Handoff

Handoff Communication Safe Transitions in Patient Care Patton

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Contents

About the author .........................................v

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

Chapter 1: The handoff communication goal . . . . . . . . . . . . . . . . . . . . . 1

Handoff communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Language of the goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Implementation expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Interpreting the goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Meeting the goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Design considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Tips for improving handoff communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Chapter 2: Problems and challenges in various patient care settings . . .17

Nursing . . . . . . . . . . . . ........................................ . . .19
Other departments . . . . ........................................ . . .20
Physician-to-physician . ........................................ . . .21

Chapter 3: Resources ... ........... ........... ........... . .23

Staff . . . . . . . . . . . . .... ............. ............. ............. . . .25
Literature . . . . . . . . .... ............. ............. ............. . . .25
The Web . . . . . . . . .... ............. ............. ............. . . .25
Technology . . . . . . .... ............. ............. ............. . . .26

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C ONTENTS

Chapter 4: Design and implementation . ........... ........... . .29

Ideas from the literature . . . . . . . . . . . . . . ............. ............. . . .33
Design for patient safety . . . . . . . . . . . . . . ............. ............. . . .35
Staff involvement . . . . . . . . . . . . . . . . . . . ............. ............. . . .35
Medical staff . . . . . . . . . . . . . . . . . . . . . . . ............. ............. . . .36
Implementation tips . . . . . . . . . . . . . . . . ............. ............. . . .37

Chapter 5: Policy development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Chapter 6: Staff training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Active communication and active listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Chapter 7: Monitoring effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Chapter 8: Barriers to overcome ..... ........... ........... . .63

Time . . . . . . . . . . . .......... ....... ............. ............. . . .65
Buy-in . . . . . . . . . . .......... ....... ............. ............. . . .65
Information needs . .......... ....... ............. ............. . . .66

Appendix A: Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

Appendix B: Frequently asked questions . . . . . . . . . . . . . . . . . . . . . . .75

Additional resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Appendix C: Case studies and field tools . . . . . . . . . . . . . . . . . . . . . . .91

Case study #1: Keep it simple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Case study #2: SBAR refresher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Case study #3: Working toward a standardized approach . . . . . . . . . . . . . . . . . .108
Case study #4: Four tips to meet the handoffs goal . . . . . . . . . . . . . . . . . . . . . .115

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C H A P T E R O N E

THE HANDOFF COMMUNICATION GOAL

WHAT IS A HANDOFF?
A handoff, also known as a handover or patient care transfer, is an inter-
active process of transferring 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 patients care.1

Handoff communication

Handoff communication is a Joint Commission National Patient Safety Goal

(NPSG) for hospitals in the United States that went into effect in 2006. It is a
focus area for Joint Commission surveyors during all of their visits to accredited
healthcare organizations in the United States.

Handoff communication is not yet an international safety goal for Joint Com-
mission International ( JCI). However, although the JCI has not yet required the
development of a patient care handover process in its safety goals, clearly there
is an international impetus to initiate improved handover communication as a
patient safety strategy.

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For example, handoff communication is a focus of attention for the World

Health Organization (WHO). The WHO, in collaboration with the Common-
wealth Fund, has created the High 5s Project designed to create solutions for
five communications-based patient care issuesone of which is handover com-
munication. (The other four focus areas are prevention of wrong-site surgery,
continuity medication errors, high-concentration medication errors, and hand
hygiene.)

The WHOs international effort will enlist a lead technical agency within each
participating nation and 10 hospitals from each nation to develop prevention
strategies and solutions. Later on, the knowledge gained from the collaboration
will be shared with other nations and their hospitals.

Language of the goal

The rationale
To develop and implement an effective handoff communication policy, its
important to understand the rationale for doing so. The Joint Commissions stan-
dards format includes a statement of rationale for most standards and NPSGs to
help explain why a standard or safety goal exists. The Joint Commission Inter-
national would probably use a similar format when adopting an International
Patient Safety Goal (IPSG) devoted to handoff communication.

The rationale for The Joint Commissions NPSG for handoffs states: The primary
objective of a handoff is to provide accurate information about a patients/

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T HE HANDOFF COMMUNICATION GOAL

clients/residents care, treatment and services, current condition, and any recent
or anticipated changes. The information communicated during a handoff must
be accurate in order to meet patient safety goals.2

There are many kinds of patient handoffs, including nursing shift changes;
physicians transferring responsibility for a patient; physicians transferring on-call
responsibility; temporary responsibility for staff leaving the unit for a short time;
anesthesiologist report to recovery room nurse, nursing and physician handoff
from the emergency department to inpatient units; other hospitals, nursing
homes, and home healthcare; and critical laboratory and radiology results sent
to physician offices.

