pdf-to-markdown/examples/Safe-Communication.md

Quality Improvement Clinic Ltd.
August 2015

# Safe Communication

## Design, implement and measure: A guide to

## improving transfers of care and handover

#### Authors:

#### Nicola Davey & Ali Cole


```
August 2015
```
## Contents:

```
Acknowledgements page 3
References page 3
Distribution & reproduction page 3
Executive summary page 4
Introduction page 5
Where can things go wrong? page 6
How do you achieve it? (The six step improvement process) page 8
```
```
Useful resources & references page 40
Appendices page 42
```
##### 1 • Startout page^10

##### 2 • Defineandscope page^13

##### 3 • Measureandunderstand page^19

##### 4 • Designandplan(includingSBAR) page^24

##### 5 • Pilotandimplement page^34

##### 6 • Sustainandshare page^38

###### “I got so used to the system being

###### broken I prepared and copied my

###### own handover sheet about my

###### husband’s condition – All the things

###### I knew they needed to know and

###### asked every time he was admitted.

###### I handed them to paramedics, A&E

###### AND ward staff as the sheets had

###### often disappeared by the time he

###### had a bed. I do wonder where they

###### all went!”


```
August 2015
```
#### Acknowledgements

This guide was originally conceived and drafted by the Authors in their own time whilst they worked at the NHS Institute for
Innovation and Improvement. Some of the examples and many of the ideas emerged as a result of the lead author’s field work
whilst completing the NHS Institute’s Patient Safety Leader Programme, and through extensive discussions with the second author.
Since the closure of the NHS Institute, additional material has been added by the second Author based on her experience of
working as a QI practitioner. The guide is a working document and it is our intention to refresh it periodically as new learning
emerges. A timeline for its production can be found on the back page.

Both Authors would like to thank the following for their contributions:
 Louise Jacox, Rebecca Bartholomew and the staff of the George Eliot Hospital
 Staff at the NHS Institute for Innovation and Improvement
 Staff at the Heart of England NHS Trust
 Fellows of the Improvement Faculty
 Sandra McNerney, script writer
 Georgette Houlbrook, Patient Representative, Wessex AHSN

#### References

This guide references some key documents that the Authors believe will help inform good practice: It is only a proportion of the good
literature available! The topic of handovers and transfer of care continue to be researched and were a subject theme for The Health
Foundation’s Clinical Systems Improvement Programme (www.health.org) in 2012- 2014. Despite research in this area, our
experience in practice suggests that very few places have used a robust method to implement small scale or systems wide
approaches to improve the many aspects of transfers of care that must be addressed in order to deliver a reliable service to
patients.

If you have achieved this goal the Authors would love to hear from you and help spread the learning so that others can understand
how they might adapt and adopt your learning to achieve reliable transfers of care in their own service. Please email
nicola@qualityimprovementclinic.com

#### Creative Commons Attribution – non-commercial

Licensed to the public under a creative commons attribution 4.0 license. Also please note and respect:
 © Copyright on diagrams shown
 All Shutterstock images purchased by Quality Improvement Clinic Ltd.


```
August 2015
```
## Executive summary

There are many reasons why teams, departments or even whole organisations will want to improve the way handover or transfers of
care happens for their patients and service users. Studies have identified clinical handover as a ‘high risk scenario for patient safety
(Clinical Handover Literature Review, 2008). They describe the dangers and consequences of poor handovers, highlighting
‘discontinuity of care, adverse events and legal claims of malpractice. But the task of passing on important information happens in
every care setting and between care settings (transfers of care) every day in patient’s homes, backs of ambulances, community
clinics, surgeries to name some. Although many of the examples we have been able to find easily are from hospitals, the
information in this guide has been written for use in all settings.

There is also the human cost; the distress, anxiety and loss of confidence that we know poor handovers can lead to for patients,
clients and their families and for staff too (see case study, Appendix A).

This guide is not about the justification for improving handovers; that is covered in detail in other documents such as the OSSIE
Guide to Clinical Handover Improvement and the Royal College of Physicians’ Acute Care Toolkit: 1 Handover. Nor is this guide a
detailed manual for improving every aspect of your handover process.

Focusing mainly on good communication – one of the most important factors for safe and timely transfers of care – this guide, and
the six step process at the heart of it, offers teams a practical improvement methodology that we know has worked well in many
care settings.

It draws on some tried and tested tools that will help you, as a manager or clinician, to:

```
 link your improvements to the wider strategic aims of your organisation
 test, measure and understand the impact your changes are having
 use the sort of structured communication tools that are delivering significant improvements in safety and quality for care
organisations and other safety critical industries across the world (e.g. SBAR, ISOBAR and IDEAL).
```
Many of the detailed tools and examples that you might want to use are included as appendices towards the end of the guide. This
means you can move through the guide more swiftly, but have a wealth of examples and ideas at your fingertips if you need them.


```
August 2015
```
## Introduction

Welcome to this guide. It has been developed to help care teams and organisations make measurable improvements in the safety
and quality of patient care by ensuring that, with every handover and transfer, the right information is given to the right people at

##### the right time and in the right way.

```
Handover [or transfer of care] is ‘ the handover of professional responsibility and accountability for some or all
aspects of care for a patient, or group of patients, to another person or professional group, on a temporary or
permanent basis ’ (Bhabra G et al. 2007)
```
We have used the word transfers of care in most, but not all, places in this guide. Transfers can include a regular handover of
care at the end of a shift, or the transfer of a **person’** s care to another ward, team, department, or service. This includes for
example when a patient is transferred from a care home to a hospital or from a community team to a hospice. Transfers of care
happen every day. They can be verbal or written; they can take place in a group or one-to-one; in person, or over the phone. But
they all share the same purpose; to communicate vital information about a person in your care.

#### Why use this guide?

Many good resources already exist to help teams deliver safe and efficient transfers of care in
different care environments (see Useful Resources, page 40 ). But, by working with frontline
care teams, we have identified a gap when it comes to giving staff the detailed steps they
need to design, implement and measure their improvements.

This guide aims to bridge that gap:

```
 It offers teams in all care environments a tried and tested methodology for
transforming ideas and aspirations into sound improvement projects that link clearly
with their organisation’s wider aims and priorities.
 It introduces and explains some of the most useful transfer of care tools, including
standardised communication tools such as SBAR (Situation, Background,
Assessment, Recommendation), and directs you to some resources on form
design that makes it easier to do the right thing.
```
```
Good communication is one of
the factors which ensures safe
and timely transfers of care.
Advice on improving other
factors is in National Leadership
and Innovation Agency for
Healthcare, Passing the Baton -
A Practical Guide to Effective
Discharge Planning (2008).
```

```
August 2015
```
## Where can things go wrong?

Poor transfer of care or handover communication is widely recognised as a major
preventable cause of harmi.

Good transfers of care rely on consistently good communication and there are many stages
in a person’s care journey where this can go wrong, including:

```
 shift to shift (continuity of care and ongoing assessment)
 across different professions (different staff groups often have different ways of
communicating and their own hierarchies to navigate)
 between departments (e.g. in a hospital where patients might pass through many
different departments)
 between different care settings (e.g. hospital and community where staff can have
different communication styles and cultures).
```
The risks can be even higher when **...**

- people have complex needs (requiring more information to be handed over and
    remembered on a day-to-day basis)
- at weekends or holidays
- if junior staff are reluctant to ask for clarification from more senior staff or other professions
- where there is no written documentation, or what is written is unclear (e.g. too many abbreviations).

##### More online...

```
The trouble with handovers is a useful video for understanding
what happens to patients, families and staff when handovers are
poor between different teams and care settings. It is a good
resource to watch with your team to encourage involvement and
stimulate discussion
```
```
‘...only 2.5% of information
from the first handover is
retained at the final handover if
there is no written record. If
notes are taken, 85.5% of
information is retained, but
this rises to 99% when a
standardised proforma is
used*’
```
```
Bhabra G, Mackeith S, Monteiro P,
Pothier DD, An experimental
comparison of handover methods
(2007)^
* Data taken over the course of five
simulated handover cycles
```

```
August 2015
```
#### ‘Passing the baton’

In a relay race, how the baton is passed between the runners is pivotal to success or failure and it’s a useful
analogy here; missed or misunderstood information can have a direct and even dangerous impact on the care
of a patient.

