Tackling hand-off communications

Evaluating the quality of hand-offs

About 80% of serious medical errors involve problems in hand-off communication, says Klaus Nether, project leader with The Joint Commission Center for Transforming Health Care, who has a black belt in Six Sigma. Further, he adds, that fact is validated by The Joint Commission's sentinel event database, which lists breakdowns in communication as one of the leading causes for such events.

And that is why the center chose hand-offs as one of the four projects since the center's inception. Nether says there are a host of complications that make hand-off communications a continuing problem for many hospitals — a problem that can cascade to other more harmful complications.

First of all, he says, are hand-offs are a huge part of the interplay of patient care and happen all over the hospital, all the time.

"I think one of the factors that comes into play is the sheer number of hand-offs that are done. I know there was one study that estimated that in a typical academic teaching hospital, there are 4,000 patient hand-offs a day, roughly about 1.6 million per year. If we are saying that 99% of the time the hand-offs are perfect, that 1% is about 40 hand-offs a day. So that's touching about 30 patients," Nether says.

Ten hospitals participated in the center's collaborative, which began in October, to look at problem solving the communication topic in a systematic way. Nether says one of the qualifications for participants was that each had experience working with Lean, Six Sigma, or change management models.

As part of the project, the roles of those involved in hand-off communications were broken down and defined as:

  • the "sender," who would be responsible for transferring the patient data and releasing the patient;
  • the "receiver," who receives the data and accepts care of the patient.

Each hospital had to then define its own project, the settings to be evaluated (whether that be internal hand-offs, such as from the ED to inpatient, or external, from the hospital to a post-acute facility), and to measure current or baseline performance.

"[A]s an aggregate, these 10 leading hospitals, more than 37% of the time, hand-offs were defective and did not allow the caregiver who was receiving the patient to safely care for the patient. But, additionally, we also saw that 21% of the time those initiating, those senders, that were transferring the care were dissatisfied with the quality of the hand-off," Nether says.

The center created a measurement tool to codify hand-offs, which Nether characterizes as a survey that looked at, among other things:

  • Was enough time allocated for the hand-off?
  • Were there interruptions with the receiver?
  • Did the receiver know the patient was being transferred?

The participating facilities came up with root causes in transition of care, hand-off communication failures, labeled as either general problems, problems with sending, or problems with receiving. (See box below.)

Validated root causes for hand-off failures


  • Culture does not promote successful hand-off, e.g. lack of teamwork and respect.
  • Expectations between sender and receiver differ.
  • Ineffective communication method, e.g. verbal, recorded, bedside, written.
  • Timing of physical transfer of the patient and the hand-off are not in sync.
  • Inadequate amount of time provided for successful hand-off.
  • Interruptions occur during hand-off.
  • Lack of standardized procedures in conducting successful hand-off, e.g. SBAR.
  • Inadequate staffing at certain times of the day or week to accommodate successful hand-off.
  • Patient not included during hand-off.


  • Sender provides inaccurate or incomplete information, e.g. medication list, DNR, concerns/issues, contact information.
  • Sender, who has little knowledge of patient, is handing off patient to receiver.
  • Sender unable to provide up-to-date information, e.g. lab tests, radiology reports, because not available at the time of hand-off.
  • Sender unable to contact receiver who will be taking care of patient in a timely manner.
  • Inability of sender to follow up with receiver if additional information needs to be shared.
  • Sender asked to repeat information that has already been shared.


  • Receiver has competing priorities and is unable to focus on transferred patient.
  • Receiver unaware of patient transfer.
  • Inability for receiver to follow up with sender if additional information is needed.
  • Lack of responsiveness by receiver.
  • Receiver has little knowledge of patient being transferred.

Source: The Joint Commission Center for Transforming Health Care. http://bit.ly/hGSzoj.

One of the biggest things they found, Nether says, beyond the accuracy and completeness of the information gathered at hand-off "was the expectations between sender and receiver were different." So they came together to talk about expectations, both generally and specifically, for what information both the receiver and sender needed.

Nether says the participants still are looking at defect rates. "[F]or every hand-off that occurs, staff fill out that survey to say if it meets their needs. If it didn't meet their needs, then it's still a defect, and then they look at well, 'What are some of the issues? Why is it still a defect?'" Some of the hospitals have implemented some solutions, but he points out that some of those take longer than others. Some are looking toward informations technology to move them forward.

Participants also have looked at whether there are common elements for a checklist-type approach to hand-offs. "What we have heard as we have gone through this because of the complexity and the nature and the complexity of the patient coming in, different diagnosis, different symptoms, can we get to that commonality? We might not. That's something we are still looking at," he says.

Individual hospitals are looking at defining their own common elements and then measuring those by looking at compliance rates, and taking it further to analyze outcomes. For instance, he says, if you have lowered defective hand-offs, what has that meant to patient safety? That could mean medication errors, adverse event occurrences, or misses. Some participants that have gotten that far along in the process are looking at sustainability.

Whether hospitals are working to leverage their electronic health record systems to improve hand-offs, Nether says, they've learned a bigger lesson: "[N]o matter how good a technical solution you have, it could be a technical solution that everybody will support, the bigger issue becomes the change management side of things you have to work with as well to get really people to accept it, to have them be accountable for it.

"So, again to really make that effective, to have that solution become effective, the technical part of it. Then you also need that change management side to get everybody engaged, and that's one of the other things that is being worked on, as well, with any of the solutions that are being implemented is to look at the change management side of things and how can you get people engaged. How can you get them accept it? Because we always know change is hard, and change gets resisted."

(Editor's note: Hospitals participating in the The Joint Commission Center for Transforming Health Care's work on hand-off communications are Exempla Lutheran Medical Center; Fairview Health Services; Intermountain Healthcare LDS Hospital; The Johns Hopkins Hospital; Kaiser Permanente Sunnyside Medical Center; Mayo Clinic Saint Marys Hospital; New York-Presbyterian Hospital; North Shore-LIJ Health System Steven and Alexandra Cohen Children's Medical Center; Partners HealthCare, Massachusetts General Hospital; and Stanford Hospital & Clinics.

Hospital Peer Review spoke with representatives from both Kaiser and Intermountain. Kaiser's journey to improve hand-off communications is recounted below. In the next issue, we will look at the work Intermountain has done.)