The requirement
As of 2006, The Joint Commission added the handoff communication expecta-
tion as a requirement under the NPSG for improving communication. The
requirement specifically expects healthcare organizations to implement a stan-
dardized approach to handoff communications, including an opportunity to ask
and respond to questions.3

The goal is applicable to, and is surveyed in, all U.S. Joint Commission full and
non-full surveys of the following types of organizations:
Ambulatory hospitals
Assisted living facilities
Behavioral facilities

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C HAPTER 1

Critical access hospitals

Home care agencies
General Hospitals
Laboratories
Long-term care facilities
Office-based surgery practices

GOALS OF A HANDOFF POLICY

Provide handoff in the same manner each time

Verbal, face-to-face communication
Two-way exchange of information
Limit distractions and interruptions

Implementation expectations

The Joint Commissions implementation expectations for handoff communica-

tion can be found in The Joint Commissions U.S. standards manual, entitled the
Comprehensive Accreditation Manual for Hospitals, and are posted on the com-
missions Web site, www.jointcommission.org. According to the CAMH,4 effective
handoff communications have the following attributes:

They are interactive communications that allow the opportunity for question-
ing between the giver and receiver of patient/client/resident information.

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T HE HANDOFF COMMUNICATION GOAL

They include up-to-date information regarding the patients/clients/resi-

dents care, treatment and services, condition, and any recent or anticipated
changes. Interruptions are limited to minimize the possibility that informa-
tion would fail to be conveyed or would be forgotten.

They require a process for verification of information received, including

repeat-back or read-back, when appropriate.

The receiver of handoff information has an opportunity to review relevant

patient historical data, including previous care, treatment, and services.

Resources
The complete rationale and NPSG language for effective handoff communication
can be found in the CAMH and at The Joint Commissions Web site. Information
about all of the Joint Commissions National Patient Safety Goals for each
accredited program can be found at the Joint Commission Web site. Go to
www.jointcommission.org, click on Patient Safety, and scroll down to reach the
National Patient Safety Goals section.

Interpreting the goal

Healthcare organizations in the United States quite often want to know exactly
where and when certain NPSGs apply. Staff members involved in planning out
the implementation often seek advice from The Joint Commission on what they

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C HAPTER 1

have to do in order to be compliant. System planners and designers often

worry about failure in their compliance effort.

However, everyone can probably see the importance of effective handoff com-
munication at the change of shift on a patient care unit. When everyone has
reached that baseline understanding, people will begin to question what The
Joint Commission and its surveyors will expect to see.

Common questions
Questions Im often asked include the following:

Do we have to do this between nursing and radiology?

Do we have to do this between the operating room and the post-

anesthesia care unit?

Does the information exchange have to be as comprehensive as SBAR

(situation-background-assessment-recommendation), or can it be less com-
prehensive?

The best advice is to avoid viewing the handoff communication safety goal as a
compliance exercise. The goal, like other NPSGs (and IPSGs), is intended to
promote better, safer care.

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T HE HANDOFF COMMUNICATION GOAL

Internationally, JCI-accredited healthcare organizations actually have an advan-

tage here, because they can create and implement a handover process that
makes good sense to them without having to be concerned about specifics of a
scoreable standard or safety goal. Now is an excellent time to begin.

To start the process, ask your staff: Where and when should we do this in
order to promote safer care? If you can see the potential for error as the
responsibility for a patient moves from one department to another, one shift to
another, or one physician to another, then implement your handoff process in
each setting where you see risk and potential benefit.

Heres another question Im frequently asked:

What is the minimum documentation we must have in order to prove that

we are compliant with the goal?

Again, the internationally accredited hospital has an advantage because you

dont need to view this as a compliance exercise. Think of your leadership role
in your hospital, and consider your role in committing your organization to the
improved handoff communication effort.

Your hospital should think through the different methods of documentation and
different techniques that might be employed, and use the one that will work
best for your organization.

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C HAPTER 1

THREE PHASES OF THE HANDOFF PROCESS

1. Exchanging information
2. Transferring responsibility of care
3. Providing continuity of care by preparing the team taking over so
theyre able to anticipate and make timely decisions

Meeting the goal

Some organizations have used white boards in the patient rooms and walking
handoffs, during which the process is discussed in the room, in conjunction
with the patient. This is clearly a useful systemit incorporates patient involve-
ment, and the visual aspect of seeing the patient while receiving the information
may aid staff in remembering key facts.

These white boards get erased, however, when patients leave the hospital, and
compliance staff can become anxious that they wont have documentation for
the JCI or another agency. Dont worry about this because you will have suc-
cessfully demonstrated compliance with the goal
if you can demonstrate your process,
if surveyors can observe it being done, and
if staff can describe the process uniformly.

You dont need to point surveyors to a specific and historical chart form. You
just need to have a credible process that is effective and that all of your staff
actually use.

