In August 2009, The Joint Commission Center for Transforming Healthcare began work on its second improvement project: improving the quality of hand-off communications. A hand-off is the transfer and acceptance of patient care responsibilities achieved through effective communication. Selected by eight leading hospitals and health systems, the Hand-Off Communications project team includes hospital leadership, clinicians and staff, and the Center’s Black Belts and Green Belts.

The Joint Commission’s Sentinel Event program has identified poor hand-off communications as a contributing factor to sentinel events with severe consequences to patients. In 2006, The Joint Commission implemented a National Patient Safety Goal that focused on health care organizations implementing a standardized approach to hand-off communications. The NPSG was moved to the standards for all accreditation programs in 2010.

The Joint Commission Center for Transforming Healthcare uses Robust Process Improvement™ (RPI) methods and tools in the development of its solutions. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates specific tools and methods from Lean Six Sigma and change management methodologies. Using RPI, project teams can discover specific risk points and contributing factors, and then develop and implement solutions and controls to improve the effectiveness of patient hand-offs thus increasing overall patient safety and health care quality.