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Abstract
Background Handoffs are ubiquitous in modern healthcare practice, and they can be a point of resilience and care continuity. However, they are prone to a variety of issues. Handoffs are linked to 80% of serious medical errors and are implicated in one of three malpractice suits. Furthermore, poorly performed handoffs can lead to information loss, duplication of efforts, diagnosis changes and increased mortality.
Methods This article proposes a holistic approach for healthcare organisations to achieve effective handoffs within their units and departments.
Results We examine the organisational considerations (ie, the facets controlled by higher-level leadership) and local drivers (ie, the aspects controlled by the individuals working in the units and providing patient care).
Conclusion We propose advice for leaders to best enact the processes and cultural change necessary to see positive outcomes associated with handoffs and care transitions within their units and hospitals.
- strategy
- communication
- improvement
- organisational effectiveness
- standardisation
Data availability statement
No data are available.
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Within healthcare, a handoff refers to the transference of responsibility of care from at least one provider to at least one other provider,1 and it involves the delivery and receipt of information. As no individual healthcare provider can be responsible for a patient at all times, handoffs are an inevitable part of the medical process. Many medical procedures involve moving patients between teams of providers (ie, preop, to surgery, to postop), which make handoffs ubiquitous in almost all types of in-hospital patient care. See further for an example scenario surrounding handoffs.
The staff of a cardiac care unit is changing shift. Nurses who were present overnight are preparing to go home, and a new team is arriving for a 12-hour shift. The lead nurse from the night before begins by providing updates on unit-level activities (eg, an upcoming “downtime” for part of the electronic health record) and an overview of the unit census (eg, there are four post procedural patients in the unit and five planned procedures for the upcoming day). Individual outgoing staff members then pair with an incoming staff member to “handoff” their patients. Each nurse from the last shift begins to handoff their patients, providing both objective information from the chart as well as interpretation of what the data could mean for the upcoming shift. A new patient is arriving on the floor, so one set of nurses are hurrying to get through handoff before the new patient arrives. Another nurse is spending extra time handing off a patient that has been particularly challenging over the past shift. The receiving nurse is taking notes to remind him of specific facts. These notes or “artifacts” will help guide care throughout the day; however, they also present possible threats to safety and can create confusion when they contradict information in the healthcare record.
When performed ‘effectively’, a handoff allows for continuity of care and coordination across multiple individuals and teams. Effective handoffs optimise both content and processes and serve as a mechanism to foster care continuity, build shared mental models and allow for additional perspectives to enhance decision making. Unfortunately, each handoff also represents a significant threat to patient safety because a handoff that conveys inaccurate, outdated or incomplete information can have dire consequences.2 According to one analysis, one in three malpractice cases that resulted in patient harm were attributed to communication failures, amounting to $1.7 billion in incurred losses.3 Errors in communication during handoffs may be implicated in as many as 80% of serious medical errors.2 More specifically, poor handoffs have been associated with information loss,4–6 adverse events,5 duplication of efforts,5 changes in diagnoses7 and increased mortality.8
Recent systematic reviews suggest that handoff improvement interventions such as a structured handoff protocol are an effective mechanism for improving subpar handoffs.9 10 Many of these interventions are specific to a profession (eg, anaesthesiologists) or involve a particular handoff tool such as situation, background, assessment, and recommendation or illness severity, patient summary, action list, situational awareness and synthesis by receiver.11
While helpful, these focused, local interventions are often insufficient because handoffs take place within a larger institutional context that can facilitate or hinder their effectiveness. Healthcare organisations would benefit from taking a more holistic, multilevel approach (ie, an approach that examines, enables, and enhances handoffs from both a top-down organisational and a bottom-up local perspective), treating it as an ongoing change management effort. From an organisational perspective, hospitals and medical centres should ensure that the conditions are in place (eg, systems, data, training, support, culture and resources) to facilitate handoffs while setting the stage for local initiatives. Top-down efforts can target system-wide needs and priorities, fund and establish recommended practices and shareable resources, and foster cross-unit sharing of best practices. At the local level, units and departments can identify and tackle specific needs, ensure system-wide and unit-specific recommendations are being followed, and communicate needs and lessons learnt to inform subsequent top-down efforts. As shown in figure 1, organisational considerations and local drivers can work together to avert or minimise unnecessary handoffs and ensure the quality of necessary ones.
