improving the quality of handover by addressing handover culture and introducing a new, multi-disciplinary, team-based handover meeting - projector

Andacthandover is "the main preventable cause of patient injury "[1]
The project aims to improve the quality of night handover in the general practice department of the teaching hospital, thus transferring patient care safety to the night team.
Through structured qualitative interviews with trainees and a baseline survey of physician's overnight handover opinions, the handover quality was qualitatively evaluated and the data set was collected for quantitative analysis by regularly observing the night handover.
The initial intervention was to have a new handover meeting at the specified time and at the new location and to invite night nurses to attend.
Prompt cards, standardized documents, clear leadership and attendance registers were also presented.
The continuous PDSA cycle introduces technology into intervention, enabling nurses to actually participate and re-participate in night practice
Put the prompt card on the agenda.
The results show that the handover time is continuously shortened from 70 minutes (n=7)to 34 minutes (n=13)post-
The number of interventions and distractions during each handover decreased from an average of 14 to an average of 8. 5.
The quality of handover has also improved, with the overall increase in the percentage of tasks handover including hospital number and admission diagnosis, a total of illness and a task time assigned to at least 10%.
After the students were investigated
They agreed that the new handover system was safer than the previous handover process (n=30).
This project shows that changing advertising
Special switching system with multiple nodes
Discipline and team-based handover methods improve the quality of handover.
In addition, it provides useful guidance for introducing a new handover meeting to a department and contains useful lessons on how to overcome cultural barriers to change within the department.
Problem Brighton Royal Sussex County Hospital there is a defined handover between the general practitioners at night and the team at night.
There is a two-hour overlap between the two shifts, in which there is no specified handover time, resulting in confusion in the handover method, including multiple personalized handover between employees, rather than a unified team approach.
Our main goal is to improve the quality of night handover within the department, thus safely transferring patient care from day to night team.
The Royal College of Physicians has identified the background handover (RCP)
It is "the main preventable cause of patient injury ". [1]
Risks associated with the handover include information not being handed over or misunderstood [2]
This can lead to "serious disruption of care continuity, improper treatment and potential harm to patients ". [2]
In addition, with the change of the Doctor's working mode, more and more handover occurs. [3]
Therefore, more and more attention has been paid to switching practices with RCP, [1]
Committee of Primary physicians of BMA ,[3]
And the Royal College of Surgery [4]
All release guidelines for creating successful handover practices.
All three institutions define handover as a transfer of responsibility between healthcare professionals for patient care. [1,3,4]
The key to successful handover depends on human factors, including technical and non-technical factors
Technical skills of team members. [5]
Technical skills are usually solved by using handover tools such as SBAR. Non-
While communication, teamwork, and situational awareness are seen as contributing to the quality of handover, technical skills are often more difficult to address. [6]
See supplementary document: ds5282. docx -“Table 1 -
Since the original data does not convey the complexity of the handover, the baseline measurement of the effectiveness of the handover is a daunting task.
Therefore, we decided to evaluate the handover using both qualitative and quantitative methods.
In order to help determine the current issue of the handover, we conducted a detailed structured qualitative interview with the trainees (
Quotation see Table 1).
This shows that the handover lacks the set time and the handover quality is considered to depend on
The trainers pointed out that many kinds of interference interfered with the handover.
Guidelines for using this information and RCP [1]
We designed a data set to evaluate switching quality (
See Tables 2A and 2B)
Collect the information of the handover meeting and the specific information of each task of the handover.
To ensure the normalization of data collection, the same observer participated in the evening handover of seven departments before designing our initial intervention.
Key preliminary findings (
7 handover, 107 handover tasks)
The average handover time is about 70 minutes (
Voyage: 45 to 92 minutes)
During each handover, about 14 distractions occurred, with an average of 5.
5 there is additional dialogue in the background of handover (see table 2A).
15 tasks were handed over per night on average;
Among them, the registrar witnessed 44% of the tasks handed over, and the nursing night doctor witnessed 0% of the tasks handed over.
In terms of the information handed over, 70% of the time was handed over to the hospital number, 79% of the time was diagnosed, 31% of the time received the associated complications, and 17% of the time was allocated to the task.
