1. Provide a brief overview of the identified clinical issue (10 points):
2. Describe in detail an evidence based action/corrective plan (10 points):
3. Identify changes that can be made to the system/process to improve outcomes (provide clear examples that are applicable to clinical practice and link to measurable outcomes) (10 points):
4. Procedure change (describe what clearly needs to occur to improve outcomes) (10 points):
5. Policy change (use the template as Appendix A to this document to develop a new policy related to the procedure) (25 points):
6. Discuss your plan, implementation, observation, and outcomes measures. (complete the PDSA Worksheet as Appendix B to this document) (25 points):
7. Identify any new resources/forms and equipment that may potentially be needed to implement this change/include the rationale and an estimated cost for utilizing these new resources (5 points):

References
 
Appendix A: Policy (A Sample Policy is included below for your review)
Policy and Procedure Manual Page: 1 of
Policy #
Effective Date: Revision Date
Subject: Handoff Communication Function: Provision of Care
KEY WORDS: handoff, report, patient transfer
I. POLICY
A. OBJECTIVE
To provide guidelines for minimal content required to be communicated between clinical care providers prior to transfer of care from one clinician to another.
B. INDICATION FOR USE

1. This policy will be used when transferring care of a patient from one clinician to another upon transfer from one unit or care area to another, post-procedure, or at other care transitions as deemed clinically appropriate.
2. The Handoff Communication Template tool will be used alone or in conjunction with the electronic medical record tool form all UMMS facilities.
3. This process and communication tool may be used for communication of patient report/summary of care in the absence of a facility specific document when transferring patients from or to another facility.
   C. DEFINITIONS

Handoff Communication The provision of verbal and/or written information from one clinical provider to another to ensure that pertinent needs for care and treatment can be provided safely
and in a timely manner.
II. RESPONSIBILITY

Licensed Independent Practitioners (LIP) Communicate pertinent clinical details to other clinicians taking responsibility for patient care using at least the minimal data elements of handoff communication as below.
Enter transfer orders as appropriate including level of care required, diagnosis, medications, and supportive care required.

All other clinical care providers Communicate pertinent clinical details to other clinicians taking responsibility for patient care during transitions in care including but not limited to:
Admission to unit Transfer between units
Discharge to home or another facility Transfer from another facility
Pre and post-procedural care – PACU, OR, or other procedure area
III. PATIENT CARE MANAGEMENT
A. Verbal or written handoff communication is required between transitions of care between clinicians that is patient specific and contains the following minimal elements:

1. Patient Name and DOB or medical record number
2. Diagnosis
   a) Reason for admission or transfer
   b) Other pertinent clinical diagnoses or problems
3. Allergies
4. Pertinent clinical details of event or current situation as required.
   a) SBAR format is encouraged – Situation, Background, Assessment, Recommendations
   (1) Includes review of clinically relevant systems assessment
5. Code Status
6. Isolation (as applicable)
7. Pertinent medications- including last dose and effect, if appropriate.
   B. Receiving clinician will have an opportunity to ask questions or seek additional detail as desired.
   C. A handoff communication will be documented including the date and time of communication and both the sender’s name and receiver’s name.
8. Prior to termination of communication, both parties must agree that an appropriate handoff has occurred.
9. Both parties will document that the handoff has occurred.
   D. If written communication is utilized, the above items will be addressed.
10. Handoff Communication form (See Attachment A) may be utilized by providers of care in any discipline.
    a) Handoff Communication Template will be available in Formfast as Form # PG74
    A specialized Handoff Communication is available for Post-procedural areas when the patient has had a procedure that requires communication back to the unit (ie: xray, CT, IR ) and the patient had no significant clinical changes.
    a) Electronic Handoff Communication is acceptable (when available) provided the minimal elements are present.
    E. Transfers To And From Another Facility
11. Handoff communication must occur using the minimum requirements listed in Section III A.
12. Telephone or written handoff is required prior to patient arrival at accepting facility
    a) Maryland Express Care will facilitate transportation from outside facility.
    b) All patients transferring from another facility must have an accepting UMMC provider.
    (1) The accepting provider will communicate to the sending provider and will assign a level of care (ie: acute care, IMC/Tele or ICU)
    c) Patient Placement Center/ Nursing Coordinator will facilitate communication between Maryland Express Care and sending facility regarding bed availability and timing of transfer (See Attachment C)
    (1) Patients will be entered into electronic bed management system by Express Care
    (2) Patient Placement Canter will assign unit and notify charge RN
    (3) Receiving RN or charge RN may contact the sending facility (at the phone number provided in electronic bed management system under comments) for report if sending facility has not already made contact.
    (a) If report suggests that patient is not appropriate for the assigned level of care, notify Maryland Express Care to request a reassessment and possible reassignment.

IV. REPORTABLE CONDITIONS
A. Lack of opportunity to ask questions/ seek clarification.
B. Absence of handoff communication.

V. DOCUMENTATION
A. Documentation that a handoff has occurred will be documented in the medical record.

1. Both parties involved in patient handoff will document that the handoff has occurred.
   B. If written handoff tool is used, the document will be filed in the patient’s medical record.
   VI. SUPPORTIVE INFORMATION
   A. SEE ALSO
2. Attachment A: Handoff Communication Template (FormFast # PG74)
3. Attachment B: Post-Procedural Handoff Communication (FormFast # PG26A)
4. Attachment C: Maryland Express Care Workflow

B. REFERENCES

1. The Joint Commission. (2013). Standard PC.02.02.01. Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission.
   C. COMMUNICATION AND EDUCATION
2. This policy will be communicated to the appropriate UMMC personnel via the following channels:
   a) The policy will be distributed to the Directors of Diagnostic Services, Chairmen of Medical Staff and Department of Nursing Committees for dissemination to their specific department staff.
   b) Updates and revisions will be communicated via Medical Staff and Nursing publications.
   c) This policy will be placed in the Policy and Procedure Manual on the UMMC Intranet site.
   DEVELOPER(S) Provision of Care Committee, Clinical Practice and Professional Development
   REVIEWED/REVISED: NEW 04/1
    
   Appendix B: PDSA (Plan, Do, Study, Act) Worksheet

PLAN
I plan to:

I hope this produces:

Steps I will need to take to execute the plan:

1. This
2. Then this…

DO
What did you observe (what was the motivating factor behind choosing this issue)?

STUDY
After researching your issue, what is your expected or desired outcome (measurement goal)? How will you measure improvement?

ACT
How does your plan align with your established purpose statement?