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Part A: PLAN (NURS 711): Michelle Stimson

A. Clearly explain the quality improvement project – what exactly are you planning to do?

At Lansing Community College (LCC), great strides are underway to fully integrate
Quality and Safety Education in Nursing (QSEN) competencies into the nursing curriculum. A
strong emphasis has been placed on the competency of teamwork and collaboration, especially
the use of the SBAR communication tool as a means for conducting verbal handoffs. Although
education on providing verbal handoffs using a vetted and standardized communication tool is
prominent throughout all levels of the nursing program, nursing faculty teaching fourth-level
nursing courses have recognized gaps in the students' ability to provide complete, well-
organized, and concise verbal handoffs.

The current clinical education model requires students to deliver handoffs in a written
format. Written handoffs are graded by clinical faculty and feedback is given to students at a
later date. Feedback tends to lose value as the student rarely remembers the details of the
patient's situation or plan of care; identical mistakes tend to be repeated. Similar observations
have been made in the simulation laboratory. Numerous students have been observed delivering
ineffective verbal handoffs while interacting with various simulated members of the healthcare
team (physical therapists, respiratory therapists, and physicians). The handoffs are scattered,
either too lengthy or too short, and often do not provide pertinent information to the situation at
hand. Students at the college have made congruent observations. After a simulation exercise,
20% of 400 student nurses either disagreed or strongly disagreed with the following statement: "I
am more confident in communicating with the interdisciplinary team" (LCC, 2015). This
statement was the lowest scoring item on a twelve question survey demonstrating the need for
further teamwork and collaboration education within the pre-licensure learning environment,
especially as it pertains to conducting verbal handoffs.

Approximately two clinical groups comprising of sixteen students have been chosen to
participate in the quality improvement project. The quality improvement project will include
several interventions. The goal of the quality improvement project is to assist fourth-level student
nurses in mastering the essential skill of delivering effective verbal handoffs in the clinical
setting.

The project will include the following elements:

1. Approximately 16 students will undergo education on best practices in delivering verbal

handoffs, specifically on the proper use of the SBAR communication tool. The education
will occur as a post-conference activity in the clinical setting.
2. While in the clinical setting, students will conduct four verbal handoffs using the SBAR
communication tool. One handoff will occur with a peer, another with the clinical
instructor, and two in the presence of the clinical instructor and assigned patient (four
verbal handoffs in total). The handoffs will occur during four separate weeks.
3. Student progress will be measured via an evaluation tool that will be completed by both
the student and clinical faculty. The evaluation tool will include a self-reflective
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component and will measure the student's ability to deliver a handoff that is concise, well
organized, and pertinent to the patient's clinical situation.
4. Self-efficacy (student confidence) surveys will be administered pre and post intervention.
5. Beside nurses working with student nurses will be updated on the specifics of the quality
improvement project, their role in supporting student growth, and any information needed
on the use of SBAR as a standardized communication tool.

The role of the project leader (Michelle Stimson) will be to a) develop and provide handoff
education to students, beside nurses, and department managers, b) develop confidence surveys
and the evaluation tool, c) assist adjunct faculty in carrying out verbal handoffs, d) analyze the
data, and e) round on the clinical faculty on a weekly basis and address any concerns faculty,
students, beside nurses, and the nurse managers may have.

The required 16 hours of clinical observation will consist of: a) observing verbal handoffs
conducted during bedside shift report, b) interviewing bedside nurses about perceived barriers
towards completing verbal handoffs at the bedside, c) meeting with a clinical nurse educator to
gain understanding on verbal handoff training for newly hired nurses, and d) meet with a CNS to
review the verbal handoff policy and procedure for Sparrow Health System.

B. Provide evidence based support that establishes a need for this project. Also include research
support for effectiveness of the proposed improvement project.

Academic nurse educators are responsible for growing and developing future nurses,
designing curriculum that reflects current healthcare trends and societal needs, and ensuring that
graduates are able to practice in complex, ever-changing environments (National League for
Nursing [NLN], 2012). To Err is Human, initiated sweeping change throughout the healthcare
industry in the domains of quality improvement and safety (Sherwood & Barnsteiner, 2012). The
report, commissioned by the Institute of Medicine (IOM), exposed the dangers of America's
flawed and fragmented healthcare system (Sherwood & Barnsteiner, 2012). Significant flaws
were identified in the domains of teamwork and collaboration; deficient communication
practices were of particular concern.

Relationships between various healthcare professionals have been shown to directly and
indirectly contribute to patient safety (Manojlovich et al., 2014). Adverse patient outcomes are
often the result of deficient communication practices and can result from delays in care,
omissions in treatment, and misunderstandings between caregivers (Abraham, Kannampallil, &
Patel, 2014; Beckett & Kipness, 2009; Horowitz et al., 2013). Reports from The Joint
Commission (TJC) have shown that communication failures are the root cause of approximately
70% of sentinel events and of those events, 75% resulted in death (Beckett & Kipness, 2009).
Effectively engaging in interprofessional relationships and communication practices has been
stymied by the way healthcare professionals are educated (Sherwood & Barnsteiner, 2012).
Nurses and physicians are taught different communication styles; nurses are detailed and
descriptive and physicians use brief statements (Beckett & Kipness, 2009). Using effective
communication practices such as the SBAR communication tool can help diminish
communication gaps between healthcare professionals (Abraham, Kannampallil, & Patel, 2014;
QSEN, n.d.). The SBAR communication tool is a standardized method of communicating;
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information is shared in a concise and structured format. The SBAR acronym stands for
Situation, Background, Assessment, and Recommendation (Sherwood & Barnsteiner, 2012).
This tool can be used for verbal handoffs, when communicating with physicians, during
transitions of care, or any time information needs to be shared (Lomax & White, 2015).