90% or more of the time was handed over to the patient's name, location, unfinished tasks and active issues, and 90% of the time assigned the task to a specific individual (see table 2B).
All data collection uses the same observers, so they provide useful insight into switching.
Their observations found that the following topics had a significant impact on the quality of the handover: lack of clear leadership, lack of normalization between transfers, multiple avoidable disturbances, the attendance of doctors who participated in and left the handover was poor, and the same patient was handed over multiple times, with multiple transfers occurring at the same time.
It was noted that a focus on technology as a center would contribute to a good handover.
We also created a survey to assess the doctor's perception of the night handover (see table 3)
, Guidelines for using RCP [1]
The problems in the "hospital patient safety culture survey" were revised. [7]
The results showed that the handover lacked the set time, the standardized sequence of procedures, the loss of important patient care information, and interference in the handover process.
These data collection methods provide different unique insights into handover quality, and this diversity helps ensure that the complexity of handover does not lose data and statistics in quality improvement projects.
See supplementary document: ds5296. docx -“Table 2 + 3 -
Handover data and findings "design this data and the" acute care kit "of the RCP is used to design a new handover meeting that will be held at the set time (8:00pm)
Every night in a fixed position.
The location moved from the doctor's office to a large workshop room because people wanted to stay away from busy work and the working environment would prompt people to pay more attention to tasks handed over rather than daily work, thus reducing distraction.
Prompt card for standardized handover (see appendix A)
The night shift registrar was appointed as the person in charge of the handover.
We provide standardized documents based on SBAR format (see appendix B)
The handover record and attendance register are introduced.
We also invited night employees to participate in the handover and promoted the use of SBAR tools (
Situation, background, evaluation, recommendation)
When the patient was handed over
Cycle One-
Implementation intervention: After the implementation of the new handover meeting, we continued to participate in the handover and collected the same set of data (
See Tables 2A and 2B).
In addition, after each handover meeting, we immediately interviewed one or two people who participated in the handover and asked them three standardized questions about the new handover meeting (
What effect is good, what effect is not good, what can be improved).
We use these data and qualitative points of view to continuously improve the handover meeting.
To provide an introduction to the above interventions, we emailed the department detailing the new handover process and used posters to promote the changes.
These preliminary meetings reduced disruption, lasted less, and the registrar witnessed an increase in the proportion of transfers.
Feedback from the first two meetings (
Collect official data only for one)
The lack of technology was considered a concern.
It was also noted that the use of the prompt card was not used, which prevented the normalization of the handover meeting. PDSA cycle 2 -
Technical introduction to the handover process: therefore, we arranged access to computers and projectors in the workshop room.
We also try to increase the registrar's participation in the new process after determining that some registrars do not know the existence of the prompt card.
We implemented this by explaining the new handover process and its fundamentals via email
Communicate through direct contact with most registrar.
The data collected shows that we are able to maintain reduced handover time and reduce interference (see table 2A)
Registered personnel continue to witness an increase in the proportion of transfers.
We also continue to see improvements in the mission.
Specific details being handed over (see table 2B).
It was pointed out that despite the invitation of night shift nurses, they did not attend the handover meeting and the trainees commented that they thought it would be beneficial. PDSA cycle 3 -
Attendance of night shift nurses at the time of handover: after further investigation, it was found that night shift nurses were unable to attend due to conflicts with their own departments.
So we negotiated with the department and agreed that the night shift doctors would change their mode of work to enable their handover to take place earlier, thus ensuring that they attend the General Medical handover.
The data collected during this period shows that the handover work continues to improve (
See Tables 2A and 2B)
Although the prompt card is still not used, it prevents the complete normalization of the handover. PDSA cycle 4 -
Rename the "prompt card" to "agenda": after consultation with multiple registrants, the prompt card appears to be too detailed and considered too laborious.
It is also found that the word "prompt card" has a negative meaning.
Therefore, we decided to reduce the amount of information on the prompt card to an absolute minimum and rename it to the agenda (see appendix C)
Make sure it is placed in a visible position in the handover room.
