1. What should I be worried about ?
Interior Health
What should I be worried about ?  
Designing Handover focused on the Receiver
Introduction
Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia.

2. 70% of all Adverse Events communication gaps
Lack of training and formal systems
We handover to “ourselves” more poorly than other specialties Greenburg 2007
Much of the research is of poor quality
Lack of standardization
Dynamic nature of handover
Challenging it’s narrow definition as “information transfer” and medical “error” source
Resisting the compliance mindset & over simplification
Combining handover and team training as inter-related skills
Manser - European Journal of Anaesthesia 2011

3. Transfer of accountability (Handoff) occurs at four key points
1. Change in Level of Care
Inpatient admission from the ED or ambulatory care clinic or community
From ICU to acute care or Acute care to ICU
From a Clinic to the ED
2. Temporary Transfer of Care
From an inpatient ward or ED to diagnostic imaging, lab, echo/ cath lab and back
3. Discharge (Transitions)
Communication to the next care provider (if known) from inpatient unit (phone, letter, discharge summary)
Communication to the home health care provider(s)
Communication to the receiving facility
4. Change in Provider or Service
RN/LPN/RRT at Change of shift report (CoSR)
Physician / resident signout
Physician / resident rotation change

4. Communication Fundamentals from Latin "communis", meaning to share
The act of conveying information through the exchange of thoughts, messages, or information, as by speech, visuals, signals, writing, or behavior.
Communication requires a sender, a message, and a recipient
Communication requires that the communicating parties share an area of communicative commonality. (Same Page)
The communication process is complete once the receiver has understood the message of the sender

6. Sender or Receiver ?
The onus is on the “sender” to ensure the ‘receiver’ understands.
This can only be achieved with feedback (Interaction)

7. In athletics, handover (passing) is a fundamental skill that is practiced, even by experts.
In fact , experts model this behavior for their juniors.

8. Interior Health CoSR Findings (Direct Observation n=26 / 11 hospitals , 2011 )
No clear standards / expectations about face : face report
Individualized / Peer expectations
Unpaid time
Most of the time allotted to task orientation
No standard Kardex – Pt care planning / many different formats, only a few explicit about D/C planning
Nursing Worksheet (“Brain”) – hand written notes carried t/o shift
Even extremely brief face : face report (< 1 min/pt) can be valuable IF structured and IF it focuses forward on potential risks.

9. Interior Health ICU Hand Over Research Highly individualized
Not simple, non linear
Time constrained
Complex tradeoffs
Local rationality (makes sense)
Cognitively taxing
Reliance on memory/ few cues
First oncoming ‘report’ crucial
Hill 2010
A Registered Respiratory Therapist (RRT) is receiving fifteen -thirty minute change of shift report (CoSR) in an Intensive care unit (ICU) for his eight to ten patients, [most of whom are on life support]. In this short time period which includes multiple interruptions, he will conduct a rapid “head to toe” review of organ system problems and ongoing treatment for all of his patients and interact with several different colleagues. He feels that the first CoSR in his ‘set’ of four shifts is the most risky because many of his patients are new to him. There is no standard process for this, everyone does it differently. With experience he has developed his own habit of asking both the Registered Nurses (RN) and Registered Respiratory Therapist (RRT);“What should I be most worried about tonight and why ?” Other colleagues have their own techniques as well.
The literature on Change of shift reports (CoSR) in hospitals indicate these interactions are highly individualized and are neither simple nor linear. CoSR is often time constrained (in some cases too long), may not even transmit the most basic relevant information, and involves complex and dynamic efficiency and thoroughness tradeoffs that must be individualized at the time within the limits of local context.
Relatively little attention has been paid to study how practitioners proactively create safety amid complexity in dynamic, time constrained situations such as change of shift report (CoSR). While proponents of high reliability organizational (HRO) theory, and accreditation organizations (Accreditation Canada 2008) may advocate for standardized handover report formats, such as “iSoBAR” (Porteous 2009), little is know as to if this is correct.

10. Healthcare Human Factors – Communication @ UHN Toronto
A properly designed communication system is fundamental to patient safety
3:22
Effective communication between clinicians, particularly during handovers, is critical for patient safety. To address this important aspect of health care, a multi-site observational study was conducted which focused on analyzing communication and clinician interaction with information technology (IT) around the critical process of patient transfer from the emergency department to general internal medicine.
The study was sponsored by Healthcare Support through Information Technology Enhancements (hSITE), a research network with a mandate of developing key components of an information technology (IT) infrastructure in the clinical environment.
Main findings included the following:
Clinicians complain about the high number of specialized communication tools and software programs. For instance, physicians often have to carry a numeric pager, a mobile phone, and often another pager and their personal phone, and access patient information in the electronic health record, in the paper chart, and in a specialized “sign-out” tool with patient summaries updated daily by physicians.
There is a general lack of awareness of patient status (i.e. location, pending tests and consults, etc). Systems designed to mitigate this issue, such as electronic whiteboards, have limited success, due to the need for manual updates and their unintuitive user interfaces.
The lines of communication between clinicians are often poor, particularly between mobile, transient physicians and stationary nurses.
Despite their many documented drawbacks, numeric pagers continue to be widely used. Additional messaging systems have been introduced, but they usually fail to properly take into account user needs, as both sending a message and replying to it involve a complex workflow.
Interruptions and distractions are frequent, as clinicians prefer direct communication to other available options. Potential consequences of these issues are workflow disruptions, delays in patient care, and inadequate access to time-sensitive patient information, which negatively impact patient safety.

