Grassroots Leads Culture Change in Clinical Handover

Clinical Handover remains one of the most perilous procedures in medicine.¹ Recognition of the inadequacies and failings in handover at Brighton Hospitals prompted the launch of the Handover Improvement Initiative, a trust-wide grassroots project with the following aims:

• Understand the current problems within handover and the cultural barriers to change
• Develop and implement solutions to ensure safe handover, high quality patient care and a better working environment for healthcare professionals
• Promote a sustainable cultural shift   

Methods

Qualitative data was obtained from semi-structured interviews of non-consultant doctors to decipher common themes and deficits in handover practice. Data was analyzed using Access coding software. A Likert-type survey of 32 doctors was completed and using The Royal College of Physicians guidelines a temporary standardized handover proforma was implemented and re-audited. Key stakeholders were involved to source funding and design a permanent electronic handover solution using agile software development. Frontline staff were trained in safe handover through online modules, case studies and hospital induction teaching. To ensure sustainability doctors present for >=2 years were enlisted. 

Results

The initial survey highlighted the majority of doctors felt current handover practice did not ensure patient safety and needed improvement. The standardized template was launched with immediate improvement; 88% felt the new system improved patient safety although a significant number requested further improvements; ideally electronic based solutions. Integrated handover software was subsequently designed and is under development. A standard operating procedure for handover was initiated and undergoing continuous development. Standardized handover was integral in final-year medical students’ curriculum through an annual teaching session. 

Key Challenges

Grassroots Team Development

The project was initiated following trainee concerns regarding the process of clinical handover within the hospital trust. Frustrated by the inefficient and sub-optimal handover process, non-consultant doctors involved in the day-to-day handover duties came together expressing this joint concern with a shared vision to improve the handover process. Utilizing new platforms including the Brighton Hospitals Innovation Forum and The Network (a grassroots collaboration of non-consultant doctors leading quality improvement), we were able to consolidate our ideas, build awareness of this critical issue and drive the project forward.

Winning Senior Support & Collaboration with Key Stakeholders

The initial challenge was finding the appropriate personnel to help develop our initiative, but once on board they were integral team-members and catalysts in the project progression. So, following formation of our grassroots team we approached the Chief of Safety to support and guide our initiative. Recognizing the gravity of the issues, he was able to align our initiative with trust priorities and inform senior staff and management throughout the trust of our project, preventing duplication and ensuring consistency of our proposed vision. We were also connected with key stakeholders including IT personnel, software officers and senior management to help design the integrated handover software.

Choice of Handover Solution

We purposely approached the problem with a broad variety of potential solutions; including paper proformas, electronic tools and restructuring of the medical on-call shift patterns. Needing immediate change in the interim prior to the launch of the Electronic Patient Record within the trust and with full agreement that an electronic solution was preferred, we settled on the plan of developing an integrated handover tool within the existing secure software utilized by the trust, which staff are already trained to use.

Software - Using the Agile Software Development process we designed the handover tool with direct end-user input. The software was tailored to local needs, ensuring ease of use, quick implementation, task accountability and management. It is currently under development.

Funding

In view of current economic difficulties within the NHS we appreciated the mammoth task of securing funding. Guided by senior team-members we collectively approached multiple funding streams ranging from national to local funds. We were fortunate to eventually secure an educational fund to cover the initial cost of software development and its annual depreciation costs.

Culture Change & Sustainability

‘In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed.’² Through dissemination of new principles to colleagues via the Network, integration with ward processes, education of final year medical students and foundation doctors we hope to foster a shared vision and instill principles of patient safety. Through the implementation of a Standard Operating Procedure, which will facilitate monitoring of the initiative and involvement of different grades of clinicians, the initiative will be embedded in the infrastructure of the hospital to ensure long-term success and continual improvement.

Key Messages

Improving Clinical Handover requires:

• A collaborative approach to tackle cultural change and implement innovative solutions.
• A combination of cultural, technological and system fixes
• Continuous involvement and training of grassroots promotes sustainability. 
• Fostering a shared vision in handover will improve patient safety.

References:

¹British Medical Association. Safe Handover Safe Patients, Guidance on clinical handovers for patients and managers. (Accessed 29th July 2013)

²Institute for Healthcare Improvement: Knowledge Centre (April 2011) http://www.ihi.org/knowledge/Pages/Changes/DevelopaCultureofSafety.aspx (Accessed 10/10/2013)