Clinical handover: critical communications

Handover is a ubiquitous feature of health care. At least 7 million handovers occur annually within Australian hospitals.1 At times, its very existence is almost unnoticed — many health professionals do not think of a telephone referral as “handover” — and at other times it is seen as a mundane chore that has to be done in addition to the “real” work of clinical staff. There can be complacency with current practices and little recognition of the high-risk nature of handover. Handover is noticed when things go wrong. One recent tragic failure was that of an elderly Aboriginal man left to die on an airstrip in the Northern Territory.2 The man had pneumonia and had been evacuated to Katherine Hospital. Before his evacuation, a nurse and district medical officer discussed the possibility of a family escort travelling with him. Although this had previously been recommended by his referring doctor, neither the acuity of the patient’s condition nor his personal circumstances (poor English and frailty) were clearly communicated, and no escort accompanied him. This was the first inadequate handover. After 9 days of treatment, he was discharged. The paperwork for his discharge was processed on a Friday, including a fax to his local community health centre advising of his scheduled Monday discharge. This fax was not seen or acted upon by the community health facility. Was this, then, handover at all? There was no checking system between the travel service and the community health centre, and it was presumed that there would be someone to collect the patient on his return from Katherine to the community. However, this was not the case. The patient was left by the pilot, alone at the airstrip some distance from town. On the Thursday, 3 days after the man was left at the airstrip, the police were informed that he was missing. His body was found the following Monday. He had died — alone, dehydrated and suffering from pneumonia. Since this tragic incident, the Northern Territory Government has taken steps to standardise and improve handover processes. The coroner’s report of the incident endorsed these steps as long as handover improvement was continual — the standardised processes would only be valuable if they were actively implemented and maintained. Problems that can arise from poor communication at handover include incorrect medications being given, delays in treatment or failure to give it, unnecessary repetition of diagnostic tests, and preventable readmissions. These failings waste time, strain health care resources and cause harm to patients. Health care professionals need to acknowledge that handover is a high-risk situation and that it is an element of their work that is integral to the delivery of safe patient care. Our own serious adverse events should not be the trigger for actions to standardise handover practice. We can learn from the mistakes of others to ensure safe transfer of information, responsibility and accountability in patient care. Clinical handover is defined as “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”.3 Accountability and responsibility are critical terms in this definition, as “transfer of information is irrelevant unless it results in action that is appropriate to the patients’ needs”.1 When this governance view is taken of handover, the minimum required information elements and handover processes become more evident. Indeed, clinicians have a duty of care to ensure that effective handover occurs.4 The poor outcomes that arise from poor handover, as well as the scarcity of existing evidence,5 have motivated the Australian Commission on Safety and Quality in Health Care to work on developing evidence-based solutions for improving handover. The articles in this supplement are contributed by teams participating in the Commission’s National Clinical Handover Initiative. Each provides a view into how handover can be improved. There are several common themes addressed in these articles, which are described below. The need for “flexible standardisation”Although the concept of flexible standardisation may seem contradictory, teams have found that both flexibility and standardisation are essential. This may mean implementing a minimum dataset, such as SBAR (situation–background–assessment–recommendation) while still allowing for customisation to ensure that it meets the needs of the local clinical context. Several of the articles describe the implementation of different standardised tools for improving handover: Yee et al (on shift-to-shift clinical handover);6 Wood et al (on handover from inpatient private mental health care to the community);7 Clark et al (on improving communication between hospital staff at handover);8 and Belfrage et al (on handover from the aged-care home to the emergency department).9 The importance of clinician involvement in the quality improvement processMost of the articles touch, in some way, on the importance of engaging clinicians throughout the clinical handover improvement process. This ensures ownership of the process and a proper understanding of the local setting. User involvement is creatively addressed in the studies by Iedema et al (on enhancing communication to improve patient safety)10 and Porteous et al (on the design and testing of a comprehensive handover form).11 The former allows clinicians to create their own handover solutions, while the latter involves clinicians in the implementation of an existing standardised tool. Methods for ensuring that handover results in a shared understanding of informationAs handovers occur frequently in health care, understanding what each type of handover is for and how it should be presented is essential for ensuring confident and competent handover by all staff. A standardised approach to handover can help clarify the purpose and content of handovers and reduce confusion. Such an approach needs to be easy to use so it can be easily taught and recalled, as demonstrated by Hatten-Masterson et al in a study of enhancing clinical communication in a private maternity hospital.12 This point is also made in the article by Quin et al on standardised clinical handover tools,13 in which clinicians were informed of the dangers of poor handover. The article by Chaboyer et al on communication via whiteboards focuses on understanding how to use whiteboards in a systematic and planned way to improve handover.14 A shared understanding may also be promoted using technological solutions, as described by Silvester and Carr in a study of a shared electronic health record.15 The effects of health care culture and organisational structureThe complexity of health care means that maintaining the continuity of patient care is a challenging process. As the article by Botti et al on maximising patient safety in complex handover situations states, “it is unlikely that any one improvement strategy will be appropriate for all”.16 Training in communication within a team seems to be a helpful strategy, as demonstrated by Stead et al in a study of TeamSTEPPS (team strategies and tools to enhance performance and patient safety).17 This project used an existing program to train staff in using a standardised handover tool (SBAR) and in communication and teamwork in and around the handover. Some aspects of handover have been only tangentially addressed by the National Clinical Handover Initiative. It has been suggested that communication errors sit on the “dark side of measurement”,18 where less-developed measures mean that problems are ignored. We still know little about the measurement of safe handover practice. In addition, the significance of documentation (including letters and notes, some of which are held by the patient) and its relationship to verbal handover has not yet been adequately explored.5 Research on ways of using documentation to optimise handover is crucial to ensure that electronic records are designed to provide maximum safety for patients. Handover should be viewed as part of the provision of safe patient care, rather than as extra, unnecessary work. Good handover means that lapses in continuity of care, errors and harm will be reduced, whether patients are in the community or in hospital, undergoing a series of investigations, being prepared for surgery, recovering or dying. Clinicians and managers need to be aware that providing good handover requires an understanding of its purpose, leadership, protected time, a systematic approach, and a supportive clinical environment. Good handover takes effort.

Christine M Jorm MD, PhD, FANZCA · Sarah White BA · Tamsin Kaneen BA

It has been suggested that you can’t improve what you don’t measure. It has also been suggested that if you don’t know where you are going, any map will do. The articles in this supplement demonstrate that researchers in Australia are mapping approaches to measuring and improving the complex arena of clinical handover. Furthermore, their collective efforts at trying to make sense of the chaotic interlude of handover are at the cutting edge of clinical research. The focus on clinical handover is a relatively recent phenomenon in the grand scheme of quality and safety efforts. Interest in handovers has grown steadily over the past decade as researchers, hospital administrators, educators and policymakers have come to realise that the potential breakdown in communication during patient handover is a serious issue affecting their institutions, clinicians and patients. Indeed, the world has woken up to the fact that ineffective handovers are a hazard to patients, and result in misuse and poor utilisation of resources. Clinicians and researchers agree that handovers serve as the basis for transferring responsibility and accountability for the care of patients from outgoing to incoming health care teams across shifts, across disciplines and across care settings. Poor continuity of clinical care, either at a patient’s referral to hospital by a primary care provider or specialist, or at discharge from hospital, can be detrimental to the patient’s wellbeing. The exchange of information and responsibility that occurs during shift changes is critical for maintaining continuity and patient safety, and can often determine the ultimate outcome of care.1 System issues are at the heart of patient handovers — clinician-to-clinician communication, coordination of transitions and creation of mechanisms for feedback and feed-forward. The complexity of the handover process presents a series of “vulnerable gaps” in patient care that can result in errors, near misses and adverse events. Research has illustrated that there is little standardisation and great variation across disciplines and health care organisations in the ways in which handovers are performed.2-4 Unlike some areas that have been the focus of safety improvements, handovers of patient care are ubiquitous, cutting across all care settings and all disciplines. The World Health Organization listed “communication during patient care handover” as one of its “High 5” patient safety initiatives.5 Improving effective communication throughout the hospital is a leading patient safety goal espoused by The Joint Commission in the United States.6 The Australian Commission on Safety and Quality in Health Care (ACSQHC) has identified clinical handover as a particular focus for 2009.7 The call to action by the ACSQHC has been heard, and this MJA supplement represents a vibrant response from Australian researchers. Developing a single approach for all handovers is not possible because of the diversity and complexity of health care. Ensuring quality and safety during times of transition will therefore require an approach that draws on all available wisdom about what is needed to improve handovers, coupled with a systems approach to understanding and improving care at the point where patients and providers meet. The articles presented here examine handovers within and across multiple care settings (including residential aged-care facilities,8,9 inpatient care,10-15 mental health16 and maternity care17); handovers from community to hospital care;18 and the effects of different financing structures (public/private, state/federal).19 The projects described use a blend of qualitative and quantitative methods, including observations, interviews, focus groups, surveys, appreciative inquiry and case studies. In addition, the studies test several interventions to improve communication around the handover process: shared electronic health records, common datasets, educational interventions aimed at increasing staff awareness, checklists and whiteboards. Six recommendations emerge from the articles in this supplement and other cutting-edge work by a diverse set of researchers around the world. 1. Seek to understand handover communication as a complex adaptive processImproving outcomes requires an appreciation of the inherent link between explicit processes and results. Focusing on the system, rather than the individual, directs attention to the processes and outcomes of care without blaming or shaming individual people.20 2. Recognise the effect of culture as a key enabler for change and improvementThe culture of a care-giving unit underpins all processes and all improvements to care. Providers who are junior or new to the system may lack knowledge and confidence. For example, immigrants may be self-conscious about their command of the language and reluctant to ask questions. Lack of experience and the effects of a different cultural background are further exacerbated in settings with a steep authority gradient. 3. Develop tools to make information readily accessible and transparentDeveloping and maintaining decision aids requires an investment of effort and money. There may be a tendency to bypass such information documentation activities if easier avenues for securing information can be identified. Well designed, ergonomic solutions and consistent policies on the use of these resources increase the chances that such tools will be successfully adopted. 4. Apply principles of human factors to clinical designDesign workspaces that help reduce or eliminate interruptions during patient handover. Learn to appreciate the impact of the built environment and its impact on patient outcomes. 5. Focus on training and sustainingHandovers are rarely taught systematically. The following principles can help to redress this: Teach providers to tell a “better story”. More effective integration of the quantitative outcomes data with the more qualitative contextual data will enhance the wisdom of carers and capture the complexity of patient stories. Provide feedback. Sustain the effort by giving feedback about individual performance and by setting performance expectations. Couple inexperienced providers with experienced incoming and outgoing providers. The experienced incoming provider can demonstrate proper enquiries about patient status and issues, and the experienced outgoing provider can demonstrate proper “story-telling” and methods. Capturing the wisdom of an 8-hour shift is more complex than one might assume. Consider the use of videotaped simulated handovers and self-directed videotaping for reflexive learning. Use of these tools can improve handover. They can demonstrate the nature of false assumptions and omissions; the effects of interruptions; good versus poor patient problem descriptions; and the consequences of relying only on written information. 6. Identify the leadership required to improve handoversEffective leadership (at microsystem, organisational and national levels) is crucial for addressing systems issues and for creating the kind of “learning” organisation that is necessary for providing safer care. Several overarching themes can be gleaned from the articles presented in this supplement. Firstly, while standardisation of process and content are at the heart of effective handover, there is also a need for local customisation so that clinicians own and champion the handover process. This cannot be overemphasised. Front-line care-giving teams need to adapt standardised protocols to meet their needs, based on their unique set of constraints and enablers. Secondly, action research methods that bridge the gap between research and practice are an effective way to engage front-line staff in improving the handover process. Translating the recommendations of this supplement into practice will involve adapting them to local needs determined by the people, process and patterns at work in Australia. The proof in these and other proposed solutions comes down to implementation. In translational research, the handover phenomenon informs the research, and the research informs the practice. Questions to help guide local implementation of new handover strategies and to measure the impact of the changesWhat are the clinical handover situations that carry the most risk for patients? What information and critical success factors are needed to better understand the process of handovers in this setting? What handover interventions are the most effective? What resources and tools are available to improve handover communication? Which individual clinicians are willing to serve as “champions” for improving the handover process? What mechanisms can be put in place to spread, sustain and transfer improvements across the organisation? What improvements can be built into information systems tools to enhance their successful adoption (eg, checklists, reminder systems, information technology solutions)? Research funding bodies in Australia (such as the Australian Research Council and the National Health and Medical Research Council [NHMRC]) need to hear this message and consider allocating 2009–2010 research priorities accordingly. Action-oriented research emphasises the need for a highly collaborative and consultative approach between researchers and care-giving teams. As Iedema and colleagues state eloquently, “When enabled and trusted to develop and redesign work processes that make sense to them, clinicians gain ownership over the solutions proposed and designs instituted”.13 Handovers are high-risk scenarios for patient safety. In the end, patients will be safer only when clinicians are engaged and leading the change required around handovers.

Julie K Johnson MSPH, PhD · Paul Barach MD, MPH

A shared electronic health record system has been successfully implemented in Australia by a Division of General Practice in northern Brisbane. The system grew out of coordinated care trials that showed the critical need to share summary patient information, particularly for patients with complex conditions who require the services of a wide range of multisector, multidisciplinary health care professionals. As at 30 April 2008, connected users of the system included 239 GPs from 66 general practices, two major public hospitals, three large private hospitals, 11 allied health and community-based provider organisations and 1108 registered patients. Access data showed a patient’s shared record was accessed an average of 15 times over a 12-month period. The success of the Brisbane implementation relied on seven key factors: connectivity, interoperability, change management, clinical leadership, targeted patient involvement, information at the point of care, and governance. The Australian Commission on Safety and Quality in Health Care is currently evaluating the system for its potential to reduce errors relating to inadequate information transfer during clinical handover.

Brett V Silvester BEng, RegPM · Simon J Carr DipCS

Objective: To evaluate the use and usefulness of an aged-care home (ACH) transfer-to-hospital envelope (the Envelope) as a tool to support safe clinical handover when an ACH resident is transferred to an emergency department (ED).Design, setting and participants: Participants in the study were 26 ACHs (1545 beds), the EDs of six major metropolitan public teaching hospitals in Melbourne, and ambulance officers involved in transferring residents from ACHs to hospitals. Transfer data were collected over an 18-week period (January–May 2008). Evaluation methods included written surveys and semi-structured face-to-face interviews (interviewees were 19 ACH staff, 30 ED staff, and 7 ambulance officers familiar with the Envelope).Main outcome measures: Use, usefulness and ease of use of the Envelope; impact of using the Envelope on clinical handover; awareness of the need for clinical handover; sustainability of the project.Results: The Envelope was used for the large majority of ACH residents transferred to hospital (ACH data: 317/355 [89%]; ED data: 85/101 [84%]); 163/165 ACH staff (99%) thought the Envelope was useful, and 148/165 (90%) said it was easy to use; 128/165 ACH staff (78%) and all interviewees believed that using the Envelope improved clinical handover; and 152/165 ACH staff (92%) indicated they would continue to use the Envelope. All interviewees thought that using the Envelope had raised awareness of the need for clinical handover.Conclusion: The Envelope is useful and easy to use. It is used in the large majority of transfers of ACH residents to EDs and is highly valued by ACH staff, ambulance officers and ED staff. Our results suggest that use of the Envelope makes clinical handover safer for patients.

