ossie-guide-to-clinical-handover-improvement

OSSIE Guideto Clinical HandoverImprovementOSSIE= Organisational leadership= Simple solution development= Stakeholder engagement= Implementation= Evaluation and maintenance

AcknowledgementsThis guide is based on learnings from the National Clinical Handover Initiative funded by theAustralian Commission on Safety and Quality in Health Care. Some material was derived fromwork developed by staff from the Australian Commission on Safety and Quality in Health Care, inconjunction with staff of the Joint Commission International WHO Collaborating Centre for PatientSafety Solutions, as part of the WHO High 5s Initiative.The Australian Commission on Safety and Quality in Health Care wishes to thank all the projectparticipants in the National Clinical Handover Initiative.The core of this improvement guide comes from the workplace-based research and handoverredesign performed by:● Royal Hobart Hospital and University of Tasmania led by Dr Kwang Chien Yee,Ms Ming Chao Wong and Associate Professor Paul Turner● Western Australia Country Health Service and Royal Perth Hospital led by Ms Jill Porteousand Dr Edward Stewart-Wynne.The Commission wishes to acknowledge the contributing authors and its staff for their work on thisguide, including:Dr Kwang Chien YeeAssociate Professor Christine JormMs Tamsin KaneenThe Clinical Handover Expert Advisory Committee provided valuable input and advice.Chair Dr Dorothy JonesMembers Dr Mary BelfrageMs Jenny CarterProfessor Wendy ChaboyerMr James DunneMs Sara Hatten-MastersonAssociate Professor Christine JormProfessor Elizabeth ManiasMs Stephanie NewellMs Christy PironeMs Annette SchmiedeDr John WakefieldDr Kwang Chien YeeThe Commission gratefully acknowledges the kind permission of the South Australian Departmentof Health, Queensland Health and the Department of Health Western Australia to reproduce manyof the images in the guide.Suggested citationAustralian Commission on Safety and Quality in Health Care (2010). The OSSIE Guide to ClinicalHandover Improvement. Sydney, ACSQHC.Australian Commission on Safety and Quality in Health Care© Copyright and Moral RightsISBN 978-0-9806298-6-6

ContentsForeword ................................................................................................................................. 2Clinical handover – some facts ............................................................................................... 3OSSIE terms ........................................................................................................................... 41. Introducing OSSIE .............................................................................................................. 51.1 What is the OSSIE Guide and who should use it? .................................................. 61.2 Why we need OSSIE – handover improvement is a priority ................................... 71.3 The evidence-base for clinical handover is limited .................................................. 71.4 Foundations of the OSSIE Guide ............................................................................ 91.4.1 Workplace research ....................................................................................... 91.4.2 User-centred approach .................................................................................. 91.4.3 Flexible standardisation ............................................................................... 101.4.4 Iterative feedback ......................................................................................... 102. Planning for OSSIE ........................................................................................................... 112.1 Resources needed for the five phases of OSSIE .................................................. 122.2 Establishing a team ................................................................................................ 143. Organisational leadership – Phase 1 ................................................................................ 153.1 Objectives of this phase ......................................................................................... 163.2 Learning about current handover practice ............................................................. 173.3 Tools and techniques ............................................................................................. 203.3.1 Shift diagram ................................................................................................ 203.3.2 Structured observations ............................................................................... 213.3.3 Structured interviews ................................................................................... 223.3.4 Risk assessment .......................................................................................... 233.3.5 Handover policy and process guide ............................................................ 233.3.6 Handover content guide............................................................................... 254. Simple solution development – Phase 2 .......................................................................... 274.1 Objectives of this phase ......................................................................................... 284.2 Developing the solution ......................................................................................... 284.3 Tools and techniques ............................................................................................. 305. Stakeholder engagement – Phase 3 ................................................................................ 375.1 Objectives of this phase ......................................................................................... 385.2 Engaging stakeholders .......................................................................................... 385.3 Tools and techniques ............................................................................................. 406. Implementation – Phase 4 ................................................................................................ 416.1 Objectives of this phase ......................................................................................... 426.2 Implementing the solution ...................................................................................... 426.3 Tools and techniques ............................................................................................. 467. Evaluation and maintenance – Phase 5 ........................................................................... 477.1 Objectives of this phase ......................................................................................... 487.2 Evaluating the solution ........................................................................................... 487.3 Tools and techniques ............................................................................................. 49Conclusion ............................................................................................................................ 51References ............................................................................................................................ 52Appendix 1 – Australian Charter of Healthcare RightsOSSIE Guide to Clinical Handover Improvement 1

ForewordClinical handover is a high risk area for patientsafety and therefore a priority project for theAustralian Commission on Safety and Quality inHealth Care.The OSSIE Guide to Clinical HandoverImprovement combines research, consensusopinion and consultation.In March 2009, the Commission released aconsultation edition of the OSSIE Guide. Itwas developed mainly from the lessons andrecommendations of 14 projects funded by theCommission, but also from seminal work atthe University of Tasmania, the Royal HobartHospital, the Western Australia Country HealthService and Royal Perth Hospital.Thousands of copies of the consultation editionwere distributed and downloaded from theCommission’s website.We are particularly grateful for sound andpractical feedback advice from healthcareprofessionals in all states and territories. Somerequested a smaller version of the guide for busyfront-line clinicians and we will provide this.We are also developing educational materialsfor those leading handover improvementsin their hospitals to improve colleagueengagement and communication.Interest and momentum in handoverimprovement is growing rapidly throughout thehealthcare system: in all jurisdictions, in localhealth areas, in educational institutions andamong front-line clinicians.In April 2010, the guide was endorsed byAustralian Health Ministers as a national guideto improving clinical handover practices at shiftchange in a hospital setting.We know this guide will enhance the improvedclinical handover movement.I commend the enthusiasm and determinationof those involved in the preparation of theguide.Yours sincerelyWilliam J. BeerworthChairmanAustralian Commission on Safety and Qualityin Health CareClinical handover projects fundedby the Australian Commission onSafety and Quality in Health Care● Bedside Handover and WhiteboardCommunication, Griffith University ResearchCentre for Clinical Practice Innovation,Queensland Health Patient Safety Centre andPeel Health Campus, Western Australia● Implementing written and verbal handover toensure optimal transfer of patients from countryto metropolitan health services, WesternAustralia Country Health Service and RoyalPerth Hospital● Inter-professional Communication andTeam Climate in Complex Clinical HandoverSituations (in the Post Anaesthesia Care Unit):Issues for Safety in the Private Sector, DeakinUniversity in collaboration with Epworth, Cabriniand Alfred Hospitals● Revolving Doors – Effective Communicationin the Handover of Mental Health Patients toCommunity Health Practitioners, St John of GodHealth Care – NSW Services● SHAREing Maternity Care – Clinical Handoverbetween Visiting Medical Officers and Midwives,Mater Health Services Brisbane Limited● The Development of SOPs and EducationalResources for Shift-to-Shift, Medical andNursing Handover, Royal Hobart Hospital andUniversity of Tasmania● Transfer to Hospital Envelope, North East ValleyDivision of General Practice● ISBAR revisited: Identifying and SolvingBARriers to Effective Handover in Inter-hospitalTransfer, Hunter New England Area HealthService● Improving Residential Aged Care Facility toHospital Clinical Handover, GPpartners● Development of e-Learning Strategy for SafeClinical Handover, University of QueenslandCentre for Health Innovation and Solutions,Queensland Health Patient Safety Centre andMed-E-Serv Pty Ltd● TeamSTEPPS TM , South Australian Departmentof Health Clinical Systems Unit and SouthAustralian Health Services● The PACT Program – Communication Trainingand Team Training to Support Handover,Albury-Wodonga Private Hospital – RamsayHealthcare● The Use of Reflective Video to ImproveHandover, UTS Faculties of Humanities andSocial Sciences, Nursing, Midwifery and Healthand Adult Education; University of MelbourneSchool of Nursing● SafeTECH – Safe tools for electronic clinicalhandover, South Australian Department ofHealth, University of South Australia andUniversity of Tasmania2 OSSIE Guide to Clinical Handover Improvement

Clinical handover – some facts● Clinical handover is a high risk scenario forpatient safety. Dangers include discontinuityof care, adverse events and legal claims ofmalpractice (Wong et al, 2008).● A survey of Australian doctors revealed that95% believed that there were no formalor set procedures for handover (Bomba &Prakash, 2005).● An Australian study of emergencydepartment handover found that in 15.4%of cases not all required information wastransferred, resulting in adverse events(Ye et al, 2007).● A survey of junior doctors in the UnitedKingdom discovered that 83% believed thatthe handover process was poor. Writtenhandover was rarely received, accountingfor only 6% of all handovers (Roughton &Severs, 1996).● A detailed analysis of nursing handoverrevealed that some handovers promotedconfusion and did not assist in patient care(Sexton et al, 2004).● Handover is among the most common causeof malpractice claims in the USA, especiallyamong trainees accounting for 20% of cases(Singh et al, 2007).● A survey of trainees in the USA suggestedthat 15% of adverse events, errors or nearmisses involved handover (Jagsi et al, 2005).A full literature review on clinical handover isavailable at www.safetyandquality.gov.auClinical Handover: Critical Communications,a supplement issue of the Medical Journal ofAustralia, is available at www.mja.com.auPatient care is complex. One element of this complexity is the number of contacts and transitionsundertaken by patients. The graph below shows that approximately 7,068,000 handovers occurannually in Australian hospitals.Figure 1: Estimated numbers of handovers conducted in hospitalsApproximate Number of Handovers per 1000 Population per Annum2000150010005000Same dayHospitalSeparations:NursesSame dayHospitalSeparations:DoctorsAll otherHospitalSeparations:NursesAll otherHospitalSeparations:DoctorsHospitalSeparations:PharmacistsType of Health Professionals or ServicesHospitalSeparations:Allied HealthProfessionalsDoctor orNurse:HospitalProceduresAmbulance toEmergencyDepartment(ACSQHC, 2008)OSSIE Guide to Clinical Handover Improvement 3

OSSIE termsClinical handoverClinical handover is thetransfer of professionalresponsibility andaccountability for some or allaspects of care for a patient,or group of patients, to anotherperson or professional groupon a temporary or permanentbasis. This definition of clinicalhandover formed the basisfor all the activities and workcarried out as part of theNational Clinical HandoverInitiative. This guide alsorefers to clinical handover assimply ‘handover’ or ‘handovercommunications’.Emotional intelligenceprinciplesEmotional intelligence refersto the ability to monitor one’sown and others’ feelingsand emotions and use thisinformation to guide thinkingand actions. Characteristics ofemotional intelligence include:self-awareness, self-regulation(including reflection andadaptation), self-motivation,social awareness and socialskills. Emotionally intelligentleaders can motivate teammembers to work moreeffectively, build intrapersonaland interpersonal trust andimplement team goals.EmpowermentThe term ‘empowerment’ isused in this guide to referto clinicians developingconfidence in their owncapacities to contribute to theimprovement process. This willensure the new process forhandover is supported by theclinicians who will be using it.Without clinician support, thenew process has little chanceof success over the long term.Flexible standardisationThis guide advocates for thestandardisation of handoverprocesses to improve thesafety of handover. However,the guide emphasises that theparticular local context of theunit, ward and institution needsto be integrated into the designof the standardised process(i.e. ‘flexible standardisation’).IterativeWithin this guide iterativerefers to the continualneed to improve handover.Handover is a dynamicpractice and should be treatedas an evolving process. Forexample, six months afterunit A introduced ISOBAR forindividual patient handovers,they were able to purchasean electronic whiteboard tosupport the process. Furtherwork was then required toensure the safe and effectiveuse of this new feature of thehandover process.Minimum data setThis guide refers to theminimum data set as theminimum content that mustbe contained and transferredin an individual patienthandover. There are manypossible minimum data setsfor handover. Refer to chapterfour for additional details.National ClinicalHandover InitiativeThe Australian Commission onSafety and Quality in HealthCare established the NationalClinical Handover Initiative withthe aim of improving clinicalhandover communicationacross all healthcare settings.A pilot program was set up aspart of the initiative to developand implement tools andsolutions to improve clinicalhandover.OSSIEOSSIE is a mnemonic,which actually equates toa framework for changemanagement. Each letter inthe mnemonic stands for achange phase: Organisationalleadership, Simple solutiondevelopment, Stakeholderengagement, Implementation,Evaluation and maintenance.The phases aim to providereaders with all the informationrequired to successfullyintroduce and sustainimprovement to clinicalhandover.User-centredUser-centred design is adesign philosophy and processin which the needs, wantsand limitations of the end userof a product or process aregiven extensive attention. Theintent is to design around howpeople can, want or need towork.4 OSSIE Guide to Clinical Handover Improvement

