Action 6.08 states
Clinicians use structured clinical handover processes that include:
- Preparing and scheduling clinical handover
- Having the relevant information at clinical handover
- Organising relevant clinicians and others to participate in clinical handover
- Being aware of the patient’s goals and preferences
- Supporting patients, carers and families to be involved in clinical handover, in accordance with the wishes of the patient
- Ensuring that clinical handover results in the transfer of responsibility and accountability for care
Intent
Clinicians use structured clinical handover processes that are consistent with the key principles of clinical handover, to effectively communicate relevant, accurate and up-to-date information about a patient’s care to ensure patient safety.
Reflective questions
How does the health service organisation describe the different situations in which structured clinical handover should take place, the method of communication, who should be involved and the structured communication tools to assist with handover?
How are the patient’s goals and preferences communicated to those involved in clinical handover?
How does the health service organisation ensure that discharge summaries are provided to the relevant people involved in a patient’s ongoing care?
Key tasks
- Document the structured clinical handover processes required in the organisation, ensuring that they are consistent with the key principles for clinical handover
- Clearly communicate the clinical handover policies and processes to the workforce, including expectations for using clinical handover processes
- Provide access to structured clinical handover tools
- Support the workforce, patients and carers to use structured clinical handover processes and tools.
Strategies for improvement
Hospitals
A helpful clinical communication framework to consider is the NSW Health Clinical Handover – Standard Key Principles, which has also been adapted by the Quality Improvement Clinic in the United Kingdom.1
The framework outlines five key principles for clinical handover:
- Leadership – nominated leader for each clinical handover or transfer of care
- Values – clinical handover at transitions of care are valued as essential to the delivery of safe care, and preparation for clinical handover is a priority
- Right people – the appropriate people are involved
- Specified time and/or place (if appropriate) – a specified setting or place has been agreed, and there is an agreed time, duration and frequency for clinical handover to occur
- Standardised process – an agreed process for clinical handover that includes an agreed set of information to be covered in transfers (minimum information content, see Action 6.07), which is communicated in a structured way, is action-focused, assigns responsibility for actions and is supported by clear documentation (see Action 6.11).
Outline the transition-of-care situations when effective clinical handover is critical to safe patient care. Consider the format in which handover might occur and how it should be delivered.
Conduct clinical handover using a structured format. Document clear, structured processes for transferring relevant patient information, accountability and responsibility for care in the organisation’s policy, using the steps outlined in this action.2, 3 This is to ensure that everyone knows the process for clinical handover, their roles and responsibilities, and what is expected.
Prepare for and schedule clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.1
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members (such as nursing, allied health or psychosocial clinicians, if appropriate).
Inform participants of the clinical handover processes and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, where appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patients who require considerable levels of attention or immediate care (for example, patients who could be, or are, deteriorating, or who may present occupational safety issues)
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
This action links to, and is supported by, Action 1.16 in the Clinical Governance Standard and Action 6.11. This requires organisations to integrate multiple information systems (where they are in use), enable access to the healthcare record at the point of care, and ensure that systems are in place to contemporaneously document relevant information in the healthcare record.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins.
The designated leader manages and facilitates the handover. This is usually the role of the most senior clinician present; however, this will depend on the handover, and it may be more appropriate to designate a clinician who is involved in coordinating a patient’s care.
If appropriate, implement multidisciplinary team handovers or rounds. These should be structured, and when and how often they take place will depend on the context of the health service organisation. Also consider whether all participants need to be present for the whole transfer, or only part of it.
Be aware of the patient’s goals and preferences
Ensure that all participants who are involved in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer if appropriate.
The TOP 5 initiative in New South Wales encourages clinicians to engage with carers to gain valuable non-clinical information to help personalise care for patients with cognitive impairment. This information is made available to every member of the healthcare team to improve communication between the patient, the carer and the team, and information is documented on a TOP 5 form:
- T – Talk to the carer
- O – Obtain the information
- P – Personalise the care
- 5 – Strategies developed.
