• Accreditation
• Ambulatory care
• Anaesthesia

Healthcare leaders and scholars have articulated gaps in handoff quality across nearly all healthcare settings. A variety of drivers, including hospital accreditation, internal and external safety event analyses and medical education objectives, have given rise to a proliferation of imperatives to improve this situation. Healthcare leaders have developed a greater appreciation that handoff is a key component of a larger set of culture and teamwork strategies that are necessary to reduce harm. Researchers and medical educators have created handoff programmes, provided empirical evidence for their positive impact on safety and worked tirelessly to disseminate them.1 ,2 Quality improvers from a variety of disciplines have begun to adapt and apply standardised handoff in an increasingly diverse array of settings.

In light of this, one might think it less than noteworthy to discover a report of a single institution's hospital-wide handoff standardisation programme.3 To the contrary, we find this report by Shahian et al 3 novel and rich with important messages. We agree with their assertion that this is the largest single-institution implementation of the I-PASS handoff system2 reported in a tertiary general hospital, in this case, Massachusetts General Hospital, which has 25 000 employees. Using a relatively low-cost approach, they managed to implement the system across 15 medical departments, as well as nursing, train nearly 6000 healthcare staff and collect observational data on process reliability at baseline and over 7 months of implementation.

Our combined experience in multiple organisations has afforded us opportunities to understand and engage with the effort to improve handoff from multiple vantage points, including through participation as a site in the I-PASS …