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QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL:
IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL
HOSPTITAL’S EMERGENCY DEPARTMENT
TMIT Student Projects QuickStart Package ™
1. BACKGROUND
Setting: Emergency departments are “high-risk” contexts; they
are over-crowded and
overburdened, which can lead to treatment delays, patients
leaving without being seen by a
clinician, and inadequate patient hand-offs during changing
shifts and transfers to different
hospital services (Apker et al., 2007). This project will focus
on the Emergency Departments in
county hospitals, specifically San Francisco General Hospital.
SFGH has the only Trauma Center
(Level 1) available for the over 1.5 million people living and
working in San Francisco County
(SFGH website)

Health Care Service: This paper will focus on intershift
transfers, the process of transferring a
patient between two providers at the end of a shift, which can
pose a major challenge in a busy
emergency department setting.
Problem: According to the Joint Commission on Accreditation
of Healthcare Organizations
(JCAHO), poor communication between providers is the root
cause of most sentinel events,
medical mistakes, and ‘‘near misses.” Furthermore, a recent
survey of 264 emergency
department physicians noted that 30% of respondents reported
an adverse event or near miss
related to ED handoffs (Horwitz, 2008). A similar survey notes
that 73.5% of hand-offs occur in
a common area within the ED, 89.5% of respondents stated that
there was no uniform written
policy regarding patient sign-out, and 50.3% of those surveyed
reported that physicians sign out
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patient details verbally only (Sinha et al., 2007). At SFGH,
handoffs occur in the middle of the
ED hallway, usually next to a patient’s gurney. Sign-out is
dependent on the Attending and
Residents on a particular shift; thus, it is non-uniform, and
hand-offs are strictly verbal.
Barriers to Quality: In a 2005 article in Academic Medicine,
four major barriers to effective
handoffs were identified: (1) the physical setting, (2) the social
setting, and (3) communication
barriers. Most of these barriers are present during intershift
transfers at SFGH. The physical
setting is usually in a hallway, next to a whiteboard, never in
private. Presentations are frequently
interrupted, and background noise is intense from the chaos of
an overcrowded emergency room.
Attendings frequently communicate with each other and assume
that the resident can hear them.
Solet et al. suggests that Residents are unlikely to ask questions
during a handoff if the
information is coming from an Attending physician. All
transfers are verbal, none are
standardized, and time pressures are well known, since sign-out
involves all working physicians

in the ED at one time.
2. THE INTERVENTION
The Institute for Health Care Improvement (IHI) lays out
several steps for conducting a quality
improvement project. First, an organization needs to explicitly
state what they are trying to
accomplish by setting “time specific and measurable aims” (IHI
website). Next, an organization
needs to establish measures that will indicate whether the
improvement works. Changes that
result in an improvement need to be identified and then tested in
a Plan-Do-Study-Act (PDSA)
cycle. Specifically, the change needs to be planned, tried,
studied, and then members must act on
what they have learned (IHI website). PDSA cycles should start
out in a small group before
being tried in a large institutional setting. Finally, the changes
should be made throughout the
institution.
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Most projects that use rapid PDSA cycles to address issues with
patient handoffs
measured their compliance with a standardized communication
method. Programs such as the
Five Ps (Patient, Plan, Purpose, Problems, Precautions), I PASS
the BATON, or SBAR, are all
acronyms for a standardized, tested procedure to ensure
compliance with the Joint Commission
requirements (Runy, 2008). Such methods may standardize the
handoff process, but may not be
considered the most efficient tool by providers; therefore,
provider satisfaction is a key
component for compliance and implementation (Wilson, 2007).
Process defect: This project will attempt to address non-uniform
patient handoffs at the SFGH
ED by using rapid PDSA cycles to implement the SBAR handoff
technique:
- S-ituation: complaint, diagnosis, treatment plan, and patient’s
wants and needs
- B-ackground: vital signs, mental and code status, list of
medications and lab results
- A-ssessment: current providers assessment of the situation
- R-ecommendation: pending labs, what needs to be done

(H&HN, 2008)
Aim (Objective): to improve patient safety, content reliability,
and peer satisfaction with SFGH
ED handoffs by having 100% compliance of the SBAR
standardized protocol within 18 months
(adapted from Owens et al., 2008)
3. STRATEGY FOR IMPLEMENTATION
The first step of this implementation strategy will be to identify
the early adopters and process
owners. A small team, perhaps of one attending and two
residents that are passionate about this
project need to be identified and initiate the first PDSA cycle
using the SBAR format for patient
handoffs. In this small group, they can work out their pit-falls,
and adapt the SBAR technique to
the physical setting and social setting at SFGH. This group may
wish to develop an index card
with an SBAR template to improve communication. The first
PDSA cycle may look something
like this:
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- Plan—develop a strategy to reduce noise and distractions, use
SBAR (perhaps with an
index card that can be passed on), and have opportunity to ask
questions.
- Do—early adopters need to try out the process during two
changes of shift.
- Study—evaluate satisfaction, review pitfalls, was it easy to
comply?
- Act—Implement changes during next two changes of shift.
Next, this group will need to identify opinion leaders within the
organization, perhaps the Chief
Resident, to help convince the early majority that this technique
will improve patient safety and
save time and effort during changes of shift. The early adopters
may want to hold a training to
convince this larger group. Next, this larger group will initiate
its own PDSA cycle, until 100%
compliance with the SBAR protocol is achieved.
Measures: (a) compliance with the SBAR format, via an “all or
none” metric, (2) provider
satisfaction via survey, which will include questions on
perceptions of time saving.

Barriers to change: The major barriers to change will be from
opinion leaders within the SFGH
ED that want to protect the status quo. Some Attending and
Resident physicians may be wary of
a new technique for fear that it may add to the amount of time it
takes at the change of shift.
Second, most of these physicians have “always signed-out this
way and have never had a
problem.” Once the early adopter group has worked out many
of the kinks in implementation,
leadership will play a key role for further adoption of this
project. Leaders may take note of the
Joint Commission’s recommendation on handoffs (JCAHO,
2006), and support this project, and
help nudge the late adopters along. However, in the long run,
provider satisfaction of the
protocol, including provider’s perceptions of saving time, will
dictate adherence, so even late
adopters need to have input during PDSA cycles.
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Simple Rules: The landmark IOM report Crossing the Quality
Chasm identified 10 simple rules
to help redesign health care processes (IOM, 2001). This
quality improvement project is in
accordance with rule ten: cooperation among clinicians.
Clinicians should “actively collaborate
and communicate to ensure and appropriate exchange of
information and coordination of care.”
Standardizing patient handoffs in a busy emergency department
setting is crucial to patient safety
and helps place patients needs first; this change manifests this
simple rule.
Cost implications: This process change does not require any
additional costs.
REFERENCE
Apker et al. (2007) Communicating in the “gray zone”:
perceptions about emergency physician-
hospitalist handoffs and patient safety. Aca Emerg. Med.
14(10), 884-94
Coleman et al. (2004) Lost in Transition: Challenges and
Opportunities for Improving the quality
of Transitional Care, Ann Intern Med. 140:533-36.
Horwitz et al. (2008) Dropping the Baton: A qualitative analysis