Support patient, carer and family involvement
Patients often feel anxious when they are being moved or their care is being transferred, particularly if no information is provided to them about the transfer or what to expect. Engage patients in transition communications to help alleviate this anxiety. Strategies to engage patients in transition communications could include6:
- Using bedside handover, which has been shown to improve patient safety and patient satisfaction by increasing the accuracy and timeliness of information transferred7, 8; however, bedside handover may not be appropriate for all circumstances or services, so consider the particular needs of the patients and the organisation
- Providing specific opportunities to include patients, carers and families in rounds, such as pausing and requesting their input and letting them know the team will follow up on complex questions and any concerns after the round
- Ensuring that structured communication tools are patient focused, such as including an opportunity to engage and communicate with patients as part of the tool
- Placing patient care boards or whiteboards around the patient’s bedside that record key information about the comprehensive care plan (such as upcoming tests and patient goals), and allowing patients, carers and families to write comments on the board for the workforce
- Signposting the organisation’s processes for transfer, including providing clear information about the steps the patient is likely to go through and the different demands that may be made of them along the way, and allowing patients, family members and carers to ask questions
- Providing patients (and carers and families, if appropriate) with discharge information, including about any follow-up appointments
- Developing a display of care team members and their roles, such as a photo board.9
Consider how the privacy of a patient and confidentiality of patient information is maintained during transfers of care. This includes when patients are engaged in clinical handover at the bedside. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet. Ask the patient if they are comfortable with bedside handovers, and let them know the purpose of bedside handovers and why they can play an important role. Let them know that sensitive information may be discussed and ask if they are comfortable with this.10 When sensitive information is handed over in a private area, involve patients by asking them if they have questions or comments, or inviting them to confirm or clarify information. Detail the options and requirements to ensure privacy in the organisation’s privacy policy, and reflect this in the organisation’s handover policy.
Also see Case study 2 in Action 6.03.
Ensure transfer of responsibility and accountability for care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as iSoBAR, ISBAR, SBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility for care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Rounding checklists
- Changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
Day Procedure Services
Conduct clinical handover using a structured format. Document clear, structured processes for transferring relevant patient information, accountability and responsibility of care in the organisation’s policy, using the steps outlined in this action. This is to ensure that everyone knows the process for clinical handover, their roles and responsibilities, and what is expected.
Prepare for, and schedule, clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.11 Day procedure services that have limited patient contact time still need to consider these factors in planning clinical handover.
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members.
Inform participants of the clinical handover processes, and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, if appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patient risks identified during pre-admission screening
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This information may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
This action links to, and is supported by, Action 1.16 in the Clinical Governance Standard and Action 6.11. It requires organisations to integrate multiple information systems (where they are in use), enable access to the healthcare record at the point of care, and ensure that systems are in place to contemporaneously document relevant information in the healthcare record.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins. This will depend on the situation of the handover.
Ensure that all participants in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer, where appropriate.
Support patient, carer and family involvement
It is essential to consider how the privacy of a patient and confidentiality of patient information are maintained during transfers of care. This includes when patients are engaged in clinical handover in or near a waiting area. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet.
Mechanisms to signpost the service’s processes, particularly when a patient is moved within the service (for example, admission to procedure, procedure to recovery), may be helpful. This could include information about the steps the patient is likely to go through and the different demands that may be made of them along the way.
Provide patients (and families and carers, if appropriate) with discharge information, including information about:
- How to manage their care when they leave the organisation
- Medicines
- Any follow-up appointments or referrals.
Ensure transfer of responsibility and accountability of care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as SBAR, ISBAR, iSoBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility of care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Information on changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
Examples of evidence
Select only examples currently in use:
- Policy documents that describe a structured clinical handover process, taking into account the setting, the minimum information content to be transferred, the relevant workforce to be involved, patient needs and care goals, and accountability for care
- Observation of clinicians’ practice that shows use of structured clinical handover processes and tools
- Records of interviews with clinicians that show that they understand the health service organisation’s structured clinical handover processes
- Records of workforce attendance at regularly scheduled meetings in which structured clinical handover takes place
- Audit results of completed documentation that demonstrates effective handover of responsibility for care, such as
- standardised transfer (intra- and inter-organisation) forms
- completed transfer forms
- standardised referral letters or discharge summaries
- checklists for ward rounds
- changes to patient care plans and pathways
- Audit results of workforce compliance with clinical handover policies, procedures or protocols
- Training documents about responsibilities and processes for clinical handover
- Communication with the workforce regarding clinical handover processes
- Information provided to consumers, carers and families that outlines their role in clinical handover processes, such as a patient charter of rights or patient admission information sheet
- Results of a patient experience survey, and patient feedback about their participation in clinical handover
- Results from workforce satisfaction surveys and feedback about referral and use of clinical handover processes.
MPS & Small Hospitals
MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established structured clinical handover processes.
Small hospitals that are not part of a local health network or private hospital group should:
- Document the structured clinical handover processes required in the organisation, ensuring that they are consistent with the key principles of clinical handover
- Clearly communicate the clinical handover policies and processes to the workforce, including expectations for using clinical handover processes
- Provide access to structured clinical handover tools
- Support the workforce, patients and carers to use structured clinical handover processes and tools.
Prepare for and schedule clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.11
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members (such as nursing, allied health or psychosocial clinicians, if appropriate).
Inform participants of the clinical handover processes and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, if appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patients who require considerable levels of attention or immediate care (for example, patients who could be, or are, deteriorating, or who may present occupational safety issues)
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This information may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins.
The designated leader manages and facilitates the handover. This is usually the role of the most senior clinician present; however, this will depend on the handover, and it may be more appropriate to designate a clinician who is involved in coordinating a patient’s care.
If appropriate, implement multidisciplinary team handovers or rounds. These should be structured, and when and how often they take place will depend on the context of the health service organisation. Also consider whether all participants need to be present for the whole transfer, or only part of it.
Be aware of the patient’s goals and preferences
Ensure that all participants who are involved in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer if appropriate.
The TOP 5 initiative in New South Wales encourages clinicians to engage with carers to gain valuable non-clinical information to help personalise care for patients with cognitive impairment. This information is made available to every member of the healthcare team to improve communication between the patient, the carer and the team, and information is documented on a TOP 5 form:
- T – Talk to the carer
- O – Obtain the information
- P – Personalise the care
- 5 – Strategies developed.
Support patient, carer and family involvement
Patients often feel anxious when they are being moved or their care is being transferred, particularly if no information is provided to them about the transfer or what to expect. Engage patients in transition communications to help alleviate this anxiety. Strategies to engage patients in transition communications could include:
- Ensuring that structured communication tools are patient focused, such as including an opportunity to engage and communicate with patients as part of the tool
- Placing patient care boards or whiteboards around the patient’s bedside that record key information about the comprehensive care plan (such as upcoming tests and patient goals), and allowing patients, carers and families to write comments on the board for the workforce
- Signposting the organisation’s processes for transfer, including providing clear information about the steps the patient is likely to go through and the different demands that may be made of them along the way, and allowing patients, family members and carers to ask questions.
Consider how the privacy of a patient and confidentiality of patient information is maintained during transfers of care. This includes when patients are engaged in clinical handover at the bedside. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet. Ask the patient if they are comfortable with bedside handovers, and let them know the purpose of bedside handovers and why they can play an important role. Let them know that sensitive information may be discussed and ask if they are comfortable with this.10 When sensitive information is handed over in a private area, involve patients by asking them if they have questions or comments, or inviting them to confirm or clarify information. Detail the options and requirements to ensure privacy in the organisation’s privacy policy, and reflect this in the organisation’s handover policy.
