Joint Commission Issues Alert on Hand-off Communication

“What we have here is a failure to communicate†is a line from the 1967 film Cool Hand Luke. It’s also a problem in the world of healthcare when one provider hands over a patient’s care to another for continued care and treatment.

Earlier this month, the Joint Commission issued a new Sentinel Event Alert to provide hospitals and other healthcare settings with a list of recommendations designed to improve communication failures. The alert also reviews contributing factors to these hand-off communication failures, solutions, research, quality improvement efforts, and The Joint Commission’s related requirements.

The Joint Commission points out that such communication failures are responsible, in part, for 30 percent of all malpractice claims resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years, according to a 2015 study.

This isn’t surprising given the number of people (especially in a hospital setting) who are responsible for patient care and who move in and out of that care during shift changes.

The hand-off process involves “senders,†those caregivers transmitting patient information and transitioning the care of a patient to the next clinician, and “receivers,†those care-givers who accept the patient information and care of that patient. In addition to causing patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.

The Joint Commission has noted that contributing factors to hand-off communication breakdowns include insufficient or misleading information, absence of safety culture, ineffective communication methods, lack of time, poor timing between sender and receiver, interruptions or distractions, lack of standardized procedures, and insufficient staffing.

The seven recommendations to improve hand-off communication include:

1. Demonstrate leadership’s commitment to successful hand-offs and other aspects of a safety culture.
2. Standardize critical content to be communicated by the sender during a hand-off—both verbally and in written form.
3. Conduct face-to-face hand-off communication and sign-outs between senders and receivers in locations free from interruptions—include multidisciplinary team members, the patient and family, as appropriate.
4. Standardize training on how to conduct a successful hand-off.
5. Use electronic health record capabilities and other technologies to enhance hand-offs.
6. Monitor the success of interventions to improve hand-off communication and use the lessons to drive improvement.
7. Sustain and spread best practices in hand-offs and make high-quality hand-offs a cultural priority.

This isn’t the first time the Joint Commission has addressed this issue. In 2012, it released a targeted solutions tool for hand-off communications.

Having the right systems in place can help hospitals and other healthcare systems avoid critical errors that can lead to serious injury or even death. The Health Law Offices of Anthony C. Vitale can assist in the development of office protocols and flow-processes to mitigate the risk exposure associated with such gaps in communication. Call us at 305-358-4500 or send an email to info@vitalehealthlaw.com and let’s discuss how we might be able to help.