Joint Commission Sentinel Event Alert Addresses Hand-off Communication

PUBLISHED: Sep 13, 2017
Relevant to: Ambulatory Care, Behavioral Health, Clinical Lab, Community Mental Health Centers, Critical Access Hospitals, Dialysis Facilities, Home Health, Hospice, Hospitals, Long Term Care, Medical Office/Clinic, Pharmacies

The Joint Commission (TJC) has issued Sentinel Event Alert #58 addressing hand-off communication. TJC defines a hand-off as, “…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.”

According to TJC there is the potential for tremendous harm to patients when hand-off communication is ineffective, incomplete or inaccurate. Effective hand-off communication is a complex process that impacts multiple aspects of patient care, with one estimate suggesting that there are over 4000 patient hand-offs per day in a typical teaching hospital. Joint Commission standard PC.02.02.01, Element of Performance 2 requires that “The organization's process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.”

Sentinel Event Alert #58 provides in-depth recommendations for both senders and receivers of patient hand-offs. While TJC acknowledges that each organization has unique issues and challenges related to patient hand-offs, they provide many suggestions to help improve the process, including but not limited to the following:

  • Ensure Leadership commitment to the hand-off process, including time and budget resources, development of a systematic approach to hand-offs, and an organizational commitment to focusing on the issue.
  • Use of standardized content to be communicated by a sender during a hand-off.
  • Use of both verbal and written communication to conduct a hand-off.
  • Creating locations within the organization that are conducive to conducting hand-offs without interruption or distraction.
  • Conduct standardized training for employees on how to send and receive a hand-off.
  • Consider the use of technology to improve the hand-off process (apps, patient portals, telehealth, etc.)
  • Routinely monitor the hand-off process and identify areas for improvement.
  • Support the use of hand-off best practices with each patient and each hand-off for every transition of care.

Included with today’s notice are example policies related to the hand-off process.

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