Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff.

Background: There is limited evidence available identifying best practices to promote and sustain optimal outpatient-to-inpatient handoff processes to ensure safe and reliable continuity of care.

Local Problem: A sentinel event occurred during the transition of care from the outpatient-to-inpatient setting. A root cause analysis revealed that the facility's standard operating procedure for patient handoffs was not consistently followed.