##### Problem Impact Solution

There are two important techniques to ensure that the ‘baton’ is always passed correctly in
the transfer of care:

- Standardisation: each participant follows the same procedure and communicates the
    same agreed content. This will have a positive impact on both the quality of care for
    patients and the productivity of the organisation.
- Streamlining: unnecessary steps in the process are identified and removed. Making
    transfers of care simple will reduce the risk (improve quality) and release time to care
    (improve productivity).

```
‘Healthcare organisations
[should] implement a
standardised approach to
handover communication
between staff, change of shift
and between different patient
care units in the course of a
patient transfer’
```
```
World Health Organisation Collaborating
Centre for Patient Safety Solutions (2007)
```
```
Variation in the
information given at
transfer of care
Important information is
not always communicated
Unreliable action taken on
the information
transferred
```
```
Poor patient
care
Safety risks
Poor use of
valuable staff
resources
Complaints
Litigation
```
```
Planned, structured
transfers of care
Right Information
Right people
Right commitment
Right space
Right time
RIGHT ACTION
```

```
August 2015
```
## Planned, structured transfer of care: what does

## it look like?

All of these checklist elements need to be in place to ensure the ‘baton’ is passed successfully and that the right information is given
to the right people at the right time, in the right way...every time.

Good practice checklist*

##### What do we need? What does it mean? Do we have it?

1. Leadership
    There is a nominated leader for each transfer of
    care/handover.
2. Values
    Transfers and handovers are valued as an essential
    part of care and preparation for handover is a priority.
3. Right people
    The appropriate people are involved.
4. Specified time
    and place

```
A specific setting or place has been agreed where
transfers of care can take place without interruption or
distraction.
```
5. Standardised
    process

```
There is an agreed process for transfers of care. This
includes an agreed set of information to be covered in
transfers (minimum data set). This is communicated in
a structured way, is action-focused, assigns
responsibility for actions and is supported by clear
documentation.
```
```
We will build on the
checklist later in the guide,
adding more detail and
suggested measures for
each of the five good
practice elements.
```
```
* Checklist adapted from page 1 of
the NSW [New South Wales] Health
Implementation Toolkit, Standard Key
Principles for Clinical Handover
```

```
August 2015
```
## How do you achieve it?

The second part of this guide shows you how to identify, plan and implement changes in a way that is most likely to deliver the
planned, structured transfers of care you want to achieve. It is based on the six step improvement process:

For those who are familiar with running improvement projects, a summary of this guide for each of the six steps is included at
Appendix M.


```
August 2015
```
### Start out

Start by finding out about any existing policies or protocols for transfer of care in your organisation. You may not know exactly
what part of the transfer process you want to improve yet, or even how wide your focus will be (e.g. team, department or
organisation). This is fine. The purpose of this first step is to get a clear idea of what is happening in your current transfer processes
and start to understand where the problems and solutions might be found.

Observe a transfer of care and record the findings, but ensure that staff know they are not being tested. Transfers of care can be
varied, depending on the time of day and who is doing it, so it’s a good idea to observe several transfers.

You can use:

```
 observation techniques (consider using photos and/or videos)
 staff, patient/client questionnaires
 group discussion and/or interviews.
```
Think about what happens before and after the transfer of care.

```
 How is information prepared for the transfer of care?
 Is information easy to find?
 What happens to documentation after the transfer of care?
```
```
You might start using observation and
process mapping techniques to help
you understand where the problems in
your transfer of care processes might
be, but they will be valuable tools later
in the improvement process too, when
you are gathering and generating
ideas for improvement.
Royal College of Physicians, Acute
Care Toolkit: 1 Handover (2011)
```

```
August 2015
```
Measure the processes you are observing. You will need to do more detailed
measurement later in your improvement project, but gathering some initial data
here as part of your observations is a good idea.

You could:

```
 Time the transfer of information.
 Count the number of interruptions during the transfer of
information.
 Count the number of times transfer of care documentation is
completed.
 List the type information included in transfers of care and record
how often this information is included in each communication.
 Measure how often the information is repeated.
```
```
A flipchart is a simple but good way to record your^
observation data.
```
##### More online...

```
For further ideas of how to map and measure current practice see
resources section for links to:
```
```
 The Quality and Value Toolkit (process mapping, patient
perspectives)
 The Productive Ward (acute), Productive Mental Health
Ward, Productive Community Hospital and Productive
Theatre Handover
 The Productive General Practice for general practice
 The Care Homes Wellbeing Programme for the care home
sector
```
```
Some of these resources are still available on the NHS Institute’s
website at: http://www.institute.nhs.uk
```
```
For alternatives contact us at http://www.qualityimprovementclinic.com
```

```
August 2015
```
#### What does ‘good’ look like?

At this stage, it is useful to consider what ‘good’ would look like for the people in your care. One way of thinking about this is to
consider what processes and behaviours you would want to see happen for yourself or a member of your family whose care is being
transferred to another person or team. If you don’t usually include patients in your improvement work, we’d encourage you to ask
their opinion, and if you want to do more see the link below on experienced-based design.

Use what you have learnt from your observations, measurements and process mapping and compare your current processes with
the elements in the good practice checklist. (see Appendix B for examples of questions you can use to prompt discussion and
generate ideas with staff, patients or clients.)

##### More online...

```
Find out more about how to use:
```
```
 Experienced based design
 Process mapping
 Root cause analysis (including the ‘Five whys’)
```
```
You could use process mapping
to map communication of
information between shifts, teams
or departments.
```

```
August 2015
```
### Define and scope

Once you have identified and captured what ‘good’ looks like in your transfer of care
processes, and started to identify what you need to improve in your own systems, the next key
step is to define a clear aim for your project.

This is where the Model for Improvement published in The Improvement Guide (Langley et
al. 1996) can help you. Whatever your project and however big or small, the Model for
Improvement will give you a simple, adaptable and thorough framework for developing, testing
and implementing changes. Using the Model for Improvement means your changes are more
likely to lead to the improvement you set out to make. (For more information on the Model for
Improvement, see Appendix C.)

#### What are we trying to accomplish?

This is the first question in the Model for Improvement. Being clear about the aim of the work
will improve your chances of success. Using a SMART aim is one way to focus your project.
(For more on SMART aims see Appendix D.)

```
Example – project aim: ‘By December 2015, reduce the time the team spends on
transfer of care (productivity) AND make the information handed over or transferred
```
##### appropriate, easy to remember, easy to understand and easy to act upon (quality)’.


```
August 2015
```
#### Link your improvement project to your organisation ’s strategic aims

A project that meets the practical, day-to-day needs of your team and your patients or clients, as well as the priorities of the
organisation you work for, will be much more likely to succeed.

Your organisation, health community or commissioning group will have a number of key issues identified as priorities. We know that
matching your improvement programme to your organisation’s ‘big issues’ will help its success.

You can find your ‘big issues’:

```
 in the organisation’s business plan or annual report
 on the trust or commissioning group website or intranet
 by asking your project sponsor
```
Examples of ‘big issues’ include:

```
 delays in discharge
 safeguarding
 patient experience
 patient harm
 workforce efficiency.
```
Capturing and tracking the link

You can track the links and test your ideas using simple ‘driver diagrams’.

This type of diagram can be useful to generate interest and commitment from your
sponsor, your project team and others you are working with. It will also help you
understand the impact of improvement work undertaken at the front line and its
contribution to the organisation’s high-level performance targets.

```
Find a good sponsor
```
```
It is important that your project is supported
by an enthusiastic and empowered sponsor.
```
```
The right sponsor will:
 provide high-level support for your
project
 offer advice
 help to engage other team members
 link your improvement project aim to
your organisation’s big issues/
strategic aims
 help remove obstacles to progress.
This might be:
```
```
 Director of Nursing or Matron
 Medical or Clinical Director
 Practice or Care Home Manager
```

```
August 2015
```
#### Example driver diagram linking a transfer of care improvement aim to the organisational aim of reducing mortality.

```
Throughout the guide you will
see how you can build on this
basic diagram, adding on your
improvement project
measures and your change
interventions as you develop
them.
```
##### More online...

```
Click here for more information about
using driver diagrams in your
improvement work
```
```
© Alison Cole and Nicola Davey, 2013
```

```
August 2015
```
#### What is the scale of your improvement project?

