Joint Commission confronts deadly miscommunications

By Bernie Monegain
10:39 AM

Ten U.S. hospitals and healthcare systems have partnered with the Joint Commission Center for Transforming Healthcare to end potentially deadly breakdowns in communication that occur during the hand-off of patients from one caregiver to another. Among their recommendations: Identify new and existing technologies to 'hardwire' into the system.

An estimated 80 percent of serious medical errors involve miscommunication between caregivers when responsibility for patients is transferred or handed-off, according to the Joint Commission.

The Hand-off Communications Project began in August 2009. During the measure phase of the project, the participating hospitals found that, on average, more than 37 percent of the time hand-offs were defective and didn't allow the receiver to safely care for the patient.

Also, 21 percent of the time the caregivers handing off the patients were dissatisfied with the quality of the hand-off. 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 10 hospitals and health systems that volunteered to address hand-off communications as a critical patient safety problem are:

  • Exempla Lutheran Medical Center, Wheat Ridge, Colorado
  • Fairview Health Services, Minneapolis, Minnesota
  • Intermountain Healthcare LDS Hospital, Salt Lake City, Utah
  • The Johns Hopkins Hospital, Baltimore, Maryland
  • Kaiser Permanente Sunnyside Medical Center, Clackamas, Oregon
  • Mayo Clinic Saint Marys Hospital, Rochester, Minnesota
  • New York-Presbyterian Hospital, New York
  • North Shore-LIJ Health System Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
  • Partners HealthCare, Massachusetts General Hospital, Boston
  • Stanford Hospital & Clinics, Palo Alto, California

Although The Joint Commission requires accredited organizations to use a standardized approach to hand-off communications, breakdowns in communication have been a leading contributing factor in sentinel events, which are unexpected occurrences involving death or serious physical or psychological injury, or the risk of death or injury. In addition to patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.

Recognizing that there is no quick fix, the center and the participating hospitals set out to solve the problems through the application of Robust Process Improvement tools. RPI is a fact-based, systematic, and data-driven problem-solving methodology that allows project teams to discover specific risk points and contributing factors, and then develop and implement solutions targeted to those factors to increase overall patient safety and healthcare quality. Barriers to effective hand-offs experienced by receivers include incomplete information, lack of opportunity to discuss the hand-off, and no hand-off occurred. Senders identified too many delays, receiver not returning a call, or receiver being too busy to take a report as reasons for hand-off failures.

 "These 10 organizations are leading the way in finding specific solutions to the complex problem of hand-off communication failures," says Mark R. Chassin, MD, president, the Joint Commission. "A comprehensive approach that focuses on systems is the only way to ensure that the many caregivers upon whom patients rely are successfully communicating vital information during these transitions in care."

The targeted hand-off solutions from the center, which are described using the acronym SHARE, address the specific 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 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. 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.

In addition to hand-off communications, the center is aiming to reduce surgical site infections following colorectal surgery through a new project launched in August 2010 in collaboration with the American College of Surgeons. Participating organizations include the Mayo Clinic, OSF Saint Francis Medical Center, Cedars-Sinai Medical Center, North Shore-LIJ Health System, Cleveland Clinic, Stanford Hospital & Clinics and Northwestern Memorial Hospital.

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