Mary K Belfrage MB BS, DRANZCOG, MPHAA · Clare Chiminello BA, GradDipLib · Diana Cooper RN, BAppSc(Nurs), GradDipHlthAdmin · Sally Douglas BAppSc(Phys), PostGradCertMHSC

Objective: To develop, using an evidence-based approach, a standardised operating protocol (SOP) and minimum dataset (MDS) to improve shift-to-shift clinical handover by medical and nursing staff in a hospital setting.Design, setting and participants: A pilot study conducted in six clinical areas (nursing and medical handovers in general medicine, general surgery and emergency medicine) at the Royal Hobart Hospital between 1 October 2005 and 30 September 2008. Data collection and analysis involved triangulation of qualitative techniques; 120 observation sessions and 112 interviews involving nurses and junior medical officers were conducted across the six clinical areas; information on more than 1000 individual patient handovers was analysed.Results: We developed an overarching four-step SOP and MDS for clinical handover, summarised by the acronym “HAND ME AN ISOBAR”. This standardised solution supports flexible adaptation to local circumstances.Conclusion: A standardised protocol for clinical handover can be developed and validated across professional and disciplinary boundaries. It is anticipated that our model will be transferable to other sites and clinical settings.

Kwang C Yee BMedSc(Hons), MB BS(Hons) · Ming C Wong BCom, MIS · Paul Turner BA(Hons), MSc, PhD

Objective: To describe and evaluate the PACT (Patient assessment, Assertive communication, Continuum of care, Teamwork with trust) Project, aimed at improving communication between hospital staff at handover.Design, setting and participants: The PACT Project was conducted between April and December 2008 at a medium-sized private hospital in Victoria. Action research was used to implement and monitor the project, with seven nurses acting as a critical reference group. Two communication tools were developed to standardise and facilitate shift-to-shift and nurse-to-doctor communication. Both tools used SBAR (situation, background, assessment, recommendation) principles. All nurses attended workshops on assertive communication strategies and focused clinical assessment of the deteriorating patient. Questionnaires were distributed to nurses and doctors at baseline, and post-implementation questionnaires and qualitative data were collected from nurses immediately after the project.Main outcome measures: Nurses’ opinions of improvement in structure and content of handover; nurses’ confidence in their communication skills.Results: At baseline, 85% of nurses believed communication needed improvement. After implementation, 68% of nurses believed handover had improved and 80% felt more confident when communicating with doctors.Conclusion: Early evidence supports the use of standardised communication tools for handover, together with specific training in assertive communication and patient assessment. Long-term evaluation of patient outcomes is needed.

Eileen Clark BA, MLitt, MSocSc · Sally Squire RN, BEd, GradDipMgt · Anne Heyme RN, GradCertOrthoNurs · Mary-Ellen Mickle RN, RM, BHS(Nurs) · Eileen Petrie RN, PGDipCPN, PhD

Objective: To evaluate the effectiveness of the implementation of a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program at an Australian mental health facility.Design, setting and participants: TeamSTEPPS is an evidence-based teamwork training system developed in the United States. Five health care sites in South Australia implemented TeamSTEPPS using a train-the-trainer model over an 8-month intervention period commencing January 2008 and concluding September 2008. A team of senior clinical staff was formed at each site to drive the improvement process. Independent researchers used direct observation and questionnaire surveys to evaluate the effectiveness of the implementation in three outcome areas: observed team behaviours; staff attitudes and opinions; and clinical performance and outcome. The results reported here focus on one site, an inpatient mental health facility.Main outcome measures: Team knowledge, skills and attitudes; patient safety culture; incident reporting rates; seclusion rates; observation for the frequency of use of TeamSTEPPS tools.Results: Outcomes included restructuring of multidisciplinary meetings and the introduction of structured communication tools. The evaluation of patient safety culture and of staff knowledge, skills and attitudes (KSA) to teamwork and communication indicated a significant improvement in two dimensions of patient safety culture (frequency of event reporting, and organisational learning) and a 6.8% increase in the total KSA score. Clinical outcomes included reduced rates of seclusion.Conclusion: TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility. It encouraged a culture of learning from patient safety incidents and making continuous improvements.