of failures during the transition
from emergency department to inpatient care. Annals of
Emergency Med. Article in press,
accessed April 21, 2009
Horwitz et al. (2009) Evaluation of an Asynchronous Physician
Voicemail Sign-out for
Emergency Department Admissions. Annals of Emergency
Med. In press, accessed April 21,
2009.
IHI website. Improvement methods-PDSA cycle.
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMetho
ds/HowToImprove/ accessed
April 29, 2009.
Institute of Medicine (IOM). Crossing the Quality Chasm.
Washington, DC: National Academy
Press, 2001.
Joint Commission on Accreditation of Healthcare
Organizations. Sentinel event root causes. Jt
Comm Perspect Patient Saf. 2005; 5(7):5–6.
JCAHO. Improving Handoff Communications: Meeting National
Patient Safety Goal 2E. Joint
Perspectives on Patient Safety. 2006; 6(8): 9-15.
Owens et al. (2008) Improvement Report: Improving Resident-
to-Resident Patient Care
Handoffs, IHI.org, accessed April 29, 2009.
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Runy, Lee Ann (2008) Patient Handoffs, the pitfalls and
solutions of transferring patients safely
from one caregiver to another. H&HN.com, accessed April 29,
2009.
SFGH website; http://sfghed.ucsf.edu/Index.htm, accessed April
21, 2009.
Sinha et al. (2007) Need for standardized sign-out in the
emergency department: a survey of
emergency medicine residency and pediatric emergency
medicine fellowship program directors.
Aca Emerg Med.; 14(2) 192-6.
Solet et al. (2005) Lost in Translation: Challenges and
Opportunities in Physician-to-Physician
Communication During Patient Handoffs. Academic Medicine;
Volume 80 - Issue 12 - pp 1094-
1099
Wilson, Mary Jane (2007) A template for Safe and Concise
Handovers, Medsurg Nursing. 16(3);
201-06.
0. Write a 1000-1250 word essay summarizing:
0. Your learning experience during the practicum
0. Assessment administration- the pre and post assessment data,
challenges and strengths.
0. Data analysis. Include a chart or graphic organizer.
0. Specific activities with the student during instruction
0. Progress made to be notated in the chart
0. Collaboration with the classroom teacher
0. Your reflection on how assessment guides instruction.
Explain how data was used to target the needs of the student

and to plan instruction.
0. Use standard essay format in APA style, including an
introduction, conclusion, and title page. An abstract is not
required. Cite in-text and in the References section.
0. Submission of Benchmark Assessment
1. Combine all of your assessment data, copies of your lesson
plans for each of the literacy areas, and reflection paper under
one APA-style title page.
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QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL
IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL
HOSPTITAL’S EMERGENCY DEPARTMENT
Cherrelle Jones
MHA 616 Policy formation and leadership in Healthcare
Organization
Dr. Jack Lazarre
December 1, 2014
1. BACKGROUND
The emergency department is a facility for medical treatment
that is mostly concerned with care for patients who require

urgent treatment. This patient’s mostly just pop in without any
prior appointment. This is a very serious attendance, as these
patients just come with life threatening illnesses, which needs
emergency attendance. The emergency unit is very complex, and
a place where people don’t understand how the next minute will
be like. The difference between life and death is always a hair
breadth away (Garcia, & Schaffer, 2010). The greatest concern
of the emergency department, therefore, is to reduce the waiting
time for the patients. Most of them can’t wait for long due to
the conditions they come in. It’s so disheartening for these
patients to come to the hospital and leave when they are not
treated. This project will focus on the emergency departments in
the county hospitals, specifically in San Francisco General
Hospital. It serves a total of 1.5 million people but has only
one Trauma center. This is very dangerous because such a big
population can be at a higher risk. It’s good therefore to come
up with solutions that could also be helpful to other hospitals
apart from this one this one in question.
2. OBJECTIVES
1. To reduce waiting time
2. Maximize patients transfer.
3. METHODS
1. Addition of more resources
2. The Emergency department to improve their relationship
and communication with one another
4. RECOMMENDATION ONE: TO REDUCE WAITING TIME
To reduce the waiting time, there must be an addition of
resources such as beds, doctors, nurses inclusive of others
(Ojeda, 2004). There can be an expansion of alternatives too.
This is for the purpose of helping the patients to make health
care choices. This will reduce the pressure in the system. This
can be done by the ministry of education through supporting the
patients with chronic illnesses (Garcia, & Schaffer, 2010). They

