by setting “time specific and measurable aims” (IHI
website). Next, an organization
needs to establish measures that will indicate whether the
improvement works. Changes that
result in an improvement need to be identified and then tested in
a Plan-Do-Study-Act (PDSA)
cycle. Specifically, the change needs to be planned, tried,
studied, and then members must act on
what they have learned (IHI website). PDSA cycles should start
out in a small group before
being tried in a large institutional setting. Finally, the changes
should be made throughout the
institution.
3

5. Most projects that use rapid PDSA cycles to address issues with
patient handoffs
measured their compliance with a standardized communication
method. Programs such as the
Five Ps (Patient, Plan, Purpose, Problems, Precautions), I PASS
the BATON, or SBAR, are all
acronyms for a standardized, tested procedure to ensure
compliance with the Joint Commission
requirements (Runy, 2008). Such methods may standardize the
handoff process, but may not be
considered the most efficient tool by providers; therefore,
provider satisfaction is a key
component for compliance and implementation (Wilson, 2007).
Process defect: This project will attempt to address non-uniform
patient handoffs at the SFGH
ED by using rapid PDSA cycles to implement the SBAR handoff
technique:
- S-ituation: complaint, diagnosis, treatment plan, and patient’s
wants and needs
- B-ackground: vital signs, mental and code status, list of
medications and lab results
- A-ssessment: current providers assessment of the situation

6. - R-ecommendation: pending labs, what needs to be done
(H&HN, 2008)
Aim (Objective): to improve patient safety, content reliability,
and peer satisfaction with SFGH
ED handoffs by having 100% compliance of the SBAR
standardized protocol within 18 months
(adapted from Owens et al., 2008)
3. STRATEGY FOR IMPLEMENTATION
The first step of this implementation strategy will be to identify
the early adopters and process
owners. A small team, perhaps of one attending and two
residents that are passionate about this
project need to be identified and initiate the first PDSA cycle
using the SBAR format for patient
handoffs. In this small group, they can work out their pit-falls,
and adapt the SBAR technique to
the physical setting and social setting at SFGH. This group may
wish to develop an index card
with an SBAR template to improve communication. The first
PDSA cycle may look something
like this:

7. 4
- Plan—develop a strategy to reduce noise and distractions, use
SBAR (perhaps with an
index card that can be passed on), and have opportunity to ask
questions.
- Do—early adopters need to try out the process during two
changes of shift.
- Study—evaluate satisfaction, review pitfalls, was it easy to
comply?
- Act—Implement changes during next two changes of shift.
Next, this group will need to identify opinion leaders withi n the
organization, perhaps the Chief
Resident, to help convince the early majority that this technique
will improve patient safety and
save time and effort during changes of shift. The early adopters
may want to hold a training to
convince this larger group. Next, this larger group will initiate
its own PDSA cycle, until 100%
compliance with the SBAR protocol is achieved.
Measures: (a) compliance with the SBAR format, via an “all or
none” metric, (2) provider
satisfaction via survey, which will include questions on
perceptions of time saving.

8. Barriers to change: The major barriers to change will be from
opinion leaders within the SFGH
ED that want to protect the status quo. Some Attending and
Resident physicians may be wary of
a new technique for fear that it may add to the amount of time it
takes at the change of shift.
Second, most of these physicians have “always signed-out this
way and have never had a
problem.” Once the early adopter group has worked out many
of the kinks in implementation,
leadership will play a key role for further adoption of this
project. Leaders may take note of the
Joint Commission’s recommendation on handoffs (JCAHO,
2006), and support this project, and
help nudge the late adopters along. However, in the long run,
provider satisfaction of the
protocol, including provider’s perceptions of saving time, will
dictate adherence, so even late
adopters need to have input during PDSA cycles.
5