Karen Stead BN, RM, MBus · Saravana Kumar BAppSc(Physio), MPhysio, PhD · Timothy J Schultz BSc(Hons), GradDipPubHlth, PhD · Sue Tiver RGN, RPN, BNurs · Christy J Pirone BSN, RN, MCISc · Robert J Adams MB BS, MD, FRACP · Conrad A Wareham BM, FRCA

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover — Enabling Learning in Communication for Safety) tool uses a “video-reflexive” technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior–senior communication and teaching. Our study showed that reflexive and “bottom-up” handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

Rick Iedema BA, MA, PhD · Eamon T Merrick RN, BHSc, MHSM · Ross Kerridge MB BS, FRCA, FANZCA · Robert Herkes MB BS, FRACP · Bonne Lee MB BS, FAFRM, MMed · Mike Anscombe MB ChB, FRACP, FACEM · Dorrilyn Rajbhandari RN, GradDipClinNurs · Mark Lucey MRCPI, FCARCSI, FJFICM · Les White FRACP, MRACMA, MHA

Objective: To describe the integration of whiteboards into ward routines in one Queensland health service district (HSD).Design and setting: Case study involving placement of whiteboards in three inpatient wards (two medical, one surgical) in a university-affiliated regional teaching hospital and in a day clinic in the same health service district. Data collection methods included 45 hours of observation of four whiteboards and 62 staff over 2 months, 11 in-depth interviews with nursing and allied health staff, and photographs of the whiteboards taken at intervals. The study was conducted from March to August 2008.Main outcome measures: Structures, processes and perceived outcomes of the use of whiteboards.Results: The physical configuration of the whiteboards did not vary, but their content and usage by various professional groups fluctuated. Whiteboards were most successfully integrated in the clinic, where they became an integral part of multidisciplinary rounds, and were updated and referred to several times each day. They were partially integrated into the two medical wards, with various health professionals updating and referring to the whiteboard. In the surgical ward, a nursing assistant updated the whiteboard, but it was not referred to by others. Staff in the clinic and on the medical wards perceived that whiteboards facilitated timely referrals, improved patient flow and enabled timely and better discharge planning, but surgical nursing staff described them as an imposition and a cause of conflict among clinical team members.Conclusions: Whiteboards have the potential to improve patient flow, but a planned approach to their use is required. Issues relating to the use of whiteboards, including staff buy-in, discharge planning and patient privacy, need to be addressed.

Wendy Chaboyer RN, PhD · Karen Wallen MN · Marianne Wallis RN, PhD · Anne M McMurray AM, RN, PhD

Objective: To evaluate the appropriateness and acceptability of five standardised tools for shift-to-shift clinical handover (CH).Setting and participants: In July 2007, a pilot project was conducted in four Victorian public health services. Five standardised tools developed by the Victorian Quality Council were trialled at night medical handover: an organisational readiness checklist, a suggested organisational policy, a recommended organisational protocol, a CH template containing a minimum dataset to be collected, and a set of key performance indicators. Baseline and post-trial data and observational data were collected, and participating medical staff completed questionnaires before and after project implementation to gauge their opinions on the usefulness of the tools.Results: The tools considered most useful were the organisational readiness checklist, the suggested organisational policy, the protocol for CH, and the CH template. Using the number of medical emergency team calls and incident reports as key performance indicators was not considered appropriate.Conclusions: The project highlighted that organisational support and commitment and stakeholder engagement and involvement are essential for implementing and sustaining changes in CH.