You may be using this guide to make a small change in the way you manage transfers of care, or you might be trying to make a
change across your whole organisation, or even across the local care community. Whatever level you are working at, you need to
set the scope of your project at the start to ensure it is manageable and achievable. Go where you think there is most need or where
there is most enthusiasm. A success early in the project is vital to help stimulate enthusiasm and spread the good work.

#### Engage staff, patients and users and set up your project team

##### Engaging stakeholders

```
Think about different ways to engage
stakeholders (staff, patients and service
users) and convince them of the
importance of improving transfers of care.
```
```
As well as patient stories, you can use
evidence and recommendations from the
transfer of care ‘Useful resources’ at the
back of this guide. The ‘Clinical
engagement’ page of the NHS Institute’s
Quality and Service Improvement Tools
has further suggestions.
```
```
Everyone wants to deliver good care; using
patient stories (like the one at Appendix A)
or staff experiences can help teams commit
to change and improvement. The film: The
trouble with handovers is a powerful
reminder about why it is so important to
transfer the right information to the right
person at the right time.
```
```
.
```

```
August 2015
```
#### Who to include in your team?

Finding the right people to champion the project and drive it forward with insight and enthusiasm is crucial. Consider what each
team member can offer; do they have expert knowledge and/or are they empowered to make decisions? This simple grid tool can
help you identify what each team member will be able to bring to the project. Examples of the team selection grid for different
settings are at Appendix E

**Project team ‘knowledge and empowerment’ grid**

(^) © Profound Knowledge Products Inc.
 Senior leadership is essential. Identify a clinical or
service champion who will be a visible and active
supporter of your improvement project.
 Include staff who are actually involved in the transfers
of care on a day-to-day basis - both those who deliver
and receive the communication.
 Consider who else might use the transfer of care
information. For example, might the physiotherapists
use or update information about falls risk on the
nursing shift handover document?
 Have you included someone from the IT team?
 Include people who can relate their experience of the
transfer of care, e.g. the patient, resident or client. As a
minimum, consider how you will get their input to the
transfer of care process. Videoing people talking about
their experiences can be a particularly powerful tool
and is not difficult to set up. The experience based
design toolkit provides further guidance on interviewing
and filming individuals.


```
August 2015
```
#### Putting it all together

By this stage, you and your team will have agreed the aim and scope of the improvement and how it fits with
your organisation’s wider strategic aims and targets. It is a good idea to capture this in one place, using a
simple template such as the one shown in Appendix F. It will be a useful focus for further discussions with
sponsors and others.

Sustainability

Sustaining your improvements should never be an afterthought. Sustainability is a crucial
and integral part of any successful improvement project. It is something you need to be
planning for from the start and will run through every aspect of your improvement work; from
how you engage leaders, staff, patients and clients in developing, testing and implementing
changes, to celebrating success at the end of your project.

See Step 6: Sustain and share (page 38) for more information about sustainability.

Further reading

```
The OSSIE Guide to Clinical Handover Improvement and the
associated implementation toolkit are highly recommended for
anyone involved in improving handover or transfer of care in
any care setting.
```

```
August 2015
```
### Measure and understand

Measurement for improvement does not have to be onerous; it is about using a few specific
measures, linked to your project aim to answer the question: ‘How will I know that my changes
have made an improvement?’

You will want to use some process measures for your change ideas and also your improvement
focus, and you will want to at least one outcome measure for your improvement project aim.

For your overarching improvement aim you might want to choose a process measure and an
outcome measure from the list below:

```
 No. of transfers right each time– based on your definition of ‘right’ (Process measure)
 No. of staff who know which patients are at risk of fall (Outcome measure)
 No of patients who get diagnostic tests when requested (Outcome measure)
 No. of staff who know who is in charge of handover and get the information they require
for their job (Outcome measure)
 No. of times when number of staff involved in handover and time taken is within agreed limit (Outcome measure)
```
You will find some more on measures for the smaller pieces – after we have described the 7 steps to measurement.


```
August 2015
```
Whatever you choose to measure, there are seven basic steps to follow:

The 7 steps to measurement

```
1: Decide project
aims
```
```
You will have already done this.
```
```
2: Choose your
measures
```
```
You may have a long list of possible measures, so you need to narrow
these down to the most appropriate.
```
```
3: Define your
measures
```
```
Be clear about exactly what you are measuring.
```
```
4: Collect data Think about what, who, how^ and when^ to measure and establish a
baseline.
5: Analyse and
present results
```
```
There are many tools to help you do this, including:
bar charts to understand common problems
 run charts or statistical process control (SPC) charts to
demonstrate your progress
 photos, videos and stories.
```
```
6: Review
measures
```
```
Look at the data regularly. What does it tell you? What should you do
next?
```
```
7: Keep going Repeat steps 4 – 6.
```
```
More online...
```
```
7 steps to measurement video
```
```
Measuring for improvement (Improvement Leaders’ Guide)
```
```
Handover and transfers of Care – Step-by-step measurement guide
```

```
August 2015
```
#### Choose your measures and start collecting your baseline data

You should not be spending lots of time collecting data! From your long list of things you could measure, just pick a few.

For your improvement project aim pick a process or outcome measure that will
tell you whether you have achieved your aim. It should be something that is
meaningful to you and your team. Outcome measures are often more meaningful
to patients, but are more frequently affected by changes that are beyond your
control. Process measures can appeal to patients and carers too e.g. the number
of transfers of care in your weekly sample that are judged to be right – particularly
if patients have been involved in creating the definition of ‘right’ e.g. the community
rehabilitation therapists meet in the team office at 4.30pm and handover all
planned actions for patients by completing the agreed online template.

So the choice on data collection is a balance between ease and reliability of collection and
whether it can inform your next action. Whatever you decide you should pick at least
one and start collecting this data now. This will give you your baseline for the
improvement project. If you don’t collect your baseline data now, it will be difficult to prove
your changes have made an improvement later.

There are often lots of things that need fixing, and your next piece of work will help you
decide where to start (your first improvement focus). From all your change ideas you
will then need to select the first change intervention. In the box below and on the next page we have given some examples of
process and outcome measures that focus on frontline care. We have also included process measures with a management focus so
that you can see the connection between your work and your organisation’s strategic objectives.

```
Remember, you may not see
changes in these measures
until you have made and
sustained several smaller
changes, or even carried out
several improvement
projects.
```

```
August 2015
```
Driver diagram showing process and outcome measures from management and frontline care perspectives

```
You may not be able to collect
data for all your project outcome
measures yet, but you need to
start planning how and when you
will.
```
```
© Nicola Davey. 2015
```
```
© Nicola Davey. 2015
```

```
August 2015
```
#### Capture and display the data

Plotting your data in a run chart is a simple way to see the variation in the system and if any improvements have been made. You
need 25 data points before doing any analysis, so using more frequent data (weekly or daily, in favour of monthly or quarterly) is
better. You can look for a ‘run’ of seven points or more - all up, all down, or all above or below the median value. The run will tell you
if an improvement has been made.

