RESEARCH ARTICLE

Improvement in Patient Transfer Process From theOperating Room to the PICU Using a Lean and SixSigma–Based Quality Improvement ProjectStephen J. Gleich, MD,a,b Michael E. Nemergut, MD, PhD,a,b Anthony A. Stans, MD,c Dawit T. Haile, MD,b Scott A. Feigal, RN,d Angela L. Heinrich, RN,d

Christopher L. Bosley, R.R.T-NPS,b Sandeep Tripathi, MDe

A B S T R A C T BACKGROUND AND OBJECTIVES: Ineffective and inefficient patient transfer processes canincrease the chance of medical errors. Improvements in such processes are high-priority local institutionaland national patient safety goals. At our institution, nonintubated postoperative pediatric patients are firstadmitted to the postanesthesia care unit before transfer to the PICU. This quality improvement projectwas designed to improve the patient transfer process from the operating room (OR) to the PICU.

METHODS: After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of theprocess to determine error-prone and inefficient areas. We evaluated primary outcome measures ofhandoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction wasevaluated as a counterbalance measure.

RESULTS: With the introduction of the new direct OR-PICU patient transfer process, the handoffcommunication error rate improved from 1.9 to 0.3 errors per patient handoff (P5 .002). Inefficiency (patient waittime and non–value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved withfewer information omissions (P, .001). Staff satisfaction significantly improved among nearly all PICU providers.

CONCLUSIONS: By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustainedimprovements in patient safety and efficiency. Handoff communication was enhanced, with fewer errorsand content omissions. The new process improved efficiency, with high staff satisfaction.

aDepartments ofPediatrics,

bAnesthesiology,cOrthopedics, and

dNursing, Mayo Clinic,Rochester, Minnesota;and eDepartment ofClinical Pediatrics,

University of IllinoisCollege of Medicine,

Peoria, Illinois

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2015-0232Copyright © 2016 by the American Academy of Pediatrics

Address Correspondence to Stephen J. Gleich, MD, Department of Anesthesiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905.E-mail: gleich.stephen@mayo.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Gleich assisted in the study design and in development of data collection tools, participated in the data collection, and drafted the initialmanuscript; Dr Nemergut assisted in the study design, participated in data collection, and reviewed and revised the manuscript; Dr Stansassisted in the study design, provided data collection, and reviewed and revised the manuscript; Dr Haile assisted in the study design,assisted in data collection, and reviewed and revised the manuscript; Mr Feigal assisted in the study design, supervised data collection, andreviewed and revised the manuscript; Ms Heinrich coordinated and supervised data collection and reviewed and revised the manuscript;Mr Bosley coordinated and supervised data collection and reviewed and revised the manuscript; Dr Tripathi supervised the study design,assisted with data collection, carried out the initial analyses, critically reviewed the manuscript, and revised the manuscript; and allauthors approved the final manuscript as submitted.

HOSPITAL PEDIATRICS Volume 6, Issue 8, August 2016 483

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

The greatest problem withcommunication is the illusion that it hasbeen accomplished.

George Bernard Shaw (1856–1950)

The annual cost of measurable medicalerrors that harm patients is enormous,estimated to be $17.1 billion in 2008.1 Avast majority of medical errors resultfrom faulty systems and ineffectiveprocesses rather than poor practices orincompetent practitioners.2 An associationbetween communication failure andpreventable medical errors has beensuggested in virtually all health caresettings.3 Handoffs are among the mostvulnerable periods of the care transition.Any error in this process has the potentialto lead to multiple subsequent errors.Operating room (OR) to PICU transfers areparticularly complex with many individualsteps in which effective communication andactive team member engagement during thetransfer process may reduce error andsubsequent patient harm.4

Improving patient handoffs is identified asa patient safety priority for our institutionas well as a national patient safety goal.In 2006, the Joint Commission established

the implementation of a standardizedapproach to handoff communications,including an opportunity to ask and respondto questions.5,6 The importance of patienthandoffs is also addressed by theAccreditation Council for Graduate MedicalEducation, which mandates that residencyand fellowship programs “must designclinical assignments to minimize thenumber of transitions in patient care.”7

