A unit that keeps missing follow-up results needs to know where the handoff fails and whether a change fixes it. Start with process mapping to locate the gap, then test one change and measure what happens.
Define the problem
Describe the affected patients or transfers, the desired improvement, and a date for reaching it.
- Quality Improvement in Nursing · The Model for Improvement
- Writing a Quality Improvement Aim Statement · Process Mapping in Healthcare
- Driver Diagrams for Nursing Projects
Test a change
Predict what will happen, try it on a small scale, then decide whether to adapt or expand it.
- Plan-Do-Study-Act Cycles · Small Tests of Change
- Audit and Feedback in Nursing · Clinical Audit and Quality Improvement
- Sustaining Nursing Practice Changes · Spread and Scale in Healthcare Improvement
Measure progress and tradeoffs
Counting named reviewers measures the handoff process. Counting results reviewed on time measures follow-through.
- Run Charts in Healthcare Improvement · Statistical Process Control in Nursing
- Balancing Measures in Quality Improvement · Structure, Process, and Outcome Measures
- Selecting Quality Improvement Measures · Pareto Charts for Nursing Teams
- Equity in Quality Improvement Measurement
Investigate failures and design safer work
Separate possible causes from verified causes and involve the people who do or receive the work.
- Root Cause Analysis in Healthcare · Failure Mode and Effects Analysis
- Fishbone Diagrams in Healthcare · The Five Whys in Safety Investigations
- Patient Partnership in Quality Improvement · Human Factors in Healthcare
- Reliability and Standardization in Nursing Work
Sources
- Institute for Healthcare Improvement: Model for Improvement (accessed 2026-11-11).
- Institute for Healthcare Improvement: Testing Changes (accessed 2026-11-11).
- Institute for Healthcare Improvement: Establishing Measures (accessed 2026-11-11).