Featured Video
This Week in Quality Digest Live
Health Care Features
Eric Cooper
Unspoken expectations are the hardest to meet
Sharona Hoffman
Vertical merger would eliminate a middleman—CVS’ pharmacy benefits manager
Scott Gottlieb
A year of advancing innovations, empowering consumers, and streamlining regulations
Jenna Gallegos
DNA samples are available via a global computer network that can be hacked
Quality Transformation With David Schwinn
System-caused problems can affect returns to hospital, increase potential for more pain

More Features

Health Care News
The FDA’s RMAT designation goes live
New company will focus on technologies for the management and automation of vital clinical processes
Marking and cutting lasers used in manufacturing endoscopic devices and catheters
Technique provides about a sixfold improvement over regular microscopes
Awards help states implement multiyear produce-safety systems
How a hospital restored quality patient care and obtained financial stability using lean
A strategic guide to implementing lean for hospital leaders

More News

The Joint Commission

Health Care

Overcoming Miscommunication Among Caregivers

New process reduces readmissions and move times by up to 50%

Published: Monday, July 2, 2012 - 16:26

(Joint Commission Center for Transforming Healthcare: Oakbrook Terrace, IL) -- An estimated 80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off. In addition to patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital. The Joint Commission Center for Transforming Healthcare is releasing a hand-off communications targeted solutions tool (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.

Ineffective hand-off communication is recognized as a critical patient safety problem in health care. The hand-off process involves “senders”—the caregivers transmitting patient information and releasing the care of that patient to the next clinician—and “receivers,” the caregivers who accept the patient information and care of that patient.

The hand-off communication TST was created to measure the effectiveness of hand-offs within an organization or to another facility, and provide proven solutions to improve performance. Using the tool and the solutions from the center’s hand-off communications project, health care organizations have reduced readmissions by 50 percent, and have reduced the time it takes to move a patient from the emergency department to an inpatient unit by 33 percent. Health care organizations also reported an increase in patient and family satisfaction, staff satisfaction, and successful transfers of patients.

Health care organizations were able to complete their hand-off communications project in approximately four months, using minimal resources. In fact, no staff was added, and only minor changes were made to the roles and responsibilities of existing staff.

The TST is an application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers.

The universal experience of the health care organizations that built and tested the TST for hand-off communications was that senders and receivers had different expectations of what constituted a successful hand-off. Using the TST, these organizations aligned expectations of the hand-off, developed a process for a successful hand-off, and fostered better relationships and communication among staff. The hand-off communications TST:
• Facilitates the examination of the current hand-off communication between two settings of care from the viewpoints of both the senders and receivers involved in the process.
• Provides a tested and validated measurement system that produces data that support and drive the need for improving the current hand-off communication processes.
• Identifies areas of focus, such as the specific information needed for the transition that is being measured. For example, the information needed for a hand-off from the emergency department to an inpatient unit differs from that needed for a hand-off from a hospital to a skilled nursing facility.
• Provides customizable forms for data collection to fit the specific needs of the transition being measured.
• Provides guidelines to determine the most appropriate and realistic hand-off communication process for a given transition, while also empowering the staff involved in the process.


All of the hand-off communications solutions that were developed by the center and the leading hospitals can be found on the center’s website. The targeted hand-off solutions from the center, which are described using the acronym SHARE, address the specific causes of unsuccessful hand-offs. SHARE refers to:
Standardize critical content, which includes providing details of the patient’s history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
Hardwire within your system, which includes developing standardized forms, tools, and methods such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
Allow opportunity to ask questions, which includes using critical thinking skills when discussing a patient’s case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.

Accredited organizations can access the TST and hand-off communications solutions on their secure Joint Commission Connect extranet. In addition to the hand-off communications TST, the center currently provides targeted solutions for hand hygiene and wrong-site surgery. Targeted solutions for surgical site infections, heart failure hospitalizations, safety culture, falls, and others will be incorporated into the TST as the center completes these projects.

For more information about the Joint Commission Center for Transforming Healthcare, click here.


About The Author

The Joint Commission’s picture

The Joint Commission

Founded in 1951, The Joint Commission is an independent, nonprofit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. It is the nation’s oldest and largest standards-setting and accrediting body in health care. It seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.