Following the introduction of the new agenda, we immediately continued to collect the data and repeated the survey to assess the doctor's perception of the night handover and raised an additional question of comparing the introduction of pre-and post-intervention handover.
The final results are discussed below and can be found in Tables 2A, 2B and 3.
Building life: the life of the project is guaranteed by including the gold standard handover process in the general medical team.
We are also currently negotiating to incorporate the handover into the physician simulation training, thus ensuring continued focus on improving the quality of the handover.
Night shift nurses provide continuity for the handover process;
Despite the frequent replacement of medical staff, they are therefore authorized to ensure the best practices during the handover and to ensure that new employees follow the established handover process.
In addition, the department has appointed a consultant in charge of the handover, who will be responsible for overseeing the new handover process.
See supplementary document: ds52 92. docx -
Appendix A, B and C"
Survey data
Specific information handover (table 2A)
Our results show that the handover time is continuously shortened (see run-chart A)with a pre-intervention (n=7)
After an average of 70 minutesintervention (n=13)
Average 34 minutes.
When these results are controlled through statistical processes (SPC)
Analyze, show all posts
The outcome of the intervention was at least 1 sigma level (18 minutes)below the pre-
The intervention means that this indicates that the reduction in handover time is related to the intervention.
During each handover, the number of distractions has also decreased (see run-chart B)
From an average of 14
The average intervention was 8. 5 post-intervention.
In this regard, there is a significant decrease in distractions due to conversations unrelated to the handover.
The new handover meeting did not affect attendance.
Interestingly, the average number of tasks handed over during the project seems to have decreased, although it is difficult to know if this is important (see run-chart C).
This is not the intended goal of the project, although this may be due to an increase in the registrar's review of the handover.
Observation data-
Specific task information (table 2B)
The introduction of a new handover meeting has increased the number of tasks witnessed by the registrar from 44% transfers prior to intervention (n=107)
Up to 90% after intervention (n=145).
Similarly, at the end of the intervention, the nurse night shift doctor witnessed the handover of 78% of the tasks (from 0%). This multi-
According to the trainees, the disciplinary factors of handover are beneficial during the night shift, as this is an opportunity to meet with colleagues, thus facilitating a lot
The disciplinary team works at night.
With the introduction of the new handover meeting, the handover quality seems to have improved, including the number of hospitals, admission diagnosis, coexistence of diseases, and the time allocated to perform tasks at least 10% (see run-charts E and F).
One possible explanation is that the pressure to hand over in front of the entire team resulted in a more deliberate handover, however, prior to the formal handover meeting, the level of embarrassment associated with low quality handover was lower.
It is also important to note that there is no significant reduction in any aspect after the handover of the taskintervention.
An unexpected benefit of the new handover meeting is that the number of tasks assigned to the night Ward has decreased
SHO from 81% front cover
After 62% intervention
Intervention, work reduction-
Night SHO also verbally appreciated load.
It seems that as the whole night team now meets and takes part in the handover at the beginning of the night shift, tasks are more often assigned to the night shift
However, they will not be present for work until they intervene.
Evaluation of the Doctor's investigation of the night handover opinions (table 3)
After the implementation of PDSA cycle 4, we immediately repeated the survey after four weeks of intervention.
As a result, the results did not reflect views on the new agenda, as this was not fully reflected within the department.
The most important result was that the trainees unanimously supported the new handover meeting, believing that the two handover systems were safer.
Trainees now also feel that there is a "regular" standardized procedure (
From "sometimes ")
, All tasks accepted when the night handover is completed are "often" possible (
From "sometimes ")
, Although they had previously "agreed" that "important patient care information is often lost during the day shift to night shift, they now "disagree or disagree" with this statement ".
Also, they are "rarely" distracted by people who answer their beeps (
From "sometimes ")
They "sometimes" noticed that there was an unrelated conversation at the same time during the handover (
From the uniform split between "often" and "sometimes).
They now admit that there is a fixed handover time and the percentage of night shift guards has increased and SHO knows how to contact night shift nurses.
Interestingly, there was no change in the perception of leadership during the handover.
See supplementary document: ds5640. docx -“Run-charts A-
F "collect lessons and limitations from pre
We found that multiple switches occurred at multiple locations at the same time.
