Sustaining Handover Improvement

Sustaining Handover Improvement Professor Rick Iedema Director of the Centre for Health Communication, UTS Dr Robert Herkes, Director of Intensive Care Services RPA Sydney Eamon Merrick RN MHSM, Research Fellow Centre for Health Communication, University of Technology Sydney Royal Prince Alfred Hospital Intensive Care Services, Sydney South West Area Health Service

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Handover & Safety Workshop •

Objectives: participants will be able to: – See, as a fly on the wall, how handovers are conducted in intensive care. – Discuss the function of handover in maintaining continuity of patient care. – Reflect on the challenges that confront attempts to improve handover. – Plan strategies for the improvement of handovers.

Data for this workshop is derived from HELiCS: Handover Enabling Learning in Communication for Safety. Research contributing to the Australian Commission on Quality and Safety in Healthcare, the National Clinical Handover Initiative: 200720081

Examining Organisational Complexity, Risk, and the Built Environment. An Australian Research Council Discovery project: 2008-20112

Clinical Handover is … “ … the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”3. “… to provide accurate information about a [patients] care, treatment, services, current condition and any recent or anticipated changes….. The information communication during handoff must be accurate in order to meet [patient] safety goals”4.

Why Handover Matters5…

A Little Exercise…

Handover & Continuity

In your groups discuss the challenges inherent in maintaining accurate handover: •People involved in handover •skill levels, expertise, professional types

•The types of information required by participants? •Where, who synthesizes this information? •Where, what, a potential sources of error? •How would improve these situations?

Handover & process complexity Clinical risk is heightened by6: • • • •

Interrupted communication and memory processes, multiple concurrent tasks and multi-tasking, Iintensified & fragmented communication, Iincreased segmentation of information (due to specialisation).

Approaches to Improving Handover7 Content standardisation

• –

Listing of specific information that should always be mentioned in a handover

Topic standardisation

• –

Specification of general topic areas that should be covered in handover

Performance standardisation

• –

The process that work groups develop/deployed for the ongoing evaluation of handover performance

Topic Standardisation

Performance Standardisation What makes handover effective? •Understanding levels of clinical expertise •Understanding clinical roles •Understanding (intuitively) team dynamics •Skill mix •Organisational dynamics •Service dynamics •Understanding & synthesizing clinical need “We must be alert to all the functions of handoff activity”

Confounding Factors8,9 •

Level of care uncertainty

•

(Non) standard time(s) for handover

•

(Variable) location where handover is conducted

•

(Different) participants in the handover (mono- vs multi-disciplinary interaction)

•

(Different) informational needs of participants

•

(Changing) length of time devoted to handover

•

Spatial organisations and arrangements (where is handover conducted?)

A Little Exercise…

In your groups identify: Where handover occurs. What about? Multidisciplinary communications Patient/ family involvement Educational functions Professional development Supervision Plan how you would improve these handovers.

Clips

Contextual Solutions Content Standardisation

• Prescriptive Guides • Role specification during handover • Ongoing review, mentoring, and supervision (formal/informal) • Creating space for different modalities of communication • Environmental arrangements/ location of handover • Situational Guides (ESBAR, MIST, FASTHUG) • Supporting multi-disciplinary communication (behavioural change) Topic Standardisation

HELiCS Approaching handover improvement through performance standardisation. • Participation • Observation • Filming • Reflexive Sessions • Implementation • Ongoing self-evaluation

Multi-disciplinary Handover Problems Identified

•Lack of clinical ‘ownership’ of patient care (nursing) •Planning of care inadequately implemented due to lack of interdisciplinary communication •Dangers of discontinuity of care

Intervention •Nurse led (facilitated by senior medical staff) handovers at ward round Outcomes

•Improved continuity of care •Educational opportunities •Clinical team building

Medical Handover Problems Identified

•Communication is prone to interruptions •Out-dated information •Time intensive >45mins

Intervention •Handover at the patients bedside led by the senior registrar Outcomes

•Visual verification of information •Precise •Concise •Professional format •Time reduced <15-30, mins

Outcomes, Organisational Culture •Opportunities for dialogic education •Coordination between disciplines •Availability of contemporaneous information •Early insight into emerging, potential, or previously unrecognised problems •Opportunity for the negotiation of supervisory support

“We must be alert to all the functions of handoff activity”

HELiCS: lessons learned from four sites intervening in handover • • • • • •

Bedside patient check Multi-disciplinary handover Cross-hierarchy communication Checklist support Agreed interruption rules Systematized documentation process

www.communicationsafety.org

References

Coiera, E., Jayasuriya, R. A., Hardy, J., Bannan, A., & Thorpe, E. C. (2002). Communication loads on clinical staff in the emergency department. Medical Journal of Australia, 176, 415-176.