Ensure transfer of responsibility and accountability of care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as SBAR, ISBAR, iSoBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility of care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Rounding checklists
- Information on changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
Hospitals
A helpful clinical communication framework to consider is the NSW Health Clinical Handover – Standard Key Principles, which has also been adapted by the Quality Improvement Clinic in the United Kingdom.1
The framework outlines five key principles for clinical handover:
- Leadership – nominated leader for each clinical handover or transfer of care
- Values – clinical handover at transitions of care are valued as essential to the delivery of safe care, and preparation for clinical handover is a priority
- Right people – the appropriate people are involved
- Specified time and/or place (if appropriate) – a specified setting or place has been agreed, and there is an agreed time, duration and frequency for clinical handover to occur
- Standardised process – an agreed process for clinical handover that includes an agreed set of information to be covered in transfers (minimum information content, see Action 6.07), which is communicated in a structured way, is action-focused, assigns responsibility for actions and is supported by clear documentation (see Action 6.11).
Outline the transition-of-care situations when effective clinical handover is critical to safe patient care. Consider the format in which handover might occur and how it should be delivered.
Conduct clinical handover using a structured format. Document clear, structured processes for transferring relevant patient information, accountability and responsibility for care in the organisation’s policy, using the steps outlined in this action.2, 3 This is to ensure that everyone knows the process for clinical handover, their roles and responsibilities, and what is expected.
Prepare for and schedule clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.1
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members (such as nursing, allied health or psychosocial clinicians, if appropriate).
Inform participants of the clinical handover processes and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, where appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patients who require considerable levels of attention or immediate care (for example, patients who could be, or are, deteriorating, or who may present occupational safety issues)
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
This action links to, and is supported by, Action 1.16 in the Clinical Governance Standard and Action 6.11. This requires organisations to integrate multiple information systems (where they are in use), enable access to the healthcare record at the point of care, and ensure that systems are in place to contemporaneously document relevant information in the healthcare record.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins.
The designated leader manages and facilitates the handover. This is usually the role of the most senior clinician present; however, this will depend on the handover, and it may be more appropriate to designate a clinician who is involved in coordinating a patient’s care.
If appropriate, implement multidisciplinary team handovers or rounds. These should be structured, and when and how often they take place will depend on the context of the health service organisation. Also consider whether all participants need to be present for the whole transfer, or only part of it.
Be aware of the patient’s goals and preferences
Ensure that all participants who are involved in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer if appropriate.
The TOP 5 initiative in New South Wales encourages clinicians to engage with carers to gain valuable non-clinical information to help personalise care for patients with cognitive impairment. This information is made available to every member of the healthcare team to improve communication between the patient, the carer and the team, and information is documented on a TOP 5 form:
- T – Talk to the carer
- O – Obtain the information
- P – Personalise the care
- 5 – Strategies developed.
Support patient, carer and family involvement
Patients often feel anxious when they are being moved or their care is being transferred, particularly if no information is provided to them about the transfer or what to expect. Engage patients in transition communications to help alleviate this anxiety. Strategies to engage patients in transition communications could include6:
- Using bedside handover, which has been shown to improve patient safety and patient satisfaction by increasing the accuracy and timeliness of information transferred7, 8; however, bedside handover may not be appropriate for all circumstances or services, so consider the particular needs of the patients and the organisation
- Providing specific opportunities to include patients, carers and families in rounds, such as pausing and requesting their input and letting them know the team will follow up on complex questions and any concerns after the round
- Ensuring that structured communication tools are patient focused, such as including an opportunity to engage and communicate with patients as part of the tool
- Placing patient care boards or whiteboards around the patient’s bedside that record key information about the comprehensive care plan (such as upcoming tests and patient goals), and allowing patients, carers and families to write comments on the board for the workforce
- Signposting the organisation’s processes for transfer, including providing clear information about the steps the patient is likely to go through and the different demands that may be made of them along the way, and allowing patients, family members and carers to ask questions
- Providing patients (and carers and families, if appropriate) with discharge information, including about any follow-up appointments
- Developing a display of care team members and their roles, such as a photo board.9
Consider how the privacy of a patient and confidentiality of patient information is maintained during transfers of care. This includes when patients are engaged in clinical handover at the bedside. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet. Ask the patient if they are comfortable with bedside handovers, and let them know the purpose of bedside handovers and why they can play an important role. Let them know that sensitive information may be discussed and ask if they are comfortable with this.10 When sensitive information is handed over in a private area, involve patients by asking them if they have questions or comments, or inviting them to confirm or clarify information. Detail the options and requirements to ensure privacy in the organisation’s privacy policy, and reflect this in the organisation’s handover policy.
