A patient’s journey in the hospital can take them through multiple units, seen and treated by dozens of clinicians. Each of these transitions creates more potential for a communication breakdown—the kind that can and does endanger patient safety every day. 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.
Alarming as those figures are, they are not surprising in an environment where doctors and nurses are regularly interrupted. One study quantified the interruptions as ranging from every two hours to a stunning 23 times each hour. And circling back to the point that patients are seen by numerous clinicians, communication breaks down more often when two or more disciplines are involved.
The Joint Commission takes action
Communication problems during transitions have become such a problem, The Joint Commission (TJC) issued a Sentinel Event Alert and accompanying infographic focused on inadequate “hand-off communication.” TJC notes that a hand-off 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 for minimizing risk of error have particular bearing on the increasing use of mobile communication devices in hand-offs. Before getting into that in more detail, a quick summary of TJC’s key eight suggestions follows:
- Determine the critical information that needs to be communicated.
- Standardize tools and methods used to communicate to receivers. These can be forms, templates, checklists, protocols, and mnemonics such as I-PASS.
- If face-to-face hand-off communication is not possible, communicate by telephone or video conference.
- If information is coming from many sources, combine and communicate it all at one time, rather than separately.
- 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
- 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.”
- 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.
- 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.
Enter the smartphone
Technology that enables better clinical communication and workflow can play a critical role in addressing all aspects of TJC’s guidance. That includes technology already in use: the ubiquitous smartphone. Clinicians and hospital employees already use them, although how much in accordance with TJC directives and suggestions, we can’t definitively say.
But aligning smartphone and communication technology with TJC matters, especially to patient safety. When you give nurses and physicians a smart phone, you’re also hard-wiring the way they communicate, which changes the way they practice. (This theme was explored in the 2017 CNO report, It’s More Than a Mobile Strategy, It’s a Change to Clinical Practice.)
So where the TJC offers eight tips, we consolidate them into four steps, in the context of using technology, the right way, during hand-offs.
1. Intuitive Communication Technology
TJC’s tips one, two, and five collectively cover determining the information that needs to be communicated, standardizing 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. Reduce Unnecessary Steps and “Middlemen”
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. In the absence of a unified communication platform described above, this can require multiple steps and communication via numerous “middlemen”—such as a switchboard. By contrast, enabling the transferring nurse to call the patient-receiving nurse directly reduces both steps and risk of communication error.
TJC’s tip six, which is about conducting hand-offs face-to-face in a designated location free from interruptions, 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. Put 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. Make Better Communication a Shared Purpose
The full text of TJC’s Sentinel Event Alert emphasizes the organizational and cultural aspects of improving hand-off communication. These span from demonstrating leadership’s commitment to successful hand-offs, to managing the environment to provide locations free from interruptions, to sustaining and spreading best practices.
In short, ending communication breakdowns requires a hospital-wide, shared commitment to do so. The complexity, distractions and communication gaps inherent in patient care require nothing less.