A study in Belgium sought to determine if standardizing verbal handoffs using the SBAR
communication tool could reduce serious adverse events in the acute care setting (De Meester,
Verspuy, Monsieurs, & Van Bogaert, 2013). Nurses were trained to use the SBAR
communication tool when communicating with physicians in the case of a deteriorating patient.
After introducing the SBAR tool, a decrease in unexpected deaths was found. The number of
unexpected deaths decreased from 16 in the pre-intervention period to five in the post-
intervention period. Patient records showed that nurses were better prepared before calling a
physician and scored higher on a perception of communication and collaboration scale in the
post-intervention period.

The QSEN initiative identified the knowledge, skills, and attitudes (KSAs) nurses must
possess in order to provide patient-centered care and work effectively within teams (QSEN,
n.d.). The competency of teamwork and collaboration involves "following communication
practices that minimize risks associated with handoffs among providers and across transitions in
care" and well as "choosing communication styles that diminish the risks associated with
authority gradients among team members" (QSEN, n.d.). Effective interprofessional
communication, teamwork, and collaboration can prevent suboptimal patient outcomes (Lomax
& White, 2015). The Joint Commission made effective communication practices during
transitions in care a National Patient Safety Goal in 2009 (Lomax & White, 2015). Handoffs are
best delivered using a standardized protocol; the use of the SBAR communication tool is
particularly effective (Lomax & White, 2015). The SBAR communication tool is supported by
several prominent entities including The Joint Commission, QSEN, and the Agency for
Healthcare Research and Quality (AHRQ) (Lomax & White, 2015).

The SBAR communication tool was designed to be used in a verbal format. Kesten
(2011) studied student nurses who were taught to deliver verbal handoffs using the SBAR
communication tool through either didactic or role-play methods. The results of the study
showed that both methods led to improvement, but the group of students receiving hands-on
role-play instruction showed greater improvement. The results were particularly true of the adult
learner. Another study by Foronda et al. (2014) confirmed that introducing the SBAR handoff
technique via hands-on clinical simulation more than doubled student handoff performance. Lee,
Mast, Humbert, and Bagnardi (2016) studied methods for increasing senior-level students'
performance in delivering verbal handoffs. Several teaching strategies were used including a
communication workshop, role-play, high-fidelity simulation, and peer review. Students in the
post-intervention period demonstrated increased self-efficacy scores on confidence surveys. Self-
efficacy in relation to reporting significant findings to another nurse or clinical instructor during
a verbal handoff significantly increased. The authors demonstrated correlations between
increased organization, increased exposure to the verbal handoff process, and increased self-
efficacy.
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Lastly, current practice within the clinical setting includes nurses delivering verbal
handoffs at the patient's bedside; beside shift report (BSR) is considered a best practice
(Costedio, Powers, & Stuart, 2013). Bedside shift report increases patient safety, improves
patient satisfaction scores, and improves handoff accuracy (Costedio, Powers, & Stuart, 2013).
Participating in BSR also promotes patient-centered care. Patient-centered care involves four
core concepts: dignity and respect, information sharing, patient participation, and collaboration
(Sherwood & Barnsteiner, 2012). Verbal handoffs that occur at the bedside allow for information
sharing between caregivers and patients as well as the ability to elicit patient preferences and
values (Costedio, Powers, & Stuart, 2013). In order to keep pace with current societal and
healthcare trends, as well as optimize patient safety, student nurses must master the skill of
delivering verbal handoffs using a vetted and standardized communication tool. Increasing
structured opportunities for students to provide verbal handoffs in the clinical setting will
produce graduate nurses that are adequately prepared to work in the 21st century healthcare
environment.

C. Where will this project take place? Describe the environment/facility/unit etc.

The project will take place in two venues; LCC and the neurological step-down unit (NSDU) at
Sparrow Hospital.

The students involved in the quality improvement project attend Lansing Community
College. Lansing Community College is located in Lansing, Michigan. The college was
established in 1957 as a means for preparing students for emerging technical careers (LCC, n.d.).
The college has received many accolades at both the state and national level and strives to meet
the educational needs of students in the local community (LCC, n.d). The Career Ladder Nursing
Program (CLNP) is housed in the Health & Human Services Building on the downtown campus.
The CLNP is an associate degree nursing program which offers several tracks. The traditional
track is comprised of a two-year plan which admits 128 students each year (LCC, 2016). There
are two non-traditional tracks: second-degree (for students with a bachelor's degree) and
advanced standing (for licensed paramedics, practical nurses, and respiratory therapists) (LCC,
2016). Each non-traditional track admits 32 students a year and takes approximately 15 months
to complete.