Example run charts capturing project outcome data

```
0
```
```
2
```
```
4
```
```
6
```
```
8
```
```
10
```
```
12
```
```
Day
1
```
```
Day
3
```
```
Day
5
```
```
Day
7
```
```
Day
9
```
```
Day
11
```
```
Day
13
```
```
Day
15
```
```
Day
17
```
```
Day
19
```
```
Day
21
```
```
Day
23
```
```
Day
25
```
```
Day
27
```
```
Day
29
```
```
Number of times standard format followed
Number of times standard format followed Median
```
```
0
```
```
0.5
```
```
1
```
```
1.5
```
```
2
```
```
2.5
```
```
3
```
```
3.5
```
```
4
```
```
4.5
```
```
5
```
```
Staff survey -Level of preparedness to deliver care
(1 = not prepared, 5 = prepared)
Staff Survey Results Median
```
##### More online...

```
Click here for more about using run charts and
simple statistical measures
```

```
August 2015
```
### Design and plan

Once you have mapped your current process and compared data about your transfers
of care with best practice, you need to decide where to start – this will be your initial
improvement focus. You may want to dig deeper into your current transfer of care
processes using process mapping and root cause analysis techniques such as the
‘Five whys’ to help you understand how your transfer fits into the bigger picture.

Revisit the driver diagram on page 15. The suggested improvement focuses are drawn from the good practice checklist
mentioned earlier in the guide (for full list see pages 45 - 46 ).

Focus your improvement effort on something in this list that you believe will help achieve your improvement project aim. For
example, you predict that finding a quiet place to communicate without interruptions will help speed up the handover or transfer of
care process. Working with your project team, choose one area as your first improvement focus. There are different ways of
doing this and you might choose to generate change ideas first before finally deciding where to focus.


```
August 2015
```
All the good practice elements are interlinked and they may all need to be worked on at some point. Some changes may be
developed very quickly (e.g. moving the location of handover); others may take a longer (e.g. changing the culture to place a higher
value on transfers of care and give them priority over other tasks).

#### Where to start?

Look at your current process map and data. Which aspects of the process need improving first? You could use a bar chart to display
the results from a staff survey and then focus your initial improvement on the most commonly-reported problems.

```
Pareto analysis is a simple technique that helps
you to focus efforts on the problems that offer the
greatest potential for improvement by showing
their relative frequency or size in a descending
bar graph.
```
```
Pareto's principle, the ‘80/20’ rule, asserts that
for many events, roughly 80% of the effects come
from 20% of the causes. For example, if
documentation is not completed, the process
takes longer and information may be missed or
mistakes made.
```
```
4 4 4
```
```
2 2
```
```
1 1 1 1 1
```
```
0
```
```
0.5
```
```
1
```
```
1.5
```
```
2
```
```
2.5
```
```
3
```
```
3.5
```
```
4
```
```
4.5
```
```
Number of staff who highlighted problem
```
```
Problems with handover identfied by staff
```

```
August 2015
```
You could use a priority matrix to categorise your improvement ideas. Quick wins can be tested and implemented immediately.
High-priority changes may take more planning and resources to achieve.

Example priority matrix

```
Likely impact on project aim
```
```
Ease of testing and implementation
```
```
Quick wins
Just do it!
```
```
Record the idea – but
consider carefully
whether it is worth
the input
```
```
LOW
```
```
LOW
(hard)
```
```
HIGH
```
```
HIGH
(easy) Nice to have Test and implement
once higher priorities
have been achieved
```
```
High priority
Plan with your team
how you will test and
implement these
ideas
```
```
Royal College of Physicians,
Acute Care Toolkit: 1
Handover (2011)
```

```
August 2015
```
#### Generate improvement ideas

Working with your team and using all the data and observations you already have, you can now focus more fully on generating
ideas for changes. These help you select your ‘change interventions’. There are lots of examples of change interventions in the
many handover resources that already exist (see Useful resources on Page 40). Use these to stimulate discussion about what is
possible in your setting. Remember improvement is context specific, so solutions that work for one team in one place don’t easily
transplant to another team in another place. Some adaption is often required in order for adoption to follow. The approach described
in this guide can be used to ‘check out’ of test a proven intervention and optimise its effect in a different place.

As an example, we have used the development of a standardised process to illustrate how you could develop and test some
change interventions.

(^) Is the right information shared at transfer
of care? Identify the pieces of information that
should be included in transfers of care. This is
the information you need to include in your
standard information template (see
examples below and in Appendix K).
Is communication structured in a
standardised way? You will need to agree
the way in which you want to standardise the
transfer of your information.
Work with your team to design a structured
Documented process: How will your new
standardised process be documented and
shared with new members of the team and the
wider organisation.


```
August 2015
```
#### Design your change intervention(s)

Design your own **‘** standard transfer of care **’** template

Let’s take one of these change interventions - standard transfer of care template – and look at how you might go about
developing, testing and implementing it. Below is an example of an information template sheet that could be used in a hospital ward
for a transfer of care. You may want to trial this one, but it is better if your transfer of care template includes information which is
specific and relevant to your own care environment. A similar approach may be used in general practice for referral letters.

Example information template for nursing shift handover (more examples in Appendix K)

(^) Example from the George Eliot Hospital


```
August 2015
```
#### Make it your own

Now create your own standard information template.

The quality of care you give is reflected in the quality of communication
you use every day. The documentation needs to reflect this by including
the right information. This information is called the minimum data set.

During the planning stage of your project you will have chosen your
SMART aim. But whatever priorities you have chosen, transfers of care
should always:

```
 communicate the right information
 focus on the goals of the patient/client
 clarify any significant changes easily
 be action focused – what needs to be done, by when and by
whom
 prioritise patients/clients with the most time-critical needs
 Include only information which is essential and adds value; try to
stay focused on the information that is essential to be transferred
at that point.
```
```
Consider including:
```
```
 your identity and role
```
```
 patient/client identifying information (at least 2
pieces is recommended, e.g. name, date of birth,
patient ID, location)
```
```
 immediate clinical situation of the patient
```
```
 most recent observations/MEWS score (status of
referral to critical care outreach team where
appropriate)
```
```
 reason for admission/referral/discharge
```
```
 relevant medical history, results of investigations,
treatment to date, current medications
```
```
 current safety/risk factors and associated care plans
(diabetes, allergies, falls, pressure areas, nutrition,
catheter, urine and bowel, infection control, cannula)
```
```
 recommended actions, timeframes and who is
responsible (tests/investigations, specialist referrals,
discharge etc). This is really important: What do
you need the person receiving the transfer of
care to do?
```
```
Remember to clarify/confirm understanding and transfer
of responsibility.
```
```
Further guidance on the minimum data set is available in
A Clinician’s Guide to Record Standards
```
##### More online...

```
The emishealth eHandover electronic handover system has been
development at Barking, Havering and Redbridge University
Hospitals NHS Trust Community Services. Based on standard
Microsoft tools that are readily available in most trusts, initial
studies have demonstrated that eHandover is delivering an
improvement in safety, productivity and staff satisfaction.
```

```
August 2015
```
#### Use ‘d ot voting ’ to define your ‘ minimum data set ’

Dot voting is one simple way to collect the opinions of those
involved in the transfer of care about which pieces of information
should be included in a standard template. For more information
on dot voting, see Appendix G.

Now think about where else this information is found. Does it
need to be included in the transfer of care template, or is it
readily available elsewhere, e.g. on a patient whiteboard which
could be used as part of the transfer of care?

You should now have a complete list of all the information you
will include in your new standard template. The next step is to
organise this information using a structured communication tool
such as SBAR (see page 31 ).

```
A simple flip chart and
some coloured pens are all
you need to carry out a dot
voting exercise.
```
```
Improvement projects
should aim to reduce, not
increase work. Changes
should avoid duplication
of task wherever this is
safe to do.
```

```
August 2015
```
#### Using ‘structured communication t ools

Structured communication tools are easy-to-remember
mechanisms that you can use to frame conversations, especially
critical ones, requiring someone’s (e.g. a clinician’s) immediate
attention and action. These tools enable you to clarify what
information should be communicated between members of the
team, and how. They can also help develop teamwork and foster

#### a culture of patient safety.

SBAR is one example. It stands for: Situation, Background, Assessment, Recommendation.
The tool consists of standardised prompt questions within four key sections, helping to ensure
that staff are sharing concise and focused information.

