Safe Communication - NHS England

1 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 Quality Improvement Clinic Ltd. P a g e | 2 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 Startoutpage102 Defineandscopepage133 Measureandunderstandpage194 Designandplan(includingSBAR)page245 Pilotandimplementpage346 Sustainandsharepage38 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.

2 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! Quality Improvement Clinic Ltd. P a g e | 3 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.

3 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!

4 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 ( ) 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.

5 Please email Creative Commons Attribution non-commercial Licensed to the public under a creative commons attribution license. Also please note and respect: Copyright on diagrams shown All Shutterstock images purchased by Quality Improvement Clinic Ltd. Quality Improvement Clinic Ltd. P a g e | 4 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).

6 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).

7 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 ( SBAR, ISOBAR and IDEAL).

8 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. Quality Improvement Clinic Ltd. P a g e | 5 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.

9 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.

10 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.