The CLNP believes nursing is a profession that offers a unique contribution to the
patient’s health, yet works collaboratively with other healthcare disciplines to optimize the health
of individuals and their identified family within the context of the larger community (LCC,
2016). Advocacy and caring are key features of the curriculum; values such as safety, quality,
patient-centeredness, and teamwork and collaboration are incorporated into course structures,
learning activities, and program outcomes (LCC, 2016). The CLNP is committed to preparing
graduates who can provide safe and effective patient care in complex healthcare systems. The
CLNP is approved by the Michigan Board of Nursing and accredited by the Accreditation
Commission for Education in Nursing (ACEN) (LCC, 2016). Approximately 12 full time and 84
adjunct faculty support the learning needs of the program (L. Pincumbe, personal
communication, May 23rd, 2017).
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The sixteen students involved in the quality improvement project will be enrolled in
nursing courses NURS 280 - Advanced Chronic Nursing Care and NURS 285 – Advanced Acute
Nursing Care. Both courses build on complex acute and chronic health concepts. In the clinical
setting, students will provide care to adults with multi-system, complex health problems in the
acute care setting (LCC, 2016). A sample of course outcomes relevant to the quality
improvement project include (LCC, 2016):

The student will:

1. Utilize proficient verbal, written, and electronic communication skills with patients,
families, and members of the healthcare team.
2. Collaborate with inter-professional teams to provide patient centered care for adults with
complex, emergent, and end-of-life health needs.

The students participating in the quality improvement project will be completing their
clinical education on the NSDU at Sparrow Hospital. Sparrow Health System (SHS), located in
Lansing, Michigan, is Mid-Michigan's largest health system (SHS, n.d.). It is comprised of
several affiliate hospitals and health centers, a Level 1 Trauma Center, regional laboratories,
pharmacies, and rehabilitation and diagnostic facilities (SHS, n.d.). The system's flagship
hospital, Sparrow Hospital, contains 676 licensed beds (SHS, n.d.). Approximately 900
physicians and 2000 registered nurses are on staff (SHS, n.d.). Sparrow Hospital is a major
teaching facility; many healthcare professional are trained via teaching affiliations with
Michigan State University, LCC, and other regional universities and colleges (SHS, n.d.).

Sparrow Health System has received many regional, state, and national honors; Magnet
recognition being one of them (SHS, n.d.). As part of the Magnet designation process, SHS
nurses adopted the Transformational Model of Professional Nursing Practice (TMPNP) (SHS,
2014). The model places the patient at the center surrounded by a practice environment that
empowers the professional nurse. The patient sits at the top of SHS's value structure directly
supported by caregivers who are "empowered and engaged" (SHS, n.d.). Sparrow Health System
values innovation and excellence. A narrative piece of the TMPNP includes the following
statement: "We all keep learning how to prevent, improve and excel" (SHS, 2014). The
Transformational Model for Professional Nursing Practice supports strategies that enhance
effective interdisciplinary teams as a means for maximizing patient outcomes.

The NSDU contains 16 beds and is located on the 10th floor of Sparrow Hospital. The
unit provides specialized care to individuals experiencing neurological disorders and exposure to
traumatic injuries. The unit is staffed by approximately 30 registered nurses, 10 ancillary staff
(nurse technicians and unit secretaries), an assistant manager, and a department manager (A.
Smith, personal communication, June 1st, 2017). The unit is open 24 hours a day, seven days a
week. One a shift-by-shift basis, the unit is staffed by five nurses, two nurse technicians, and one
unit secretary; nurses work 12 hour shifts (A. Smith, personal communication, 2017). Sparrow
Health System is a designated Neurological Center of Excellence and was Michigan's first
certified Comprehensive Stroke Center (SHS, n.d.). Sparrow Hospital is the only verified Level 1
Trauma Center in the Mid-Michigan area (SHS, n.d.).
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D. Who else will be involved in this project? What will their roles be? (Include the agency and
preceptor in this section, and provide an overview of the agency and the preceptor’s
qualifications, title, and contact information).

Several individuals will assist in the planning and implementation of this project
including nursing faculty, nursing administrators, bedside nurses, and a clinical nurse specialist.
Tracy Alberta will serve as the preceptor for this project. Ms. Alberta has her master's degree in
nursing education and is currently employed as a professor of nursing through LCC; she has
served in the role for over ten years (T. Alberta, personal communication, May 23rd, 2017). Over
a 27 year nursing career, Ms. Alberta has practiced as a critical care nurse, nurse administrator,
and a clinical nurse educator (T. Alberta, personal communication, May 23rd, 2017). Ms.
Alberta has an extensive background in working with student nurses in both the didactic and
clinical setting. Ms. Alberta can be reached at by phone at 517-483-9607 or by email at
albertat@star.lcc.edu.

Anita Smith, the clinical nurse specialist (CNS) for Trauma Services at SHS, will also be
assisting with this project. Ms. Smith will be overseeing the clinical observation hours as well as
supporting the educational process for the bedside nurses and nurse managers. Ms. Smith has her
master's degree in nursing education and has been employed as a CNS for three years (A. Smith,
personal communication, June 1st, 2017). Ms. Smith has an extensive background in
perioperative nursing, nursing education, and nursing administration (A. Smith, personal
communication, June 1st, 2017). Ms. Smith has guest lectured at several regional and state
conferences as well as, authored publications in peer-reviewed nursing journals (A. Smith,
personal communication, June 1st, 2017). Ms. Smith can be reached by phone at 517-364-3017
or by email at anita.smith@sparrow.org

Lori Pincumbe, the Director of Nursing at LCC, will be providing administrative support
for the project. Ms. Pincumbe has a master's degree in nursing education. Her role is to provide
access to supplies such as paper and the copy machine, provide release time for Ms. Alberta,
assign clinical instructors to support the project, and keep LCC's relationship with Sparrow
Hospital strong and vibrant. Ms. Pincumbe can be reached by phone at 517-483-1477 or by
email at pincul@star.lcc.edu.

