What’s New in the Patient Safety World

August 2012

New Joint Commission Tools for Improving Handoffs



The Joint Commission recently released its new Targeted Solutions Tool™ (TST) for Hand-off Communications. This is an outstanding tool that every healthcare organization can utilize to improve patient care and coordination across all levels of the continuum of care. The Targeted Solution Tools are free to organizations accredited by The Joint Commission. Previous TST’s have addressed hand hygiene and wrong-site surgery and have proven very valuable. You’ll find this one even more valuable.


In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and March 2012 What’s New in the Patient Safety World column “More on Perioperative Handoffs” we stressed that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization. Though using a structured communication format or tool is important, the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”. The new Joint Commission TST for Hand-Off Communications takes on that very philosophy. It stresses that because there are so many root causes of failed handoffs you need to implement those proven solutions tailored to the root causes in play at your organization, not an off-the-shelf generic solution that addresses things you may already be doing well. Many of those root causes are listed in the summary document describing the program.


Their tools are tailored for a variety of handoffs. In their introductory webinar they highlighted handoffs between long-term care and acute care hospitals and handoffs from the emergency department to the inpatient units. But they have solutions in place for all the most common handoff scenarios. They have not yet posted tools for the shift-to-shift handoff but are in the process of piloting solutions for that as well and expect those tools to be up online within a few months. The tools and solutions were developed and implemented by the Joint Commission Center for Transforming Healthcare in conjunction with many participating hospitals you’ll readily recognize for their commitment to quality.


They stress the importance of the “sender” and the “receiver” getting together early in the implementation process to align their goals. They emphasize that the sender and receiver often have very different expectations about what they will get from a handoff. They have tools to help you determine what common root causes are present in suboptimal communications between your organization and your partners. Once you choose a type of handoff to focus on they provide tools that have been proven effective for that type of handoff and those types of root causes you’ve identified. Further, they provide measuring tools and audit tools so that you get feedback on your improvement endeavors. Since their programs heavily involved staff trained in LEAN and Six Sigma and RPI (Robust Process Improvement™), you will see statistical process control charts of defect rates, pareto charts of reasons for failed hanoffs, times series charts, etc. in their toolkits.


Are their solutions successful? In one handoff project involving an acute care hospital and long-term care facilities they were able to reduce 30-day readmission rates substantially and also helped lower hospital length of stay. In another they achieved a 33% reduction in the time to transfer patients from the ED to the acute care units


We have no doubt that any healthcare organization will find a tool to address handoff problems relevant to their own circumstances. This TST is a very valuable tool.




Read about many other handoff issues (in both healthcare and other industries) in some of our other columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS™

August 28, 2007           Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008      Hot Topic: Handoffs

November 18, 2008      Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009              Interruptions, Distractions, Inattention…Oops!

April 13, 2010              Update on Handoffs

July 12, 2011               Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011               Communication Across Professions

November 2011            Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012                 New Joint Commission Tools for Improving Handoffs

August 2012                  Review of Postoperative Handoffs







The Joint Commission. Center for Transforming Healthcare. Joint Commission introduces new, customized tool to improve hand-off communications. June 27, 2012



Joint Commission Center for Transforming Healthcare. Improving Transitions of Care: Hand-off Communications.




A Look at the Joint Commission. Robust Process Improvement™ at the Joint Commission. Bulletin of the American College of Surgeons. August 2011 p. 75















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