A group of 10 leading U.S. hospitals and healthcare systems have teamed up with the Joint Commission Center for Transforming Healthcare on the Hand-off Communications Project, to use new methods to find the causes of and put a stop to dangerous and potentially deadly breakdowns in patient care.
Healthcare organizations have long struggled with the process of hand-offs, passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another.
During the measure phase of the Hand-off Communications Project, which began in August 2009, participating hospitals found that, on average, hand-offs were defective more than 37 percent of the time, and didn’t allow the receiver to safely care for the patient. In addition, senders were dissatisfied with the quality of the hand-offs 21 percent of the time.
Using solutions targeted to the specific causes of an inadequate hand-off, participating organizations that fully implemented the solutions achieved an average 52 percent reduction in defective hand-offs, the Joint Commission stated.
The hospitals and health systems participating in the project are:
- Exempla Lutheran Medical Center in Wheat Ridge, Colo.;
- Fairview Health Services in Minneapolis;
- Intermountain Healthcare LDS Hospital in Salt Lake City;
- Johns Hopkins Hospital in Baltimore;
- Kaiser Permanente Sunnyside Medical Center in Clackamas, Ore.;
- Mayo Clinic, Saint Mary's Hospital in Rochester, Minn.;
- New York-Presbyterian Hospital in New York City;
- North Shore-LIJ Health System Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, N.Y.;
- Partners HealthCare, Massachusetts General Hospital in Boston; and
- Stanford Hospital & Clinics, Palo Alto, Calif.
Breakdowns in communication have been a leading contributing factor in sentinel events or the risk thereof. Defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital, according to the Joint Commission, of Oak Brook, Ill.
The Center for Transforming Healthcare and the participating hospitals set out to solve the problem using Robust Process Improvement (RPI) tools, which is a data-driven problem-solving methodology that allows project teams to discover risk points and contributing factors, and then develop and implement targeted solutions to increase patient safety and healthcare quality.
The targeted hand-off tool from the Center, SHARE, addresses the causes of unsuccessful hand-offs:
- Standardize critical content, which includes providing details of the patient's history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
- Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
- Allow the opportunity to ask questions, which includes using critical thinking skills when discussing a patient's case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
- Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
- Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.