Currently, the leadership team on the NSDU is in a state of flux (A. Smith, personal
communication, June 1st, 2017). Once a leader has been established, the new leader will be
notified of the project and their potential role in supporting the learning needs of the student
nurses on the unit.

Two clinical adjunct faculty will assist with the project implementation. Clinical
assignments have yet to be determined (L. Pincumbe, personal communication, May 23rd,
2017). Adjunct faculty assigned to fourth-level students on the NSDU at Sparrow Hospital will
be selected to assist with the project.

The NSDU unit at Sparrow Hospital employs approximately 30 registered nurses. Since
the unit contains only 16 beds, each nurse working on a day in which students are present will be
assigned a minimum of one student nurse (sometimes 2 or 3). The bedside nurse is responsible
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for supporting the learning needs of the students and providing professional role modeling. The
role of the beside nurse during the project implementation phase will be multifaceted: support the
growth and development of verbal handoffs practices using the SBAR communication tool, role
model effective communication practices, provide support and encouragement to students,
answer pertinent questions regarding interdisciplinary communication, and provide constructive
feedback when handoff practices are witnessed.

E. Complete an assessment of the QSEN graduate level competencies. Consider a minimum of 3

KSAs within the 6 competencies that you will focus on as a part of the overall quality
improvement project. (Note: These should align with your project goals.)

a) Teamwork and Collaboration--Skill: "Use communication practices that minimize risks

associated with handoffs among providers and across transitions of care" (QSEN, 2012, p.
10).

The quality improvement project is based on communication practices that minimize the
risks associated with handoffs: use of the SBAR communication tool, clinical immersion in
conducting verbal handoffs, and conducting verbal handoffs at the patient's bedside.
Education on best handoff practices will be provided to students, faculty, and hospital
personnel as well as role modeled by clinical nursing faculty.

b) Quality Improvement--Skill: "Select and use quality improvement tools to achieve best
possible outcomes" (QSEN, 2012, p. 5).

Many quality improvement tools will be used to achieve the best possible outcomes. A RCA
will be conducted to discern the role of handoff practices in sentinel events. An FMEA will
be used to investigate handoff communication practices on inpatient units and assess the risk
of failure and harm due to system processes. Confidence scales will measure student self-
efficacy in the pre and post intervention period. An evaluation tool will be used to measure
student performance over time. The Plan-Do-Study-Act cycle is supporting the quality
improvement project framework.

c) Teamwork and Collaboration--Attitude: "Appreciate the risks associated with handoffs

among providers and across transitions in care" (QSEN, 2012, p. 10).

An extensive literature review was conducted exploring the risks associated with handoffs.
Several studies demonstrated a link between poor handoff practices and patient harm as well
as, identified gaps in nursing curricula in relation to adequately preparing graduates to
communicate effectively within teams. The evidence was compelling enough to convince
faculty members and the clinical agency partner to appreciate the need for adopting a new
clinical education model that supports evidence-based handoff practices.

d) Quality Improvement--Skill: "Design, implement, and evaluate small tests of change in daily
work (e.g., using an experiential learning method such as Plan-Do-Study-Act) (QSEN, 2012,
p. 6).
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Introducing verbal handoffs into clinical education is considered a relatively small change;
handoffs are only one aspect of the entire clinical model. The quality improvement project
has been designed as a pilot; only two clinical groups comprising of sixteen students will
participate. Using an pilot approach allows the project leader and preceptor to make needed
tweaks and improvements along the way before the change is officially rolled out to a larger
audience. In the end, a pilot approach paired with the PDSA cycle produces a stronger, more
reliable end product.

F. Complete an assessment of the ANA Scope & Standards of Practice for your specialty role.
Identify a minimum of three professional standards that will be met by completion of this
project. (Note: These should align with your project goals.)

a) Standard I: Facilitate Learning:

"Nurse Educators are responsible for creating an environment in classroom, laboratory, and
clinical settings that facilitates student learning and the achievement of desired cognitive,
affective, and psychomotor outcomes" (NLN, 2012, p. 14).

Pertinent subcategories of Standard I include: a) implements a variety of teaching

strategies appropriate to learner needs, desired learner outcomes, content, and context, b)
grounds teaching strategies in educational theory and evidenced-based teaching practices,
c) develops collegial working relationships with students, faculty colleagues, and clinical
agency personnel to promote positive learning environments, d) maintains the
professional practice knowledge base needed to help learners prepare for contemporary
nursing practice, and e) serves as a role model of professional nursing (NLN, 2012, p.
14-15).

b) Standard III: Use Assessment and Evaluation Strategies:

"Nurse educators use a variety of strategies to assess and evaluate student learning in
classroom, laboratory and clinical settings, as well as in all domains of learning" (NLN,
2012, p. 17).

