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WP2 Qualitative Handover

Assessment of handovers between different microsystems at the primary care / hospital interface

Workpackage leader - Karolinska University Hospital, Sweden






The aim of this workpackage is to identify the barriers and facilitators to effective handovers (all handovers changed) in the social, linguistic and technological contexts in which they take place in different European settings.


Description of work and role of participants

In pursuit of the aim to identify the barriers and facilitators to effective handover in the social, linguistic and technological contexts in which they take place in different European settings, the following activities will be performed:

  • Recruiting key stakeholder groups in Sweden, Poland, Spain, Italy, The Netherlands.
  • Conducting interviews in different focus groups.
  • Development of process maps.
  • Assessment of different tools used in communication and treatment and their effect on the communication process (Artifact analyses).

The representatives from key stakeholder groups in Sweden, Poland, Spain, Italy and The Netherlands have been identified. Although the handovers processes will be studied as a whole in each country.

Every country will have a country specific focus:

  • Sweden - Handovers at the Emergency Department
  • Poland - Geriatrics
  • Spain - Women and patients from minority groups
  • Italy - Handovers at the Emergency Department
  • The Netherlands - Chronic diseases (i.e, Asthma, Diabetes, congestive heart failure)



We will conduct individual interviews to identify barriers and facilitators in handovers. While traditional work in the this area focuses on identifying and fixing root causes, this strategy may not account for the complex underlying dynamics that make relationships work. We will also conduct focus group interviews with each key stakeholder group. We will develop a process map to define the perceptions of the current process, satisfaction with the process, and highlight the vulnerabilities and potential areas for improvement.


Individual Interviews

To adequately represent the views of all stakeholders in the hospital-primary care communication dynamic, hospital physicians, hospital nurses, community nurses and GPs, patients and families, will be recruited to participate in independent interviews to document barriers and facilitators which are attributable to poor inpatient physician-PCP communication. Interviews will be scheduled for 1 hour and conducted privately, with one investigator serving as the interview moderator. The interview protocol is developed in the project based on work by Dr. Julie Johnson. Interviews will be digitally recorded to assure accuracy and subsequently transcribed. Identifying information will be excluded from the transcript and data will be collected in an anonymous fashion to ensure truthful reporting of incidents.

Interview questions will include probes to determine the level of communication between the PCP and the hospital, the characteristics of the current communication strategy and finally whether additional information from the PCP would have been useful in the management of a patients’ clinical course [For example, “Is there any information that you didn’t receive from the patient’s primary care physician that you wish that you would have had while caring for the patient?”]. We have used a similar recruiting strategy for our study of supervision by Drs. Johnson and Barach and colleagues with a participation rate of over 90% from residents. PCPs will be asked general questions regarding the current status of inpatient physician-PCP communication regarding their hospitalized patients, their satisfaction with the current strategy and whether there were patients who were admitted to the inpatient service over the previous month in which information regarding their clinical course was incomplete. Finally, to perform a complete 360° evaluation and determine the impact of ineffective communication on all parties involved, patients and/or families will be recruited as interview participants. Patients will be queried regarding their perception of their primary care physicians’ knowledge of their clinical course and regarding events post-discharge, including follow-up appointments, medication changes, etc. in which difficulties occurred as a result of their primary care physicians’ lack of awareness of the handover challenges.

We plan to conduct interviews over a six month period. Over this time course, we will have the opportunity to interview hospital physicians and nurses. We will also identify primary care physicians, who have had their patients admitted during this time course and approach them for participation. Finally, patients who agree to participate in the study and also consent to contact their primary care physicians will be identified and approached for an individual interview.

We anticipate that each interview will last for 60 minutes, and they will be digitally recorded for transcription. Word files of the transcripts will be analyzed using Atlas.ti, a qualitative analysis software.


Focus groups and process maps

As part of the interviews we will conduct focus groups with primary care physicians, hospital care teams and patients and/or families in each of the countries (Sweden, Poland, Italy, Spain and The Netherlands). The focus group questions will be designed to elicit the current process of the inpatient – primary care transition from each stakeholder groups’ perspective.