SBAR:
 encourages staff to communicate assertively and effectively, reducing the need for
repetition
 helps staff anticipate the information needed by colleagues
 prompts staff to formulate information with the right level of detail.

```
‘ HAND ME AN ISOBAR ’ is another example of a
structured communication tool. Developed by the
Royal Hobart Hospital in Tasmania, it is one of
several examples featured in the OSSIE Guide to
Clinical Handover Improvement (Australian
Commission on Safety and Quality in Healthcare).
```

```
August 2015
```
Once you have chosen the structured communication approach you want to use,
you need to arrange your minimum data set accordingly.

You could:

```
 put all the pieces of information you want to communicate onto sticky notes
 put up flipcharts on the wall – one for each letter of the tool you have
chosen, e.g. SBAR, ISOBAR, RSVP etc.
 in the case of shift handovers, include a flipchart for a safety briefing at the
beginning or end
 ask the team to move the sticky notes to the flipchart they think is most
appropriate.
```
##### More online...

```
For prompt cards and other resources to
help you use SBAR in several different
settings (including acute, primary care and
community mental health) see:
```
```
There are lots of good examples of standard
protocols in the OSSIE Guide to Clinical
Handover Improvement.
```
```
The ABC of handover is another model
which prompts the communication of clinical
and operational issues between shifts
```
```
RSVP is a similar structured communication
tool developed by Portsmouth Hospitals.
```
```
Use a flipchart to capture data for
each letter of the tool you have
chosen, e.g. Situation,
Background, Assessment,
Recommendation.
```

```
August 2015
```
The next step is to design your template based on these information groups.

```
 Decide how you will indicate which patients are priorities and add this to your template.
 Prompt the person receiving the transfer of care to clarify and read back the information and confirm they are taking over
responsibility for care from this point.
```
Don’t worry about getting too technical with document function and layout for your initial testing of the template. Try finding
someone in your team or organisation with some spreadsheet or word processing skills to mock one up for you. Or simply draw
one by hand for your initial testing.

#### Document your standard process

As well as standardising the information you are going to communicate, you need to also standardise the process for
communication. You will develop this process and test your change interventions for the other areas of good practice. You will
also need to test the best way to document your standard process and communicate it to everyone involved. An example of a
documented process is attached at Appendix K.

#### Choose and review your measures

Once you have developed your change interventions, you will need to decide
which measures will be most helpful. Choose just a couple of measures that you
think give the best feedback about the impact of your change intervention.
Whatever you choose, make sure the data can be collected quickly and easily, e.g.
if you choose to measure whether or not something happens in a particular way,
the answer can be simply ‘yes’ or ‘no’.

```
Appendix H uses the ‘good practice checklist’ and shows
some suggested measures that you might want to
consider for each improvement intervention. You will
notice that these often overlap.
```
```
Developing your measures for improvement is an
iterative process. In some cases, you will only be able
to refine your measures once you have designed your
test of change. For example, you can’t measure
whether the new process is followed until you have
defined what the new process is.
```
```
Think of measurement of
change interventions as
providing a ‘before’ and ‘after’
snapshot of each test.
```

```
August 2015
```
### Pilot and implement

This is where you use the ‘plan, do, study, act’ (PDSA) cycles in the Model for Improvement.
The tests are repeated until a reliable change has been established (see Appendix I & J for worked
examples)

Plan: Plan which change intervention you will test (e.g. structured transfer of care sheets), where
you will test them, who will support you and how you will train and inform all staff.

Do: Train your test team and start using the tools. Experience has shown that implementation
works best when staff are fully involved and encouraged to develop or modify their own version of
your change intervention (see ‘Flexible standardisation’ on page 37).

Study: Assess the impact of the intervention using the measures you have agreed and refined. One
of the most useful measures of success will come from staff feedback.

Act: Is your intervention ready to be implemented? If not you will need to run the PDSA test cycle
again. If it is ready for implementation, you will need to plan how you will roll it out to the wider
department or organisation and, crucially, how you will sustain the improvement in the long term.

##### More online...

```
Click here for more on the Model for
Improvement and PDSA:
```

```
August 2015
```
Example: PDSA cycle to test a standard transfer of care template (form)

#### Plan: (what, where, when, who, how)

```
Keep your initial testing small. Test on:
 one patient, resident or client
 one bay or unit
 half a ward, or a floor
 one shift
 variety of transfers of care (early / late shift / nights).
TIP: Use the test documentation for handover or transfer of
care alongside the old format during testing to minimise risk
and ensure continuity of care.
```
```
Do:
Continue the testing for as long as you need; it may
be a few days, weeks or even longer, depending on
your service.
You may find that the same information might not be
relevant for all types of transfers.
TIP: You may need to repeat the test cycle a few
times to find the transfer of care documentation
and processes that work best for your team.
```
```
Study:
During each test, capture what happens using your chosen
measures and record them. This will allow you to study the
results and feedback. From this data, you can then work out your
next action and plan your next test. Consider these questions:
 Are the fields on the documentation all adding value for
your patients/residents/clients?
 Has everyone been involved?
 How will information be updated in the template and
whose responsibility will it be?
 Do those people have the appropriate technical skills to
do this?
 What training is needed to roll this out further?
 Does the layout help staff find information easily?
 Do we print the transfer of care documentation as a
record and if so how?
TIP: When observing tests it is important to note the factors
that may lead to variability (eg what information gets
```
##### included or left out when it’s ‘busy’ and when it’s ‘quiet’).

```
Act:
Increase the size of your test as you gain confidence
in the new transfer of care design. Keep going until
you are happy that the format is suitable to be tested
for a longer period on its own and not alongside the
```
##### old process.

```
See Appendix I for a detailed
example of how one team
used PDSA to test a new
handover template.
```

```
August 2015
```
#### Plan for implementation

Once you are confident that your design is about right, start to plan your tests for implementation.

We have used the development of a standard information template as our change intervention example. But, of course, this is just
one change that could help you to meet your improvement project aim. You may now want to look at other change interventions
before rolling out to whole teams or your wider organisation. Consider what works best for your project:

Either way, before you implement your new transfer of care process, you will need to plan tests to manage any risks associated
with stopping the old process. You will also need to engage and educate the teams involved.

As you plan your tests for implementation, think about:

 Training – Training will be required for initial implementation and will be
ongoing to ensure new team members understand the transfer of care process.
 Documentation – What documentation, policies and procedures are required
and who will be responsible for updating documentation over time?
 Resourcing – What resources are required to implement the change (e.g.
printers, electronic devices)?
 Measurement – Plan which measures will be used during and after
implementation and make sure these are visible to stakeholders.
 Engaging stakeholders – Continue to engage stakeholders and communicate
the rationale for change (see page 16 ).
(Adapted from Langley, Moen et al, The Improvement Guide 2nd Edition (2009))

To reduce risk and increase user acceptance you might
want to use a Simulation – this could involve staff trying
out the new system using a case study?
See Appendix J for a detailed
example of how one team used
PDSA to test the
implementation of a new
transfer of care process.


```
August 2015
```
**‘** Flexible **’** standardisation

You may need to run small tests with each team so that they can make small adjustments that work for them. Instead of a rigid
approach, consider ‘flexible’ standardisation. This allows teams or departments to make small changes of their own that are shown
(by measurement) to improve things in their setting. But there still need to be a control in place to avoid ad-hoc changes and many
different versions being used across your organisation.

One method is to implement a control group to decide what can be changed and what has to stay. This decision may be linked to
the priorities outlined in your project plan which reflect the organisation’s big issues. For example, if you have linked the transfer of
care project to length of stay, you may want to ensure that expected date of discharge stays in all documents.

Spreading Good Practice

As you achieve improvements in your transfer of care process it is really important to spread your good practice throughout the
system in which you work.

Think about which teams, departments or communication processes you could target next. For example, if you started by improving
communication when transferring patients between wards or departments within your organisation, could you adapt the same
communication tool for discharging patients from hospital to care homes, rehabilitation and primary care services?

```
 For more information on how to do this, see Sarah W Fraser, Accelerating the Spread of Good Practice: A Workbook for
Healthcare (2002).
```

```
August 2015
```
### Sustain and share

##### ‘The most successful organisations are those that can implement and sustain effective improvement

##### initiatives leading to increased quality and patient experience at lower cost.’

Sustainability Model and Guide

We have already said at the start of this guide that sustaining your improvements should
never be an afterthought, but something to consider at the very beginning of your
improvement work. Naturally, however, sustainability is something you will want to
consider as you roll out and share the new processes you have developed and refined.