Introducing OSSIE1.1 What is the OSSIE Guide andwho should use it?1.2 Why we need OSSIE –handover improvement is apriority1.3 The evidence-base for clinicalhandover is limited1.4 Foundations of theOSSIE Guide1.4.1 Workplace research1.4.2 User-centred approach1.4.3 Flexible standardisation1.4.4 Iterative feedbackOSSIE Guide to Clinical Handover Improvement 5

Clinical handover is an integral part of clinicalcare, practised in a multitude of ways, in allhealthcare settings, every day. Failures inclinical handover have been identified as amajor preventable cause of patient harm. Poorhandover can also lead to wasted resources.Consequences include: unnecessary delaysin diagnosis, treatment and care; repeatedtests, missed or delayed communication of testresults; and incorrect treatment or medicationerrors.Current handover processes are unreliable andhighly variable. Standardisation of handovercontent and process will improve the safety ofhandover by ensuring consistency in criticalinformation exchanges.Clinical handover is:‘the transfer of professionalresponsibility and accountability forsome or all aspects of care for a patient,or group of patients, to another personor professional group on a temporaryor permanent basis’Australian Medical Association in their ‘SafeHandover: Safe Patients’ guideline (AMA, 2006)and United Kingdom National Patient SafetyAgency (2004)1.1 What is the OSSIE Guide andwho should use it?‘OSSIE’ stands for the following five phases:O = Organisational leadershipS = Simple solution developmentS = Stakeholder engagementI = ImplementationE = Evaluation and maintenanceAchieving sustainable improvement in theprocesses of health care and in patientoutcomes is difficult. OSSIE is a focusedchange management framework to supportimplementation of standardised clinicalhandover. The OSSIE Guide assists readersto design, implement, evaluate and maintainclinical handover improvement programs thatcontain a standardised process and contentdata set.The clinical handover improvement frameworkpresented in this guide is based on researchconducted on medical and nursing shift-to-shifthandover within an acute care hospital setting.We believe that the principles presented here,however, could guide improvement of otherhandover situations, including multidisciplinary,primary care and community handovers.The OSSIE Guide is intended for use by ateam working together to achieve the goal ofclinical handover improvement. All clinicianscan improve their own handover practice, buthandover is a group practice and to ensurepatient safety, we need to improve the handoverpractices of all staff.If a mnemonic is used to organise and planparticipation in handover, the safety of patientswill improve as critical information is more likelyto be transferred and acted upon.This guide does not provide a quick fix forimproving handover. What it provides isdirection on how to improve handover byfollowing a series of manageable activities– the five phases of OSSIE.Resources are required for successfulhandover improvement. However, manysuccessful clinical handover improvementteams have started with little and found thatsupport and resources could be obtained.6 OSSIE Guide to Clinical Handover Improvement

1.2 Why we need OSSIE –handover improvement is apriorityThe system for the delivery of healthcareservices is very complex. Breakdown in thetransfer of information or in ‘communication’ hasbeen identified as one of the most importantcontributing factors in serious adverse events.Information transferred between healthcareproviders should include all relevant data, beaccurate, unambiguous and occur in a timelymanner. This information enables actions to betaken to provide the care that a patient needs.There is an international trend to reduceworking hours for staff (especially junior medicalofficers), as staff fatigue is now recognised asa patient safety risk. The Australian MedicalAssociation has produced guidelines for safeworking hours (AMA, 2005). Reduced workinghours and the introduction of flexible workinghours have led to increases in the numberof shifts required and in the number of stafflooking after the same patient. This meanseffective and efficient handover processes havebecome even more essential.Many hospitals do not have a clear policyfor effective handover and practice is highlyvariable. Shift-to-shift handover amongstmedical staff is not a well defined process. Thenursing profession, on the other hand, has along tradition of practising shift-to-shift handover– although there is still room for improvementin order to optimise the accurate transfer ofinformation, responsibility and accountability.Interdisciplinary handover can be very effectivebut it is less common.1.3 The evidence-base forclinical handover is limitedThere are many aspects of handover whichare largely unstudied. Many questions can beasked for which there is no evidence-basedanswer, such as:● Which are the most importantcommunications?● Which communications directly or reliablycorrelate with action for patient care?● Is information being delivered in multiple waysor at multiple times, leading to redundancy?● Does that redundancy add to safety or makeit more likely that important information is notacted upon?Handover is a complex and wide area of study.Handover communication occurs via differentmodalities and at different points throughoutthe process of care. Reflect for a moment onan in-patient during a single hospital admissionand consider how much sharing of clinicalinformation occurs related to patient care.These communications include: what is writtenin the medical record and other charts (e.g.medication, fluid balance); what is written in ahandover record; and what is discussed duringward rounds, handovers and by staff in informalconversations.The issues for a patient with chronic illness,multiple admissions and care in both public andprivate institutions and by multiple specialistteams are even more complex. Solutions toimprove handover safety in these specialisedcircumstances are not discussed in this editionof the OSSIE Guide to Clinical HandoverImprovement. Many require development of oure-health infrastructure.Although there has been a proliferation ofhandover literature in recent years, researchinto best handover practice for differentclinical situations is ongoing. The lack of anestablished evidence-based structure, interms of content, process and informationtools, has led to handover being a highlyvariable and ‘individual-dependent’ process.It is within this context that the OSSIE guidehas been developed. However, two importantevidence-based principles for best practicein handover are emerging: face-to-facecommunication and documentation.OSSIE Guide to Clinical Handover Improvement 7

Face-to-face communicationFace-to-face communication providesmore opportunity to clarify information.A simple communication techniqueis ‘Read-back’ or ‘Check-back’ (USDepartment of Defence, 2005). Theperson receiving information can verifyit by repeating the information and thesender can confirm that it has beenunderstood correctly.As well as handing over patientinformation, face-to-face handovercan lead to opportunities for socialinteraction, education and teambuilding. O’Connell and Penney(2001) say that handover is where‘nurses can debrief, clarify informationand update knowledge.’In one study, verbal handovers viatape recorder were found to be brieferand did not fully reveal the patient’soverall condition (O’Connell & Penney,2001). This may lead to staff thenspending more time finding andclarifying information about the patient.DocumentationStudies have shown that verbalhandovers are more commonlyused than written handovers (seefor example Roughton and Severs,1996). In research conductedby Manias and Street (2000),the majority of nurses also usedhandwritten notes during handover,while medical staff were found toprefer verbal conversation handovers(Bomba & Prakash, 2005).Engaging in verbal handover only,compared to verbal handoverwith some documentation, reliesheavily on memory skills andhas been classed as a high riskstrategy (Bhabra et al, 2007). Theperformance of doctors on simulatedhandover cycles showed that only33% of information was retainedafter the first handover cycle andonly 2.5% of information wasretained after five handover cycles(Pothier et al, 2005). However, usingpre-prepared data sheets resulted inthe full maintenance of data.Improved documentation ofhandover can also have the benefitof minimising repetition and canreduce the length of handover.8 OSSIE Guide to Clinical Handover Improvement

1.4 Foundations of the OSSIEGuideThe OSSIE Guide originates fromworkplace-based research and teacheshandover standardisation that is customisedfor the workplace. The guide calls this fl exiblestandardisation. Central to the foundationalwork that informed this guide is the inclusionof a user-centred approach and iterativefeedback to help design a standardisedhandover process and content that issustainable.1.4.1 Workplace researchThe core of this improvement guide comes fromthe workplace-based research and handoverredesign performed by two of 14 teamsinvolved in the Australian National ClinicalHandover Initiative.The Royal Hobart Hospital and University ofTasmania (RHH/UTAS) developed the OSSIEconcept. This group has been conductingresearch on shift-to-shift handover since 2004.The seven researchers included nurses,doctors and information systems experts:Kwang Chien Yee, Ming Chao Wong, PaulTurner, Jolene Robertson, Sharee Eldridge,Helen Courtney-Pratt and Diana Coombes.The work was supported by a six-membersteering committee and a 20-member expertsupport team.What does standardisedhandover look like?Under an effective standardised handoverprocess all participants know the purpose ofthe handover and the information that theyare required to know and communicate.They know what documentation is required.Senior staff make sure handover keepsthe form that has been agreed by theclinical unit to be best for patient safetyand unit efficiency. They do this, forinstance, by ensuring that participants in aroutine verbal handover are free to attend,attend on time, and deliver the relevantinformation. Relevance is determined byconsidering what information staff need tocommunicate to transfer responsibility andaccountability. Staff handing over to the nextshift communicate the actions and degreeof vigilance required to ensure the patient iscared for safely.Their data collection process included120 observation sessions, 121 interviews,200 hours of shift shadowing and analysis ofmore than 1000 patient handover records. TheRHH/UTAS team conducted a detailed literaturereview (217 articles) which is published atwww.safetyandquality.gov.au.The standardised clinical handover processdeveloped by the RHH/UTAS team issummarised as ‘HAND ME AN ISOBAR’ (refer tosection 4.3 for more details). This guide uses theprinciples found within this handover process.The Western Australia (WA) Country HealthService and the Royal Perth Hospital team ledby Jill Porteous (with Pauline Crommelin, TedStewart-Wynne, Madeleine Connolly and AdeleLake) developed the ISOBAR concept to meetthe needs of handover for inter-hospital transfer.ISOBAR proved an excellent mnemonic and washighly effective in helping staff in WA regionalareas improve their handovers. ISOBAR isnow in widespread use in many institutions forboth shift-to-shift handover and to guide phonecommunications with medical staff. ISOBARalso proved a good fit for the minimum singlepatient handover content set developed by theTasmanian team (and some of the other teams).1.4.2 User-centred approachThe guide emphasises user-centredapproaches to design and user engagementin the quality improvement process. Newprocesses imposed on clinicians often failbecause they do not fit easily into clinicalpractice. So study of the practices and viewsof handover ‘users’ – the clinicians involved inhandover – is crucial.It is important that when clinical staff areengaged to improve handover, their views areobtained and respected. In fact, all cliniciansmust be engaged through the whole process inorder to achieve the best outcomes. If cliniciansfeel that their views have been incorporated,they will take ownership of the situation and thechange is more likely to be sustainable.OSSIE Guide to Clinical Handover Improvement 9

1.4.3 Flexible standardisationThe OSSIE Guide provides an approach toimproving the safety of handover. Cliniciansneed to understand their own work andorganisational context in order to bestutilise the evidence on better handover. Thestandardisation that is chosen needs to fitthe particular needs of the patients and staffwho are the participants in handover. Theseneeds vary widely as clinical units may havespecialised and differing functions (e.g. aneonatal unit or stroke unit). Even units witha similar purpose, for instance general adultintensive care units, vary in size and physicallayout and their patient populations can bevery different. Staffing is even more variable –between country and city, public and private,teaching and non-teaching institutions. Thetypes, award conditions and numbers of healthprofessionals also vary. Medical officers whoare responsible for care may not be on site ormay be on site but not available for handover.Handover between units or institutions addsits own complexity. A transport team may beinvolved, requiring extra communication stepsand there may also be delay during which thepatient’s condition may deteriorate. Inevitablythe priorities, culture and staffing ratios ofdifferent units vary in ways that can add riskto handover (e.g. a patient transfer from highacuity areas with high staffing ratios such as theemergency department to a general medical orsurgical ward).This guide emphasises the need to engagestaff and to develop a solution that fits withlocal culture and clinical practice. The needto deliver standardised solutions for betterpatient outcomes is also recognised. Addingunnecessary time, work or complexity tohandover could decrease patient safety, thequality of care delivered and staff satisfaction.Therefore, standardisation in handover hasto have the clear intent of ensuring patientsafety and harmonising with local needs andwork practices. This guide provides guidanceon implementing a standardised process forhandover, tailored for a local context.1.4.4 Iterative feedbackDue to the complexity of our healthcare system,it is difficult to fully predict the effects of anyprocess improvement intervention. The iterativefeedback process, as demonstrated in Figure 2,allows improvements to respond to changingcircumstances and/or consequences, as well asensuring continual and increasing engagementof clinicians. This is similar to the better knownPDSA cycle of ‘Plan-Do-Study-Act’.The process of iterative feedback is timeconsuming and at times frustrating but it isalso essential to engage clinical staff andmaintain their commitment to improving clinicalhandover. If a good initial understanding of thecurrent clinical handover process is assembledthen the number of iterative cycles may bereduced.Figure 2: Iterative feedback processIdentify newproblems andpotential solutionsObservationClinical processmappingRevisionPrototypingReflection andclinical processre-engineeringUserfeedbackMonitoring andevaluation(Yee et al, 2009)10 OSSIE Guide to Clinical Handover Improvement

