The Center's Collaborating Hospitals

In 2009, ten of the Center’s collaborating hospitals and health systems began a project focused on ineffective hand-off communications. A hand-off process involves the caregivers transmitting patient information (called senders) and transitioning care of a patient to the next clinician (called receivers) the caregivers that accept patient information and care of that patient.

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, the project team, together with the Center, examined their hand-off communications problems, and identified their specific causes for failures and barriers to ineffective hand-off communications. They then identified, implemented, and validated solutions that improved their performance. The handoff communications project was then piloted with additional organizations to validate the methodology and targeted solutions. 

Project Team

Project Team
Exempla Lutheran Medical Center, Colorado
Fairview Health Services, Minnesota
Intermountain Healthcare, Utah
Kaiser Permanente, California
Mayo Clinic, Minnesota
New York-Presbyterian Hospital, New York
North Shore-LIJ Health System, New York
Partners HealthCare, Massachusetts 
Stanford Hospital & Clinics, California
The Johns Hopkins Hospital, Maryland

Pilot Team
Alliance HealthCare Services, California
Aunt Martha’s Youth Service Center, Illinois
Bartlett Regional Hospital, Alaska
Jacksonville Center for Endoscopy, Florida
RML Specialty Hospital, Hinsdale, Illinois
RML Specialty Hospital, Chicago, Illinois
The George Washington University Hospital, Washington, D.C.
The Massachusetts General Hospital, Massachusetts
Mountainview Regional Medical Center, New Mexico
Wentworth-Douglass Hospital, New Hampshire
Winthrop University Hospital, New York

Project Results

  • By using solutions targeted to the specific causes of an inadequate hand-off, participating and pilot organizations that had fully implemented solutions achieved an average of over 50% reduction in defective hand-offs.
  • Using the tool and the solutions from the Center’s Hand-off Communications project, health care organizations reported an increase in patient and family satisfaction; staff satisfaction; and successful transfers of patients (reduced bounce backs).
  • The Hand-off Communications project does not have to be limited to one hospital setting and can include looking at transitions of care to external facilities as well. One hospital focused on transitioning patients from their in-patient units to a nursing home and were able to reduce their inadequate hand-offs from 29% in baseline to <1% after improvements were put in place.
  • This improvement in hand-off communications was attributed to reducing their 30-day readmission rates from 21% in baseline to 10% after improvements.

Our Hand-off Communications Targeted Solutions Tool

The Center’s Hand-Off Communications Targeted Solutions Tool® (TST®) is an innovative web-based application designed to help health care organizations understand barriers to successful hand-offs and implement evidence-based solutions that lead to reductions in adverse events caused by faulty communication.

Additional Resources