NR 543 Week 4 Handoff Analysis Example

Handoff Analysis: Six Points Where an Inpatient MRI Request Passes From One Person to Another, How Each Receiver Learns It Has Arrived, and Why the Handoff From the Unit Back to the MRI Technologist Averages Longer Than the Scan

Student Name

College of Nursing, Chamberlain University

NR 543: Information Workflow in Healthcare

Instructor Name

Month Day, Year

Handoff Analysis: Six Points Where an Inpatient MRI Request Passes From One Person to Another, How Each Receiver Learns It Has Arrived, and Why the Handoff From the Unit Back to the MRI Technologist Averages Longer Than the Scan

The Interval Between

At every handoff in a care process, the sender is finished and the receiver has not started. In between, the item is nobody's active work. That interval is usually where most of the elapsed time sits, and it is invisible to both parties, because each experiences only their own part. This analysis examines the six handoffs in the inpatient brain MRI process on our stroke and neuroscience unit, using timestamps from 38 requests over two weeks and a day of direct observation. For each handoff it asks three questions: what passes from sender to receiver, how the receiver learns that it has arrived and how long the interval lasts.

Six Handoffs

Handoff 1: Provider to neuroradiologist. What passes is the order, with a clinical question. The receiver learns of it by checking the protocol worklist, which is sorted by urgency, so routine inpatient orders sit below emergency studies. Median interval: about 2 hours in the morning, 40 minutes in the afternoon.

Handoff 2: Neuroradiologist to nurse. What passes is the protocolled order, which triggers the screening form. The nurse learns of it only when the form appears as a task on the nursing worklist among dozens of others, with no indication of urgency. Median interval before the nurse opens the form: 1 hour 40 minutes.

Handoff 3: Nurse to MRI technologist. What passes is the completed screening form. The technologist learns of it only by checking a screening review list, which is checked when the technologist is between scans. Median interval: 35 minutes. When the form is returned as incomplete, the reverse handoff, technologist to nurse, is signaled by a message in the record's inbox, which nurses on this unit check irregularly; median interval before the nurse sees it: 2 hours 15 minutes.

Handoff 4: Technologist to scheduler. What passes is a cleared request. The scheduler sees it on the scheduling list. Median interval: about 25 minutes during office hours; after 5 p.m. the evening technologist schedules, adding a delay for requests cleared late in the day.

Handoff 5: Scheduler to unit clerk and transport. What passes is the slot time. The clerk learns of it from a notice on the unit's patient list and requests transport, ideally 45 minutes before the slot. In 9 of 38 requests the clerk requested transport less than 20 minutes before the slot, usually because the notice was not seen.

Handoff 6: Radiologist to neurologist. What passes is the report. The neurologist learns of it from the results inbox. Median interval after the report is signed: under an hour during rounds, longer overnight.

The Longest Handoff

The reverse handoff at step 3, when a technologist returns an incomplete screening form to the nurse, is the longest interval in the process, with a median of 2 hours 15 minutes, longer than the scan itself and far longer than any other handoff. It is also the least visible. The technologist sends an inbox message and moves on; the nurse is at the bedside and sees the message only when next at a computer with time to open the inbox. Nothing on the nurse's worklist or the patient list shows that an MRI is waiting on the nurse.

This handoff is where the screening loop found in the current state map does its damage. A request returned for an uncertain implant history waits more than two hours before the nurse even knows, and then waits again for someone who can answer.

What Makes a Handoff Short or Long

Comparing the six handoffs, the short ones share two features: the receiver works from a list designed for that task, and the list is checked frequently as part of the receiver's normal work. The long ones share the opposite: the item arrives in a place the receiver checks irregularly, mixed with unrelated items, without any sign of urgency. A systematic review of nursing handoffs found the literature dominated by descriptive and opinion work, with standardized approaches widely recommended but rarely tested rigorously (Riesenberg et al., 2010). The MRI process has no standardized handoff at all; each transfer depends on a receiver noticing an item in a list built for something else.

Information That Does Not Pass

Some handoffs pass the task without the information the receiver needs. The protocol order passes to the nurse without any note that the patient cannot answer screening questions, although the admission assessment records aphasia. The screening form passes to the technologist without the chart's implant history, which the technologist must look up separately. Professional guidance on MR safety expects screening to draw on all available sources, including records and family, when a patient cannot answer (Kanal et al., 2013). The handoffs do not bring those sources together; each receiver assembles them again.

Implications

The analysis suggests that the most valuable changes are not faster work at any step but shorter intervals between steps, especially the reverse screening handoff. Lean approaches to health care improvement emphasize improving flow between steps, not only the steps themselves (Mazzocato et al., 2010). Three possibilities follow for the future state proposal: making the returned screening form visible on the nurse's worklist and the patient list; flagging, at the moment of ordering, patients who are unlikely to be able to answer screening questions; and passing the chart's implant history with the form so the technologist does not have to search for it. Each targets an interval, not a task.

References

Kanal, E., Barkovich, A. J., Bell, C., Borgstede, J. P., Bradley, W. G., Froelich, J. W., Gimbel, J. R., Gosbee, J. W., Kuhni-Kaminski, E., Larson, P. A., Lester, J. W., Nyenhuis, J., Schaefer, D. J., Sebek, E. A., Weinreb, J., Wilkoff, B. L., Woods, T. O., Lucey, L., & Hernandez, D. (2013). ACR guidance document on MR safe practices: 2013. Journal of Magnetic Resonance Imaging, 37(3), 501-530. https://doi.org/10.1002/jmri.24011

Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in healthcare: A realist review of the literature. Quality and Safety in Health Care, 19(5), 376-382. https://doi.org/10.1136/qshc.2009.037986

Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24-34. https://doi.org/10.1097/01.NAJ.0000370154.79857.09