1. Safer Handover Rapid Improvement Event 9th – 11th May 2017
OUTBRIEF

2. Focusing on Value: Statement
All information relevant to my care must be reliably communicated to me and those supporting me in a clear, accurate and unambiguous manner. It must be readily available and ensure that responsibility for actions are clearly set out (v.3)

3. Safer Handover Referral from primary to secondary care
OUTBRIEF

4. Current State Key messages: Top 3 observations
Differing GP Practice referral processes are a barrier to standardisation across the board.
A lack of understanding of each others internal processes and the associated unintended consequences
Its complicated!
Top 3 waste/measures
Duplication of effort for all AND unnecessary communication
It can take up to 114 days for a standard referral but ONLY 30 minutes value added for patient
84 steps in the current process but ONLY 3 value added for the patient
Key gaps to address in future state
Multiple handoffs create risk
Lack of opportunity for primary and secondary care clinicians to have a clinical conversation

5. Lessons Learnt
It’s a miracle that patients ever get what they need! … But it happens in spite of the system because people work harder not smarter
There is a huge commitment from all to change the system
Technology MUST enable safe handover
Recognition that silo working is no longer sustainable, reliable, efficient and, most importantly, safe

6. Safer Handover Improving safety of patient transfers from secondary to primary care

7. Current State Key messages: Top 3 observations
Duplication of work and cross-checking
Lack of certainty/visibility of actions and communications
Unknown ownership and responsibility for elements of patient care.
Top waste/measures
Duplication of communications(Verbal and written)
Delays in planning and process of discharge
Time investigating/fact finding for clinical information
Key gaps to address in future state
Integrated communications/pt records/medicines records
Reduction of unnecessary communications and handoffs
Accurate medicines information sharing
Culture change - Collaboration

8. Lessons Learnt It’s good to talk
Assumptions and misunderstandings are rife
IT can do more than we know – if we use it right
IT can be a barrier – changes are needed
Reducing the IT options, so everyone does it consistently, can be better.

9. What we need support with: Safer Handover Key Messages and Challenges
Safety at handover of care is the priority for everyone
Handover process needs to be simplified
We want a joined up system
We need to reduce the number of handovers and therefore the risk attached
Support required for overcoming challenges:
Support to move forward further and faster based on the momentum of this event
Clarity from both organisations on how the action plan will be taken forward and owned
Governance : Clinical Standards Board? Programmed into two assurance structures.
Support with developing and making a collaborative approach happen
IM&T that enables the system to deliver joined up, patient centric care
Review of governance to ensure joint ownership, implementation and completion of actions.

10. Thank you!