This makes data collection challenging because the entire handover process cannot be captured.
So, from experience, we followed the cover of the night ward because they received the vast majority of the tasks handed over.
This technology enables us to standardize our data collection, but may result in an underestimation of the amount of work and task handover witnessed by night shift registrants.
Similarly, the proportion of tasks that SHO witnessed in the evening is likely to exceed-estimated.
The data collected during the handover may be biased by the observer because the observation of all the handover also designed the intervention and therefore invested in the project in person, possibly showing the subconscious desire to verify the intervention.
This is inevitable because this project is the basis of academic rotation for first authors, so they are the only one who can attend the night handover and invest enough time for the project.
We try to solve this problem by standardizing data collection methods, such as applying strict definitions of what constitutes distraction.
In addition, we have added a strong element of quality feedback to ensure that an independent assessment of handover is included in the analysis.
Another concern about the data collected is that because participants are aware of the quality of the handover being observed, they may have changed their behavior accordingly.
Although this is likely to happen, it may affect the pre-
Intervention and post
The outcome of the intervention is equal and therefore the final conclusion should not be changed.
The challenge of this project is to address a handover culture that has been deeply embedded in the department for many years.
Since the person who introduced the intervention was the doctor in the second year of the department's foundation, the task became more difficult;
The medical level is relatively low.
In addition, registrants only work in the Department of General Medicine and therefore may not see an alternative handover system for several years, so it is difficult to convince them of the benefits of the new handover system.
Address these challenges in a variety of ways.
The support of the department consultants is very valuable because we can borrow their authority when discussing handover issues with the trainees.
In order to solve the problem of the participation of the Registrar, we not only try to interact with the registrar in person (
Not purely by electronic means)
However, we also ensure that we have solid qualitative and quantitative evidence of the shortcomings of previous handover arrangements and how the new handover system will address these issues.
Interestingly, although we have successfully received support from the registrar for the new handover meeting, we cannot encourage the continuous absorption of the prompt card or agenda.
Afterwards, we want to know if we are too ambitious and establishing a new handover meeting is a major challenge for the handover culture of each department.
When addressing cultural barriers to acceptance of change, it is better to achieve this change in small, unobtrusive increments rather than huge leaps.
With this project, for example, we can wait a few months until the handover meeting is really embedded in the department and then re-
Introduce a basic agenda (see appendix C)
Handover meeting.
Once this is fully adopted, we can slowly expand the agenda until it contains all the details in the initial prompt card (see appendix A).
This project has proven to replace advertising.
Special switching system with multiple nodes
Team discipline
The method based on switching not only improves the quality of switching, but also reduces the length of switching time and interference during switching.
In addition, the views on the quality of the internal handover of the department have also been improved.
This project not only provides useful guidelines for introducing new handover meetings to departments, but also provides relevant handover tools, however, it also contains useful lessons on how to overcome cultural barriers to change within the sector.
By providing strong arguments for change, involving older people on an individual, personal basis, and borrowing power from supportive consultants, it is possible for junior doctors to challenge a widely accepted cultural norm within a department.
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"Communication in the hands of patients-
Patient safety solutions; 2007.
Volume 1, solution 3.
Council of junior doctors of British Medical Association
"Safety handover: clinical handover guidance for safe patients, clinicians and management personnel ".
London: The Royal College of Surgeons.
Safety handover: guidance from working hours instruction working group.
London: RCS 2007 Manser T, Foster S, Gisin S, etc;
"Assess the quality of patient handover during the nursing transition.
Sudanese Armed Forces Health Care in qualifying. 2009;
19: e44Pezzolesi C, Manser T, Schifano F, et al;
Human factors in clinical handover: development and testing of doctor handover "handover performance tool"2013 Feb; 25(1):58-
Health Care Research and Quality institutions;
Investigation on safety culture of hospital patients 2004.
Statement of interest statement acknowledges non-ethical approval this project is considered exempt from ethical approval as there are clear handover guidelines recommended by multiple organizations (1, 3, 4).
The project attempts to implement these guidelines to the department and measures improvements in compliance through the audits described and regular feedback.