can also create a bigger space by increasing the bed capacity or
even creating more urgent centers. It could also help to teach
people on how to handle some diseases on their own. This
creation of public awareness will reduce the overlap of patients
in the hospital (Hall, 2010).
Another way to reduce waiting time is by putting patients
before profits. Sometimes, the reason people wait for hours just
to see a doctor is because, they are not bringing profits to some
individual’s pocket. This is not the right thing to do especially
in a hospital setup because life is better than money. The
patients should be made a priority over other things. This is not
to say that corruption is the main reason there is a delay, but
sometimes it contributes to. Looking at private hospitals where
they charge any amount, I have never seen any moment their
patients complain of being delayed. These hospitals get money
and give their best. Thus, patients, no matter how much they are
paying, they should be treated without delay, unless otherwise
(Garcia, & Schaffer, 2010).
Another way of reducing waiting time has a common waiting
list. Sometimes patients can behave weird. They know they
can’t treat themselves, and that’s why they came to the hospital,
and they won’t heed to the hospitals orders. You will hear some
of them in their dying beds specializing on the doctor and the
surgeon they want to see. If the patients can be made to
understand the importance of seeing a surgeon who is available,
the better. This will reduce the time for waiting. If they just
wait until they get the physician they want, then they will have
to wait longer.
It could also help to have a better coordination in the
Emergency departments. Time should be taken care of. When
there are snuggeries to be done, there are a lot of things that
needs to be done during the preparation. The surgical
equipment’s need to be standardized. There are also other
procedures that include pre-screening and testing. If all this
activities are well coordinated, there can be a lot of time left
over for other patients (Garcia, & Schaffer, 2010).

It is also very important to expand the team work. For any
hospital unit to be complete we need the physicians, nurses,
nurse practitioners and other health professionals. If a hospital
unit is made of this combination, which can corporate and have
a great team work, then, coordination of activities will be
faster. Again, if they work in their areas of specialization, there
will be good utilization of scarce resources and the reduction of
waste (Hall, 2010). .
I also recommend that, to solve the problem of long waiting
still, there should have modernization of electronic information
system. When hospitals use manual means of records, before
finding out the details of the patients, it takes all the time. If the
patients records are stored electronically, in this case being
updated, the time that would be saved, would be utilized to
attend another patient.
Lastly on this, is important to improve community health care.
Home care and home support keeps people out of the hospitals
for long. If people can eat healthily, and they be shown how to
practice healthy living, the emergency units could have less and
fewer people. This could be a long time plan, but it’s worth it
(Hall, 2010). Improvement of access to family heath care,
whereby there are built community clinics and urgent health
care censer, there will be less and lesser queue in the ERs.
5. RECOMMENDATION TWO: INCREASING THE
TRANSFER OF PATIENTS
Internships handovers of physicians has been identified as an
area of a very great risk, for adverse effects, which represents a
very critical step in the care transition of patients. The most
important of all steps that can solve this is communication that
is clear (Lowers, 1998). Today, in most hospitals, patients are
cared for by a team of many doctors and many nurses. This
doctor keeps on going off shift and the next one comes in to
continue with the shift. In the middle of all this, it is important
for the outgoing doctor to pass on clear information to the
incoming one. There are some patients who feel like this
method denies them an opportunity to have their privacy. They

can be made to understand that this is for their own good. There
is a new technology that is of great help in this process of
transferring information, from one doctor to another as they
exchange shifts. Use of tapes for the doctors to record what they
are doing is a bit difficult. This is because; it does not pass on
clear information due to background noises and other
challenges. Sometimes the records might take all the time due to
interruptions, which bring a need for a repeated process (Garcia,
& Schaffer, 2010).
6. GAIN
The greatest gain of this recommendation processes is that, it
will reduce the queuing time for the patients. There is nothing
painful like having a patient, who is in pain, sited down for
hours, just to wait for treatment. In this case, it is not less
severe ailments such as flu, but very serious ones such as a
heart attack (Garcia, & Schaffer, 2010). The above
recommendations are very important if waiting time is to be
reduced, and the handoffs of doctors are effective, this process
can be so smooth. The aftermath of every treatment is for the
patient to get well.
7. RESOURCES
As said earlier, resources are very important. There is nothing
that can be achieved, unless the necessary resources are put into
the process (Hall, 2010). . The reason the time on waiting is
too long is contributed somehow but scares resources. Extra
resources are, therefore, needed.

References
Garcia, C., & Schaffer, M. (2010). Population-based public
health clinical manual: The Henry Street model for nurses
(Second ed.).
Hall, R. (2010). Patient flow: Reducing delay in healthcare
delivery (Second ed.).
Lowers, J. (1998). Medical guidelines and outcomes at work: 25
approaches to improving care and lowering costs ([2nd ed.).
Alexandria, VA: Capitol Publications.
Ojeda, A. (2004). Health. San Diego, Calif.: Thomson/Gale ;.