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Part A: PLAN Incorporating a Safe Shift to Shift RN HandoffA. Clearly explain the quality improvement project – what exactly are you planning to do?For my project I will implement a formalized process for registered nurses (RN)’s shift to shift handoff on a neuro trauma intensive care unit (NTICU) at MidMichigan Health-Midland. This will follow the Situation, Background, Assessment, Recommendation (SBAR) format in paper form. The proposed project will be implemented for four weeks. Currently, the nurses perform shift to shift RN handoff verbally at the nurse’s station. They utilize an array of different paper tools, as well as constructing information on blank sheets of paper. The current handoff process has been demonstrated by seasoned, as well as new critical care nurses within the department, to be a challenge with relaying information appropriately. This leads to a higher occurrence of patient care omissions in information being shared. In one research study, nurses on surgical units had an increase of 33% of patient information to keep track of than medical units during shift to shift handoff (Matney, Maddox, & Staggers, 2013). This critical care unit has a significant volume of surgical patients, therefor the team potentially has a higher opportunity for patient care errors in comparison to non-surgical units when providing handoff. Some of the current NTICU RNs state that they would like to improve patient safety and collaboration through an improved shift to shift handoff process. They also indicate that they are frustrated by frequent omissions of information being relayed to them during handoff. B. Provide evidence based support that establishes a need for this project. Also include research support for effectiveness of the proposed improvement project.Nursing collaboration has been the subject of controversy for decades. More importantly, the question of how nursing collaboration impacts patient safety has been in the forefront of research in recent years. Current research depicts the impact on patient safety. However, there is minimal evidence to support any one single method (Riesenberg, Leitzsch, & Cunningham, 2010). The American Association of Critical Care Nurses (AACN) includes nurse collaboration in its Healthy Work Environment Standards along with indicating its impact on patient care (Holly & Poletick, 2013). The Joint Commission (JC), also included nurse collaboration in its 2007 National Patient Safety Goals (Holly & Poletick, 2013). This included a formalized process for handoff where nurses to have time to ask questions during the handoff. Seven years later, many organizations continue to have no formalized process for collaboration during the nurse to nurse handoff. It is important for this neuro trauma critical care unit to enhance a culture of safety through structured collaboration with shift to shift RN handoff. According to the Joint Commission Center for Transforming Healthcare, providing a structured process such as the Hand-off Communications Project can improve the RN receiver’s perception of satisfaction by 52.9% (2013). Structured handoff communication and collaboration in organizations with high reliability consist of three components which include; face to face RN to RN communication, use of structured templates, and the ability to critically think through information in a predictive manner, rather than listing completed tasks (Halm, 2013). These components will be incorporated into the project. Standardized methods for handoff has been demonstrated to decrease errors with nursing practice. In 2010, Mission Hospital in Mission Viego California, reported 750 near misses being thwarted by the use of instituting standardized tools for handoff communication in a six month time period (Stevens, 2011). Stevens goes on to report that pharmacy related errors decreased from 18% to 2% in 2010 (2011). Other research demonstrates the amount of patient information omissions decreasing from a mean of 4.96% to 2.29% per handoff, with a result of home medication issue error rates decreasing from 38% to 9% (Younan & Fralic, 2013). Additionally, this study exhibited a decrease lack of RN knowledge related to abnormal laboratory findings from 90% to 48% (Younan & Fralic, 2013).C. Where will this project take place? Describe the environment/facility/unit etc.MidMichigan Health-Midland is a 240 bed, acute care, not for profit hospital that is part of the MidMichigan Health System in Lower Michigan. NTICU is an eight bed unit on the third floor of the main building. There are 10 day shift RNs and 10 night shift RNs. All RNs work 12 hour shifts. Each nurse is responsible for caring for two critical care patients. All patient rooms are private, with full glass walls facing the nurse’s station. Each room has a computer on wheels (COW). There is one small nurse’s station with five desktop computers. There is minimal counter space and significant foot traffic throughout the small area. At each handoff there are eight nurses engaged in the process. 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. A signed agreement from the agency representative and preceptor should be included in this section.)The preceptor for my project is Jan Penney, RN, MSN, Vice President and Chief Nursing Officer. She is chosen for the preceptor because she is a strong advocate for nursing practice and an active participant on the safety team for the organization. There is one nurse Manager, Michelle Abedrabo RN, BSN who will be an assistive coordinator and a cheerleader. Four (two from each shift) motivated RNs, who will help develop the tool, promote the concept and role model the new handoff behaviors. There is no educator or clinical nurse specialist support for this critical care division to assist with implementation and monitoring of the shift to shift handoff.