Abstract:
Introduction/Purpose: As patients move from a skilled nursing facility across the transitions of
care, the possibility for poor communication regarding patient information is introduced.
Ineffective communication among health care providers is commonly at the root of poor patient
outcomes and medical errors. A lack of standardized handoff processes is commonly at the root
of communication failures. The Joint Commission has required the implementation of
standardized hand-off communication tools as a remedy for communication failures. The
purpose of this quality improvement project was to implement and evaluate the effectiveness of
an evidence-based standardized hand-off process in a skilled nursing facility. Methods: This
quality improvement project utilized a pre-/post intervention design which included
implementing a standardized hand-off form in a skilled nursing facility over a 12-week time
period. The nurse practitioners were trained in a 30-minute educational session on the new hand_x0002_off form. Compliance and error of omission rates were tracked. Results: Outcomes included a
97.2% compliance rate in utilization of the hand-off form, a 97.2% compliance rate in the
completion of all components on the hand-off form, 0% errors of omission that resulted in
failures of the health care provider at the receiving facility to address the reason for the patient's
referral, and 0.6% follow-up requests for additional patient information from the health care
provider at the receiving facility. Conclusion: A standardized hand-off process in a SNF may
improve hand-off communication quality and reduce errors in omission leading to improved
provider communication across the transitions of care and better patient outcomes.