At our institution, patients transferringfrom the OR to the PICU were first admittedto the postanesthesia care unit (PACU)for initial evaluation and stabilization.With an intermediary admission to thePACU, we hypothesized that multiple levelsof inefficiency existed with numerousopportunities for errors. Handoffs occurredfirst between the surgical and anesthesiateams and the PACU provider, subsequentlybetween PACU providers, and finallybetween PACU and PICU providers. Thebaseline transfer process was complexwith multiple transfers and handoffs, asgraphically demonstrated in Fig 1. Thefinal handoff process to the PICU wasunstructured with no standard policy onthe contribution of surgical, anesthesia,

PACU, or PICU providers. In addition, thehandoff happened separately amongnursing, medical, and respiratory therapiststaff, leading to the possibility of differentinformation being conveyed.

Concomitantly, hospital handoffs and caretransitions between patient-care unitswere identified as hospital-wide areas forimprovement via an employee safety surveyproject in 2013–2014. Consequently, theseareas are specifically targeted for localimprovement.

An improvement in efficiency and patientsafety was sought by streamlining theprocess of transition of care from the ORto the PICU and eliminating the intermediaryPACU admission for nonintubated pediatricorthopedic spine patients. The primaryaims of this quality improvement (QI)project were to (1) decrease the numberof handoffs by 50%, (2) decrease inefficiencybetween the OR and PICU by 50%, and (3)decrease handoff errors, including a 50%reduction in omitted and/or incorrectinformation during patient care handofffrom the OR to PICU. The secondary aimsof the project included examining thecommunication patterns across the

FIGURE 1 Value stream map: direct observation of the baseline transfer process (OR-PACU-PICU, n 5 6 patients). Square, patient transfer events;hexagon, wait time (minutes): time spent while waiting for handoffs (time spent in the PACU during routine recovery patient carecounted as wait time); circle, process time (minutes): time to conduct the process of handoff and patient transfer; triangle, handoffcontent errors (total for all 6 patients).

484 GLEICH et al

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

postoperative pathway and implementingstructured measures to decrease risks incommunication and handoff failure.

METHODS

This study took place at Mayo ClinicChildren’s Center, a tertiary academicpediatric medical center with a 16-bedmedical/surgical PICU and ∼600 annualpostoperative admissions. All consecutivepediatric orthopedic spine patients, aged0–18 years, undergoing posterior spinalfusion for correction of scoliosis were usedas the study population during the studyperiod. Only patients who were extubated inthe OR before arrival in the PICU wereincluded. As a QI project, this work wasclassified as exempt and did not requireInstitutional Review Board approval orinformed consent. All ethical guidelines forQI projects were followed.

Quality Improvement Philosophies:Lean and Six Sigma

We used Lean and Six Sigma methodology,which are data-driven quality improvementphilosophies commonly used in thebusiness and manufacturing arenas.8 Leanprinciples are aimed at reducing waste,

thus improving efficiency and quality. Thegoal is to reduce non–value-added activities,such as patient travel or duplicate work.We used value stream mapping (Fig 1) tographically analyze the baseline processand identify areas of inefficiency. Six Sigmamethodology aims to reduce variationand defects through standardized define,measure, analyze, improve, and controlsteps. In the PICU practice, Six Sigmaprinciples are used to standardize theprocess and reduce medical errors,including communication handoff errors.

Initial Analysis: Direct Observationof Baseline Process

To understand how patient transferprocess functioned before intervention, weperformed value stream mapping by directobservation of the complete process ofcare transition from the OR to the PACU andto the PICU from May 1, 2014, throughJune 30, 2014 (Fig 1). Barriers to effectivepatient transfer were identified and plottedon an Ishikawa fishbone diagram (Fig 2).Both value-creating and non–value-creatingactivities were mapped from the start ofthe process (completion of the OR case) to

the conclusion (care transition to the PICUstaff). The number of handoffs and thecontent of each handoff, including whichpersonnel were present at the time ofhandoff, were recorded via directobservation and documented on a datacollection tool (Supplementary Fig 4).

