quality in action

Ensuring Effective Care Transition

Communication: Implementation of an Electronic
Medical Record–Based Tool for Improved Cancer
Treatment Handoffs Between Clinic and
Infusion Nurses
Chintan Pandya, PhD, MPH, MBBS1; Tammy Clarke, RN, MS, OCN, BMTCN1; Elizabeth Scarsella, MSBA, RN, BSN, OCN1;
Alex Alongi, BS1; Stephanie Buia Amport, MBA, CPHQ2; Lauren Hamel, PhD3; David Dougherty, MD, MBA4
abstract

PURPOSE Ineffective handoffs contribute to gaps in patient care and medication errors, which jeopardize patient
safety and lead to poor-quality care. The project aims are to develop and implement a standardized handoff
process using an electronic medical record (EMR)–based tool to ensure optimal communication of treatment-
related information for patients receiving cancer treatment between oncology nurses.
METHODS A multidisciplinary team convened to develop a standard and safe treatment handoff process. The
intervention was developed over a series of phases using Plan-Do-Study-Act methodology, including current
workflow process mapping; identifying gaps, limitations, and potential causes of ineffective handoffs; and
prioritizing these using a Pareto chart. An EMR-based tool incorporating a standardized treatment handoff
process was developed. Study outcomes included proportion of handoff-related medication errors, tool utili-
zation, handoff completion, patient waiting time, and nurse satisfaction with tool. All outcomes were evaluated
before and after the intervention over a 1-year period.
RESULTS The proportion of medication errors as a result of ineffective handoffs was reduced from 10 of 17 (60%)
pre-intervention to 11 of 34 (32%) postintervention (P = .07). The EMR-based handoff tool was used in 9,274 of
10,910 (85%) patient treatment visits, and the handoff completion rate increased from 32% pre-intervention to
86% postintervention. Patient waiting time showed an average reduction of 2 minutes/patient/month. A majority
of nurses reported that the new tool conveyed necessary information (85% of nurses) and was effective in
preventing errors (81% of nurses).
CONCLUSION Multidisciplinary stakeholders guided the development and implementation of a standard handoff
process and an EMR-based tool to optimize communication between nurses during patient transition. The
intervention was associated with a reduction in the proportion of medication errors as the result of ineffective
handoffs. In addition, the intervention improved communication between nurses.
J Oncol Pract 15:e480-e489. © 2019 by American Society of Clinical Oncology

ASSOCIATED
CONTENT BACKGROUND handoff form with or without verbal exchange of es-
Appendix Wilmot Cancer Institute (WCI) at University of sential treatment-related information between nurses
Author affiliations Rochester Medical Center is a Quality Oncology is an expected practice at WCI. However, only 32% of
and support
Practice Initiative–certified cancer center that serves text-based handoff forms were completed between
information (if July 2014 and June 2016. In the same period, quality
applicable) appear
more than 6,000 analytic cancer cases throughout the
at the end of this upstate New York region. In 2011, WCI transitioned to evaluation of reported safety events with review of
article. the Epic electronic medical record (EMR) system. This medical records indicated that 60% of medication
Accepted on February required changes to cancer care delivery patterns, error events (10 of 17 events) were because of in-
11, 2019 and workflows, and clinical documentation including effective handoff communication between clinic and
published at infusion nurses. Ineffective handoffs can contribute to
handoff communication between nurses to exchange
jop.ascopubs.org on
April 4, 2019:
critical information about patients. During the transi- gaps in patient care, jeopardize patient safety, result in
DOI https://doi.org/10. tion of patients from the clinic to the infusion center to medication error, and lead to poor quality care
1200/JOP.18.00245 receive cancer treatment, the use of a text-based delivery.1,2

