Move from information transfer to exchange
Move from information transfer to exchange
Improve information exchange by clarifying intent
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Hundreds of service handoffs take place everyday when patients are transferred between caregivers and units. Ideally, a hand-off transfer of responsibility for a patient occurs without a break in patient care and associated activities. A successful handoff avoids unwarranted changes in patient care goals, decisions, or plans, including dropping or reworking activities that others were told would be done by the previous caregiver. The Joint Commission is encouraging hospitals to improve patient care by analyzing and improving work processes to avoid poor communication during service handoffs. An increasing number of studies show that traditional methods of gathering patient data, organizing it, and communicating it among caregivers may not support high quality patient care. Practitioners must move beyond long-standing practices of information transfer (based on a one-way monologue) and toward a more effective system of information exchange (based on two-way dialogue).
Improving information exchange during service handoffs starts with clarifying the intent. What is considered a handoff and what caregivers are trying to achieve during these handoffs? Handoffs don’t only occur at shift change or at transition points (admission, transfer between units, discharge). During a patient’s day, there may be multiple patient handoffs — junior resident to senior resident, physician to nursing staff, surgery team to recovery room staff, nurse to nurse handoffs.
What about handoffs that don’t directly involve the patient. For example, is there a handoff between staff who draw a blood specimen and the person who runs the lab test? The Joint Commission has not clearly defined what is meant by "hand-off communications" thus, each organization must clarify the meaning of the term. Don’t assume everyone has the same definition of a handoff.
Although there may be hundreds of handoffs that occur during a patient’s hospital stay, not all of these situations are critical to patient safety. Common examples of potentially critical handoffs are shift changes for nursing staff and residents and transfer of patient care responsibilities from one physician to another or from one medical team to another, such as after a patient has had surgery and is transported from the operating room to the post-anesthesia recovery unit. Even seemingly routine handoffs, such as transport of an inpatient to the nuclear imaging department, can be problematic if there is poor communication.
For instance, in one hospital, an MRI technician described a situation in which she had a particularly difficult time calming a developmentally disabled child during a test — only to find out later that the child was deaf. This vital information was never relayed to the technician when the patient was transported from the inpatient unit. Also consider hand-off situations that involve other facilities or post-discharge caregivers, such as when patients are transferred to another hospital or discharged home for home care services. The transfer of inpatient care by a hospitalist to outpatient care by the patient’s primary physician is another example of a potentially critical handoff.
Next, describe the meaning of a "safe handoff." This description serves as the basis for setting improvement goals. Some organizations incorporate the description into a policy statement. For instance: To ensure safe and effective communication when patient care responsibility is transferred from one caregiver to another caregiver, the oncoming caregiver should receive information needed to:
- safely and effectively accomplish routine patient care responsibilities;
- resolve potential issues or concerns;
- manage unexpected or non-routine situations.
Caregivers must be discouraged from viewing the handoff as only a transfer of information. The most common deficit in patient handoffs is the tendency to view it as a data transfer rather than a higher level information exchange. The ideal patient handoff should be a discussion, not just an exchange of information. The caregiver that simply rattles off a series of facts about the patient and then leaves has not fulfilled his or her duty.
Once the critical handoffs have been identified and hand-off expectations clearly defined, it’s time to prioritize which information exchanges will undergo scrutiny first. The service handoffs that create the greatest risk for errors are the most likely candidates for immediate action. Review data about past incidents to determine where miscommunications contributed to the event and the handoffs involved. Study the details of these incidents to gain a better understanding of what aspects of the handoff were defective. A secondary purpose for evaluating past incidents is to substantiate the need for improving communication among caregivers. Unless there is a compelling case for change, stakeholders will be reluctant to put their hearts into it while enduring a needed change. Failure to develop the case for change will cause communication improvement efforts to lose focus, lose momentum, and be stymied by the traditions of the past.
Bring everyone involved in a critical handoff together to discuss ways of improving communication at vital points in the patient care transition. For instance, if transfer of a patient from the operating room to post-anesthesia recovery is considered a high-risk handoff, involve surgeons, anesthesiologists, nurse practitioners, bedside nurses, OR nurses, transport staff — anyone who is engaged in information exchange.
Start the discussions by drawing a high-level flow chart of patient flow and identifying the hand-off points. This can be a good time to explore ways of cutting down on the number of handoffs. By changing the process, it may be possible to reduce problems by minimizing or eliminating handoffs.
Next, ask people to define the characteristics of each handoff, taking into consideration the organization’s definition of a safe and effective handoff. For example:
- Who is primarily responsible for ensuring satisfactory information exchange?
- What key communication steps need to be followed?
- What minimal information needs to be communicated?
- How should information be exchanged?
- Who should be involved in this exchange?
It is essential that people work together as a team to identify the minimal set of information that needs to be imparted during the handoff and how best to accomplish the communication. With so many individuals involved in the care of patients, it is essential that everyone agree on minimal standards for information exchange. The communication mechanism may vary from unit to unit or situation to situation; however, the same essential information should be communicated during a handoff. Listed in the box above are categories of information that should serve as minimum components of a handoff.
The specific information to be exchanged in each category will vary according to the situation. When designing hand-off logistics, caregivers should consider research findings and the recommendations of professional groups and "best practice" institutions. At the end of this article are sources of information on how to design better handoffs.
Whatever process changes are made to improve exchange of information during patient handoffs, caregiver training in communication techniques also is important. Safe and effective hand-off communications depend on the ability of caregivers to prioritize relevant information and transfer insights effectively. Practitioners and staff may have received no formal training in hand-off communication; it is often just learned on the job.
No matter how efficient the hand-off process becomes, the proper information exchange won’t take place if people don’t have the right communication skills.
Additional Resources
Hundreds of service handoffs take place everyday when patients are transferred between caregivers and units. Ideally, a hand-off transfer of responsibility for a patient occurs without a break in patient care and associated activities.Australian Council for Safety and Quality in Health Care. Clinical Handover and Patient Safety: Literature Review Report. March 2005. Online document (PDF): www.safetyandquality.org/clinhovrlitrev.pdf
Hansten, R. Streamline change of shift report. Nurse Manager. 2003; 31(8): p. 58-59.
Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 2004; Oct; 13 Suppl 1:i85-90.
Patterson E, Roth E, Woods D. Handoff strategies in settings with high consequences for failure. International Journal for Quality Health Care. 2004; 16:125-132.
Perry S. Transitions in care: Studying safety in emergency department signovers. Focus on Patient Safety. 2004; 7(2): 1-3
Priest CS and SK Holmberg. A new model for the mental health nursing change of shift report. Journal of Psychosocial Nursing & Mental Health Services. 2000. 38(8): p. 36-43.
Simpson, KR. Perinatal patient safety: Handling handoffs safely. The American Journal of Maternal/Child Nursing. 2005; 30(2): 152.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.