Planning for OSSIE2.1 Resources needed for thefive phases of OSSIE2.2 Establishing a teamOSSIE Guide to Clinical Handover Improvement 11

The OSSIE Guide is designed for use by ateam working together to achieve the goalof clinical handover improvement. Whileindividual enthusiasm and efforts to improveclinical handover are welcome, it is unlikely thatindividuals will be able to drive adoption of astandardised process, or sustain a long-termchange for a unit or an organisation. The highturnover of staff in health care, as well as staffon rotation or relieving in other locations, mayalso work against sustained success in isolatedunits.Adequate resources must be provided and thehandover improvement should be linked to theorganisation’s governance and accountabilityarrangements. Organisational reform attemptsare more likely to be successful if aligned tothe organisation’s aims, values and safety andquality plans.2.1 Resources needed for thefive phases of OSSIEPhase 1: Organisational leadershipThis phase is resource intensive. It includesobtaining the views of as many participantsas possible and promoting the handoverimprovement process. In this phase, resourcerequirements should also be identified for theremaining phases of the clinical handoverimprovement process, including dedicated stafftime, communication and tool requirements andtraining. Clinical and managerial leads shouldbe identified and all key staff in the organisationshould be briefed.Phase 2: Simple solution developmentThis is the most resource intensive phaseas it involves user-centred design principles,meaning that the success of this phase isdependent on the number of participants whohave input into the design. These opinionswill differ and must be reconciled to produce asolution that provides standardisation.Phase 3: Stakeholder engagementThis phase lasts for the duration of the project.Due to regular movement of staff, stakeholderengagement must be a continual process toensure success.Phase 4: ImplementationThis phase is time consuming and constantcommunication is required from the projectteam. There are many change managementand team based tools available to encourageclinical engagement. Opportunities for creativeteam building should be taken. Constantreminders and support are required to get staffto incorporate new practices into their routinework, as changing behaviour takes practise.Evaluation should not happen early in theimplementation phase as it will not reflect thereal impact of the program.Phase 5: Evaluation and maintenanceAn ongoing improvement plan will ensurefuture adaptation of the standardised solutionto changing clinical contexts and practices.Evaluation and maintenance require significantresources and time.12 OSSIE Guide to Clinical Handover Improvement

‘I think the implementation of a programis going to take much longer than weoriginally thought… it’ll be about sixmonths before you see any change andabout 12 months really and you’ve got tocommit resources to that.’Participant, November 2008 clinical handoverworkshopFigure 3: Time-resource chartPhase 1:Organisational leadershipResourcesPhase 2:Simple solution developmentPhase 4:ImplementationPhase 3:Stakeholder engagementPhase 5:Evaluation & maintenanceTimeTime and resource requirements need serious consideration. In the illustrative time-resource chartabove (Figure 3), the length of the bars represents the estimated time required and the height of thebars represents the estimated resources required. The resource requirement is more intense at thebeginning of the handover improvement process but it will vary considerably based on the size andcomplexity of wards, units and organisations.The total time required is dependent on factors such as the resources available, the preparednessof the unit or organisation, the availability of individuals to commit to the project and the size of theunit or organisation. It is recommended that at least 12 months be allowed for the whole project.OSSIE Guide to Clinical Handover Improvement 13

2.2 Establishing a teamWhile the exact number of members and theskill mix within any team will be variable, it issuggested that the following be sought at thebeginning of the project:● A project leaderThe project leader should be a clinician whohas strong interest in quality improvement andclinical handover.Remember to consider that some teammembers may be involved in multipleimprovement projects at one time. Ifimprovements to handover are to besuccessful, quarantined time for the project willbe required.● Senior supportA senior support person can guide theteam through organisational policy and theestablishment of organisational support.● Quality and safety expertiseQuality and safety expertise will ensure thatthe project follows the local quality and safetyframeworks and dovetails with other localimprovement projects. Systems and changemanagement expertise can be brought in duringthe implementation and adaptation phases.It is, however, desirable that individuals withthese skills are involved from the beginning.This is especially important if the handoverimprovement involves new electronic tools.● Clinician champions (or clinical leads)Clinician champions assist with staffengagement and empowerment.● Education expertiseImproving handover requires significant effortin educating and training clinicians. Educationalexpertise will assist with this process.● Patients, carers and consumersInvolve a patient or carer on the project team.Alternatively a team member may provideor coordinate input from patients, carers orconsumers (for instance, this can be sought byinterview). The need for this perspective shouldbe considered from the beginning of the projectand hospital consumer advisory committeesmay be able to assist.● Project team trainingThe project team should undergo appropriateprofessional development and necessaryup-skilling through invited training sessionsand expert advice from external consultants(e.g. change management consultants) at thebeginning of the project.Case study: team compositionExample 1Hospital A wishes to implement a formalend-of-term handover for junior doctors.The project team includes a project leader(the director of clinical training), the qualityand safety officer and representatives fromthe junior doctors and from the specialtysupervisors for junior doctors.Example 2Hospital B is having problems with thehandover between ambulance officers andthe emergency department nursing staff.The project team includes a project leader(the nursing unit manager), the triagemanager, a nursing educator, ambulanceofficers and the medical director of theemergency department.Example 3Hospital C is interested in implementingan electronic clinical handover platform formedical handover.The project team includes heads of themedical department, a project leader,a clinical change champion, a qualityand safety officer, educators, hospitalinformation technology managers andchange consultants.Information technology designers andinformation systems experts are requiredduring the design and implementationphase of the project. The softwarecompany provides information technologydesigners and the information systemsexperts from the local university agree toparticipate.14 OSSIE Guide to Clinical Handover Improvement

Organisationalleadership – Phase 13.1 Objectives of this phase3.2 Learning about currenthandover practice3.3 Tools and techniques3.3.1 Shift diagram3.3.2 Structured observations3.3.3 Structured interviews3.3.4 Risk assessment3.3.5 Handover policy andprocess guide3.3.6 Handover content guideOSSIE Guide to Clinical Handover Improvement 15

Phase 1 begins once a team has beenestablished, resources are identified and teammembers understand the rationale for the needto adapt standardised solutions to improveclinical handover.During this phase it is necessary to emphasisethat clinical handover improvement is apriority. It is important to recognise that forclinical practices, like clinical handover, manystaff might not realise the need to change.Leadership needs to be demonstrated throughobtaining a clear understanding of the currentclinical handover practices; assisting staffto understand the rationale for change; andidentifying motivators and barriers for change.An analysis of the risks of existing andproposed practices is required. Different ortailored project teams and solutions might berequired for different wards or clinical areaswithin the same organisation. Empowerment ofstaff through the clinical handover improvementprogram is essential for long-term success.‘It’s about identifying what your issuesare and also what the strengths are atthe sites. You may be doing some thingsreally well. You don’t want to throweverything out in the change.’Participant, November 2008 clinical handoverworkshop3.1 Objectives of this phaseDuring this phase the team seeks to:● Prioritise the clinical handoverimprovement processThe success of the handover improvementinitiative is dependent on its priority within thelocal clinical unit and within the institution.It is important to identify other quality andsafety projects and potential future changesto clinical practice to avoid creating ‘changefatigue’ among staff. Ideally, clinical handoverimprovement should be aligned with theorganisational strategic vision and other qualityimprovement projects.● Understand local practice from theclinicians’ perspectiveThis should include the context (e.g. team workenvironment, multidisciplinary care), content(e.g. information exchanged) and process ofcurrent handover practices. Some individualsmay have very good insights and ideas forimprovement. These should all be taken intoconsideration in the design and implementationprocess.● Understand the motivators andbarriers for changeThis process should include the identificationof barriers as well as the motivators forchange. These may include environmentalfactors (e.g. busyness of the ward and wardculture), technological factors (e.g. availabilityof electronic medical records and healthprofessionals’ proficiency with these records)and human factors (including staff adherence toexisting systems and competing work tasks).● Provide leadership by helping staff tounderstand the rationale for changeFor your clinical handover improvementinitiative to be successful, staff need tounderstand the rationale for change. Thisinvolves gathering information about localexperience to construct a compelling rationalefor change. Adverse events and data abouttheir own practices (e.g. length of time spentin handover or video footage of handoverpractice) are the most powerful material forconvincing clinicians of the need for change.● Lead through empowermentLeadership needs to be provided to cliniciansthrough empowerment, utilising emotionalintelligence principles, as well as leadershiptraining and strategies to reward goodperformance. For examples on how this canbe done, refer to chapter five on stakeholderengagement.16 OSSIE Guide to Clinical Handover Improvement

3.2 Learning about currenthandover practiceA full understanding of the current clinicalhandover practice should be developedduring the organisational leadership phase ofthe project. There should be a collaborative,problem solving approach to this phase.Clinicians must be given reassurance thatthe process is non-judgemental and thatthe observation findings will not be used forpersonal performance evaluation. Failure toengage clinicians at this stage will have asignificant impact on future progress.There may be differences in perceptionbetween management and senior and juniorclinicians. If so, these need to be documented.There are often differences between theperceptions of clinicians and the real-lifepractice of handover (as measured usingobservational techniques). We rarely do whatwe say we do. It is critical to identify andunderstand these gaps before proceeding tosolution design.At the end of this section there are toolsthat can help with the systematic analysis ofhandover practices. The team should use thesetools to help them answer the following 10questions. Answering each of these questionshelps with the design and implementation ofsolutions for clinical handover improvement.1. What type of handover is currentlypractised?The current practice of handover should beclearly described (e.g. office based discussions,bedside, tape recorded). The content iscommonly transmitted verbally or in a writtenformat or both ways. The receiver of thehandover information then either documents theinformation in a written form or relies solely ontheir memory to recall the information.The project team should check whetherthere are any existing policies andprotocols covering handover. If thereare, it is important to find out whetherstaff are aware of them and whethernormal clinical practice complies withorganisational policy.Case study: understandinghandoverResearch revealed the importanceof observation sessions and ofinterviews.Interview with senior clinician‘The handover process is orderly. Mostconsultants, including myself arrive ontime and handover starts at 8 am. Itthen goes through a fixed format withopportunities for everyone to speakand be involved in the process.’Interview with junior clinician‘It is generally speaking quite good.Sometimes it starts a bit late and weas the juniors often do not participatemuch in the process.’Observation session six‘8.05 am. Handover had beencompleted as the consultant arrivedearly and started the process at7.50 am. There were only four peoplein the room and most staff had notarrived by the completion of thehandover session.’2. When does handover occur?To avoid wasting staff time and devaluingthe handover process, shift-to-shift handovershould be conducted at a fixed time and fixedplace and it should be punctually attended.The effectiveness and efficiency of handoversare affected by shift structure so it is importantto develop a clear understanding of the shiftstructure in place. Where staff are workingstaggered shifts, or using team nursingmodels, it is very important to obtain a clearunderstanding of the current practice of transferof responsibility.Appropriate shift overlap is essentialfor good clinical handover. Inadequateshift overlap will result in inadequatehandover. Long shift overlap, however,can result in confusion regardingresponsibility for patient care during theshift overlap.OSSIE Guide to Clinical Handover Improvement 17

