ED Accreditation Update

Defective handoffs reduced by 52%

Participants focus on their EDs

Using solutions targeted to the specific causes of an inadequate hand-off, organizations participating in an initiative headed by The Joint Commission Center for Transforming Healthcare that fully implemented the solutions achieved an average 52% reduction in defective handoffs. Of the 10 organizations that participated, seven have addressed the transition from the ED to patient floors.

The initiative involved the use of "Robust Process Improvement," a process improvement approach that uses the tools of Lean, Six Sigma, and change management, according to Klaus Nether, MT (ASCP) SV, a Black Belt with the center. "It's a systematic approach to problem solving," Nether explains.

One of the participating facilities, the Steven and Alexandra Cohen Children's Medical Center of New York, in Glen Oaks, originally began with a "pass the baton" tool, but modified into a more sophisticated handoff tool. Dina Cicillini, RN, director of Patient Care Services of Pediatric Emergency Services. "We basically constructed a tool for handoffs that covered all the important points of care provided to the ED patients and translated it in a comprehensive way to the inpatient providers who were now going to take care of the patients. We also mimic the tool when we give handoffs internally, because the same critical elements should be covered in any transfer." The tool includes such information as patient's name, gender, date of birth, diagnosis, procedure, initial assessment upon presentation, interventions and lab results, and status.

Cicillini says the major barrier that was addressed by the form was being able to make a meaningful connection with the provider receiving the patient while both sides of the handoff are multi-tasking and have a small amount of time to focus on the handoff.

The staff was not happy with the original handoff form and re-designed it, she says. Now, Cicillini says, they gather all the necessary information, sit in as quite an area as they can find, and complete the report in standard format so that the receiver knows exactly what they should be receiving and can easily identify what's missing because the sender and receiver have the same number of elements to look for.

"At the end of the handoff I'm looking at the same tool. It's standardized communication with a built-in double-check," Cicillini explains. (In developing such a form, it's essential to have the frontline staff involved, says Cicillini. See the story below.)

More information to come

Nether says more information soon will be made available. He notes, for example, that five of the 10 participating hospitals still are implementing solutions and will report their progress in the coming weeks.

"They will then implement their control plans to monitor improvement, as well as sustaining it over time, which is a unique part of this program," Nether says. "We will then start piloting the process as well as the targeted solutions in demographically diverse hospital and healthcare systems."

One reason for the pilot programs, he explains, is that the criteria for choosing the participants included a requirement that they already had experience with these tools. "As we go to pilot, we want to make sure that any organization, regardless of size or experience, will be able to follow this step-by-step process," Nether explains.

All the tools and the measurement system will be shared with the pilot participants, so that they will be able to measure their current baseline performance and identify and validate their specific root causes. "There isn't a single root cause," notes Nether," and they differ from organization to organization."

In the second half of 2011, he says, this information will be available on the Web (www.centerfortransforminghealthcare.org.) free of charge. "You'll be to go in and follow the process step-by-step, the way the participating hospitals did," he says. (An outline of the proper handoff process is also found in a Joint Commission standard. See the story below.)


For more information on improving handoffs, contact:

  • Carol Mooney, RN, MSN, Senior Associate Director, Standards and Interpretation Group, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5900.
  • Klaus Nether, MT (ASCP) SV, Black Belt, The Joint Commission Center for Transforming Healthcare, Oakbrook Terrace. Phone: (630) 792-5297.

Standard outlines handoff process

The proper process for handoffs is outlined in The Joint Commission standard PC.02.0201.EP2, notes Carol Mooney, RN, MSN, senior associate director at the Standards and Interpretation Group, who adds that they formerly were covered under a National Patient Safety Goal.

"Typically when we move a goal into the chapter, it is because we have brought attention to it and the education was out there and there was more compliance, but we didn't want to eliminate our focus on it," she explains.

In fact, she notes, compliance levels for the standard are about 99%. So why would The Joint Commission Center for Transforming Healthcare involve numerous hospitals in an initiative to improve their handoffs? Klaus Nether, MT (ASCP) SV, a Black Belt with the center, says, "Studies have shown that in a typical hospital there are 4,000 patient handoffs every day. If you are doing a really good job 95% of the time that's about 200 failures a day, and the consequences of these can be serious: anything from inappropriate treatment to delay of treatment to extended lengths of stay and increased healthcare costs."

Mooney says that Element of Performance (EP) 2 under the standard states that the process for the handoff "provides for the opportunity for discussion between the giver and receiver of patient information." She adds that a note in the EP states that such information might include the patient's condition, care, treatment, medications, services, and any recent or anticipated changes in any of these.

Mooney notes that "just the setting itself" in the ED makes compliance a challenge. One way to ensure success, she says, is "to develop a standardized process so that various disciplines, such as nursing, know how to report off to the nurses on the units when the patient gets transferred up to the floor."

Management Tip

Involve staff in new tools

When developing a new tool, such as a handoff form, it's critical to have your frontline staff involved in that process, says Dina Cicillini, RN, director of Patient Care Services of Pediatric Emergency Services at the Steven and Alexandra Cohen Children's Medical Center of New York.

"They are the ones that will be using the tool, and it has to make sense for their workflow," Cicillini says.

In addition, she says, you should be sure to have an "exclusive" rollout for such a tool. "There are lots of things going on in the ED, so make this a focused rollout so you can sustain and maintain it," Cicillini says. "You have to give it your full attention."