The Sustainability Model and Sustainability Guide are valuable resources which will
help you build sustainability into the fabric of your improvement work.

```
 The Sustainability Model is a diagnostic tool that will help you identify strengths
and weaknesses in your implementation plan and predict the likelihood of
sustainability for the improvement initiative.
 The Sustainability Guide provides practical advice on how you might increase
the likelihood of sustainability for your improvement initiative.
```
Click here to access the Sustainability Model and Guide

```
‘ Senior leadership engagement
and clinical leadership
engagement in your project are
two of the key factors in
sustaining project
improvements’
```
```
NHS Sustainability Guide
```

```
August 2015
```
#### Share and celebrate success

Tell people how well the new handover or transfer of care is working. Not only do those doing it need
to know, but tell other wards, teams, departments, directors and the whole organisation to spread the
good practice and gain recognition for the hard work the team and all the staff have done. Consider
how you can spread the word using:

```
 team meetings and existing transfer of care meetings
 one-to-one conversations
 posters (see Appendix L)
 newsletters
 individual letters/emails.
```
#### Keep measuring....

Agree to measure processes and outcomes periodically to ensure you are sustaining
improvements and that staff aren’t tempted to return to old ways of working.


```
August 2015
```
## Useful resources

Reports and standards

```
 OSSIE Guide to Clinical Handover Improvement http://www.safetyandquality.gov.au/our-work/clinical-communications/clinical-handover/ossie-
guide/
 Implementation Toolkit for Clinical Handover Improvement http://www.safetyandquality.gov.au/wp-
content/uploads/2012/02/ImplementationToolkitforClinicalHandoverImprovement.pdf
 Communication During Patient Hand-Overs, World Health Organisation Collaborating Centre for Patient Safety Solutions (2007)
http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf
 Safe handover: safe patients - Guidance on clinical handover for clinicians and managers, BMA Junior Doctors Committee, http://www.bma.org.uk
 Acute Care Toolkit: 1 Handover, Royal College of Physicians (2011) http://www.rcplondon.ac.uk/resources/acute-care-toolkit- 1 - handover
 A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when
patients are admitted to hospital, Academy of Medical Royal Colleges (2008) https://www.rcoa.ac.uk/sites/default/files/FPM-clinicians-
guide2.pdf
 'Passing the Baton - A Practical Guide to Effective Discharge Planning', National Leadership and Innovation Agency for Healthcare
http://www.wales.nhs.uk/sitesplus/829/page/36467
 Clinical Handover Literature Review, The eHealth Services Research Group, University of Tasmania for the: Australian Commission on Safety
and Quality in Health Care (ACSQHC) 2008. MC Wong, KC Yee, P Turner. http://www.safetyandquality.gov.au/wp-
content/uploads/2008/01/Clinical-Handover-Literature-Review-for-release.pdf
 Safe Clinical Handover. A resource for transferring care from General Practice to Hospitals and Hospitals to General Practice
http://www.aci.health.nsw.gov.au/resources/acute-care/safe_clinical_handover/Safe_Clinical_Handover.pdf
 An experimental comparison of handover methods Bhabra G, Mackeith S, Monteiro P, Pothier DD, Ann R Coll Surg Engl. 2007 Apr;89(3):298-
300 http://www.ncbi.nlm.nih.gov/pubmed/17394718
```
Tools and guides

```
 The Improvement Guide, Langley, Moen et al. Jossey-Bass, 1996 , 2nd Edition 2009
 The trouble with handovers video http://www.focusbiz.co.uk/the-trouble-with-handovers/
 NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover
http://www.aci.health.nsw.gov.au/resources/acute-care/safe_clinical_handover/implementation-toolkit.pdf
 Quality and service improvement tools (process mapping, patient perspectives) http://www.institute.nhs.uk/qualitytools
```

```
August 2015
```
```
 The Productive Series: http://www.institute.nhs.uk/productives
o The Productive Ward (shift handovers module)
o The Productive Mental Health Ward (shift handovers module)
o The Productive Operating Theatre (handover and teamworking modules)
o The Productive Community Hospital (handover module)
 The Care Homes Wellbeing Programme http://www.institute.nhs.uk/carehomes
 Experience Based Design Toolkit http://www.kingsfund.org.uk/projects/ebcd
 Model for Improvement (including PDSA) http://www.institute.nhs.uk/pdsa
 Improvement Leaders’ Guides:
o Process Mapping, Analysis and Redesign http://www.nhsiq.nhs.uk/media/2594717/ilg_-_process_mapping__analysis_and_redesign.pdf
o Measuring for improvement http://www.nhsiq.nhs.uk/media/2541082/improvement_leaders_guide_-
_measurement_for_improvement.pdf
 The 7 steps to measurement video https://www.youtube.com/watch?v=Za1o77jAnbw
 Run charts and simple statistical measures (including a video guide) http://www.institute.nhs.uk/spc
 Root cause analysis (including the ‘Five whys’) http://www.institute.nhs.uk/rca
 eHandover https://www.emishealth.com/products/ehandover/
 Structured communications tools
o SBAR http://www.institute.nhs.uk/sbar
o The ABC of handover http://emj.bmj.com/content/early/2012/01/03/emermed- 2011 - 200199.full
o HAND ME AN ISOBAR http://www.safetyandquality.gov.au/our-work/clinical-communications/clinical-handover/ossie-guide/
o RSVP http://www.workforce.southcentral.nhs.uk/pdf/NESC_RSVP_0209.pdf
 Sustainability Model and Guide http://www.evidenceintopractice.scot.nhs.uk/media/135265/sustainability_model.pdf
 Accelerating the Spread of Good Practice: A Workbook for Healthcare Sarah W Fraser, (2002). Via Amazon.
```
Case studies and presentations

```
 Using a communication framework at handover to boost patient outcomes, Christie, P and Robinson, R, Nursing Times, 1 December, 2009 , Vol
105 , No 47 http://www.nursingtimes.net
 Improving hospital weekend handover: a user-centered, standardised approach Mehra A and Henein C. BMJ Qual Improv
Report 2014; 2 : doi:10.1136/bmjquality.u202861.w1655 http://qir.bmj.com/content/2/2/u202861.w1655.full
 Improving the safety of patient transfer from AMU using a written checklist, Hindmarsh D, Lees L, Acute Med. 2012;11(1):13-7.
http://www.ncbi.nlm.nih.gov/pubmed/22423341
```

```
August 2015
```
## Appendices

Appendix A: Ollie’s story ................................................................................................................................................................................................ 43

Appendix B: Good practice checklist – examples of questions to prompt discussion and generate ideas ...................................................................... 45

Appendix C: The Model for Improvement ....................................................................................................................................................................... 47

Appendix D: SMART aims ............................................................................................................................................................................................. 48

Appendix E: Team Selection Grid Examples .................................................................................................................................................................. 49

Appendix F: Example project template ........................................................................................................................................................................... 50

Appendix G: Dot voting .................................................................................................................................................................................................. 51

Appendix H: Good practice checklist – suggested measures ......................................................................................................................................... 52

Appendix I: Example PDSA for testing a new handover template .................................................................................................................................. 53

Appendix J: Example PDSA for testing new transfer of care process ............................................................................................................................. 54

Appendix K: Examples of standardised communication templates ................................................................................................................................. 55

Appendix L: Example of how a poster can be used to spread the word about new processes ....................................................................................... 58

Appendix M: Summary of the six step improvement process for transfer of care ........................................................................................................... 59


```
August 2015
```
Appendix A: **Ollie’s** story

This case study tells the story of a real NHS patient. The patient did not die as a result of
a series of errors and was thankfully **not ‘clinically harmed’. But** he could have been, as
his care was compromised more than once through poor handover practices.