3. What is the role of consumers,patients and their families?Patient-centred care involves the activeparticipation of patients, consumers, carersand family members in the planning, deliveryand evaluation of care and the design of thehealth system. As patients are the common linkbetween all forms of handover, they should beincluded on the improvement team wheneverpossible.Patient concerns about handover need to beexplored even when a direct participatory role inhandover is not anticipated. The effectivenessof handover communication may be enhancedby the participation of patients, carers andfamily members. Consider if bedside handoveris appropriate, as it has been shown toenhance patient satisfaction and improve safety(Chaboyer et al, 2008).Project teams should also be aware ofthe Australian Charter of HealthcareRights which describes the rights of allconsumers using the Australian healthsystem and is available in Appendix 1.4. Who attends and leads handover?A designated team leader should takeresponsibility for the overall conduct of thehandover. The leader will commence handoverand then supervise individual staff, ensuring allrelevant information is given and the actions areunderstood by the oncoming staff. The leader isoften the most senior staff member present.Leadership makes handover efficient andensures safety by reducing the risk ofcontent omission.All patient care is multidisciplinary but manycommunication practices, including many currenthandover practices, are unidisciplinary (e.g.nurses handing over to nurses and doctorshanding over to doctors). Consider whetherunidisciplinary handover is the right model orwhether the introduction of a multidisciplinarymodel could improve the safety of handover.Consider whether multidisciplinary handover isfeasible (e.g. do different professionals changeshift at the same time; is there a place bigenough for all professionals to be involved?).More multidisciplinary handover hasbeen proposed to reduce the risk ofdiscontinuities in patient care. Thisis especially important in complexclinical cases or where multiple teamsof healthcare professionals interactconstantly in order to provide patient care(for instance in intensive care units).The involvement of multiple teams ofhealthcare professionals in the handoverprocess might not always be an efficientuse of time. This is especially the case ifeach team member carries out their owntasks independently. However, patientcare is delivered through multidisciplinaryaction and a level of coordination of careis required (e.g. a nurse manager knowswhich teams need to see which patients,and will hand that information over to theoncoming nurse manager).5. How is continuity of patient careassured during handover?As the clinical handover process often takesclinical staff away from patient care, it is veryimportant to ensure that patient care continues.The team should identify how well and by whatmethods current handover practice assurescontinuity of patient care.Patient care needs that must be providedfor during the handover process include:● expected arrival or physical transfer ofpatients, especially unstable patients● treatment or management which mustbe provided at a specific time● unexpected emergencies duringhandover periods● toileting and response to patient call bells.6. Is handover documented and whatrelationship does this have topatient records?Some handover information may be regularlyreferred to as a permanent part of the patientrecord (e.g. discharge summaries from theatreor intensive care unit) or may be short-term insignificance (e.g. ‘we’re expecting the porter fromtheatre to come for the patient soon’). Handoverinformation may be taped, typed or just written ona piece of paper to serve as a memory aid. Therelationship between any handover documentationand other patient records must be clearlyidentified. The legal status of documentation thatresults from handover should also be determined.18 OSSIE Guide to Clinical Handover Improvement

The handover improvement teamshould consider whether handoverdocumentation should be archived in thepatient notes or in some other form. Thecurrent state of the medical record, suchas paper-based, electronic or scannedrecords, will affect this choice. Handoverdocumentation does not replace theneed to document patient progress andmanagement plans clearly in the patientprogress notes.7. What other roles does handoverplay?The role of the handover will vary considerably,depending on the type of handover and otherprocesses available to assist with thesefunctions. The process of handover may providean opportunity for group decision making anddecision support or it may act as a regulartrigger for clinical decision making. Handovers,especially shift-to-shift handovers, carry a veryimportant informal teaching role for junior staff.Students and junior staff learn clinical practiceand culture through observation and informalinteractions with staff members.The current clinical handover processmay serve additional important functionssuch as teaching, staff bonding ordebriefing. It is important to considerother ways to provide these functionsif the implementation of a standardisedhandover means they no longer have aplace during handover.8. Is current handover efficient andeffective?Factors that affect the efficiency andeffectiveness of clinical handover include:interruptions, noise levels, language proficiency,cultural awareness and human performance(such as fatigued staff finishing night work). Itis important to recognise the impact of thesefactors on the process of clinical handover.Distractions to the clinical handoverprocess should be identified andresolved. These might include numberof chairs, physical privacy, audio privacyand restriction of non-handover activitiessuch as consumption of food duringhandover time.9. Is there a standardised format forhandover information?The efficiency and effectiveness of handover canbe improved with a standardised format for thedelivery of most information. There may alreadybe some formal or informal standardisationwithin the current handover process. This shouldbe identified and described. It is also importantto note the variability of the format and factorswhich may lead to variability (e.g. ‘when it’s busy,handover is shorter and we sometimes leave outthings like social history’).Clinical handovers should follow aparticular format and a checklist shouldbe available to ensure all aspects arecovered. The use of a minimum dataset for individual patient handover willminimise interruption as the receiver ofhandover understands what to expect.10. Are tools used to assist withhandover preparation and thehandover process?Various tools might be used to assist clinicalhandover. These may include whiteboards,electronic data projectors or clear clinicalhandover guidelines. Spreadsheets or wordprocessing tools might also be used forinformation support. True electronic handovertools are databases that have an interface whichallows simultaneous access by multiple users toview and enter handover data. The informationcontent in any tools used should be analysed.A well-designed tool should both force anddocument the clear transfer of responsibility andaccountability of patient care.Tools used in handover, especiallyelectronic tools, must allow for thetransfer of responsibility and informationon patient care. It is important that onetool is used by all clinicians to updateclinical handover information. Forinstance, the combination of a handoverbook and an electronic handover toolwould be unsafe.OSSIE Guide to Clinical Handover Improvement 19

3.3 Tools and techniquesThere are three key techniques that will help you answer the 10 questions and understand yourprocesses: the use of a shift diagram, structured observations and structured interviews. Othertechniques might be helpful, such as the use of video (information on this is available on ourwebsite at www.safetyandquality.gov.au). The use of surveys as a primary investigative tool is notencouraged as there are limitations in the richness of information which surveys generate.3.3.1 Shift diagramMaking a shift diagram will help the project team gain an understanding of how their organisation,ward or unit’s shift structure affects handover processes.Figure 4: Sample shift diagramMorning handover:0800hrs to 0830hrsEvening handover:1630hrs to 1700hrsNight handover:2130hrs to 2200hrsDay shift (4 teams)Extended shift (1 team)Night shift (1 team)0800hrs0830hrs1630hrs1700hrs2130hrs2200hrs0800hrs0830hrs(next day)20 OSSIE Guide to Clinical Handover Improvement

3.3.2 Structured observationsObservation sessions should be performedto study the handover process. Video hasbeen successfully used for observations andit creates data that engages staff (Iedema etal, 2009). Observations can also be recordedusing pen and paper.Below are some matters that should beconsidered by the project team, as well as a listof variables that should be collected during theobservation of a handover.Table 1: Data to be collected duringobservationsCommon data to be recorded in eachwork domain where clinical handover isobserved:a. The standard time(s) of the day forhandoverb. The location(s) in the work area wherehandover is conductedc. The participants in handovercommunication (e.g. outgoing andincoming staff)d. The length of time taken for handover (e.g.in minutes)e. Whether a common structure or set of rulesis employed (e.g. read-back)f. The quality of the information transferred(e.g. clarity, brevity and thoroughness)g. Other topics discussed at handoverh. The level of interaction between staffmembers (e.g. do new clinicians askquestions and receive responses?)i. The functionality of tools used (e.g.electronic media, checklists, handoversheets)Clinician observer vs non-clinicianobserverClinician observers provide the benefit ofunderstanding the current system and languageused. However their views may be biased.Non-clinician observers, on the other hand, maynot be accepted by the unit and/or individualswithin it and they may face difficulties inunderstanding the culture and terminologyused. It should be noted that clinician observerswill need to be given an allocated time forobservations when they are not participating inhandover.Number of observations requiredThe number required is highly variable.However, at least 10 observation sessions aregenerally required for a single ward to enablethe project to reach a clear understanding of therange of existing practices.OSSIE Guide to Clinical Handover Improvement 21

3.3.3 Structured interviewsBelow is a list of suggested interview questions.Interviews will reveal clinicians’ perceptionsof handover process and content. They mayalso serve to engage clinicians to participatein the change process. Interviewees must begiven opportunities to describe the currentprocess and to make suggestions for futureimprovements.The number of interviews required is highlyvariable. However, it is recommended that fora single ward a number of interviews shouldbe conducted with staff at all levels of seniorityand all specialities involved in or affected by thehandover process. The main themes should beidentified from the responses to each questionand an analysis and summary should beprepared to share with the team and others.Table 2: Interview questionsSection 1 – Perceptions of clinicalhandover1. What is your definition of clinical handover?2. What are the functions of clinicalhandover?3. What do you think the transferring ofresponsibility and accountability duringhandover means?Section 2 – Handover processes inrespective departments1. Can you please discuss how handover iscurrently conducted in your department?2. What do you think are the positive aspectsof your current handover process?3. What do you think are the negative aspectsof your current handover process?4. How do you think your current handoverprocess could be improved?5. What information do you require forcontinuity of patient care during your shift?6. How could information technology help youwith handover?Section 3 – Handover education andtraining1. How did you learn how to do handover?2. How do you think handover should betaught?Section 4 – Patient, family and carerquestionsThese questions should be designed bythe team to be relevant to the specific unit,as the roles of patients and families in bothhandover and engagement in care processesare highly variable (for instance, a spinalrehabilitation unit versus a neonatal intensivecare versus an emergency department).Patients may be affected by handover evenwhen the handover is not at bedside. Forinstance, they may notice being checked onin preparation for handover or complain aboutstaff absence during handover.Some examples of questions for patients,families and carers, which could be tailoredfor use, include:1. How do staff work together to care for you?2. How effective do you feel thecommunication is between doctors andnurses regarding your care?22 OSSIE Guide to Clinical Handover Improvement

With the information gleaned from the shiftdiagram tool, structured observations andinterviews, the team should then complete thefollowing three tools: the risk assessment, thehandover process guide and the handovercontent guide.3.3.4 Risk assessmentThis risk assessment should determine currentproblems with handover and potential risks ofcurrent practice for patient safety. Consider thefollowing five points when conducting the riskassessment:a. For each handover scenario, describe whatclinicians do, based on the informationgathered through observation sessions.b. Identify for each handover scenario specificways that the process could break down orfail due to gaps in handover.c. Identify and analyse how such gaps areidentified (or not identified).d. State the effect of the breakdown oninformation, responsibility and accountabilitytransfer.e. Identify what clinicians do to recover fromdiscontinuities in handover.3.3.5 Handover policy and processguideIn order to ensure success in clinical handoverimprovement, clinical handover must be seenas a priority and part of the duty of care ofhealthcare professionals. Each institutionmust therefore ensure good current handoverpolicy is in place. The handover policy must bedistributed to all clinicians and compliance tothe policy must be ensured. It is important tounderstand whether the current policy supportsclinical service needs.The project team should develop and completea summary table, similar to the one on thefollowing page. This table aims to assist theproject team to gain an understanding ofany current relevant policies and proceduresavailable, as well as clinician perceptions andobserved practice.‘We talk very much about the transferof information but what this hasbrought along is the emphasising andmarketing of that notion of transferringresponsibility.’Participant, November 2008 clinical handoverworkshopExamples of risks or problems include:● insufficient staff to do handover and attend topatients● lack of clear understanding of emergencyresuscitation process during handover● participants not being available● participants being distracted● incomplete information provided● required documents not being available● no opportunity for clarification● the incoming team not understanding oraccepting accountability for care.OSSIE Guide to Clinical Handover Improvement 23

Table 3: Understanding the process of handoverDomain and issues Policy Perception fromstaffFactors which mayinfluence handover:• environmentalfactors such asinterruption and shiftoverlap• informationexchange• human performance.Is there a policy tominimise the impactof various factorson the effectivenessand efficiency ofhandover?What do staff thinkabout these factors?Do staff understandpolicies relating tothese factors?What do staff thinkthey do to minimisethe impact of thesefactors?Real-life practiceWhat are the impactsof these factors onhandover?Has policy in placebeen followed?Do staff developcertain practices(‘work-arounds’) toavoid the impacts ofthese factors?Tools to assist thehandover process:• flow charts• posters• documentation ofeach shift.Is there a policy forthe utilisation of toolsto assist the handoverprocess?Is there a policy forauditing the handoverprocess?What do staff thinkabout tools to assistthe clinical handoverprocess?What tools do staffneed/utilise forhandover from theirperspective?What tools are utilisedto assist the clinicalhandover process?Are handover toolsavailable all the time?Is there any feedbackto staff regarding theprocess?The environment forhandover:• Is there a fixedvenue?• Is there a fixedtime?• Who attendsand who leadshandover?Is there a policy onthe venue, time andduration for handover?Is there a policyfor attendance athandover?Is there a policy forleadership duringhandover?What do staff thinkabout the location,time and duration ofhandover?What do staff thinkabout attendance athandover?Is there a clear leaderduring handover?Are the time,duration and venueof handover clearlyunderstood?Is there a consistencyin attendance?Does the leaderensure theeffectiveness andefficiency of theclinical handoverprocess?Handovercharacteristics:• type of handover• content• opportunity forclarification.Is there a policy forthe type of handoverrequired during eachshift?Is there a policyon the agendaitems/checklists forhandover?What do staff thinkabout the type ofhandover which iscurrently being used?What do staff thinkabout content forhandovers?Is there anyconsistency in thetype of handoverconducted for eachshift?Is there anyconsistency in theformat of handoverprocess?Is there anyopportunity forclarification?24 OSSIE Guide to Clinical Handover Improvement

