Co-ordination of clinical handover: a contingency approach Manda Broekhuis and Tanja Lips University of Groningen, University Hospital Groningen The Netherlands

The 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 handovers Supervision Patient record Large ward round Multidisciplinary handovers - delineation: handovers between physicians

Introduction Clinical handover: Weak link in the chain of the health care process And, at the same time, little research on the subject

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

Research 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 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 propositions ContingencyIntensityFormalization Size Patiënt flow -Inpatients -Outpatients -Turnover rate -Predictability Patient characteristics Number of medical sub specialisms No impact No impact

University Hospital Groningen

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

Method 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 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 units General surgeryLung diseaseSpecial dentistry and oral surgery Large unit (in terms of beds and staff) Small unit Many sub- specialties Medium number sub-specialties Medium turnoverLow turnoverHigh turnover Mix inpatients and outpatients More inpatientsMore outpatients Life threatening and not life threatening BothNot life threatening

Pattern 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 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

Formalization 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 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

Conclusion 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