Additional Retrospective Analysis

To gather more data on the average “delay”in the OR to PICU transfer, an additionalsubgroup of orthopedic spine patientsfrom January 1, 2014, through April 30,2014, was analyzed. For these patients, thetime spent in the PACU was retrospectivelyabstracted from the electronic medicalrecord and analyzed as wait 1 processtime.

Intervention

The primary intervention, initiated onOctober 1, 2014, was the implementationof a direct transfer process from the ORto the PICU. We created a new patientworkflow (Supplementary Fig 5) tostandardize the process, combining Leanand Six Sigma methodology8 to reduceinefficiency (patient wait time) and reducehandoff errors. The new process began

FIGURE 2 Ishikawa fishbone diagram indicating barriers to effective OR-PICU transfer. PCA, patient-controlled analgesia.

HOSPITAL PEDIATRICS Volume 6, Issue 8, August 2016 485

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

after reservation of a postoperative PICUbed. During surgery, the PICU was updated1 to 2 hours before procedure completionand again when the patient was leaving theOR upon procedure completion. The patientwas transported directly to the PICU byrepresentatives from the anesthesia andsurgical teams. While fully monitored onthe transport cart, a structured verbalhandoff using a handoff paper tool wasperformed between the OR team and theassembled PICU team. The PICU attending orfellow was designated as the handoff leaderto ensure compliance with the structuredhandoff. One author was always presentto audit the new process during theimmediate intervention study period.

We implemented a structured handoff tool(Supplementary Fig 6), which was usedas a script/checklist for the verbal handoff.The handoff tool was completed by theanesthesia provider before transportingthe patient to the PICU.

Before the implementation of the directto PICU transfer of our study patients,multiple meetings and presentationsoccurred with stakeholders, including thepediatric orthopedic surgery division, ORnursing group, anesthesia groups, and PICUteams. An educational e-mail and posterwere developed and circulated describingthe new direct to PICU transfer process.On the day of surgery, we performed brief“just-in-time” training to further educate theanesthesia and PICU staff about the newprocess and to familiarize the staff withthe new handoff communication tool.

Outcome Measures

Process measures were defined as follows:

Process time (PT): time (minutes) toconduct the process of handoff andpatient transfer.

Wait time (WT): time spent while waiting forhandoffs (time spent in the PACU duringroutine recovery patient care counted as WT).

First time quality: the percentage of time aprocess step is completed accurately thefirst time.

Number of handoffs and handoffoccurrences: calculation of the number oftimes a handoff (or care transition

without handoff) occurred betweenproviders during the process (recordedvia direct observation).

Error rate (critical to quality measure):content and errors in the handoff processcalculated by direct observation includingOR to PACU handoff, during PACUadmission, and PACU to PICU handoff. Allcommunication errors (including wrongprocedure reported, inaccuratemedication/blood product administrationreported, and incomplete informationsuch as absent providers) were countedas numbers and calculated as hand offerrors/patient. This metric was comparedboth pre- and post-intervention.

Counterbalance Measures

PICU staff satisfaction: We used PICUstaff satisfaction as the primarycounterbalance measure. A 10-pointsatisfaction questionnaire with7 domains was conducted immediatelyafter the handoff process(Supplementary Fig 7). This survey wasa measure of overall satisfaction andperceived value from the PICU staffacross all the disciplines and conductedfor the registered nurse, respiratorytherapist, PICU resident, and the PICUattending physician or fellow separatelyboth pre- and post-implementation.

To assess the sustainability of the newpatient transfer process, weretrospectively measured adherence tothe new direct transfer process andcompared PT 1 WT between theimmediate intervention phase (October 1,2014–December 31, 2014) and theextended intervention phase (January 1,2015–December 1, 2015).

Analysis

Pre- and post-intervention data weretabulated and analyzed by statisticalsoftware (JMP 10.0.0, © SAS Institute Inc.,2012). Student t test was used forcomparison, and significant results weredefined as P , .05.