Case study: Royal Hobart Hospital & University of Tasmania projectThe clinical handover project at the Royal Hobart Hospital and University of Tasmania involvedthree clinical areas: General Medicine, General Surgery and Department of Emergency Medicine.This case study describes how information obtained from the first phase assisted the developmentof standardised clinical handover solutions for the Department of Emergency Medicine. Therewas a total of 20 observation sessions and 16 interviews with interns, residents, registrars andconsultants. Furthermore, 50 patient handover messages were analysed.Table 5: Handover in the Emergency DepartmentDescriptionThe Department of Emergency Medicine at the RoyalHobart Hospital looks after acute presentations of allpatients, including paediatric, adult care, women’shealth, mental health and trauma. The Department ofEmergency Medicine differs from other clinical areas,especially with regard to the complex, dynamic andintensive nature of the communication required inhealth care delivery.The Department of Emergency Medicine looks aftermany patients at any one time. Many patients are sickand have the potential to deteriorate rapidly, requiringrapid interventions.There is a common working area in the middleof the department, allowing constant interactionand discussion where necessary. Patients at theDepartment of Emergency Medicine require continualon-the-ground care by medical officers.Shifts of medical officers in the Department ofEmergency Medicine are staggered in order to meetthe demand for medical care over each day. Handoverof patient care is only accepted by senior medicalstaff. Junior medical staff start their shift seeing newpatients.The main task of the Department of EmergencyMedicine is to determine whether the patient willrequire inpatient care, or whether a diagnosis can bereached and a management plan derived in order todischarge the patient from the hospital.There are three main clinical handover sessionsper day, regardless of the day of the week. Thesehandover sessions are mainly concerned with thesenior member of the team handing over to the othersenior member of the incoming team starting the newshift.Some of the junior medical officers finish at 1700hrsand there is no formalised handover at that time.Handovers from junior doctors at the end of their shiftare highly variable due to a lack of dedicated receiversof these handovers. Some junior doctors are notfamiliar with the handover policy while others mightnot have informed the person accepting handoverabout the transfer of responsibility and accountability.Many doctors stay beyond the end of their shift inorder to sort out their patients rather than handingover to other doctors. The nature of emergencydepartment (i.e. busy department with multipleinterruptions) affected the nature of handover.How does it affect handover in theDepartment of Emergency Medicine?The standardised information transfer (minimumdata set) must be flexible enough to accommodatemany different clinical scenarios.The handover process must ensure the transferof the most recent patient care requirementsand preparation for handover should only occurimmediately before the handover.The handover process must be efficient andbrief in order to ensure good patient care. Seniorclinicians who accept handover of patient caremight already have some knowledge about thepresentation of the patient.It is inappropriate to take most medical staff awayfrom the clinical area for handover.Junior medical officers who start after the mainhandover session will not need to know aboutother patients in the department.The outgoing team is handing over the patientpermanently to the incoming team. Therefore,handover in the Department of EmergencyMedicine must be thorough and concise inorder for the incoming team to accept the fullresponsibility and accountability for the patient.This includes clearly communicating the dischargeplan for the patient or whether the patient hasbeen accepted by an inpatient team.The standardised handover solution is thereforespecifically designed to achieve improvementin that particular area as a matter of priority. Itis anticipated that the standardisation processmight spread to other areas over time. The mostimportant emphasis of the standardised handoverprocess must be the identification of a receiverof ongoing responsibility and accountabilityfor patient care. The senior colleague mustunderstand that they are receiving responsibilityfor patient care and have the ability to do so atthat time, rather than just providing advice andguidance.This is only possible through commitmentdemonstrated by staff to patient care. Theproposed standardised solution must allow thisflexibility to continue in order to best suit theworking environment.

Simple solutiondevelopment – Phase 24.1 Objectives of this phase4.2 Developing the solution4.3 Tools and techniquesOSSIE Guide to Clinical Handover Improvement 27

The next phase is the development of asimple solution for improved handover whichincorporates the principles outlined in thischapter. By the end of this phase, the projectteam will have set a date for implementationand have all the tools ready for theimplementation of the standardised solution.The standardised solution should includestandardised content and process and it shouldincorporate local context.Health care processes can be divided intothose that are repetitive, routine or non-routine(Lillrank & Liukko, 2004). Clinical handover isan example of a routine process, being similarbut not identical every time. Routine processescan be defined and improved by the use ofchecklists and best practice guidelines thatstandardise while leaving room for situationalvariation. Standardisation means informationcan be conveyed more efficiently and withhigher reliability.In most high reliability organisations, however,emphasis is on delivering the most importantinformation first, rather than on a fixed structurefor communication (Patterson, 2008). Thissuggests that in health care it is importantthat handover standardisation is not allowedto minimise the focus on what clinical expertsdeem the most critical information.4.1 Objectives of this phaseIn this phase the project team will:● ensure the standardised handoversolution developed is patient-centred andpractice-centred● engage clinicians in the design of astandardised handover solution whichincludes process and content transfer● engage clinicians in the design of informationtools to assist implementation.4.2 Developing the solutionUser-centred designThis simple solution development phaseshould engage and involve as manyclinicians as possible to create a collaborativeatmosphere among staff and ensure that thedesign is user-centred. During this phase, allcomments and recommendations should betaken on board. The project team will thenneed to balance conflicting views and theavailability of resources to achieve the optimaloutcome. Methods to involve staff may includecollaborative design workshops, consultationsand voluntary trialling of processes andstandardised content formats.Process flow chartThe first step in designing the improvedstandardised clinical handover process is todevelop a flow chart of the current handoverprocess. This should be compared with theprinciples for handover presented in thischapter. From this comparison the gaps andstrengths should be identified and a revisedhandover process developed.Process and information toolsOnce the team has developed the newprocess for handover that meets local needs,information tools should be developed to helpclinicians change their practice. For example,written handover sheets can be developed thatincorporate the new process. Posters, memoryaids and guidelines can be displayed in placeswhere they will be noticed and read. Suchinformation tools should be easily available andshould be used at every handover session.28 OSSIE Guide to Clinical Handover Improvement

Principles for handoverPrinciple 1: Handover requirespreparationHandover requires preparation prior tohandover time. Clinical handover has to bevalued as one of the top priorities in clinicalwork. It is vital that clinicians understand thisand remind each other of the importance ofclinical handover for safe patient care.Allocating staff for continuity of patient careDuring handover it is essential that emergencypatient care is delivered by staff. Clearallocation of staff members is essential toreduce disruptions and ensure safe patient careduring handover.Nominating participants, time and venueThe attendance of key staff should bedetermined. This should include incomingand outgoing team members who are directlyresponsible for the care of the patient to behanded over. The handover process shouldhave a clear starting time and a venue whichprovides minimal disruptions.Obtaining the relevant documentsPrior to handover the clinicians should obtainand update necessary documents. This mayinclude name lists, handover sheets andelectronic handover forms and may alsoinclude checking observations or results. Thisguide recommends that verbal handover becomplemented by documentation. All essentialinformation should also be clearly documentedin patient progress notes. An example of ahandover sheet is included in this chapter.Principle 2: Handover needs to be wellorganisedClear organisation for handover will ensure theeffectiveness and efficiency of the process. Thisinvolves:Making sure all participants have arrivedClinicians should be provided with paid andprotected time to attend handover. Punctualityduring handover sessions is important andshould reflect the professionalism of cliniciansinvolved.Electing a leaderThe handover of patients during a shift changeshould be supervised by a designated leader.This is usually the role of the most seniorclinician present. The leader should ensure thatall relevant communication items are covered ina timely manner.Principle 3: Handover should provideenvironmental awarenessClinical handover should inform the incomingteam of any environmental issues which mightimpact on their shift.Alerts, attention and safetyHandover should include notification aboutpatients who might require significant levels ofcare or immediate attention; are deteriorating orwho might deteriorate; or present occupationalsafety issues. Information should be providedabout the condition of the work environment(e.g. plumbing problems) that may impact onsafety. Potential patient movements shouldbe highlighted so that incoming teams candevise plans to manage their workload. Staffingnumbers and arrangements may also need tobe described.Principle 4: Handovers must includethe transfer of accountability andresponsibility for patient careThe handover of individual patients must beachieved through a standardised contentdelivery. Structures for individual patienthandover (minimum data sets) are providedin this chapter, which may be adapted to thelocal context. It is important to emphasisethat standardised individual patient handovermust ensure the transfer of responsibility andaccountability.Minimum data sets have successfullyimproved face-to-face, telephone and tapedhandover. However, this guide emphasises thatface-to-face handover is the preferred optionwherever possible as it allows for interactionand clarification during handover.Several of the mnemonics piloted as part ofthe National Clinical Handover Initiative arepresented in this chapter. There is no evidencethat any handover mnemonic is better – thatis, more able to ensure patient safety – thananother.OSSIE Guide to Clinical Handover Improvement 29

4.3 Tools and techniquesThe principles presented in the previous sectioncame from a mnemonic for handover which wasdeveloped by Royal Hobart Hospital and theUniversity of Tasmania.The principles and the minimum dataset ISOBAR can be combined to form astandardised process and content set forhandover called ‘HAND ME AN ISOBAR’ whichis presented in the flow chart below.HAND ME AN ‘ISOBAR’HANDPrepare forhandoverHey, it is handover time,an important clinical task.Allocate staff for continuity ofpatient care.Nominate participants,time and venue.Document by using handoversheet.MEOrganisehandoverMake sure all participants havearrived.Ensure leadership is providedduring handover.ANProvideenvironmentalawarenessAlert to special patient needs orrisks and environmental issuesin the ward.Notice patient and staffmovements and numbers.ISOBARIndividualpatienthandoverIdentificationSituationObservationsBackgroundAssessment and actionResponsibility30 OSSIE Guide to Clinical Handover Improvement

‘ISOBAR’‘ISOBAR’ refers to:I = IdentificationS = Situation and statusO = ObservationB = Background and historyA = Assessment and actionsR = Responsibility and risk managementI = Identification of patientThis step, which ensures patients are correctlyidentified, should include three identifiers: forexample, patient name, date of birth and medicalrecord number.S = Situation and statusThis step includes the patient’s current clinicalstatus (e.g. stable, deteriorating, improving),advanced directives and patient-centred carerequirements including the prospect of dischargeor transfer.O = ObservationThis step ensures the incoming team is informedof the latest observations of the patient andwhen they were taken. It serves as a checkingmechanism to identify deteriorating patients foremergency response assistance. Unit membersneed to be aware of local emergency responsecall criteria and process.Why introduce ‘O’ for observation?In some handover mnemonics, observationis included under ‘S’ (i.e. situation). However,handover research in several Australianstates showed that ‘old’ or inaccurateobservations were frequently handed over.There are numerous reported cases whereassistance was not called for patients whosuffered serious deterioration or death.Observations were sometimes recordedover a long period of hours, including acrossshift handover, that should have prompted acall for assistance. The explicit introductionof ‘O’ is therefore designed to ensure that ifpatients meet call criteria for an emergencyresponse team or process that handover atleast will trigger that call.B = Background and historyThis step provides the incoming team with asummary of background; history (the presentingproblem, background problems and currentissues); evaluation (physical examinationfindings, investigation findings and currentdiagnosis); as well as management to date andwhether it is working.A = Assessment and actionsThis step is to ensure that all tasks and abnormalor pending results are clearly communicated.Most importantly, there must be an establishedand agreed management and escalation of careplan, which could include:● a shared understanding of what conditionsare being treated or, if the diagnosis is notknown, clear communication of this fact toeveryone● tasks to be completed● abnormal or pending results (must includerecommendations and the agreed plan andwho to call if there is a problem)● a plan for communication to the senior incharge● clear accountability for actions.R = Responsibility and risk managementClinical handover must include the transfer ofresponsibility as staff are leaving the institution.This can only be achieved through acceptanceof tasks by the incoming team, which is bestensured by face-to-face handover. Whererisks are identified for a patient, clinical riskmanagement strategies (such as for infectiousdisease alerts or alerts for DVT prophylaxis)should be clearly communicated.● Responsibility transfer and task acceptanceideally includes accepting handover sheetsor signing of handover sheets.● Readback of critical information is helpful,especially in situations where face-to-facehandover is not possible.● Risks and management plans should beincluded in handover when required.OSSIE Guide to Clinical Handover Improvement 31

