Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO) : primary research

Background and objectives: Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover. Methods: Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways. Results: Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows. Conclusions: The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training.

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation

An evaluation of a nurse led unit: an action research study

This study is an exemplar of working in a participatory way with members of the public and health and social care practitioners as co-researchers. A Nurse Consultant Older People working in a nurse-led bed, intermediate care facility in a community hospital acted as joint project lead with an academic researcher. From the outset, members of the public were part of a team of 16 individuals who agreed an evaluation focus and were involved in all stages of the research process from design through to dissemination. An extensive evaluation reflecting all these stakeholders’ preferences was undertaken. Methods included research and audit including: patient and carer satisfaction questionnaire surveys, individual interviews with patients, carers and staff, staff surveys, graffiti board, suggestion box, first impressions questionnaire, patient tracking and a bed census. A key aim of the study has been capacity building of the research team members which has also been evaluated. In terms of impact, the co-researchers have developed research skills and knowledge, grown in confidence, developed in ways that have impacted elsewhere in their lives, developed posters, presented at conferences and gained a better understanding of the NHS. The evaluation itself has provided useful information on the processes and outcomes of intermediate care on the ward which was used to further improve the service

Evaluation of the organisation and delivery of patient-centred acute nursing care

In 2002, a team of researchers from the School of Nursing, University of Salford were commissioned by Bolton Hospitals NHS Trust to evaluate the delivery and organisation of patient-centred nursing care across the acute nursing wards within the Royal Bolton Hospital. The key driver for the commissioning of this study arose from two serious untoward incidents that occurred in the year 2000. Following investigation of both these events the Director of Nursing in post at that time believed that poor organisation and delivery of care may have been a contributory factor. Senior nurses in the Trust had also expressed their concern that care may not be organised in a way that made best use of the skills available

The perception of ageing and age discrimination

Key messages: – Perceptions of ageing can subject older people to patronising forms of prejudice, which may be expressed in the language and tone used to communicate with older patients, the settings in which they are placed and the framing of treatment options. – Healthcareprofessionalsandorganisationsshouldbeawarethatolderindividuals are potentially vulnerable to age prejudice and stereotyping processes. – Healthcare could bene t from much more deliberative questioning of age-based assumptions and of how attitudes interact with policies, structures and practice

An overview of the research evidence on ethnicity and communication in healthcare

• The aim of the present study was to identify and review the available research evidence on 'ethnicity and communication' in areas relevant to ensuring effective provision of mainstream services (e.g. via interpreter, advocacy and translation services); provision of services targeted on communication (e.g. speech and language therapy, counselling, psychotherapy); consensual/ participatory activities (e.g. consent to interventions), and; procedures for managing and planning for linguistic diversity

The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders

Requirements of time management tools for outpatient physiotherapy practice

The effects of electronic appointment booking systems on the time management activities of health professionals have received little attention to date. We report on time management practices in three outpatient physiotherapy departments with different paper and electronic systems. The study has identified a set of time management activities and associated social behaviours common to physiotherapy departments. The convenience, flexibility and expressive nature of paper diary systems is of significant value to users, whilst the clarity and superior database functionality of electronic systems are valued by staff using this medium. The study highlights several potential barriers to the effective deployment of electronic booking systems in physiotherapy departments, including poor resource and training provision, concerns regarding restrictive diary control measures, the continued reliance on burdensome duplication procedures and the need to coordinate multiple information artefacts, which need to be addressed if such technology is to be successfully designed and deployed. Copyright © 2005 SAGE Publications (London, Thousand Oaks, CA and New Delhi)

A case study of stakeholder perceptions of patient held records: the Patients Know Best (PKB) solution

Introduction: Patients Know Best (PKB) provide a patient portal with integrated, patient controlled digital care record. Patient controlled personal health records facilitate coordinated management of chronic disease through improved communications among, and about patients across professional and organizational boundaries. An NHS foundation trust hospital has used PKB to support self-management in patients with Inflammatory Bowel disease; this paper presents a case study of usage. Methods: The Stakeholder Empowered Adoption Model provided a framework for consulting variously placed stakeholders. Qualitative interviews with clinical stakeholders and a patient survey. Results: Clinicians reported PKB to have enabled a new way of managing stable patients, this facilitated clinical and cost effective use of specialist nurses; improved two-way communications, and more optimal use of outpatient appointments and consultant time. The portal also facilitated a single, rationalised pathway for stable patients, enabling access to information and pro-active support. For patients, the system was a source of support when unwell and facilitated improved communication with specialists. Three main barriers to adoption were identified, these related to concerns over security; risk averse attitudes of users; and problems with data integration. Conclusions: Patient controlled personal health records offer significant potential in supporting self-management. Digital connection to healthcare can help patients to understand their condition better and access appropriate, timely clinical advice

Managing major health service and infrastructure transitions: A comparative study of UK, US and Canadian hospitals

increasingly common as health systems evolve in response to innovations and process improvements, and to the changing demands for healthcare. Sometimes new health service designs need to be supported by changes to the healthcare infrastructure if they are to be successfully implemented and sustained ? service delivery models and its built and technical infrastructure must be transformed simultaneously. Just tackling one of these issues is challenging for all involved. Doing both these tasks at the same time can be overwhelming and risky. But there can also be advantages in such radical change. It can provide an opportunity to radically rethink ways of delivering healthcare. Conducting simultaneous infrastructure renewal and service redesign means that care processes, not plausible in the old infrastructure, may be more easily designed into the new facility. Major restructuring efforts are rarely systematically evaluated with outcomes measured or best practice shared (Walston and Chadwick, 2003). However, we do know that ?whole system? organisational change in healthcare ? change which impacts on all areas of the organisation across all levels and stakeholder groups ? is often hampered by a failure to plan effectively (NHS, 2008). It is generally accepted that the successful introduction of healthcare innovations requires the approval of relevant stakeholders (e.g. physicians, government bodies, primary care providers), and that planning and implementing major changes in healthcare service or infrastructure design requires practice- based examples to learn from. While there is considerable experience in the planning and implementation of health services changes, there is little written about combined services and infrastructure change. Organisations searching for such information may have to look for examples beyond those found in their own country. Studying similar cases across different organisational and international contexts also increases the likelihood of determining pivotal factors that underpin success