11. How ICU Experts Communicate
They learn how to perceive like experts.
Expert nurses, Doctors and RRTs use the repetitive teachable moments to help train themselves and others how to;
filter out irrelevant information
tune their detective powers to look ahead
“see what for others is invisible”
Deeply understand each others roles
Manage efficiency thoroughness tradeoffs
Practice , develop expertise
Exercise intuition
Collaborative sense-making
Cascading situation awareness
Actively utilize anticipation and foresight
Conclusion
Clinicians experience successes far more than failures, while using essentially the same tactics to get through their day.
This study demonstrates that ICU Doctors, Nurses and Respiratory
Therapists believe face to face communication at change of shift report is crucially important and that they already share a mental model and expectations (between professions) about what an ideal change of shift report (CoSR) is composed of.
Planning expertise (anticipation) can be transferred within and across disciplines through cascading CoSR.
This may have important implications about learning how to perceive like an expert. Expert nurses, doctors and RTs may use the repetitive teachable moments [in those thousands of handovers per year] to help train themselves and others how to both ; filter out irrelevant information and tune their detective powers ….honing their sources power to look ahead and ‗see what for others is invisible‘.
This is one of a very few studies to ask an interdisciplinary group of ICU clinicians (nurses, physicians & respiratory therapists) what they do, within and across disciplines in Intensive care, during CoSR to anticipate and forestall problems .
Hill 2010 CJRT 46/4 Winter

12. Forward focused verbal handover
Handover Suggestions based on literature reviews, peer reviewed original research and direct observation
Forward focused , concise synthesis , receivers’ perspective
Anticipatory planning modeled in practice by PCCs
Even a brief face : face report (< 1 min/pt) can be valuable IF it is structured and IF it focuses forward.
Focus on the system of information flow from N-D / N-D through the Patient Care Coordinator/ Charge RN.
Test a template for anticipatory verbal report using the IDRAW acronym ;
Identity
Diagnosis, (Sick , Not Sick ?)*
Recent changes,
Anticipated changes,
What should I watch out for ?
Forward focused verbal handover
* discussion with Dr. Ertel on handover urgency ; sick vs. not sick

13. House – Puffer (0:33) http://www.youtube.com/watch?v=dMAS2S51bM8

14. How can I communicate like an expert ?
Frame the interaction on forward focus and encourage interaction
and anticipatory questions such as;
“What are you worried about ?”
“What should I be worried about ?”
Evaluate outcomes like accuracy of prediction vs. form compliance
Face : face interaction
Use of multiple /minimum data sets
Patient care summary
“Brain”- Pt census for oncoming shift notes
Opportunity to ask and answer questions (read back)
Discussion, agreement of intention going forward
*Anticipatory questions (active receiver) Hill 2012

15. How can I help the receiver accept this patient ?
Interactivity is Key
“How we communicate with ourselves and with others produces the nature of the society and environment where we live and breath and have our being.
Central to culture
"Senders" and "receivers" interacting (like yin and yang)
Our interactions create our realities” (Freed)
"Senders" and "receivers" interacting like yin and yang
“Our interactions create our realities” (Freed)

16. Handover Standards for PCCs ? Virginia Healthcare 2012
Explicit standards for;
Patient through put / Communication / Handover

18. References
Hill W., Nyce,J. (2010a) Human Factors in Clinical Shift Handover Communication (Review) Canadian Journal of Respiratory Therapy 46.1 Spring Hill,W. (2010b) Cognitive Human Factors in ICU – Techniques clinicians report that they use to develop their anticipation, intuition and foresight at change of shift report (CoSR) Canadian Journal of Respiratory Therapy 46.4 Winter Freed,K. (2007) Global Sense, Awakening your power to change our world Hill (2012) - Handover Communication - Direct observation of Change of Shift Report (CoSR) Assessment of current state on 26 units at 11 hospitals in Interior Health Interior Health Patient Safety Report 2011, Poster BC Quality Forum 2012 Manser (2011) Minding the Gaps; moving handover research forward European Journal of Anaesthesia Olvera,M. (2011) Draw 3 – a new handover tool focused on the receiver . IHI Expedition on Handover March 23,2011 Hand off - Frequently asked questions