e480 Volume 15, Issue 5

 EMR-Based Intervention for Effective Nurse Communication
The WCI quality and safety team participated in ASCO’s
Quality Training Program in 2016 to develop an intervention
to improve and standardize communication during hand-
offs between clinic and infusion nurses for patients re-
ceiving cancer treatments. The aims of this quality
improvement project were as follows: (1) to develop and
implement an intervention consisting of a standard treat-
ment handoff process using the EMR-based tool, and (2) to
evaluate the effect of the intervention on the primary study
outcome (ie, medication errors as the result of ineffective
handoffs) and secondary outcomes (ie, tool utilization,
handoff completion, patient waiting time, and nurse sat-
isfaction with tool).
METHODS
We implemented a formal quality improvement (QI) in-
tervention using the well-established Plan-Do-Study-Act
methodology to develop a standard and safe treatment
handoff process and an EMR-based handoff tool.3 A
multidisciplinary team consisting of clinic and infusion
nurses, oncologists, pharmacists, a medical informaticist,
and an information analyst was assembled. First, the team
developed a project charter, conducted a review of baseline
data, and formulated an aim statement. Second, a handoff
process map (Appendix Fig A1, online only) was created to
highlight barriers to effective communication during patient
transition from clinic to infusion center. Third, with input
from nurses involved in patient treatment handoff, a cause-
and-effect diagram (Fig A2, online only) and a Pareto chart
(Fig 1A) were created to identify the most significant bar-
riers to an effective handoff process and to guide devel-
opment of the new handoff process.
Through cause-and-effect analysis and multivoting, it was
determined that the most commonly reported barriers to
effective handoffs were “handoff tool was not user-friendly”
and “a lack of standardization of handoff workflow.” Using
the Situation-Background-Assessment-Recommendation
(SBAR) framework, which captures the four central com-
ponents of handoff communication, an EMR-based
handoff tool (WCI Handoff Tool) was developed to over-
come these barriers.4 On the basis of input and consensus
from providers involved in cancer treatment delivery and
process, the team developed the contents for each com-
ponent of the SBAR framework. All components of the
handoff process are entered into discrete data fields in the
WCI Handoff Tool to enable efficient capture of relevant
data and to automate tracking and reporting (Appendix
Fig A3, online only). Education for implementation of the
new handoff process and WCI Handoff Tool was provided
via group presentations and information sheets for clinic
and infusion nurses.
MEASURES AND DATA ANALYSIS
The primary outcome was the proportion of medication
errors as the result of ineffective handoffs (medication
Journal of Oncology Practice
errors as the result of ineffective handoffs/total medication
errors). These data were obtained from the incident reporting
system, and the cause of error was determined through chart
review by an oncology quality nurse manager. Secondary
process outcomes were objective handoff communication
measures. These included the following: (1) handoff tool
utilization rate, which was whether the clinic nurse com-
pleted the tool before the patient received treatment; (2)
handoff completion rate, which was utilization rate plus
whether the handoff tool was reviewed by the infusion nurse
before treatment was administered; and (3) patient waiting
time, which was the time from patient check-in at the in-
fusion center to the time treatment was started. Last, we
elicited nurse satisfaction with the tool by conducting pre-
implementation and 1-month post-implementation follow-up
assessment surveys. Descriptive statistics were used to
analyze the primary and secondary outcomes. Bivariate
analysis was performed using the t test and x2/Fisher’s exact
test in SAS version 9.4 (SAS Institute Inc., Cary, NC).
RESULTS
The proportion of medication errors as the result of in-
effective handoffs was 32% (11 of 34 errors) during the
1-year postintervention period compared with 60% (10 of 17
errors) during the 2 years before intervention (P = .07). The
WCI handoff tool was used in 9,274 of 10,910 patient visits
(85%) and completed in 86% of those visits (7,976 of
9,274) during the 1-year study period (Fig 1B). Patient
waiting time was reduced by an average of 2 minutes/
patient/month between pre- and postintervention periods,
but this finding was not statistically significant (Appendix
Table A1, online only).
Of the 60 clinic and infusion nurses who received the pre-
intervention assessment survey (presurvey), 42 nurses (26
clinic and 16 infusion) completed it (70% response rate). A
majority of nurses (64%; 27 of 42 nurses) responded to a
postintervention follow-up survey (postsurvey). A majority of
nurses in postsurvey (85%) found the new tool to be
somewhat/very effective in preventing errors (v 48% pre-
survey), and 81% (postsurvey) of nurses reported that the
new tool conveys all necessary information to treat patients
safely (v 58% presurvey; Table 1).
DISCUSSION
We designed and implemented a QI intervention consisting
of a standardized treatment handoff process and an EMR-
based tool. Findings demonstrated improved handoff
communication between nurses as well as improvement in
quality and process outcomes. Specifically, the intervention
resulted in a lower proportion of medication errors as a
result of ineffective handoffs, increased utilization of the
handoff tool, decreased patient waiting times, and in-
creased nurse satisfaction with the handoff process and
tool. The promise of EMR systems to enable improved
processes, documentation, and reporting has yet to be
e481
 Pandya et al