Overview of situation:

Over a one year period Ollie, as he was known to his friends, was admitted to hospital at least 3
times. As well as the condition he was admitted for, Ollie had epilepsy which was well controlled
with medicine. After the first admission, he and his wife, Georgette, got to know the routine.
Georgette would hand a copy of Ollie’s current prescription record to the Ambulance Crew, they
would take notes and hand it back to her. By the time she met up with Ollie in A&E, his
prescription record would have disappeared, and so she went armed with another copy to hand
in. Within 24 hours he would have passed through the Medical Admissions Unit and be on a
ward, and his prescription record would once again be incomplete. So Georgette would provide
a further copy of his current prescription.

On one occasion, the prescription was written, but Georgette and Ollie knew that the dose of his epilepsy medication was wrong. They pointed this out
twice on the first day, and again on the second day. It was eventually corrected.

Georgette is clear that these poor practices were not the result of bad clinicians, but on gaps
in information transfer and lack of clarity and/feasibility for task completion amongst team
members. Georgette continues to share this story and hopes that one day there will be no
gaps.

##### Snapshot:

##### In the last year of his life Ollie was

##### admitted to hospital several times.

##### Even though his wife, Georgette,

##### developed an ‘A&E survival pack’ to

##### keep him safe, her planned

##### ‘information handovers’ failed to

##### result in an accurate prescription

##### for his regular epilepsy medicine.

##### When his prescription was wrong,

##### no one seemed to take

##### responsibility to get it put right.

##### Even

```
Although Ollie understood that going one day
without his epilepsy medicine was unlikely to
trigger a seizure, he still got anxious – and he
knew that this anxiety COULD make a seizure
more likely. This worried Georgette too!
```

```
August 2015
```
The patient perspective

Both Ollie and Georgette were reassured by staff that they had been heard and that the error would be corrected. But when it remained unchanged for
a second day Georgette felt she had to stay, all day as it turned out, until it was put right. Whilst they both knew and understood that a small delay
would not trigger a seizure, their confidence was dented, and they remained anxious throughout the hospital stay.

Staff perspective

For many staff this story will not be unusual. It may even be common place. But it is unlikely
that many instances will be reported or counted as service failures as the outcome is
classified as ‘patient received medicine and no adverse event’. Negative impacts on patients
such as ‘anxiety’ are rarely captured, and it is usually only when a catastrophe occurs that the
effect of serial failures become visible to the staff who have been involved along the way.

We can become accustomed to the way things are, and frequently accommodate shortcomings by ‘working around’ the barriers to deliver what is most
urgently needed. Although evidence shows that the human brain has a limited memory capacity, meaning that an existing task must be dropped to
make way for a new one when the ‘list is full’, the way we work doesn’t reflect this knowledge.

If you haven’t already done so, you could start thinking about what you might change and how you will know if this results in an improvement!

```
Insanity: doing the same thing over and over
again and expecting different results.
Albert Einstein
```

```
August 2015
```
Appendix B: Good practice checklist **–** examples of questions to prompt discussion and generate ideas

```
What do we need? What does it mean? Think about...
```
```
Leadership
There is a nominated leader
for each transfer of
care/handover.
```
```
 Who should have overall responsibility for the transfer of care? This would
involve ensuring participants attend; introducing and orientating new team
members; prioritising urgent elements of transfer of care.
```
```
Values
Transfer and handovers are
valued as an essential part of
care and preparation for
handover is a priority.
```
```
 How can we ensure information transfer is confidential and non-judgemental?
 How is the importance of transfer of care reinforced in the team, department
or organisation? (culture)
 What training is required to ensure staff understand their accountability in
relation to giving and receiving information? Who will design and deliver this
training? How will staff be released from clinical duties to attend training?
 How will patients or clients understand their role in transfer of care?
 Do staff and patients or clients have guidelines on transfer of care?
```
```
Right people
The appropriate people are
involved.
```
```
 Who needs to attend the transfer of care (think about multidisciplinary
handover)? Do they need to be present for whole transfer or just part of it?
 At what points do patients, clients and carers want to be involved in the
transfer of care process?
 How will students and junior staff get the most learning opportunities from
handover?
 Who will cover the unit while transfer of care occurs?
 What happens in emergencies?
 How can interruptions be prevented?
 Who will be involved in regular review and audit of transfer of care
processes?
 Who will prepare information and documentation for transfer of care?
```

```
August 2015
```
What do we need? What does it mean? **Think about...**

Specified time and
place

```
A specific setting or place
has been agreed where
transfers of care can take
place without interruption or
distraction.
```
```
 When should the transfer of care happen?
 How does this relate to time of shift change?
 How long should the transfer of care take?
 How can we ensure it starts on time?
 Does the transfer of care process need to be different depending on the time
of day?
 Where should the transfer of care happen?
 Is the environment quiet with no interruptions? If not, how can interruptions
be reduced?
 Does any part of transfer of care happen with the patient or in a public area?
 How and where is confidential information transferred?
```
Standardised
process

```
There is an agreed process
for transfers of care
This includes an agreed set
of information to be covered
in transfers (minimum data
set). This is communicated in
a structured way, is action-
focused, assigns
responsibility for actions and
supported by clear
documentation.
```
```
 What information would be included in a standard transfer of care template or
electronic handover record? (The minimum data set.)
 How much of this information overlaps with other disciplines? How could
multidisciplinary transfer of care be most effective?
 How and when in the process will the person receiving the transfer of care
ask questions, confirm understanding and accept responsibility for the
patient/client?
 Do you want to use structured communication tools (eg SBAR, ISOBAR,
RSVP etc.) or develop your own?
 What happens to documentation following the transfer of care? How could it
be designed to go directly into patient notes?
 How is the agreed transfer of care process documented? How do new staff
and patients/clients find out about the process?
```

```
August 2015
```
Appendix C: The Model for Improvement

The Model for Improvement gives you a simple, adaptable and thorough framework for developing, testing and implementing changes. Using the
Model for Improvement means your changes are more likely to lead to the improvement you set out to make.

```
The first thing you need to do when using the model is answer
these three key questions
```
```
Then you carry out the ‘plan, do, study, act’ (PDSA) cycles.
These cycles are used to test an idea by trialling a change and
assessing its impact. The key to PDSA cycles is to repeat them;
keep testing small changes until they deliver the sustainable
improvement you are looking for.
```
```
 Plan the change and how you will test it.
 Do the change and tests.
 Study the data before and after the change and learn
from it.
 Act on the learning by refining the change and planning
another PDSA cycle to test it.
```
```
For more
```
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP, The
Improvement Guide: A Practical Approach to Enhancing
Organizational Performance (2nd Edition). Jossey Bass, San
Francisco (2009)^ v

##### More online...

```
For more on the Model for Improvement see:
```
```
 Quality and service improvement tools
 Improvement Leaders’ Guides – Process Mapping, Analysis and
Redesign
```

```
August 2015
```
Appendix D: SMART aims

SMART aims are a good way to ensure your project aim is clearly defined.

```
Set a SMART improvement project aim:
Specific: Have a clear and specific improvement aim, e.g.
‘structured transfer of care, right each time’.
Measurable: Ensure data is available to measure the scale of the
problem and your success in addressing it.
Achievable: Set a suitable challenge and don’t be afraid to set
your aim high. Resist setting your aim too low just to improve your
chances of succeeding.
Realistic: Consider the factors beyond your control which may limit
the impact of the project, e.g. closure of a unit for refurbishment;
major staff changes; availability of sponsor.
Time: Set a deadline and stick to it, e.g. by December 2015.
```

```
August 2015
```
Appendix E: Team Selection Grid Examples

```
Authority to make changes
```
```
YES
```
##### Acute example

```
YES NO
```
```
NO
```
```
© Profound Knowledge Products Inc.
```
```
Senior Sister
Therapy Lead
Registrar
Lead paramedic
```
```
Junior Staff
```
```
Directors
Consultants
Matron/ Senior Nurse
```
```
Receptionist ward clerk/
Patient / CarerClient /
Improvement Specialist
IT expert
```
```
Detailed
```
```
Knowledge [of the process]
```
```
Authority to make changes
```
```
Detailed Knowledge
```
```
YES
```
##### Residential home example

```
YES NO
```
```
NO
```
```
© Profound Knowledge Products Inc.
```
```
Floor Supervisor
```
```
Care home staff
GP
Reception Staff
```
```
Home Manager RelativesResident
```

```
August 2015
```
Appendix F: Example project template

