Standardized approach
Q. What is meant by “standardizing” an approach to hand-off communication?
A. This means your organization must define, communicate to staff, and implement a process in which information about patient/client/resident care is communicated in a consistent manner. Standardization provides a means to educate staff about the process and helps support consistent implementation throughout the organization. Ideally the handoff process would be similar throughout the organization, but practically the hand-off process may differ from one setting or function to another but not from unit to unit when the unit functions are essentially the same. A standardized approach should identify the following items:
- The hand-off situations to which it applies
- Who is, or should be, involved in the communication
- What information should be communicated, for example,
- Diagnoses and current condition of the patient/client/resident
- Recent changes in condition or treatment
- Anticipated changes in condition or treatment
- What to watch for in the next interval of care
- Opportunities to ask and respond to questions ideally in-person
- When to use certain techniques (e.g. repeat-back or SBAR)
- What print or electronic information should be available
Taped report
Q. Our nursing staff prefers to audiotape the change-of-shift report. Is this acceptable?
A. We do not specifically prohibit the use of taped reports. However, this method will not be acceptable unless it includes an opportunity to ask clarifying questions and to receive answers in a time frame that is consistent with having complete and accurate information available to the patient’s caregivers when they are providing the care.
Radiology and other diagnostic testing units
Q. Is hand-off communication required when a patient moves from an inpatient unit to radiology or other diagnostic testing unit?
A. Yes. The information communicated may be limited to what is relevant to the procedure, but it is a hand-off and should follow a standardized procedure. At the very least, this will ensure that staff in the testing area know that the patient is there and it will provide an opportunity to properly identify the patient and the test to be done. Organizations should strongly consider the inclusion of special precautions (e.g. isolation, fall risk or suicide risk) in the hand-off process.
Physical therapy and other intermittent care
Q. Does the hand-off requirement apply to services like physical therapy where patients are seen only on the day shift? We have relied on the progress notes in the chart to “hand-off” between therapists from one day to the next. Is this acceptable?
A. NPSG.02.05.01 does apply in this situation, but the relevant time frames are expanded so the details of the hand-off process may vary from other hand-off processes. However, whatever method is used, there must still be an opportunity to ask and get responses to questions. Using the chart notes as the medium for communicating patient-specific information between therapists is acceptable as long as the incoming therapist can get answers to any questions in a time frame that is consistent with safe care for the patient.
Physician-to-physician hand-offs
Q. What are the expectations under NPSG.02.05.01 for physician-to-physician hand-offs?
A. NPSG.02.05.01 requirement does apply to physicians; it’s not just for nurses and other non-physician staff. The requirement is to standardize the process. It is recognized that the process may be different for different types of hand-offs, so a physician-to-physician hand-off will be different from a nursing change-of-shift report. That said, there still needs to be a standardized process for MD hand-offs. There does not necessarily need to be a policy, but there has to be, in some form, a description of what the “standardized process” is, and that process needs to be communicated to and understood by all those physicians who will be involved in hand-off communication. The process must be done with some reasonable degree of consistency. These processes should be clearly stated in the medical staff procedures and training program.
This will be surveyed by asking several physicians what the process is for hand-off communication, such as when signing out one’s patients to a covering physician. The surveyors might ask where this is described (e.g. bylaws or rules and regulations) and how new physicians on staff know what is expected when signing out to a covering physician. They will also look for opportunities during the survey to observe the process. If there are hospitalists, the surveyors may talk with them and ask how often they do not have sufficient information to provide the needed care to a patient. These processes should be clearly stated in the medical staff procedures and training program.
The Joint Commission requires that the hand-off be done according to the listed elements of performance, which do not include any documentation requirements. Requirements for documentation of the hand-off process are left to the organization.
Simply identifying in the clinical record who the covering physician is will not meet this requirement. The requirement is for exchange of patient/client/resident-specific information and there must be an opportunity for the receiver of that information to ask questions and get clarification, if needed.
The hand-off can be done by using a written report but there must still be an opportunity for the receiver of the information to ask questions and get clarification. Our advice is: Keep it simple but make sure that whoever is taking over responsibility for a patient client/resident’s care will have sufficient information to do so safely.
Hospitalists
Q. Our organization uses hospitalists at night. Many, if not most, of the patients won’t even need to be seen by the hospitalist. What are the expectations for hand-off? Is it expected that there will be communication about each and every patient that the hospitalist will be covering? What about discharge to the primary care physician (PCP)?
A. If the hospitalist assumes responsibility for the care of a patient, relevant information about that patient must be handed off, whether the patient subsequently is attended by the hospitalist or not. These processes should be clearly stated in the medical staff procedures and training program.
Discharge to the PCP is a matter of timing. The same principles of standardization of the hand-off process including an opportunity for Q&A, still apply but they can be conducted in a more protracted time frame and by other than face-to-face communication as long as the hand-off is completed by the time the PCP sees the patient in follow-up.
Medical specialists
Q. For physician hand-offs, does the same process have to be used throughout the hospital. Can different specialties use different methods of communication within their call group?
A. In the case of physician hand-offs, the process may vary among different specialties or settings of care. For a given setting or patient population or specialty, the process should be reasonably standardized in order that sufficient patient-specific information is consistently communicated to facilitate continuity of care and patient safety. Whatever the details of the hand-off process, there must be a defined minimum set of data about each patient that must be communicated when responsibility for the patient’s care is handed off.