Team # 942 -- Physician Handoff Communication Project
College of Medicine

July 2009


To improve the effectiveness of physician/ordering provider handoffs for the benefit of the patients we serve. Of 3,000 root cause analyses reported by Joint Commission (JC) accredited health care facilities between 1995 and 2004, >65% were caused by communication problems. In 2005 the number was nearly 70%. At least 50% of communication breakdowns occur during the transition of care – i.e., at the time of handoff communication.

Team Membership

  • Noel Ballentine, Co-Physician Champion
  • Eric Bradburn, Co-Physician Champion
  • Gregory Caputo, Co-Executive Sponsor
  • Chris DeFlitch, Co-Executive Sponsor
  • Robert Cherry, Member
  • Derek Culnan, Member
  • Lillian Erdahl, Member
  • Carol Freer, Member
  • Neerav Goyal, Member
  • Aaron Knudson, Member
  • Lynda Martin, Member
  • Kate Millay, Member
  • Uchenna Ofoma, Member
  • Samer Rajjoub, Member
  • Edwin Robles, Member
  • Serene Shereff, Member
  • John Showalter, Member
  • Nicole Swallow, Member
  • Michael Ward, Member

Results Achieved to Date

  • ExpectedResults: Qualitative survey data was used in determining current state of handoff effectiveness. Data focused on two information points: 1. percentage of handoffs that were interactive with an opportunity to ask questions and have them answered, and 2. the percentage of handoffs the receiver considered to be effective for appropriate management of patient care and treatment. Also used in determining current state were process diagrams and Failure Modes and Effects Analysis (FMEA). This project served as PSHMC's Joint Commission-required FMEA for 2009. A new Handoff Communications Policy was written and is in the process of being vetted for approval, posting, and promulgation to providers and multidisciplinary staff. A new, computer-generated Handoff Communication tool has been developed, piloted, evaluated, revised, and re-posted for use by SICU, Internal Medicine, and Trauma Surgery providers.
    Once this first implementation phase is completed, the handoff Process and Tool will be rolled out to other medical services throughout the hospital. Future plans also include expanding the project focus to include multi-disciplinary staff.




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