Organisational conditions and local drivers for effective handoffs.
Organisational considerations for prioritising effective handoffs
Although handoff efforts often originate at the local level (ie, specific departments or units) and are typically implemented in such contexts, attempts to understand and improve handoffs should not reside exclusively at the local level. Organisational actions can set the stage for local actions. Three such organisational actions are shown in figure 1: (1) assessing the current state and organisational readiness, (2) reducing/eliminating unnecessary handoffs and (3) ensuring handoff quality. Assessing the current state involves clarifying the areas of greater need. Assessing current readiness can help prioritise handoff improvement efforts by establishing the frequency and likely risk of specific handoff points throughout the organisation. As part of this, the organisation should periodically attempt to answer two questions: what are the most common/frequent handoff points? and where are the greatest risk points? An example of assessing the current state is provided further.
In response to a recent near-miss event, the director of patient safety seeks to understand more about handoffs across the institution. She develops and administers a survey to examine where and how frequently handoffs occur, who is involved in handoff processes, and when formal (eg, shift change) and informal handoffs (eg, ‘covering’ for lunch) occur within each unit. She then works with her team to observe various units, thus allowing her to augment survey data (‘work as described’) with direct observation (‘work as done’). These data are mapped out at an organisational level to help understand the flow of information, surface gaps in knowledge and process, and identify opportunities for improvement. The director of patient safety recognises the lack of standardisation across units and identifies a few places where it may be possible to reduce the number of handoffs.
Based on the current state assessment, it may be possible to identify areas where the frequency of risky or unnecessary handoffs may be reduced, perhaps by shifting work processes or other organisational changes (eg, adjustments to scheduling that preclude the need for a handoff). While candidates for reducing handoff frequency may be identified organisationally, in most instances, the feasibility and practicality of making such changes will need to be confirmed at the local level. Clearly, though, not all handoffs can be curtailed; some handoffs are and will always be necessary, given shift lengths and the scope of most patient care paths (eg, surgery). Therefore, we need to ensure the quality of those handoffs. Properly conducted handoffs offer many benefits (eg, boosting resilience, building shared mental models, updating information and providing a learning opportunity).
Recommendations at the organisational level
Recommendation 1: establish recommended practices that promote high-quality handoffs
High-quality handoffs typically rely on a structured handoff process, deter interruptions, employ face-to-face communications, include closed-loop communications and are allotted ample time.12 Although these recommended practices apply universally to any handoff, they may manifest differently in various specialty areas, and other locally relevant practices may be needed. For example, information that must be conveyed in one area may be superfluous in another. For a postoperative patient, information about estimated blood loss in surgery might be essential, whereas for a patient who had a stroke, clear transmission of information related to the neurological exam is critical. However, in both instances, information recipients should use closed-loop communications to ensure information exchange accuracy. At the organisational level, it is helpful to identify handoff practices that apply across the system to help establish a common starting point for local initiatives, but that does not suggest that all handoff processes will be identical.
Recommendation 2: consistently communicate about the importance of, and best practices for, effective handoffs
To ensure quality, it is important to consistently send messaging throughout the organisation about the criticality of handoffs and the need to adhere to best practices of effective handoffs.13 This messaging should come from senior leadership, but it is also important to identify trusted leaders at the unit level who will champion this message throughout the organisation. A simple but important component of this messaging is that everyone involved in handoffs, whether receiver or sender, is expected to solicit and ask questions and voice any concerns that emerge during a handoff.
Recommendation 3: ensure that accurate, timely information is readily available at key handoff points
Quality handoffs rely on accurate, readily available information.12 A cumbersome user experience (eg, an awkward interface or poorly designed report) can hinder a provider’s access to potentially important information and can lead to the conveyance of inaccurate information. Confusing or complex electronic medical record interfaces make it more difficult to enter or extract information, potentially producing delayed or outdated information at the time of the handoff. Identifying and remediating information gaps or confusion can eliminate a key barrier to handover quality. Further, we provide an example of an instance where adjustments were made to improve the quality of information available during handoffs.
