The National Patient Safety Goal (NPSG) requiring healthcare organizations to implement a standardized approach to handoff communications (NPSG 2E) went into effect in January 2006. The most frequently cited root cause of sentinel events evaluated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is communication. Data show that communication is identified 65% to 70% of the time in the more than 3,000 root cause analyses reviewed between 1995 and 2005. Handoff communications are clearly a vulnerable step in the provision of patient care. This NPSG allows us to focus on communication processes to improve patient safety across the continuum of care.
Q NPSG 2E states that we have to implement a standardized approach to handoff communications. Does this mean that every handoff has to be the same?
A No, it doesn't. By standardizing, your organization needs to define, communicate to staff, and implement a process in which information about patient care is communicated in a consistent manner. Through staff education, your staff-including the medical staff-will understand which handoff situation applies; who should be involved in the handoff; what information should be communicated (e.g., diagnosis and current condition, recent changes, anticipated changes, and what to watch for); opportunities to ask and respond to questions; when to use certain techniques such as repeat back and SBAR (situation, background, assessment, recommendation); and what print or electronic information should be available.
Given the situation and persons involved, different information will need to be shared in the handoff. For example, nursing change of shift will involve detailed information about the patient's condition, changes in orders and the plan of care, activities of daily living, results of any testing, psychosocial issues, and other information. If the handoff is to a transporter moving a patient from one department to another, the information shared will most likely focus on keeping the patient safe during the transfer-the need for I.V. administration or O2, patient alertness and orientation, fall risk, etc. Physician-to-physician handoffs may be more focused on disease process, current condition, symptoms, and any anticipated changes.
Q Does the handoff requirement mean that we can no longer use audiotaped report for nursing change of shift?
A Audiotaped report can be an acceptable method for meeting the handoff requirement if it includes the opportunity to ask and respond to questions. When caregivers are audiotaping their report for the next shift, ensuring that they cover all of the required information is critical to its effectiveness. Having guidelines or a checklist can assist the outgoing caregiver in providing a more detailed account of that patient's day, thereby helping the incoming caregiver have a clearer picture of what that patient's plan of care is and how to proceed. Having the outgoing caregiver available to respond to any questions the incoming caregiver may have is required. But relying on the incoming caregiver to contact the previous caregiver at home isn't an acceptable alternative, as staff members are generally reluctant to do so, preferring instead to try to sort it out themselves.
Q As a nurse leader, what are my responsibilities regarding the implementation of standardized handoff communications?
A Nurse leaders, along with other clinical leaders in the organization, are responsible for ensuring that the NPSGs have been successfully implemented. There are five expectations for this particular requirement. In 2006, these were found in the Implementation Expectations document, separate from the accreditation manual. For 2007, all of the NPSGs have been reformatted to incorporate the Implementation Expectations as elements of performance in the NPSG chapter of the accreditation manual.
Once your organization determines its approach to the goal, all leaders need to be consistent in their expectations for compliance. In addition to educating staff and monitoring compliance, be sure to engage the staff and physicians in meaningful dialogue, allowing for the identification of issues, barriers, and other impediments to success. Then follow through with leadership to address those areas of concern to continually improve your processes and effectiveness.
When surveyors are on-site, they'll want to find out how you know that your organization is in compliance with this goal. Being able to speak about monitoring efforts, performance improvement activities, and any other methods you may have employed to ensure compliance will enable the surveyors to understand your processes.
Keeping your staff members up to date and engaged in the benefits of the handoff process will foster their ability to also dialogue with the surveyors and enhance understanding.