Also see Case study 2 in Action 6.03.
Ensure transfer of responsibility and accountability for care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as iSoBAR, ISBAR, SBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility for care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Rounding checklists
- Changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
Day Procedure Services
Conduct clinical handover using a structured format. Document clear, structured processes for transferring relevant patient information, accountability and responsibility of care in the organisation’s policy, using the steps outlined in this action. This is to ensure that everyone knows the process for clinical handover, their roles and responsibilities, and what is expected.
Prepare for, and schedule, clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.11 Day procedure services that have limited patient contact time still need to consider these factors in planning clinical handover.
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members.
Inform participants of the clinical handover processes, and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, if appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patient risks identified during pre-admission screening
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This information may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
This action links to, and is supported by, Action 1.16 in the Clinical Governance Standard and Action 6.11. It requires organisations to integrate multiple information systems (where they are in use), enable access to the healthcare record at the point of care, and ensure that systems are in place to contemporaneously document relevant information in the healthcare record.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins. This will depend on the situation of the handover.
Ensure that all participants in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer, where appropriate.
Support patient, carer and family involvement
It is essential to consider how the privacy of a patient and confidentiality of patient information are maintained during transfers of care. This includes when patients are engaged in clinical handover in or near a waiting area. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet.
Mechanisms to signpost the service’s processes, particularly when a patient is moved within the service (for example, admission to procedure, procedure to recovery), may be helpful. This could include information about the steps the patient is likely to go through and the different demands that may be made of them along the way.
Provide patients (and families and carers, if appropriate) with discharge information, including information about:
- How to manage their care when they leave the organisation
- Medicines
- Any follow-up appointments or referrals.
Ensure transfer of responsibility and accountability of care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as SBAR, ISBAR, iSoBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility of care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Information on changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
Examples of evidence
Select only examples currently in use:
- Policy documents that describe a structured clinical handover process, taking into account the setting, the minimum information content to be transferred, the relevant workforce to be involved, patient needs and care goals, and accountability for care
- Observation of clinicians’ practice that shows use of structured clinical handover processes and tools
- Records of interviews with clinicians that show that they understand the health service organisation’s structured clinical handover processes
- Records of workforce attendance at regularly scheduled meetings in which structured clinical handover takes place
- Audit results of completed documentation that demonstrates effective handover of responsibility for care, such as
- standardised transfer (intra- and inter-organisation) forms
- completed transfer forms
- standardised referral letters or discharge summaries
- checklists for ward rounds
- changes to patient care plans and pathways
- Audit results of workforce compliance with clinical handover policies, procedures or protocols
- Training documents about responsibilities and processes for clinical handover
- Communication with the workforce regarding clinical handover processes
- Information provided to consumers, carers and families that outlines their role in clinical handover processes, such as a patient charter of rights or patient admission information sheet
- Results of a patient experience survey, and patient feedback about their participation in clinical handover
- Results from workforce satisfaction surveys and feedback about referral and use of clinical handover processes.
MPS & Small Hospitals
MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established structured clinical handover processes.
Small hospitals that are not part of a local health network or private hospital group should:
- Document the structured clinical handover processes required in the organisation, ensuring that they are consistent with the key principles of clinical handover
- Clearly communicate the clinical handover policies and processes to the workforce, including expectations for using clinical handover processes
- Provide access to structured clinical handover tools
- Support the workforce, patients and carers to use structured clinical handover processes and tools.
