JCAHO’s 2006 National Patient Safety Goals: Handoffs are biggest challenge

Surveyors will zero in on the way caregivers communicate

Is your organization still struggling to comply with the Joint Commission’s existing National Patient Safety Goals? If so, you may be bracing yourself at the thought of additional requirements, while at the same time, recognizing the need to address high-risk areas. With its new 2006 goals, the Joint Commission apparently struck the right balance, according to quality professionals interviewed by Hospital Peer Review.

"I think they added what was needed and pushed us where we needed to be pushed. But they weren’t unreasonable — they were sensitive to the requirements and how difficult it is," says Kim Shields, RN, clinical systems safety specialist at Abington (PA) Memorial Hospital.

The Joint Commission decided not to increase the total number of requirements from 2005 to 2006, with no more than two new requirements added, says Richard J. Croteau, MD, JCAHO’s executive director for strategic initiatives. "We made a decision early on in the process to limit the number of new requirements," he says. "It’s a matter of keeping the focus on those areas considered to be most important. We believe very strongly that we can accomplish more by focusing on a small number of expectations than by flooding the field and trying to do everything at once."

Two goals were retired, including the goal regarding free-flow protection on all general-use and patient-controlled analgesia intravenous pumps, as well as the requirement to assess and periodically reassess each patient’s risk for falling and address identified risks.

"Although they are retiring two goals, they still require maintenance to ensure continued compliance with the processes established in previous years," says Mary M. Owen, RN, MPA, director of outcomes case management at University of California, Irvine Medical Center in Orange.

Compliance with the retired goals still is necessary, since the requirements are incorporated or implied in existing standards. "So they didn’t really go away, but it was nice to see the list not keep growing and growing," says Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation at Baptist Health in Jacksonville, FL.

JCAHO’s focus on patient safety has changed the landscape of performance improvement in health care dramatically, Owen says. "It has scripted organizations on their quality work plans for the year. But in that change, it may disempower organizations to identify internal opportunities for improvement without adding additional manpower resources."

With the cost of health care increasing at the bedside, whether from nursing ratios or technology advancements, resources for performance improvement are lower priority, Owen explains. "A complex paradigm shift is occurring. We need to ensure the shift is balanced so that these excellent patient safety initiatives are effective and not a landslide," she adds.

Here are the new requirements for 2006, with strategies for each:

  • Implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions.

This goal was "right on the money," Shields says. "I think we all hated to see it because it is a difficult fix. When we start looking at this, we will recognize that the problem is even bigger than we thought it was. Everybody just needs to take a deep breath and understand that whatever process may be in place, anything we do is an improvement from what we are already doing."

Misinformation or ineffective communication at handoff points is one of the most common causes of adverse events, Croteau warns. "Two-thirds of all of our sentinel events are related to breakdowns in communication, and most of that is at handoffs," he says.

Every organization will have to take an in-depth look at handoffs and how to improve communication, Halvorsen emphasizes. "I’m glad to see this one — this has always been something that’s been a concern, and we could all do better. This is really a very, very dangerous process in a patient’s care, and it’s extremely important that we do it right."

The challenge for organizations will be designing the right infrastructures to support the needed actions, says Christine Macaulay, RN, MSN, CEN, a Philadelphia-based consultant specializing in accreditation compliance and health care quality.

"Communication handoffs have been a challenge in all my 20-plus years experience," she says. "Getting point-of-care staff to assume leadership in patient safety is easy. But without formal mechanisms in a blame-free environment — one that focuses on process rather than finger pointing — the outcomes may not be realized."

Surveyors will want to see that your organization has a defined process for how information will be communicated. You’ll need to identify which handoffs to address — which typically will include nursing change of shift and physicians going off duty and transferring responsibility to another physician — and determine what information needs to be communicated.

"In addition to having a defined process that addresses those things, we will want to know that those expectations have been communicated to all the staff who are involved in handing off, and through direct observation and interviews, determine that this is actually being done consistently, which is the most important piece," adds Croteau.

Whenever a patient moves from one area to another and new caregivers are involved, there is an expectation of transferred information, and if something isn’t clear, you need a system to ensure it can be clarified immediately.