‘iSoBAR’iSoBARidentify – Introduce yourself and yourpatientSituation – Why are you calling?Briefly state the problemobservation – Recent vital signs andclinical assessmentBackground – Brief relevant historyAgree to a plan – Given the situationwhat needs to happen? What do youwant?Readback – Confirm sharedunderstanding. Who is doing what andby when?iSoBAR – where ‘i’ stands for identify (andincludes the clinicians involved in the handoveridentifying themselves), ‘A’ stands for ‘Agreeto a Plan’ and ‘R’ stands for ‘Readback’ – wasused for the National Clinical Handover Initiativeproject led by the Western Australia CountryHealth Service and Royal Perth Hospital.iSoBAR was initially developed for use duringinter-hospital transfer, where handover occurredover the telephone, accompanied by transferdocumentation. iSoBAR is now in use acrossmany handover scenarios in Western Australiaas it proved easy to adapt and integrate intoexisting work processes.iSoBAR lanyard card‘ISBAR’ISBARIntroduction – I amSituation – What’s going onBackground – Brief relevant historyAssessment – What I think ishappeningRecommendation – What you areasking them to doISBAR was adapted for use in the NationalClinical Handover Initiative project ‘ISBARrevisited: Identifying and Solving BARriers toEffective Handover in Inter-hospital Transfer’,carried out by Hunter New England AreaHealth Service.Hunter New England Area Health trialled theuse of ISBAR for inter-hospital transfer. Theclinicians who used ISBAR as part of theirpilot reported that it was simple, memorableand portable. Staff had increased confidencein giving and receiving clinical handover andaudits of medical charts indicated that thequality of information improved. ISBAR was wellreceived and continues to be used across theHunter New England Area Health region.REMEMBERISBARClinical conversations should be clear, focussed andthe information relevant.Poor communication risks patient safety and contributes to adverseoutcomes.I – Introduction“I am……………. (name and role)”“I am calling from …………………..”“I am calling because……………….”S – Situation“I have a patient (age and gender) who isa) stable but I have concernsb) unstable with rapid/slow deterioration”“The presenting symptoms are………….”B – Background“This is on a background of…………”(give pertinent information which may include:Date of admission/ presenting symptoms/ medications/recent vital signs/test results/status changes)A – Assessment“On the basis of the above: The patients’ condition is ……….. And they are at risk of ………. And in need of …………..”R – RecommendationBe clear about what you are requesting.e.g. “This patient needs transfer to/review ………Under the care of…..In the following timeframe …………”HNEH Clinical Governance ISBAR Poster Printed October 2008 For further information ring Clinical Governance on 49214168ISBAR poster32 The OSSIE Guide to Clinical Handover Improvement

‘SBAR’SBARSituation – What is the situation?(Chief complaint, current status)Background – What is the clinicalbackground? (Previous history)Assessment – What is the problem?(Results of assessment, vital signs andsymptoms)Request/recommendation – Whatdo I recommend/request to be done?(Suggested and anticipated changes,critical monitoring)Note: the text inside the brackets relates tothe variation on SBAR used by the ‘BedsideHandover and Whiteboard Communication’project.A structured communication algorithm, SBARhas been popularised and supported by KaiserPermanente in the US and by the US JointCommission.SBAR stands for:S = SituationB = BackgroundA = AssessmentR = RecommendationThis mnemonic has been used in manycommunication situations, including in healthcare for executive briefings or incident reports,but also in many non-health situations such asmilitary briefings.When SBAR is used for handover, patientand healthcare-specific detail is typicallyadded to the four communication elements(Haig et al, 2006). The expansion of SBARwith disease-specific, age-specific orcircumstance-specific agreed data sets hasbeen recommended (Webster, 2008).Many variations of SBAR have been developedto support handover, including adaptation foruse by the following National Clinical HandoverInitiative teams:● ‘TeamSTEPPS TM ’, South AustralianDepartment of Health Clinical Systems Unitand South Australian Health Services● ‘Bedside Handover and WhiteboardCommunication’, Griffith University ResearchCentre for Clinical Practice Innovation,Queensland Health Patient Safety Centreand Peel Health Campus, Western Australia● ‘The PACT Program – CommunicationTraining and Team Training to SupportHandover’, Albury-Wodonga Private Hospital– Ramsay HealthcareThe PACT Program piloted at Albury-WodongaPrivate Hospital used two SBAR communicationtools to standardise and facilitate shift-to-shiftand nurse-to-doctor communication. Nurseswho participated in the pilot believed handoverhad improved and 80% felt more confident whencommunicating with doctors.SSituationBTime and Date :………………………………… Identify yourself Identify your Unit Give the patient’s name State current patientlocation Briefly state the problem Identify when it happened /startedD.O.B. _______/__________/_________ Sex __________Affix patient labelProblem ……………………………………………………………………..………………………………………………………………………………..………………………………………………………………………………..State severitySevere Very concerned Concerned Controlled Name of professional being contacted……………………………………………….…………………….…………Number called / contact reached (eg mobile / pager)…………………………………………....................................................Number and time of attempts made to reach person being called……………………………………………………………………………….Information could include:Admitting diagnosis /operation …………………………………………………………………………...........……………………………………………………………………………………………………………………...Date of admission ……………………………………………………………………………..…………………Most recent vital signs BP ………………. HR ……….………Temp ……………………..Pain Score …………… RR ……………… SaO2 …………… Urine output ……………..Pt on oxygen? Yes No Litres / min…………. IV Fluid …………………………………………Test Results ……………………………………………………………………………………………………..………………………………………………………………………………………………………………..........Pt mental state ……………………………………………………………………………………………..........Assessment of skin / extremities ……………………………………………………………………………….Your assessment should be concise, clear, assertive, and factualA………………………………………………………………………………………………………….................………………………………………………………………………………………………………….................………………………………………………………………………………………………………….................………………………………………………………………………………………………………….................……………………………………………………………………………………………………………………...I suggest / request that:RExamples of……………………………………………………………………………….recommendations may ……………………………………………………………………………….include:Does Dr want a response back – what parameters do they wish to be Pt needs to be seen now notified about – phone number to contact and time Order change………………………………………………………………………………. Transfer to alternate facility ………………………………………………………….............................. Request for tests needed Doctor’s Orders / comments ……………………………………………. Talk to the patient and/or ………………………………………………………………………………..family………………………………………………………………………………..………………………………………………………………………………..………………………………………………………………………………..Outcome: ……………………………….……………………………………………………………………….……...……………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………..Print Name: ………………………………….. Signature: ………………………Designation: ………………….BackgroundAssessmentRecommendationsSBARCOMMUNICATION TOOLUnit Record No. _____________________________________Surname __________________________________________Given Names _______________________________________SBAR COMMUNICATION TOOL MR 126SBAR communication toolOSSIE Guide to Clinical Handover Improvement 33

‘SHARED’SHAREDSituation – Reason for admission/phone call; change in condition;diagnosis-specific informationHistory – Medical; surgical;psychosocial; recent treatment;responses and eventsAssessment – Results; blood tests;X-rays; scans; observations; severity ofconditionRisk – Allergies; infection control;literacy/cultural; drugs; skin integrity;mobility/fallsExpectation – Expected outcomes;plan of care; timeframes; dischargeplan; escalationDocumentation – Progress notes; carepath; relevant electronic health; record/databaseSHARED was adapted for use by the NationalClinical Handover Initiative project, ‘SHAREingMaternity Care – Clinical Handover betweenVisiting Medical Officers and Midwives’, MaterHealth Services Brisbane Limited.The SHARED framework was piloted withinthe Mater Mothers’ Private Hospital and MaterPrivate Hospital Redland. It sought to addressthe communication issues associated with thecritical time around the following clinical pointsof care: referral from the midwife to the visitingmedical officer (VMO) when a change in thewoman’s condition is diagnosed; and referralfrom the VMO to the recovery nurse/midwifepost-Caesarean section.This project found that a standardised approachusing SHARED to define the minimum datasetcan improve the accuracy and appropriatenessof information exchanged.At every clinical handover, ensure you have...Who you areWhy you are communicatingWho you are communicating aboutSITUATIONRelevant to current presentation;observations, tests, assessmentsand resultsASSESSMENTWhat needs to be doneIn what timeframe and by whomAs well as anticipated responsesand outcomesEXPECTATIONSI O NI T U A THISTORYASSESSMENTRISKEXPECTATIONI O ND O C U M E N T ATHISTORYRISKDOCUMENTATIONImportant information relevantto patients’ current presentationImportant and relevantinformation to keep the patientsafeImportant and relevant informationwritten down in appropriateclinical recordSHARED poster34 OSSIE Guide to Clinical Handover Improvement

The table below is an example of how the handover process can be adapted to local conditionswhile still introducing standardisation. This guideline was developed by Royal Hobart Hospital,Department of General Internal Medicine.Table 6: A sample local process guideMorning medical clinical handover order of proceedingsSTEP 1STEP 2Establish the clinical handover leader‘Capping’ systemi. Establish patient numbers of ‘on-take’ units and each unit.ii. Highlight if the ‘Capping’ system is to be activated.iii. Refer to the ‘Capping’ guideline for patient allocation.Note that ‘Capping’ is a local strategy to manage workload.This is an example of flexible standardisation.STEP 3STEP 4STEP 5STEP 6STEP 7STEP 8STEP 9Note forMondayHighlight definite or potential consults to advanced traineeNight registrari. To present cases which might need specialty input first.ii. Other new admissions.iii. Consultations from wards.Medical seniori. Night medical senior to present admissions to be ‘handed back’ under the12 months guidelines.ii. Evening medical senior.iii. Please state the UNIT, CONSULTANT, WARD, URN clearly at the beginningof the presentation.Night interns and potential consultsIssues on the ward overnight, especially unstable patients.Unknown or incorrectly listed patientsEach unit to check and notify ‘unknown’ patients or ‘incorrectly listed’ patients.Mortality within the last 24 hoursi. Report of mortality within the last 24 hours (or over the weekend).ii. Please report the unit and URN of the patient.iii. Reminder to interns to forward the case notes to Department of GeneralInternal Medicine.Noticesi. Staff absence to be reported.ii. Reminder for meeting scheduled for the day.iii. Other notices or issues arising.Start with handbacks from Friday on-take unit, followed by Saturday and Sundayhandbacks, and then follow the above agenda.The protocol has clearly set out the steps required to achieve good handover. It includesestablishing a leader, alerts and notices as well as individual patient handover. As part of theworkload planning and management of this particular unit, however, the clinical handover protocolincludes a ‘Capping’ system, which allows units to hand over patient care to other units in orderto balance the workload among different units. This protocol also includes a section to identify‘unknown’ or ‘incorrectly listed’ patients in order to ensure clear delineation of the responsibility ofcare for each patient.OSSIE Guide to Clinical Handover Improvement 35

Table 7: Paper form to assist staff to practise standardised and better handoverClinical handover sheet UNIT:Are you prepared for handover?Are we ready and is the leader present?(Sick patient requiring attention, special instruction, any equipment or staffingproblems etc.)I (dentify)S (ituation)O (bservation)B (ackground)A (ssessmentand action )R (esponsibility)URN, nameand location(or sticker)RememberMET criteriaHistory,evaluation,treatment todateActionrequired, whoto call if thereis a problemAcceptresponsibility,questionsand provideclarification36 OSSIE Guide to Clinical Handover Improvement

Stakeholderengagement – Phase 35.1 Objectives of this phase5.2 Engaging stakeholders5.3 Tools and techniquesOSSIE Guide to Clinical Handover Improvement 37

Stakeholders are individuals or groups who areinterested in an issue. In health care settingsmany stakeholders will be materially affectedby changes to handover. However, theirengagement is essential to ensure the successof the project.Although many of the activities in Phase 1 –organisational leadership – include stakeholderengagement, this chapter provides moreguidance to the project team.5.1 Objectives of this phaseIdentifying and engaging with all relevantstakeholders is the key objective of this phase.This includes:● ensuring stakeholders understand theobjectives of the project and their respectiveroles● empowering staff to participate● ensuring the sustainability of clinicalhandover improvement through thecontinued commitment of all stakeholders tothe improvement process.‘The issue is really getting the people whodon’t think it’s all that credible or don’tquite get the concept and trying to gettheir attention. Making them think abouthow to improve things. That’s a slightlydifferent issue than the process.’Participant, November 2008 clinical handoverworkshop5.2 Engaging stakeholdersIdentification of stakeholdersFrom the beginning of the project, the needsand contributions of the following groups ofstakeholders should be considered by theproject team:● the financial support/funding body● advisory team members such as a steeringcommittee and reference groups● the support team, such as managers andheads of department● all clinicians● patients and carers● external stakeholders, such as otherinstitutions which have successfullyimplemented solutions or researchorganisations.While all stakeholders who are interestedin clinical handover improvement shouldbe encouraged to participate in the project,some stakeholders are powerful within theorganisation and may wish to promote specificagendas which may be in conflict with the aimsof clinical handover improvement.Individuals who are already working on clinicalhandover projects may feel threatened bya new project. It is therefore essential thatthe project team consider strategies such asinformal discussions, good project managementstructure and identification of opportunitiesfor collaboration, in order to develop a sharedcommitment for clinical handover improvement.Front-line staff often feel disempowered whenchange is ‘top-down’. Staff empowerment willalso be important to create an environmentwhich encourages problem solving and rapidadoption of best practice.Professional development requirementSome clinicians who are supportive of handoverimprovement might feel that they lack certainskills to fully engage and be involved in theproject. Professional development opportunitiesshould be provided for interested clinicians, suchas improving skills in leadership, education,training and risk management in order for themto be fully involved in the project. Six hoursof online education modules on handoverdeveloped by the University of Queensland areavailable on the Commission’s website.TrustClinicians are highly trained professionals whoare proud of their contributions to the health andwellbeing of patients. They tend to take seriouslyany criticism and comments regarding theirperformance. Quality and safety initiatives musttherefore maintain trust by engaging cliniciansin a non-threatening way. This will involve takingtime to understand clinicians’ work and providingthem with reassurance that they are deliveringquality care, but that things can be done better.Communication strategiesMiscommunication is a real risk to the successof the project. Communication strategies suchas a website, emails, newsletters, pamphletsand workshops should be used. Whileelectronic media make it easy to meet continualcommunication needs, the message might notreach all staff. The project team should maintainregular face-to-face contact as the primarycommunication and stakeholder engagementstrategy.38 OSSIE Guide to Clinical Handover Improvement

