Continuity of care is of prime importance in hospitals where care is provided 24 hours a day by many medical teams and after-hour doctors¹. This creates a need for effective handovers between the doctors and teams In NSW Public Hospitals. Junior Medical Officers (JMOs) are the key to providing critical and coordinated care to patients.  

In 2004, a root cause analysis took place following a patient's adverse event in one of the wards at Nepean hospital. Analysis of information indicated that inadequate handover and follow up among Junior Medical Officers were key factors that needed improvement. 

Following a review of the Junior Medical Officers (JMO) handover process, the implementation of a new structured process and web-based hand over system called "iHandover" was put in place.

This process has now been in place for 2 years and has had a major impact on how JMOs perform handovers with vast improvements to patient continuity of care and safety.

The key aim of the iHandover project was to increase patient safety and improve the continuity of care by implementing changes to the way clinical handovers by junior doctors were performed.

Nepean Hospital is 460-bed teaching hospital covering all major medical and surgical specialties.  During after-hour shifts the hospital is covered by 1 surgical JMO and 1 medical JMO (2 medical JMOs on weekend days).

In the past few years, there has been an increasing realisation that verbal handovers were not providing optimal care to patients. In 2004, a patient adverse event occurred in one of the hospital wards.  The root cause analysis of this event indicated that inadequate handover and follow up were key factors and needed improvement. 

Subsequently, at a monthly, hospital-wide JMO mortality and morbidity meeting it was identified the need for a review of the JMO handover process and the implementation of changes if required.

The project consisted of a number of steps. Initially, a review of existing clinical handover system in practice took place. This included face-to-face interviews and small group discussions with JMOs. As issues were identified, a more systematic approach was instituted where a questionnaire was distributed to all junior doctors at the hospital requesting their input on current handover practices and suggestions for improvement.

Further analysis was conducted via searching of medical literature on how clinical handovers were conducted at other hospitals. Guidelines from the British Medical Association and the junior doctors for clinical handover were also reviewed.

The analysis of the existing handover procedures was performed over the period of two months through JMO discussion and observation. It became apparent that rather than a single shortcoming, two major areas were identified as requiring further investigation being handover organisation and structure, and human factors leading to inadequate handover detail.

Handover organisation issues:

• Handovers were essentially verbal without any recorded details,
• Handovers were not structured or formalised leading to handovers that were frequently rushed, often not much more than handing over of the pager between shifts,
• Handovers were dependent on the JMO's personal style, attention level and memory,
• Occasionally handovers did not occur at all (the surgical JMO was unavailable assisting in surgery, or the JMO was attending a sick patient),
• Handovers were reactive - responding to problems rather than anticipating them, and
• Handover technique was 'picked up' and learnt on the job by JMO's without training or coaching on the appropriate process of handovers.

Handovers were also compromised by the following 'human' factors:

• The JMO failed to record details of the patient, hence the patient was 'missed',
• The JMO did not record all of the patient details resulting in confusion or incorrect identification of the patient,
• Often only those patients who were dealt with during the shift were handed over to the next shift, with patients from previous shifts now lost to further follow up,
• The JMO was unaware of 'sick' patients, especially from the day teams, and
• The JMO was often unaware of patients admitted to the wards from ED or ICU.

While not problem areas in themselves, it was frequently commented that:

• There was no ability to follow up handover actions without reference to patient notes, and
• Handovers were unrecorded and as a consequence lost as a reference for future handovers and clinical record.

As a result of the information collected, it became apparent that the entire process required remodelling. In addressing each of the problems listed above, the JMOs identified that the new handover process must fulfill the following basic requirements:

• Recognition of handover as critical to patient safety and continuity of care
• Need for a uniform, structured and formalised process - not dependent on a JMO's personal style,
• Need for a handover log for patient and task entry, with the ability to update, review and sign off entries - available regardless of time and location,
• Able to produce a printable 'handover list' of 'sick' patients and clinical tasks, and
• The handover process itself must be owned by JMOs to encourage responsibility and to make modifications to the process as appropriate.

In August 2004, a new handover process was implemented covering the following:

• Organisation and administration:
  • Introduction of a scheduled overlap between shifts dedicated to handover and hand back of 30 minutes duration
  • JMOs were remunerated for this handover time
  • The handover period was "protected" time (with exception of emergency cases) and this was communicated to all wards and staff
• Medical Education:
  • Introduction of handover rules and guidelines (with an updated JMO duty profile) setting out the how, when and where of clinical handovers
  • JMO training in handover procedures was introduced at intern orientation with ongoing reviews during JMO training sessions
• Electronic Handover Log:
  • The development and implementation of a secure, electronic handover log (intranet based)
  • Criteria for the entry of handover patients and tasks were set with clearly defined rules regarding quality of information to be provided
  • Guidelines and rules clearly defining the appropriate use of the electronic handover system were devised.

"iHandover" - Patient Handover List.  All identifiable patient details have been removed

"iHandover" - Follow up Request details.  All identifiable patient details have been removed

In September 2005, a year after the new handover process was implemented, a survey was conducted to identify JMO's perceptions on the adequacy of the new handover process.

60 JMOs were identified as working at the hospital at the time of survey in September 2005.  This group included local and overseas graduate interns (Post graduate year 1, PGY1), residents (PGY2 and above) who had worked at Nepean Hospital pre iHandover and those who had worked at other hospitals. A survey was distributed with questions through email and printed survey questionnaires

The questions fell into the categories of: awareness of the handover process and orientation (52% reporting having received a formal induction into the system); preferred handover methods and perceived effects of the new method of handover on patient safety and workflows (85% of respondents believed the workflow JMOs was better with the new system and 66% believed it has led to better handovers); and use patterns and acceptability of the new system (Over all 71% believed the new system made their job easier.) 

Overall the new process and usability of iHandover was rated ≥4 on a likert scale by 66% of JMOs.

Majority of questionnaire respondents commented on improvements to patient safety and continuity of care.

The Clinical Handover process is relevant to every health site. The effective transmission of patient information regarding patient health status and need for follow up is performed on every shift by hospital staff including JMOs.

1. Whitt N & Harvey R.  Continuity of Care and Patient Satisfaction. Auckland Hospital (2005) 10th National Prevocational Medical Education Forum, Perth WA.