Pertinent subcategories of Standard III include: a) uses a variety of strategies to assess

and evaluate learning in the cognitive, psychomotor, and affective domains, b)
implements evidence-based assessment and evaluation strategies that are appropriate to
the learner and to learning goals, c) uses assessment and evaluation data to enhance the
teaching-learning process, and d) provides timely, constructive, and thoughtful feedback
to learners (NLN, 2012, p. 17).

c) Standard IV: Participate in Curriculum Design and Evaluation of Program Outcomes:

"Nurse educators are responsible for formulating program outcomes and designing curricula
that reflect contemporary healthcare trends and prepare graduates to function effectively in
the healthcare environment" (NLN, 2012, p. 18).
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Pertinent subcategories of Standard IV include: a) ensures that the curriculum reflects

institutional philosophy and mission, current nursing and healthcare trends, and
community and societal needs so as to prepare graduates for practice in a complex,
dynamic, multicultural healthcare environment, b) bases curriculum design and
implementation decisions on sound educational principles, theory and research, c) revises
the curriculum based on assessment of program outcomes, learner needs, and societal and
healthcare trends, d) implements curricular revisions using appropriate change theories
and strategies, and e) creates and maintains community and clinical partnerships that
support educational goals (NLN, 2012, p. 18).

d) Standard V: Functions as Change Agent and Leader:

"Nurse educators function as change agents and leaders to create a preferred future for
nursing education and nursing practice" (NLN, 2012, p. 19).

Pertinent subcategories of Standard V include: a) participates in interdisciplinary efforts

to address healthcare and educational needs locally, regionally, nationally, and
internationally, b) promotes innovative practices in educational environments, and c)
develops leadership skills to shape and implement change (NLN, 2012, p. 19).

G. Complete an RCA or FMEA with key stakeholders and/or peers with an understanding of the
issue you will be addressing. Include a conceptual map as part of your plan. (See Appendix A &
B)

An RCA and FMEA were completed to help identify the cause of a sentinel event that
occurred at Sparrow Hospital in 2016. The event involved an elderly female that had fallen,
sustained a femur fracture, and died unexpectedly 14 days later due to a perforated bowel; the
patient did have a bowel movement at any point during the hospital stay (A. Smith, personal
communication, June 1st, 2017). Both the RCA and FMEA were conducted with key
stakeholders including professors of nursing, the director and CNS of Trauma Services, a
performance improvement specialist, and a bedside nurse. During the RCA, the chronological
sequence of events leading to the outcome were examined; a fishbone diagram helped delineate
the causes of the problem (See Appendix A). Each arm of the diagram was explored using the
"five why's" approach (Sherwood & Barnsteiner, 2012). Four proximate causes were identified:
a) as needed bowel protocol medications were not administered, b) lack of coordination of care
between members of the interdisciplinary team, c) staff exhibited knowledge gaps regarding
constipation and narcotic administration, and d) the electronic health record (EHR) lacked
documentation regarding the patient's bowel patterns. The team indentified many factors
contributing to the proximate causes including a lack of interdisciplinary rounds, poor handoff
practices, lack of training and mentoring for new nurses, high staff turnover rates, heavy
workloads for both physicians and nurses, and no standardized protocols for documenting bowel
movements in the EHR. Also noted by both the CNS and professors of nursing was the gap
between practice expectations and nursing curriculum; student nurses lack exposure to effective
handoff practices. Although many factors led to the sentinel event, not using a standardized
communication tool such as SBAR, nor following best practices for verbal handoffs (BSR and
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interdisciplinary rounds) as well as, gaps in graduate and new nurse training were highlighted.
The RCA echoed the findings of TJC regarding communication failures and sentinel events.

A FMEA was used to evaluate handoff communication practices on the inpatient units
(See Appendix B). The Institute of Healthcare Improvement (IHI) supports the use of FMEAs as
a means to assess risk of failure and harm due to system processes (Sorrentino, 2016). An FMEA
consists of multiple steps including: defining the process, assembling the multidisciplinary team,
mapping out the process, indentifying failure modes and causes, calculating risk priority numbers
(RPN), and evaluating the data to design quality improvement efforts (Sorrentino, 2016).
Handoff practices on inpatient units were analyzed due to the location of the sentinel event.
On inpatient units, handoffs occur in one of three ways: during the admission process, during
shift-to-shift report, or during the transfer to another facility, unit, or procedural area. The
admission handoff was identified as high risk due to the lack of EHR interfacing between
Sparrow Hospital and outlying facilities, patients and family members not having relevant
history and drug information available, and poor adherence to standardized handoff practices
(use of SBAR and face-to-face handoff). As a result, critical information may be omitted and
patients can stuffer harm and/or death due to the over or under prescribing of medications and/or
tests and procedures. The shift-to-shift handoff process was also identified as high risk due to the
lack of RN adherence to BSR practices, poor use of SBAR, not having the EHR open during
handoff, and a lack of patient input. The transfer handoff process was also identified as fraught
with risk. Challenges with EHR interfacing with outlying facilities was one of the highest RPN
scores. Also, ICU transfers typically occur in times of crisis causing multiple key pieces of
information to be omitted; another very high RPN score. Although issues with EHR interfacing
between receiving and transferring facilities received the highest RPN score, nursing curriculum
redesign is not a feasible solution to the problem. What can be addressed via innovative clinical
educational models is the way students are trained to deliver and receive verbal handoffs which
the committee agreed would decrease the harmful effects from the identified failure modes.

