Co-ordination of clinical handover: a contingency approach Co-ordination of clinical handover: a contingency approach

Manda Broekhuis and Tanja LipsUniversity of Groningen, University Hospital

GroningenThe Netherlands

The definition of clinical handoversThe definition of clinical handovers

• The process of receiving and providing information of a certain patient, in order to provide the right kind of care to this patient

• Subjects:Daily and weekly handoversSupervisionPatient recordLarge ward roundMultidisciplinary handovers

- delineation: handovers between physicians

IntroductionIntroduction

Clinical handover:

Weak link in the chain of the health care processAnd, at the same time,little research on the subject

HandoversHandovers

Federal fuses are the result of years of scientific study combined with the experience of years

Research questions and definitionResearch questions and definition

Research questions:- How does the organization of clinical handovers differ in

different medical departments- Which factors can be identified to explain these differences?

Organization of clinical handovers; some elements distinguished: pattern in daily and weekly handover meetings, degree of formalization, supervision, multidisciplinary handovers

Medical departments: functional grouping

Theoretical frameworkTheoretical framework

• Focus on the intensity in pattern of clinical handovers meetings and degree of formalization

• Tension between accountability (formalization, protocols, patient record) and quality of information transferred and transformed (differences in level of uncertainty, ambiguity and predictability require different information tools)

• Pattern depends on characteristics of - Department: e.g. number of beds and of staff members- Patient flow: e.g. ratio outpatients to inpatients, turnover

rate, predictability of HC process- Patient characteristics: e.g. seriousness of illness,

uncertainty and/or ambiguity in needs

Preliminary propositionsPreliminary propositions

Contingency Intensity Formalization

SizePatiënt flow-Inpatients-Outpatients-Turnover rate-Predictability Patient characteristicsNumber of medical sub specialisms

+

+---+

+

+

No impact+-+-

No impact

University Hospital GroningenUniversity Hospital Groningen

University Hospital GroningenUniversity Hospital Groningen

• 1300 beds • 400,000 outpatient visits• 9900 day care operations• 30,000 admissions• 25,500 surgery • 76.72 occupancy rate• 8300 employees• 22 medical departments, grouped

by specialism

MethodMethod

• See outline• Core activity: 8-13 dialogues between

(a) physicians of the visited unit and (b) committee of physicians of different units

• Reflection, feedback, report, and follow-up (6-9 months later)

• 20 case studies and 17 follow ups • Qualitative analysis of the reports and the

follow-ups

Pattern in organization of handover: example of 3 unitsPattern in organization of handover: example of 3 units

• General surgery: - Daily: 2 * patient discussion, final check- Weekly: 4 * MD meeting, 3 * education/research meetings, closing

the week, indication meeting- Patient record: additional, supportive

• Lung diseases:- Daily: ward round, 2 * patient discussion- Weekly: 3 * MD meeting, large ward round, release discussion,

outpatient discussion- Patient record: additional, supportive

• Special Dentistry and Oral Surgery:- Patient record most important- Daily: 2 * ward round- Weekly: referee meeting, patient discussion

Different departments and unitsDifferent departments and units

General surgery

Lung disease Special dentistry and oral surgery

Large unit (in terms of beds and staff)

Small unit Small unit

Many sub-specialties

Many sub-specialties

Medium number sub-specialties

Medium turnover

Low turnover High turnover

Mix inpatients and outpatients

More inpatients More outpatients

Life threatening and not life threatening

Both Not life threatening

Pattern in organization of handoversPattern in organization of handovers

• The ‘intensity’ in pattern of daily and weekly handovers meetings: substantial confirmation of propositions

• Size (unit level) seems less important than other contingency factors (more patient level)

• Different patient and flow characteristics influence intensity and degree of formalization: seriousness of illness, routine level, level of uncertainty and unpredictability

• Some differentiation to particular patient groups within a department

Additional findingsAdditional findings

- Contingencies seem to be more important than accountability: not always tension

- Objective to transfer and to develop knowledge (patient level and patient group level)

- Importance of ‘soft’ contingencies: quality of the handover instances, motivation to learn, atmosphere, crafting of tasks, age, relevance attached to clinical handovers, trust

- Problem: how to organize handovers if specialization increases

FormalizationFormalization

• Confirmation of propositions

• Accountability: aware, yet hard to put in practice

• Especially patient records used to formalize (pre-fab constructions, tailoring to patient characteristics)

Other finding: organizing supervision of handoversOther finding: organizing supervision of handovers

- Large number of in- and outpatients: free scheduled supervisor

- * Turnover low: weekly schedule* Turnover high: daily schedule

- Large number of subspecialties: how to organize the best supervision? more need for joint meeting, “transactive memory”, good relationships

- Seriousness of illness: more active supervision- Job crafting: physical and psychological accessibility

ConclusionConclusion

• Organizing handovers depends on several variables. Dominant seem to be:

- patient characteristics - flow characteristics- number of subspecialties

• However: organizing handovers is a matter of hard and soft contingencies

• Research used to improve clinical handovers• Next project: developing organization of

handovers in a MD with a patient oriented grouping