4 Steps to Address The Joint Commission’s Sentinel Event Alert on Hand-Off Communication

October, 2017

Address The Joint Commission’s

The Joint Commission (TJC) has a definition of a hand-off, and it shows the inseparable relationship between patient hand-offs and communication:

“A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care.”

This definition was part of TJC’s Sentinel Event Alert 58: Inadequate hand-off communication. The Alert cites a study which estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years.

Hand-off communication is as critical to patient safety as it ever was, and the Alert’s guidance is as relevant today as when it was published in September 2017. Sentinel Event Alert 58 is worthy of a fresh look. 

In this blog, I consolidate TJC’s eight tips from the Alert into four steps and emphasize the role clinical communication and workflow technology can play in supporting patient safety during hand-offs.

4 Steps to Better Hand-Off Communication

1. Incorporate Forms and Checklists
Collectively, TJC’s tips one, two, and five talk about determining the information that needs to be communicated, standardizing on how to communicate it, and managing how care teams send and receive communication.

Technology can help here.

Look for a communication platform that can incorporate templates and automatically attach patient, event, and care team context to calls and messages.

Vocera^® software has standardized drop down boxes so you don’t have to type out full messages. Patient-specific data captured in the physiologic monitor and other systems can be sent to a clinician’s mobile device. And, you can configure Vocera software to provide much of the context in TJC’s tip five with a communication protocol.

2. Connect Directly and Instantly
TJC’s tips six and seven are about conducting hand-offs face-to-face in a location free from interruptions. A common reason people don’t conduct hand-offs face-to-face is they’re busy and can’t find each other.

Vocera technology helps solve that by enabling care team members to connect directly and instantly, with no need to know names or numbers. The software system routes calls, messages, and notifications with automatic escalation paths.

When a hand-off requires a group meeting, use Vocera technology to call members of a broadcast group with the single touch of a button.

3. Enhance Hand-Offs with Information in Context
Tips four and eight are closely related. Tip four is about combining information and communicating it in a consolidated way, and tip eight is about integrating the EHR with other technologies. The goal is to get more complete information more easily.

Look for a communication platform that can integrate with other clinical and operational systems, including the EHR, and leverage system integration to automate portions of the hand-off template. The Vocera Platform integrates with the systems you use – more than 150 in all. This means you have more information to inform clinical decision making.

4. Address Organizational and Cultural Aspects
The full text of TJC’s Sentinel Event Alert emphasizes the organizational and cultural aspects of improving hand-off communication. These include:

• Demonstrating leadership’s commitment to successful hand-offs and other aspects of a safety culture
• Managing the environment to provide locations free from interruptions
• Sustaining and spreading best practices, and making high-quality hand-offs a cultural priority

The Experience Innovation Network, part of Vocera, sponsored a Patient Safety & Quality Healthcare (PSQH) webinar called Communication Deconstructed: 7 Elements of Effective Clinical Communication.

The webinar features Marty Scott, MD, MBA, formerly chief transformation officer at Hackensack Meridian Health; and Sue Murphy, RN, BSN, MS, chief experience and innovation officer at UChicago Medicine. 

The webinar explores the importance of building a shared purpose to guide all clinical communication, and discusses humanized communication tools that help hardwire communication excellence. View the webinar here.

Strengthen the Information Chain to Strengthen Patient Safety

Every clinician who works with the patient applies his or her clinical observation and assessment tools, draws conclusions, and adds to the chain of data and information. Within this chain, data points sometimes slip. This is how communication begins to break down.

What happened over the previous 12 hours is relevant for the next 12 hours. With Vocera, hospitals strengthen the integrity of the information trail to reduce the burden of remembering and strengthen patient safety.