RESULTSQuality Gaps and Interventions

After direct observation of the baselineprocess, 4 major factors causing high rates

of handoff errors and delays in patient carewere identified, and specific QI methodswere used to address each. Multiple andfragmented handoffs were remedied witha single handoff policy (intervention). Afterimplementation, multiple plan-do-study-actcycles were performed to evaluate theobstacles, and specific measures wereundertaken to find solutions. Due to initialunfamiliarity with the new process, wefound that designating a handoff leaderhelped guide the process. Inconsistentand erratic handoffs were observed,complicated by frequent distractions,which were improved with workflowmodels and standardization of the handoffprocess.8 Delays in patient care with anintermediary PACU admission werealleviated with our main intervention(direct OR-PICU transfer) using Lean QImethodology and reduction of waste (WT).9

Value Stream Mapping

We performed direct observation of thecomplete baseline transfer process(OR-PACU-PICU, n 5 6) and intervention(direct OR-PICU, n 5 4) for pediatricposterior spinal fusion patients. The meanbaseline WT was 90 minutes, whichdecreased to 32 minutes (258 minutes)after intervention. The PT also decreasedfrom 25.5 to 16.5 minutes (29 minutes).The FTQ also markedly improved from 0%(ie, there were no patients who made itthrough the baseline OR-PACU-PICU processwithout at least 1 handoff error) to 67%after intervention (Table 1).

From the expanded retrospective analysisof our electronic medical record, thebaseline WT of 27 postoperative patientsimproved from a median of 110 to20 minutes for 40 patients in theintervention phase (P , .001, Fig 3).

Handoff Content and Error Reduction

The baseline mean number of handoffsimproved from 4 separate handoffs to asingle consolidated handoff (400%reduction). The handoff communication toolwas used for all patients (100%). In addition,the handoff content similarly improved(Table 2). The handoff content improvedfrom 2.6 to 9.3 (P , .001) and from 5.0 to10.0 (P , .001) for surgical and anesthesia

486 GLEICH et al

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

handoff, respectively (n 5 12 baseline,n 5 9 intervention phase). The handofferror rate substantially improved from1.9 errors per patient-handoff in thebaseline phase to 0.3 errors per patient-handoff in the intervention phase(improvement of 1.6 errors per patient-handoff, P 5 .002).

Counterbalance Measures

Survey of staff satisfaction among themultidisciplinary PICU staff was performedfor 40 staff in the baseline phase and

42 staff in the intervention phase. PICUstaff satisfaction significantly improvedafter the introduction of the direct OR-PICUtransfer process and initiation of astructured handoff process for nursing,respiratory therapy, and the PICU attendingphysician/fellow group (Table 3).

Sustainability

The intervention was sustained with a meanWT1PT of 19.4 minutes for 9 patients in theimmediate intervention phase versus23 minutes for 31 patients in the extended

intervention phase (P 5 .41). Two patients(6%) during the extended interventionphase did not adhere to the new processand had an intermediary admission to thePACU due to bed unavailability in the PICU.

DISCUSSION

In this Lean and Six Sigma-based QI project,we demonstrated an improvement in thepatient transfer process from the OR to thePICU. We instituted a new, direct OR-PICUtransfer process with a structured handofffollowing examination of areas of error andinefficiency in the baseline process throughvalue stream mapping. We subsequentlyobserved an improvement in efficiency,as measured by a reduction in patient WT.In addition, handoff communication wasimproved, including the number of handoffs,content, and error rate. This process wasimplemented with high satisfaction amongthe multidisciplinary PICU staff.

Our study demonstrated a significantreduction in the number of handoffs by

TABLE 1 Value Stream Map Results for Baseline and Intervention Processes

Category Baseline (OR-PACU-PICU), n 5 6 Intervention (Direct OR-PICU), n 5 4 Change

WT (mean 6 SD, min) 90 6 32 32 6 11 –58

PT (mean 6 SD, min) 25.5 6 11 16.5 6 16 –9

FTQ 0% 67% 167%

Detailed process steps are shown in Fig 1. FTQ, percentage of time a process step is completed accuratelythe first time. For this project, the accurate process was defined as “a direct face to face handoff withoutany errors and all members present”; PT, time (minutes) to conduct the process of handoff and patienttransfer; WT, time spent waiting for handoffs (time spent in the PACU during routine recovery patient carecounted as WT).

