Joint Commission provides tips for improving handoffs

This September, The Joint Commission posted an infographic on “high-quality hand-offs.” The infographic is a companion to the accreditor’s Sentinel Event Alert (SEA) 58 on inadequate handoff communications and its effect on patient care. Transferring a patient’s care between providers is major point of failure for healthcare. Every transfer runs the risk of key treatment information being garbled, forgotten, or not passed on.

“Potential for patient harm—from the minor to the severe—is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote in SEA 58. “When hand-off communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few.”

Along with the eight tips in the infographic, the SEA listed several steps to minimize handoff problems, including:

1.    Standardize the content that’s shared during a handoff. This includes standardized tools and methods (e.g., forms, templates, checklists, protocols, mnemonics, etc.) to communicate to receivers.
2.    Conduct face-to-face handoffs in locations free from distractions.
3.    Teach staff how to conduct a successful handoff as both the sender and the receiver.
4.    Use electronic health record capabilities and other technologies to enhance handoffs between senders and receivers.
5.    Measure how successful these interventions are at improving handoff communication and use the lessons to drive improvement.