The Australian Commission on Safety and Quality in Health Care (ACSQHC) sought to develop a program to address communication issues associated with critical times around specific clinical points of care within a private hospital setting.  MHS received funding from the ACSQHC and in response sought to develop a program to address communication issues associated with clinical handover at two critical clinical points of care within a private maternity setting:

• Referral from the midwife to the VMO when a change in the woman’s condition is diagnosed e.g. haemorrhage, change in maternal condition vital signs, established labour, concerns regarding maternal/fetal condition in labour, imminent birth of a baby;
• Referral from the VMO to the recovery nurse/midwife post caesarean section.

Historically there has been no ‘best practice’ for improving hand-over communication within the health care setting exists nor any guide as to the length of time to effect behavioural change.  The literature identifies the following as successful strategies:

• a structured time allocated approach
• the use of tools that encompassed the important data elements
• tools that supported a common language, and
• the addition of written documentation to sustain the handover process.

The existing handover mnemonic SHARE was modified to become SHARED, standing for S-situation, H-history, A-assessment, R-risks, E-expectations and escalation, D-documentation which with accompanying definitions provided a method for enhancing the quality and accuracy of information passed between clinicians.  From here a number of support tools were developed:

• A “swing tag” providing access to the SHARED framework at all times;
• A “Phone Handover Guide” providing a prompt to the information which should be collected and communicated as part of the communication of a critical situation or change in patient condition;
• An “I SHARED…….” Sticker which when inserted into the medical record following a phone conversation with a VMO highlights when this occurred and is a prompt to document the intent and outcome of the communication.

The SHARED Framework for Clinical Handover outlines and explains the essential components of clinical handover. These components are essential for the provision of safe and effective healthcare. The SHARED Framework assists clinicians to participate in comprehensive, appropriate and safe clinical communication irrespective of clinical setting.

Information Packs were developed and distributed to over 400 clinicians across both sites and Learning Guides were provided to Unit Managers and Clinical Facilitators.  In addition to this face to face education sessions were provided to midwifery and nursing staff while VMO’s were kept informed of the progress of SHARED through a regular newsletter.

Pre and post implementation measures including clinical incident data, patient and staff satisfaction and a chart audit were examined in an attempt to show the effect of the SHARED Framework on outcomes.  Upon reflection it has been noted that the implementation time was not long enough in order to effect and sustain behavioural change post implementation of the SHARED framework but did provide a good pilot program and assist in identifying future areas of need.

The pre-implementation staff survey forwarded to VMO’s, midwives and nurses identified a number of issues with the current state of handover which included:

• The quality of handover can be dependent on VMO/midwife involved.
• Difficulties communicating with clinicians directly involved in patients care.
• Appropriate information not always provided.
• A systematic approach or tools to improve consistency would be helpful.
• The quality of handover is inconsistent and dependent on person providing handover.
• At times inadequate information provided.

Conversely, the post-implementation staff satisfaction survey identified that  the majority of respondents are aware of the SHARED framework and its support tools and have found SHARED helpful, with some dissatisfaction around the introduction of this framework and its associated processes for clinical handover.  Respondent’s comments indicate this was due to a sense of dissatisfaction related to the introduction of any increase in paperwork or time away from direct patient care. This issue is continuing to be addressed and managed through linkages and inclusion of the SHARED Framework in existing tools and processes in particular Clinical Care paths and IT solutions.

The results of the chart audit demonstrated an improvement in ‘adequate overall’ documentation from 13% to 24% following implementation of the SHARED framework.  Significant improvements were shown in relation to the legibility of documentation, time entered and signature used.

In terms of Patient Satisfaction the results remained stable at MPHR relating to the following questions regarding:

“Communication between doctors and nurses regarding your care”;
“How staff worked together to care for you”.

At MMPH satisfaction around the question “How staff worked together to care for you” improved by 6.9 mean score points and saw this question move from 10th to 19th most important (correlation coefficient slightly decreased from 0.76 to 0.71) on the priority index.

With the ACSQHC project now complete, MHS has provided ongoing funding for the Clinical Handover Initiative. Support to existing hospitals utilising the SHARED framework will continue.  In addition to this implementation of the SHARED Framework and clinical handover solutions will continue across many specialties including but not restricted to the following:

• Post Operative Handover;
• Inter Departmental transfer;
• End of Shift Handover (Medical and Nursing/Midwifery);
• Telephone Communication.

For further information on the Clinical Handover Program supported by ACSQHC please refer to

 www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-05 or contact