Furthermore, during the focus groups, we will use open-ended questions designed to elicit both barriers and facilitators of effective transitions of care. Advantages of using a focus group methodology for this include the ability to explore and clarify multiple stakeholder views of the workflow and the roles that each play in ensuring continuity during the inpatient-ambulatory, and understand divergent cultures of the inpatient/outpatient setting.

We will use groups consisting of 6 to 8 hospital care teams, primary care physicians, resident physicians, and patients/families. Each focus group will be scheduled for 1 hour and will be digitally recorded for transcription. Word files of the transcripts will be analyzed using Atlas.ti, a qualitative analysis software.

Process mapping is a method that can be used to describe and analyze how an individual clinician interacts both with the system itself and with others within that system. Process mapping describes what an individual is required to do, in terms of cognitive processes, actions or both to achieve the system’s goal. Understanding transitions as a process is important because a high degree of process awareness often drives the design of the work. By mapping the process, the members of the team can gain insight into how their colleagues perceive the same tasks. Ultimately, results depend on effective process – improving outcomes requires appreciating the inherent link between process and result and identifying potential areas to focus improvement that does not focus on the individual, but instead on the system that is producing the processes and outcomes of care. Visualizing the process can also help identify process inefficiencies (e.g., parallel or redundant processes) that are barriers to providing coordinated patient care. In this initial step, participants will be counseled to map the current perceived process, not the desired process, so that opportunities for improvement can be identified.


Artefact analyses

There are limitations to how much can be learned from what people say. In addition, self-report methods such as interviews and focus groups to assess patient safety risk are subject to biases, such as hindsight bias, which overestimates risk of certain processes that happened to be associated with a bad outcome or underestimates risks of processes that were associated with a good outcome. To triangulate the data collected through interviews and focus groups and to more fully understand some of the complexities of the inpatient – ambulatory transition, we will also conduct an artefact analysis. While observation is another way to triangulate interviews, direct observation of communication between inpatient physicians and PCPs is difficult to do with this project due to the current variability, sporadic nature of the communication, and concerns of the Hawthorne effect. Because of the unpredictability for timing of these communications, it also makes it particularly costly. Artefact analysis or the study of any notes or materials used in the daily workflow of patient care may serve as a powerful supplement to the self-report data. Cognitive artefacts may be defined as "those artificial devices that maintain, display, or operate upon information to serve a representational function and that affect human cognitive performance." Cognitive artefacts are, in other words, man-made things that seem to aid or enhance our cognitive abilities. Some examples are calendars, to-do lists, computers, or simply tying a string around your finger as a reminder.” The study of a cognitive artefact yields insight into the nature of the artefact itself as well as insight into the technical work situation and intentions that the artefact represents.

With respect to PCP communication, a cognitive artefact could be a physician note as a reminder to contact the PCP on the sign-out or on the chart. In addition, the physician progress notes may contain information about contact with the primary care physician. The discharge summary and paperwork, which at times note any follow-up appointments with the primary care physician, may be a useful artefact for the quality of the ambulatory-inpatient transition. Lastly, primary care physician notes after seeing a patient who was recently hospitalized may also provide information regarding whether communication occurred and the quality of that communication.

Our team will conduct an artefact analysis of relevant materials (i.e., notes, emails, scrap paper, etc) which may provide insight to the quality of the inpatient-ambulatory transition, with a particular focus on communication between inpatient physicians and PCPs.

We will partner with the EUNetPas consortium in collecting patient safety handover best practices. This will avoid redundancies and/ or duplication of Work. EUNetPaS (European Union Network for Patient Safety) is a project funded and supported by the European Commission within the 2007 Public Health Programme. This project is coordinated by Dr. Jean Bacou of HAS (French National Authority for Health). Its purpose is to establish an umbrella network of all 27 EU Member States and EU stakeholders to encourage and enhance their collaboration in the field of Patient Safety (culture, reporting and learning systems, medication safety and education), thus maximising efficiency of efforts at EU level. EUNetPaS will establish common principles at the EU level through the integration of knowledge, experiences and expertise gathered from individual Member States and EU stakeholders, facilitate the development of Patient Safety programmes in Member States, and also provide support to less advanced countries.



D3 Report on the barriers and facilitators to effective handovers in the social, linguistic and technological contexts in which they take place in different European settings.