H. Identify a change and leadership theory that you will employ during project implementation.
Support.

The quality improvement project will be guided by Lewin's (1951) change management
theory. Lewin's theory is comprised of three phases: unfreezing, changing, and refreezing; the
model was designed to support planned change (Wojciechowski, Pearsall, Murphy, & French,
2016). The unfreezing phase involves challenging the status quo by demonstrating a need for
change (Wojciechowski et al., 2016). A need for change has been demonstrated via faculty
observations, an extensive literature search, and a RCA and FMEA. Effective handoffs practices
promote patient safety; BSR is considered a best practice. Students best master this skill through
clinical immersion where verbal handoffs are conducted using a standardized communication
tool. The new idea or process is introduced in the second stage (Wojciechowski et al., 2016). In
this stage, role modeling, coaching, and training are used to increase stakeholder by-in and offset
the resistance to change. Verbal handoff education will be provided to students, faculty, and
hospital staff. Ongoing coaching and role modeling will come from nursing faculty, the project
leader, and the project preceptor. Data will be collected during this stage. Students will complete
self-efficacy surveys pre and post intervention and be scored on an evaluation tool that will
measure progress over time. The last stage, freezing, involves sustaining the change
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(Wojciechowski et al., 2016). During this stage, retraining and/or reeducation may need to occur.
The project is planned as a pilot, therefore, more employees and stakeholders would need to be
on-boarded in order to finalize the process. Stabilizing the change requires ongoing
administrative support, continued data collection, and adopting open communication practices
(Wojciechowski et al., 2016). Lewin's change management theory partners well with the PDSA
cycle supported by the Lean Systems Approach (Wojciechowski et al., 2016). The PDSA cycle
is the quality improvement model chosen to support the project plan.

Project planning, implementation, and evaluation will be supported by the

transformational leadership theory as described by Burns (1978). Transformational leaders create
work environments that support transparency, honest feedback, and collaboration (Marshall,
2011). Transformational leaders understand it is the follower who makes the leader, however, it
is up to the leader to set the follower up for success (McCallum, 2013). The implementation
phase of this project will require professors of nursing, administrators, clinical staff, and students
working together towards a common goal. Applying transformational leadership principles such
as a shared vision, a team approach towards problem solving, and opportunities for growth will
increase stakeholder buy-in (Marshall, 2011). Including key-stakeholders during the planning
stage will increase the chance of creating a shared vision. During the implementation stage, the
project leader and preceptor will employ transformational leadership principles by supporting
and motivating the team (lead by example, provide encouragement, share faculty and student
observations regarding verbal handoffs, supply needed materials, and have a physical presence
on the units during clinical hours), intervening when appropriate (manage conflict between the
bedside nurses, administrators, and students), and collaborating with clinical faculty (remove
barriers, brainstorm solutions, and provide encouragement and support) (Marshall, 2011).

I. How will you assess or measure whether your improvement project worked? How/will
informatics technology be used?

Project success will be measured via confidence surveys and an evaluation tool.
Confidence surveys will be used to measure student self-efficacy in the pre and post intervention
period. Student progress and proficiency will be measured via an evaluation tool. The evaluation
tool will be completed by both the student and clinical faculty; a self-reflective component will
be included. After completing a systematic review of verbal handoff evaluation tools, Davis et al.
(2017) found four categories most often assessed during the verbal handoff process: content,
process, handoff organization, and professionalism. Content is defined as the components of the
handoff such as the patient's medical history, treatment plan and hospital course to date (Davis et
al, 2017). Process is the quality of the handoff whereas handoff organization evaluates the order
of the handoff which could include following the SBAR format in an appropriate manner (Davis
et al, 2017). Professionalism evaluates behaviors exhibited by the person giving the handoff
(Davis et al, 2017). The goal of the evaluation tool will be to measure the student's ability to
deliver an handoff that is professional, concise, well organized, and pertinent to the patient's
clinical situation.

Informatics technology will be used to complete the literature search and identify
evidence-based handoff practices. In the clinical setting, the EHR will be used by both the
student and the clinical instructor to collect pertinent patient data. Excel software will be used to
 12

collect, organize, and analyze the data collected from the confidence surveys and evaluation
tools. Pareto charts could assist the team in analyzing data regarding the type communication
errors committed by students during the verbal handoff process (American Society for Quality,
2017). Pareto charts allow data to be measured in one work cycle or over days or weeks
(American Society for Quality, 2017). The data of interest would be pulled from the evaluation
tools and could assist the project team in identifying process and educational gaps allowing for
potential correction in future semesters.

J. Predict what you think will happen as a result of your improvement project.

Lee et al. (2016) found a correlation between increased exposure to verbal handoffs and
increased self-efficacy scores. The authors also noted an increase in verbal handoff proficiency
in the post-intervention period. The quality improvement project is modeled after the work of
Lee et al. (2016), therefore, increased self-efficacy and increased student proficiency regarding
verbal handoff delivery is expected.

K. Create goals, objectives, and timelines for the project. Consider the earlier identified QSEN
competencies and “DSA” components of the “PDSA” model in completing the grid.

See Appendix C
 13

References

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001351

American Society for Quality. (2017). Learn about quality: Pareto charts. Retrieved from:

http://asq.org/learn-about-quality/cause-analysis-tools/overview/pareto.html

Beckett, C. D., & Kipniss, G. (2009). Collaborative communication: Integrating SBAR to

improve quality/patient safety outcomes. Journal for Healthcare Quality, 31(5), 19-28.

Burns, J.M. (1978) Leadership. New York, NY: Harper & Row.

Costedio, E., Powers, J., & Stuart, T. (2013). Change-of-shift report: From hallways to the

bedside. Nursing, 43(8), 18-19.

Davis, J., Roach, C., Elliott, C., Mardis, M., Justice, E., & Riesenberg, L. (2017). Feedback and

assessment tools for handoffs: A systematic review. Journal of Graduate Medical

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De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improves

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simulation to improve communication skills of baccalaureate nursing students: A pilot

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 14

Horowitz, L. I., Dombroski, J., Murphy, T. E., Farnan, J. M., Johnson, J. K., & Arora, V. M.

