Joint Commission Seeks Care Transition Improvements

Studies have repeatedly shown that a prominent vulnerability to patient safety exists in the hand-off between hospital care teams, such as during shift changes.  During this critical period, important information about a patient’s condition or plan of care may not be communicated or accurately understood by the oncoming team.  For this reason, The Joint Commission has proposed solutions to address the threats of adverse events related to care transitions; the Joint Commission’s proposals were developed through its Center for Transforming Healthcare, which worked with 10 hospitals to identify the root causes of hand-off communication failures during the transition of care and develop targeted solutions for each of those causes.

Some of the causes of communication failures common to the participating hospitals consisted of:

• Institutional culture, such as lack of teamwork and respect, that does not promote successful hand-off;
• Ineffective communication methods;
• Inadequate time devoted to a successful hand-off;
• Communication of inaccurate or incomplete information;
• Competing priorities of the oncoming team that prevents a focus on the transferred patient.

The Joint Commission’s report proposed a variety of solutions in an attempt to address the common causes, such as by establishing a dedicated workspace or setting conducive to providing report that is quiet and without distraction; using standardized forms, tools, and methods, such as checklists; and, educating providers on what constitutes a successful hand-off and standard training on how to achieve that goal.  Details of other causes and solutions proposed by the Joint Commission can be found in its recent publication.

The hospitals that participated in this collaborative project reported a 53% reduction of defective hand-offs when implementing the proposed process improvements.  According to the report, 34% of the care transitions were defective before implementing the proposed solutions, whereas the defective rate dropped to 16% after implementation.

There is no doubt that the transition in care during shift changes in a hospital represents a vulnerability to patient safety; some hospital units, such as the Emergency Department and ICU, may be more vulnerable than others given the patient population and level of care provided.  Taking steps such as those proposed by the Joint Commission may help reduce this vulnerability and risk.

Jonathan B. Stepanian, Esq.

Jon is an attorney whose practice is specialized in litigation, complex medical professional liability defense, health care, and providing legal counsel on numerous issues associated with day-to-day hospital operations. He has successfully tried several cases to verdict as first-chair trial counsel before juries in both state and federal court. Jon has also represented clients in appellate litigation, mediation, and in connection with administrative agency investigations.

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