The in-depth analysis performed by the Director of Patient Safety identified a few information “risk points.” She noted that providers often created artifacts to support their exchange of information, and that the information captured was important for patient care, yet could pose a safety hazard. She assembled a workgroup to examine these artifacts and design a more robust set of tools that could be deployed across several units. For example, they recommended that post-procedure notes from the cardiac catheterization could populate a cognitive aid in the electronic healthcare record. The recovery team could add a brief note, so that the nuances of the patient’s care isn’t lost. This could look like a set of vital signs, a neurological exam, and fluid intake, with a brief message that the patient was disoriented for an extended period of time. The data-driven information was helpful, and the addition of expert observations yielded crisp yet meaningful documentation to inform the handoff.
Recommendation 4: provide training resources that create opportunities for practice and feedback
Care providers are more likely to conduct quality handoffs if they have access to relevant training resources, have the opportunity for practice, and receive constructive, timely feedback.14 At the organisational level, leadership should ensure resources are available for developing and delivering training that builds handover-related competencies. Because effective handoffs are contingent on the conveyance of accurate and timely information, it is critical that individuals are trained how to synthesise received information, ask clarifying questions and employ closed-loop communication techniques. Although seasoned clinicians may see less of a need to participate in such training, it is important that providers across the medical education continuum have opportunities for practice and feedback,15 as such experts can model exemplary behaviour that help novices learn the desired behaviours.16 For a summary of these recommendations, please see table 1.
Organisational recommendations for promoting effective handoffs
The organizational workgroup develops and implements a handoff training module that complements current team training efforts. The module targets the knowledge, skills, and attitudes necessary to implement effective handoffs. The training module is then adapted by each unit to ensure relevance while maintaining a core set of educational objectives. The organization facilitates training by providing the time and staff needed to allow full participation by all staff.
To ensure sustainability, the workgroup performs observations of unit handoff processes to identify implementation challenges and note opportunities for improvement. They consider if it makes sense to create more formal ways to evaluate handoffs and provide feedback. They decide that in situ simulations can provide opportunities to observe staff performing handoffs in low-risk situations. They decide to use those simulations to offer “safe” feedback to individuals, and to identify system-level threats related to handoff processes.
Local drivers for enabling handoffs
At the local level, it is important to clarify expectations about recommended handover practices including process, protocol, timing, location, participants and interruptions. Ultimately, everyone who will be performing handoffs needs a shared mental model (ie, a common understanding) about how handoffs should be conducted in their unit.
Recommendations at the local level
Recommendation 1: ensure team members receive adequate training and have tools that support structured communications and handoffs
Quality handoffs typically follow an agreed-on process to convey necessary information. The proper handoff process can be reliant heavily on context to ensure that a shared mental model emerges as a result of the handoff exchange. Teams that have a shared mental model are not simply ‘born’; they require adequate training.14 Local leadership is typically in the best position to ensure that their teams have the training and tools they need to develop and sustain shared, accurate mental models about their patients and a common understanding of how handoffs should occur in their unit.
Recommendation 2: follow and reinforce the recommended structured handoff protocols consistently
Handoff tools and processes are only effective if providers adhere to the recommended structured handoff protocols consistently. This recommendation may seem intuitive, but deviation from protocol is quite prevalent. According to a report by the Joint Commission in 2017, gaps in communication during handoff processes continue to exist. Research has shown that without a standard handoff process, up to 72% of handoffs contained at least one error.17 Therefore, a structured handoff process should be enacted locally by each unit especially for complex handoffs and handoffs across units (ie, surgical handoffs to postanaesthesia care). Local leaders should model and reinforce effective handoff practices such as ensuring the presence of relevant team members; exchanging patient information including diagnosis, recent changes, anticipated events and treatment course; and leaving time for questions and answers.18
Recommendation 3: promote psychological safety
Psychological safety involves the willingness to take interpersonal risks through behaviours, such as asking and soliciting questions and raising concerns. A lack of psychological safety can greatly jeopardise handoff quality. According to Edmondson et al,19 there are five organisational antecedents that can lead to psychological safety. These include team leader behaviour, informal group dynamics, trust and respect, use of practice, and supportive organisational context.19 Local leadership needs to ensure that anyone involved with a handoff can confidently ask questions and clarify information, without fear of repercussions based on authority gradient. Improved psychological safety can positively influence feedback and help-seeking behaviours, speaking up about concerns, innovation and boundary spanning.19
Recommendation 4: provide local feedback to providers and provider teams
To remediate handoff performance or even consistently conduct effective handoffs, providers and teams need local feedback. To best improve handoff quality, timely and detailed feedback should be given to providers and provider teams. For example, trained observers could periodically provide constructive feedback about whether ample time was spent in the handoff, accurate information was provided, closed-loop confirmation was exhibited, and clarifying questions were asked. Feedback is also useful for encouraging providers to be accountable to one another, providing adequate information, and conveying a high-quality synthesis of the handoff by the recipient.