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.)It is important to foster teamwork and collaboration for the implementation and sustainability of this project. Therefor the Graduate-Level Quality Safety Education for Nurses (QSEN) Competency of Teamwork & Collaboration has been chosen. This will directly impact the quality and safety of nursing practice on NTICU. I have chosen the following Knowledge, Skill and Attitude for the shift to shift RN handoff project.Describe appropriate handoff communication (QSEN Institute, 2012).The project team will review evidence based literature, tools, and anecdotal reports from various organizations to develop a new handoff process. Criteria will be developed by the team for the desired process.Use communication practices that minimize risks associated with handoffs among providers and across transitions of care (QSEN Institute, 2012).An SBAR tool will be developed with the handoff team. The tool will be a consistent paper instrument for all of the RNs on both shifts to utilize for the process. This new process is expected to carry over into the future for handoffs to other levels of care, such as when a patient is transferred out of the intensive care unit. There will also be methods developed for decreasing interruptions during the handoff process. Appreciate the risks associated with handoffs among providers and across transitions of care (QSEN Institute, 2012).The value of an improved patient handoff will be increased after reviewing current evidence based practice (EBP) literature and attending the PowerPoint presentation from the project lead. The current process will be reviewed by the team by utilizing the root cause analysis (RCA) exercise. This will assist to identify potential risks to the current process. 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.)Through quality and practice, I will assist the team with the handoff quality improvement process. It will be accomplished through structuring an evidence based process in a responsible ethical manner. Through collaboration and research, I will consistently communicate with all of the stakeholders. It is my intention to incorporate an interdisciplinary team to enhance staff satisfaction, while incorporating educational opportunities, utilization of technology and evidence based practice. (American Nurses Association [ANA], 2009).The Nursing Administration Scope & Standards of Practice that have been chosen for this project are:Quality in practice (American Nurses Association [ANA], 2009).This will be demonstrated through the hypothesis that the new handoff process will in effect improve safe patient care. Through the RCA, the processes related to concerns for patients will be identified. Attempts will be made to rectify those identified. Streamlining the process and utilizing consistent tools will ensure vital information will not be omitted. Patient safety checks during the handoff will impact correct information being shared and assist to eliminate any identified concerns. Collaboration (American Nurses Association [ANA], 2009).During the handoff communication, collaboration between caregivers will be encouraged and enhanced. Professionalism will be optimized through demonstration and consistent structured template utilization. Sidebar conversations will be kept to a minimum for the same reason. It is proposed that there will be less interruptions, thus allowing the nurses to ask more detailed questions and receive answers that can be immediately noted and addressed. Research (American Nurses Association [ANA], 2009).An evidence based practice literature review regarding handoff will be performed. Evidence that has been published within the last five years will be viewed by the team for effective solutions for creating and evaluating a consistent handoff process. SBAR will be the skeleton for the template as it is widely researched and supported in the literature for its efficacy with various styles of handoff.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. (Note: Examples you may use are included in this project guide.)The original location for the project has been recently changed from a neurosurgical medical unit unexpectedly therefor the RCA listed here is from the original department’s staff. An additional RCA will be conducted with the staff from the NTICU. The information is relevant for both locations. It is included here. The RCA was conducted with 3 day shift RNs and 2 night shift RNs related to ineffective RN to RN handoff. The nurse manager, Cathy Ahearn was not able to attend due to unforeseen circumstances. Jessica Garvey, Quality Specialist, attended as well. The conclusions ascertained from the RCA were concerns with process, tools, communication, time constraints, technology, environment, education, and staff culture. Process included inconsistent practices from the various RNs having no policy to direct them. Tools involved not having a single consistent method that is evidence based. Communication discovered omissions and inaccuracies in information being shared. Time constraints pointed towards staff concerns of bedside handoff taking too long. Technology is not user friendly, offers little useful information and is extremely slow to obtain. The environment on the unit is too noisy with numerous interruptions. There is a lack of education on handoff during orientation and there is no educator to support the process. Lastly, the