A Model for Building a Standardized Hand-off Protocol

1 646 November 2006 Volume 32 Number 11In July 2003, the Accreditation Council for GraduateMedical Education (ACGME) set limits for residentduty the main driving force was toreduce sleep deprivation and improve patient safety, oneunintended consequence was the increase in the numberof handoffs during patient care. The discontinuity of carethat thereby results has the potential to undermine thebeneficial effects of work hour safety ofthe Hand-off process has been called into question by anumber of different sources and studies which suggestthat handoffs are often characterized by communicationfailures and environmental 6 The handoff is also the subject of a Joint Commissionon Accreditation of Healthcare Organizations NationalPatient Safety Goal, which went into effect January 1,2006.

2 Written as a new requirement of Goal 2, Improvethe Effectiveness of Communication Among Caregivers,this addition requires hospitals to implement a stan-dardized approach to Hand-off communications andprovide an opportunity for staff to ask and respond toquestions about a patient s care6,7(Sidebar 1, page 647).Although the standard applies to all handoffs that occurbetween all personnel within all health care settings, thefocus of this article is on the handoffs between residen-cy trainees at academic teaching hospitals. Becausemedical trainees receive little to no formal training oreducation in communication during handoffs, there isan inherent opportunity to influence the practice ofA Model for Building a StandardizedHand-off ProtocolNational Patient Safety GoalsBackground:The Joint Commission has made a Standardized approach to Hand-off communications aNational Patient Safety Goal.

3 Method:An interactive 90-minute workshop ( Hand-off clinic) was developed in 2005 to (1) develop a stan-dardized process for the handoff, (2) create a checklistof critical patient content, and (3) plan for dissemina-tion and training. Conclusion:To date, 7 of 10 residency programs haveparticipated. Analysis of these protocols demonstratedthat the Hand-off process is highly variable and discipline-specific. Although all disciplines required a verbal handoff, because of competing demands, verbal commu-nication did not always occur. In some cases, the transferof professional responsibility was separated in time andspace from the transfer of information. For example, intwo cases, patient tasks were assigned to other teammembers to facilitate timely departure of a postcall resi-dent (to meet resident duty-hour restrictions), but resultswere not formally communicated to anyone.

4 The Hand-off clinic facilitated the incorporation of closed-loop communication by requiring that follow-up on thesetasks be conveyed to the on-call :This Model for design and implementa-tion can be applied to other health care Arora, , Johnson, , Editors:Marcia M. Piotrowski, , , Peter Angood, , Paula Griswold, , Gina Pugliese, , , Sanjay Saint, , , Susan E. Sheridan, , , Kaveh G. Shojania, Readers may submitNational Patient Safety Goals inquiries and submissions to Steven Berman and Marcia Piotrowski 2006 Joint Commission on Accreditation of Healthcare Organizations647future addition, as academic teachinghospitals continue to adopt systems to ensure that duty-hour restrictions are met, an increased focus on theintegrity of the handoffs is crucial to patient safety dur-ing these times of transition.

5 Although relatively little information about educa-tional initiatives exist in the medical literature to guideresident and staff hospital physicians in meeting thesestandards, much can be learned from other high-riskindustries that have been engaged in studying andimproving handoffs. From direct observations at theNational Aeronautics and Space Agency, nuclear powerplants, and transportation dispatch centers, a frame-work of strategies for handoffs has , such as standardization and face-to-face ver-bal update with interactive questioning, resonate direct-ly with the Hand-off requirement and are supported byevidence and expert opinion as best practices associat-ed with improved Hand-off ,7,10 Drawingon this literature, as well as preliminary data, we pres-ent a Model for Building a Standardized Hand-off proto-col to meet this National Patient Safety Goal.

6 We alsoreview our preliminary experience with the Protocol atthe University of a Model for Standardized HandoffsThe handoff can be thought of as a communication ofinformation (content) that can take place through dif-ferent modalities, which can include a written or verbalcomponent. Two guiding principles underlie this , the Standardized Protocol for handoffs needs to betailored to discipline and organization. That is, recog-nize that what works in one discipline may not work inNovember 2006 Volume 32 Number 11 Requirement 2 EImplement a Standardized approach to Hand-off com-munications, including an opportunity to ask andrespond to for Requirement 2 EThe primary objective of a hand off is to provideaccurate information about a patient s care, treatment,and services, current condition and any recent or antici-pated changes.

7 The information communicated during ahand off must be accurate in order to meet patientsafety goals. In health care there are numerous types ofpatient hand offs, including but not limited to nursingshift changes, physicians transferring complete respon-sibility for a patient, physicians transferring on-callresponsibility, temporary responsibility for staff leavingthe unit for a short time, anesthesiologist report topost-anesthesia recovery room nurse, nursing andphysician hand off from the emergency department toinpatient units, different hospitals, nursing homes andhome health care, critical laboratory and radiologyresults sent to physician Expectations for Requirement 2E1. The organization s process for effective hand off communication includes: Interactive communicationsallowing for the opportunity for questioning betweenthe giver and receiver of patient The organization s process for effective hand off communication includes: Up-to-date informationregarding the patient s care, treatment and services,condition and any recent or anticipated The organization s process for effective hand off communication includes: A process for verification ofthe received information, including repeat-back orread-back, as The organization s process for effective hand off communication includes.

8 An opportunity for thereceiver of the hand off information to review rele-vant patient historical data, which may include previ-ous care, treatment and Interruptions during hand offs are limited to mini-mize the possibility that information would fail to beconveyed or would be forgottenSidebar 1. Joint Commission National Patient Safety Goal 2:Improve the Effectiveness of Communication Among CaregiversSource: Joint Commission on Accreditation of Healthcare Organizations: 2007 National Patient Safety Goals Hospital Version Manual Chapter, includingImplementation Expectations. (last accessed Sep. 5, 2006). Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations648 November 2006 Volume 32 Number 11another, given each discipline s unique , what constitutes an effective handoff forone discipline may be different for the same discipline inanother organization.

9 Although certain components maybe generalizable, the successful adoption of a standard-ized Hand-off Protocol is highly dependent on the degreeto which it is tailored for end users in an organizationalsetting. It is the method by which you create the proto-col and the method that is presented here that is gen-eralizable across disciplines and , standardization is the core goal for bothhand-off process and content. For example, although anidentifiable safe Protocol may be currently in use for themajority of handoffs in a certain discipline and organiza-tion, it is the variability of the Hand-off Protocol that isthe target for improvement. The four steps in our modelare outlined in Table 1 (above) and discussed in detailbelow.

10 Develop a Standardized Process The first step is to draw a flow diagram. Then every-one understands what his job is. If people do not see theprocess, they cannot improve it. DemingUnderstanding handoffs as a process is importantbecause a high degree of process awareness often drivesthe design of the work. By mapping the process, themembers of the team can gain insight into how their col-leagues perceive the same tasks. Ultimately, systemsimprovement requires (1) appreciating the inherent linkbetween process and results and (2) identifying potentialareas for improvement with a focus on the system that isproducing the processes and outcomes of care11ratherthan on the individual.