Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers
June 27, 2012
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(OAKBROOK TERRACE, Ill. – June 27, 2012) An estimated 80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off. In addition to patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital. Today, the Joint Commission Center for Transforming Healthcare is releasing a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.
Ineffective hand-off communication is recognized as a critical patient safety problem in health care. The “hand-off” process involves “senders,” the caregivers transmitting patient information and releasing the care of that patient to the next clinician, and “receivers,” the caregivers who accept the patient information and care of that patient.
The Hand-off Communication TST was created to measure the effectiveness of hand-offs within an organization or to another facility, and provide proven solutions to improve performance. Using the tool and the solutions from the Center’s Hand-off Communications Project, health care organizations have reduced readmissions by 50 percent, and have reduced the time it takes to move a patient from the emergency department to an inpatient unit by 33 percent. Health care organizations also reported an increase in patient and family satisfaction; staff satisfaction; and successful transfers of patients. Health care organizations were able to complete their Hand-off Communications Project in approximately four months, using minimal resources. In fact, no staff was added and only minor changes were made to the roles and responsibilities of existing staff.
The TST is an application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers.
The universal experience of the health care organizations that built and tested the TST for Hand-off Communications was that senders and receives had very different expectations of what constituted a successful hand-off. Using the TST, these organizations aligned expectations of the hand-off, developed a process for a successful hand-off, and fostered better relationships and communication among staff. The Hand-off Communications TST:
- Facilitates the examination of the current hand-off communication between two settings of care from the view points of both the senders and receivers involved in the process.
- Provides a tested and validated measurement system that produces data that support and drive the need for improving the current hand-off communication processes.
- Identifies areas of focus, such as the specific information needed for the transition that is being measured. For example, the information needed for a hand-off from the emergency department to an inpatient unit differs from that needed for a hand-off from a hospital to a skilled nursing facility.
- Provides customizable forms for data collection to fit the specific needs of the transition being measured.
- Provides guidelines to determine the most appropriate and realistic hand-off communication process for a given transition, while also empowering the staff involved in the process.
All of the hand-off communications solutions that were developed by the Center and the leading hospitals can be found on the Center website. The targeted hand-off solutions from the Center, which are described using the acronym SHARE, address the specific causes of unsuccessful hand-offs. SHARE refers to:
- Standardize critical content, which includes providing details of the patient’s history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
- Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
- Allow opportunity to ask questions, which includes using critical thinking skills when discussing a patient’s case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
- Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
- Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.
The Hand-off Communications collaborating hospitals and health systems are:
- Exempla Lutheran Medical Center, Colorado
- Fairview Health Services, Minnesota
- Intermountain Healthcare LDS Hospital, Utah
- Kaiser Permanente Sunnyside Medical Center, Oregon
- Mayo Clinic Saint Marys Hospital, Minnesota
- NewYork-Presbyterian Hospital, New York
- North Shore-LIJ Health System Steven and Alexandra Cohen Children’s Medical Center, New York
- Partners HealthCare, Massachusetts General Hospital, Massachusetts
- Stanford Hospital & Clinics, California
- The Johns Hopkins Hospital, Maryland
Accredited organizations can access the TST and hand-off communications solutions on their secure Joint Commission Connect extranet. In addition to the Hand-off Communications TST, the Center currently provides targeted solutions for hand hygiene and wrong site surgery. Targeted solutions for surgical site infections, heart failure hospitalizations, safety culture, falls, and others will be incorporated into the TST as the Center completes these projects.
Statements from the TST Pilot Organizations
“Aunt Martha’s Youth Service Center’s Hand-off Communications Project has had a far reaching impact on our agency. We were not only able to improve the hand-off in our outlined project area (OB and Health Case Management), but the lessons learned from this project will be communicated throughout our agency as we undergo agency wide care coordination initiatives. This project has enabled us to develop solutions addressing some of the barriers related to hand-off communication improving the delivery of high quality, innovative health care and social services.”
Stacy Baumgartner, project manager, Performance and Quality Improvement Department, Aunt Martha’s Youth Service Center, Olympia Fields, Illinois
“Our work on the Hand-off Communications Project has helped us improve patient safety by improving communications between emergency room physicians and admitting primary care physicians. With the help of the Joint Commission Center for Transforming Healthcare, we have identified and corrected communication barriers and hope to extend the lessons to other care providers throughout our hospital.”
Mignon Benjamin, MD, Bartlett Regional Hospital, Southeast Alaska Regional Health Care Consortium
"The TST distills the learning of some of the best health care systems in the country into one tool that enables any health care provider to define the issues around problematic transfers, measure them and create actionable data. This is a tool that translates the vision of the Center for Transforming Healthcare into action. We have found it to be invaluable."
Terrence O’Malley, M.D., medical director, Non-Acute Care Services, Partners Healthcare, Massachusetts General Hospital, Boston, Massachusetts
For more information about the Joint Commission Center for Transforming Healthcare, visit www.centerfortransforminghealthcare.org.
The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Blue Cross and Blue Shield Association, Cardinal Health, Ecolab, GE Healthcare, GlaxoSmithKline (GSK), Johnson & Johnson and Medline Industries, as well as the support of the Federation of American Hospitals, GOJO Industries, Inc., and The ARAMARK Charitable Fund.