9. Simple Rules: The landmark IOM report Crossing the Quality
Chasm identified 10 simple rules
to help redesign health care processes (IOM, 2001). This
quality improvement project is in
accordance with rule ten: cooperation among clinicians.
Clinicians should “actively collaborate
and communicate to ensure and appropriate exchange of
information and coordination of care.”
Standardizing patient handoffs in a busy emergency department
setting is crucial to patient safety
and helps place patients needs first; this change manifests this
simple rule.
Cost implications: This process change does not require any
additional costs.
REFERENCE
Apker et al. (2007) Communicating in the “gray zone”:
perceptions about emergency physician-
hospitalist handoffs and patient safety. Aca Emerg. Med.
14(10), 884-94
Coleman et al. (2004) Lost in Transition: Challenges and

10. Opportunities for Improving the quality
of Transitional Care, Ann Intern Med. 140:533-36.
Horwitz et al. (2008) Dropping the Baton: A qualitative analysis
of failures during the transition
from emergency department to inpatient care. Annals of
Emergency Med. Article in press,
accessed April 21, 2009
Horwitz et al. (2009) Evaluation of an Asynchronous Physician
Voicemail Sign-out for
Emergency Department Admissions. Annals of Emergency
Med. In press, accessed April 21,
2009.
IHI website. Improvement methods-PDSA cycle.
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMetho
ds/HowToImprove/ accessed
April 29, 2009.
Institute of Medicine (IOM). Crossing the Quality Chasm.
Washington, DC: National Academy
Press, 2001.

11. Joint Commission on Accreditation of Healthcare
Organizations. Sentinel event root causes. Jt
Comm Perspect Patient Saf. 2005; 5(7):5–6.
JCAHO. Improving Handoff Communications: Meeting National
Patient Safety Goal 2E. Joint
Perspectives on Patient Safety. 2006; 6(8): 9-15.
Owens et al. (2008) Improvement Report: Improving Resident-
to-Resident Patient Care
Handoffs, IHI.org, accessed April 29, 2009.
6
Runy, Lee Ann (2008) Patient Handoffs, the pitfalls and
solutions of transferring patients safely
from one caregiver to another. H&HN.com, accessed April 29,
2009.
SFGH website; http://sfghed.ucsf.edu/Index.htm, accessed April
21, 2009.
Sinha et al. (2007) Need for standardized sign-out in the

12. emergency department: a survey of
emergency medicine residency and pediatric emergency
medicine fellowship program directors.
Aca Emerg Med.; 14(2) 192-6.
Solet et al. (2005) Lost in Translation: Challenges and
Opportunities in Physician-to-Physician
Communication During Patient Handoffs. Academic Medicine;
Volume 80 - Issue 12 - pp 1094-
1099
Wilson, Mary Jane (2007) A template for Safe and Concise
Handovers, Medsurg Nursing. 16(3);
201-06.
Bookmarks
QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL:
TYPE YOUR SPECIFIC TITLE HERE
Fill-in the details below between the brackets
BACKGROUND
Setting: Here, describe the place that you will focus on for this
proposal and the specific of that place.
[].
Health Care Service:In this section, share the specific health

13. care service that you are proposing a quality improvement for.
[].
Problem:In this section, describe the specific problem you have
found. Be sure to include evidence from sources that support
this is a problem.
[].
Barriers to Quality:Here, share any barriers that exist that
hinder the quality that is needed. Be sure to provide evidence
from sources to support your claims.
[].
THE INTERVENTION
In this section, discuss the intervention or solution you are
proposing to improve the quality of the problem you have
identified. Provide evidence from sources to support your
suggestions.
[].
Here, include the overall process that will be used to implement
the proposed solution.
[].
Aim (Objective):Here, state the objective of the proposed
intervention.
[].
STRATEGY FOR IMPLEMENTATION
Here, identify and describe the steps or the strategy that will be
taken to implement the intervention.
[].
Measures: In this space, share what will be used to measure the
implementation of the intervention or how the results of the
implementation will be measured.

14. [].
Barriers to Change: Here, include a discussion of any barriers
that could get in the way of the proposed change. Include any
evidence from sources that can support your claims.
[].
Simple Rules:Here, include the rule that will be satisfied by
your proposed intervention.
[].
Cost Implications: Here, include any costs associated with the
proposed intervention.
[].
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