Finally, to ensure local and organisational alignment, units and departments should identify and communicate their handoff needs and lessons learnt in a bottom-up manner. This can inform and update leadership about organisational conditions, and surface needs that merit broader attention/resources. Units can also share successes and best practices. When effective handoff techniques are shared centrally, they can then be disseminated to others in the organisation or incorporated into future training and tools. For a summary of these recommendations, please see table 2.
Team-level (‘local’) recommendations for promoting effective handoffs
Implications of a multilevel perspective
Taking a multilevel approach requires a specific way of conceptualising and approaching the problems and solutions associated with handoffs. Because this multilevel approach is not necessarily the norm (efforts are local driven as opposed to approached holistically), it is important to consider the implications of this approach.
One key takeaway is that that improving handoff quality should not rely solely on handoff education and interventions (eg, introducing a handoff protocol bundle). Although educational interventions can certainly strengthen handoffs, other forms of improvement can target scheduling, dedicated handoff environments or changes to bedside layouts. Scheduling changes, for instance, could restructure handoffs in a way that reduces information loss; meanwhile, dedicated handoff environments may provide an opportunity to mitigate distractions or interruptions. Put simply, modifications to improve the safety surrounding handoffs goes well beyond the introduction of a handoff-training curriculum or tools.
Another noteworthy point is that a multilevel approach entails effortful, organisational change. Simply focusing on the local level may result in unnecessary or redundant efforts and will likely be insufficient to sustain long-term change. From top-level decision makers to front-line providers, everyone involved can contribute to and support ongoing improvements to handoff processes that can enhance workflow, patient outcomes and financial results. Clearly, handoff changes and potential improvements are executed at the local level; however, central leadership can provide guidance and support for change, and can communicate best practices and the priorities of the organisation.
Finally, we posit that a holistic approach is intrinsically iterative. Embracing a holistic approach includes a future in which the organisation continually monitors and adjusts the processes surrounding handoffs. There is a need for consistent reporting of insights from the local level (ie, the front-line providers) to the organisational level, and in turn, policy and resource decisions should be responsive to local needs. Success becomes more than just the typically measured outcomes (eg, errors) and instead becomes a constellation of metrics that are applied at multiple levels of the organisation ranging from data on individual handoffs up to organisational culture. For instance, longitudinal data may be collected (eg, through surveys, observations and patient charts) about the handoff practices and patient outcomes. Ultimately, the metrics collected can be used to monitor handoffs consistently across time to iteratively improve the process and ensure that changes are working as intended.
Conclusion
Handoffs are a frequent, team-based event that can be critical to patient care and safety. To manage the improvement and sustainment of effective handoffs, organisations should take a holistic approach. Leadership must mindfully approach optimising handoff processes and ensuring handoff quality at both the organisational level and the local level. It is best to view this as an iterative, ongoing learning opportunity where change efforts are assessed for efficacy and improvement across time.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Contributors All author’s contributed substantively throughout the writing of this paper. The idea was originated among JRK, EL, ST and ES. We then brought on RF and PG as our medical counterparts to refine and ground the ideas. AG helped substantively with literature review and iterative drafts of the manuscript. RF also provided vignettes throughout the manuscript. All authors wrote a portion of the manuscript and worked on multiple edits and iterations to achieve the final version presented here.
Funding This work was partially supported by the Center for Clinical and Translational Sciences (University of Texas Health Science Center, Houston, Texas, USA), which is funded by the National Institutes of Health (Clinical and Translational Award UL1 TR003167) from the National Center for Advancing Translational Sciences. Rice University is a partner on this grant. This work was also partially funded by the University of Texas Southwestern Office of Medical TeamFIRST Quality Enhancement Plan (no award grant number).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.