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realized for a large number of health care organizations. nurses was significant and sustained during the study
This is largely because of a lack of comprehensive, mul- period. Intervention components that may have contributed
tidisciplinary design of tools as well as a lack of optimal to such significant improvement in outcomes potentially
integration in clinical care workflows.5 In this QI in- include a user-friendly and efficient EMR-based tool, nurse
tervention, early engagement of multidisciplinary stake- training on standardized workflow and tool use, continuous
holders resulted in standardization of the handoff process, education, a monthly report tracking utilization of the tool,
development of an optimal handoff tool, and higher uptake and provider accountability. Moreover, the WCI Handoff
and integration of the intervention in routine clinic Tool was designed using the SBAR framework to capture
workflows. important information necessary for accurate chemother-
apy administration. Hence, the tool is user-agnostic and
The proportion of medication errors as the result of in-
can be used by any health care team member involved in
effective handoff decreased after intervention (11 of 34 v 10
the treatment administration workflow.
of 17 medication errors), despite a relatively shorter post-
intervention period (1 v 2 years) and higher total medication These findings should be considered within the limitations
error events (17 v 34 events) reported in the incident of the project. First, the influence of intervention on patient
reporting system. The increase in overall reporting may be satisfaction was not evaluated. However, it would be hard to
as a result of an increase in nurse awareness of the handoff argue that a patient would be satisfied with receiving cancer
process and their role in patient safety. The WCI Handoff care in a setting where communication between providers
Tool utilization and handoff completion rate between is poor, treatment delays are commonplace, and patients

e482 © 2019 by American Society of Clinical Oncology Volume 15, Issue 5

 EMR-Based Intervention for Effective Nurse Communication

TABLE 1. Pre- and Postintervention Survey Results (N = 27 nurses)

Pre-Intervention (%) Postintervention (%)
Effectiveness of patient handoff tool in ensuring safe
treatment*
Not at all effective 3.70 0
Somewhat ineffective 18.52 0
Neutral 22.22 11.11
Somewhat effective 37.04 40.74
Very effective 18.52 48.15
Effectiveness of patient handoff tool in preventing errors*
Not at all effective 7.41 0
Somewhat ineffective 18.52 0
Neutral 25.93 14.81
Somewhat effective 33.33 44.44
Very effective 14.81 40.74
Effectiveness of patient handoff tool in promoting patient
satisfaction*
Not at all effective 7.69 0
Somewhat ineffective 11.54 0
Neutral 46.15 25.93
Somewhat effective 26.92 55.56
Very effective 7.69 18.52
Frequency of use of the handoff tool for same-day
appointments
Never 14.81 3.70
Rarely 0 0
Sometimes 3.70 7.41
Frequently 29.63 33.33
Always 51.85 55.56
Staff-identified barriers (same-day appointments)
Time consuming 0 0
Not part of current workflow 18.52 3.70
Not a service-line priority 11.11 0.00
Not used by counterpart 7.41 3.70
Other 7.41 3.70
Nurses responding “yes”:
Patient handoff tool conveys necessary information to 57.69 81.48
treat patient safely
Patient handoff tool has all of the helpful information* 66.67 100.00
Patient handoff tool is easy/very easy to use 66.70 85.10

*P , .05, statistically significant difference.

experience adverse events from medication errors as the
result of ineffective handoff. Second, the handoff form that
was used in the pre-intervention period—albeit relatively
infrequently—was not standardized and did not have
discrete elements to allow evaluation of its salient char-
acteristics, such as what components of communication
were included (eg, incomplete laboratory results) or which
ones contributed to the medication error rate. This limited
our ability to make meaningful and important comparisons
between the two. The review of medication errors and their
causes was performed by a single quality nurse manager,
which could have led to bias in the study outcome esti-
mates. Finally, medication errors are self-reported in the
incident system and susceptible to individual biases, such

Journal of Oncology Practice e483

 Pandya et al

as the ability to identify error and under- or over-reporting.
For example, a decrease in the number of incidents may
indicate high-work volume and a lack of time to enter in-
cidents as opposed to an actual reduction in incidents. Or,
it could represent an increased focus on another quality
area (eg, infusion reactions) that overshadowed the need
to report medication incidents. Future work could be
strengthened by using a more robust method to capture
medication error rate, such as multiple independent reviews
of the incident system reports or an objective outcome
measure.
The QI intervention resulted in a standardized treatment
handoff process and a reduction in the proportion of
medication errors as a result of ineffective communication at
WCI; it can be used as a model for rapid cycle improvement.
Future efforts will focus on addressing noncommunication-
related factors contributing to medication errors in patients
with cancer who are receiving treatment.

