Addressing The Joint Commission’s Sentinel Event Alert in Four Steps
Many hands go into the care and recovery of patients. It’s not unusual for patients, depending on their health status, to be transferred among multiple units, such as the trauma center, the ICU or Emergency Department. Nor is it uncommon for patients to be treated and evaluated by dozens of doctors, nurses and other clinicians within the course of a single stay.
A patient’s journey through a care setting can be enormously complex and is ripe for critical communication breakdowns, presenting a clear and present threat to his or her safety.
Think of hospital communication as a chain, forged link by link. Every clinician who works with the patient applies his or her clinical observation and assessment tools, draws conclusions and adds to the chain. Critical data points that are missed due to confusion, competing priorities or significant lag time between when information is sent verbally and received electronically represents weak links that can break the chain and result in patient care errors.
Ineffective Clinical Communication—Defining the Problem
According to a survey by the Risk Management Foundation of the Harvard Medical Institutions, 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.1
On average, doctors and nurses are interrupted once every two hours to 23 times each hour.2 Forty-three percent of the time, those interruptions disrupt direct patient care tasks or interventions. Inefficient communication processes and interrupted processes can have a negative effect on safety.3
There’s a two times greater likelihood that cross-disciplinary exchanges will result in a communication failure versus intra-disciplinary communication. Communication breaks down more often when two or more disciplines are involved.4
Thirty percent of communications about surgical procedures included a failure. Thirty-six percent of those failures resulted in consequences, such as tension among the care team members (which leads to further communication breakdown) or procedural error.5
Communication hand-offs have become such a problem that in September, The Joint Commission (TJC) issued a Sentinel Event Alert and accompanying infographic focused on inadequate hand-off communication. In the alert, TJC suggests a set of actions for senders and receivers of hand-off communication.
What Is a Hand-Off?
TJC’s infographic, 8 Tips for High-Quality Hand-Offs, provides a definition of a hand-off that is worth repeating:
“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.”
TJC’s suggestions have bearing on organizational culture, especially the role of leadership, and on the use of technology in hand-offs.
Technology drives behavior because it demands that users interact with it in a specific way. This was the focus of my 2017 CNO report, It’s More Than a Mobile Strategy, It’s a Change to Clinical Practice. When you give nurses and physicians a phone, you’re hard-wiring the behavioral aspects of the way they communicate, and this changes the way they practice.
Eight Tips for Quality Hand-Offs
The suggestions in the TJC alert and infographic vary slightly, but their intent is the same. For simplicity, I will reference the infographic’s eight tips in this section.
Tip 1: Determine the critical information that needs to be communicated.
Tip 2: Standardize tools and methods used to communicate to receivers. These can be forms, templates, checklists, protocols, and mnemonics such as I-PASS.
Tip 3: If face-to-face hand-off communication is not possible, communicate by telephone or video conference.
Tip 4: If information is coming from many sources, combine and communicate it all at one time, rather than separately.
Tip 5: Make sure the receiver gets the following minimum information:
• Sender contact information
• Allergy list
• Code status
• Medication list
• Dated laboratory tests
• Dated vital signs
• Illness assessment, including severity
• Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
• To-do action list
• Contingency plans
Tip 6: When conducting hand-offs or sign-outs, do them face-to-face in a designated location free from non-emergency interruptions, such as a “zone of silence.”
Tip 7: When conducting a hand-off, include all team members and, if appropriate, the patient and family. This time can be used to consult, discuss, and ask and answer questions.
Tip 8: Use electronic health records (EHRs) and other technologies (such as apps, patient portals, telehealth) to enhance hand-offs between senders and receivers — don’t rely on them on their own.
Four Steps to Optimize Hand-Off Communication
Technology that enables better clinical communication and workflow can play a critical role in addressing all aspects of TJC’s guidance. Where TJC offers eight tips, we consolidate them into four steps, or concepts.
