Background: Communication has been cited as the most common root cause in sentinel events, with failed patient care handoffs contributing to an estimated 80% of serious preventable adverse events. Handoffs to sub-acute care such as nursing homes are at particularly high risk for communication breakdown given high patient complexity and comorbidity.

Our healthcare system includes a 400-bed acute care hospital and 112-bed sub-acute care facility. Our system did not have a standardized handoff process for hospital transfers. For providers (MDs, PAs, NPs) and nursing, verbal handoffs and discharge documentation were highly variable in quality, format, and completion. Communication about travel and team/unit assignment was chaotic, involving providers, social workers, nurses, and unit secretaries. Handoff data from June 2014 -April 2015 showed that for 159 transfers, handoff was absent for 29 transfers (18%).

Purpose: Our main objective was to improve the handoff process from an acute inpatient hospital to a sub-acute care facility.  Specifically:  

1) Increase usage and standardize content of verbal handoff

2) Simplify communication modes

2) Decrease inappropriate transfers and delays in care (transfer, discharge summary completion)

Description: In conjunction with Patient Safety, we conducted a Healthcare Failure Modes Effects Analysis (HFMEA) on handoffs from Mar-Oct 2016.  


1) Establish Interdisciplinary Team: hospital and subacute care providers, nurses, social workers, and unit secretaries

2) Define goals, outcomes, and a data collection system

3) Process map transfers with detailed sub-process maps

4) Conduct Failure Modes Analysis to identify failures 

5) Hazard Analysis to prioritize failures based on severity and probability

6) Action Plans for high scoring failures:

  • Standard Operating Procedures (SOP) for transfer notification and cancellations
  • Standardize verbal handoff content for nursing and providers (I-PASS: I: Illness severity; P: Patient summary; A: Action items; S: Situation awareness and contingency planning; S: Synthesis by receiver)
  • Retrain administrative staff on travel processes

Evaluation and results: We developed 7 measures that were tracked daily from Apr-Oct 2016 (interventions began June 2016). Provider verbal handoff improved from 80% to 100%  and I-PASS uptake improved from 11% to 82%. Discharge documentation was high at baseline (93-96%) and remained at 95%. Nursing verbal handoffs were also high at baseline (93-100%) and remained at 100%.  Transfers with “unfinished business” and adverse events decreased from 10% to zero.

Conclusions: The HFMEA process improved several handoff process measures for acute care to sub-acute care transfers. Key features were sound data collection, collaboration with Patient Safety, and having an interdisciplinary team from both acute and sub-acute care. A systematic process was essential: process maps to evaluate processes and failures, analysis to prioritize failures, and action plans to develop interventions.