NURS FPX 4005 Assessment 4 Stakeholder Presentation
Student Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Stakeholder Presentation
Good afternoon, all. I am ________. I will assist you in dealing with poor communication at critical care handoff at Riverview Medical Center. Avoidable errors, treatment delays, and risks to patient safety derive from the exchange of inconsistent information between providers. It presents an interdisciplinary care plan to improve handoff consistency, enhance team coordination, and facilitate safe and smooth patient transitions.
Organizational Issue
A major concern at Riverview Medical Center is the absence of a standardized handoff communication during critical care transitions, which threatens patient safety and continuity of care. The causes of these issues are poor communication, lack of workflow structure, and lack of cross-departmental collaboration. Data loss, care delays, and medical errors occur because of the lack of real-time information exchange between physicians, nurses, and other care team members. Patients, therefore, have increased risks of adverse outcomes, and the hospital has a higher incidence rate and a potential regulatory consequence (Desmedt et al., 2021).
Moreover, unclear roles and fractured handoff processes diminish staff morale and contribute to burnout as healthcare professionals deal with communication breakdowns. Safe transitions in care also impact the hospital’s reputation, as unsafe transitions can negatively affect patient satisfaction and prevent future patients. Hassan et al. (2024) mentioned that structured, team-based handoff strategies, such as SBAR and I-PASS, significantly reduce communication errors and improve patient outcomes. This supports implementing a formal interdisciplinary handoff protocol to improve collaboration, enhance safety, and facilitate care transition failures at Riverview Medical Center.
Importance of the Issue
To deliver safe, high-quality care, gaps in critical care handoff communication must be addressed at Riverview Medical Center. A structured handoff protocol will enable consistency, teamwork, and real-time communication between interdisciplinary team members. The hospital can standardize tools such as SBAR and I-PASS and conduct regular staff training of these tools to reduce the variability of patient transitions and ensure accurate, timely information transfer. Nurse, physician, communication specialist, and administrator coordination will improve patient outcomes, promote a culture of safety, and decrease avoidable readmission rates (Shahian, 2021). This project enables Riverview’s commitment to patient-centered care, increases provider accountability, and strengthens Riverview’s resilient, collaborative healthcare workforce.
Relevance of an Interdisciplinary Team Approach
An interdisciplinary team used to improve handoff communication at Riverview Medical Center must bring together physicians, nurses, case managers, pharmacists, and allied health professionals to aid in safe, consistent, and accurate transitions in critical care. Unique insights from each team member into the patient’s condition and treatment needs are brought to the table with each team member, which, when combined, close gaps, reduce redundancy, and ensure informed, unified care. SBAR and I-PASS are standardized tools everyone uses to talk about things commonly, making it clearer, consistent, and accountable when patients are handed off (Patel et al., 2024).
This interdisciplinary approach’s direct support of improved outcomes includes better teamwork, real-time information sharing, and reduced risk of error or missing information. Collaborative handoff rounds align care goals and responsibilities between disciplines so that all providers work toward the same treatment and discharge plans. Best practices are trained on continuously, communication competence is built, and a culture of safety and trust is reinforced. This translates into fewer delays, better continuity of care, and higher quality patient outcomes, which aligns with the institutional goals around patient safety and performance for Riverview (Patel et al., 2024).
Interdisciplinary Team Roles
The following are the roles and responsibilities of interprofessional team members in this issue:
- Nurse Leaders: Lead SBAR and I-PASS during transitions, monitor handoff effectiveness, and ensure each patient’s care plan is communicated clearly across shifts.
- Case Managers: Coordinate discharge planning and follow-up care, liaising between departments to minimize care fragmentation.
- Pharmacists: Review and reconcile medications during transitions, preventing prescription errors and ensuring continuity of pharmacologic therapy.
- Physicians: Provide clinical oversight during handoffs, ensuring that diagnoses, treatment changes, and critical updates are accurately relayed to the incoming team.
Achieving Safer Transitions and Better Outcomes
At Riverview, improving communication coordination between teams involved in patient handoffs will help eliminate communication breakdowns, prevent unnecessary readmissions, and increase patient satisfaction. This is supported in research, as Patel et al. (2024) showed that interdisciplinary collaboration increases communication effectiveness and improves patient satisfaction and well-being. According to Shahian (2021 structured handoff tools such as I-PASS facilitate clearer transitions and timely decision making. By using a standardized process, rooted in I-PASS, collaborative rounds, and continuous education, Riverview will reinforce team accountability, streamline patient transitions, and continue to ensure safe, high-quality care (Shahian, 2021).