Diana M Quin BA(Hons), MPH · Annie L Moulden MB BS, FRACP · Simon H Fraser MB BS, FRACP, MPPM · Olive K E Lee BN(Hons), MN · Patricia McGarrity BAppSc(Physio), MHumBioeth

Objectives: To develop and test a standardised clinical handover discharge strategy for improving information transfer between private mental health hospitals and community practitioners.Design, setting and participants: A quality improvement intervention using collaborative, iterative methods to develop a standardised discharge and outcome assessment strategy. 150 patient participants were consecutively recruited from two private mental health care hospitals in New South Wales between April and September 2008. Opinions of community practitioners and patients on the discharge process and discharge documentation were solicited by written questionnaires and telephone interviews.Main outcome measures: Community practitioner satisfaction; patient satisfaction; documentation of discharge date at least 48 hours before discharge; faxing of discharge summaries to community practitioners within 48 hours of discharge; proportion of patients receiving a follow-up telephone call within 7 days or 14 days of discharge.Results: Both community practitioners and patients believed the intervention was positive. Between Cycle 2 and Cycle 3, documentation of the discharge date at least 48 hours before discharge remained unchanged at 50%; the proportion of discharge summaries faxed within 48 hours of discharge went from 0 to 82% in Cycle 2 and fell to 65% in Cycle 3. Telephone follow-up of patients within 7 days and within 14 days improved by 10% and 6%, respectively, between Cycle 2 and Cycle 3.Conclusions: A standardised discharge communication strategy improved the timeliness, content, and format of information provided to community practitioners. The intervention was well accepted by patients and providers.

Susan K Wood RN, GradCertHEc · Allison K Campbell RN, BHSc(Nurs) · Judith D Marden BPharm · Lavinia Schmidtman MB BS, FRANZCP · George H Blundell RN, BHSc(Nurs) · Noella J Sheerin RN, BAppSc(HMvt), GradCertE-Health(HI) · Patricia M Davidson RN, MEd, PhD

Midwives and visiting medical officers have a unique relationship within private hospital maternity settings. The effective exchange of accurate information between them is a fundamental element of patient safety and is vital to the success of the clinical handover process. The SHARED (situation, history, assessment, risk, expectation, documentation) project developed, implemented and evaluated a framework and support tools for improving clinical handover in two private maternity hospitals. The project included a pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data. A standardised approach to handover, using the SHARED framework with a standardised minimum dataset, improves the accuracy and appropriateness of information.

Sara J Hatten-Masterson BN, RN · Marnie L Griffiths BHlthSc, MMidPract

Effective communication at clinical handover is important for improving patient safety and reducing adverse outcomes. In consultation with doctors, nurses and allied health staff in the Western Australian Country Health Service, we developed a clinical handover checklist, adapted from an existing tool for standardising communication. The acronym “iSoBAR” (identify–situation–observations–background–agreed plan–read back) summarises the components of the checklist. We designed a comprehensive iSoBAR handover form to reduce the number of existing clinical handover forms. The new form, with an accompanying toolkit, was initially trialled in the Kimberley region, but is now being adopted more widely. Early adoption of the new form has been attributed to extensive clinician involvement and leadership. There is a need for further research to assess whether the use of handover checklists improves patient outcomes.

Jill M Porteous BHlthSc, GradDip Public Sector Management · Edward G Stewart-Wynne MB ChB, FRACP · Madeleine Connolly RN, GradDipEd · Pauline F Crommelin RN, GradCert Leadership and Management

Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.

Mari Botti RN, PhD · Tracey Bucknall RN, PhD · Peter Cameron MB BS, MD · Megan-Jane Johnstone RN, PhD · Bernice Redley BN(Hons), PhD · Sue Evans GradDipClinEpid, PhD · Shelly Jeffcott BSc(Hons), PhD