Date of Conferral
8-11-2026
Date of Award
August 2026
Degree
Doctor of Nursing Practice (DNP)
School
Nursing
Advisor
Margaret Harvey
Abstract
The quality improvement project focused on the inconsistent documentation and communication of the transfer of veterans in and out of a Veterans Affairs Medical Center. Lack of transparency in handoff knowledge and ineffective documents posed a risk of delayed care and patient injuries. The staff provided an audit tool with staff education to monitor completion of mandatory transfer steps, such as special mode travel approval, equipment needs, nurse-to-nurse handoff, transfer notes, consent, and physician correspondence. This method was based on the evidence found in literature indicating that structured checklists and handoff tools minimize missed information and facilitate safer care transitions between care settings. The team went through three audit phases based on identified chart reviews in which each required item was scored as complete or incomplete. Findings indicated a definite positive trend, as the overall checklist completion increased from 30%, then 60%, and ultimately, 100% according to the three phases. All of the measured categories, such as provider communication and transportation documentation, displayed the same trend of improvement. This finding confirms previous research that regular audits and timely and targeted feedback reinforce employee behavior and accountability in the long term. The study was only confined to one site and a limited number of transfers per phase, which may not be applicable to larger and busier centers. The results, however, show that a normal audit and education model would close the gaps in documentation that are common across the Veterans Affairs Medical Center. The team suggests that the audit tool should become an integral element of the transfer workflow, with continuous monitoring assigned, and the model should be tested in other locations. These measures support the project's goal of creating a unified interfacility transfer process that improves patient outcomes for Veterans.
Recommended Citation
Brown, Petrice Robinson, "Standardizing Interfacility Transfer In and Out Processes Across the Local VA Setting" (2026). Walden Dissertations and Doctoral Studies. 20651.
https://scholarworks.waldenu.edu/dissertations/20651