Most stakeholders are busy so it is importantthat communication is brief. Stakeholders areoften involved in multiple projects or changeprocesses simultaneously. Therefore, eachproject update must provide adequate contextfor stakeholders to renew their commitment tothe handover project.Ideas for what might be communicated atproject updates:• the organisation’s decision andcommitment to improve clinical handover• the rationale for participation in the initiative• a description of the problem to beaddressed (inconsistent handovercommunication)• the proposed solution (standardisedhandover communication)• the costs and benefits of participation• incentives to clinical staff to participate• support and resource allocation from theorganisation.Updates and continual engagementIt is important that stakeholders receive regularupdates from the project team regarding theprogress of the project work plan, especiallyduring the early phases of the project. Shortface-to-face sessions during scheduledmeetings of staff are the most effective way ofreaching as many staff as possible. Feedbackfrom staff must be acknowledged and, ifnecessary, an action plan devised to deal withthe issues raised.The project team should ensure there is duerecognition of the contributions and successesof all staff and wards participating in theproject and that these are made public. Thiswill provide incentives to staff to continuallyimprove and champion the process. This mightinclude provision of refreshments at the end ofshifts, awards or certificates of appreciation orinvolvement of key staff in public presentations.Innovation and promotionThe communication and engagement processshould include innovative methods to promotethe project. These may include stationerywhich could be used for handover and patientcare, activities to raise awareness of theproject, activities to generate a sense of socialbelonging and team building activities.Change champions, including junior staff, areessential but they are often busy. Financialincentives, even if available, might not be anattractive incentive for them to participate in theproject. It is important to understand and deployincentives which will be most useful, such asopportunities for professional development liketraining courses for certain skills, conferencepresentations and paper submissions. Theseactivities may attract the participation ofchange champions by advancing their careerdevelopment.Case study: OSSIE in the EDThe Department of Emergency Medicineof Hospital D planned to undertakethe five steps of the ‘OSSIE’ Guide toimprove nursing handover. While theproposal had a high level of seniorsupport, the project officer found thatnurses on the ground were less thanenthusiastic.In order to engage nurses, the projectofficer used the following methods:• A series of photos were taken duringhandover time to attract attention.• Short face-to-face presentations weredelivered to nurses using the photosas the discussion point.• A weekly quiz regarding handover,with incentives, was organised for10 weeks to increase awareness ofthe project and handover as a whole.• Printed pamphlets and pens labelledwith ‘handover’ were distributed to allstaff.• Safety goggles were supplied to stafffeaturing ‘handover = safety’ stickers.These activities successfully engagednurses to participate in the clinicalhandover improvement initiative.OSSIE Guide to Clinical Handover Improvement 39

5.3 Tools and techniquesStakeholder engagement strategiesThe table below guides the project team through various stages of stakeholder engagement,including strategies the project team can use.Table 8: Stakeholder engagementStages Objectives StrategiesIdentification ofstakeholders and initialcontactProject briefing and initialengagementActive involvement andengagementMaintenance ofengagementTo ensure adequate representationfrom all relevant departmentsTo ensure stakeholders have thecapacity to contribute to the projectTo alleviate concerns regarding theprojectTo ensure clear understanding ofthe project’s scope, aims and likelyoutcomesTo ensure clear understanding ofroles and responsibilityTo generate a shared commitmentand understanding for the projectTo generate momentum for changeTo best utilise available expertisefor project successTo identify and involvechange champions for projectimplementationTo obtain feedback and commentsin order to identify problems earlyTo provide updates and progressfor proper project governanceTo maintain enthusiasm andcommitmentTo encourage active participationTo ensure dissemination ofoutcomes and successesTo acknowledge participation andcommitments from stakeholdersTo motivate stakeholders forcontinual improvementFace-to-face contactOpportunity for socialisationInformal contact first, followed byformal acknowledgementFace-to-face brief meetingSummary of the project available inprinted formatProject details (electronic or printed)available upon requestIncentives such as refreshmentsand stationery are useful to engagefront-line staffClear statement of what the projectis ‘not about’Selective identification andinvolvement of individuals whenrequiredProvision of incentives forchange champions e.g. certificateof participation, professionaldevelopment, presentations andpublicationsProvision of incentives for feedbackand comments such as a luckydrawRegular updates through printedor electronic media such asnewsletters, pamphlets andwebsitesBrief face-to-face sessions duringregular scheduled meetings suchas in-serviceInnovative ideas such as a weeklyquiz gameFace-to-face brief presentation withsenior management presenceFormal acknowledgement such asgrand rounds and certificatesAcknowledgement of wardinvolvement such as provision ofsafety equipment and teaching aids40 OSSIE Guide to Clinical Handover Improvement

Implementation– Phase 46.1 Objectives of this phase6.2 Implementing the solution6.3 Tools and techniquesOSSIE Guide to Clinical Handover Improvement 41

In this phase the project team will implement ahandover solution. Successful implementationwill require continued staff engagement aswell as the development of support materialincluding education, memory triggers andinformation tools. The implementation processshould ensure clinicians receive positivefeedback and successes should be celebratedwith the project team.6.1 Objectives of this phaseThe activities described in this chapter willassist the team to successfully implement thenew handover process. These activities are:● developing a project plan for implementation● delivering education and training programs tostaff● piloting and potentially revising the handoversolution● spreading the new handover process● establishing a continual learning strategy● developing innovative activities to ensuresuccess during implementation.6.2 Implementing the solutionThe project team should develop a plan forimplementation. The scale of the plan willvary considerably depending on the size ofthe planned implementation. A whole hospitalimplementation will be entirely different to oneinvolving a small unit and a single discipline orsub-discipline. A large scale implementationwill require consideration of governance, riskmanagement and the development of a workplan.The implementation phase is time consuming sothe project team needs to spread the workloadto other clinical champions in order to maintainenthusiasm for the project. The involvementof more than one clinical champion per unit orward is desirable. This will mean the resourcerequirements for individuals in the project teamare less intensive.The project team should also consider theresource requirement for staff time and othercosts, such as printing and engagementactivities.RisksThe project team should be aware of – anddevelop strategies to reduce – the commonrisks that can affect the success of handoverimprovement initiatives, such as:● unavailability of clinical team members● competing demands and interests of staff● inadequate resources● delayed delivery of information and supporttools● difficulty educating all staff.42 OSSIE Guide to Clinical Handover Improvement

Pilot implementationDespite all efforts to understand the localcontext, there can be unintended consequencesduring the implementation phase. So it isadvisable to pilot test the new handoverprocess and to revise the implementation planaccording to feedback from the pilot test.The following issues should be considered priorto pilot implementation:● Choice of clinical area and handoverscenarioIt is wise to start with a manageablehandover scenario and an area that hasenthusiastic leaders and staff.● Engagement of pilot clinical areasFull engagement of pilot areas is essentialand staff should be actively encouraged toparticipate in the plan for implementation.Engaged staff can become the ambassadorsfor full implementation and the spread ofhandover improvement to other areas of theorganisation.● Every shift versus specific shiftThe implementation team needs to considerwhether the new handover processshould immediately be applicable to allshifts/handovers or only to specific shifts/handovers. For instance, a shift-to-shiftstandardisation process might start with themorning shift, as the most number of seniorstaff are available at this time to assist withimplementation.● Meaningful evaluation and revisions asneededThe implementation process in the pilotareas should be measured and documentedclearly, including issues such as timelinessand consistency of implementation, anyimpact on other activities and the impact onpatient care. Feedback and evaluation fromstaff should be used to guide revision of theinitial process, contents or tools.Policy developmentThe handover solution must be clearlydescribed and embedded in unit (and/orinstitutional) policies. Such policies usuallydescribe management accountabilities andinclude a review date for the policy.Spreading the new processOnce pilot projects have been completed andfeedback has been incorporated, the newprocess should be spread to other units andwards using a staged approach. Staff from thepilot sites should be rewarded and their positivecomments should be documented and used aspart of any spread strategy (refer to chapter fiveon stakeholder engagement for examples andideas). Clinical leaders from pilot sites canassist with spread.Differences between wardsWhile the process and content of clinicalhandover might be similar, it is important thatobservations and interviews be done in allnew wards/units implementing the clinicalhandover improvement program. The numberof observations and interviews, however, couldbe reduced, as some lessons can be learntfrom pilot sites.The differences in handover practice as wellas technical capacity of different wards mayrequire adjustments to the new handoverprocess for the solution to be successfullyimplemented across multiple wards and units.Scope creepIssues identified during the handover projectare likely to be broader in scope than theintended objectives in this framework.Other quality and safety issues – such ascommunication problems, staff rosteringproblems, bed-blocks and bed managementissues – can overlap with handover, but arebroader in scope than the intended objectivesof clinical handover improvement. Theimplementation team and the project team willneed to be aware of scope creep and remainfocused on the specific area of handover.Intensive education and trainingprogramThe required amount of education and trainingwill vary, but these activities should involveall current staff (and potential staff, especiallywhere staff are on a rotation roster). Workingpatterns should be considered as it may bemore difficult to schedule training for part-timeor casual roster staff. Face-to-face training isrecommended but the project team shouldalso consider e-learning and ‘train the trainer’strategies.OSSIE Guide to Clinical Handover Improvement 43

The implementation phase must include intensive education and training programs forall staff. The program should provide enough information to allow the adoption of theprocess and the standard content delivery. The design of these educational programsshould be simple and competency-based. The following table outlines suggestedcontent for the education and training program.Table 9: Suggested content for clinical handover education and trainingPatient safety and medical errors• Medical errors are common.• Communication problems are one of the major causes of medical errors.• Patient safety requires systems interventions and a safety culture.• In a handover situation, standardisation is the systemic intervention.• The success of the process requires everyone to learn it, embrace it and encourageother people to follow it.Handover is a high risk area for patient safety• Local case study.• Some data and statistics from the literature (they should tailored to the local clinicalcontext, e.g. nursing versus medical, specific wards).• The lack of standardisation is the major risk of clinical handover.Handover is a priority for patient safety improvement, nationally andinternationally• Handover is a high priority area for patient safety improvement internationally.• Handover is a high priority area for patient safety improvement in Australia and is apriority for the Australian Commission on Safety and Quality in Health Care.• Discussion of current initiatives in this area.• Handover is a priority area for improvement within the local setting.The local standardised process for handover• Current handover process and problems associated with it.• The rationale for the new process.• The new standardised process of handover must be introduced in a step-by-stepmanner until all participants understand the process.The local standardised content for handover• Current content of handovers and problems associated with it.• The rationale for a standardised content transfer.• Introduction of the standardised content transfer.Techniques to improve communication/team work during handover• Any techniques which may be introduced, such as team work or communicationtechniques.Local implementation plan, including consideration for e-learning• Overview of implementation plan.• Date that it will start (be clear and specific).• Feedback and contact number for the team.44 OSSIE Guide to Clinical Handover Improvement