1. Use Forms and Checklists
TJC’s tips one, two, and five collectively cover 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 has standardized drop down boxes so you don’t have to type out full messages. Patient-specific data captured in the physiologic monitor (such as heart rate, blood pressure, respiratory rate, SpO2, and EKG strip) can be sent to a clinician’s smartphone.
2. Connect Directly and Instantly
TJC’s tip three is about communicating verbally via video conference if face-to-face communication is not possible. Communication platform technology should enable care team members to connect directly and instantly, with no need to know names or numbers. The software system should be able to route calls, texts, alerts, and alarms by name, role, or group, with automatic escalation paths.
Consider a common scenario in which a patient needs to be transferred to a different floor or department. The existing workflow can take five or more steps:
1. The nurse in the transferring unit calls the patient-receiving unit nurse via the unit phone, but receives no answer.
2. The transferring nurse tries again, using the call list, switchboard, or page – or gives up and tries again later.
3. The patient-receiving nurse may try to return the call, in some cases using a landline to avoid tying up the unit phone.
4. The process repeats, often several times.
5. The transferring and receiving nurse connect.
Communication technology can help with this aspect of hand-off communication. For example, enabling the transferring nurse to call the patient-receiving nurse directly or broadcasting critical information to a dispersed group of clinicians.
TJC’s tip six, which is about conducting hand-offs face-to-face in a designated location free from interruptions, at first glance might seem to have little to do with technology. However, a common reason people don’t conduct hand-offs face-to-face is that they’re busy and they can’t find each other. Tip seven extends the hand-off meeting to include patients and families. The issues in tips six and seven are similar, and can be addressed with the same communication technology.
3. Enhance Hand-Offs with Information in Context
Tips four and eight are closely linked. Tip four is about combining information and communicating it in a consolidated way, and tip eight is about integrating the EHR with other technologies. It’s all about getting more complete information more easily.
Look for a communication platform that can be unified with other clinical and operational systems, including the EHR, and leverage system integration to automate portions of the hand-off template. This means you will have more information, for example, about clinically significant alarms that have taken place during a given clinician’s shift. What’s been happening over the last 12 hours is relevant for the next 12 hours.
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
• Including multidisciplinary team members and the patient and family, as appropriate
• Standardizing training
• Monitoring the success of interventions
• Sustaining and spreading best practices, and making high-quality hand-offs a cultural priority
A chain is only as strong as its weakest link. The complexity, distractions and communication gaps inherent in patient care require a shared purpose that guides all clinical communication. It also calls for humanized communication tools that help hardwire communication excellence.
Bibliography
1. CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).
2. Grundgeiger, T., & Sanderson, P. (2009). Interruptions in healthcare: theoretical views. International Journal of Medical Informatics, 78(5), 293-307. http://ai2-s2-pdfs.s3.amazonaws.com/6149/4f5a065fd69269b61578ffe5629918663d63.pdf
3. Rivera, A. J., & Karsh, B.-T. (2010). Interruptions and Distractions in Healthcare: Review and Reappraisal. Quality & Safety in Health Care, 19(4), 304–312. http://doi.org/10.1136/qshc.2009.033282
4. Hu, Y. Y., Arriaga, A. F., Peyre, S. E., Corso, K. A., Roth, E. M., & Greenberg, C. C. (2012). Deconstructing intraoperative communication failures. Journal of Surgical Research, 177(1), 37-42. https://insights.ovid.com/pubmed?pmid=22591922
5. Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, G. R., Reznick, R., ... & Grober, E. (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care, 13(5), 330-334.
Rhonda Collins, MSN, RN, is the chief nursing officer at Vocera, where she works with hospitals and health systems around the world to improve clinical communication and workflows. Through her previous work as vice president of women and children’s services at Baylor University Medical Center, and as a practicing labor and delivery nurse for more than 16 years, she gained deep experience in crafting best practices for high performing healthcare teams.
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