FIGURE 3 Quantile graph demonstrating reduction in wait times in postoperative patients (from extubation to PICU handoff). WT (electronicmedical record): baseline phase (n 5 27) and intervention phase (n 5 40). IQR, interquartile range (25%–75%).

HOSPITAL PEDIATRICS Volume 6, Issue 8, August 2016 487

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

instituting a direct OR-PICU transferprocess. By elimination of the PACUadmission, we showed a 400% reductionin the number of handoffs. For each patienthandoff, the risk of error increases. In astudy of anesthesia providers, each handoffincreased the risk of major morbidity ormortality by 8%.10 Although the PACU hasa vital role for adequate recovery ofsurgical outpatients and patients admittedto the general care floor, our data suggestinefficiency and an increased risk ofhandoff error with an intermediary PACUstop before PICU admission.

The content of each handoff and the handofferror rate improved after the intervention.Our handoff error rate decreased by 81%,which is comparable to 2 postoperativehandoff studies that demonstrated ahandoff error reduction rate of up to76%.11,12 Although our study was notdesigned to detect outcome changes,better postoperative handoffs have alsobeen shown to improve patient outcomesand reduce complications.13

We found the presence of a handoff leaderhelpful to organize the new process. Thehandoff leader role was fulfilled by thePICU attending physician or fellow. This isanalogous to a code-team (cardiac arrest)leader, where improved team performanceis observed with an effective leader.14 Inthe absence of a leader, because theprocess was new to all stakeholders, itfrequently degenerated into a non-

standardized and erratic process withfrequent distractions. Correspondingly, astudy of postoperative pediatric cardiacsurgical patients demonstrated majordistractions, which were improved by thebedside nurse announcing a “sterilecockpit” environment (where nonessentialcommunications are prohibited) andinitiating the handover process.15

We introduced a handoff communicationtool which was available in the OR for theanesthesia personnel to use during thesurgical case and in the PICU for the PICUresident to complete during handoff. Thetool additionally functioned as a handoffchecklist to reduce the risk of omittedinformation. Consequently, we observed asignificant increase in the handoff contentreported, which is analogous to 2 studiesof ICU handoffs for postoperative cardiacsurgical patients.16,17 By making the toolavailable to the OR and PICU teams,familiarity was increased and omitteditems were quickly recognized, promptinga query to the surgical or anesthesiapersonnel.

Our multidisciplinary PICU staff was moresatisfied with the direct OR-PICU transferprocess. We initially expected that asubstantial change in the process of handoffand potential greater labor of acceptingfresh postoperative patients might decreaseoverall staff satisfaction. However, weobserved an improved satisfaction amongalmost all providers for all the aspects

of the handoffs, which is similar to priorhandoff studies.18,19

We acknowledge several limitations inour study. Our methodology involved adirect observation process, whichrequired a substantial amount of personnelresources and time. With no additionalfunding for this project, our resources werelimited and consequently, the number ofpatients who could be directly observedthrough the process was small. Despite lownumbers of patients who were directlyobserved, we identified many factorscontributing to the ineffective transfer ofpostoperative pediatric patients to the PICU.In addition, our subject population includeda focused group of pediatric orthopedicspine patients. However, our results,particularly the improvement in handoffcommunication with a structured process,should be generalizable to the greaterpostoperative pediatric population.

We recognize that certain behaviors of careproviders may have been altered becauseof the Hawthorne effect (observer effect).20

For patients who arrived to the PICUafter business hours, there were studypersonnel, including the PICU attendingphysician or fellow and charge nurse,who were directly involved in the study ofthe new process. With enhanced awarenessand attention dedicated to the new directOR-PICU transfer process, our improvementmay be exaggerated and may not besustainable. However, after the immediateintervention phase, we retrospectivelyanalyzed an extended intervention phase,which included 11 additional months(total of 14 months after the firstintervention). The improvements weresustained with no difference in timesbetween the 2 intervention periods. Only2 cases failed to adhere to the new transferprocess, both due to immediate PICU bedunavailability from external factors beyondour control. Lastly, we subjectivelyobserved continued satisfaction with thenew process and the improved informationsharing after concluding the study. Withcontinued “maintenance” education andexpansion of the new transfer process toother surgical subspecialties, we anticipatethe process and improvements will be