RN staff culture is plagued with various attitudes regarding handoff and their processes are organized. See RCA graph attachmentH. Identify a change and leadership theory that you will employ during project implementation. Support.Lewin’s change theory will be utilized. This type of theory can help to simplify an overall complicated process and has been widely utilized throughout the years (Mitchell, 2012). The three stages of Lewin’s theory are unfreezing, moving and refreezing. During the unfreezing stage the current process and issues will be assessed. This phase will take 2 months. Moving from the old method to the new method will require ways to unfreeze the current cultural ways of thinking of performing RN to RN handoff. An educational presentation, with greater than 80% of the staff in attendance, will be provided by the project lead to address the need for the shift in culture and the impact to patient safety and nurse satisfaction. The motivation of the RNs for this type of change will also be addressed. Project champions will be selected based on past performance with performance improvement and passion for a change in handoff procedures. A team of staff, along with the champions will be the core team to perform the root cause analysis process. Barriers will be assessed and a new handoff process will be developed that includes the paper based SBAR tool. Evidence based practice will need to be referenced for increasing the value for the nurses to change the current culture. Baseline surveys will be administered to the staff RNs during this initial phase. For the moving stage, staff will be selected based on the first stage to assist with implementing a pilot change process. Education for the use of the developed tools will be provided. After the new process is piloted, the process will be expanded to the rest of the team to incorporate during handoff for both shifts. During the last stage, the refreezing stage, the new handoff process will be implemented, tweaked and cemented into practice. The developed tools will be implemented during this stage. The process will be monitored to determine adherence to the new process, for feedback and for coaching the new culture. Champions will serve as mentors for the rest of the team. Staff huddles will be completed weekly to determine how the process is going at the front line. Any concerns can be addressed during implementation, rather than at the completion of the project. RN surveys will be completed in this final phase. Outcomes will also be celebrated during this final stage. Lewin’s change theory will be complimented by a combination of Relationship-Based Care and Transformational Leadership. It is this style of leadership that develops the team to their maximum ability while mentoring the growth and emergence of new leaders (Koloroutis, 2004, Chapter 2). For the relationship based leadership model, the patient and family are the center of each of the outward dimensions which include leadership, teamwork, professional nursing, care delivery, resources and outcomes (Koloroutis, 2004, Chapter 1). As a transformational leader it will be important to demonstrate to the staff why the change is important and involve them in the decision making process. Transformational leaders are effective when they listen to the stakeholders, challenge the norm, influence the process and affirm the process progress (Luzinski, 2011). In an effort to challenge the norm, resources such as EBP tools will be encouraged to promote consistency and structure to the handoff process. Throughout any change development the transformational leader will allow voices to be heard (Luzinski, 2011). It will also be essential to model the desired behaviors based on a model of relationships in a caring environment (Koloroutis, 2004, Chapter 2). As the leader, I will demonstrate and monitor these expected behaviors. Teamwork will be fostered through the group dynamics in creating the new process. Opinions will be understood and processes will be developed based on feedback from the team. Professional nursing communication will be modeled during the team meetings. It will be a collaborative relationship between myself and the team, learning from one another and coming to a common agreement on the chosen methods determined during the process. The project lead person will be available to the staff to mentor, answer questions, and brainstorm solutions to identified barriers. For this project to be successful, there must be the development of informal leaders from the RN team from each shift. These RNs will be the front line champions for the project. If this does not occur the new handoff process may not be cemented into the daily practice of all of the RNs after the project completion. The process will be in jeopardy of reverting back to the previous culture. As with many leadership models, it is important to include the patient when developing any plan of care (Jasovsky, Morrow, Clementi, & Hindle, 2010). During the change process, the central premise will be the safety outcomes related to the patient. Safety in the delivery of care will be impacted by the outcome of the group’s overall process at project completion.I. How will you assess or measure whether your improvement project worked? How/will informatics technology be used?Near misses will be tabulated. Omissions of information that are caught during or after the handoff process will be written down and put into a designated box at the nurse’s station by the receiving RN. This information will be tabulated and used for celebration at the closure of the project. Demonstrate how often the paper SBAR paper