Prepare for and schedule clinical handover
Consider the organisation’s environment and decide on the best time for clinical handovers to take place. This may include assessing the environment that the handover is taking place in (for example, ensuring that participants can hear and see each other without interruptions), and setting an agreed time, duration and frequency for clinical handover.11
Nominate all key participants for clinical handovers. Consider the need for multidisciplinary input, including clinical and non-clinical workforce members (such as nursing, allied health or psychosocial clinicians, if appropriate).
Inform participants of the clinical handover processes and expectations for participating in handover.
If possible, involve patients, carers and families as key participants in handover.
Allocate specific roles to members of the workforce during handover to ensure continuity of patient care and reduce disruptions. This includes nominating a leader at each clinical handover.
Set the method and location for clinical handover, preferably face to face and in the patient’s presence, if appropriate.
Make structured communication tools, such as iSoBAR, ISBAR, SBAR or SHARED, available to the workforce. These tools are designed to be flexible and adaptable to the local workforce environment. Resources including videos and templates are available on the Commission's website.
Support clinicians and the workforce to have situational awareness. This refers to maintaining an awareness of the ‘big picture’, and thinking ahead to plan and discuss contingencies. Ensure an open and ongoing dialogue as part of the handover, which keeps members of the team up to date with what is happening and how they will respond if the situation changes. This includes informing the workforce about:
- Patients who require considerable levels of attention or immediate care (for example, patients who could be, or are, deteriorating, or who may present occupational safety issues)
- Potential patient movements
- The condition of the work environment and staffing numbers that may affect safety (for example, high workload, busy environment).4, 5
Have relevant information at clinical handover
To ensure that the most up-to-date and relevant information is communicated, put systems and processes in place to enable clinicians to obtain the necessary documents and information before handover. This information may include the healthcare record, advance care plans, progress notes, prepared handover sheets, test results, and information written on electronic journey boards or patient care whiteboards.
Organise relevant clinicians and others to participate
All relevant participants should be present before handover begins.
The designated leader manages and facilitates the handover. This is usually the role of the most senior clinician present; however, this will depend on the handover, and it may be more appropriate to designate a clinician who is involved in coordinating a patient’s care.
If appropriate, implement multidisciplinary team handovers or rounds. These should be structured, and when and how often they take place will depend on the context of the health service organisation. Also consider whether all participants need to be present for the whole transfer, or only part of it.
Be aware of the patient’s goals and preferences
Ensure that all participants who are involved in the handover are aware of the patient’s goals and preferences (see Action 5.13).
If unsure, check with the patient, or their family or carer if appropriate.
The TOP 5 initiative in New South Wales encourages clinicians to engage with carers to gain valuable non-clinical information to help personalise care for patients with cognitive impairment. This information is made available to every member of the healthcare team to improve communication between the patient, the carer and the team, and information is documented on a TOP 5 form:
- T – Talk to the carer
- O – Obtain the information
- P – Personalise the care
- 5 – Strategies developed.
Support patient, carer and family involvement
Patients often feel anxious when they are being moved or their care is being transferred, particularly if no information is provided to them about the transfer or what to expect. Engage patients in transition communications to help alleviate this anxiety. Strategies to engage patients in transition communications could include:
- Ensuring that structured communication tools are patient focused, such as including an opportunity to engage and communicate with patients as part of the tool
- Placing patient care boards or whiteboards around the patient’s bedside that record key information about the comprehensive care plan (such as upcoming tests and patient goals), and allowing patients, carers and families to write comments on the board for the workforce
- Signposting the organisation’s processes for transfer, including providing clear information about the steps the patient is likely to go through and the different demands that may be made of them along the way, and allowing patients, family members and carers to ask questions.
Consider how the privacy of a patient and confidentiality of patient information is maintained during transfers of care. This includes when patients are engaged in clinical handover at the bedside. If sensitive information is to be discussed, consider options for conducting aspects of the handover in a private area. Sensitive information may also be recorded on the handover sheet. Ask the patient if they are comfortable with bedside handovers, and let them know the purpose of bedside handovers and why they can play an important role. Let them know that sensitive information may be discussed and ask if they are comfortable with this.10 When sensitive information is handed over in a private area, involve patients by asking them if they have questions or comments, or inviting them to confirm or clarify information. Detail the options and requirements to ensure privacy in the organisation’s privacy policy, and reflect this in the organisation’s handover policy.