Consequences of Inaction
If Riverview Medical Center fails to utilize an interdisciplinary handoff communication strategy, patient safety risks and preventable medical errors will continue. Without standardized tools such as SBAR or I-PASS, critical patient information may be missed during transitions, leading to adverse outcomes, delayed treatments, and increased sentinel events. A lack of structured communication also causes fragmented care, lower staff confidence, and accountability among team members. While consistent handoff practices can diminish burnout and staff turnover, continued reliance on inconsistent handoff practices can frustrate clinicians and negatively impact morale. Poor handoff may also lead to higher readmission rates, compliance problems with accreditation standards, and operational costs (Abraham et al., 2021). If there are communication gaps, Riverview Medical Center risks compromised care continuity, lost patient trust, and damage to its institutional reputation.
Summary of the Interdisciplinary Plan
Based on evidence, Riverview Medical Center has developed an interprofessional plan to close the communication gaps during critical care transitions by improving collaboration among physicians, nurses, case managers, pharmacists, and allied health staff. Standardized communication tools including SBAR and I-PASS are used in the plan to ensure clear, structured handoffs and minimize information loss, thus improving patient safety. Care teams will be aligned to unified goals and discharge plans through interdisciplinary transition rounds, and regular training workshops will cover handoff best practices, active listening and accurate documentation. This approach promotes mutual accountability, and every team member participates in seamless, high-quality care transitions (Shahian, 2021).
The evidence strongly points to the efficacy of structured, interdisciplinary communication in improving outcomes. Mulfiyanti & Satriana (2022) mention that using such tools as SBAR helps ensure consistency and reduce medical errors in the patient handoff. Fox et al. (2021) also point out that interprofessional collaboration allows for more efficient care delivery, fewer readmissions, and more satisfied providers. Integrating these practices is intended to align Riverview Medical Center with organizational goals for patient safety, satisfaction, and clinical excellence, as well as safely transition patients to other care settings.
Implementation and Resource Management
Strategic planning and resource allocation are needed to implement an effective interdisciplinary handoff communication program at Riverview Medical Center. The Plan-Do-Study-Act (PDSA) cycle will guide sustainability efforts and patient safety during critical care transitions (McGovern, 2022).
Planning Phase
Riverview Medical Center will determine key challenges in the Plan phase: inconsistent handoff communication, fragmented workflows, and lack of standardized protocols. Physicians, nurses, case managers, pharmacists, and allied health staff will be trained in a comprehensive training program to improve structured communication, collaboration, and documentation. Standardized handoff protocols with SBAR and I-PASS will be established, and feedback systems, such as staff surveys and patient safety reports, will be evaluated for potential barriers before implementation (McGovern, 2022).
Doing Phase
In the Do phase, a structured handoff communication pilot program will be launched within some departments to test this. The staff will be trained through simulation-based training to improve handoff procedures, real-time collaboration, and active listening skills. The tools for digital handover will be tested, and EHR integration will be tested to ensure a smooth transfer of information. Communication efficiency, staff compliance, and incident reports will be carefully tracked (McGovern, 2022).
Study Phase
The pilot phase data will be analyzed to examine performance indicators such as reduced handoff errors, improved teamwork, and improved provider satisfaction. Based on feedback from frontline staff and patient outcome trends, training modules, communication workflows, and handoff documentation will be refined (McGovern, 2022).
Act Phase
Based on pilot results, the program will be expanded hospital-wide to Riverview Medical Center to reinforce structured handoff communication and ongoing interdisciplinary collaboration. Regular refresher training, quarterly team meetings, and routine audits guarantee sustained improvements. Continuous monitoring of communication effectiveness and patient outcomes will support long-term optimization of the handoff process in the hospital (McGovern, 2022).
Management of Resources
The interdisciplinary handoff improvement plan can be implemented at Riverview Center through a phased rollout using the PDSA cycle to ensure effective resource use. Staffing will include nurse managers, communication experts, and hospital administrators who will dedicate time to oversee handoff procedures, conduct training, and assess outcomes. Existing resources such as meeting spaces, communication platforms, and digital tools will support SBAR training and its implementation. Additional costs may include hiring external communication consultants ($100–$150 per session) and providing staff workshops on handoff practices ($500–$1,000 annually). Access to records, shift schedules, and handoff audit data is essential but does not incur additional costs. The estimated financial impact encompasses staff time for training, meetings, and data review, with an anticipated annual cost of $10,000–$15,000.