TABLE 2 Handoff Content Scores for Surgical and Anesthesia Team Personnel and HandoffError Rate for Baseline and Intervention Processes

Baseline (OR-PACU-PICU), n 5 12 Intervention (Direct OR-PICU), n 5 9 P

Surgical handoff 2.6 6 4.1 9.3 6 1.4 ,.001

Anesthesia handoff 5.0 6 4.6 10.0 6 0.0 ,.001

Overall handoff error ratea 1.9 0.3 .002

a Errors per patient handoff.

TABLE 3 Comparison of Average Staff Satisfaction Scores for Baseline and InterventionProcesses (Scale of 0–10)

Baseline (n 5 40) Intervention (n 5 42) P

Registered nurse 7.12 6 2.8 9.5 6 0.78 ,.001

Respiratory therapist 6.2 6 3.4 9.0 6 1.6 ,.001

Resident 7.8 6 2.4 8.5 6 2.0 .160

Attending physician/fellow 5.3 6 3.1 9.3 6 1.4 ,.001

488 GLEICH et al

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

sustained. Future steps for this QI workinclude expanding the direct OR-PICUtransfer for all pediatric surgicalsubspecialties with a structured handoff. Inaddition, other sources of admissions to thePICU, such as the emergency department,should be considered for a single,structured bedside handoff.

We did not include all possiblecounterbalance measures, including theperceptions of the surgical and anesthesiateams. Future study should also include theimpact on the OR schedule and OR turnovertime, which may be considerable. Familysatisfaction should also be considered.

CONCLUSIONS

By using QI methodology to design andimplement a new direct OR-PICU patienttransfer process, substantial improvementsin overall efficiency, handoff communication,and staff satisfaction were achieved.

REFERENCES

1. Van Den Bos J, Rustagi K, Gray T, HalfordM, Ziemkiewicz E, Shreve J. The $17.1billion problem: the annual cost ofmeasurable medical errors. Health Aff(Millwood). 2011;30(4):596–603

2. Palmieri PA, DeLucia PR, Peterson LT, OttTE, Green A. The anatomy and physiologyof error in adverse health care events.In: Savage GT, Ford EW, eds. PatientSafety and Health Care Management.Bingley, United Kingdom: Emerald GroupPublishing Limited; 2008:33–68

3. Segall N, Bonifacio AS, Schroeder RA,et al; Durham VA Patient Safety Center ofInquiry. Can we make postoperativepatient handovers safer? A systematicreview of the literature. Anesth Analg.2012;115(1):102–115

4. McElroy LM, Collins KM, Koller FL, et al.Operating room to intensive care unit

handoffs and the risks of patient harm.Surgery. 2015;158(3):588–594

5. Arora V, Johnson J. A model for buildinga standardized hand-off protocol. Jt CommJ Qual Patient Saf. 2006;32(11):646–655

6. The Joint Commission. Transitions ofcare: The need for a more effectiveapproach to continuing patient care.2012. Available at: www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf. Accessed January 4, 2015

7. Riebschleger M, Philibert I. Newstandards for transitions of care:discussion and justification. 2015.Available at: www.acgme.org/acgmeweb/Portals/0/PDFs/jgme-11-00-57-59[1].pdf. Accessed May 15, 2015

8. Besunder JB, Super DM. Lean Six Sigma:trimming the fat! Effectively managingprecious resources. Crit Care Med. 2012;40(2):699–700

9. Kubiak TM, Benbow DW. The Certified SixSigma Black Belt Handbook. 2nd ed.Milwaukee, WI: ASQ Quality Press; 2009

10. Saager L, Hesler BD, You J, et al.Intraoperative transitions of anesthesiacare and postoperative adverse outcomes.Anesthesiology. 2014;121(4):695–706

11. Catchpole KR, de Leval MR, McEwan A,et al. Patient handover from surgery tointensive care: using Formula 1 pit-stopand aviation models to improve safetyand quality. Paediatr Anaesth. 2007;17(5):470–478