That will call into question the practice of making audiotapes of change-of-shift reports for nursing staff, which commonly is done at many organizations. "That will not be an acceptable way of meeting this requirement," Croteau explains. "If the nurses have any questions, and they often do, they either make their best guess or call nurses from the previous shift at home, which they’re often reluctant to do."

Real-time communication

Face-to-face communication is ideal; if this is not possible, real-time communication also can be done over the telephone, he says. "This really isn’t about written communication, it’s more of a real-time communication, because we’re taking care of patients in real time," Croteau stresses.

Patients are put at risk during busy periods and changes of shift when caregivers don’t take the time to ensure a safe transfer process, adds Halvorsen.

"I’ve always felt it was best to have a face-to-face approach to transfers and discharges. When we are at a high census or extremely busy, the use of transfer sheets with written information is probably not the safest way to communicate," she explains. Transfer and discharge forms should include an opportunity to ask questions face to face, and if that’s not possible, then a telephone conversation should take place. "We often get in a hurry and rely on written communications — but if I’m on the receiving end and don’t understand something they wrote, I should be able to follow up and ask questions."

Make sure that forms are conducive to communication about the care of the patient, Halvorsen explains. "We had to do the same thing for medication reconciliation, so this goes hand in hand with that. We are currently reviewing all of our transfer and discharge forms and making necessary changes, including adding appropriate prompts for information gathering."

With JCAHO and other quality agencies requiring ongoing monitoring of many indicators, facilities have been pressed to add extra staff, especially since a lot of the monitoring has to be done manually. "To monitor this particular process would require observation of transfers and discharges, or retrospective data collection on forms, both of which requires more staff," she notes.

Electronic records are one solution to the handoff requirement, but the cost and implementation of a software program to support communication can be a major barrier. In addition, few software vendors can meet the needs of all the different venues in the communication loop such as the physician office, home care, satellite care center, hospitals, long-term care, and rehabilitation centers, Macaulay says. "Many health care systems are going down the road to full computerization but are still in the half-electronic and half-paper system," she says.

Create a checklist noting information that should be exchanged during a handoff, including the reason for handoff (such as following a procedure or test, prior to a procedure or test, or movement of patient from one unit to another), condition of patient, any complications, and the time and place of the handoff, recommends Kathleen A. Catalano, RN, JD, director of regulatory compliance services for Dallas-based PHNS Inc. "The quality manager is going to need to monitor the effectiveness of any mechanism put into place," she adds.

Abington Memorial currently is implementing an electronic medical record for orders and lab test results, but nurses are not yet documenting electronically, Shields says. "Physicians can access the information from inside or outside the hospital, which certainly helps, but it doesn’t address the problem of when patients are outside of the institution."

Computerized discharge instructions are being developed so information can be printed out for laypeople or using medical terminology, depending on whether the patient is being discharged to home or a nursing home, with copies sent to the patient’s primary physician or specialist. "That is one way we are going to improve communication on the discharge end," she continues.

However, in smaller hospitals, a paper system can work very well, as long as everyone documents in a single place, Shields says. "Organiza-tions shouldn’t be discouraged just because they don’t have an electronic system. A good paper system, with everybody using the same tool, can be very effective," she says. "No one has the time to look at other places, and that’s how we tend to miss things."

A medication reconciliation sheet is being developed so clinical professionals can document on a single form. "Right now, nurses and doctors document the patient’s medication history on separate forms. Physicians may be unaware of additional medications the patient told the nurse about, if they do not reference the nurse’s medical history list," Shields says.

The goal’s requirements are very broad, since handoffs occur so frequently in the organization as patients move through the continuum of care.

"It doesn’t have to be transferring the patient from one hospital to another, or a different level of care of service; it could be something such as the patient going for a procedure or test," Halvorsen says. "It’s important to talk to people down there and give them a report on the patient. There has to be communication between care providers anytime there is a handoff in providing care."

For example, lab results may fall through the cracks when patients are going from the inpatient to outpatient setting. "Lab or radiology test results not documented on the patient’s chart prior to discharge may fall into a black hole where no one ever follows up on the results, because the outpatient physician is unaware that the tests were ordered," Shields notes.

To address this, at Abington, instructions were added to the discharge sheet stating, "Make sure that all lab tests and radiology results have been reviewed prior to discharge. If not, make sure you let the doctor know there are test results pending."