tool utilized. Staff will be asked to turn in all SBAR forms to a basket at the nurse’s station for review by the project lead. Nurses will be asked to date and include their name on each tool for tabulating data. The SBAR paper tool will be utilized 100% of the time by all nursing staff. Daily census sheets will be compared to staffing grids and assignment sheets to determine how many are used against patient census. Utilize an electronic survey to query the nursing staff before and after to understand their impression on staff satisfaction & collaboration related to the new handoff process impacting patient safety. A survey monkey will be utilized as a baseline and after the project completion. J. Predict what you think will happen as a result of your improvement project.There is great value as a leader for improving the shift to shift RN handoff. Cornell and Townsend hypothesized that efficiency will be improved in regards to time at task and overall consistency would improve (2013). This can have substantial impact to nurse satisfaction. Other evidence also suggest an improvement in communication, fewer omissions of information, decreased errors, increased patient knowledge, improved nurse satisfaction, enhanced patient satisfaction scores, and increased nurse to nurse collaboration (Halm, 2013).During this project, there are three things that are intended to occur. The first being, near misses/omissions of information will decrease by 25%. According to Younan & Fralic, omissions of information in one study fell from 4.96 to 2.29 per patient handoff (2013). The second will be to have 100% compliance with the SBAR tool utilization. The third, an increase in the perception of nurse satisfaction and collaboration between nurses by 50%. Using a standardized handoff tool improved the amount of appropriate information from 57% to 84% (Agarwal et al 2012).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 attachments)ReferencesAgarwal, H. S., Saville, B. R., Slayton, J. M., Donahue, B. S., Daves, S., Christian, K. G., ... Harris, Z. L. (2012). Standardized postoperative handover process improves outcomes in the intensive care unit: A model for operational sustainability and improved team performance. Critical Care Medicine, 40, 2109-2115.American Nurses Association. (2009). Nursing administration scope & standards of practice. Silver Spring, MD: Nursebooks.Cornell, P., & Townsend Gervis, M. (2013). Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. Journal of Nursing Administration, 43, 422-428.Halm, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-162.Holly, C., & Poletick, E. B. (2013). A systematic review on the transfer of information during nurse transitions in care. Journal of Clinical Nursing, 23, 2387-2396. , D. A., Morrow, M. R., Clementi, P. S., & Hindle, P. A. (2010). Theories in action and how nursing practice changed. Nursing science Quarterly, 23(29), 30-38. Retrieved from: Commission Center for Transforming Healthcare. (2013). , M. (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management.Luzinski, C. (2011). Transformational leadership. The Journal of Nursing Administration, 41(12), 501-502.Matney, S. A., Maddox, L. J., & Staggers, N. (2013). Nurses as knowledge workers: Is there evidence of knowledge in patient handoffs? Western Journal of Nursing Research, 36(2), 171-190.Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37.Quality Safety Education for Nurses Institute. (2012). Retrieved from: , L. A., Leitzsch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24-34.Stevens, J. D. (2011, May). Implementing standardized reporting and safety checklists: Developing processes to create a culture of safety. American Journal of Nursing, 111(5), 48-53.World Health Organization. (2009). A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Retrieved from: , L. A., & Fralic, M. F. (2013). Using “best-fit” interventions to improve the nursing inter-shift handoff process at a medical center in Lebanon. The Joint Commission Journal on Quality and Patient Safety, 39, 460-467.Will be completed for final submission with scanned copyStudent-Preceptor AgreementThe overall objective of this experience is to provide an on-site setting in which a student, with the preceptor (professional employee of a health care agency), will complete a quality improvement project.Agency name __MidMichigan Health- Midland_______Student name __Marie Wendt_____Student Telephone # _989-529-1957 Preceptor name __Jan Penney RN, MSNPreceptor’s Title _Vice President and Chief Nursing Officer___Preceptor Telephone #_989-839-3645_______________________Preceptor email___jan.penney@_______________The following goal(s), objectives, and activities will be completed by the student during this project/practicum.Develop, implement and evaluate a safe, efficient handoff process to be utilized consistently by all RN staff on neuro trauma intensive care unit.Activities include constructing team of stakeholders related to nurse to nurse handoff, evaluate current handoff process, and develop paper tools for efficient, safe, consistent handoff process. I will also educate current RN staff on impact of non-optimal shift to shift handoff report related to evidence based practice. Throughout the process I will perform baseline, concurrent and retrospective evaluations.SIGNATURE SIGNIFYING AGREEMENT TO THE TERMS OF THIS PRECEPTOR AGREEMENT:Student _________________________________________ Date ___________________Preceptor(s) _______________________________________ Date ___________________Student-Agency AgreementAgency name __MidMichigan Health-Midland__________________________________Student name ___Marie