12. Joy BF, Elliott E, Hardy C, Sullivan C,Backer CL, Kane JM. Standardizedmultidisciplinary protocol improveshandover of cardiac surgery patients tothe intensive care unit. Pediatr Crit CareMed. 2011;12(3):304–308

13. Agarwal HS, Saville BR, Slayton JM, et al.Standardized postoperative handover

process improves outcomes in theintensive care unit: a model foroperational sustainability and improvedteam performance. Crit Care Med. 2012;40(7):2109–2115

14. Yeung JH, Ong GJ, Davies RP, Gao F,Perkins GD. Factors affecting teamleadership skills and their relationshipwith quality of cardiopulmonaryresuscitation. Crit Care Med. 2012;40(9):2617–2621

15. Chen JG, Wright MC, Smith PB, Jaggers J,Mistry KP. Adaptation of a postoperativehandoff communication process forchildren with heart disease: aquantitative study. Am J Med Qual. 2011;26(5):380–386

16. Karakaya A, Moerman AT, Peperstraete H,François K, Wouters PF, de Hert SG.Implementation of a structuredinformation transfer checklist improvespostoperative data transfer aftercongenital cardiac surgery. Eur JAnaesthesiol. 2013;30(12):764–769

17. Zavalkoff SR, Razack SI, Lavoie J, DanceaAB. Handover after pediatric heartsurgery: a simple tool improvesinformation exchange. Pediatr Crit CareMed. 2011;12(3):309–313

18. Petrovic MA, Aboumatar H, BaumgartnerWA, et al. Pilot implementation of aperioperative protocol to guideoperating room-to-intensive care unitpatient handoffs. J Cardiothorac VascAnesth. 2012;26(1):11–16

19. Vergales J, Addison N, Vendittelli A, et al.Face-to-face handoff: improving transferto the pediatric intensive care unit aftercardiac surgery. Am J Med Qual. 2015;30(2):119–125

20. Sedgwick P, Greenwood N.Understanding the Hawthorne effect.BMJ. 2015;351:h4672

HOSPITAL PEDIATRICS Volume 6, Issue 8, August 2016 489

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

DOI: 10.1542/hpeds.2015-0232 originally published online July 28, 2016; 2016;6;483Hospital Pediatrics 

Feigal, Angela L. Heinrich, Christopher L. Bosley and Sandeep TripathiStephen J. Gleich, Michael E. Nemergut, Anthony A. Stans, Dawit T. Haile, Scott A.

Based Quality Improvement Project−PICU Using a Lean and Six Sigma Improvement in Patient Transfer Process From the Operating Room to the

ServicesUpdated Information &

http://hosppeds.aappublications.org/content/6/8/483including high resolution figures, can be found at:

Supplementary Material

3.DCSupplementalhttp://hosppeds.aappublications.org/content/suppl/2016/07/19/6.8.48Supplementary material can be found at:

Referenceshttp://hosppeds.aappublications.org/content/6/8/483#BIBLThis article cites 16 articles, 2 of which you can access for free at:

Permissions & Licensing

mlhttp://www.hosppeds.aappublications.org/site/misc/Permissions.xhtin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.hosppeds.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on October 20, 2020www.aappublications.org/newsDownloaded from

DOI: 10.1542/hpeds.2015-0232 originally published online July 28, 2016; 2016;6;483Hospital Pediatrics 

Feigal, Angela L. Heinrich, Christopher L. Bosley and Sandeep TripathiStephen J. Gleich, Michael E. Nemergut, Anthony A. Stans, Dawit T. Haile, Scott A.

Based Quality Improvement Project−PICU Using a Lean and Six Sigma Improvement in Patient Transfer Process From the Operating Room to the

http://hosppeds.aappublications.org/content/6/8/483located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://hosppeds.aappublications.org/content/suppl/2016/07/19/6.8.483.DCSupplementalData Supplement at:

Print ISSN: 1073-0397. Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 1948. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

by guest on October 20, 2020www.aappublications.org/newsDownloaded from