(^) Adapted from outline in the (^) OSSIE Guide to Clinical
Handover Improvement. Available on Slide Share at
[http://www.qualityimprovementclinic.com](http://www.qualityimprovementclinic.com)


```
August 2015
```
Appendix G: Dot voting

Dot voting is a simple way to collect input from the whole team about the information that should be included
in your communication tool.

```
 Using your observation of the current transfer of care process, create a list of all the information which
is currently discussed.
 Add any additional information that should perhaps be included; either because it is recommended
best practice or because staff/patients/clients want to see it included.
 Let all staff have the opportunity to vote by sticking or drawing a dot next to the information they feel is
most important in enabling them to provide good quality care.
 Remember to include both the staff who are delivering and receiving the transfer of care. This might
mean involving individuals from outside your immediate team if you are transferring patients between
units/departments.
 Use different colour pens to identify different roles, e.g. different colours for trained and untrained
staff.
```
After everyone has voted, the information with the most dots is the information you need to focus on.


```
August 2015
```
##### Appendix H: Good practice checklist – suggested measures

```
What do we
need?
```
```
What does it mean? Suggested measures
```
```
Leadership
There is a nominated leader for each
transfer of care/handover.
```
```
 Staff survey – is leadership clear and does leader fulfil role?
 Do new team members understand the process?
 Is leader indicated on transfer of care process checklist (if used)?
```
```
Valued
Transfer and handovers are valued
as an essential part of care.
```
```
 Number of interruptions
 Staff/patient/client survey - do individuals value & understand the transfer of care process?
 How many patients/clients know who is in charge of their care?
 Do transfer of care guidelines exist and are they visible?
 Number of staff trained in transfer of care process
 Is documentation completed?
```
```
Right people
The appropriate people are involved. ^ Staff time invested in transfer of care (including Staff/patient/client satisfaction with transfer of care processpreparation time)
 Number of incidents in unit/on floor during transfer of care
 Is documentation completed?
```
```
Specified
time and
place
```
```
A specific setting or place has been
agreed where transfers of care can
take place without interruption or
distraction.
```
```
 Number of interruptions
 Staff /patient/client survey – are timing and location appropriate?
 Time transfer of care - does it start on time and how long does it take?
 Staff time invested in transfer of care
```
```
Standardised
process
```
```
There is an agreed process for
transfers of care. This includes an
agreed set of information to be
covered in transfers (minimum data
set). This is communicated in a
structured way, is action-focused,
assigns responsibility for actions and
supported by clear documentation.
```
```
 Is documentation complete? y/n
 Length of time for transfer of care
 Staff/patient/client survey – is appropriate information included in transfer of care? Is
anything missing or not required?
 Audit of transfer of care – is standard communication process followed each time?
 Number of pieces of information in minimum data set which are communicated
 Number of pieces of documentation filed in patient notes (or wherever process says they
should be)
 Number of outstanding actions not completed at end of shift.
```

```
August 2015
```
Appendix I: Example PDSA for testing a new handover template

```
Plan We plan to.... in order to (aim)
AimGet staff input to improve the design of the new handover template.
Plan
 Use the new ISOBAR handover template for 1 bay of patients at afternoon shift handover.
 Feedback will be gathered during the test and via a flipchart in the nurses office.
Risk Management
 All staff will have copies of both the old and new handover templates for the chosen bay.
Measurement Plan
Handover will be timed and number of patients used to calculate handover time per patient.
The following questions will be asked:
 Suggestions to improve the template? Content, layout, design?
 Any other information needed during the shift? Or not needed?
 What support would you like to help you use the template?
Do: What we did was..... (brief description of actions)
 Bay 3 was handed over by Staff Nurse KS to Staff Nurse YB.
 Time to handover Bay 3 –5:45 minutes
 Feedback:
o Addition of mobility and dietary needs is good
o Expected Date of Discharge is not required
o Include patient age as well as date of birth
o Increase font size for recommended actions column
o With suggested changes it will be better than current template
o Guidelines for completing the template on the computer are required
o More practice using SBAR and readbackis required for it to feel comfortable
Study Looking at what happened, what we learned from this was..... ( lessons learned)
 Handover per patient using the new template is quicker than the current process. This may be because it
eliminates the need for questions until all information has been communicated about that patient.
 The template is popular, with some changes to be made.
 Although the team asked to remove expected date of discharge, Senior Sister wants to keep to encourage
discharge planning.
Act What we plan to do next is .... (state next plan)
 Make agreed changes and test template again with night staff for 2 bays.
 Deliver more training and practice opportunities using SBAR with readback
```

```
August 2015
```
Appendix J: Example PDSA for testing new transfer of care process


```
August 2015
```
Appendix K: Examples of standardised communication templates

```
Reproduced with permission of
Dr Sebastian Yuen
```

```
August 2015
```
Reproduced with permission of the
Heart of England NHS Foundation
Trust


```
August 2015
```
Standard Nursing Handover
Procedure - HAND ME AN
ISOBAR - Example


```
August 2015
```
Appendix L: Example of how a poster can be used to spread the word about new processes


```
August 2015
```
Appendix M: Summary of the six step improvement process for transfer of care

#### ^1

- **Start out (page 10)**
    - Refer to existing policies and procedures for transfers of care in your organisation
    - Observe, measure and process map the current communication process
    - What does good look like? Compare your policy and communication process with the good practice checklist.
       (Appendix B)

##### 2

- **Define and scope (page 13)**
    - Begin to answer the three questions of the model for improvement (Appendix C)
    - Set your project aim and scope and link this to your organisational big issues on a driver diagram (page 22)
    - Engage staff, patients, clients and residents using patient stories and evidence from useful resources
    - Choose your project team, include senior and frontline staff and patients/clients/residents
    - Document your project plan (Appendix F) and use the sustainaiblity guide to think about long term impact of change

##### 3

- **Measure and understand (page 19)**
    - Choose and define your outcomes and process measures, collect baseline data and display on run or SPC charts

##### 4

- **Design and plan (page 24)**
    - Design your standard transfer of care template and test using Plan Do Study Act (PDSA) cycles (Appendix I & J)
       - Use dot voting to define your minimum data set (Appendix G)
       - Select a standardised communication tool (e.g. SBAR) to organise your minimum data set
    - Generate and test other change ideas using the good practice checklist (Appendix B) and examples (Appendix K)
    - Choose process measures (Appendix H) collect data and display on run or SPC charts

##### 5

- **Pilot and implement (page 34)**
    - Document your new standardised transfer of care process
    - Plan your tests for implementation using PDSA cycles. Plan training, measurement, resources & stakeholder
       engagement. (Appendix I & J)
    - Consider 'flexible standardisation' and spread good practice to other teams, departments and organisations

##### 6

- **Sustain and share (page 38)**
    - Use the sustainability guide to ensure your changes will be sustained
    - Celebrate and spread your success through conferences, posters, journal articles etc. (Appendix L)


```
August 2015
```
#### Product timeline

```
2011 - 2012 - First learning phase
QI project, Patient Safety Leaders Programme, NHS Institute for Innovation and Improvement
Ali Cole, Quality Improvement Project Lead. Nicola Davey, Topic Expert
Staff at George Eliot Hospital NHS Trust (see acknowledgements on page 3)
```
```
2012, First deisgn and testing phase
Sandra McNerney, Freelance Writer
Focus Groups x 2, NHS Institute Associates, Fellows and Critical Friends
```
```
2013 - 2014 - Second learning phase
Nicola Davey, Quality Improvement Practitioner, Quality Improvement Clinic Ltd
Ali Cole, QI Practitioner and Topic Expert
```
```
2014 - 2015 - Second design and testing phase
Nicola Davey, Quality Improvement Practitioner, Quality Improvement Clinic Ltd
Rachel Hammel, Learning Expert, Quality Improvement Clinic Ltd
```