Date of Graduation

Spring 5-17-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



The purpose of this project is to improve hand-off procedure between Skilled Nursing Facility (SNF) and Emergency Department (ED). Patient population consists of all retired veterans who currently reside in California Department of Veterans Affairs, Veterans Home of California (CalVet) – the state long-term care facility for elderly. The problem occurs when continuation of care is compromised due to poor exchange of information at the time of transfer to ED. Nurses in SNF need a step-by-step procedure that will improve the process of transfer and the intention of this project is to create a process that will become daily nursing routine. The clinical leadership theme specifically for this project is Leadership Outcomes Manager with the focus on improving communication. To implement the project Clinical Nurse Leader started on one 84-bed unit. The rationale was drawn from the data collected at the end of year 2017, showing that 70% of transfers in this unit resulted in incomplete or missing hand-offs at the time of transfer. The SWOT analysis and the fishbone diagram are used to better understand the cause and to analyze the problem. To implement the change Kotter’s theory of change was used. The expected results to lower the incidence of missing or incomplete hand-off by 30% were met. It is important to mention, that CalVet SNF has limited ability to communicate electronically, so the resources available to implement this change were limited to paper communication tools, such as SBAR and Essential Patient Information tool. Furthermore, the goal to implement the change facility-wide in SNF was accepted by leadership and will begin May 1st, 2018.