Collaborative learningAs the new handover process is spread to otherunits and/or scenarios, the project team shouldfacilitate opportunities where unit and wardstaff can share experiences and carry out somecollaborative learning. This could include:● Pilot site showcaseThe pilot team should invite staff who are aboutto commence implementation to visit wardsand units where implementation has alreadyoccurred. This provides opportunities forinterdisciplinary and interdepartmental learningas well as exchange of ideas.● Regular seminars by clinical championsOrganising regular seminars provided by clinicalchampions facilitates continual staff up-skillingand engagement. The seminars could includethe following topics:• feedback and continual evaluation from wardsand units• anticipated expansion and spread• success stories and experiences• problems and challenges faced• suggestions for future improvement.Promotional strategiesEngage staff during the implementation phasethrough marketing and branding strategies toensure widespread uptake. Consider activitiesthat celebrate success stories in order togenerate momentum for widespread adaptationof the standardised process and contents.Project promotion strategies could include:● distribution and posting of materials, such asbrochures, posters and lanyards● marketing and branding of the handovertools.Annual handover awareness campaigns forthe whole organisation should be considered.A re-audit of compliance should be undertakenand new processes rewritten if necessary.OSSIE Guide to Clinical Handover Improvement 45

6.3 Tools and techniquesIndividual work planThis is a detailed individual work plan for each site/clinical area that can be adapted for use by theproject team.Table 10: Individual work planOSSIETask name Duration StartdateDefine and assign a governance groupIdentify governance groupIdentify senior administrator ‘contact’ forresource decisionsAssign representatives individual groupsAssign facilitatorDevelop and approve a work planInitial draft of work planReview and revision of planApproval of the work planRisk assessment of the processIdentification & prioritisation of failurerisksProposal for adaptation or redesign ofthe processDevelop and approve a standardised processReview the initial draftRevision of standardised process ifnecessaryApproval of the processApproval of the tools to assistimplementationDevelop and approve standardised contentReview the initial draftRevision of standardised contentApproval of standardised contentApproval of information toolsDevelop a communication strategyInitial communicationUpdate newslettersOther communication platformsPilot test the processIdentify pilot test protocolSet a ‘go live’ dateEnsure all tools available for pilotDevelop an evaluation planStructure evaluationsProcess evaluationsContent evaluationsOutcome evaluationsDissemination of resultsInitial draft of maintenance planReview and revision of planApproval of the maintenance planFinishdateDependenciesResources46 OSSIE Guide to Clinical Handover Improvement

Evaluation andmaintenance – Phase 57.1 Objectives of this phase7.2 Evaluating the solution7.3 Tools and techniquesOSSIE Guide to Clinical Handover Improvement 47

An evaluation plan should be developedso the project team can measure andcontinue to improve handover practice duringimplementation.A maintenance phase is pivotal to thesustainability and long-term success of a clinicalhandover improvement project. It is importantthat this is not the responsibility of just oneindividual.The project team should ensure there areongoing resources and responsibilities toenable the project to continue regardless ofstaff turnover and promotions.There are many frameworks and strategiesavailable to guide the development of anevaluation plan. This chapter offers anapproach that builds on the measurementwork undertaken prior to implementation (forexample, the observations conducted duringPhase 1 – organisational leadership).7.1 Objectives of this phaseLocal context and flexible adaptation ofstandardised solutions continue to be importantconsiderations during the evaluation andmaintenance phase of clinical handoverimprovement. The five objectives in this phaseare to develop:● tools to evaluate the impact of the clinicalhandover improvement process● an evaluation framework and plan● strategies to disseminate evaluation datalocally● strategies for continuing education andtraining for relevant staff● strategies to maintain clinical handoverimprovement.7.2 Evaluating the solutionResources for the evaluation andmaintenance phaseThis phase requires significant resources andstaff time. Human resources are necessaryfor the continual engagement of staff and toensure a continual supply of support tools (e.g.brochures, posters). Once the clinical handoversolution has been implemented throughoutthe organisation, regular monitoring of keyparameters should continue for at least threeyears.The evaluation plan should include somemonitoring activities to ensure:● early identification of ‘drifting’ and ‘deviations’● identification of potential unintendedconsequences, such as increased data entrywork for staff, distraction from other tasksdue to additional time spent on handover andgaps in the patient record due to the creationof handover forms that are not integrated● that the handover solution is integrated withthe current clinical practice● that new improvements are incorporated asevidence and knowledge is gained in thearea of clinical handover.Pre-implementation andpost-implementation measuresComparing pre-implementation andpost-implementation data is a usefulmeasure for your handover improvementproject. Use the methods in chapter threefor collecting pre-implementation datato now collect the post-implementationdata and compare the results.Periodic analysis of evaluation data is requiredin order to revise the clinical handoversolution in keeping with the principle of flexiblestandardisation taught in this guide. Evaluationdata should be collected at a specificpre-defined interval (e.g. three-monthly).Evaluation contentThe following measures can be used in theevaluation plan:● structural measures such as demographicand structural data about units and theirhandover processes● process measures such as:– consistency and completeness in theperformance of critical steps in the newprocess– level of participation of staff as specified inthe process design– time for completion of the new handoverprocess– effectiveness (e.g. follow-up calls foradditional information or clarification)– efficiency measures for patient care (e.g.length of stay).48 OSSIE Guide to Clinical Handover Improvement

● content measures, including:– consistency and completeness of deliveryof required content– consistency of transfer of information,responsibility and accountability– efficiency of the content transfer● cultural measures, including:– staff and patient satisfaction.Learning from adverse eventsGaps in the continuity of patient care resultingfrom breakdowns at handover will not usuallycause harm, as a robust and resilient systemprovides other barriers to patient harm.However, it is beneficial to learn from adverseevents involving handover when they do occur.When examining the handover incident staffshould consider if the handover improvementsolution could be adapted to avoid or minimisethe risk of similar patient safety incidents in thefuture.Dissemination of evaluation dataThe evaluation phase should include theprovision of regular reports of aggregate andanalysed data to the governance group and toall staff to encourage future improvement.‘We always tend to debrief when there’sa problem, but [positive debriefing]reinforces the positive processes andpeople can learn what’s right and what’swrong.’Participant, November 2008 clinical handoverworkshopProvision of continual education andtraining for relevant staffWithin the clinical environment, there is oftena regular turnover of staff. All staff must beprovided with the knowledge and skills on theorganisation’s handover practices, prior tocommencement of employment.Continuing staff will also benefit from regularrefresher courses in order to continue deliveringbest practice and best performance. Theproject team should be aware of new researchon clinical handover so the team can updatetheir staff education and training packageaccordingly.What happens when the project is‘over’?This guide recommends that a plan isprepared for maintenance of clinical handoverimprovement. That is, that the project is never‘over’. However, it is not necessary to continuethe focus, resources and energy needed for thedesign and implementation of the standardisedprocess. In practical terms this means thatthe project team can be disbanded, but thestandardised process must be documented andbecome part of hospital policies.Maintenance and updating of the standardisedsolution is an organisational responsibilitythat will sit with a designated individual, aswill educating new staff on the new process.For a small unit, organisation and planningfor maintenance may be simple; for a largeinstitution, it may be necessary to plan ahead.This plan could include a ‘let’s look again athandover’ month every year or two, promotedand organised by senior management toencourage units to collect new data and updateor improve their processes as necessary.7.3 Tools and techniquesEvaluation techniquesDifferent data collection processes andtechniques can be used in this phase. Theproject should consider the pros and cons ofvarious techniques. Often a combination oftechniques can be beneficial. Some examplesinclude:● direct observations● interviews with participating staff● a retrospective audit of documentation● a prospective audit of documentation● incident reporting● mortality and risk estimation techniques● reflective methods, such as video-reflectiveethnographic methods (Iedema et al, 2009).OSSIE Guide to Clinical Handover Improvement 49

Table 11: A sample evaluation planMeasures Parameters Collection method Evaluation interval(sample answers)Structural measuresType of organisation(urban/rural; public/private;community/academic;etc.)Size of organisation (beds;visits)Specific types ofhandovers where aprocess has beenimplemented and numberof locations (e.g. numberof wards)Process measures% of staff that understandthe new process (practiceand theory)% of handovers completedaccording to new process% of handoversinterrupted% of handovers withoutneeded documentationAverage time for handoverand cost of this timeParticipant and patientsatisfactionOutcome measuresHave clinical errorsoccurred due toinsufficient information?Does analysis point to aspecific problem with ahandover scenario wherea new process has beenimplemented?Survey and/ordirect questioningof staffObservationObservationObservationObservationSurvey andinterviewObservationalIncident monitoringAfter training, then at3, 6, 12 monthsRepeated afteralterations to the newprocessWeekly for first monthand then monthlyWeekly for first monthand then monthlyWeekly for first monthand then monthlyWeekly for first monthand then monthlyMonthlyObservational work inhigh risk areas (e.g.ED, ICU) weekly forfirst month and thenmonthly.Incident monitoringReporting(sample)All staffRandomhandoversRandomhandoversRandomhandoversRandomhandoversMonthlyRandomshiftsContinuousNote: Parameters – must be determined by the institution and based on their observational workprior to implementing the handover solution50 OSSIE Guide to Clinical Handover Improvement

ConclusionAs mentioned in the previous chapter, theproject is never truly over and perhaps theOSSIE Guide should not end with a Conclusionbut a Continuation of OSSIE section. Handoveris a dynamic practice that can and should beallowed to change and evolve.The OSSIE Guide makes organising, carryingout and sustaining the improvement to clinicalhandover a manageable activity. The OSSIEframework helps the project team by breakingup the handover improvement project into astepped process of five phases with attainablegoals and associated work tasks. By ensuringlocal ownership and support at all levels of thehealth institution, OSSIE can help the projectteam to introduce improvements to handoverpractices that are not just grudgingly acceptedbut are met with enthusiasm.Introducing a change into clinical practiceis not easy. It takes a substantial amount oftime, resources and energy. Having said that,improving clinical handover is also an areawhere a determined local team has a realopportunity to make a positive impact andimprove patient safety.OSSIE Guide to Clinical Handover Improvement 51

ReferencesAustralian Commission on Safety and Quality inHealth Care. (2008). Windows into safety andquality in health care. Sydney: ACSQHC.Australian Medical Association. (2005). Nationalcode of practice: hours of work, shiftwork androstering for hospital doctors Australian MedicalAssociation Ltd.Australian Medical Association. (2006). SafeHandover: Safe Patients. Guidance on clinicalhandover for clinicians and managers [ElectronicVersion], from http://www.ama.com.au/web.nsf/doc/WEEN-6xFDKNBhabra, G., Mackeith, S., P., M., & Pothier, D. D.(2007). An experimental comparison of handovermethods. Annals of The Royal College ofSurgeons of England, 89(3), 298-300.Bomba, D. T., & Prakash, R. (2005). A descriptionof handover processes in an Australian publichospital. Australian Health Review, 29(1), 68-79.Chaboyer, W., McMurray, A., Johnson, J., Hardy,L., Wallis, M., & Chu, F. Y. S. (2008). Bedsidehandover: quality improvement strategy to‘transform care at the bedside’. 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AUSTRALIAN CHARTER OFHEALTHCARE RIGHTSThe Australian Charter of Healthcare Rights describes the rights of patients and other people usingthe Australian health system. These rights are essential to make sure that, wherever and whenevercare is provided, it is of high quality and is safe.The Charter recognises that people receiving care and people providing care all have important parts to play inachieving healthcare rights. The Charter allows patients, consumers, families, carers and services providing healthcare to share an understanding of the rights of people receiving health care. This helps everyone to work togethertowards a safe and high quality health system. A genuine partnership between patients, consumers and providersis important so that everyone achieves the best possible outcomes.Guiding PrinciplesThese three principles describehow this Charter applies in theAustralian health system.Everyone has the right to be able1 to access health care and thisright is essential for the Charter to bemeaningful.The Australian Government2 commits to internationalagreements about human rights whichrecognise everyone’s right to have thehighest possible standard of physicaland mental health.Australia is a society made up of3 people with different culturesand ways of life, and the Charteracknowledges and respects thesedifferences.For further information please visitwww.safetyandquality.gov.auWhat can I expect from the Australian health system?MY RIGHTSAccessI have a right to health care.SafetyI have a right to receive safe andhigh quality care.RespectI have a right to be shownrespect, dignity andconsideration.CommunicationI have a right to be informedabout services, treatment,options and costs in a clear andopen way.ParticipationI have a right to be included indecisions and choices about mycare.PrivacyI have a right to privacy andconfidentiality of my personalinformation.CommentI have a right to comment on mycare and to have my concernsaddressed.WHAT THIS MEANSI can access services to address myhealthcare needs.I receive safe and high qualityhealth services, provided withprofessional care, skill andcompetence.The care provided showsrespect to me and my culture,beliefs, values and personalcharacteristics.I receive open, timely andappropriate communicationabout my health care in a way Ican understand.I may join in making decisionsand choices about my care andabout health service planning.My personal privacy ismaintained and proper handlingof my personal health and otherinformation is assured.I can comment on or complainabout my care and have myconcerns dealt with properly andpromptly.

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