Ensure transfer of responsibility and accountability of care
Key objectives of clinical handover are to maintain continuity of care, and to transfer professional responsibility and accountability for some or all aspects of patient care. This requires a clear understanding of who is responsible for tasks that need to be performed at any given time, and who may be held accountable for the decisions made and directions specified for a patient’s care.11
The importance of ensuring the transfer of responsibility and accountability for patient care is emphasised in structured communication tools such as SBAR, ISBAR, iSoBAR and SHARED (see Action 6.07). These provide an opportunity for clinicians to request, recommend, read back/check back and communicate expectations. For example:
- What do I recommend or request to be done?
- What am I asking them (the recipient) to do?
- Has the person I am communicating to confirmed receipt of information? – ask participants to confirm understanding (check back) and provide an opportunity for participants to ask questions
- Does everyone understand what is going to happen next, who is doing what and by when?12
Put processes in place to clearly document the transfer of responsibility and accountability across the patient’s journey, who is responsible and accountable for patient care, and what has been agreed on. Examples of documentation that shows effective handover of responsibility of care could include:
- Completed transfer forms
- Referral letters or discharge summaries
- Rounding checklists
- Information on changes to patient comprehensive care plans and pathways.
When a patient is discharged from the organisation, ensure timely communication of critical information to the patient, their general practitioner and/or their primary carer. This may be in the form of a discharge summary (see Actions 6.04 and 6.07). Consider the significance and complexity of the patient’s health issues and risks of harm (see Action 5.13), and ensure that the discharge summary is provided to all the relevant people involved in the patient’s ongoing care.13 This includes ensuring that patients, carers and families understand the discharge plans, and (if relevant) who their ongoing care providers are, especially if English is not their first language (see Action 2.10). Ensure that documentation in the discharge summary has correct and up-to-date contact details of all relevant clinicians, and reflects the most current communications about care.
References
- Davey N, Cole A. Safe communication: design, implement and measure. A guide to improving transfers of care and handover. Southampton (UK): Quality Improvement Clinic; 2015.
- Australian Commission on Safety and Quality in Health Care. Implementation toolkit for clinical handover improvement. Sydney: ACSQHC; 2011.
- NSW Department of Health. Implementation toolkit: standard key principles for clinical handover. Sydney: NSW Department of Health; 2009. https://www.aci.health.nsw.gov.au/resources/acute-care/safe_clinical_ha… (accessed Sep 2017).
- Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85–90.
- Vincent C. Patient safety. 2nd ed. Oxford: Wiley-Blackwell (BMJ Books); 2010.
- Australian Commission on Safety and Quality in Health Care. Engaging patients in communication at transitions of care. Sydney: ACSQHC; 2015.
- Chaboyer W, McMurray A, Johnson J, Hardy L, Wallis M, Chu FYS. Bedside handover: quality improvement strategy to ‘transform care at the bedside’. J Nurs Care Qual 2009;24(2):136–42.
- McMurray A, Chaboyer W, Wallis M, Johnson J, Gehrke T. Patients’ perspectives of bedside nursing handover. Collegian 2011;18(1):19–26.
- Slade D, Manidis M, McGregor J, Scheeres H, Stein-Parbury J, Dunston R, et al. Communicating in hospital emergency departments: final report. Sydney: University of Technology; 2011.
- Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: a case study. Int J Nurs Prac 2010;16(1):27–34.
- Eggins S, Slade D, Geddes F, editors. Effective communication in clinical handover: from research to practice. Berlin: De Gruyter; 2016.
- Cunningham N. Editorial. Clinical Communique 2015;2(1):1–2.
- WA Department of Health. From death we learn 2014. Perth: WA Department of Health; 2015:7–9.