For many, the choice to enter a healthcare profession is driven by the desire to help and heal; a sense of duty that makes navigating the complexities of their daily work look nothing short of heroic to a layperson. But despite the best of intentions and efforts, the challenges of a complex work environment – time pressure, information overload, family member needs, and physical demands—all while sustaining patient safety and quality of care—create conditions where costly errors can be made.
There is a key factor that consistently contributes to whether a life is saved or lost. That factor is communication.
The Role of Communication and Standardized Protocols
According to the Joint Commission, approximately 70% of sentinel events in medical care are related to communication mishaps. One key area where communication fails is in patient handoffs: the transfer of patient care and authority from one provider to another. In 2017, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and their effect on patient care. Research shows that handoffs are brittle and prone to medical error (Nether, 2017; The Joint Commission, 2017, SEA 58). They are places where important information about the patient’s story can be dropped, forgotten, or misinterpreted—posing huge risk for patient harm.
The escalating impact of ineffective communication is tragic but not surprising given that team processes including decision making and coordination are tightly coupled with communication (Mohammed & Dumville, 2001). Significant research and lessons learned from the field suggest that both standardization of communication protocol and training are key to developing effective team communication processes. (Salas, Tannenbaum, Kraiger, & Smith-Jentsch, 2012).
Improving Communication and Patient Handoff Protocols
In 2018, TiER1 was awarded a Phase II SBIR research grant by the Defense Health Agency (DHA) to improve patient handoffs in combat casualty care environments. The ultimate goal is to enhance patient outcomes and optimize survivability of patients who are injured on the battlefield and transported to a medical facility. While combat casualty care is a unique environment, it shares the characteristics of most healthcare settings: ambiguous, stressful, high-risk, time-pressured, and physically and emotionally draining.
To help address the challenge of patient handoffs in combat casualty care, we embarked on a 3-year journey to standardize and improve patient handoffs. What have we done so far?
- We developed an understanding of the performer.To design human-centered solutions, our work always begins with discovery to understand the performer and the challenges of their work. We interviewed experienced first responders to understand the combat casualty care context and to map out the “journey” of the patient from point of injury to arrival at a medical facility. Based on the first responders’ experiences and insights, we identified the multiple handoffs that typically occur, and the challenges and vulnerabilities associated with each of those handoffs.
- We identified what exists today to support patient handoffs. Before designing solutions, we recognize the importance of understanding the tools, processes, and systems that currently exist to support the performer. We identified existing handoff processes, training, and tools used in combat casualty care handoffs–including the ways in which information about the patient is (or is not) communicated.
- We developed requirements. Based on an analysis of the work and associated challenges of handoffs in combat casualty care, we created a set of requirements for 1) a new handoff protocol, 2) a redesigned documentation tool, and 3) handoff training. For example, the handoff training needs to be flexible to integrate with various contexts, maintain engagement, accommodate time constraints, explicitly convey impact of patient handoffs, incorporate practice and feedback, and be assessed similarly to all medical tasks and procedures.
- We designed a protocol, tool, and training to support effective handoffs. Once we identified the requirements and validated them with subject matter experts, we developed and evaluated a new patient handoff protocol—the Effective Combat Casualty Care Handoff Operations (ECCCHO) Method, a redesigned Tactical Combat Casualty Care (TCCC) card for documentation, and handoff training. The handoff protocol incorporates key elements that can help mitigate the challenges and vulnerabilities in combat casualty care, including closed-loop communication and explicit transfer of authority. The TCCC card uses more intuitive and user-friendly design for documentation, and the training helps medics not only understand the handoff protocol but also helps them understand the impact that their communication has on the ultimate survivability of the patient.
What’s Next?
Our next step in improving patient handoffs is to evaluate the new protocol and training at the Uniformed Services University of the Health Sciences (USUHS) and validate both tools with first responders in civilian trauma settings, where patient handoffs often mirror those in a combat environment.
Saving Lives
Communication and effective application of standardized team processes are essential skills for those working on the front lines of healthcare. Effective, patient-centered communication processes can be intentionally trained and supported through standardization of those processes, intentional training, and support tools. Whether within a combat setting or a civilian hospital, effective team communication processes can make or break desired patient outcomes and survivability. That’s not a battle we’re willing to lose.
Want to be involved in the evaluation of the ECCCHO protocol?: If your health system is interested in learning more about ECCCHO or discussing how to get involved in the evaluation of ECCCHO for improving patient handoffs and survivability, please contact the authors at healthcare@web-archive-2025.tier1performance.com.
About the Authors:
Anna Grome is an Organizational Psychologist and Principal Consultant at TiER1. With nearly 2 decades of experience, she partners with clients in both public and private-sector organizations to consult, design, and build customized solutions to optimize organizational performance.
Dr. Camilla Knott is a Performance Research Director and Consultant at TiER1, and has focused her work on training/assessment of complex cognitive skills and leader development for various organizations across the DoD. She uses well-established and novel scientific methods to solve real-world problems, and is particularly passionate about this approach when it comes to designing solutions for complex, high stakes environments.