Wendt___________________________________________Student Telephone # __989-529-1957 _________ Agency representative ____Collen Markel__________________________ Agency representative Title _____Manager, Grow your own_________Agency representative Telephone #__989-839-3120______________________ email__colleen.markel@________________SIGNATURE SIGNIFYING AGREEMENT TO THE TERMS OF THIS AGREEMENT:Student _________________________________________ Date ___________________Agency representative _______________________________________ Date ________Incorporating a Safe Shift to Shift RN HandoffTitle of Quality Improvement Project:Goals with QSEN/ANA SupportSub-Objectives to meet Goal Activities to meet Each Sub-objectiveTimeline for each Goal 1:Develop safe, efficient handoff process to be utilized consistently by all RN staff on neuro trauma intensive care unit.Meets QSEN Competency(ies)/KSA(s):Use communication practices that minimize risks associated with handoffs among providers and across transitions of careMeets ANA Scope & Standards for specialty role:CollaborationGoal 2:Implement safe, efficient handoff process.Meets QSEN Compentency(ies)/KSA (s)Describe appropriate handoff communicationMeets ANA Scope & Standards for specialty role:Quality in practice1.1Construct team of stakeholders related to nurse to nurse handoff1.2Evaluate current handoff process1.3Develop paper tools for efficient, safe, consistent handoff processPosterPocket cardSBAR ToolLog bookBasket for collected SBAR tools2.1Educate current RN staff on impact of non-optimal shift to shift handoff report. Including benefits of such process. 2.2 Increase RN knowledge of Evidence based research related to handoff process2.3Demonstrate efficient and effective shift to shift handoff based on team findings2.4GO live1.1Ask manager for 4 motivated staffAttend staff meeting, after PowerPoint presentation request motivated volunteersEmail staff to request passionate membersOne on one recruitment opportunities by project lead1.2Observe team perform current handoff processSchedule meeting for RCA with handoff teamPerform RCA with newly developed teamCreate criteria for desired process1.3Review evidence based practice with handoff teamTeam members to bring report tool examples, templates and ideas.Develop prototype toolsTake developed tools to RNs for feedback2 RNs from Handoff team to trial newly developed toolDebrief after pilot with team2.1Handoff Power point presentation by project leadJoint Commission video presentationAddress questions and concernsReview how barriers have been addressedReview how & what to report near misses2.2Distribute a minimum of 3 evidence based research literature articles to RN staff/team Hardcopy EmailCreate communication binder on the unit2.34 RNs to demonstrate (Role Play) to the RN staff, effective versus ineffective handoff process2.4Distribute finalized scriptDistribute finalized safety pocket cardDistribute finalized SBAR toolHang postersNurse manager & project lead to do walking rounds during handoff processAsk RNs to hand in SBAR report tools in basket at nurses station1.1January 13, 2014January 22, 2015January 13, 2015January 13, 20151.2January 20, 2015 January 20, 2015January 20, 2015January 20, 20151.3January 20, 2014January 27, 2014February 2, 2015February 2, 2015February 9, 2015February 16, 20152.1February ___, 2015February ___, 2015February ___, 2015February ___, 2015February ___, 20152.2February 2, 20152.3February 24, 20152.4 February 26-27, 2015February 26-27, 2015February 26-27, 2015February 26-27, 2015March 2, 2015 March 2, 2015 through March 27, 2015Goals with QSEN/ANA SupportSub-Objectives to meet Goal Activities to meet Each Sub-objectiveTimeline for each Goal 3:Evaluate handoff processMeets QSEN Competency(ies)/KSA(s)Appreciate the risks associated with handoff’s among providers and across transitions of careMeets ANA Scope & Standards for specialty roleResearch3.1Baseline evaluation3.2Concurrent evaluation3.3Retrospective evaluation3.1Ask RNs to report near misses found during their shift in log book at nurses station for 28 daysProject lead ask patients for feedback after current handoff process performedAdminister baseline survey monkey to RN staff 3.2Monitor RN handoff on both shift for consistencyProject lead ask patients for feedback after new handoff performedAsk RNs to report near misses in a log book kept at the nurse station for 28 days3.3Develop questionnaire for survey monkeyAdminister survey monkey to RN staff3.1February 1, 2015 through February 28, 2015February 1, 2015 through February 28, 2015February 1, 2015 through February 28, 20153.2March 2, 2015 through March 29, 2015March 2, 2015 through March 29, 2015March 2, 2015 through March 29, 20153.3January 20, 2015March 30, 2015 through April 24, 2015 CommunicationToolsStaffProcessEnvironmentEducationTimeConstraintsTechnologyIneffective RN to RN Shift HandoffOmissionsInaccurate infoSidebar conversationsCulture AttitudesUnorganizedVariesNo one to enforceNot Evidence BasedAssignmentsToo rushedToo longNo OrientationNot clearly defined// No educatorPoor quality InfoSlowNot User friendlyNoisyInterruptionsPatient Needs/AcuityInconsistentOpinionsNo handoff policyCommunicationToolsStaffProcessEnvironmentEducationTimeConstraintsTechnologyIneffective RN to RN Shift HandoffOmissionsInaccurate infoSidebar conversationsCulture AttitudesUnorganizedVariesNo one to enforceNot Evidence BasedAssignmentsToo rushedToo longNo OrientationNot clearly defined// No educatorPoor quality InfoSlowNot User friendlyNoisyInterruptionsPatient Needs/AcuityInconsistentOpinionsNo handoff policy ................
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