(2013). Validation of a handoff assessment tool: The Handoff CEX. Journal of Clinical

Nursing, 22(0), 1477-1486. doi: 0.1111/j.1365-2702.2012.04131.x

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http://www.lcc.edu/about/history/

Lansing Community College [LCC]. (2015). Spring 2015 student evaluations. [Handout].

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[Handout]. Department of Nursing, Lansing Community College, Lansing, MI.

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nursing students. Nurse Educator, 41(4), 189-193

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Lomax, S. W., & White, D. (2015). Interprofessional collaborative care skills for the frontline

nurse. Nursing Clinics of North America, 50(1), 59-73. doi: http://dx.doi.org/10.1016/

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Manojlovich, M., Kerr, M., Davies, B., Squires, J., Mallick, R., & Rodger, G. L. (2014).

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 15

McCallum, J. S. (2013). Followership: The other side of leadership. Ivy Business Journal,

September/October 2013. Retrieved from http://iveybusinessjournal.com/publication/

followership-the-other-side-of-leadership/

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http://qsen.org/competencies/pre-lisensure-ksas/

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Knowledge, skills and attitudes. Retrieved from http://www.aacn.nche.edu/faculty/

qsen/competencies.pdf

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Blackwell.

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0000000000000169

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aboutsparrow

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Issues, 21(2). doi: 10.3912/OJIN.Vol21No02Man04


ROOT CAUSE ANALYSIS DIAGRAM
Lack of coordination
of care
No interdisciplinary
rounds
High workloads RN and
physician workloads
High turnover rates;
young, inexperienced
nursing leadership
Lack of orientation and
training; lack of expert
RN mentors
Knowledge gap:
narcotic use and constipation
Appendix A 16
PRN bowel protocol
medications not administered
Unknown date of last BM;
poor handoffs
Inexperienced nurses;
lack of handoff Unexpected death of
training/standardization elderly female s/p hip
fracture due to bowel
perforation
Key stakeholders not involved
in designing EHR flowsheets
Multiple locations in EHR
to document BMs; gaps in
documentation protocols
Insufficient documentation
in the EHR
 Appendix B 17

Failure Modes Effects Analysis (FMEA) Chart

Process Failure Mode Effect Sev Cause Controls Prob Risk Recommended Actions
Step 1-3 1-3 Index
CARE Anywhere
software to assist Send paper chart with
Outside facilities
with EHR patient, interface as many
do not interface 2 6
interfacing-- facilities with EHR as
with EHR
Sparrow Hospital possible.
participates
Pt/family bring
documents detailing
medical history and
Critical CARE Anywhere
prescribed medications
information software to assist
upon admission. EHR
omitted Patient/family with EHR
2 6 interface with primary
poor historians interfacing--
3 physician practices.
(ex: allergies, Sparrow Hospital
Patient identify key
mediations, participates
Admission Pertinent
co-
caregiver who can
Handoff information provide pertinent medical
morbidities)
not information.
(From ED, communicated One Call--
Reeducate staff
surgery, and/or standardized call
Standardized regarding best handoff
another unit, gathered system to connect
handoff practices, create SBAR
or outlying during the physician to
processes not 2 6 template in EHR, prepare
facility) admission physician and
followed/No use graduate RNs to
process caregiver to
of SBAR communicate effectively
caregiver (staffed
during handoffs
by nurses)
EMR interface with
Pharmacists
primary physician
Over/under assigned to assist
practices, improve
prescribing of with medication 3 9
process for gathering
medications reconciliation
best medication history
process
Poor outcome/ possible, collaborate with
3
patient harm local pharmacies to
CARE Anywhere
assist in the medication
Needed tests not software to assist
reconciliation process,
ordered/unneeded with EHR 3 9
Pt/family bring
tests ordered interfacing--
documents detailing
Sparrow Hospital
medical history upon
 18

participates admission, send paper

Radiological chart with patient from
report interface outlying facilities,
system in place interface EHR with as
many facilities as
possible, have patient
identify key caregiver
who can provide
pertinent medical
information.
Pt rights and info
regarding BSR
provided to
patient and family Complete handoff at pt
Pt input is not
upon admission. 2 6 bedside; invite pt to
solicited
Critical BSR handoff participate.
information 3 education
omitted provided at RN
orientation.
BSR handoff
EHR not opened policy requires Have EHR open during
2 6
during handoff EHR to be open shift-to-shift handoff.
during handoff.
Shift to Handoff does Seek patient
Shift not occur at Info regarding understanding of BSR
Pt refuses to
Handoff the patient's BSR provided to practices; provide
participate in 1 4
bedside patient and family education/information to
handoff
upon admission. pt and family regarding
the benefits of BSR.
Explore reasons why RN
BSR handoff
refuses BSR, remove
Pt input is not policy in place.
2 RN refuses to barriers to BSR, increase
provided BSR handoff
complete handoff 2 4 training/mastery of BSR
education
at bedside practices, increase
provided at RN
accountability via
orientation.
leadership rounding.
RN is floated to Use standardized form
another unit; (SBAR) for written
None 1 2
handoff is handoffs; employ other
handwritten methods for handoff if
 19

RN floated (?? Charge

RN)

