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Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff.
J Nurs Care Qual
August 2021
Department of Community & Family Medicine, Dartmouth-Hitchcock, Lebanon, New Hampshire (Dr Alexander); Office of Veterans Access to Care, Veterans Health Administration, Washington, District of Columbia (Ms Rovinski-Wagner); VA Quality Scholars Fellowship Program, White River Junction VA Medical Center, Vermont (Ms Rovinski-Wagner and Dr Oliver); Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Ms Rovinski-Wagner); White River Junction VA Medical Center, Vermont (Ms Wagner); and Departments of Community & Family Medicine and Psychiatry, and the Dartmouth Institute Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dr Oliver).
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.