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Project Reports to the EU

From Handover research Deliverable D1 – Report on training needs and appropriation guideline per region and category
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Authors: Dr. W. Kicken Dr. M. van der Klink Dr. S. Stoyanov Prof. Dr. H.P. A. Boshuizen

The HANDOVER project acknowledges that training and learning are important means to encourage the implementation of handover models and tools. This deliverable describes the training needs analysis, which can be considered as the first step in the design and delivery of training in handover. The training needs analysis encompasses the examination of training content, training design and conditions and prerequisites that affect the transfer of training from the training site to the workplace. A literature study and 18 interviews with training specialists working in hospitals in Spain, Poland and The Netherlands were used to collect information concerning the training needs. The report provides practical guidelines in the form of quality indicators that can be applied for decisions on the content of the training, for selecting the most appropriate training design and for establishing favourable conditions that increase the effectiveness of the training. The report concludes with some remarks concerning the further development of the quality indicators and the training in handover.

From Handover research Deliverable D2 – Report on the likely cost of the various prototype interventions based on a model of the likely costs
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Authors: Prof. Richard J. Lilford Mr. Peter J. Chilton Dr. Karla Hemming Dr. Celia A. Brown Mr. Alan J. Girling Paul Barach Miss Wendy Fox¬Kirk

Abstract: A report providing a model for the assessment of cost effectiveness of organisational interventions such as handover in healthcare settings. The proposed model is an extended Donabedian Chain. Upstream interventions have diffuse effects creating problems with statistical power if downstream end points are measured. The difficulty of measuring the effect of upstream interventions such as that for handover is discussed and the conclusion reached that if an intervention is relatively inexpensive then worthwhile (cost effective) effects will not be detectable at the level of the patient. The importance of assessing the value of information is also discussed with Bayesian techniques suggested as the key methodology to address this issue.

From Handover research Deliverable D3 - Report on Handovers in European settings
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Authors: Dr. H. Hansagi, Dr. M. Olsson, Dr. S. Bergenbrant, MSW. M. Flink, Dr. P. Barach, Dr. G. Öhlén


Abstract: The aim of WP2 activities was to identify barriers and facilitators to effective handovers in the primary care - hospital interface. This deliverable reports a prospective, qualitative study performed in The Netherlands, Spain, Poland, Italy and Sweden. Patients with chronic diseases, and discharged home from hospital, and their respective care providers were recruited. Interviews, process mapping, and artifacts were used. Phases and roles in handovers are dependent of the social contexts of the countries. Incomplete information e.g. lack of medication lists, were indentified as barriers. Timeliness of information Is critical in some countries, whereas shared IT-systems, personal contact between care provider, and special transfer nurse are facilitators. Communication, both between professionals, and between care providers and patients could be improved. Since this is qualitative research, and because each European country has its own distinct healthcare system, these empirical findings cannot be statistically generalized or taken as policy documents. Still, these findings are sufficiently evident to be helpful in tailoring future interventions to barriers in handovers and to improve continuity of care.

Keywords: Handover, barriers, facilitators, primary care/hospital interface, social, linguistic, technological contexts, European settings

From Handover research Deliverable D4 - CP-CSA-NoE Periodic Report
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Authors: Prof. Paul Barach, Dr. Loes Pijnenborg



From Handover research Deliverable D5 - Identify Basic Elements of Effective Communication
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Authors: Paul Barach, MD, MPH; Petra Gademan, MD; Cor Kalkman, MD, PhD; Julie Johnson, MSPH, PhD; Loes Pijnenborg, MD, PhD


Abstract: The impact of organizational culture on care coordination and transitions of care in the primary care – hospital interface is critical to patient safety and professional responsibility. The aims of this Deliverable are to: (a) identify referral and discharge barriers and facilitators to effective and safe patient handovers; (b) determine how variations in handover processes lead to “near misses” and adverse outcomes; and, c) explore the roles and responsibilities of healthcare providers as well as patients and their carers. We conducted a prospective, qualitative study in The Netherlands, Spain, Poland, Italy and Sweden. Patients with chronic diseases, discharged home from hospital, and their respective care providers were recruited for individual and focus group interviews.

We determined the effectiveness and efficiency of various methods and models for integrating and sustaining best practices in improving care processes and patient outcomes. The triangulation of multi modal improvement science methods in this study, including analyses of barriers and facilitators, Ishikawa diagrams, near misses, process maps and analyses of roles and responsibilities is innovative and facilitates cross-country learning. We found that while the prevailing handover practices differ across Europe, many of the identified referral and discharge barriers and facilitators appear to be similar in the different countries and settings. The key themes underpinning the barriers and facilitators for patient discharge and referrals that emerged from the analysis include: communication content, process, and tools; attitudes; organizational factors; community resources; patient awareness, and patient empowerment.

All stakeholders, including the patients, agree upon the need for an active patient role in the handover process. However, both patients and professionals are concerned about the amount of responsibility to be put upon patients. Family members are perceived as of great importance to facilitate handover, both by patients and professionals. The lack of awareness to different professional perspectives, inherent to primary and secondary professional domains, seems to influence the roles and responsibilities in patient diagnosis and treatment. Though most professionals think they carry a shared responsibility in this respect, in practice there is no shared responsibility. Because of multiple assigned roles and unclear responsibilities, especially with nursing professionals, the time of discharge can create barriers in handover. We demonstrated that it is common that the general practitioner plays an essential part in the coordination of patient care. Multiple factors, such as the lack of direct contact between professionals, involvement of multiple professionals and the lack of feedback, make it difficult for the general practitioner to fulfil this role excellently and be accountable.

Near miss and vignette analysis suggest that involved professionals facilitate handover because they view patient handover as part of their care process. However, most roles and responsibilities are not clearly defined. Near misses and vignette analysis shed light on the complex process-outcome relationship and enable us to refine methods of handover and other strategies to assure safe, effective, and efficient transitions in given clinical populations. The fragmented delivery care model, misaligned payment styems and cultural differences at the interface between the hospital and primary care play a key role in hindering effective and safe handover practices.

Keyword: Handover, patient safety, near misses, barriers, facilitators, primary care hospital interface, process maps, Ishikawa charts, culture, roles and responsibilities