EHR does not

Some SARs & Send paper chart with
interface with
ECFs have limited patient containing
outlying facilities
EHR interfacing 3 9 pertinent information in
especially SARs
capabilities. an easy to read format.
& ECFs
Case managers
SAR & ECF staff and social Collaborate with local
are very difficult workers are SARs & ECFs for best
3 9
to contact for assigned as method for completing
handoff liaisons between transfer handoffs.
facilities.
3 Collaborate with case
managers and
Long LOS leads interdisciplinary team to
to complicated create an accurate,
patient story: too None 2 6 readable discharge
Transfer many details to summary; develop
Handoff Pertinent info communicate method to create a
not "snapshot" of the
(To SAR, communicated patient's medical story.
ECF, ICU, during transfer Reeducate staff
Surgery, BSR handoff
handoff Standardized regarding best handoff
Inpatient policy in place.
Critical info handoff practices, create SBAR
Rehab) BSR handoff
omitted processes not 2 6 template in EHR, prepare
education
followed/No use graduate RNs to
provided at RN
of SBAR communicate effectively
orientation.
during handoffs.
Transfers to ICU Rapid Response Reeducate staff
3 typically occur RN assists with regarding best handoff
during a crisis verbal handoff practices, create SBAR
situation; multiple and coordinating 3 9 template in EHR, prepare
pieces of care with graduate RNs to
information are interdisciplinary communicate effectively
omitted team. during handoffs
 20

EHR orders/MAR
follows patient in Use standardized handoff
inpatient setting practices (SBAR),
Medications are (Surgery & conduct face--to-face
Poor not taken as Inpatient Rehab). handoff whenever
outcomes/ prescribed (over Printed possible, interface EHR
patient harm or under dosing) documents and with outlying facilities as
(readmissions, 3 prescriptions sent 2 6 much as possible,
unexpected to SARs and involve the patient in the
deaths) ECFs. Discharge transfer handoff process,
phone call have EHR open if handoff
processes in occurs face-to-face.
place.
EHR orders/MAR
follows patient in Use standardized handoff
inpatient setting practices (SBAR),
(Surgery & conduct face--to-face
Inpatient Rehab). handoff whenever
Transfer
Printed possible, interface EHR
instructions were
documents and 2 6 with outlying facilities as
not followed and/
prescriptions sent much as possible,
or understood
to SARs and involve the patient in the
ECFs. Discharge transfer handoff process,
phone call have EHR open if handoff
processes in occurs face-to-face.
place.

QUALITY IMPROVEMENT PROJECT PROPOSAL PLANNING GUIDE
Title of Quality Improvement Project:
Goals with QSEN/ANA Support
Goal 1:
Integrate structured verbal handoffs
into clinical education.
Meets QSEN Competency(ies)/KSA(s):
Teamwork and Collaboration--Skill:
"Use communication practices that
minimize risks associated with handoffs
among providers and across transitions of
care" (QSEN, 2012, p. 10).
Teamwork and Collaboration--Attitude:
"Appreciate the risks associated with
handoffs among providers and across
transitions in care" (QSEN, 2012, p. 10).
Meets ANA Scope & Standards for
specialty role:
Standard I, III, IV & V (NLN, 2012)
Goals with QSEN/ANA Support
Goal 2:
Understand pre and post data to
determine if project was successful.
Meets QSEN Competency(ies)/KSA(s):
Quality Improvement--Skill: "Select and
use quality improvement tools to achieve
best possible outcomes" (QSEN, 2012, p.
5).
Quality Improvement--Skill: "Design,
implement, and evaluate small tests of
change in daily work" (QSEN, 2012,
p. 6)
Meets ANA Scope & Standards for
Appendix C
Sub-Objectives to meet Goal
1.1
Educate students and NSDU nurses
on best handoff practices and the
proper use of the SBAR
communication tool.
1.2
Create a structured process for
conducting verbal handoffs in the
clinical setting.
1.3
Ensure compliance to change.
Sub-Objectives to meet Goal
2.1
Obtain pre and post intervention data
via confidence surveys and
evaluation tools.
2.2
Analyze data using excel software.
2.3
Share data with key stakeholders.
21
Activities to meet Each Sub-objective Timeline for each
1.1-
1.1--Develop educational materials.
-Week 1 & 2 of the
Attend clinical post-conference and unit
clinical rotation
staff meetings; provide education to
(September 4th-18th)
students and staff.
1.2--Provide template to clinical faculty
1.2-
prior to the start of the clinical rotation
-Weeks 1-2 of the
outlining the verbal handoff process/
clinical rotation
timeline. Provide handouts and SBAR
(September 4th-18th)
tools to students.
1.3
1.3--Round on units; meet with clinical
-Weeks 1-7 of the
faculty and students weekly. Conduct
clinical rotation (Sept
verbal handoffs with students.
4th--October 17th)
Activities to meet Each Sub-objective Timeline for each
2.1--Develop confidence surveys and an 2.1-
evaluation tool. Distribute confidence - Confidence survey
surveys and evaluation tools to clinical data will be collected on
faculty. weeks 1 & 7; evaluation
tool data on weeks 2-6.
(Sept 4th-Oct 17th)
2.2--Work with project preceptor and
supportive personnel to identify trends in 2.2 Weeks 9-12.
data.
(October 30th-Nov 13th)
2.3--Convey findings at faculty meetings, 2.3 Weeks 12-14
staff meetings and the course site.
(Nov 20th-Dec 4th)
 Appendix C
22

specialty role:

Standard III & V (NLN, 2012)

23
24