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T HE HANDOFF COMMUNICATION GOAL

TYPES OF HANDOFFS

Handoffs can occur in many places. There is almost no limit to their

type. Here are some examples:

Nursing shift changes

Physician shift changes
Physicians transferring on-call coverage
Occupational, respiratory, or physical therapy
Staff leaving the unit for a short time period, such as a meal break
Technician shift change
Anesthesiologist report to post-anesthesia care unit nurse
Nurse-to-physician handoff from the emergency department to inpatient
units, to another hospital, to home care, etc.
Cross-coverage when patient acuity level changes
Critical laboratory and radiology results sent to physician offices
Transfer between units, such as emergency department in intensive
care unit, intensive care unit to floor, labor and delivery to postpar-
tum, etc.
Facility transfers
Ambulance to hospital
Discharges home

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C HAPTER 1

Design considerations

You want to develop your process so that you create consistency in communi-
cation during handoffs. The process used should promote consistency of con-
tent by establishing some baseline norms. Key fields of information might
include:
admitting diagnosis
co-morbidities
vital signs
allergies
planned interventions
issues requiring intervention by oncoming or receiving staff
special diets

Your hospital has the opportunity to design the process and to agree on the
minimum required content.

Its important to keep in mind, however, that whatever you decide to include,
the process must be applicable to each patient being handed off. Once you
have determined the minimum content for the handoff, you will need to prompt
staff by using a standardized form or standardized white board, such as in the
example earlier in this chapter.

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T HE HANDOFF COMMUNICATION GOAL

Dialogue
Another key part of the handoff process is dialogueactive discussion between
the staff members who are departing and those who are arriving, or the sending
and receiving staff.

The form or whiteboard itself does not demonstrate compliance with the goal,
nor does it provide the additional safety you are striving for. Staff must be able
to ask questions about the information that will be present on the form. The
sending staff members answers to these questions provide the receiving staff
with additional information they need to meet the needs of the patient.

Some organizations have sought electronic solutions to their handoff communi-

cation issues. These facilities have instituted taped change-of-shift reports, or
require electronic snapshots that summarize key information about the patient.
These tools by themselves, again, cannot demonstrate compliance. They only
provide the capability to institute a handoff process. By themselves, they are not
an acceptable handoff, but they can be incorporated into a comprehensive
handover process. In the case studies section of this book, we describe one
hospital that effectively implemented an electronic solution to its handover
process.

Environment
In addition to providing time for active discussion between staff, it is also
important for hospitals to provide an environment that is conducive to that
active discussion. This means time that is interruption-free and quiet enough
that each party can be heard.

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C HAPTER 1

Promoting the concept of active communication means staff need to feel com-
fortable asking questions, and the group dynamic has to support the concept
that there are no stupid questions. Asking questions like, What else can I tell
you? may help active outreach by participants and thus encourage two-way
dialogue.

In addition, staff members need to object to colleagues who dont participate

appropriately or attempt to short-circuit or rush the process. The handoff com-
munication process doesnt work if the sending and receiving staff members
dont work as a team.

As you design your process, you must include opportunities for constructive
criticism of the process, colleagues, and departments that may not be contribut-
ing as needed.

Tips for improving handoff communication

Handoff communication design is not a one-person job. The most essential

concept is to involve those who will be doing the handoffs in the design of your
handoff process. A department head or a performance improvement coordinator
cannot design the process in a vacuum. They must involve staff in the design of
the process in order to get staff buy-in, and to make sure that the design is
workable. An excellent design that cant actually be instituted is valueless.

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T HE HANDOFF COMMUNICATION GOAL

Remember, if the JCI adopts handover communication as an IPSG, the JCI sur-
veyors wont just evaluate your policies and proceduresthey will actually eval-
uate the execution of your policies and procedures.

The system must be workable. Its also important to design a system that is
practical and achievable by your staff. If you design something that requires
staff to document 10 pages of information and takes an hour per patient, com-
pliance will be nonexistent. Staff will look for shortcuts or will not follow the
process at all. You can design for failure if the process is too cumbersome.
Whatever you design must actually be implementable.

Pilot-test your process. A key component of the design has to be pilot-testing,

which includes a phase for evaluating staff satisfaction with the new process
and staff adherence to the new process. Your internal evaluation is critical
before a hospitalwide launch. You dont know whether your new process works
satisfactorily until you ask staff and you look at records to see whether it is
followed.

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C HAPTER 1

Endnotes

1. Thomas E. Wallace, Preventing FatalitiesEffective Critical Communication

Handoffs (audioconference, 2005 Joint Commission Resources Inc.).

2. The Joint Commission, Comprehensive Accreditation Manual for Hospitals,

NPSG 2E rationale statement, 2007 Joint Commission Resources, Inc. Oak
Park, IL, and at www.jointcommission.org. Web site accessed April 2007.

3. Ibid, NPSG 2E.

4. Ibid, NPSG 2E elements of performance 3 and 4.

16 2007 HCPro, Inc. HANDOFF COMMUNICATION, GLOBAL EDITION

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