If the initiative to enhance handoff communication at Riverview Medical Center is not implemented, existing communication gaps will likely continue. This can heighten patient safety risks and increase the likelihood of errors. Ineffective handoffs may cause delays in care and incomplete transitions, potentially resulting in legal action and regulatory fines (Keebler et al., 2022). Communication breakdowns can also frustrate staff as crucial patient information may be missed, contributing to higher staff turnover. This turnover disrupts team cohesion, raises recruitment and training expenses, and lowers morale. Poor handoff procedures can ultimately diminish patient satisfaction by delivering inconsistent and unsafe care, negatively impacting the hospital’s reputation.
Evaluation of Outcomes
If the handoff improvement project at Riverview Medical Center is successful, communication-related errors will decrease, collaboration on the team will improve, and readmissions to the hospital will decrease. Reducing handoff-related errors and adverse events will be one key evaluation criterion, which will be tracked through incident reporting systems and data comparison before and after the implementation. This is consistent with the evidence from Fox et al. (2021) on communication failures as a leading cause of sentinel events. Increased staff adherence to standardized communication tools such as SBAR and I-PASS will indicate success. This will be monitored as documented through direct observation and regular audits of documentation practices. Finally, reducing 30-day hospital readmission rates will show that coordinated care transitions improve patient outcomes. These criteria will ensure that the project’s effectiveness will be clear and that continuous quality improvement efforts will be supported.
Conclusion
Finally, communication gaps during critical care handoffs at Riverview Medical Center require a structured interdisciplinary approach to address these gaps and improve patient safety, reduce medical errors, and improve overall care outcomes. The hospital can greatly improve communication and collaboration among healthcare providers by utilizing standardized tools like SBAR and I-PASS, staff training, and ongoing feedback mechanisms. This will save the facility from adverse patient outcomes and readmissions and help create a culture of accountability and teamwork. Using the PDSA cycle helps in the effective management of the initiative and in the efficient use of the resources in support of Riverview’s commitment to providing high-quality, patient-centered care.
References
Abraham, J., Meng, A., Sona, C., Wildes, T., Avidan, M., & Kannampallil, T. (2021). An observational study of postoperative handoff standardization failures. International Journal of Medical Informatics, 151, 104458. https://doi.org/10.1016/j.ijmedinf.2021.104458
Desmedt, M., Ulenaers, D., Grosemans, J., Hellings, J., & Bergs, J. (2021). Clinical handover and handoff in healthcare: A systematic review of systematic reviews. International Journal for Quality in Health Care, 33(1). https://doi.org/10.1093/intqhc/mzaa170
NURS FPX 4005 Assessment 4 Stakeholder Presentation
Fox, S., Gaboury, I., Chiocchio, F., & Vachon, B. (2021). Communication and interprofessional collaboration in primary care: From ideal to reality in practice. Health Communication, 36(2), 125–135. https://doi.org/10.1080/10410236.2019.1666499
Hassan, A. E., Mohammed, F. A., Zakaria, A. M., & Ibrahim, I. A. (2024). Evaluating the effect of teamstepps on teamwork perceptions and patient safety culture among newly graduated nurses. BioMed Central Nursing, 23(1), 170. https://doi.org/10.1186/s12912-024-01850-y
Keebler, J. R., Lazzara, E., Griggs, A., Tannenbaum, S., Fernandez, R., Greilich, P., & Salas, E. (2022). Holistic strategy for promoting effective handoffs. BMJ Leader. https://doi.org/10.1136/leader-2022-000639
McGovern, V. L. (2022). Quality improvement initiative through staff development: Using education to increase preoperative handoff communication. University of New Hampshire Scholars’ Repository. https://scholars.unh.edu/thesis/1605/
Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376-380. DOI: 10.55299/ijphe.v2i1.275
NURS FPX 4005 Assessment 4 Stakeholder Presentation
Patel, S. M., Fuller, S., Michael, M. M., O’Hagan, E. C., Lazzara, E. H., & Riesenberg, L. A. (2024). Handoff mnemonics used in perioperative handoff intervention studies: A systematic review. Anesthesia & Analgesia. https://doi.org/10.1213/ane.0000000000007261
Shahian, D. (2021). I-PASS handover system: A decade of evidence demands action. BMJ Quality & Safety, 30, bmjqs-2021-013314. https://doi.org/10.1136/bmjqs-2021-013314
