Always Events: Inova Health System


Organization/Institution: INOVA Health Systems
Principal Investigator(s): Mary Ann Friesen, PhD, RN, CPHQ:
Project Title: Developing a Patient-Centered Approach to Handoffs

Always Event(s): Patients will always be included in the ISHAPED handoff shift-to-shift hand-off process at the bedside as this will add an additional layer of safety by allowing the patient to communicate potential safety concerns.

Overview: This project will build on previous research by the Inova Health System (IHS) to improve the quality and safety of patient care by enhancing communication and encouraging patient participation. Recent reviews of patient safety and satisfaction at Inova identified the shift-to-shift handoff as a process in need of improvement. Inova responded by convening a quality-improvement team to develop a new strategy for conducting the shift-to-shift handoff, one that standardizes procedures and incorporates a bedside component. Entitled “ISHAPED” (I=Introduce, S=Story, H=History, A=Assessment,

P=Plan, E=Error Prevention, and D=Dialogue), this strategy also provides patients and their families the opportunity to participate in the handoff process. The proposed project aims to 1) measure patient satisfaction and perceptions regarding the ISHAPED bedside handoff process, 2) use the patient feedback to optimize and standardize the bedside handoff process, and 3) develop a training video and companion toolkit to educate nurses on how to conduct a safe, effective and patient-centered bedside hand-off across multiple settings.


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