Critial Path Network

JCAHO to look closely at patient handoffs

Communication lapses will be key focus

An emergency department patient is brought in for an X-ray, but the nurse forgets to tell the radiologist about the patient’s allergy to contrast dye. During a change of shift, a caregiver doesn’t mention that the patient is at high risk for a fall injury. When a patient is transferred, the receiving facility isn’t given a complete list of medications the patients is taking.

Whenever patients are "handed off" from one health care provider to another, it is a dangerous time, according to Peter Angood, MD, vice president and chief patient safety officer for the Joint Commission’s International Center for Patient Safety.

"I think the important message out of this is that the JCAHO has gathered a decade’s worth of data related to sentinel event activity — and a common theme that’s always at the top is the issue of communication," he explains. "And one of the most important areas is handoffs. It’s a high-risk period, and there is a tendency to undercommunicate."

Clinicians are now being challenged to demonstrate that processes are in place to address all types of hand-off communication, with the JCAHO’s new 2006 National Patient Safety Goal #2E. Organizations must implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.

You must have processes in place to ensure that information is transferred from one caregiver to the next on the patient’s condition, current problems that are active or potentially active, and the stability or potential instability of vital signs or physiologic status.

"What surveyors will be looking for is that institutions have implemented the structure and processes to effectively deal with managing handoffs," Angood says.

What they are looking for

Surveyors also will be looking for obvious lapses or processes that contribute to poor communication during handoffs, such as the use of tape recorders, illegible handwriting, use of nonstandardized forms, and the inability to contact an individual for follow-up questions.

"We are not being too prescriptive about all this, because there are a multitude of environments out there," says Angood. "Ideally, there should be good face-to-face communication. And if needed, there should be a way to contact people to clarify issues about patient care."

The problem with tape recorders is that there may be a tendency to provide minimal information if the staff person is eager to get off duty, says Angood. "They will occasionally miss information. And you’ve got the new person coming in trying to settle into their day, listening to the message while patients are arriving, which results in inattentive listening."

Inconsistent communication during patient handoffs has, at times, led to a patient’s safety being placed at risk, says Rita Stockman, RN, MSA, director of hospital quality at William Beaumont Hospitals. The organization recently implemented a re-engineering process to address handoffs.

"The risk may be due to a gap in information, or perhaps the inability to rapidly locate the information in the medical record," says Stockman. "Variances in the reporting process have been demonstrated over time."

A "Hand Off Task Force" designed and implemented an improved process for transfer of inpatient information. The goal was to ensure that during a patient transport, each team member plays an active role in handing off the patient.

A "Transport Procedure Checklist" documents the transfer of the patient — and responsibility for their care — from one department and caregiver to another.

"Each caregiver involved in this handoff plays a distinct role in ensuring the clinical information is current, actively communicated, and that the patient is safe," says Jayant Trewn, PhD, the organization’s research engineer.

The project was implemented from March 2004 to July 2005, with five teams, as follows:

  • The "Continuity of Care" team designed the hand-off project.
  • The "Data Elements" team determined the data elements that were to be included in the hand-off form.
  • The "Performance Standard & Transfer of Information" team determined the performance evaluation standards and an information system to access data elements.
  • The "Research and Publication" team developed and implemented the hand-off project evaluation methodology and assessed the success of the change.
  • The "Education Subgroup" developed and implemented the hand-off training. The project was steered by a core group, with monthly review meetings held. A "Plan, Do, Check, Act" methodology was used, with the following cycle of activities: Evaluation of current hand-off process, redesign of hand-off process, testing of new processes using direct observation and user feedback, redesign of the process and form, implementation of revised form and reevaluation of change, and ongoing monitoring of the hand-off process.

The evaluation and feedback information was used by the task force to revise the form and improve the hand-off process. During the pilot, emergency department (ED) staff identified the need to include a separate form for their admitted patients, since there were specific data elements that needed to be included.

The hand-off process is being monitored on a monthly basis by the task force, using direct observations on a sample of handoffs as they occur on units.