Set up discharge instruction sheets in a checklist format, Shields recommends. "Some organizations have generic discharge instruction sheets with a lot of space for narrative notes, but without a checklist, you may forget to address important discharge instructions," she says.

Ensure information is shared with all the physicians involved in the patient’s care, Shields advises.

"We have to make sure that handoffs aren’t going to just one doctor. If you have electronic records, make sure everybody involved gets a copy of the discharge instructions. If you have a paper system, set up a faxing system to make sure discharge instructions go to all doctors involved in the patient’s care. Again, you don’t have to have an electronic system to make this doable," she underscores. "When the patient is discharged, the unit secretary can fax it to all the doctors involved. It is more work, but it certainly is worth it."

  • Label all medications, medication containers, or other solutions on and off the sterile field in perioperative and other procedural settings.

"What we’re looking for is pretty simple — we’re looking for labels on all medications, period," Croteau says.

Even though JCAHO’s standards already include a requirement that all medications should be labeled, there has been a longstanding practice in surgery to have medications available for anesthesia without labeling them, he notes.

"Unfortunately, we’ve had some horrendous adverse events, including children dying, as a result of injecting something someone thought to be a medication and turned out to be cleaning fluid or another substance, simply because it was there and wasn’t labeled," Croteau adds.

Anesthesiologists often will draw up medications to be administered during surgery, and there may be two or three unlabeled syringes that can get mixed up, he says.

"We put it into the safety goals to call attention to this and put a spotlight on it. We will be surveying it more intensely, specifically for surgically invasive procedures," Croteau says, adding that surveyors will use direct observation and interview staff to determine compliance.

"The medication labeling goal is already in effect within our organization and was a point of emphasis during our accreditation survey last year," Owen says. "Anesthesia has been the key to this improvement."

When medication labeling was addressed at Baptist Health, anesthesiologists were resistant at first, Halvorsen explains. "That was a real culture shift for them; they set up the same field every time they do a case, and that’s when errors are made," she says. "We identified a few anesthesiologist champions for change to address this in anesthesia departmental meetings."

There is no system fix to assure that medications aren’t labeled incorrectly — you have to rely on the practitioners to do the right thing, Shields says. "If we were doing the right thing all along, this wouldn’t have to be a goal," she adds. "Most importantly, this involves leadership buy-in. It has to start at the top, and there has to be zero tolerance for not doing it. Otherwise, people will go back to their old ways."

Practitioners don’t start out with the mindset that they are going to make an error. In their minds, they feel their method of preparing medications is safe, Shields notes. "They feel they are so busy and this is one additional thing to do," she says. "But there continue to be reports of medication mix-ups, with patients getting the wrong medication."

The best way to educate staff is through stories about adverse outcomes that occurred at your organization because of mislabeled medications, Shields adds. "That really brings it home without making it seem punitive. Staff have to understand that not only is it the right thing to do, but now we’re required by an outside regulatory body to be compliant."

A cultural change in behavior is needed, she emphasizes. "It’s not just educate and forget. You need tracking mechanisms and metrics to measure improvement. Studies show that it takes anywhere from 12 to 18 months for behavioral culture changes to occur in an organization. You can’t just throw it on there as the flavor of the month and move on to another project."

To monitor improvement requires direct observation of cases, Shields says. "You hate to use the word policing, but someone needs to go through ORs or procedural units to observe staff compliance with labeling syringes before procedures," she advises. "Pick one day a week when you go through five or six units. To look at the entire house would be too overwhelming, so start small, do a sample, and that’s your baseline. The most important thing is to give feedback to the practitioners."

[For more information, contact:

  • Kathleen A. Catalano, RN, JD, Director, Regulatory Compliance Services, PHNS Inc., One Lincoln Centre, 5400 LBJ Freeway, Suite 200, Dallas, TX 75240. Phone: (214) 257-7112. Fax: (214) 707-7403. E-mail: Kathleen.Catalano@phns.com.
  • Mary M. Owen, RN, MPA, Director, Outcomes Case Management, University of California, Irvine Medical Center. Phone: (714) 456-8964. E-mail: mowen@uci.edu.
  • Kim Shields, RN, Clinical Systems Safety Specialist, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001-3788. Phone: (215) 481-4378. Fax: (215) 572-9087. E-mail: KShields@amh.org.]