A quality improvement project improving post-operative transitions of care in a level IV NICU.

Objective: Transitions of care are critical periods when NICU patients are at risk for miscommunication leading to patient harm. This quality improvement project aimed to decrease post-operative hand-off-related failures and improve communication in a level IV NICU.

Project Design: The Vermont Oxford Network transitions of care framework was used to develop a safe surgical hand-off definition; (1) all team members present, (2) a structured hand-off format utilized, and (3) an environment conducive for hand-off. Interventions included using standardization for process improvement, scripting ideal communication, and simulation to establish behavioral norms of effective communication.

Results: Post-surgical hand-off-related care failures decreased from 75% pre-implementation to 6% post-implementation (p < 0.00001) by increasing the percentage of hand-offs meeting pre-defined criteria.

Conclusion: Using quality improvement methods to implement process and behavioral changes to improve communication, our team reached our goal of decreasing post-operative hand-off-related care failures.