AFFILIATIONS AUTHOR CONTRIBUTIONS

1
University of Rochester Medical Center, Rochester, NY Conception and design: Chintan Pandya, Tammy Clarke, Elizabeth
2
Yale New Haven Health, New Haven, CT Scarsella, Alex Alongi, Stephanie Buia Amport, Lauren Hamel, David
3
Wayne State University School of Medicine, Detroit, MI Dougherty
4
Dana-Farber Cancer Institute, Boston, MA Administrative support: Stephanie Buia Amport
Collection and assembly of data: Chintan Pandya, Tammy Clarke,
Elizabeth Scarsella, Alex Alongi, David Dougherty
CORRESPONDING AUTHOR
Data analysis and interpretation: All authors
Chintan Pandya, PhD, James P. Wilmot Cancer Center, University of
Rochester Medical Center, 601 Elmwood Ave, Box 704, Rochester, NY Manuscript writing: All authors
14642; e-mail: chintan_pandya@urmc.rochester.edu. Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
AND DATA AVAILABILITY STATEMENT ACKNOWLEDGMENT
Disclosures provided by the authors and data availability statement (if We thank Elizabeth Guancial, Karen Mietus, Lynn Rich, Nathaniel Wade,
applicable) are available with this article at DOI https://doi.org/10.1200/ Sean Goonan, Margaret Blaney, Melanie Bobry, Jen Galdys, and
JOP.18.00245. Elizabeth Alvino for their participation and contribution to the study. We
also thank our project sponsors, Jonathan Friedberg and Brian Martin.

REFERENCES
1. Kitch BT, Cooper JB, Zapol WM, et al: Handoffs causing patient harm: A survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 34:563-570,
2008
2. Joint Commission on Accreditation of Healthcare Organizations: National Patient Safety Goals Hospital Version Manual Chapter, including implementation
expectations. 2007. https://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm
3. Arora VM, Johnson JK, Meltzer DO, et al: A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care 17:11-14, 2008
4. Haig KM, Sutton S, Whittington J: SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 32:167-175, 2006
5. Asan O, Nattinger AB, Gurses AP, et al: Oncologists’ views regarding the role of electronic health records in care coordination. Clin Cancer Inform 2018:1-12,
2018

n n n

e484 © 2019 by American Society of Clinical Oncology Volume 15, Issue 5

 EMR-Based Intervention for Effective Nurse Communication

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Ensuring Effective Care Transition Communication: Implementation of an Electronic Medical Record–Based Tool for Improved Cancer Treatment Handoffs
Between Clinic and Infusion Nurses
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held
unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about
ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jop/site/ifc/journal-policies.html.

David Dougherty
Honoraria: inPractice
No other potential conflicts of interest were reported.

Journal of Oncology Practice e485

 Pandya et al

APPENDIX

Same-Day Infusion Handoff Process

Checks in at
Checks out Check in
clinic, arrived
of at
Patient

in EMR, and
clinic and infusion
has blood
makes and
drawn unless
follow-up arrived
done the day
appointments in EMR
before

MD/APP Makes
Provider

Communicate
sees patient decision
plan
and Seen without RN about
to
decision next
RN
to treat steps

Seen with RN

Handoff Information Makes prn

Identifies if
Clinic RN

tool is gathered phone call

patient going Information Yes Yes Release No Yes
initialized/ from EMR Finalize Urgent to infusion
to infusion known to initialize chemo-
loaded if and provider handoff? issue? RN to
for same-day handoff? therapy?
not started is entered update
treatment
prior into handoff the plan

No No Yes

No
Handoff tool Handoff tool
is not not
initialized completed

Yes Yes

Checks schedule Are

Reviews
printed for pods Checks chart Checks Are assessment,
Patient handoff tool No
and identifies for consent, flowcast Looks Yes laboratory laboratory results No
arrived in Is handoff and signs off Pages Issues
if patient coming orders, for for results within parameters,
initialized? whether team resolved?
Infusion RN

from clinic for laboratory schedule? appointment handoff consent and

complete or complete?
same-day results information orders
not
treatment signed?
Yes

