Joint Commission Touts Research on Reducing Handoff Failures

A 10-hospital collaborative to reduce handoff failures, the root cause of four in five adverse events, successfully cut by 52% the number of faulty handoffs by identifying reasons why communication fails, says Mark Chassin, president of the Joint Commission.

Chassin says that when these solutions are refined, they may become part of the commission's hospital accreditation process, with a report on their outcomes expected by mid 2011. Also in the works is the development of a way to quantify how reducing handoff failures improves outcomes, he says.

Chassin spoke during a briefing with representatives of several hospitals participating in the commission's Center for Transforming Healthcare. And during that session, many noted that lack of respect between sender and receiver, and varying cultures and focus—for example between the emergency room team and an inpatient team—may explain some reasons why information that must be conveyed is not.

"This is a ubiquitous problem," said Chassin, former Executive vice president for Excellence in Patient Care at Mount Sinai School of Medicine and former Commissioner of the New York State Department of Health.

"There's potential for miscommunication "each time a patient moves from one area of care to another, for example, from the emergency department to a medical surgical inpatient unit, from an intensive care unit to an inpatient unit or from a recovery room to an inpatient unit or from one set of providers to another set during a change of shift."

In just one average-sized teaching hospital, for example, he says there are 4,000 patient handoff opportunities for error every day, " or 1.6 million a year. If you think about those staggering numbers, you think about how many opportunities there are for miscommunication."

The hospitals, which began the project in August, 2009, realized that on average, 37% of their handoffs were defective.  Information that was provided by the sender, or received by the receiving caregiver, was insufficient to guarantee safe care, they realized.  Additionally, 21% of the time senders were dissatisfied with the quality of the handoff.

"It is unfortunately not uncommonly the case that the caregivers involved in sending a patient to the care of another set of caregivers don't really believe the time that is necessary to do this process well is something they ought to be spending their time on," Chassin says.

"Often senders and receivers don't work together routinely as teams, and get to know each other, they are commonly parts of other teams that don't routinely interact you can get that 'siloed' view that leads to barriers to good communication."

"We've realized that different people even within different disciplines have different pressures and expectations," said Michael Aylward, MD, of the University of Minnesota's Fairview Health Services. "The reality is their training is very different."

Susan Mullaney, CEO of Kaiser Permanente Sunnyside Medical Center in Clackamas, OR, says that the process needs to bring in a sense of respect for both the sender and receiver. The senders need to give the report, and then take time with the receiver to make sure they've really had all their questions answered. "And the organization needs to respect that you need to dedicate the time and effort to this important interaction. I don't think we've done that in the past."

In an interview yesterday, Chassin, a board-certified internist who practiced emergency medicine for 12 years recalled a classic case of faulty handoff that he knew personally. An elderly woman was admitted to the hospital with an order for 300 mg of dilantin three times a day. "The resident got the information from an electronic source, and didn't recognize there might be a problem."

The hospital's pharmacist, however, reviewed the order and saw the error. He filled only the first dose and told the evening nurse. " 'Make sure the next shift knows about this,' he warned. But that communication never happened, either on the physician's side or the nurse's side. The problem was not discovered until the patient had a toxic reaction; she spent three to four days in a severely toxic state."

The solutions the team has come up with are called SHARE, which includes five elements: Standardize critical content, Hardwire within your system, Allow opportunity to ask questions, Reinforce quality and measurement and Educate and coach.

Among some of the solutions the team discovered are these:

1. Set aside a time and place for the sending and receiving team to exchange information, a time when there are no distractions or competing priorities.

2. Standardize the crucial information that both sender and receiver need to have.

3. Develop forms, tools, checklists and bring in new or adapt existing technologies to the handoff process

4. Allow opportunities to ask questions.

5. Reinforce quality and measurement by holding staff accountable, monitoring compliance and using data to determine ways to improve.

Facilities volunteering to participate in the handoff project are: