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Patient Safety

Observations and Lessons Learned in Patient Safety.

The Art of Handoff Communication


Klaus NetherBy Klaus Nether, D.H.Sc., MMI, CSSMBB
Executive Director, High Reliability Product Delivery
Joint Commission Center for Transforming Healthcare

Hospitals continue to struggle with the art of handoff communication—the process of communicating patient information from one caregiver to another—or from one team of caregivers to another—for the purpose of ensuring the continuity and safety of a patient’s care. 

Communication was one of the top root causes of sentinel events reported to The Joint Commission from 2011 through 2013. And, ineffective handoff communication has been a primary contributing factor in many studies of causes leading to medical errors. 

How can we prevent ineffective handoff communication? A new Sentinel Event Alert from The Joint Commission reviews contributing factors to handoff communication failures, solutions, research, quality improvement efforts and The Joint Commission’s related requirements. The alert also offers seven recommendations to improve handoff communication, as outlined in the blog post “Two-Way Communication is Key.”

Targeted Solutions Tool® for Handoff Communications 
In addition, the Sentinel Event Alert recommends the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool® (TST®) for Handoff Communications as one instrument to help health care organizations improve handoffs. 

The TST® is an innovative application, free to Joint Commission accredited health care organizations, that guides organizations through a systematic approach to accurately measure current performance, identify specific root causes for failures, and offer proven solutions targeted to the specific root causes identified.

The TST® for Handoff Communications:

  • facilitates the examination of the current handoff communication between two settings of care from the viewpoints of both the senders and receivers involved in the process

  • provides a tested and validated measurement system that produces data that supports the need for improving the current handoff communication process

  • identifies areas of focus, such as the specific information needed for the handoff communication process that is being measured

  • includes customizable forms for data collection

  • offers solutions specific to the root causes identified 

Case Study: Bartlett Regional Hospital
The TST® is proven to be effective. A study from the March 2016 issue of The Joint Commission Journal on Quality and Patient Safety details how a community hospital—Bartlett Regional Hospital, Juneau, Alaska, a 73-bed, Level 4 trauma center—improved its handoff communication process between the emergency department and four private physician groups admitting and delivering patient care.

After implementing the TST® and its targeted solutions for the hospital’s identified root causes, the defective rate of handoffs decreased by 58.2 percent. Defective handoffs previously occurred at a rate of 29.9 percent (32 defective handoffs/107 handoff opportunities) during baseline before dropping to 12.5 percent (13 defective handoffs/104 handoff opportunities) in the improve phase. The number of related adverse events related to handoff communication declined as the handoff communication defective rate improved. 

It’s not just Bartlett Regional Hospital who found success using the systematic approach found in the TST® for Handoff Communications. One health care organization reduced readmissions by 50 percent, while another reduced the time it took to move patients from the emergency department to an inpatient unit by 33 percent. 

I often hear from health care organizations that they do not have additional resources to allocate to improve handoff communication. Rest assured—improved handoffs can happen with only minimal resources. In fact, most organizations do not require any additional staff and need to make only minor changes to the roles and responsibilities of existing staff to use the TST®

To get started on improving handoff communication at your organization today, visit the Joint Commission Center for Transforming Healthcare’s website. Knowing the art of handoff communication can result in significant improved outcomes for your organization.