Holding
No pattern No Wait Release
Patient
until the for chemo-
No treated
clinic laboratory therapy
appointment results
is complete
Yes

Patient Problem area

FIG A1. Process map for same-day infusion handoff process. APP, advanced practice provider; EMR, electronic medical record; MD, medical doctor; prn,
pro re nata (as needed); RN, registered nurse.

e486 © 2019 by American Society of Clinical Oncology Volume 15, Issue 5

 EMR-Based Intervention for Effective Nurse Communication

Tool process Ineffective communication Patient

Infusion RN “pull”
to use tool If provider decides not to give chemotherapy
Tool is not always used
but orders are signed and handoff is
Data in the tool can be to completion Patient issues
not complete, the infusion RN will
lost, depending on release the chemotherapy
individual usage Clinic RN edits handoff after
infusion RN reviews it
Patient arrives in infusion
before handoff is complete Required data are unavailable The patient is late
or evolving Note “needs cosigned height/weight”
Tool is used differently
depending on the team
or RN style Orders are not signed and
infusion RN may call clinic RN
Tool completion is uncoupled for orders, especially if System issues
from patient treatment provider doesn’t answer page
Note says OK to treat but
“CMP pending” is written in
Data in the tool may not be
accurate or updated
Understanding the use of the tool
Tool utilization review is too Handoff is not complete
cumbersome Incomplete
handoff between
Everyone does handoff different clinic and infusion
Layout of tool is not user friendly Handoff not started
Information/comments It takes time to type in multiple factors;
in flowcast are incorrect Clinic RN needs time
it is time consuming Time for infusion RN to keep to complete handoff
checking if handoff is finalized
Infusion RN does not by clinic RN
Clinic RN adds follow-up
check handoff
appointments needed to
handoff, but that is a message Handoff does not count Clinic RN is working with
Patient calendar
for secretaries (not infusion RNs) The location of the tool in eRecord toward patient documentation multiple providers
is incorrect
Handoff is only used for
Infusion RN is too busy some patients
Tool is uncoupled from to check for handoff
the patient encounter. Handoff is not completed Clinic volume or case load
Clinic RN does not see the by the clinic RN
patient with the provider

Schedule Tool structure User variability Time

Purple is clinic and infusion Pale highlight are identified

barriers
Red is infusion
Dark highlight is top 7
Blue is clinic identified barriers

FIG A2. Cause-and-effect diagram. CMP, comprehensive metabolic panel; RN, registered nurse.

Journal of Oncology Practice e487

 Pandya et al

SITUATION
Scheduled treatment category for today

Cancer treatments Chemotherapy Antibody Immunotherapy Transfusion IV fluids

Electrolytes Bisphosphonate Immunization Antibiotics Injection

Growth factor Other

Is this a new cancer Yes No

treatment?

BACKGROUND

Consent obtained Yes No Not needed

Laboratory results
Yes Not needed Pending
complete
ASSESSMENT
Current patient Scheduled treatment Scheduled treatment with change
status
Urgent or emergent treatment New treatment plan

Additional Disease progression Difficult social/emotional situation

relevant
information Other

RECOMMENDATION
OK to treat for Yes No Pending
scheduled
treatment

FIG A3. Epic-based Wilmot Cancer Institute handoff tool. IV, intravenous.

e488 © 2019 by American Society of Clinical Oncology Volume 15, Issue 5

 EMR-Based Intervention for Effective Nurse Communication

TABLE A1. Patient Waiting Times During Treatment Visit (5 months pre- and postintervention)
Median Time From Premedication Visit to Treatment Infusion Median Time From Patient Check-In to Treatment Infusion

Month Pre-intervention (h:min) Postintervention (h:min) Pre-intervention (h:min) Postintervention (h:min)

1 0:34 0:28 1:02 1:03
2 0:31 0:28 1:03 1:00
3 0:35 0:30 1:08 1:00
4 0:29 0:31 1:01 1:04
5 0:31 0:31 1:04 1:02
Average 0:32 0:296 1:036 1:018
Difference 0:024 0:02

Abbreviations: h, hour; min, minute.

Journal of Oncology Practice e489

Used with permission. Copyright © American Society of Clinical Oncology 2019. All rights
reserved.