#MEQAPI – Tweetchat April 6th 2017 3ET: Quality Improvement vs Patient Handoff

Next tweetchat: Thursday April 6th, 2017 3:00-4:00 PM ET

Topic:  Quality Improvement vs Patient Handoff

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This week the #MEQAPI topics relate to British Medical Journal and Physician’s Weekly articles related to safe and effective patient handoff.

Patient handoff and discharge are two of the most risky events in the patient journey through the care process, and account for the lion’s share of mistakes and missed opportunities. Incomplete or incorrect information transfer, (or failure to transfer at all) can result in sub-optimal patient outcomes, injury, or death.

The BMJ Quality & Safety report that over 6000 doctors, nurses, and therapists have been trained on the I-PASS patient handoff method at Massachusetts General Hospital to improve handover quality, and reduce preventable errors and adverse outcomes.

Dr. Amy Starmer wrote in Physician’s Weekly of positive effects of a patient handoff program that she and colleagues developed using I-PASS. Dr. Starmer has offered to attend the chat to provide additional insights and updates.

Standardizing the patient handoff process and making it a “no interruption” activity can reduce risks due to distraction, multitasking, and missed steps, while also reducing missed opportunities.

Quality Improvement approaches can greatly increase adoption and effectiveness of standardized handoff processes by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the handoff process and remove obstacles to adoption and compliance.


We will take a QI approach, and discuss the next topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Handoff

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps in handoff, etc.
    • Insurance Models
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc.
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a bad handoff
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a bad handoff
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a bad handoff
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a bad handoff
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a bad handoff
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a bad handoff


The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

MEQAPI numbers Apr 6


MEQAPI Participants